THE MAKING OF CONTEMPORARY AMERICAN
PSYCHIATRY, PART 2:
Therapeutics and Gender Before and After World War II
Joel T. Braslow and Sarah Linsley Starks
University of California, Los Angeles Neuropsychiatric Institute
In this article, the 2nd in a 2-part series, the authors use patient records from
California’s Stockton State Hospital to explore the changing role of gender norms
and other cultural values in the care of psychiatric patients. The authors show that
cultural values are always imbedded in psychiatric practice and that their role in that
practice depends on the patients, treatments, and therapeutic rationales present in a
given therapeutic encounter. Because the decade following World War II witnessed
dramatic changes in psychiatry’s patients, therapeutics, and rationales, Stockton
State Hospital’s patient records from this time period allow the authors to show not
only the extent to which gender norms shape psychiatric practice but also how
psychiatry’s expansion into the problems of everyday life has led to psychiatry
taking a more subtle and yet more active role in enforcing societal norms.
Contemporary American psychiatry provides us with a biological explanation
and cure for nearly every painful psychological state, fueling a multibillion dollar
market for psychiatric drugs. The extensive use of these drugs has furthered a
biological vision of the self and, in so doing, has made the social nature of how
we define and treat psychological suffering increasingly invisible. Two changes in
psychiatric practice in the 1950s played fundamental roles in the creation of this
contemporary psychiatry: an enormous expansion of what counted as treatable
psychiatric illness and the introduction of antipsychotic drugs. This is the second
article in a series that looks at these midcentury changes in the context of state
The first article in the series (Starks & Braslow, 2005) looked in detail at two
major events in psychiatric history during the mid-20th century: (a) the post-
World War II expansion of psychiatric diagnosis into problems of everyday
living, evidenced by the rapid rise in admissions of patients with nonpsychotic
Joel T. Braslow is an associate professor of psychiatry and biobehavioral sciences at the
University of California, Los Angeles (UCLA) Neuropsychiatric Institute, associate professor in the
UCLA Department of History, and a researcher in the Veterans Affairs Desert Pacific VISN 22
Mental Illness Research, Education, and Clinical Center. His research focuses on 20th century
psychiatric therapeutic practices. Sarah Linsley Starks is a staff research associate at the Health
Services Research Center of the UCLA Neuropsychiatric Institute and will be a doctoral student in
the UCLA Department of Health Services beginning in September 2005. Her research interests are
mental health services and policy.
The two articles in this series were supported by a National Institutes of Mental Health Career
Development Award (MH01856), the UCLA Neuroscience History Archives, the UCLA/NIMH
Center for Research on Quality in Managed Care (1P30MH068639), and the Veterans Affairs Desert
Pacific VISN 22 Mental Illness Research, Education, and Clinical Center.
Correspondence concerning this article should be addressed to Joel T. Braslow, Department of
Psychiatry and Biobehavioral Sciences, University of California, Los Angeles Wilshire Center,
10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90024-6505. E-mail: email@example.com
History of Psychology
2005, Vol. 8, No. 3, 271–288
Copyright 2005 by the Educational Publishing Foundation
diagnoses and (b) the introduction of the first antipsychotic drugs in the early
1950s. Using patient records from California’s Stockton State Hospital (see
below), we examined the therapeutic rationales that governed the treatment of the
psychotic patients who characterized the state hospitals prior to World War II, as
well as treatment of the nonpsychotic patients who entered the hospital in
increasing numbers in the years following the war. We looked at the ways patients
were treated before and after the introduction of antipsychotic drugs, which at the
time were considered “major tranquilizers” and were prescribed for most patients,
irrespective of diagnosis.
In this article, we examine how psychiatric disease categories and therapeu-
tics—along with the therapeutic rationales that tied them together—intersected
with culture to shape psychiatric practice. We use gender as an exemplar of
culture, examining the importance of gender roles in shaping care. First, we look
at the patients, treatments, and therapeutic rationale that characterized psychiatry
prior to World War II: psychotic patients, lobotomy, and behavioral control. We
then look at one of the earliest instances of contemporary psychiatry: the treat-
ment of nonpsychotic patients with antipsychotic drugs, which was governed by
a very different therapeutic rationale than that used in treating psychotic patients
(for more on this, see Starks & Braslow, 2005). Gender role considerations were
an important part of care in both of these instances, but they manifested them-
selves in very different ways: in the first case, by shaping which patients received
lobotomy, and in the second, by shaping the kinds of problems that brought
patients to the hospital and the interpretations that accompanied their treatment.
Our study is largely based on patient records from Stockton State Hospital.1
Although we have described this institution in the previous article, let us briefly
summarize. Stockton, California’s oldest mental institution, is located about 30
miles south of Sacramento. Like state hospitals throughout the country, it en-
countered an almost endless stream of patients from the moment its doors opened
in 1853. By 1910, over 2,000 patients resided in the hospital, and by 1955 that
number had grown to nearly 4,500. Overcrowding at Stockton reached a peak in
1937, when the California Department of Institutions estimated that the hospital
was 33% over its ideal capacity (California, year ending June 30, 1937, p. 21), but
improved dramatically following the war thanks to an increase in state and
national attention to mental health and, most importantly, increased funding for
state hospitals in California (California Department of Mental Hygiene, 1957;
Kolb, Frazier, & Sirovatka, 2000).
