Slavery and Its Afterlives in US Psychiatry

Abstract

Antecedents of racist treatments of Black patients by the psychiatric profession in the United States affect the way they view treatment today. Specifically, in this essay, we explore the enduring consequences of racial science on various treatment practices.

We examined a range of primary sources on the history of racial theories about the mind, medical and psychiatric publications, and hospitals. We contextualize this analysis by examining the secondary literature in the history and sociology of psychiatry. Through analyzing racial thinking from the antebellum through the Jim Crow periods, we show how US medicine and psychiatry have roots in antebellum racial science and how carceral logics underpinned the past and present politics of Black mental health.

Changing this trajectory requires practitioners to interrogate the historical foundations of racist psychiatric concepts. This essay urges them to reject biological racial realism, which bears reminiscences to 19th-century racial science, and embrace the variable of race as a social construct to study social inequalities in health as a first step toward moving away from the legacies of past injustices in medicine. (Am J Public Health. 2024;114(S3):S250–S257. https://doi.org/10.2105/AJPH.2023.307554)

In the early afternoon of May 1, 2023, Jordan Neely, a 30-year-old Black man, was strangled by a White ex-Marine in a subway train in New York City. As documented in the press, Neely suffered from mental illness and was unhoused for years. In New York City, mentally ill people can be forcibly remanded to hospitals, as was done to Neely on several occasions. During the winter before his death, Neely disappeared from an inpatient treatment center. Three months later, he was killed. This last stop in a psychiatric facility reveals enduring connections between incarceration and mental health care, as Neely’s admission was part of a plea deal. Likewise, the deluge of police-involved killings of mentally ill Black people such as Daniel Prude in 2020 shows the cumulative effect of racial marginalization and mental illness on the likelihood of being subjected to law enforcement officers’ use of force.¹ It also exposes the porous boundaries between mental health and racialized carceral logics in the United States (i.e., the systematic and disproportional selection of racialized individuals for punishment). Following the definition previously given by social scientists who study racialized discipline, we also define carceral logics as having an impact on representations and practices broadly in society, beyond state institutions.²

Neely’s killing is not a singular, disconnected episode of violence. Indeed, examining the intersection between mental health and racialized carceral logics unveils a structural continuum of subjugation evidenced by a long history of oppressive treatment toward Black patients in US psychiatric care. This historical review requires returning to 19th-century medical theories and practices to show how physicians systematically “naturalized” Black persons as an intellectually inferior laboring class during the antebellum era. Along these lines, we ask how 19th-century racial science connected carceral logics to Black mental health and how this symbiosis still underpins the psychiatric stereotypes and contemporary treatments of Black patients.

Through an examination of the antecedents of racist treatments of Black patients by the psychiatric profession, we support four statements with specific historical or contemporary evidence. Analyzing discourses on undeservingness, inferiority, and labor, we offer evidence that the long-term connections between carceral logics and Black mental health solidified because of (1) the historically chronic underfunding of Black mental health services from the 19th century onward based on the underlying stereotype of Black patients as “undeserving poor,” (2) the dissemination of theories in craniometry about Black people’s inferior intelligence, (3) the institutional use of racialized forced labor to treat and “cure” Black people’s mental health in public hospitals from the 19th century onward, and (4) the reactivation today of beliefs in biological racial realism and genetic racial differentialism in expert and lay circles.

HISTORICAL CONTINUITIES OF INCARCERATION AND AUSTERITY

In the media, Neely’s case has been analyzed as a system failure. As New Yorker journalist Adam Iscoe argued, “police and corrections officers became de-facto mental-health-care providers, one 911 call at a time.” As noted, Neely had been forcibly hospitalized on several occasions. Indeed, as Neely was unhoused and not being treated at the time of his death, his social and medical trajectory exemplified institutional neglect and systemic racism at a microsocial scale. This dynamic can be interpreted as the direct result of the systemic underfunding of New York’s mental health services since the 1950s, despite lawmakers’ repeated but never-fulfilled promises to provide community-based outpatient care to those most in need.³

Neely’s case also highlights another deeply connected dynamic: the systemic reciprocity between the underfunding of public psychiatric services across the United States and the rise of the carceral state—namely, the alarming growth of the prison population and criminal justice offenses targeting Black individuals.⁴ Sociologists such as Loïc Wacquant have addressed the rapid growth of the prison population in tandem with the racialization of the carceral system. This trend parallels the chronic lack of public assistance for disinherited, Black, mentally ill patients who, instead of being cured in hospitals, end up in the criminal justice system.⁵

