THE MAKING OF CONTEMPORARY AMERICAN
PSYCHIATRY, PART 1:
Patients, Treatments, and Therapeutic Rationales Before
and After World War II
Sarah Linsley Starks and Joel T. Braslow
University of California, Los Angeles
This article, the 1st in a 2-part series, uses patient records from California’s Stockton
State Hospital to unearth the midcentury roots of contemporary American psychi-
atry. These patient records allow the authors to examine 2 transformations: the
post–World War II expansion of psychiatry to include the diagnosis and treatment
not only of psychotic patients but also of nonpsychotic patients suffering from
problems of everyday living, and the 1950s introduction of the first psychotropic
drugs, which cemented the medical status of these new disorders, thus linking a new
therapeutic rationale to biological understandings of disease. These transformations
laid the groundwork for a contemporary psychiatry characterized by voluntary
outpatient care, pharmacological treatment of a wide range of behaviors and
distress, and a doctor–patient relationship and cultural acceptance of disease that
allow psychiatric patients to identify themselves as consumers.
Contemporary American psychiatry owes much to transformations that oc-
curred in the middle of the 20th century, in the decades shortly before and after
World War II. During this time, the scope of psychiatry expanded dramatically:
The concept of psychiatric illness grew to include a broad range of problems of
everyday living, and the widespread biological treatment of psychiatric ills was
made possible by the introduction of antipsychotic drugs, the first therapeutic
drugs in psychiatry’s now immense pharmacopoeia. These transformations made
possible the development of a contemporary psychiatry that is made up primarily
of outpatient psychiatric consumers and that is simultaneously psychological and
biological—a psychiatry that is far removed from that of the early 20th century
but that nonetheless owes its existence to the very foundations that it has so
notably left behind.
Sarah Linsley Starks, Health Services Research Center, Neuropsychiatric Institute, University
of California, Los Angeles; Joel T. Braslow, Department of Psychiatry and Biobehavioral Sciences,
Neuropsychiatric Institute, University of California, Los Angeles.
Sarah Linsley Starks is a staff research associate at the Health Services Research Center of the
University of California, Los Angeles (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. Joel T. Braslow is an associate professor of
psychiatry and biobehavioral sciences at the 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.
Correspondence concerning this article should be addressed to Joel T. Braslow, Department of
Psychiatry and Biobehavioral Sciences, Wilshire Center, University of California, 10920 Wilshire
Boulevard, Suite 300, Los Angeles, CA 90024-6505. E-mail: firstname.lastname@example.org
History of Psychology
2005, Vol. 8, No. 2, 176–193
Copyright 2005 by the Educational Publishing Foundation
Prior to World War II, American psychiatry was characterized by the insti-
tutional care of severely ill psychotic patients, whose illness was characterized by
out-of-control behavior and treated, often involuntarily, with somatic therapies,
which included hydrotherapy, electroconvulsive therapy (ECT), and lobotomy.
Because early psychiatric practice is so heavily associated with the asylum (and
later the state hospital), it is easy to forget that many of the transformations that
foreshadowed contemporary psychiatry took place prior to deinstitutionalization,
within the walls of the state psychiatric hospital. In the two articles in this series,
we use the records of California state hospital patients hospitalized between 1940
and 1965 to examine the early stages of two of these transformations: the dramatic
expansion of the kinds of problems that led patients to seek psychiatric care, and
the introduction of the first psychotropic drugs.
In the first article we argue that the postwar diagnostic expansion did more
than just increase the number of psychiatric patients and diseases categories: It led
to the creation of a new therapeutic rationale, or way of understanding disease and
cure (Braslow, 1997). Prior to the 1940s, institutional psychiatry was dominated
by a therapeutic rationale that equated disease with disordered behavior and
viewed behavioral control as the object of psychiatric treatment. While this
therapeutic perspective continued (and continues) to guide the treatment of
severely ill patients (most often diagnosed with a psychotic disorder, e.g., schizo-
phrenia), the postwar expansion of psychiatry into the treatment of problems of
everyday life allowed this prewar rationale to be joined, and eventually tempered
to some extent, by one much more familiar to contemporary psychiatry. This new
rationale transformed psychological suffering into treatable biological disease and
laid the groundwork for our contemporary psychopharmacological era, in which
patients willingly offer up their distress for treatment with psychotropic drugs. In
the second article (Braslow & Starks, in press), we return to California state
hospital records to understand the ways cultural values informed the treatment of
psychotic and nonpsychotic patients before and after the introduction of antipsy-
chotic drugs. Using gender as an exemplar of culture, we show that the impact of
cultural values on psychiatric care depended on the particular interaction of the
patient’s diagnosis, the biological effects of the treatment, and the therapeutic
rationale governing the patient’s care, as well as the patient’s gender.