Remarkably, given the often overcrowded nature of the hospital, physicians
and staff kept wonderfully rich patient records. These records include admission
and discharge summaries, continuous (progress) notes, treatment and medication
order sheets, and transcripts of clinical case conferences and doctor–patient
interviews. In the first article in this series (Starks & Braslow, 2005), we used
these records to examine the treatment of two kinds of patients: (a) the psychotic
1All patient cases cited are from California’s Stockton State Hospital. The use of these patient
records was approved by the State of California Human Subjects Institutional Review Board. All
patient names and identifying data have been changed to protect patient confidentiality. Should
readers have interest in any specific cases cited, they may write to the California Department of
Mental Health, 1600 9th Street, Room 151, Sacramento, CA 95814 for permission.
272 BRASLOW AND STARKS
patients that characterized the early state hospital and (b) the nonpsychotic
patients who flooded into the hospital following World War II, seeking care for
problems of everyday life. These patient cases offered a window into not only the
expansion of the scope of psychiatry but also the early use of antipsychotic drugs,
both of which laid the foundation for much of contemporary psychiatric theory
and practice. In this second article, we return to these two sets of patients to see
how culture—and in particular gender—manifested itself in the care of psychotic
and nonpsychotic patients. Through these patients’ stories, we see the role of
cultural values—in particular gender norms—in shaping psychiatric practice, as
well as how psychiatry’s expansion into problems of everyday life has led to
psychiatry taking a more subtle and yet more active role in enforcing societal
Psychotic Patients, Lobotomy, and Therapeutic Discipline
In the early 20th century, those state hospital patients who did not suffer from
an organic diagnosis (e.g., dementia, epilepsy, brain damage) or from some form
of substance abuse were most likely diagnosed with a psychotic illness (e.g.,
schizophrenia, involutional psychosis, or manic-depressive illness). Unlike the
nonpsychotic disorders, which expanded rapidly following World War II (see
Table 1), the psychotic disorders have remained relatively stable throughout the
20th century and continue to comprise much of what we think of as serious mental
illness and as institutionally based psychiatry. Prior to World War II, the care of
psychotic patients characterized nearly all of psychiatric practice within state
mental hospitals. Also characteristic of these hospitals were chronic troubles with
overcrowding and inadequate staffing: In 1946, for example, Stockton’s seven
physicians had 4,400 patients in their care (California, year ending June 30, 1949,
Within this institutional context, the rationale that governed the treatment of
state hospital patients with psychotic disorders was one of therapeutic discipline:
Hospital physicians and staff defined treatable psychiatric illness as refusal to
behave and identified behavioral control as the purpose of most therapeutic
endeavors. Before the introduction of antipsychotic drugs in 1954, psychotic state
hospital patients were treated with a range of somatic therapies: hydrotherapy,
Mean Number of First Admissions to California State Hospitals by 5-Year
Period, Diagnosis, and Gender, 1935–1960
Data from California (multiple years) are from years ending June 30, 1935–1950,
1953–1956, 1959–1960, and biennia ending June 30, 1952 and 1958.
273 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
insulin coma therapy, the convulsive therapies (including metrazol and electro-
convulsive therapy [ECT]), and lobotomy. Lobotomy was used as a treatment of
last resort, after repeated efforts to control behavior with ECT and other somatic
therapies had failed. Stockton physicians performed their first lobotomy in 1947
and abruptly abandoned the surgery when antipsychotic drugs became available in
1954; in those 7 years, they performed only 245 lobotomies (on 232 patients, of
which 13 patients were lobotomized twice).
When antipsychotic drugs were introduced to Stockton in 1954, their use in
psychotic patients quickly supplanted the use of lobotomy. The therapeutic
rationales that governed the use of both treatments were much the same: antipsy-
chotic drugs were seen as a more efficient way of instilling therapeutic discipline
in disorderly patients. However, as the abandonment of lobotomy suggests,
physicians were much less reluctant to prescribe antipsychotic drugs than they
were to perform a lobotomy. Hardly a treatment of last resort, antipsychotic drugs
were given to 75% of the 159 psychotic patients in our sample between the years
1954 and 1964 (47% received drugs alone, and 28% received drugs and ECT; see
Table 2). This fact is not in itself surprising, given how devastating and irrevers-
ible the biological effects of lobotomy could be. Of more interest are the ways the
use of lobotomy and antipsychotic drugs in psychotic patients differed on the
basis of whether a patient was a man or a woman.
As shown in Table 3, treatment of Stockton psychotic patients with lobotomy
was remarkably skewed with respect to gender. Men accounted for only 15% of
patients treated with lobotomy, whereas they accounted for 41% of psychotic
patients treated with antipsychotic drugs following their introduction in 1954 (and
for 41% and 53% of psychotic patients treated with ECT before and after 1954).
Stockton physicians did not hesitate to prescribe antipsychotic drugs for men:
They gave them to 67% of psychotic men and 82% of psychotic women in our
Psychotic Patients at Stockton: Treatment With ECT and/or Antipsychotic
Drugs, Before and After 1/1/1954
Prior to 1/1/1954 (n ? 62)39
Men (n ? 29)16
Women (n ? 33)23
On or after 1/1/1954 (n ? 159)14
Men (n ? 73)9
Women (n ? 86)5
We systematically sampled patients from California’s Stockton State Hospital
using the date of final admission. Restricting that sample to patients whose final admission
occurred between 1/1/1940 and 12/31/1964 resulted in a sample of 251 patients (183
psychotic, 68 nonpsychotic). Of the 183 psychotic patients, 62 were in the hospital prior
to 1/1/1954, and 159 were in the hospital on or after 1/1/1954. We assessed patients in
each of these subsamples for whether they were treated with electroconvulsive therapy
(ECT) and/or antipsychotic drugs during the relevant time period (prior to 1/1/1954 in the
first subsample and between 1/1/1954 and 12/31/1964 in the second subsample).