Racialized populations live in communities subject to chronic disinvestment and lack access to outpatient care, which stands as the majority setting for most mental illness treatments in the United States.⁶ Through the emergence of a new “government of social insecurity,” Wacquant shows how racialized populations in the United States were seen as not “playing by the rules of white, middle-class society” and labeled as not deserving of assistance, the “undeserving poor.”⁷ This chronic lack of public assistance contributes to the overcriminalization of “undeserving” Black Americans, as the lack of access to curative institutions often forced them into punitive ones. Wherever public assistance was denied to Black patients, they entered punitive institutions. They were moved from the “left hand” to the “right hand” of the state, their behavior being criminalized and deemed uncurable.⁸

The rise of carceral logics parallels the demographic trend of deinstitutionalization that many historians of psychiatry have analyzed since the 1960s.⁹ Deinstitutionalization happened for various reasons, including assumptions that community mental health would replace state hospitals with a more humane approach. However, deinstitutionalization has had the reverse effect, withdrawing public assistance for vulnerable populations.¹⁰ Yet, this history of chronic lack of public assistance for Black patients and labeling them as “undeserving” has roots in the 19th century. Indeed, in the antebellum era, enslaved people suffering from mental illness received little care, and their institutionalization was determined by enslavers’ willingness to pay hospital fees.

In antebellum society, enslaved people were forced into a state of “social death” (i.e., not considered as fully human). Their social and mental status were not regarded as worthy of care, and, therefore, they were seen as “undeserving.” Enslavers only considered enslaved people’s mental condition when it impeded the amount of unpaid labor they could perform.¹¹ As a consequence, in the antebellum era, mentally ill enslaved people were forced to continue working or, if perceived as dangerous for others, were locked away in local jails, as documented by historian Peter McCandless.¹² This dynamic shows the symbiosis between carceral logics and Black mental health well before 20th-century trends in mass incarceration.

Similarly, these racialized carceral logics found new life after the Civil War. As most Black freedmen and freedwomen resided in Southern counties and parishes, new financial debates arose concerning the mental care and public assistance made available to them. Some institutions such as the Central Lunatic Asylum for Colored Insane in Virginia were funded by Reconstruction Era (1865–1877) state legislatures. Newly elected Black legislators fought to provide public assistance to this vulnerable population. Opening in 1869, this institution became the first in the country to host Black patients only.¹³ However, as Southern states gradually implemented the segregationist Jim Crow regime after 1877, opening public institutions for Black citizens caused public controversy. White legislators in Virginia and North Carolina opposed the funding of institutions that provided public assistance for Black people, lamenting the costs inflicted upon White taxpayers.¹⁴

Antitaxation ideologies and the racialization of public support have long-lasting legacies in the US South. As historian Romain Huret argues, in the immediate wake of the Civil War, the North Carolina legislature hotly debated African Americans’ citizenship status and sought to refuse them public assistance.¹⁵ Public discourse among Whites reflected this further. Local newspaper editorialists reacted furiously to the collection of newly established federal taxes by Radical Republicans, who aimed to protect African Americans’ emancipation and provide basic services through the Freedmen’s Bureau.¹⁶ Furthermore, antitax rhetoric proves how carceral logics and racialized discourses on the “undeserving” poor was tied to the politics of mental health care in the 19th century.

THE CONTEMPORARY INFLUENCE OF 19TH-CENTURY THEORIES

The symbiosis between carceral logics and Black mental health is also connected to the history of racism in psychiatry and medicine throughout the 19th century. While medical and scientific theories of race extend back to at least the 17th century, prominent antebellum physicians disseminated novel theories about Black people’s intelligence and psychological traits as a justification for enslavement in the 1850s. These theories also supported distinctive carceral logics, confining Black people to agricultural labor in the US South.

While originating in a different social and political context, these theories can be interpreted as historical antecedents for the politics of neglect and coercion central to Jordan Neely’s death. In his popular science blog, psychiatrist Awais Aftab contended that Neely’s death could be analyzed as “illustrative of sanism,” which can be defined as “an irrational prejudice against people with mental illness,” who are defined by psychiatrists and lay circles as “erratic, deviant, sexually uncontrollable, emotionally unstable, superstitious, lazy, and ignorant” and demonstrating “a primitive morality” in mainstream society.¹⁷ As a matter of fact, these stereotypes coincide with negative representations of Black hypermasculinity as featured in newspapers such as The American Conservative, targeting Neely specifically.¹⁸ Calling Neely a “bothersome street performer,” senior editor Declan Leary argued that Neely “behaved irrationally, even viciously.” Leary’s stance provides an almost perfect application of sanism and the stereotypes of innate dangerousness associated with Black males in modern society.

