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Asylum Ways of Seeing
Psychiatric Patients, American Thought and Culture

Heather Murray

Dec 2021 | 336 pages | Cloth $45.00
American History / Psychology
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Table of Contents

Contents

Introduction
Chapter 1. What Can't Be Cured Must Be Endured
Chapter 2. Biological Psychiatry and the "Happy Drone"
Chapter 3. Communities, Selfhood, and "Lonely Crowds"
Chapter 4. From Possessive to Expressive Individualism
Chapter 5. Liberating "Those Whose Ways Are Different"
Epilogue. Withdrawing from the Fray at the End of the Century

Notes
Bibliography
Index
Acknowledgments


Excerpt [uncorrected, not for citation]

Introduction

In 1928 the matron of the Racine County Asylum in Wisconsin received a letter from a mother asking how her daughter was doing in the hospital. Since the matron had told this mother previously that her daughter was "extremely nervous and hard to handle," this mother wanted to know if her daughter had "quieted down any." The matron offered reassurance that her daughter had been "down to our Christmas party and seemed to enjoy it very much. She received a package from her husband the day before Christmas and we gave her all the fruit and candy and nuts we thought good for her." Still, the matron was obliged to say that "we do not see any change in your daughter. . . . She does not take an interest in anything. She seems to be perfectly contented to sit and look out of the window all day."

This image of an indifferent psychiatric patient, lost in her own private world and staring out an institutional window, would come to have a completely different valence between the interwar era when these letters were written and the post-World War II period. The characterization of a psychiatric patient as oblivious, or even an automaton, a figure that would become so chilling and troubling to patients' rights advocates of the late twentieth century in their critiques of mental hospitals, was not so terrifying from the standpoint of the earlier twentieth century but instead was more neutral, simply a way of being in the hospital. As difficult as it may be for twenty-first-century readers to imagine, this figure was considered a soul at peace, in an accepted, if not a coveted, emotional state. It is the changing nature and observation of the patient that is the subject of this book.

Images of the automaton patient—passive, resigned, and absented from the world in the cloistered setting of the hospital—animated psychiatry over the course of the twentieth century, often serving as a metonym for the nature of mental illness of any kind as experienced in an institution. For Swiss psychiatrist Eugen Bleuler, writing in 1911, the affect of emotionlessness and acquiescence was especially characteristic of patients hospitalized with dementia praecox or "the schizophrenias," as it was known at the time. In a well-known passage from his book on dementia praecox, he observed that those who were institutionalized for long periods of time "sit about the institutions in which they are confined with expressionless faces, hunched up, the image of indifference. They permit themselves to be dressed and undressed like automatons, to be led from their customary place of inactivity to the mess hall and back again without expressing any sign of satisfaction or dissatisfaction." These kinds of observations have been made not just about patients with schizophrenia but also in reference to the institutionalized population writ large, as though the mental hospital environment itself was inherently atrophying and life draining to its denizens. By the 1950s some social scientists had even given this phenomenon a name: "institutionalitis." Neurologist and author Oliver Sacks evoked this kind of patient figure too when he reflected upon abandoned asylums from his vantage point in the early twenty-first century, noting that it was once "perfectly permissible" for patients to "just stare into space." Perceptions of these institutionalized automatons have not always been stagnant, however, and neither have the sensibilities associated with them, most particularly resignation.