Our examination is based largely on patient records from Stockton State
Hospital.1Stockton, 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. New construction never kept pace with this
escalating patient population. In 1937, at the height of overcrowding, the Cali-
fornia Department of Institutions estimated that the hospital was 33% over its
ideal capacity (California Department of Mental Hygiene, 1935–1960, year end-
1All patient cases cited are from 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
for permission to review the cases.
177 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
ing June 30, 1937, p. 21). Conditions at Stockton improved dramatically follow-
ing the war, as both state and federal government paid renewed attention to mental
health. The National Mental Health Act of 1946 authorized the creation of the
National Institute of Mental Health, which took over the annual census of patients
in mental hospitals (formerly conducted by the Bureau of the Census), supported
the training of mental health clinicians, and provided funding to assist states in
planning for community-based mental health services; between 1948 and 1954,
the nation saw a dramatic increase in community-based mental health clinics
(Kolb, Frazier, & Sirovatka, 2000). During this same period, the California State
Legislature increased funding for state hospitals nearly fourfold, from $25 million
in 1947 to nearly $100 million in 1957, helping to reduce overcrowding to less
than 2% (California Department of Mental Hygiene, 1957), even as the state
hospital population continued to grow both in numbers and in the scope of
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 this first article, we use these records to examine the treatment of
two kinds of patients: the psychotic patients who characterized the early state
hospital, and the nonpsychotic patients who flooded into the hospital following
World War II, seeking care for problems of everyday life. These patient cases
offer a window onto not only the expansion of the scope of psychiatry but also the
early use of antipsychotic drugs, two phenomena that laid the foundation for much
of contemporary psychiatric theory and practice. In the second article, we return
to these two sets of patients to see how culture—in particular, gender—manifested
itself in the care of psychotic and nonpsychotic patients.
Postwar Diagnostic Expansion
Throughout the 20th century, psychiatrists divided psychiatric illness into two
main classes: “organic” and “functional” (Kaplan & Sadock, 1994, p. 336). They
classified as organic those illnesses for which there was an obvious cause (e.g.,
intoxication) or brain lesion (e.g., dementia), whereas the functional disorders—
those most commonly associated with the practice of psychiatry—had no ascer-
tainable biological cause. Psychiatrists further subdivided the functional disorders
into the psychotic and nonpsychotic groups, which in turn ramified into specific
diagnoses. The distinction between organic and functional was dropped in the
1994 publication of the American Psychiatric Association’s (APA’s) Diagnostic
and Statistical Manual of Mental Disorders, but the distinction between psychotic
and nonpsychotic disorders has retained its importance and has changed little over
time. Much of this stability is due to the stability of the psychotic disorders as a
whole. Though the borders between specific psychotic illnesses (e.g., schizophre-
nia, involutional psychosis, and manic–depressive illness) have shifted about,
these shifts were of minor consequence for the basic concept of psychosis (Noyes,
1934, 1948; Noyes & Kolb, 1958).
In the early 20th century, state hospitals almost exclusively housed patients
with psychotic disorders, organic diagnoses, or substance abuse. Patients with
178 STARKS AND BRASLOW
nonpsychotic diagnoses were few and far between. Table 1 shows the annual
number of first admissions to California state hospitals, beginning with fiscal year
1934–1935 and ending with 1959–1960. In 1934–1935, of the 4,523 patients
admitted for the first time to California state hospitals, 1,821 (40%) were diag-
nosed with a psychotic disorder, while only 63 (1%) were assigned a nonpsychotic
diagnosis. The remaining 2,639 (58%) were diagnosed with an organic illness or
with substance abuse—illnesses that fall outside of this article’s focus on func-
tional psychiatric illness (California Department of Mental Hygiene, 1935–1960,
year ending June 30, 1935, Table 5). Thus, prior to World War II, psychiatric
therapeutics in California state hospitals were almost entirely concerned with the
care of severely ill patients with psychotic diagnoses.
