The psychopathic hospital

Abstract

A new psychiatric institution emerged in the late nineteenth and early twentieth centuries: the psychopathic hospital. This institution represented a significant development in the history of psychiatry, as it marked the profession’s reorientation from asylum-based to hospital-based care, and in this way presaged the deinstitutionalization movement that would begin half a century later. Psychopathic hospitals were also an important marker of psychiatry’s efforts to redefine its professional boundaries and respond to its vociferous critics. This entailed both a rapprochement with general medicine in an effort to assert its scientific bona fides and a redefinition of its scope of practice to absorb non-certifiable ‘borderland’ cases in order both to emphasize non-coercive treatment and to enlarge the profession’s boundaries.

Introduction

One of the most significant events in the history of psychiatry in the latter half of the twentieth century was the discharge of hundreds of thousands of patients from mental hospitals throughout the Western world, in a process known as deinstitutionalization. This event, though crucially important in the history of twentieth-century psychiatry, has received scant attention from researchers. As Kritsotaki, Long and Smith (2016: 3) remark, ‘[u]nlike the history of asylums, which dominated the historiography of mental illness and psychiatry until the 1990s and continues to attract the attention of both scholars and students, the history of deinstitutionalisation is only beginning to be told’.

This process of great institutional change has often been ascribed to external forces acting upon psychiatry, typically in the mid-twentieth century – most notably the advent of antipsychotics, the antipsychiatry movement, and financial pressures impacting health care budgets. For example, in the journal Psychiatry, Trevor Turner (2004) has argued that ‘most important . . . was the government’s perception that cheaper, non-hospital care was available’. He goes on to cite ‘a forceful anti-psychiatry movement’ and ‘the rise of the new psychopharmacology’, beginning with the introduction of chlorpromazine, as the key drivers of this phenomenon. Edward Shorter (1997: 279), in his book A History of Psychiatry, postulates that ‘[w]hat initiated the massive discharge of psychiatric patients to the “community”, a process known as deinstitutionalization, was the introduction of antipsychotic drugs in 1954, the year the Food and Drug Administration licensed chlorpromazine’. Similarly, in a recent asylum history monograph, Joelle Abi-Rached (2020: 14) argues that ‘the use of powerful drugs (especially antipsychotics) and various socioeconomic forces heralded the ultimate downfall of large psychiatric institutions in a process that came to be called deinstitutionalization’. She goes on to argue that ‘the process of deinstitutionalization . . . followed the antipsychiatry movement of the 1960s’ – the implication being that this movement was a prime cause of deinstitutionalization. Although these forces played important roles in accelerating this process, such explanations ignore the deeper roots of this seismic shift in how and where psychiatric patients were treated.

In fact, the origins of deinstitutionalization are more complex, have earlier antecedents, and reflect broader changes in the history of psychiatry than conventional explanations allow. As Gerald Grob (1983) has observed, psychiatry had already begun to turn away from the asylums by the late nineteenth century, and was changing due to the complex interplay of both external and internal pressures. Indeed, ‘the changes in American psychiatry that began in the late nineteenth century were not simply the products of external criticism; they represented also a response to its increasingly marginal status’, thus also representing a desire for transformation from within (p. 62).

This paper aims to elucidate some of these changes in order to place the history of deinstitutionalization in a broader context of disciplinary change within psychiatry in the late nineteenth and early twentieth century. It contends that deinstitutionalization must be appreciated as one element within a broader transformation in how psychiatrists thought about their patients, treatments and institutions. Changes in how psychiatric patients were imagined, how effective treatments were understood, and how the therapeutic value of institutions was redefined, all conspired to erode the relative significance of state hospitals and asylums within the evolving field of psychiatry. The emergence of psychopathic hospitals at the turn of the century played an important part in this transformation, and the study of these new institutions offers a lens through which to view a psychiatric profession in evolution.

Psychopathic hospitals and deinstitutionalization

Although deinstitutionalization has not been well studied, it is certainly well known as a phenomenon. Much more obscure in the history of psychiatry is another institution that played an important part in psychiatry’s movement away from the asylums: the psychopathic hospital. This institution – pioneered in Germany in the second half of the nineteenth century (Engstrom, 2003: 1–7) and established in cities across North America in the early decades of the twentieth – represented the profession’s renewed institutional answer to the question of psychiatry’s purpose in a society undergoing rapid changes, particularly in the medical profession writ large, and in the provision and oversight of social services (Grob, 1983: 3–6). While the psychopathic hospitals were not established to serve as competitors to the asylums, they nevertheless contributed to the decline of such institutions by virtue of their success in elaborating a new type of psychiatry practised in a new setting.

Indeed, when asylums began discharging their patients in the 1950s and 1960s, they were not depriving their patients of all psychiatric care – at least in theory. Instead, patients were entering a parallel mental health care system of outpatient services meant to maintain stability as long as possible combined with, for those in need, brief hospital stays to treat episodes of acute decompensation. This system was the outgrowth of the psychopathic hospitals. Although these hospitals had not been envisioned as institutions catering to patients with severe and persistent mental illness, from the beginning they often treated more of these patients than intended – indeed, dementia praecox was the number one diagnosis treated at the Boston Psychopathic Hospital, one of the earliest and most prominent such institutions (Pressman, 1997). The model of psychiatry that they established came to define the practice of post-institutional psychiatry, and it remains the most prevalent model today.

The psychopathic hospitals were representative of, and partially responsible for, the significant forces that were changing what psychiatry was, whom it served, and where it was practised at the turn of the twentieth century. Although many of the novel elements of mental health care that arose around this time did not originate in the psychopathic hospitals, such elements were integrated into new psychiatric institutions in ways that would have a lasting effect on the field; in this way, they complicate previous historical accounts that have cited the rise of private practice as a driver of change within psychiatry in this era by demonstrating how extra-institutional ideas were reintegrated into new institutions (see, for example, Scull, 2018). They were, more than either asylums or private practitioners, responsible for elaborating a new argument for psychiatry’s medical and scientific credentials. Also, they laid the foundation for the mental health care system of today. Despite all of this, they have been little studied and often marginalized in the historiography of psychiatry.