This is a book about people with mental illnesses and distress and those in their orbits who cared for and observed them—what I call patient cultures. I focus on the institutionalized, as well as those facing the prospect of institutionalization, their ideas, and their cultural and emotional expression in the face of this. What kinds of cultures, sensibilities, and concepts did an array of psychiatric hospitals as institutions create and facilitate? And how did these both resonate with and generate more widespread thought and culture beyond the hospital? I uncover here the voices of patients, their family members, psychiatrists, and hospital observers, and I consider both state and private institutions, as well as biological and psychoanalytical psychiatry. I explore the lives, writings, and politics of those who faced hospitalization owing to a range of emotional and cognitive afflictions and suffering, among them depression, bipolar disease, and schizophrenia, in their various incarnations over time, as well as "conditions" once treated in psychiatric hospitals, such as alcoholism and dementia in old age, not to mention distress that patients themselves had difficulty discerning, identifying, and categorizing. I recognize the amorphous quality of a term such as "mental illness," and patients' ambivalence about the very idea, whether this took the form of uncertainty about the boundary between sickness and moral character during the early twentieth century, the initial enthusiasm about a more pronounced medicalization of mental illness at midcentury, more rigorous political questionings of labels in the late twentieth century, or a proliferation of psychiatric identities at the turn of the millennium. I also recognize the abstraction of the category of "the patient." While I do not wish to elide important differences regarding class, race, and gender among patients, I suggest that once a patient identity becomes created, these distinctions also matter in relation to the transformative experience of being hospitalized, or being ill, or simply feeling alienated or internally tumultuous, all of which can change an individual's capacity for observation, sharpen political ideas, and initiate more conscious considerations of the emotional lives of others.

In addition to patients and their caregivers, the setting in which care was administered is a central character here, hovering in the background even when a patient had not yet been hospitalized or if a place for treatment was uncertain. The difficulty of writing about these institutions is that they are so freighted with a past of well-documented cases of neglect and abuse, whether this took place in the asylums of the interwar period, the overcrowded "snake pits" of the early postwar period, or the underfunded state hospital, the "cuckoo's nest," of the final third of the twentieth century. Poignant narratives of exploitation animate both this book and the narratives of other historians. And yet, acknowledging and analyzing the nature of this particular kind of institutional violence does not preclude an analysis of the styles of personhood and institutional citizenship that ran parallel to broader styles of selfhood and citizenship in society. It is in these hospitals that patients gave more conscious thought to the unfolding of time, to the physical and the built environment, to the nature and needs of communities versus those of individuals, and to scientific modernity. Psychiatric hospitals are contradictory in the sense that they require withdrawal from society but emphasize sociability among patients, and they have an intriguing ambiguity about them as places, since they can be simultaneously zones of intensified intimacy and sites of oppression. They can be fleeting, transient "non-places," while at other times sites where chronic illnesses played out and where patients lived out their days. The individuals encountered in them offer personal, emotional assessments not just about the nature of violence but about community, individualism, conformity, science, and human rights, all themes that have animated twentieth-century America but that have been especially urgent in the reflections of patients and their observers. As such, these institutions suggest a unique way of seeing and imagining.

Within the patient culture of mental illness, resignation has been a central demeanor of the psychiatric institution—captured most poignantly in the automaton patient—as well as a response to institutionalization, and even a strategy within it. I trace a shift over the course of the twentieth century from a resigned, tragic sensibility that this patient embodied to a more possibility-seeking, utopian sensibility that shaped not only demeanors of and attitudes toward mental illness but other political or daily life realities. Resignation contrasted starkly with the institutional and emotional citizenship and community required of one in hospitals, something that became ever more pressing over the course of the postwar period. In insisting upon this style of active citizenship, and in introducing a patient to scientific concepts, the hospital itself had a hand in undermining the automaton that it was purported to create. The hospital interacted with and fashioned forces outside the institutional walls that also upheld and deepened a need for active citizenship and self-transformation: most particularly, scientific modernity in the interwar years, the heightened fears of totalitarianism in the early postwar years, and the political agency of the counterculture and rights culture during the late twentieth century.