Following the war, the distribution of patients admitted to state hospitals
changed dramatically, as patients increasingly entered the hospital with nonpsy-
chotic ailments. Between 1934–1935 and 1959–1960, the number of nonpsy-
chotic first-time admissions increased from 63 (1%) to 2,736 (17%), an astonish-
ing 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 nonpsy-
chotic 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 nonpsy-
chotic diagnoses (California Department of Mental Hygiene, 1935–1960, year
ending June 30, 1935, Table 5; year ending June 30, 1960, Table 26).
This increase in nonpsychotic patients reflects not a reclassification of patients
who previously would have been diagnosed as psychotic but rather a redrawing of
the line between “diseased” and “normal” psychological distress that resulted in
the creation of entirely new patients. On admission to California’s Stockton State
Hospital, the source of our patient records, these patients told familiar tales of
anxiety, depression, relationship troubles, employment difficulties, and, some-
First Admissions to California State Hospitals by Fiscal Year and Diagnosis,
from infectious diseases (especially syphilis), trauma, senility, circulatory disease, sub-
stance abuse, and other organic causes. Data are from the California Department of Mental
Hygiene (1935–1960): years ending June 30, 1935, Table 5; June 30, 1940, Table 7; June
30, 1945, Table 10; June 30, 1950, Table 23; June 30, 1955, Table 17; June 30, 1960,
Organic diagnoses include epilepsy, mental deficiency, brain syndromes resulting
179MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
times, legal or moral transgressions. Many had sought the help of general
practitioners, private psychiatrists, or religious professionals before coming to
Stockton. Some went to the hospital on the advice of a physician, others were
taken by family members or the police, and many sought or acquiesced to
hospitalization because they simply could not bear to be in the outside world any
Also worth noting about these new patients is that they were consistently, and
increasingly, more often men than women. Fifty-eight percent of nonpsychotic
patients admitted to California state hospitals between 1935 and 1940 were men;
between 1955 and 1960, 65% were men (California Department of Mental
Hygiene, 1935–1960, years ending June 30, 1935–1940, 1955–1956, 1959–1960;
biennium ending June 30, 1958). Though the reasons for this sex 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 stories of a number of male patients,
which we hope helps to show a side of early anxiety and depression that was not
all about child rearing and housework. In the second article in this series, we
examine in more detail the role of gender in the hospitalization and treatment of
both psychotic and nonpsychotic patients (Braslow & Starks, in press).
The postwar years saw an expansion not only in the number of patients whose
feelings or behavior qualified them as ill but also in psychiatrists’ efforts to make
sense of this nonpsychotic illness. In 1952 the APA published the first edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM–I), replacing
the diagnostic taxonomy sanctioned by the APA in 1933. Reflecting recent trends
in psychiatric theory, the DSM–I was informed by psychoanalytic psychiatry and
by Adolf Meyer’s (Winters, 1951) emphasis on illness stemming from failures in
an individual’s adaptation to biological or psychosocial stresses (Grob, 1991;
Horwitz, 2002). It left the major psychotic disorders relatively unscathed while
substantially enlarging the ways nonpsychotic illness could be experienced and
named. The nonpsychotic diagnoses sanctioned by the APA in 1933 (and used by
California until 1953) included “psychoneurosis,” “psychopathic personality,”
“primary behavior disorders,” and “sexual psychopathy” (California Department
of Mental Hygiene, 1935–1960, year ending June 30 1950, p. 70). The DSM–I
elaborated on the old as well as created new designations: “psychoneurotic
reaction” (with seven subcategories), “personality pattern disturbance” (with four
subcategories), “personality trait disturbance” (with four subcategories), “antiso-
cial reaction,” “dyssocial reaction,” “sexual deviation,” “special symptom reac-
tion,” and “transient situational personality disturbances” (with six subcategories;
APA, 1952, pp. 31–42).
This expansion of the scope of psychiatry into everyday problems of liv-
ing—a transformation that was evident in psychiatric theory, state hospital prac-
tice, and American culture—coincided with another major event in psychiatry:
the introduction of the first psychotropic drugs. Chlorpromazine, the first of these
drugs, was introduced in state hospitals in 1954 and used to treat patients across
a broad range of diagnoses. We first look at the introduction of these drugs and
then examine records from Stockton State Hospital to see how these drugs and
other treatments were used to treat both psychotic and nonpsychotic patients.