The psychopathic hospital: definitions

The psychopathic hospitals took different forms. These institutions were not governed by an overarching body, and they varied in their aims and physical make-up. I use the term psychopathic hospital somewhat loosely – as was the practice at the time – to include a variety of institutions, some of which explicitly described themselves as psychopathic hospitals, and others – like the Phipps Clinic – that were neither called psychopathic nor hospitals, but were self-consciously part of the same movement and responded to the same pressures.

What, then, was the psychopathic hospital? It was an institution that was developed, in many ways, in contrast to the asylums. In this way, the psychopathic hospital was an answer to psychiatry’s critics both inside and outside the discipline. It had many aspects that were designed to differ from, and address deficiencies in, the rural asylum system. In terms of location, the psychopathic hospitals were situated in urban areas, and were intended to serve the needs of the city. Part of the rationale for this was that they were meant to assess and treat less severe mental disorders and incipient cases of more severe ones; to do this effectively, such facilities needed to be as accessible as a city hospital. As Dr Albert M Barrett, Director of the State Psychopathic Hospital at the University of Michigan described:

[T]he field of work that will serve the purposes of the state as a whole will not meet the psychiatric problems that exist in every densely populated community. The density of population with its complicated social situations, the character of problems that are presented to organizations doing welfare work, those that arise in the schools, and especially in the courts dealing with crime and delinquencies, these and many other problems that have become apparent in larger cities during recent years require a special type of institution to adequately carry on the functions of a municipal psychopathic hospital. (Barrett, 1921: 310)

The argument here is that a dynamic social landscape required dynamic treatment, and that state-level institutions could not cater for city-level needs.

This raises several other important points regarding what the psychopathic hospital was and how it changed psychiatry. Firstly, it defined the psychiatric patient differently. In general, asylums and state hospitals were established to provide care and accommodation for the ‘certifiably insane’. These were patients whose mental disorder was severe enough to merit involuntary admission and treatment. In contrast, the psychopathic hospital was established to treat ‘borderland cases’: the swathe of patients who suffered from mental distress yet were not severe enough to merit certification (Clark and Montgomery, 1904). These were typically conceptualized as either early presentations of more severe illnesses – which would benefit from expedited diagnosis and treatment – or cases of sane individuals suffering on account of various stressors. This shift toward less severe presentations, along with less coercive means of treatment, represented a complex interplay of efforts to delineate an arena of professional competence, defend psychiatry’s legitimacy in the face of critics, and enhance its relationship with general medicine.

Secondly, these facilities changed what happened in a psychiatric institution. They represented a conceptual shift away from institutionalization or providing long-term residence to the mentally ill and towards shorter stays focused on diagnosis and acute treatment. In this respect they foreshadowed deinstitutionalization through the process of demedicalizing ‘care and custody’ of the chronically mentally ill in favour of these more targeted interventions (Braslow and Messac, 2018). Indeed, such calls would be made explicitly in the era of deinstitutionalization, such as these made by Dr Harry Solomon in his Presidential Address to the APA in 1958:

If my description is correct and my projections reasonably accurate a new attack on the ‘care and custody’ of the long term ill must be attempted. Unpalatable as it may appear, one must face the fact that we are doing little by way of definite treatment of a large number of our chronic hospital population . . . I tentatively suggest that facilities be established devoted to care and custody of a group of chronically ill individuals for whom, at the present time, we have no clear-cut definitive medical or psychiatric treatment. I suggest that such facilities be planned as a colony or home rather than as a hospital. I suggest that a new discipline be developed for the proper management of these individuals. (Solomon, 1958: 8)

Thirdly, the imitation of – and at times merging with – general hospitals was intentional. The profession was responding directly to criticism of country alienists and their lack of scientific rigour and medical bona fides (Scull, 2018). The psychopathic hospitals therefore sought to associate themselves with general hospitals, universities and medical schools. They focused not only on diagnosis and acute treatment but also on research. They often justified their utility by concentrating on the treatment of mental disorders that had clear causes and thus were more easily understood in medical terms, like alcoholism and tertiary syphilis (Southard, 1913). In this way they sought to insinuate themselves more firmly within general medicine, by responding to the emergence of the general hospital as a medical phenomenon in the early twentieth century and also to psychiatry’s critics.

Indeed, appreciating the radical transformation in the general hospital’s role within medicine is essential to contextualizing the psychopathic movement. As Paul Starr (1982: 145) has noted:

Few institutions have undergone as radical a metamorphosis as have hospitals in their modern history . . . The moral assimilation of the hospital came at the end of the nineteenth century with its scientific redefinition and incorporation into medicine. We now think of hospitals as the most visible embodiment of medical care in its technically most sophisticated form but before the last hundred years, hospitals and medical practice had relatively little to do with each other.

This late nineteenth-century development not only shifted the nucleus of general medicine but set the stage for a major shift in psychiatric practice as well – one that would see the discipline’s centre of gravity move from the asylum to the hospital, where it remains today.

Psychopathic hospitals: a missing page in the historiography

The history of the development of psychiatric practice outside of the asylums has received some attention from eminent scholars in the field. Andrew Scull, for example, contends that extra-institutional efforts by neurologists, ‘disaffected asylum doctors’, Rockefeller Foundation endowments for psychiatry, and the mental hygiene movement all played important roles in ‘the shift away from institutional psychiatry’ in the first half of the twentieth century (Scull, 2018). He also notes the ‘limited role of psychoanalysis during most of this period’ between 1900 and 1950, in contrast to other scholars who have suggested that psychiatry in this period was bifurcated between asylum physicians and psychoanalysts (e.g. Shorter, 1997: 238). Scull does not, however, address the development of the psychopathic hospitals over the same time frame.