These arguments also strikingly resemble racial science and the carceral logics propelled by polygenesis in 19th-century medical circles. Polygenists theorized that each “race” was created for and in different climates, constituting separate species. In tandem, craniometry was the influential anatomical science of the intellect that anatomists saw as proving polygenesis. Craniologists, like the influential anatomy professor Samuel George Morton, collected skulls, organized them by race, measured their cranial capacity, and created an average of the measurements. Morton drew upon many antebellum medical advancements. It was anatomical in nature. It relied on specialized instrumentation and medical statistics. Thus, craniologists created a science influenced by many defining features of antebellum medical progress.¹⁹

Craniologists also influenced medical education.²⁰ For example, in 1861, University of Pennsylvania anatomy professor Joseph Leidy published his influential anatomy textbook, An Elementary Treatise on Human Anatomy. In this and later editions, Leidy discussed supposed cranial differences dictated by race. He asserted that White people had the largest cranium. Elsewhere, he claimed that Whites possessed the heaviest brains, supposedly proving their superior intelligence. This was also a sexist science. Leidy claimed that the lighter average weight of women’s brains in comparison with men’s proved women’s inferior intelligence.²¹

Other anatomy faculty also taught their students about craniometry and polygenesis at Harvard University and Columbia University. These schools each trained thousands of antebellum doctors. Thus, polygenists shaped theories of race and intelligence in antebellum medicine and politics.²²

Polygenesis also upheld larger carceral logics. For some Northerners, Southern slavery represented a mass carceral project, protecting them from cohabitation with Black people. Daniel Drake, professor of pathology and the practice of medicine at the Louisville Medical Institute, illustrated this dynamic in a series of articles in 1851 for The National Intelligencer, a leading US newspaper. Theoretically, Drake opposed slavery. As a colonizationist, he believed that Black people in the United States should voluntarily “return” to Africa. Drake, however, acknowledged that this process would be slow. He opposed emancipation, because Black people were supposedly temperamentally and constitutionally unsuited for freedom. Thus, he insisted that Black people must be confined to the South, where most would remain enslaved.²³

Thus, antebellum medical doctors’ theories about Black people’s bodies and minds aligned with the political and social debates contemporary to their production. Moreover, medical educators reproduced these ideas, and their students implemented racialized systems of labor in the United States’ first asylums.²⁴

Carceral logics of racial science could also be seen in some Southern medical discourse pathologizing mentally ill enslaved individuals. Published in 1851, Samuel Cartwright’s invented diagnosis of drapetomania illustrated the carceral logics of antebellum racial science and theories of the mind. Like Drake’s argument that fleeing slavery for the North was unhealthy, Cartwright claimed that fleeing the plantation was a mental illness called drapetomania. While drapetomania was hardly universally accepted, Cartwright influenced US politics and medicine. His peers in the North even recognized his expertise. In 1826, one of his articles received an award from the Medical Committee of Harvard University.²⁵

Cartwright’s diagnosis of drapetomania mirrored his proslavery political beliefs. He theorized drapetomania in the immediate context of the Compromise of 1850, which comprised five laws dealing with the issue of slavery and territorial expansion. Among other controversial policies, the Compromise of 1850 amended the Fugitive Slave Act, requiring Northerners to help capture self-liberated individuals. The 1850 act gained much support from Southern White elites, because it drastically expanded their influence over Northern states and the enslaved population. Cartwright’s theorization of drapetomania extended the logic of the Fugitive Slave Act of 1850 to the medical sphere. He pathologized self-emancipated individuals, restoring the social and moral order that reigned over Southern plantations. A frequent correspondent with prominent Southern politicians, Cartwright was well aware of the political potential that his medical theories represented.²⁶

This dynamic relationship between medicine and politics also mirrored Drake’s position in the early 1850s, writing that Black people must be confined to Southern slavery until they emigrated back to Africa. In an 1851 letter to John Collins Warren, retired professor of anatomy at Harvard Medical School, Drake explicitly invoked the Fugitive Slave Act as context for his advocacy for Black colonization. Specifically, he hoped to “terminate the colonizing of free Black people within the limits of the United States.”²⁷

After the Civil War, physicians continued to pathologize Blackness in mental health care. This continuity existed in the circulation of the category of “political excitement,” listed as a cause of insanity and applied to Black patients in the annual reports of Southern asylums and hospitals such as the Central Lunatic Asylum for Colored Insane in Virginia.²⁸ One of the theoreticians of “political excitement” was medical professor Joseph Jones at the University of Louisiana and former Confederate officer who studied under Joseph Leidy at the University of Pennsyvania. In his 1889 medical lecture at the 11th annual session of the Louisiana State Medical Society in New Orleans, he defined the cause of his Black patients’ mental afflictions as “certain political and race changes, such as those wrought by the great American civil war of 1861–1865.”²⁹ Jones participated in the Redeemers’ ideology, which intended to restore a moral, social, and political order based on White supremacy. Jones accused the 1863 Emancipation Proclamation of harming the health and moral character of African Americans, who should not have been freed.