I suggest that a sense of inevitability was more likely to define ideas about mental illness within the confines of institutional psychiatry particularly during the interwar era, and this posture toward one's lot in life had its parallel in a larger sensibility and mode of engagement with life: a sense that one was powerless to change the way things are, that what can't be cured must be endured. I do not seek to disparage resignation as a sensibility; as philosopher Susan Neiman reminds us, a synonym for "resigned" is "philosophical." Instead I wish to understand how it is that resignation went from being interpreted as wisdom in the early twentieth century, to being understood as a capitulation to dubious scientific and political forces by midcentury, to being viewed as a profound violation of selfhood and the integrity of emotional expression by the century's end. How did the automaton, accepting of one's lot in life, both in the psychiatric hospital and beyond, come to assume such an unsettling and menacing valence over the course of the twentieth century, an aspect of freakery—a human, but not quite—rather than a particular perspective on reality?

Throughout this book, I cover distinctive eras in American psychiatry and in societal sensibilities and ideas. The period between World War I and World War II is an especially intriguing starting point for thinking about the theme of resignation. During these years critics and observers of American hospital psychiatry suggested that the mental hospital or asylum was more custodial than caretaking, a departure from the reformist attempts to create humane, bucolic institutions during the nineteenth century. This custodialism in itself suggested an irretrievability of the mentally ill. Interwar asylum psychiatrists were often isolated from the intellectual currents in both broader professional medicine and psychoanalysis. Confronting these institutions, patients were forced to take a pause from the clamor, speed, sensory shocks, and newness of modernity, and some saw no choice but to simply "be" in the hospital. If medical observers and sometimes even patients themselves accepted mental illness and institutionalization as an unrecoverable fate and as part of the inherent pain of the universe, they could conflate this inescapability with a sense of tranquility and suspended time that characterized resignation. Feeling benumbed, oblivious, and sequestered could even be compelling as a response to the tumults of modernity.

At the same time, during the interwar years, the hospital as an institution ironically destabilized the demeanor of the automaton that it helped facilitate for management purposes or that patients adopted simply to exist in the asylum. As an emotional demeanor, resignation contrasted with the emotional citizenship of the hospital. The psychiatric hospital as an institution could intensify a patient's powers of observation and introspection. But it also powerfully suggested and enforced an institutional citizenship that emphasized association, voluntarism, participation, civic obligation, belonging, community, and solidarities among the suffering. It was a contradictory atmosphere of withdrawal that emphasized sociability.

Resignation expresses itself passively—or, more charitably, as peacefulness—while curing and the pursuit of possibilities express themselves more actively, perhaps even as unrest. Incurability has its most striking parallel in resignation and the institutionalized automaton, and curability has a parallel in more utopian thinking and the active, seeking agentive individual, who had no need for hospitalization. The ideational realms of psychiatric hospitals also could introduce patients, and by extension their families, to scientific modernity, whether this took the form of psychoanalysis, diagnosis, or, particularly by midcentury, psychosurgeries and psychotropic drugs. The sense of unrecoverability that characterized the interwar period changed when more institutions offered biological psychiatry and psychosurgeries at midcentury, lobotomies and electric shock therapy most prominent among them, that located mental illness in brain anatomy and were thought to cure everything from chronic schizophrenia to chronic depression. As scientific modernity came to be seen as something that the individual could engage with and possibly manipulate, autonomy and self-possession deepened as ideals in the institutional setting. And when psychiatrists, patients, and family members alike began to have more faith in biological cures for all forms of mental illness at midcentury, they embraced an ideal of activity and transformation over passivity and resignation.

But psychosurgeries also demonstrated the fraught relationships between individuals and a scientism that potentially reduces people to automatons, the very archetypal figures of the mental hospital that patients and their families thought they could avoid by turning to biological psychiatry. The zombie figure in particular inhabited an early post-World War II American imaginary, and psychiatric hospital populations felt they had a firsthand acquaintance with this specter. While the rejection of the conformist and the embrace of authenticity over the course of the postwar period have figured in historical discussions about the impact of totalitarianism on American thought and culture, the history of psychiatry can uniquely illuminate the disconcerting figure of the automaton, often read as a passive bystander who haunted so many areas of American culture, from political writings to popular culture.