Scull (2018: 390) further suggests that ‘[i]n the first three decades of the twentieth century, when . . . psychiatrists working outside the institution looked for an intellectual justification of their daily practice, it was the murky writings of Adolf Meyer, rather than the doctrines of Sigmund Freud, that most of them embraced’. While Scull is certainly correct to note Meyer’s prominence – and that Freud’s ascendance came later – extra-institutional psychiatry was already widespread before Meyer rose to prominence, and justifications for this type of work were quite varied. Furthermore, Meyer was not the first, and far from the only, psychiatrist of the era to promote an eclectic ‘nature and nurture’ theory of psychiatric aetiology and treatment (see, for example, Southard, 1914). His was one of numerous efforts to integrate psychosocial factors with biological ones – hence the twin pillars of maladjustment and ‘psychobiology’. Contemporaries like EE Southard were also arguing for the ‘free interchange of structural and functional concepts’ in addressing psychopathology, in this way offering another argument that psychiatry was both thoroughly medical while remaining attuned to psychosocial factors and historical practices like moral therapy that had been developed in asylum settings (Abraham, 2017). In other words, Meyer was part of the psychopathic hospital movement, and focusing on his individual contributions, important as they are, risks obscuring our understanding of what that broader movement was and how it influenced the discipline.

It is important to note, as well, that Meyer rose to prominence first as director of the New York Pathological Institute in 1902, then as director of the Phipps Clinic at Johns Hopkins, which opened in 1913 – both important institutions in the psychopathic movement. Whereas Meyer’s ideas have largely faded from psychiatry, the legacy of the psychopathic hospitals has not. Indeed, Scull and Schulkin (2009) cite ‘the evanescence of his influence, once he had passed from the scene’, and argue that ‘it was his institutional location, rather than the power of his ideas, which made him so central to what remained at his death a marginal and stigmatized specialty’, referring to Johns Hopkins ‘at a time when it was almost certainly the premier medical school in the United States’ (p. 5). The institution of the psychopathic hospital, in contrast, is very much alive in terms of the degree to which contemporary psychiatric inpatient wards and outpatient departments reflect its structure and ideals. Consequently, there is considerable knowledge to be gained through examination of the psychopathic hospitals beyond what might be appreciated through analysis of individual psychiatrists like Meyer alone.

The limited scholarly work on psychopathic hospitals themselves has tended to focus either on their roots in Germany (Engstrom, 2003: 199–203), or on a single North American institution – such as the book by Elizabeth Lunbeck (1994) on the Boston Psychopathic Hospital (BPH). Lunbeck’s fascinating work, although limited to the BPH, offers a fuller articulation of how psychiatry was changing in the early twentieth century than those ascribing these changes to a single figure. Like Grob, she identifies a discipline undergoing a broad attempt to redefine itself; what she quite crucially points out is that this involved not only the well-known emphasis on science but also psychiatry ‘staking its disciplinary claim to “the normal”’ (p. 47). She suggests that psychiatry was engaged in the parallel processes of claiming a scientific pedigree while also claiming jurisdiction over a wide swathe of new patients and their milder problems. This helpfully frames how the profession was shifting in its attempt to exert its influence in new ways; it also undermines the notion that any one individual was responsible for this shift – highlighting the broader social and professional forces at play. Yet Lunbeck’s work, though illuminating of the local context in Boston, does not provide an overview of the psychopathic hospital movement as a whole.

The same could be said for Susan Lamb’s scholarship on the Phipps Psychiatric Clinic at Johns Hopkins University, which opened in 1913 and operated under the psychopathic model (Lamb, 2012). While intriguing in its own right, the focused scope of such work does not address the broader changes affecting psychiatry in this period. Indeed, Jack Pressman (1997), in his critique of Lunbeck’s work, honed in on this very charge of being exceedingly narrow – only to advance the idea that Adolf Meyer (director of the Phipps Clinic) was the key figure in this transformation – a proposition that, in its own way, obscures both the deeper roots and broader processes that shaped the psychopathic hospitals.

Without detracting from the importance of any of these leading figures or institutions, it is instructive to observe that they were all part of a broader movement; it had begun before their time and it spread wider than any one of them could reach. Indeed, it began on another continent several decades earlier, with changes in German science and statecraft that began in the latter half of the nineteenth century (Engstrom, 2003: 1–15). Another eminent historian of psychiatry, Gerald Grob (1983), has admirably described many of the broader forces that transformed psychiatry, beginning in the late nineteenth century. He deftly analyses the critiques, pressures and changes that led psychiatry to redefine its identity from 1875 to 1940 – the key period in the shift away from the asylums. He notes that ‘[a]lthough members of an established specialty in the late nineteenth century, psychiatrists found themselves under attack from a variety of individuals and groups, including other physicians, social activists, lawyers, state regulatory agencies, and former patients’, which quickly led psychiatrists ‘to redefine the foundations of their specialty’ as one preoccupied with ‘the study and treatment of mental disease rather than the care of individual patients’ (p. 70). He rightly describes the origins of these changes as beginning in the late nineteenth century – before figures like Meyer had risen – and he contextualizes them to a society where ‘states began to reexamine public policies toward all dependent groups’ from the 1860s onward (p. 46). These broad themes – changes in state organization, changes in medical organization, and antipsychiatric social pressures – also reflected developments in Germany in the latter half of the nineteenth century; it has been well established that Germany was the leader and model for North American psychiatry at this time, particularly as regards the psychopathic hospitals (Engstrom, 2003: 199–252). But although Grob (1983) accurately links the transformation of psychiatry in this era to the broad sociopolitical forces noted above, he has little to say about the psychopathic hospitals, with a tendency to focus on the evolution of private practice.