No. of patients
274BRASLOW AND STARKS
sample (p ? .0388; see Table 2). What, then, made them so reluctant to use
lobotomy in their male patients that they lobotomized six women for every one
man (85% vs. 15%)? As Table 3 suggests, one cannot attribute this difference to
the gender distribution either of the patient population as a whole or of those
diagnosed with dementia praecox, the most common diagnosis among Stockton
lobotomy cases: Men slightly outnumbered women in both respects and thus, by
numbers alone, should have been at least equally likely candidates for lobotomy
(e.g., California, year ending June 30, 1949, p. 66).
It is important to note that Stockton’s lobotomy gender distribution was more
dramatic than, but nonetheless consistent with, the national average. An exhaus-
tive survey of public and private mental hospitals and general hospitals with
psychiatric wards reported that between January 1, 1949 and June 30, 1951,
surgeons lobotomized 12,296 patients, nearly 60% of whom were women
(Kramer, 1954). Thus, although Stockton may be a somewhat extreme case of
physicians’ tendency to lobotomize more women than men, this tendency was
nonetheless widespread. Patient records from Stockton, which include transcripts
of clinical conferences and patient interviews, provide a revealing window into
the ways cultural values shaped physicians’ decisions and interpretations sur-
rounding the use of lobotomy.
Psychotic Patients, Lobotomy, and Gender
In an earlier analysis of lobotomy at Stockton, Braslow (1997) examined
some of the reasons that physicians often found women to be especially good
surgical candidates (pp. 152–175). This examination, however, fell short in
explaining why doctors lobotomized men so infrequently: Physicians’ reluctance
to lobotomize men stemmed from reasons distinct from those that encouraged
Psychotic Patients at Stockton: Gender Distribution Within Diagnostic
Categories and Treated Populations
No. of patients
New admissions, by diagnosis
Any psychotic diagnosis, 1945–1950 (n ? 1,800)
Dementia praecox, 1945–1950 (n ? 1,181)
Lobotomy, 1947–1954 (n ? 232)
ECT, pre-1954 (n ? 39)
ECT, 1954 onward (n ? 59)
Antipsychotic drugs, 1954 onward (n ? 119)
ECT and/or drugs, 1954 onward (n ? 133)
New admissions data is from California (multiple years): years ending June 30,
1946–1950. Lobotomy data is from Stockton State Hospital’s surgical logs of all lobot-
omies performed; data on electroconvulsive therapy (ECT) and antipsychotic drugs is
from the systematic sample described in the note of Table 2. Lobotomy patients’ ages (n ?
192) ranged from 19 to 88 years, with an average age of 41 years. Of the 145 cases in
which race could be determined, 125 were White (86%), 10 were Hispanic (7%), 8 were
Black (6%), and 2 were Asian (1%). This ethnic distribution differed little from the
demographics of the hospital (California, 1950, p. 54).
Male %Female %
275 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
them to operate on women. Specifically, doctors’ disinclination to lobotomize
men arose out of contradictions between their conceptions of proper male gender
roles and the biological consequences of the intervention itself—consequences
that were unique to lobotomy and thus led to a unique role for gender in the
context of this treatment.
Much like other somatic treatments, lobotomy provided a therapeutic means
by which to control patient behavior. This behavioral control was as important for
men as for women, as in the case of Edward, a patient whose doctors decided on
lobotomy after he remained “continually hyperactive and combative” after more
than 200 electroshock treatments (see Starks & Braslow, 2005, p. 185). Unlike
these other treatments, however, the biological effects of lobotomy led to severe
and permanent changes in patients’ personalities and capabilities. Though these
changes were tied up in the behavioral control effected by the surgery, and thus
were to some extent desirable, physicians did not view them as unambiguously
positive. The desirability, acceptability, or lamentability of the changes depended
on how they would contribute to or detract from a patient’s ability to fulfill the
roles that were expected of him or her.
Not surprisingly, the nature of these roles was highly dependent on the
patient’s gender. In particular, treatment decisions were influenced by the degree
to which the dependence induced by lobotomy was acceptable in male versus
female patients. As doctors saw it, the surgery produced neurologically castrated
men: childlike, pathologically indifferent or apathetic, and incapable of meaning-
ful labor. Physicians not only found these characteristics much less palatable in
their male patients but also saw them as possessing real repercussions for the male
patient’s ability to function independently of the institution. We look first at how
physicians assessed characteristics of dependence in their male patients—viewing
them as childlike, apathetic, and incapable of labor—and then at the implications
that these characteristics had for a patient’s capacity to function as a man in the
social world outside of the hospital.
Lobotomy consistently created what Walter Freeman called a
“surgically induced childhood,” a fate that was inimical to the fulfillment of male
role expectations and, therefore, that Stockton physicians were quite hesitant to
inflict on their male patients (Freeman & Watts, 1942). Preparing a patient’s
worried mother for this almost inevitable outcome, the superintendent at Stockton
wrote to her: “It is necessary to give these patients a rather long training course
much as one trains a little child in good behavior.” One means of enforcing this
behavior, according to Freeman and his coauthors, was spanking. “Spanking,”
they wrote, “is as effective a method as we know, since it seems to recall
childhood experiences of a similar nature.” They cautioned that although it “is
good for the patient,” spanking “may distress the family” (Ewald, Freeman, &
Watts, 1947, p. 212).
Stockton physicians viewed this return to childhood as quite consistent with
femininity and, thus, as a restoration of the way things should be. When Emily
Starbuck was hospitalized at 27 years of age, her physician commented: “For past
several years has been totally irresponsible about care of her children—has been
immoral.” Six years later she was lobotomized, with the following outcome: “Her
immediate postoperative reaction was good . . . She has become more interested
276 BRASLOW AND STARKS
in housekeeping duties . . . She has shown none of the assaultive behavior that she
did prior to operation. She is childlike, naı ¨ve, and quite friendly.”