Critics of hospital psychiatry became more vociferous during the early postwar era, and not just because the promises of psychosurgeries seemed more uncertain then. Some observers focused on mental hospitals themselves and called for reforms, writing exposés of these overcrowded, underfunded, and sometimes virtually uninhabitable institutions. In turn, the "lonely crowds" that animated the social science landscape at midcentury had their most intriguing laboratory in the mental hospital. These institutionalized patients themselves came to embody styles of postwar era personhood and citizenship that rendered the hospital a site much more freighted with perceived American national character and ideology than it had been a generation before. As passivity and resignation became more politicized, a patient was no longer being wise by simply accepting her fate as an institutionalized mentally ill person—instead, she was being an automaton, a figure now viewed more disparagingly as one who had dubious political commitments and was perhaps even prone to totalitarianism.

In the name of reform, psychiatric observers and critics helped prepare a social and intellectual foundation for deinstitutionalization during the 1960s, a movement that posed a more powerful repudiation of resignation and a commitment to individual rights, possibility seeking, and emotional fulfillment beyond the hospital. Some historians have charted a parallel evolution of "grand expectations" in American society in personal as well as social and political life, and they have explored, sometimes from a conservative political perspective, the evolution from a duty-bound consciousness to a more rights-based one. According to this perspective, this shift was shaped by postwar consumer culture and the promises of personal happiness that it offered, by the postwar civil rights movement and its compelling suggestion that the downtrodden of all guises identify with African Americans seeking rights and restitution, and by an emerging countercultural emphasis on self-realization. Patient writings during this era suggest that the counterculture may have flourished and been heightened in direct tension with the hospital setting, which served as a glaring example of an oppressive societal structure that coerced the individual into acquiescence. By the 1960s and 1970s, the tranquil, resigned psychiatric patient came to be viewed as a tragic violation of individual authenticity.

In no era were psychiatry's critics bolder than during the last third of the twentieth century, when they called into question many forms of psychiatric and medical authority, with the mental hospital often at the center of their critiques. In this vein of thinking, a patient's lot in life was more than just a tragedy, and something could—indeed should—be done to rectify or eliminate oppressive societal structures. Psychiatric patients of this deinstitutionalization era also offer a particularly striking view into neoliberalism, in this instance meaning the displacement of state institutions by political and economic privatization strategies. In stark contrast to the midcentury liberalism that mental hospitals embodied, exhibiting a faith in social welfare, social institutions, government, and the behavioral sciences to solve problems, late twentieth-century neoliberalism was distinctly unwedded to social welfare and to institutions, participation, and citizenship. What happens when the hospital as a reflective context is gone? What happens to ideas without a place to express them? The newly placeless patient could repudiate the institutionalized subject, and seemingly a life of resignation as well.

Especially by the century's end, some patients and caregivers were embracing a new era of biological psychiatry based on curing biochemical mental illnesses, which was perceived as potentially liberating the mentally unwell from the institution. But amid this remedicalization, some also longed for a better hospital, or simply a refuge from suffering; this desire became more prominent when the promises of biochemistry seemed uncertain. This yearning was not as direct or literal as seeking reinstitutionalization; instead it expressed itself more as an amorphous need for community, diffuse forms of care, reciprocal intimate relationships, sympathetic witnessing from public authorities, and creativity in day-to-day life. The psychiatric institution was still, by definition for many observers, antithetical to this kind of fulfillment.

Once perceived as a necessary "pause" during the early twentieth century, this sense of being absented from the larger world in a mental hospital came to be viewed as a punitive halt that simply enforced the creation of a self-evacuated subject, the precise opposite of the liberal, autonomous, self-possessed individual. By the century's end, the more passive, resigned institutionalized subject was displaced by a more active, politically engaged, rights-bearing patient who questioned the given-ness of life and who was by nature institution-less. Over the course of the twentieth century, emotional vibrancy and animation displaced serenity and imperturbability as ideals for care and treatment and a way of being, as personal demeanors and political ones alike. The seemingly acquiescent and dormant psychiatric hospital patient, once seen by cultural observers as inevitable during the early twentieth century, came to be viewed, during the mid- to late twentieth century, not only as a mechanical figure disturbingly stripped of an interior life but as politically, personally, and aesthetically dubious.