Assessing these varied works that address the psychopathic hospitals in a glancing or circumscribed manner, it seems important to offer an overview of this broad movement. Such an endeavour will allow us to better situate more focused works that examine individual figures and institutions, and will fill in a missing page in the history of psychiatry – one that has in fact played a large role in shaping the parameters of contemporary psychiatric practice.

A false dichotomy

The historiography of psychiatry has often been characterized by a sense of arrivisme, with the writers of a given period heralding the psychiatric advances of the day (or those purportedly just around the corner) as the true scientific psychiatry that contrasts with the dark era of the past (Lunbeck, 1994: 6). This is as applicable today as it was to the leaders of the psychopathic movement more than a century ago. Interrogating this tendency facilitates the dual task of avoiding a blind spot in the literature while also developing an understanding of the problems that precipitated it – problems that the psychopathic movement sought to resolve.

Braslow (2000) has noted this tendency in his observation of the way psychiatry’s history was written in the context of the very different dominant paradigms of the 1940s and the 1990s:

Histories of psychiatry often have found themselves tightly linked to these gyrations in psychiatric theory and practice, yet many of these works tell us little about the nature of clinical care. Spanning the last fifty years of psychiatric historiography, Gregory Zilboorg’s 1941 History of Medical Psychology and Edward Shorter’s 1997 History of Psychiatry: From the Era of the Asylum to the Age of Prozac exemplify this particular genre, falling far short of illuminating the contemporaneous practices that have so strongly influenced them. Writing on the eve of psychoanalytic hegemony, Zilboorg chronicles a story that leads inexorably toward the triumph of psychoanalytic truth and largely ignores what he saw to be the blind alleys of biological psychiatry. Not surprisingly, given the revitalization of biological psychiatry, Shorter, more than fifty years later, has turned this history on its head: for him, psychoanalysis was an ill-begotten detour into pseudoscience, while contemporary biopsychiatry has been the inevitable outcome of psychiatric science and practice. (pp. 795–6)

Although Shorter’s book is now 25 years old, biological psychiatry continues to be the dominant paradigm in the field, and his account of psychiatry’s march toward biology continues to hold its appeal, even if its deficiencies have been identified by certain scholars. Yet perhaps more significant than the struggle to situate this account within its own historical moment is the fact that the psychopathic hospitals do not figure in Shorter’s rendering of psychiatric history – this, in spite of their importance in elaborating a new type of psychiatry that worked hard to reconcile what he appears to view as irreconcilable: the psychosocial with the biological.

Indeed, as Braslow has highlighted, Shorter viewed early twentieth-century psychiatry as locked in a battle between two opposing trends. Shorter (1997: 238) writes:

For half a century, the discipline of psychiatry stood trapped between the choices of custodial care and individual psychoanalysis. Forced to come up with alternatives, psychiatry cobbled together a band of options ranging from bromide sleep to ECT to social clubs. So desperate were workaday psychiatrists to dodge the awful choice between custodialism (for the poor) and psychoanalysis (for the rich), that they were willing to try anything that held promise. Thus for half a century, the discipline of psychiatry averted choosing between the neurobiological paradigm on the one hand and the psychogenic paradigm on the other. After the 1960s, this kind of pragmatic eclecticism no longer became possible. The neurobiological paradigm came roaring back from the grave in which Kraepelin had interred it – with medications that truly worked and evidence that psychiatric illness represented a biological phenomenon far deeper than troubled human relations or a schizophrenogenic mother. The alternatives of the first half of the twentieth century were almost all wiped from the slate by the advent of the second biological psychiatry.

While there is certainly truth in the position that there were different treatments available to different social classes, such history evokes a Hegelian telos of progress that skirts as many important questions as it answers. It takes a clearly pro-‘biological’ stance and sets up a purportedly non-biological strawman as the vanquished party in psychiatry’s beleaguered but ultimately successful quest to rejoin the ranks of medicine and offer chemical solutions for ‘a biological phenomenon’. Yet what is more significant about this view than its reductionism or its failure to assess the psychopathic movement is the degree to which it recreates psychiatry’s longstanding tendency to trample the past in an effort to stand taller in the present. Indeed, such narratives were in use well before Zilboorg in the 1940s, and they played a role in how psychiatrists in the early twentieth century sought to distinguish the psychopathic hospitals from the asylums. Lunbeck (1994: 48), in her monograph about the Boston Psychopathic Hospital, describes this phenomenon:

Determined to inhabit the scientist’s persona, psychiatrists regularly engaged in the ritualistic slaying of their forebears as they unburdened themselves of a disciplinary heritage that they argued was embarrassing, informed by superstition, and unscientific, tainted by association with its poorly trained practitioners, the alienist-administrators. Presiding over what they imagined was psychiatry’s rebirth, they cast the moment as one of disciplinary discontinuity, playing down what they owed to their predecessors.

This ‘scientist’s persona’ did not have to await the psychopharmacological inventions of the mid-twentieth century to find form; it was alive and well in 1900. Indeed, in contrast to Shorter’s view, we might note Braslow’s assertion that, far from feeling ‘trapped’ or resorting to solutions that were ‘cobbled together’, psychiatrists of the early twentieth century felt themselves to be endowed with modern and effective treatments. He notes:

Although it has been argued that psychiatrists entered the modern era with the introduction of shock therapies and lobotomy in the 1930s and antipsychotic drugs in the 1950s, practicing psychiatrists of the 1910s and 1920s did not feel that they were practicing in the dark ages of therapeutics. (Braslow, 1997: 52)