In evaluating their male patients, however, physicians often reported this
transformation with a good dose of frustration, as with this recently lobotomized
His ideational content is very childish and juvenile. . . . [The] patients regard him
as rather comical and childish. . . . He has such a short attention span that he does
not maintain much interest in any given task and does not complete it. . . . On
interview the patient answers questions coherently and relevantly. . . . The content
of these topics is very childish. He asks questions that one would expect of a six
or seven-year-old child.
These two cases show the strikingly different assessments that physicians
were able to make about the behaviorally identical outcomes of biologically
identical surgeries. Gender norms fundamentally shaped these assessments so that
an outcome that deterred physicians from operating on their male patients could
be at best a neutral consideration (and at worst an encouragement) in the decision
of whether to operate on their female patients.
Another consistent effect of the frontal lobe damage intentionally
inflicted by lobotomy was to make patients apathetic or indifferent—as if, some
observed, the patient’s soul had somehow stolen away during the surgery (Green-
blatt, Arnot, & Solomon, 1950). A physician’s reading of this consequence
depended critically on the patient’s gender. In female patients, doctors interpreted
this as a positive clinical effect, one that reinforced a woman’s proper gender role.
After noting the demure indifference in a lobotomized woman, a Stockton
physician suggested its therapeutic significance to a colleague: “[M]aybe that is
what cures them.” These interpretations resonated with family members as well,
though undoubtedly not with the women themselves. A satisfied husband, whose
lobotomized wife now cooked and cleaned without complaint because she had
become quite indifferent, enthused: “I think it is for the best really because she
doesn’t worry at all about anything.”
In male patients, however, apathy was seen as an untoward, rather than
curative, consequence of surgery: As effectively as it helped to bring female
patients into compliance with female gender roles, lobotomy-induced apathy
demolished any chance that male patients might succeed as men. The case of
Frank Brothers, lobotomized when he was barely 20, illustrates these particularly
dark results. Though Frank first experienced disabling psychiatric symptoms as a
young adolescent, his parents resisted institutionalizing him, hoping that he
eventually would outgrow his troubles. Despairingly, they watched as his behav-
ior deteriorated and he became increasingly violent. When they learned that a new
“miracle” surgery was available at Stockton State Hospital, Frank was hospital-
ized and, a few days later, lobotomized. As evidenced by Frank’s postlobotomy
examination, the surgery effectively vanquished his violent spells, but not without
The family was here this morning. I gave them the stall—
Dr. Adams: So did I . . . Hello Frank.
277MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
Dr. Adams: Who came to see you today?
Dr. Adams: Who came to see you today?
Dr. Adams: Can you write? (Gives patient paper and pencil.)
Write your name. Catch the pencil, do not let it roll off the
table. Write your name. Do you want to be coaxed?
(Patient does not try to write.)
Dr. Adams: He is doing pretty well though.
(Gets up and hands patient the pencil.) Write your name—take
it easy now, that is it, just write your name.
(Patient writes a little then looks around.)
He wrote Frank, is that it?
Dr. Adams: Yes.
I think he should have another month’s training here.
Groping for some positive assessment of Frank’s listlessness, Adams offered:
“He will not be assaultive, that is one thing.” Clearly disheartened by Frank’s
deficits, his physicians no doubt viewed this as a Pyrrhic victory: Left unsaid,
because it was apparent to all assembled, was that though Frank would no longer
be violent, he also would never be independent.
The degree of postoperative apathy induced in Frank would hardly be viewed
as a positive outcome in any patient—man or woman. This apathy was, however,
much more at odds with male gender roles than female ones and, as such, posed
a particularly agonizing dilemma when it came to lobotomizing male patients. In
deciding whether to operate on a male patient, physicians had to consider whether
the gain in behavioral control was worth the cost: a surgically induced indiffer-
ence that vitiated any possibility for the patient to live up to society’s expectations
of him. The weighty nature of this consideration is apparent in Bob Mason’s case
record. When Bob’s ill behavior continued unabated postlobotomy, his dismayed
physicians convened a case conference to consider another assault on his frontal
lobes. The highly unusual nature of this meeting signaled their growing frustration
over his conduct: Up to that point, Stockton physicians had never lobotomized a
male patient more than once.2Despite their desire to end his violent behavior, a
second lobotomy was not to be taken lightly:
2By the end of the lobotomy program at Stockton State Hospital, 13 women had been
lobotomized two or more times, whereas only one man had undergone multiple lobotomies.
278 BRASLOW AND STARKS
The family was talking about further lobotomy.
How do you feel about that?
Dr. Rubinger: I do not think I would consider it at this time.
. . . We cannot do any more harm. It might do some good . . .
The risk you take is there is too much apathy and dullness.
There is the question of how much.
In this case, knowing it and taking it as a total picture, it
would be far better to have him apathetic than the way he is.
It is not necessarily true . . .
After the lobotomy he was rather restless and apathetic for a
You feel that a lobotomy might be indicated?
It might satisfy the family.
Do you think a lobotomy might help the fellow?
It would quiet him down, I think but then the family will be
unhappy because he is hypoactive.
Although these physicians believed that a second lobotomy had a good chance
of quelling Bob’s violent behavior, that was not reason enough. They were
unwilling to subject Bob to a cure that they saw as potentially worse than the
Incapable of meaningful labor.
A successful operation, one that pacified a
previously incorrigible patient, almost invariably further worsened the patient’s
already compromised ability to perform meaningful labor. This troubling outcome
was repeatedly noted in Stockton physicians’ narratives. Although of little import
in gauging the success of lobotomy in women, in the lobotomized male patient it
signaled yet another erasure of his status as a functioning man, as we see in
Stockton physicians’ assessments of Tom Rudnick.
