Summers, Martin. Madness in the City of Magnificent Expectations: A History of Race and Mental Illness in the Nation’s Capital. New York: Oxford University Press, 2019.

Reviewed by Debra Kram-Fernandez

Madness in The City of Magnificent Expectations is concerned with the history of psychiatric care for Black, Brown, and White Americans suffering from serious and/or chronic mental illness. The study spans the period from the mid-nineteenth century to the 1970s, when deinstitutionalization resulted in the scaling back or closing of major mental hospitals. Author Martin Summers astutely focuses on the history of Saint Elizabeth’s Hospital in Southeast Washington, DC. 

Summers makes a convincing case for the importance of the hospital. Saint Elizabeth’s was the first psychiatric hospital to receive federal funding. A large part of its mission was to provide exceptional care to mentally disabled Civil War veterans. The hospital’s affiliation with teaching hospitals ensured up-to-date and progressive models for care and treatment. Federal support for the hospital contributed to its setting standards in the United States and abroad for quality and benevolent care. 

Originally the “Government Hospital for the Insane,” Saint Elizabeth’s was designed not only for whites requiring psychiatric services, but also for Black and Brown veterans, soldiers and naval officers, and civilian residents of Washington, DC. Inevitably a separate lodge for “colored people” was designed and built for what became the campus of Saint Elizabeth’s. Even so, Saint Elizabeth’s was perhaps the first hospital to take a proactive approach in handling the influx of Black and Brown patients suffering from serious mental illnesses.

Summers’s underlying concern is how at Saint Elizabeth’s the Black psyche was differentiated from the white, leading to racialized and often diminished treatment for Blacks. As there has been a dearth of studies concerning the history of treatment of mental illness among African Americans, this book goes a long way toward filling a gap in the literature.

His central argument is that Saint Elizabeth’s did more than reflect the racism of its time. As an influential institution it actively contributed to racism by privileging the white psyche as the norm while dismissing the Black psyche as aberrant and more resistant to treatment. Summers begins by showing the subpar living quarters at Saint Elizabeth’s for people of color, and that the conventional therapeutic activities for Blacks—active housekeeping and janitorial labor—often fell short of the meaningful and purposeful activities of whites. At Saint Elizabeth’s people of color might be perceived as dangerous, child-like and liable to breakdown under the stress of new-found freedom. Such prejudicial stereotyping significantly limited therapeutic expectations even during periods when, by modern standards, expectations for treatment were uncommonly optimistic.

Scholars writing about the history of African American mental health issues have conventionally emphasized that racial discrimination within psychiatric care settings simply mirrored the racism within society-at-large. Summers recognizes the merit of that approach but digs deeper, looking beyond systemic racism itself to focus on specific and more visible dynamics of treatment. He also calls out the psychiatric field, whose well-intentioned effort to describe discriminatory treatment may, in itself, have unwittingly racialized the Black psyche. 

Summers does a beautiful job interweaving major shifts in the history of mental health care, abolitionism, and emancipation with the economic, political, and environmental factors that, after the Civil War, posed enormous challenges to freed African Americans. He explains why, for purposes of appropriate historical contextualization, he has been obliged to use terms that in reference to slavery, race, and mental illness might now be considered stigmatizing and hurtful.

Drawing on a classic historic framework laid out by Gerald Grob, Summers designates three periods of change and innovation in treatment of serious mental illness: The Asylum Cure, Mental Hygiene, and Community Integration. These approaches reflect what we now might consider a naïve optimism in which substantial cures for serious mental illness were expected and championed. Summers seamlessly and impressively fills in the missing pieces of the historical narrative, incorporating along the way the experiences of African American patients. 

That said, Summers also shows Black individuals and families maintaining agency in directing their own care or care of friends and family. We see African American patients interacting with Saint Elizabeth’s staff in ways that positively affect therapeutic outcomes. 

We are indebted to Martin Summers for providing a broad-ranging history of the shifts in treatment of serious and/or chronic mental illness against the backdrop of abolitionism, the Civil War, and emancipation. And the setting—a prominent hospital built in 1855 on the border between North and South—could not be more symbolic or appropriate. 

Historians, mental health professionals, and those interested in connections between psychology, politics, race, and economics are indebted to Summers for uncovering several missing pieces in the puzzling landscape of social injustice. 

There may be a moral here: assumptions in psychiatry do not easily loosen their grip, and expectations held by clinicians today with regard to prognosis may have real and sometimes unfortunate consequences. For many who experience serious mental illness, the capacity to gain or maintain hope is the most critical factor in recovery. To extent that physicians and care givers betray a lack of hope, the chances of recovery may be diminished. We see that in the story of Saint Elizabeth’s, and we see that today.

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Debra Kram-Fernandez did her undergraduate studies at the State University of New York at Albany (1985), her Master’s degrees in Social Work (MSW) and Dance Therapy (MS) at the City University of New York, Hunter College School of Social Work (1991), and her doctoral degree at the City University of New York, The Graduate Center in Social Welfare (2011). She completed the Women’s Therapy Centre Institute two-year clinical training program (2019), and she has been on faculty at the State University of New York- Empire State College since 2012. Areas of interest include social work practice with groups, creative arts therapies with diverse populations, ethical practice amid diversity in human services, and the recovery perspective in work with people with serious mental illness. She is a certified yoga instructor (RYS-200) and deeply interested in the scholarship of embodied health and wellness. 

Featured Image (at top): A map of the District of Columbia in 1862, including Washington City, the City of Georgetown, Washington County, and Alexandria County (which was ceded back to Virginia in 1846). Saint Elizabeth’s is located in the southeastern corner of the District, south of Uniontown and near Fort Snyder, one of the many forts that protected the capital from Confederate forces. “Topographical Map of the Original District of Columbia and Environs,” E. G. Arnold and G. Woolworth Colton, 1862, Library of Congress, Geography and Map Division.