Thus, these two medical categories reveal continuities between racial science and White Southern political interests before and after the Civil War. Southern physicians developed these theories, reflecting how supposed expertise on Black bodies often originated in the US South.³⁰

Whether before or after the Civil War, many Southern doctors believed that Black people were mentally and physically suited for enslavement and the brutally exploitative sharecropping labor regime that replaced it. Medical educators also reinforced these beliefs, as the idea of temperamental adaptation to enslavement or peonage was taught at Northern and Southern medical schools.³¹ Whether in terms of mental or physical health, racial policy routinely bore carceral overtones. As demonstrated by the circulation of the “political excitement” category in Southern state institutions, racial science was not only confined to theoretical endeavors such as Drake’s and Cartwright’s writings. Medical theories on racial differentiation were disseminated in asylums and hospitals, where scientific theories about Blackness were applied to Black patients’ bodies. Each of these theories also shared an overarching logic: that Black people’s mental fitness relied on their confinement to agricultural labor in the South.

RACIAL VIOLENCE AND CARCERAL LOGICS IN INSTITUTIONS

Asylums reproduced—in novel ways—previous carceral logics and the racial violence of slavery. They were originated as primary sites for the installment of social and medical control over bodies and minds to restore docility in the Black population. What had formerly been mere theories on racial inferiority were now being applied directly to Black patients. From the late 19th century to the mid-20th century, therapeutic treatments were often organized in the form of physical labor for Black patients, under the pretext of occupational therapy.³²

Even though these 19th-century institutions originated in a distinct period, they can be analyzed as the foundations of 20th- and 21st-century psychiatric institutions.³³ Reflecting these continuities when reacting to Neely’s killing, Mayor Eric Adams stated that his death proved the need for forced hospitalization of mentally ill people unable to adapt to life in society. This response was heavily criticized by his political allies and New York Civil Liberties Union activists, who saw in Adams’s statement a return to “the failed approaches of force and coercion” that have long been systemic of psychiatric institutions.³⁴ Indeed, many sociologists of psychiatry have highlighted how “total institutions” such as modern psychiatric hospitals were still based on coercive measures including physical restraint and treatment through labor, labeled as “work therapy” even in the 21st century.³⁵ As a consequence, while many dissimilarities exist between the past and present, 19th-century asylums can be seen as the cornerstones of contemporary psychiatric hospitals, especially their enforcement of treatment regimens based on carceral logics.

In the 19th century, the discourse of cure and recovery was justified according to a broader ideological belief among the medical community that Black patients had a “natural” ability and desire to work, mimicking the antebellum moral order. A prime example of this dynamic was Daniel Burr Conrad, the first superintendent of the Central State Hospital in Virginia. Burr Conrad was a typical Southern asylum director, educated about racial science at the University of Pennsylvania. Graduating in 1853, Burr Conrad would have learned about Black people’s supposed intolerance of cold and suitability for labor in the South from Professor George Bacon Wood and about craniometry from anatomists such as Leidy and his predecessor William Horner. It is unsurprising, then, that Burr Conrad underlined the importance of labor in one of his first reports for the institution. He explained that “from our experience during the past two years … , we are inclined to think that this manual labor is the chief, if not the only, means of cure we possess for this class of our insane, coming as they all do from the totally uneducated former slave class.”³⁶ Emphasizing labor as “the chief” curative, Burr Conrad established a clear link between moral treatment in the form of labor and the supposed specificities of previously enslaved Black people.

In the mid-to-late 19th century, physicians such as Burr Conrad naturalized Black people as an intellectually inferior laboring class, directly applying racialized carceral logics to Black asylum patients from the postbellum period through the 1940s. Indeed, the naturalization of labor infused therapeutic practices in Southern states up to the 20th century. In a newly emancipated society, Black men represented a potential threat to White society by disrupting work regimes, or by refusing the social roles to which a segregationist society confined them. At public psychiatric hospitals in Louisiana between the 1900s and 1940s, Black patients worked long hours in agricultural fields.³⁷ Briefly put, for administrative officials, Black patients provided unpaid labor for the operation of the asylum.³⁸

Therefore, in their writings, administrators advertised values such as the curative, the transformative, and the restoration of good health and sanity.³⁹ Physicians depicted how well White patients behaved together, presenting their integration into rituals of social interaction as the promise of rapid reintegration into the White social order outside of the asylum. They coded recovery for Black people around norms of docility, labor productivity, and, consequently, the suppression of newly acquired civil rights.⁴⁰ While the White patients also worked, thus showing that occupational therapy was not only applied to Black patients, the labor they performed was less physically demanding and outside the realm of these racialized carceral logics.⁴¹ In contrast, the asylum for Black patients was designed as a workhouse that established physical labor as transformative treatment. These asylums’ most clear departure from carceral institutions was that medical officers sought to attain the final goal of curability.