During the first 7 years of his continuous hospitalization, Tom had become
increasingly recalcitrant, unpredictable, and violent. His physicians’ commentar-
ies charted not only Tom’s descent but also their own growing helplessness in
dealing with him and their eventual decision to lobotomize him. Their notes
written after the surgery plotted a new course for Tom: Although lobotomy had
vanquished the outward manifestations of his inner torment, he had become “quite
contented to remain in the hospital for the rest of his life.” “He is,” a doctor
commented 2 years after the surgery, “lazy and sneaky, and needs complete
supervision while performing duties.” The physician conceded that, although Tom
now “does as he is told,” the lobotomy had made him either willfully slothful or
truly incapable of work, and—irrespective of the cause of his indolence—the
operation had assured Tom’s permanent dependence on the hospital: “The staff is
not willing that he should leave the hospital by himself as they feel that he would
279 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
quickly become a public charge and have to be returned.” In the end, Tom actually
did leave. Nearly a decade after his lobotomy, his physicians candidly acknowl-
edged in their final entry that Tom was “unimproved.” A sad and dubious
therapeutic success by any measure, the denouement of Tom’s sojourn at Stockton
was as ironically anticlimactic and bureaucratically sterile as his hospitalization
had been tumultuous. The final tersely written and barely legible doctor’s order
directed that he be sent to another, less restrictive institution, a quiet affirmation
that Tom, if nothing else, no longer required the therapeutic discipline of the state
The above characteristics were important not only
because physicians and families preferred that patients’ humanity (and therefore
masculinity or femininity) remain intact but also because those characteristics had
real consequences for whether there would be a place for the patients in the social
world outside of the hospital. Postlobotomy patients who were childlike, apa-
thetic, and incapable of meaningful labor were practically guaranteed to be
dependent on the hospital or, if well enough to be discharged from the institution,
on family members.
Dependence on others—financial, emotional, or physical—was much more
acceptable in women than in men. At Stockton, postlobotomy patients had a much
better chance of becoming independent of the hospital if they were women than
if they were men. Of all lobotomized patients, 24% of men and 62% of women
were eventually discharged, either to the care of their families or to a nursing
home, whereas 19% of men and 9% of women were transferred to another state
hospital, unlikely ever to leave their new institution. Of lobotomized men, 57%
never left Stockton, compared with 29% of lobotomized women.
These numbers cannot reasonably be explained on the grounds that male
lobotomy patients were simply more impaired, either at the outset or as an
outcome of the surgery. Lobotomy was a treatment of last resort in all patients,
and so even though physicians were more likely to decide against lobotomy when
a patient was a man, it is unlikely that they lobotomized any patients—men or
women—who were not exceptionally ill. As for surgical outcomes, the biological
effects of lobotomy (though interpreted in a gendered light) were the same in men
and women, and thus the level of impairment was objectively the same.
Instead, it seems that the importance of gender in lobotomy went beyond
physicians’ willingness to perform the surgery. Society—patients’ own families
not excepted—was apt to be more tolerant of postlobotomy characteristics in
women than in men and thus was more likely to have a place for lobotomized
women than for lobotomized men. Regardless of the reasons that lobotomized
men were unlikely to be discharged, the fact of these discharge rates probably was
not lost on physicians. Physicians were probably even more reluctant to loboto-
mize men versus women because of the knowledge that men had such a low
probability of being able to leave the hospital after the surgery.
Stockton physicians’ reluctance to lobotomize their male patients, in contrast
to their relative willingness to prescribe antipsychotic drugs for male or female
patients, shows the complex interaction between the social and the biological in
280 BRASLOW AND STARKS
psychiatric practice. Treatment decisions and outcome evaluations depended on
the particular intersection between the biological effects of the treatment, the
patient’s diagnosis, the physician’s therapeutic rationale, and social values such as
gender role expectations. When treating psychotic patients with lobotomy, Stock-
ton physicians weighed the need for behavioral control against the outcomes of
the surgery, and they found these outcomes much less acceptable in male patients
than in female patients. Antipsychotic drugs, although employed with essentially
the same therapeutic rationale, had outcomes that were much more acceptable in
patients of either gender. Thus, physicians prescribed them widely for psychotic
men and women. As we will see in the next section, they also prescribed these
same drugs for nonpsychotic patients of both genders. Although gender did not
determine which nonpsychotic patients got treated, it did figure heavily in inter-
pretations of disease and cure.
Nonpsychotic Patients, Antipsychotic Drugs, and a New
Following World War II, the distribution of patients admitted to state hospi-
tals changed dramatically as patients increasingly entered the hospital with
nonpsychotic ailments. Between the years 1934–1935 and 1959–1960, the num-
ber of nonpsychotic first-time admissions increased from 63 (1%) to 2,736 (17%),
an astonishing 4,243% increase. In contrast, psychotic first-time admissions
increased from 1,821 (40%) to 6,130 (39%), or 237%—roughly the same steady
increase as overall first admissions (246%). Thanks to the spectacular increase in
nonpsychotic admissions, the 15,665 patients admitted for the first time in
1959–1960 included 6,130 (39%) with psychotic diagnoses and 2,736 (17%) with
nonpsychotic diagnoses (California, year ending June 30, 1935, Table 5; year
ending June 30, 1960, Table 26).