Still, aspects of resignation lingered, often expressed as a kind of ambivalence about the institution of the psychiatric hospital itself or simply as a means to make the unbearable bearable. And resignation was not incompatible with patient intellectual curiosity, which was often shared by their caregivers when assessing psychiatric hospitals, and the science, biological concepts, therapy, and citizenship routines that these institutions embodied. Though other areas of intellectual inquiry, especially cultural history, have been quite keen to think about the critical capacities of groups once considered simply acquiescent, whether consumers or TV watchers or radio listeners, this reflection has not been as prevalent in the history of medicine, which has been more interested in the tensions between exploitation, social control, and agency. To suggest that patients can be intellectually interested in their illnesses or in the experience of being in an institution is not to belittle their suffering or to presume a certain class and education elitism. The patients and their family members who wrote to, for example, their governor or their local state hospital psychiatrist often were by their own admission not formally educated and did not mince words about the depth of their suffering, but at the same time their intellectual curiosity as well as their emotional and political intelligence are apparent. Though the cultural cachet of self-knowledge has been traditionally thought of as the province of the bourgeoisie, especially during the modern era when intellectuals and the upper-middle class embraced psychoanalysis, broader swaths of the American population have shared in the desire for self-knowledge and engagement with science and medicine.

"We need to talk about mental illness," exhort public health campaigns in contemporary America, as if to suggest that the taboos surrounding mental illness are still so entrenched that few would dare discuss this aspect of the human condition, beyond the dimly imagined afflictions and gothic curiosities that feature so prominently in contemporary horror films and novels. And yet, patients have been talking about mental illness with their family members, hospital psychiatrists, and fellow patient communities, as well as representing their thoughts and experiences in an array of intimate and cultural genres, over the past century. Moreover, the mentally "well" have been visiting and beholding the unwell and have been captivated, especially by hospital environments, and recording these perceptions in ways that manifest both fascination and revulsion, exoticization and fear, sympathy and callousness, care and repudiation. And mental hospitals as institutions have long been faced with huge expectations, dissected, complained about, lavishly praised when helpful, and condemned when insensitive or abusive, like families themselves. These caregivers and the potential need for them all still inhabit and animate the American imaginary.

Historians of medicine have long been encouraging more chronicling of the patient's perspective to the point that this call has become a truism. In turn, some scholars have called for more attention to responses to madness in the community; others have decried the "absent entity" of the caregiver in medical history; and still others argue that the family's role in caregiving has not been given enough emphasis. Historian Gerald Grob famously invoked the figure of the "invisible patient," lost to historians because of the mostly aggregate data of psychiatric statistics of illnesses from the twentieth century. These patients are also "invisible" because psychiatric archival sources can be frustratingly fragmentary and elusive to researchers working on the twentieth century owing to restricted access to case notes and patient records.

Despite this displaced patient subjectivity, patient voices survive in revelatory letters to psychiatrists at both state hospitals and private institutions, as well as to public officials, and in intimate correspondence—a corpus that historian Michael Pettit has called a "therapeutic archive." Their voices also animate anthropological and sociological ethnographies of patient life in psychiatric hospitals, advice literature and films addressed to larger mental health publics, hospital publications, patient newsletters, medical textbooks, medical periodicals, and memoirs or "autopathographies," not to mention creative venues: novels, documentary films, plays, poetry, and patient drawings. Their caregivers' voices, be they family members or hospital doctors, also survive in these kinds of sources, allowing a glimpse into the moral and emotional economies surrounding the patient over time.