LEGACIES OF 19TH-CENTURY RACIAL SCIENCE

As highlighted throughout this essay, theories and medical practices interweaving discussions on labor, punishment, and undeservingness were not restricted to the 19th-century US South. Indeed, in many ways, 19th-century and 20th-century racial science helps us understand broader aspects of contemporary society. For example, Neely’s killing is a contemporary case that highlights powerful connections between mental health and carceral logics in the United States. It serves as a pivotal example that reveals, flagrantly and shockingly, how discourses on undeservingness, Blackness, and criminality remain intertwined.

Racial differentiation in the treatment of mentally ill patients is also tied to the recent revitalization of biological racial realism (i.e., theories supporting so-called innate racial differences), which reflects the long-term development of racial science.⁴² Paradoxically, this revitalization has been taking place despite a consensus among social scientists condemning biological racial realism. In article after article, social anthropologists and sociologists have stressed how the variable of race should be considered in the medical field as a social construct and a social determinant rather than a genetic, biological essence.⁴³ As scholars Merlin Chowkwanyun and Adolph Reed Jr have recently cautioned regarding the COVID-19 pandemic, discussion of racial disparities must be contextualized within broader socioeconomic factors. Otherwise, scholars risk reinforcing biodeterminist explanations for disparities rather than highlighting social causes.

This same risk exists in mental health practice.⁴⁴ Despite acquiring negative connotations after the eugenics movement, biological racial realism still looms as a threat. In lay circles, White nationalists have recently attempted to revive racial science—a development largely overlooked by the general public. For instance, sociologists Aaron Panofsky, Kushan Dasgupta, and Nicole Iturriaga have shown how White nationalists have attempted to promote racial realism and hereditarian explanations for behavioral differences by publishing amateur papers on the OpenPsych platform, at the margins of academic research.⁴⁵ Relying on writings by controversial psychologists such as Arthur Jensen, these papers argue that a correlation exists among race, intelligence, and IQ. These authors even argue that their work is rooted in antebellum racial science. On several occasions, Jensen and his regular coauthor J. Philippe Rushton have cited the work of the influential antebellum polygenists Josiah Nott and George Gliddon, establishing a deep lineage beginning with craniometry.⁴⁶ Racial realists are often adept at mimicking academic language and gain wide followings through wearing the mantle of scientific legitimacy. These contemporary political and social misuses of disproven theories are one of the enduring legacies of 19th-century racial science developed in the United States.

Beyond race realists, many geneticists, biologists, and physicians still use the notion of race as a biological or genetic variable in peer-reviewed research. Let us consider explanations given for the consistent high rate of psychotic disorder diagnoses among African Americans. In the absence of “genetic evidence” to support the overdiagnosis of schizophrenia among Black people, some psychiatrists and historians argue that clinicians’ racial bias should be considered as a potential explanation.⁴⁷ Yet, others still contend that genetic predispositions underlie this trend, despite this lack of positive evidence.⁴⁸ When genetics are not mentioned, cultural differences are described as accounting for disparities, denoting cultural essentialism—a belief in innate, fixed, and essential cultural characteristics.⁴⁹

CONCLUSION

By linking economic structure, racial science theories, and therapeutic practices, this essay has shown how carceral logics have underpinned politics of Black mental health from the 19th century onward. Instead of focusing solely on the development of theories that advance carceral logics, namely 19th-century racial science and 21st-century biological racial realism, we have shown how the spread of carceral logics relied on economic decisions regarding public assistance given to Black mentally ill patients and on racialized therapies for Black patients that link Blackness and labor. Overall, these examples should act as powerful reminders that social scientists, physicians, and biologists as well as the general public should remain vigilant toward the political and social uses of science and the framing of race as a potential “biological” variable, especially in light of technological advancements made toward personalized medicine today and in the near future. The disentanglement of carceral logics and Black mental health will only come at the price of a careful assessment and acknowledgment of past and present injustices in psychiatry and medicine.