This increase in nonpsychotic patients did not reflect a reclassification of
patients who previously would have been diagnosed as psychotic but rather
reflected a redrawing of the line between “diseased” and “normal” psychological
distress that resulted in the creation of entirely new patients. Thus, these individ-
uals’ status as patients was an entirely new phenomenon, as was the rationale that
governed their treatment: Unlike the behavioral control central to the treatment of
psychotic patients, the care of nonpsychotic patients involved the biological
treatment of internal psychological distress, required agreement between physi-
cian and patient, and gave medical meaning to patients’ failings without absolving
them of moral responsibility (for more information on these new patients and the
rationale governing their care, see Starks & Braslow, 2005).
Also worth noting about these new patients is that they were consistently, and
increasingly, more often men than women. Of nonpsychotic patients admitted to
California state hospitals between 1935 and 1940, 58% were men; between 1955
and 1960, 65% were men (see Table 1; California, years ending June 30,
1935–1940, 1955–1956, 1959–1960; biennium ending June 30, 1958). Though
the reasons for this gender distribution are unclear, it is an interesting counterpoint
to the common perception that early neurotic patients were usually women (Metzl,
2003). In our look at the treatment of these nonpsychotic patients, we tell the
281 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
stories of both male and female patients, hopefully helping to show a side of early
anxiety and depression that was not all about child rearing and housework.
As in the treatment of psychotic patients, Stockton psychiatrists prescribed
antipsychotic drugs for both male and female nonpsychotic patients. In our sample
of 61 nonpsychotic patients (27 men and 34 women) hospitalized after the
introduction of antipsychotic drugs, Stockton physicians prescribed drugs for 37%
of men and 59% of women (see Table 4). These treatment rates are not signifi-
cantly different (p ? .0909), and the records of nonpsychotic patients do not
suggest that Stockton physicians were particularly reluctant or enthusiastic to
prescribe drugs for patients of one gender or the other. Instead, a patient’s gender
was central to the kinds of problems that brought him or her to the hospital, as
well as the ways physicians interpreted these problems as illness, decided to treat
them, and evaluated the outcomes of treatment.
Gendered Social Failings
Entering a state psychiatric hospital entailed the acknowledgment (whether by
the patient or by those responsible for his or her involuntary commitment) that the
patient was experiencing significant difficulty in the world outside of the institu-
tion. Prior to World War II, when the vast majority of state hospital patients
suffered from psychotic disorders, this difficulty was often evidenced by ex-
tremely bizarre behavior. In the years following the war, however, as problems
that previously would have been grounds for moral censure, social opprobrium,
and personal humiliation were forged into objects of medical intervention, much
milder forms of dysfunction became grounds for institutionalization. Those non-
psychotic patients who entered the hospital after the war tended to do so because
of a sense—whether acknowledged by themselves or only by their families—that
Nonpsychotic Patients at Stockton: Treatment With ECT and/or Antipsychotic
Drugs, Before and After 1/1/1954
No. of patients
69Prior to 1/1/1954 (n ? 16)
Men (n ? 6)
Women (n ? 10)
On or after 1/1/1954 (n ? 61)
Men (n ? 27)
Women (n ? 34)
We systematically sampled patients from California’s Stockton State Hospital
using the date of final admission. Restricting that sample to patients whose final admission
occurred between 1/1/1940 and 12/31/1964 resulted in a sample of 251 patients (183
psychotic, 68 nonpsychotic). Of the 68 nonpsychotic patients, 16 were in the hospital prior
to 1/1/1954, and 61 were in the hospital on or after 1/1/1954. We assessed patients in each
of these subsamples for whether they were treated with electroconvulsive therapy (ECT)
and/or antipsychotic drugs during the relevant time period (prior to 1/1/1954 in the first
subsample and between 1/1/1954 and 12/31/1964 in the second subsample).
282BRASLOW AND STARKS
they had failed on some level as human beings. Though patients experienced these
failures as very basic and personal, in a more general sense each of them had
failed to live up to society’s expectations—expectations which, because of the
nature of social norms, were strongly dependent on a patient’s gender.
Herbert Bailey’s hospitalization at Stockton provides us with an example not
only of the kinds of failures that brought patients to the hospital but also of the
extent to which these failures depended on gender-specific expectations. Herbert
was not psychotic by any measure—he had a firm grasp of reality and denied all
of the stigmata of insanity, such as hallucinations and delusions—and his telltale
signs of neurosis (mostly in the form of failing to “live up to his responsibilities”)
would rarely, if ever, have led to his hospitalization prior to the war. But in 1957,
marital and occupational disappointments provided ample justification for his
psychiatric diagnosis and hospitalization—a fate that 39-year-old Herbert will-
ingly sought, if not enthusiastically, then at least as preferable to the world outside
of the state asylum. Ineffectually supporting his wife and children and frequently
out of work, Herbert desperately wanted psychiatric help. Fearful that he might be
turned back at the hospital’s gates, he contrived an intentionally botched armed
robbery to prove his need for professional care. This plan proved a rare success
for Herbert: He was taken promptly to Stockton, where the admitting physician
probed his self-professed deficiencies over the course of at least two interviews
before diagnosing him with a “psychoneurotic reaction”:
He has been having much difficulty with his wife, and this is understandable. It is
the second marriage. There are four children to be looked after. He is an inade-
quate person himself and had been unable to make a proper living for himself and
his family . . . and has resorted to alcoholism to excess. . . . He is a dull normal
person at best and has been a somewhat inadequate individual and has been unable
to make his way in life.
Epitomized by his bungled robbery, in which a healthy man would have made a
better show of it, the symptoms of Herbert’s disease—summarized by his inability
“to make his way in life”—all pointed to an illness rooted in newly staked-out
Interpretations of these new illnesses in male patients—by doctors, families,
and patients themselves—had much to do with definitions of masculinity and
what one had to do to be a psychologically healthy man. Such gendered under-
standings are especially striking in the case of Theodore Howland, who was
voluntarily hospitalized in the early 1950s after his wife learned from their
11-year old daughter that he had asked her to expose herself in front of him:
Over a 36-day period from that time he made numerous attempts to view her
nakedness, pinch her legs, once patting her on the vulva (over the blanket she was
under), asking her to allow him to feel of “that hairy place” [his words]—going in
to kiss her at all hours of the night.