On the contrary, these turn-of-the-century psychiatrists felt that they were living through an era of psychiatric practice that was exciting, dynamic and scientific. PM Wise, incoming President of the American Medico-Psychological Association (the forerunner of the American Psychiatric Association), summed up the attitude in his 1901 inaugural address when he remarked that ‘[w]e are on the threshold of a great epoch, and [stand] at the entrance to a century which promises so much, after our farewell to the greatest century of the world’s history’ (Wise, 1901: 79). The mood was not of stagnation and desperation, but of hope and progress. Indeed, Dr Wise forcefully rebuked critics who pushed a narrative of stagnation, addressing their bleak, and in his view misguided, view of psychiatry head on:

It is often charged against our special branch of medicine that, in many respects, we have made no advance in the last hundred years. A representative journal recently stated that ‘our knowledge of the essential nature of insanity, of the causes which foster and produce it, of the means by which it might be prevented and cured, is scarcely greater now than it was a hundred years ago.’ This shows crass ignorance . . . the most perverse pessimist must admit that the century has done for insanity in its practical aspect what the previous millennium failed to do. It has been established that insanity is primarily and essentially a disease of the body or rather a manifestation of such disease; that mind function has a physical basis; that the mental phenomena known as insanity is therefore a physical disorder. (p. 84)

It is also worth noting here that, whereas some scholars have ascribed the idea that mental illness was biological to the popularising works of Adolf Meyer, these concepts were already widespread in the psychiatric community before Meyer rose to the forefront of American psychiatry as director of the New York Pathological Institute in 1902 and then the Phipps Psychiatric Clinic at Johns Hopkins University in 1913. Indeed, Wise was not an outlier in his perspective. In 1903, the new President of the Association, Dr G Adler Blumer, commented in his inaugural speech that ‘[n]ever has there been a time . . . when the mental invalid has been better housed and more intelligently treated’ (Blumer, 1903: 12). Such intelligent treatment included both new institutional settings – like the ‘new departments for the insane in general hospitals and our so called psychopathic hospitals’ (p. 12) – and new clinical and laboratory interventions that were viewed as being on the cutting edge of medicine and science. Thus, in contrast to Shorter’s contention that psychiatry was dismayed and disorganized until the ‘second biological psychiatry’ enjoyed a revival from the 1960s onwards, psychiatrists of the early twentieth century felt themselves to be operating in an era ‘big with promise’ and full of innovation. The purported discontinuity between the ‘first’ biological psychiatry of the German neuropathologists like Alois Alzheimer in the nineteenth century and the psychopharmacologists of the late twentieth century is misleading; indeed, the psychopathic hospital is a good example of the ways in which these eras – along with the supposed gulf between psychosocial and biological camps – were bridged.

What accounts for this discrepancy? Shorter, despite his erudition, has perhaps in some ways recapitulated psychiatry’s longstanding empiricist tradition of condemning the discipline’s misguided past while lauding its newfound footing and future prospects. Ironically, this is precisely the historical framework utilized by the very early twentieth-century psychiatrists whom Shorter places in the centre of his narrative about a psychiatric Dark Age. In this light, Shorter’s contention could be understood as a further iteration of this age-old psychiatric narrative. Given the chronicity of this position within psychiatry’s self-concept, we are beckoned to explore the function of this psychiatric Bildungsroman. What is it about psychiatry that leads its practitioners to spurn the past, elevate the present, and glorify the breakthroughs that are, no doubt, just around the corner? Also what, if anything, does this tell us about the history of deinstitutionalization and psychopathic hospitals?

We can usefully reflect on Shorter’s words regarding Kraeplin’s ‘interment’ of biological psychiatry. By this, Shorter refers to the great psychiatrist’s proclivity for clinical, rather than laboratory, study. However, there is a strong theme of reductionism in this line of argument. Kraeplin was in large part the originator of the diagnostic concepts of bipolar disorder and schizophrenia – the two most significant severe mental illnesses. The very research apparatus that supports the ‘neurobiological paradigm’ espoused by Shorter is based on this nosology – a state of affairs that has only begun to be challenged within the past decade (Cuthbert and Insel, 2013). The waters, it seems, are far murkier than Shorter would allow with respect to what is biological and what is not. The history of the psychopathic hospital movement has been obscured by this kind of reductive thinking. Yet in many ways the movement itself represents an attempt to answer this very question. The early advocates of the psychopathic hospitals sought to grapple with the messy problem of medicalizing psychiatric practice in an era during which the practice of medicine writ large was undergoing profound transformation, and psychiatry’s place in the new order was anything but certain. Yet in contrast to what scholars like Shorter might suggest, the leaders of psychopathic hospitals sought to promote their scientific and medical identity in ways that preserved, rather than denigrated, the psychological and sociological aspects of psychiatric work.

In summary, this Manichean manner of understanding early twentieth-century psychiatry’s intellectual dynamic could not be further from the truth. Instead of being locked in a dismal dilemma between psychoanalysing the rich (who are implied to be not sick) and warehousing the poor (who are implied to be unaltered by the effort), we see in fact a much more nuanced and synthetic movement afoot. In the psychopathic hospital, we witness the example of psychiatrists who passionately embraced science, who fought to bring psychiatry tight to the bosom of general medicine, and who jettisoned the asylum in favour of the hospital. Yet they also championed many of the things that are so often cited as constituting the antithesis of the biomedical model: enlarging the scope of patients within the psychiatric purview to include higher functioning individuals (i.e. ‘neurotic’ patients); embracing allied professions like social work in recognition of the importance of social factors in psychiatric illness; and asserting expertise over a vast array of less severe symptoms that were ‘part and parcel of what was for many the dreary business of making it from one day to the next’ (Lunbeck, 1994: 81).

The psychopathic hospital: a building of ideas

Not only was the psychopathic hospital the institutional forebear of contemporary psychiatric institutions, but its history can also serve as a lens for observing the discipline’s reorganization during this era. It was an institution, established in North America by the early twentieth century but based on a German model of the late nineteenth century, that eroded the simplistic dichotomy of pre- and post-biological interventions. In doing so, it undermined the idea that deinstitutionalization was simply the corollary of the new biological means of patient management. As Lunbeck (1994: 3) states, ‘[i]n the early years of the twentieth century . . . American psychiatry was fundamentally transformed from a discipline concerned primarily with insanity to one equally concerned with normality, as focused on normal persons and their problems as on the recognized insane’.

