Martin Summers’ Madness in the City of Magnificent Intentions is a true magnum opus. Beyond being an authoritative history of Saint Elizabeths Hospital, it is also a history of over a hundred years of the care for the mentally ill in the capital of the United States and, in particular, a history of race relations and racism in American psychiatry.
Summers’ book is organised chronologically, tracing from the founding of the hospital to the District’s deinstitutionalisation in the 1970s and 80s. In this meticulously sourced volume, Summers strikes a balance between an institutional history with a history of people, telling poignant stories and reconstructing the voices of patients and families to explore how this institution shaped their life. Reconstructing these voices from the late nineteenth century, Summers demonstrates both his sensitivity to the narratives of patients and families, and his virtuosity in archival research. He complicates narratives of community relations with institutions, showing for instance how black families sought admission of their loved ones to gain access to the care they were no longer able to provide (p. 87). His analysis of patient letters and letters to family members helps reconstruct the voices of those whose lives were directly impacted by this institution.
Summers’ main contribution in this impressive manuscript is the interweaving of a history of race relations within a larger history of psychiatry. Reviewing patient records, correspondence, and other administrative documents, he persuasively demonstrates how African American patients were viewed and treated differently by both physicians and other staff members at Saint Elizabeths. He brings the receipts: he provides data and tables (pp. 165–7) demonstrating disproportionate use of restraints and seclusion amongst African American patients, regardless of gender. He demonstrates compelling data on the use of work as therapy in African Americans in comparison to white patients, based on sampling of case files (p. 180).
Historians of psychiatry have commonly agreed that psychoanalysis was predominately utilised with white patients, based on racist views that African Americans would not benefit from this more intellectual form of treatment. Yet, until this book, there was little in-depth analysis of what practitioners thought of their patients, and sparse engagement with clinical interpretation. Summers’ research and analysis (pp. 170–5) is a compelling reconstruction of clinicians’ (mostly racist) views on psychoanalysis and psychotherapy with African American patients. It relies on detailed patient records to shed light on how patients might have interpreted psychoanalytic interventions (p. 176). Summers is able to incorporate patient care records and perspectives to add depth to his understanding of how psychoanalysts viewed the psychodynamics of African American patients. Summers’ understanding of how psychoanalytic interpretations may have clashed with African American patients’ behaviour, better understood through a lens of a different medical epistemology – the belief in the power of conjure – is particularly illuminating.
Masterfully woven within this history is a history of therapeutics in psychiatry and their interpretation. Summers depicts the transitions in psychiatric therapeutics over the course of a century through the lens of treatments that were performed within Saint Elizabeths’ walls. Summers also provides a history of local and federal politics and how these shaped a hospital that was unique in its operation as a federal institution. Examining budget appropriations (p. 70), congressional investigations (pp. 224–5), local District legislation (pp. 102–94), and federal desegregation policies, Summers intertwines a history of a politics, local and federal, and how these shaped the care of individuals.
His analysis of the race relations between African American staff and their patients is a significant contribution beyond his work on physicians and their patients. The history of St Elizabeths Hospital, and the care of mentally ill individuals in general, is always greater than simply the physician–patient relationship (pp. 186–9, 237–9). Paying close attention to how both nurses and attendants experienced race relations and their lived experience of segregation within this institution is a powerful and poignant addition to the story Summers tells.
Summers’ writing is dense, filled with primary source quotes, and the book is so rich with detail that the moments in which the author steps back to offer a big-picture analysis and narrative are particularly welcome. In fact, hearing more of a narrative within the details would have perhaps rendered the book more accessible. Regardless, Summers’ book is a major contribution and will serve as a new standard for writing histories of psychiatric institutions.