These sources demonstrate that patients and their intimate observers have been creators of culture and producers of ideas in their own right, particularly in their narrations and analysis of emotions, illnesses, selfhood, and hospital experiences. Ideas were not just imbibed from the outside world and adapted within the institution; they flowed outward as well. Intellectual histories of psychiatry need not solely derive from the perspective of psychiatrists, just as patients are not solely the embodiments of "lived experience." The kinds of sources that I take up here allow me to connect the history of psychiatry in the United States to intellectual and cultural history broadly construed. Social histories of psychiatry and its institutions have been and continue to be foundational in the field, particularly in the United States, and have explored themes of institutionalized captivity, the carceral state, coercion, exploitation, social control, and surveillance, as well as forms of power and resistance, both subtle and overt, and engagement with the state, in fascinating ways. I depart from these somewhat in that I am not trying to verify a social reality or engaging in a case study of an individual hospital but rather focusing more on the representations of these hospital experiences and feelings in both intimate and creative venues.

Historians as well as popular culture have tended to present, with good reason, fairly limited possibilities for the existence of a person with mental illness in the context of a psychiatric hospital, often in an atmosphere of social control. A 2009 YouTube upload called "Shocking Paranormal Imagery!" at the Milledgeville State Hospital in Georgia, which was notorious for its overcrowding and patient exploitations at midcentury, also showed some photos that were distinctly un-shocking, such as lingering shots of the grounds or the trees, or just prosaic things like laundry facilities. These kinds of everyday details also come to life readily in the cultural and imaginative outputs about the hospital, as well as instances of comfort or whimsy or sweetness, perhaps heightened in an overall atmosphere that offered these moments only sparingly, such as patient puppet making and puppet shows at Central Griffin State Memorial Hospital in Oklahoma, pet shows at Osawatomie State Hospital in Kansas, and song fests at Eastern State Hospital in Tennessee during the 1950s. These moments demand our attention, just as instances of inhumanity and systems of cruelty do, perhaps especially because of the existence of those systems.

The relationship between history and acts of violence, or historical narrative and the unfolding of a particular tragedy, is deeply ingrained, though in less sensationalized forms than in homemade paranormal videos. These thematic frameworks make sense in the history of psychiatry, too, given the breadth of the carceral state and the well-chronicled instances of patient suffering in institutions. In exploring the idea of the hospital as an imaginative space, in which not solely patient captivity or agency can unfold, I uncover surprising and complicated instances of human connection, as well as often unresolved yearnings for community life, themes that have animated histories of other captive communities but have not been as prevalent in the history of psychiatry. Wartime and prison contexts are not the only ones in which unusual solidarities between people can develop, and expanding the lens to the hospital allows for more thinking about the emotional intensities within an array of subsocieties.

This reflection also allows for the insertion of "sick" individuals into the more common race, class, and gender paradigms of human and social difference, categories that have a contentious basis in biology or that have been biologized against the will of those they purport to represent. The "mentally ill"—and even the "disabled" writ large—do not tend to inhabit diversity conversations in the same way that race, class, gender, and even sexuality have. As such, people with mental illnesses constitute an unusual "minority" who can sometimes "pass" and at other times cannot and who are sometimes willing to see themselves among the ranks of other oppressed groups. Perhaps because mental illness in particular can be considered more purely a personal misfortune rather than a subject position, it is often relegated to fantastical realms or quiet conversations among those who face similar suffering, despite the pleas of patient activists to see it as more of a political or social identity. This sense of minoritization is often more heightened and urgent in the physical context of the hospital or when someone is facing the prospect of institutionalization, which reinforces a sense of existing in a parallel society.