Although this psychopathic model first emerged in Germany in the second half of the nineteenth century, it attracted contemporaneous attention in North America. The first publication on ‘The psychopathic hospital of the future’ appeared in 1867 in the American Journal of Insanity (Earle, 1867). By the 1890s, efforts were afoot to build the first psychopathic hospitals in the USA, and in 1895 the New York Pathological Institute was founded, although this urban psychiatric research facility did not have any beds (van Gieson, 1898: 1–7). In 1902, the first psychiatric ward in a general hospital in the USA was established: Ward F at Albany Hospital under the direction of J Montgomery Mosher (1909). In 1906, the Michigan State Psychopathic Hospital was established (Anon., 1908), and in 1912 the Boston Psychopathic Hospital opened its doors (Lunbeck, 1994: 11). In 1913, the Phipps Clinic at Johns Hopkins was inaugurated (Stephens et al., 1986: 747). The movement then quickly spread across the country and beyond. By 1919, the Winnipeg Psychopathic Hospital had opened its doors – the first in Canada (Hendrie and Vasarmis, 1971: 185). It was followed by the Toronto Psychiatric Hospital and the Clinique Roy Rousseau in Quebec City, both established in 1926 (Stokes, 1967: 521). Gradually, psychiatric wards in general hospitals, as well as urban psychiatric institutions affiliated with hospitals and universities, became commonplace. The adjective ‘psychopathic’ faded away, just as the type of psychiatric practice it described became ubiquitous. This was the infrastructure that had been elaborated over half a century at the time that deinstitutionalization is commonly understood to have begun.

Many psychopathic hospitals and their leaders were engaged in a project not only of creating a new setting for care but also of catering to a new kind of patient – and thus creating a new kind of psychiatry. In the 1908 Biennial Report of the Michigan State Psychopathic Hospital – the first such hospital in North America, opened in 1906 – it was asserted that ‘[t]he Psychopathic Hospital is an institution for the treatment of mental conditions bordering on insanity’ (Anon., 1908: 6). It was further elaborated that ‘those who are suffering from psychopathic conditions’ could be defined as ‘those who are mentally disturbed but who are not insane’ (p. 6). The psychopathic hospital was not just a new kind of institution; it was aimed at a new kind of patient.

Although the psychopathic hospitals may not have represented the first attempt to bring such patients to medical attention, they nonetheless performed the delicate work of making space for these ‘disturbed’ individuals in an insanity-focused psychiatry while concurrently endeavouring to bolster the scientific bona fides of the field. Thus, the Michigan Psychopathic Hospital was not only intended to aid those who were disturbed but not insane, but also to be a centre for clinical and laboratory research: ‘One of the chief purposes of the Psychopathic Hospital, as stated in the statutes, is to carry on “research in the phenomena and pathology of mental diseases”’ (Anon., 1908: 6). Such institutions were, furthermore, typically intended to serve as teaching sites for medical schools, in a further effort to broaden physicians’ exposure to psychiatry and cement the discipline’s place within the medical field. As noted in its annual report:

The State of Michigan has the creditable position in the history of psychiatry in America of being the first to establish a University Hospital, for the care and treatment of mental diseases; and of providing adequate facilities for the instruction of medical students of the University regarding insanity. (p. 8.)

Intellectual interest in psychopathic hospitals began with their contemporaneous development in Germany in the 1860s and became much more elaborate in the first decade of the twentieth century (Earle, 1867). In the 1904 issue of the American Journal of Insanity, for example, a detailed rationale and plan for psychopathic hospitals in American cities of all sizes was described by L Pierce Clark, a psychiatrist who would later serve as President of the American Psychiatric Association (APA); his co-author was the architect who had collaborated on the designs. Such facilities were rationalized in the following manner:

The underlying causes for creating special mental clinics or city asylums in German cities were the same as with us, namely, the urgency of early care of the acute insane, the remoteness of the great country district asylums, and the formality and delay of admissions to these hospitals. Moreover, there was pressing need for public provision for the psychoneuropath, the hysterical, epileptic, alcoholic and borderland cases of insanity not certifiable, yet in need of prophylactic psychopathic treatment. It has been amply proven that observation and careful adjustment of broad principles of treatment to this large class of psychoses and neuroses have resulted in a marked diminution in the demand for so many private sanatoria which, as with us, are only too often impossible for the poor. At Giessen in 1896, 6.5 per cent of the total admissions were not of the class of certifiable insane, and in five years it increased to 23 per cent. Increased attention to this class is very much encouraged for obvious reasons. (Clark and Montgomery, 1904: 2)

Such facilities were intended not only to serve neurotic and other less severely impaired patients, but also to execute several other important functions, each of which constituted an argument for the relevance of psychiatry to contemporary medical care (and a response to critics). The first was that the psychopathic hospitals could serve a number of conditions that were more readily seen as ‘medical’ than many other psychiatric disorders, such as epilepsy and alcoholism. The second was that they constituted a public service – and one that was non-coercive, serving as it did the population of non-certifiable patients – for those patients who would otherwise have to seek care in a private setting.

