July 06, 2020

By Kylie M. Smith, Ph.D.

People with mental illness have always been discriminated against. They have been denied full participation in society and labeled as dangerous and criminal. Many have been locked in institutions that acted more like prisons designed to punish than hospitals designed to treat. 
In the 1960s, a series of federal legislation and court cases tried to end this discrimination. In the process, these cases revealed how deep the inequalities ran. And as bad as they were for anyone with mental illness, they were even worse for the most marginalized people in the system, African American men, women and children.
These problems continue today due to a history of systemic discrimination.

Claiming that Segregation Was “Medically Necessary”

In 1963, the Community Mental Health Centers Construction Act (CMHA) was passed to change the way people with mental illness were confined. CMHA recognized that hospitals were too often places of custody rather than care and provided money to states to build new community-based services. 
When the Civil Rights Act was passed in 1964, it included a clause, Title VI, that declared it illegal for any facility or service receiving federal funds to discriminate on the grounds of race. Some states that were still actively pursuing policies of racial segregation were in danger of losing existing funding and of not receiving any Medicare funding. 
Rather than accepting these rulings and finding ways to end discrimination and segregation, states like Alabama and Mississippi chose to fight the federal government in court. They claimed that it was their right to run state services free of federal interference and that it was medically necessary to segregate patients along racial lines.

Using Psychiatry as a Justification for Mistreatment 

The idea that segregation was medically justified was based on a long history of racist ideas in psychiatry. Physicians and psychiatrists argued from the early 1800s that African Americans were biologically “inferior”. The most infamous of these, Samuel Cartwright, argued that slavery was their natural state because they benefited from the hard work and were incapable of looking after themselves outside the system. In 1851, Cartwright published a report where he invented two “psychiatric” disorders, draeptomania and dysaesthesia aethiopica, to explain the tendencies of enslaved people to run away or to resist hard work as mental illness. 
Cartwright also claimed that enslaved people demonstrated child-like simplicity and lack of complex emotional processes which were characteristics of their entire race. Hospital superintendents used these ideas to justify a lack of any real therapeutic treatments for African American patients. This led to a dual system in many hospitals where Black patients were kept in separate substandard facilities and put to work in the hospital laundry, kitchen and fields. 
These conditions were not seriously challenged until the 1960s. Inspired by new Civil Rights legislation, lawyers and activists fought for an end to racial segregation in all the country’s hospitals, including its psychiatric ones. In 1967, the Office of Equal Health Opportunity within the Department of Health, Education and Welfare (HEW) inspected facilities in the South, and found that psychiatric hospitals (particularly in Alabama and Mississippi) continued to operate in breach of the Civil Rights Act. 
The HEW inspector, Marilyn Rose, wrote that, “the general wards were horrid.” She explained that “there were only five doctors, four of whom were foreign. They were not licensed in the U.S. and did not have credentials as psychiatrists in their native country. The fifth psychiatrist was the administrator, obviously not conversant with modern psychiatry, and seemed to be running a southern plantation.”  
Behind these harmful practices lay the idea that Black people were somehow less than human, that they didn’t feel the same way that white people did, or that they weren’t suitable for things like psychoanalysis or group therapy. 

How These Practices Define Psychiatry Today

What makes this kind of discrimination possible? When I talk to people about my research, some of them, especially ones born in the South, say “oh but that’s just how it was back then.” Yes, but that doesn’t make it right. People at the time knew it wasn’t right, and the NAACP Legal Defense Fund went to court to end these discriminatory practices. 
In the case against Alabama, the judge drew on expert testimony from Black and white psychiatrists who said there was no medical justification for segregation or discrimination. Sadly, racism in psychiatry did not end with these cases and the later deinstitutionalization movement. 
Recent work by historian and psychiatrist Jonathan Metzl shows that the ideas that underpinned these past practices merely shifted terrain in the 1970s. For example, psychiatrists added the word “aggressive” to the definition of schizophrenia, and marketed pharmaceuticals directly at Black patients who they felt were more “out of control.” 
The long-term effect of this shift has been a disparity in diagnostic rates. Black men are more likely to diagnosed with schizophrenia than white, with no scientific basis. Black patients continue not to seek mental health services. And the criminal justice system continues to push Black people with mental illness into prisons.

How History Can Help Us Understand the Way Forward 

While this history is tragic, it doesn’t mean things are hopeless moving forward. Federal agencies are funding more research to try and understand the causes of disparities in access, treatment and care. But it’s important to remember that biology or genetics do not cause those disparities. It is history, culture and politics that treat people differently. 
We need to teach this history to our practitioners so they understand what factors have shaped the way people approach mental health. And we need to recognize the impact of this history on individual wellness. To be actively discriminated against, to be thought less of, because of the color of your skin is both stressful and traumatizing. 
In 2003, the Human Genome Project found that human genetics are 99% the same. In 2020, it’s time to let go of old ideas about human difference, and make sure that everyone has access to the mental health services they need and deserve. 

Dr. Kylie M. Smith has a Ph.D.in the history of psychiatry, and is an Associate Professor and the Andrew W. Mellon Faculty Fellow for Nursing and the Humanities at Emory University in Atlanta. Her book “Talking Therapy: Knowledge and Power in American Psychiatric Nursing” was recently published by Rutgers University Press. Her new project is about the history of segregation in psychiatric hospitals in Georgia, Alabama and Mississippi.

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