"Minority" consciousness is central to the question of resignation, as this has been a disposition for both working-class and racialized people, at times a strategic one. Sociologist Lillian Rubin has written about resignation in white American working classes, an attitude of "things just happened." Abstract comments about the problems of human nature—often a brutal, white human nature—made within a sensibility of resignation, of "the way people are," also have a voice in early twentieth-century African American novels. In Jessie Redmon Fauset's 1924 novel, There Is Confusion, one of her characters, Brian, both acknowledges and contests this as a truism when he notes that often a "time comes when [a Black man] thinks, 'I might just as well fall back . . . a colored man just can't make any headway in this awful country.' Of course, it's a fallacy. And if a fellow sticks it out he finally gets past it, but not before it has worked considerable confusion in his life." Expressions of resignation as responses to suffering, often the only conceivable responses to suffering, were quite important among vulnerable populations in the early twentieth century but became complicated and sometimes disavowed as the century wore on. The psychiatric realm has yet to be inserted into this conversation. Moreover, exploring a history of sensibilities in this way can illuminate those that have been seemingly discarded, and why, as well as how they might linger through traces, be resurrected, or simply exist by other names in the contemporary moment.

The archival sources that I draw from here, particularly intimate correspondence between patients and family members and their psychiatrists, are fragmentary and often subject to censorship. Moreover, the records from various state hospitals are inconsistent and vary by hospital and by state. Some records are held by state hospitals that are still in operation, some have been destroyed due to destruction schedules to ensure patient privacy, and some simply have been lost. What does exist in hospital records, from scattered private correspondence, to annual reports, to patient newspapers, to architectural plans, allows for some reflection about the chasm between what has been documented and what has not, or what has been preserved and what has not. These sources are not meant as a repudiation of medical archives, such as doctors' notes or patient records; they are meant to suggest that those sources do not always reveal the moods, perceptions, and introspection that I am interested in here, such as representations of what it feels like to be in a mental hospital, or patient longings and fantasy lives, or their political consciousness within institutional environments. Patients and their intimate observers' correspondence and testimonials are distinct genres in the same way that doctors' notes are. At the same time, I recognize that the patient voices I have had access to are themselves curated samples, by their families, by government officials, by psychiatrists, or by other institutional authorities. Whether a patient was expressing gratitude for care, or outrage over abuse, or something much more ambivalent, these sources illuminate patients who had at least some level of engagement with the medical establishment.

Privacy regulations have had something of a decontextualizing effect on my sources, sometimes stripping patients of not only identifying factors but clues as to their class background, generational cohort, and ethnoreligious or racial background. Moreover, all states have varying policies about what can and cannot be seen, as well as different twists on privacy laws, and this has had a shaping factor on the evidence that I present. Not all hospitals kept such correspondence either in their own or in state archives, and I have tried to be cognizant of all the evidence that has been forgotten, erased, or never recorded.

I also recognize that privacy laws and archival attempts to preserve patient privacy and preclude patient identification are relevant to understanding a desire for anonymity, so powerful for those who are vulnerable for a host of reasons, among them mental illness, disability, sexuality, and race, and is perhaps even more compelling now in an era of more pronounced surveillance states and cultures and hypervisibility. On the one hand, anonymity is a necessary protection against physical and psychological violence, perhaps even against emotional and political superficiality. Historian Susan Lawrence reminds researchers that privacy laws are only concerned with the rights of the living and their relatives rather than the "non-existent legal status of the privacy of the dead" who only have a "symbolic existence." Perhaps it is not always possible to project the privacy desires of the dead from one historical moment to another. In 1941, a young African American woman who was a patient at Searcy Hospital, a segregated Alabama institution then exclusively for Black patients, wrote a stirring letter to the governor of the State of Alabama, Frank M. Dixon, to testify to the appalling patient living conditions there, as well as physical and emotional abuses. "I have been informed not to sign my name to any letter I write you, but since I write the truth the whole truth and nothing but the truth I deem it unnecessary to write an anonymous letter!" she said. "I am willing to shout the truth to a nation! We need help! Now!" There is an irony in anonymizing this powerful voice.