Not only were some of the illnesses addressed given a more medical valence, but the treatment too was seen as highly scientific and organized, with the promotion of hydrotherapy, electricity, and nutritional therapy, together with behavioural strategies. While it has been argued that the first physicians to address this population of subacute patients were the neurologist and general practitioners operating in the outpatient setting (Scull, 2018: 390), it was the psychopathic hospitals that elaborated a framework for integrated inpatient and outpatient care for this, or indeed any, psychiatric population:

The interior arrangement of the hospital permits a convenient classification; open observation wards for acutely disturbed cases; permanent baths for the maniacal; hydrotherapy and electricity and special diets for all cases. Those patients who need to go about a great deal, more than the limited confines of the gardens permit, should either be discharged as sufficiently convalescent to return to their homes for an out-clinic observation and care, or, if still in need of restricted liberty, should be sent to a state hospital. (Clark and Montgomery, 1904: 7)

Such attempts at furthering psychiatry’s scientific bona fides were not isolated to Clark’s writings. EE Southard, the first director of the BPH which opened in 1911 (and the first President of the APA not to have been an asylum superintendent), described the work of the psychopathic hospital in equally biomedical terms:

There is, however, a possibility of novelty for us in this field, as some forthcoming work by H.M. Adler, Chief of Staff of the Psychopathic Hospital, will show. He has secured a quantitative record in the red blood-cell count of the effects of prolonged baths. In certain instances he has been able to predict the probability of an excitement in a patient by observation of oncoming cyanosis. (Southard, 1913: 1973)

While extolling their scientific virtues, these institutions sought at the same time to promote the social and psychological aspects of mental illness and its treatment – thus embarking on an attempt, ongoing to this day, to situate psychiatry in the liminal space between art and science. In the same article, Southard goes on to state:

In the first place, let me insist that far too little stress has been laid in this country on sociologic and psychologic matters in their relation to medicine . . . I conclude that the outpatient and social service relations of a psychopathic hospital must be among its most important functions. (p. 1973)

Such efforts to join together the biological with the social and psychological in the understanding of psychiatric disorders are often attributed to Adolf Meyer, who certainly came to be the most prominent American psychiatrist from the 1910s to the 1940s (Lamb, 2014: 1). Although Meyer was a great populariser, and he did coin the nebulous term ‘psychobiology’ sometime around 1908 (Abbott and Egloff, 2008: 244), to attribute such efforts to him is to reason backward from his later popularity. In truth, as Lunbeck (1994: 3) has noted, ‘[a]ligning themselves with science and the forces of progress, a number of early-twentieth-century psychiatrists envisioned greater possibilities for their speciality and set out to remake it’. There was, in other words, a larger group of psychiatrists grappling with the very issues of how to marry psychiatry’s humanistic elements with the medicalizing imperatives of the early twentieth century. For example, Charles P. Bancroft, Medical Superintendent of the New Hampshire State Hospital and President of the APA, outlined these same intersections in his 1908 inaugural address:

Psychiatry is no longer a circumscribed field. Neurology, psychology and sociology are now closely related with psychiatry. As mind is the latest and most perfect expression of evolution in the universe, so the study of its morbid variations must necessarily concern every part of the nervous system through whose functioning its present evolutionary attainment has been reached. As mind is modified by environment, so social conditions become identified with and oftentimes responsible for its morbid manifestation. The psychiatrist cannot afford to neglect the science of sociology in his study of the cause, development and treatment of mental diseases. Psychology is assuming an increasingly important position in psychiatry, because, dealing as it does with mental processes, it enables the psychiatrist to apply the principles of normal psychic laws to the operations of diseased mind and thereby form a clearer conception of the complex mental phenomena of the insane mind that underlie abnormal conduct. (Bancroft, 1908: 2)

In other words, the interest in the biological, psychological, and sociological factors at play in psychiatric disorders was not the work of a single individual, but rather the hallmark of a movement. As Bancroft went on to describe in the same address, the site where such work could take place was the psychopathic clinic:

The establishment of psychopathic wards and pavilions in connection with general hospitals in the large metropolitan centers, as in Germany, France and Italy abroad, and in New York at Bellevue, and Pavilion F at Albany, is another evidence of the tendency toward the realization of the hospital treatment of the disease. But especially noteworthy is the connection of psychopathic wards with general hospitals in cities that contain one or more medical schools, because of the facility such association gives for the better clinical instruction of the medical student in the acute psychoses . . . the movement has been inaugurated and in the no distant future [sic] such special wards will, I believe, become a feature of general hospitals in the larger cities. (p. 3)

By the turn of the century, such psychopathic institutions were emerging in various locations throughout the USA. As alluded to above, there were ‘observation wards’ at Bellevue Hospital in New York City, which had constructed a ‘pavilion for the insane’ in 1879 and an ‘alcoholic ward’ in 1892 – before ultimately constructing a new Bellevue Psychopathic Hospital in 1931 (Hilton, 2021). JM Mosher established Pavilion F, the first psychiatric ward in a general hospital, in Albany in 1902 (Mosher, 1909). Similar institutions began popping up in other cities in the early years of the twentieth century.

Consequently, while Meyer was ‘[b]y common consent . . . the most prominent and influential American psychiatrist of the first half of the twentieth century’ (Scull and Schulkin, 2009: 5), it is important to note that some of his signal ideas were iterations of existing concepts with which the field as a whole was grappling at the turn of the century. This distinction is important because it points towards the broader causes of change within psychiatry. These would include the pressures of neurologists and general practitioners, the antipsychiatry movements of the late nineteenth century, the increased oversight and organization of social welfare including asylums, as well as intellectual and structural changes within medicine, such as the emergence of the modern general hospital and the development of antibiotics (Engstrom, 2003: 88–120; Grob, 1983: 70; Scull, 2018). It also points towards the institutional answer to these pressures that sought to bring psychiatry into the twentieth century.

The institution that was developed to advance this new form of psychiatry – at once laying claim to the scientific mysteries of medicine and the prosaic problems of everyday life – was the psychopathic hospital. Bearing in mind Shorter’s contention that Kraeplin was largely responsible for the decline of what he terms the ‘first biological psychiatry’ in the late nineteenth century, it was perhaps ironic that these institutions were modelled on the German example, especially Kraeplin’s clinic in Munich. As Lunbeck (1994: 11) writes:

In June 1912, the Boston Psychopathic Hospital formally opened its doors, signifying to the city’s reform-minded psychiatrists that their profession had come of age. An imposing, four-story brick building modeled on the German psychiatrist Emil Kraepelin’s Munich-based clinic, the hospital represented in concrete form all that was new in psychiatry. It was, in the estimation of its proponents, closer in conception, design, and operation to the general hospital than to the isolated, overcrowded, and scientifically backward asylum.