Viewing this intolerable behavior not as a criminal act but as psychiatric
disorder, Mrs. Howland insisted that Theodore seek help in the hospital or else she
would leave him. His Stockton physicians echoed this interpretation, diagnosing
him as suffering from an “inadequate personality,” characterized by the Diagnos-
tic and Statistical Manual of Mental Disorders as the following:
283 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
an inadequate response to intellectual, emotional, social, and physical demands.
They are neither physically nor mentally grossly deficient on examination, but they
do show inadaptability, ineptness, poor judgment, lack of physical and emotional
stamina, and social incompatibility. (American Psychiatric Association, 1952,
As his hospitalization progressed, it became clear that Theodore’s physicians
saw his sexual proclivities only as signifiers of an illness with much deeper roots.
At a staff conference, in language indebted to the growing hegemony of psycho-
analysis in American psychiatry (even in large, overcrowded, state hospitals),
Theodore’s physician offered the following encapsulation:
Evaluating the entire picture, one finds a family situation of a dominant wife and
a basically dependent husband. This automobile [accident] can be probably con-
sidered to have been a trigger mechanism for putting into play all the unsatisfied
dependency needs of the patient, however, the patient has been, and is still unable
to accept his dependency role and this is in conflict with his ideals of masculinity.
He has apparently regressed from a relatively juvenile sexual attitude to that of an
infantile level in a response to impotence in the sexual interrelationships with his
wife and in response to her dominant role. This is apparent also in the social
relationships of the family in the occupational area where the wife has again taken
the dominant role . . . [he] is incapable of coping with his ideals of what a
“masculine” individual would do.
All of Theodore’s symptoms—his unemployed state, his dependence on his
wife’s income, his poor (to say the least) parenting skills—orbited around what
his physicians saw as his most glaring problem, namely, his failure to be a man.
As the interview ended, Theodore hammered the last nail in the coffin of his
moribund masculinity: He “broke under the stress of discussing his inability to
master his ideas of masculinity” and cried.
Though life failings brought more men to California hospitals than women,
the failures and distress that led to the hospitalization of nonpsychotic women
were every bit as gendered as those suffered by Herbert or Theodore. Olive
Wilson had become increasingly depressed following the birth of each of her
several children, until she finally found herself “unable to carry on at housework”;
her distress over this, along with her rocky relationship with her husband, led her
to seek voluntary admission to Stockton in the early 1950s:
Dr. Adams: What would you like to do that you cannot do now?
I would like to keep my house and my husband . . .
Dr. Adams: Do you get mad at your husband?
Dr. Adams: What do you do?
I do not know. I forgot.
Dr. Adams: Kick his teeth in or go in the bedroom and cry?
I tell him off, what I think.
284 BRASLOW AND STARKS
Dr. Adams: What does he do?
He laughs. He knows. He understands. He is not so dumb . . .
Dr. Adams: Maybe you got the wrong husband?
I do not know whether he is the wrong one or not. I seem to like
him pretty well.
Dr. Adams: Does he like you?
Sure, I like my husband.
Dr. Adams: I like mashed potatoes. Is that the way you like your husband?
Just about. I like mashed potatoes. What is wrong with mashed
Dr. Adams: Usually you get more involved emotionally with your husband
than with mashed potatoes.
Olive’s concerns—depression linked to her role as a mother and concern that
her unhappiness impaired her ability to “keep my house and my husband”—were
as dependent on her roles as a woman as was Herbert’s distress over his failures
as a breadwinner, husband, and father. The importance of gender had little to do
with the nature of psychiatry or of Stockton State Hospital and everything to do
with the social world in which both patients and doctors lived: The ways patients
felt distressed or unhappy, or judged themselves as failures, depended on expec-
tations (including their own) that were often shaped by their roles as men or
women. The physician’s part in all of this was simply to try to make sense of a
patient’s unhappiness or failure—as when Theodore’s doctors attributed his
problems both to his own dependent tendencies and to an overly dominant wife,
or when Dr. Adams interrogated Olive’s emotional disengagement out of a
suspicion that a mismatched marriage was the cause of her troubles—and, when
possible, to try to fix whatever it was that seemed to be the problem.
Nonpsychotic Patients, Antipsychotic Drugs/ECT, and Gender
When patients were hospitalized for failures of everyday life like those
described above, both the need for treatment and the interpretation of its effec-
tiveness were inextricably tied up in social judgments in which the patient’s
gender was an important factor. For example, when Steven Harris admitted
himself to Stockton in 1956 complaining of fits of anxiety, his failure to hold
down a job soon surfaced as the greatest sign of his illness:
Patient states that for the past five years he has not been able to hold any job for
more than six months. Each time he starts on a job for two or three months, his
boss would learn about his changing jobs frequently in the past and talk about him.
He would then get so angry and quit the job immediately.
Steven’s physicians were quick to sympathize with his wife, who saw in his
hospitalization the hope “that he could be self-supporting.” They diagnosed him
285 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
with an “emotionally unstable personality,” which made him incapable of fulfill-
ing his duties as a man: “He cannot be a good husband to his wife because of
lacking a steady job and income.” As a remedy for this decidedly male failing, the
doctor prescribed a simultaneously biological and psychological cure in the form
of chlorpromazine and psychotherapy. One month later, his doctors believed that
he had recovered sufficiently to be discharged—a decision that they based on his
willingness “to leave and get a job.”