The impulse to protect patient privacy has been noble insofar as it protects a patient, even as a non-living historical subject, from stigma and malicious gossip, but it is also contradictory and certainly imposes a constraint on discussion, the very factor that many patient advocates say is also necessary to destroy the stigma of mental illness. Some vulnerable groups have considered privacy anathema and fought against it, in the name of pride (racial pride or gay pride, most prominently), or as is more often the case for those with mental illnesses, in the name of dignity.

Perhaps because so many patients have died nameless and seemingly anonymous, an eagerness to do justice to their existence also suffuses historical reflections about them. An intriguing example is a collection about the Willard State suitcases: four hundred suitcases filled with patients' belongings were discovered in 1998 in the attic after the Willard Psychiatric Center closed in 1995. The authors explored the contents of ten suitcases and noted that "spirits of the suitcase owners had been awakened without their consent, and we felt that we owed them our utmost effort to do them justice." They take up this kind of spiritual language throughout the book, writing that when the abandoned suitcases were first discovered, curators and state workers who were roaming the grounds of the abandoned buildings trying to collect things that might be worth preserving before the demolition crews came were struck by the "awesome sight" of "crates, trunks, hundreds of standard suitcases . . . all neatly arrayed under the watchful eyes of the pigeons who had come to join the lost souls and their worldly possessions."

Of course there is something spiritual about history, and this is particularly the case when exploring such deeply personal effects of the dead. Perhaps, too, preservationists are animated by a protest against the namelessness and dehumanization of bureaucracy that so frightened many prospective psychiatric hospital patients and their families, especially during World War II and the postwar era. Thousands of state hospital patients were buried in anonymous, often numbered graves in the United States. Sometimes patients did not have coffins, and their bodies were simply buried in shrouds. At other times they had no grave markers, or if they were cremated, their ashes might be left in random locations throughout the hospital grounds. Many hospitals harbor these "friendless" patients whose families did not collect their bodies to buried. Organizations have formed to put names on the gravestones of patients who have died in asylums, in a sense reclaiming them from abstract bureaucracy and powerfully announcing that they are not just "numbers," akin to the work being done now at genocide sites. Preservationists want to at least mark the asylums as important sites for death and, by putting names on asylum gravestones, restore the possibility of grieving and mourning for these individual patients.

I do not want to diminish the importance of this historical preservation work so much as to call to mind larger questions about who can be seen as a respectful observer, chronicler, and interpreter of these patients, or a bestower of "dignity." A historian reading archival sources is not an inherently more reverential observer than a preservationist, but I do suggest, following historian Elizabeth Lunbeck, that observation through study has the potential to be a mode of empathy, while recognizing how freighted observation of the vulnerable has been historically.

Beyond these archival sources, there is also an extant body of creative works and memoirs written by people with mental illness, as well as their caregivers, well-known ones to be sure, but also those that few people have read. These sources, in combination with therapeutic archives—and I do not wish to establish a hierarchy between the two—allow for an illumination of the public, communal self of the asylum era who told very different stories about mental illness than the more amorphous "cerebral subject" that characterizes turn-of-the-millennium era psychopharmacology and de-institutionalization.

Such sources also allow for a meditation on more abstract questions: How have people given narrative form to and why have they metaphorized mental illness and the experience of hospital life throughout the twentieth century? In what ways did they convey suffering, their fantasy lives, and their sense of rights in their institutional environments—if they thought of themselves as having them—over time? The institutional contexts in which patients composed these reflections—and the moment when these contexts were gone—are central here.

One of the appeals of an immersion into writings of all forms by patients and those who cared for them is that they offer their readers a form of emotional and even moral intensity. Perhaps this is why university medical humanities programs try to make doctors more morally aware and emotionally responsive by reading literature. But part of that project of humanizing medicine also could be to historicize it, to illuminate how basic medical decisions, such as leaving patients alone to live out their days in a hospital, or attempting to cure them and to liberate them from the institution, have both shaped and been shaped by broader ideas and emotional dispositions about what the individual could and should accept in life or try to change.

Notes
Introduction

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