While the psychopathic hospital was moving psychiatry ever closer to the model of general medicine – and placing it in closer and more frequent contact with other kinds of physicians and institutions – the leaders of these new psychiatric centres were simultaneously promulgating the paramount importance of psychological and social factors. Indeed, Adolf Meyer, who coined the term psychobiology to emphasize the importance of psychological and biological factors in mental illness, and who is considered to have influenced the emergence of the biopsychosocial model (Wallace, 2007), was one of the most ardent champions of the psychopathic movement. In a 1907 paper entitled ‘Reception hospitals, psychopathic wards, and psychopathic hospitals’, Meyer argued for the need for improvement in the care provided to the mentally ill, and remarked that:

among all the plans of improvement the most forcible has been for some years that of obtaining psychopathic hospitals or hospital wards in or close to the cities, similar to the European university clinics and city asylums. Dr. Frederick Peterson has been among the first to advocate measures of relief with his proposition concerning psychopathic hospitals. In Ann Arbor the late Dr. J. J. Herdman, and in Albany, Dr. M.J. Mosher actually achieved a solution; many other localities are seriously interested in the matter, so that to-day the problem is one of the most actual and commanding the greatest attention. (Meyer, 1907: 221)

In this light, it appears that the story of the conflict between psychiatry’s psychological and biological wings is not defined by the latter’s victory over the former, but by a false premise – or at least an exaggerated and misleading one. Even a century ago, some of the most prominent, and most ‘biological’, psychiatrists in America were pointing out the falseness of this dichotomy. Indeed, as Dr Southard, Director of the Boston Psychopathic Hospital and Professor of Neurobiology at Harvard, remarked in a 1914 article:

For my part . . . I feel that somehow the hypotheses which for better or worse I was fain to describe as the mind twist and brain spot hypotheses are in some sense and in the long run identical hypotheses . . . for the explanation of certain forms of mental disease are entirely consistent with each other, since from a different angle each is dealing with the same facts. (Southard, 1914: 118)

These terms, as one might intuit, refer to ‘the distinction between those who uphold the hypothesis of psychic factors as opposed to those supporting the hypothesis of encephalic factors’ in the aetiology of mental disorders (p. 117).

Although the Boston Psychopathic Hospital, where Southard was director, was among the leading North American institutions championing this type of practice, it was far from an isolated case. Indeed, Meyer was a strong proponent of this kind of integrated, pragmatic approach, first at the New York Pathological Institute and then at the Phipps Clinic at Johns Hopkins. As noted in the quotation above, he was also in the company of other like-minded physicians such as Dr Herdmann and Dr Mosher at Ann Arbor and Albany, respectively. Other psychopathic hospitals would soon follow, with missions that sought to marry the medical model to clear sociological concerns. For example, the Winnipeg Psychopathic Hospital of 1919 was also established to meet a set of objectives that read as highly contemporary, as listed by Hendrie and Varsamis (1971):

• 1) To minimize the stigma attached to mental illness.

• 2) To treat ‘early recoverable’ cases and so prevent prolonged institutionalization and chronicity.

• 3) To relieve mental hospitals of overcrowding.

• 4) To be a centre of psychiatric teaching and research.

Rather than a psychiatry that is adrift, waiting for modern psychopharmacology to rescue it from obscurity, this is psychiatry in recognizable form, and with a clear agenda to insinuate itself more closely into the fabric of medical science and into society more generally. As in Boston, the Winnipeg facility was placed in the heart of a large city, rather than in a pastoral setting, where the asylums had typically been located. This choice had multiple meanings; it can be understood as a repudiation of moral therapy, a nineteenth-century notion of the bucolic setting’s restorative power. It declared that mental illness was not to be hidden from view, but instead that it was a greater part of life than had yet been accepted. It affected not just those whose impairment was severe and chronic, but also the ‘early recoverable’ – those whose illness was less entrenched and perhaps less severe. It asserted that, unlike mediaeval and early modern binaries of madness versus sanity, mental illness could coexist with mental wellness, much as the body could fall prey to an infection and then be cured. Indeed, the psychopathic hospital ideal was imbued with the notion that psychiatric disorders were medical issues with physical foundations, as noted above by Southard, while also paying heed to psychosocial factors.

Conclusion

The psychopathic hospitals are important for several reasons. They developed the template for contemporary psychiatric practice. They constitute an important part of psychiatry’s turn away from the asylums, thus setting the stage for deinstitutionalization. They shifted and enlarged the scope of psychiatric care. They served an important integrative function, combining inpatient and outpatient treatment models, and joining biological and psychosocial perspectives. They also offer a lens through which to understand the broader social changes and developments within medicine that were taking place at the time, and to which psychiatry was responding.

They demonstrate also that, in contrast to the assertions of certain scholars, the first half of the twentieth century was not an off-piste adventure down a dead-end road, a series of jettisoned misadventures that gave way to the scientific salvoes of 1960s psychopharmacology. It was, instead, a period of intense transformation and synthesis, one that both established the boundaries of contemporary psychiatric practice and sought to absorb and integrate seemingly disparate branches of psychiatric knowledge – bringing psychotherapeutic and biomedical approaches closer together, rather than driving them apart. Given their important role in these transformative and synthetic efforts, the psychopathic hospitals merit further study. They are more significant, and their effects more enduring, than any one psychiatrist, however prominent. Their neglect in the literature is unwarranted and obscures our understanding of the very institutions and practices of which contemporary psychiatry is comprised.