Female patients also received treatments such as psychotherapy, ECT, and
antipsychotic drugs in an effort to restore them to their proper gender role. When
Wendy Johnson voluntarily admitted herself into Stockton in the early 1950s, she
reported that she was unhappy in her marriage and exhausted from caring for her
very active toddler:
Even though this patient has been able to complete her housework, she has, since
December 1950, become concerned about her own worthiness as a mother and as
a wife. She tells her husband that she now knows why she has never been able to
be a good wife to him, but is unable to explain to him what she believes.
Wendy evoked mixed feelings in her doctors: Described as “an acute actor-
outer” who “has had repeated affairs with other men, abortions, although she does
have the decency to get depressed about it,” she also elicited admiration. “This
woman,” wrote her psychologist, “has intelligence, energy and good matu-
rity . . . and, in general, is better adjusted and more secure than her husband.” Yet,
it was Wendy who had offered herself up as a patient to be healed, and, as such,
it was she and not her husband who needed treatment. Furthermore, her trans-
gressions of prescribed gender roles not only marked her as a patient but also
dictated what needed treatment:
Her natural drive and ambition have tended to conflict with her husband’s similar
drive and ambition. Incidentally, hers seems to overshadow his, and in view of his
latent homosexuality, this should be corrected. She needs to make a definite effort
to contribute to his male ego and to subdue something of her own drive and
competency for his sake.
On her first admission in 1951, the doctors “corrected” her “drive and
ambition” with psychotherapy and ECT. Six years later, when she returned to the
hospital (again voluntarily) still haunted with “guilt feelings about infidelity on
her part while her husband was in the Merchant Marine during the war,” her
doctors treated her with the newly available antipsychotic drugs as well as ECT
Though a patient’s sex had little impact on rates of treatment for nonpsychotic
disorders, gender norms nonetheless were very much a part of patients’ and
physicians’ understandings of disease and cure. The expansion of psychiatry into
the diagnosis and treatment of nonpsychotic disorders led to a therapeutic ratio-
nale (see Starks & Braslow, 2005) in which biological cures could be applied to
inner distress and everyday failures. As a result, societal expectations and val-
286 BRASLOW AND STARKS
ues—and therefore ideas about gender—fundamentally shaped the ways doctors
and patients understood disease and cure.
Gender has always been a part of psychiatric practice, simply because gender
is a part of the social worlds inhabited by doctors, patients, and their families.
Though certainly one could read psychiatric patient records to trace shifts in
gender norms and other sociocultural values over time, these norms and values are
not the only factors determining the role of gender in psychiatric care. Any
therapeutic interaction is made up of the patient’s symptoms; the psychiatric
theory, diagnosis, and possible treatments that the psychiatrist brings to both
patient and symptoms; the therapeutic rationale that governs the patient’s treat-
ment; and the social context and values of both patient and physician.
In the years prior to and immediately after the introduction of antipsychotic
drugs, psychotic patients were hospitalized and treated as a result of overtly
disordered behavior, and the rationale governing their treatment essentially was
one of behavioral control. Though gendered interpretations were not entirely
absent, they were not essential to the determination or interpretation of disease.
Instead, gender became important in certain treatment deliberations: The unpleas-
ant side effects of lobotomy forced clinicians to weigh the desirability of partic-
ular deficits in a given patient; whereas the less unpleasant effects of antipsychotic
drugs meant that gender played little role in prescription rates.
As psychiatry expanded its scope into problems of everyday living, however,
gendered understandings became much more integral to psychiatric practice.
Psychiatry mapped itself onto the social terrain of patients’ inner worlds, creating
psychiatric disease categories and explanations that made sense to patients and to
those around them. Though the psychiatry of everyday living has often been
criticized for the medication and subjugation of women, our Stockton records
suggest that the role of gender in psychiatry grew out of the role of gender in life:
Nonpsychotic patients were hospitalized and treated with antipsychotic drugs
regardless of gender, but they were hospitalized, analyzed, and treated as men or
as women, just as they were evaluated as men or as women in the world outside
of the hospital.
The therapeutic rationale that governed the treatment of nonpsychotic patients
was never one in which biological cures (ECT, antipsychotic drugs) were at odds
with the psychosocial problems for which they were prescribed. Physicians
prescribed antipsychotic drugs for Steven and Wendy without once suggesting a
biological cause for their difficulties. However, this early form of biological
treatment laid the groundwork for later shifts in psychiatric understanding that
would favor the biological over the psychosocial. In the decades that followed,
psychiatrists would find new classes of psychotropic drugs to be useful in
particular disorders, and theories about why and how the drugs worked would
give birth to new theories of the disorders themselves. The biological explanations
of contemporary psychiatry would be mapped onto the psychosocial understand-
ings of the mid-20th century, much as those understandings previously had
mapped themselves onto patients’ inner and social worlds.
Contemporary psychiatry’s—and society’s—language of self has become
287 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 2
much more biological over the past half century, obscuring the extent to which Download full-text
today’s biopsychiatry is built upon the psychosocial foundations of the mid-20th
century. Stockton patient records from the mid-20th century reveal the remarkable
extent to which social and cultural determinations are imbedded in the practice of
psychiatry, from interpretations of a patient’s unhappiness to evaluations of the
biological effects of lobotomy. They also suggest that the role of cultural judg-
ments was less a manifestation of a sinister social agenda and more a reflection of
the social values of the time. Social values are unlikely to disappear from
psychiatry, no matter how thoroughly biological its treatments and theories
become. Instead, psychiatry becomes increasingly value neutral in appearance
only, even as its means of intervening into our selves and social worlds continue
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Received April 15, 2002
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Accepted January 24, 2005 y y
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