180 STARKS AND BRASLOW
Introduction of Antipsychotic Drugs
The antipsychotic drugs, also called neuroleptics, ataractics, or major tran-
quilizers, had their birth in the laboratories of the French pharmaceutical company
Rho ˆne-Poulenc when Paul Charpentier, in 1950, first synthesized RP4560, later
designated chlorpromazine. Initially Rho ˆne-Poulenc believed that chlorpromazine
might have a variety of applications, ranging from diminishing nausea to decreas-
ing itching, and they named it Largactil to emphasize its many uses (Grob, 1994,
pp. 228–230; Shorter, 1997, pp. 246–255; Swazey, 1974). By 1951 physicians
began recognizing chlorpromazine’s ability to calm agitated patients without
overly sedating them, and the potential markets for the drug expanded to include
psychiatric applications. Smith Kline & French bought the North American rights
in 1952 and received U.S. Food and Drug Administration approval to market it
under the trade name Thorazine in May 1954.2
By 1956, 4 million patients in the United States had taken chlorpromazine,
yielding $75 million in profits in 1955 alone (Healy, 1997, p. 46; Overholser,
1956, p. 198). The bulk of this market was due to the drug’s psychiatric
applications, thanks to therapeutic properties that differed notably from those of
previous drugs used by psychiatrists. Though psychiatric practice had incorpo-
rated the use of sedatives since the 19th century, these drugs (e.g., bromides,
barbiturates, hyoscine, and chloral hydrate) were often referred to as “chemical
straitjackets.” They continued to be important tools in the institutional care of
psychiatric patients through the 1950s, but they never were seen as therapeutic
(Braslow, 1997). The role of chlorpromazine and other antipsychotic drugs as the
first therapeutic pharmaceutical agents can be seen from Table 2, as they both
complemented and displaced the use of ECT.
Early on, Smith Kline & French recognized that state hospitals, with over a
half a million captive potential consumers, represented an enormous market.
These institutions brimmed with severely ill patients for whom a steady onslaught
of somatic cures often failed, leaving lobotomy as the treatment of last resort. It
is not surprising that physicians were eager to try the newly introduced drug as an
alternative to surgery. In a typical early report on chlorpromazine, a psychiatrist
The patients were selected because they were difficult nursing problems, and the
other treatments had reached a point of diminishing returns. . . . The symptom-
atology displayed by these patients was manifested by one or several of the
following factors—extremely noisy for prolonged periods of time, confusion of
such a degree that they needed constant supervision, agitated, destructive, hyper-
active, impulsively assaultive, denudative, smearing, soiling, requiring repeated
seclusion and sedation. (Kurland, 1955, p. 322)
As a means of quelling these “assaultive, denudative, smearing, soiling”
behaviors, drug treatment had much to recommend itself over psychosurgery. The
2Another antipsychotic drug was also introduced in 1954. This drug, called reserpine, had
similar effects to those of chlorpromazine, yet it tended to take longer to work. Subsequent reports
suggested that it also had the disconcerting side effect of producing profound depression in patients.
Though used quite extensively in the middle to late 1950s, this drug never enjoyed the same success
181 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
medication was easily administered, ostensibly produced relatively minor side
effects,3and rapidly and predictably subdued those behaviors that had previously
led to lobotomy. In fact, antipsychotic drugs proved so effective in therapeutically
eliminating recalcitrant, hostile, and violent behaviors that lobotomy disappeared
Throughout the late 1950s and early 1960s, physicians prescribed antipsy-
chotic drugs not only for the psychotic but also for the newly minted nonpsychotic
patients described in the previous section—a history that is obscured by the now
accepted name of antipsychotic and its implied specificity for psychotic disorders.
The first American Journal of Psychiatry report on chlorpromazine underscored
its manifold utility:
It may be applied to the treatment of all conditions in which vegetative distur-
bances play a role, such as anxiety states, severe neurosis—including obsessions—
symptoms following drug withdrawal, manic-depressive disorders, certain cases of
acute and florid schizophrenia, and in a wide variety of psychosomatic disorders.
(Wortis, 1954, p. 508)
3Physicians early on did observe a number of side effects, most of which did not preclude
continued use. The most common side effects consisted of dry mouth, constipation, blurred vision,
muscle stiffness, and sedation. Of greater concern, patients occasionally developed jaundice. Rarely,
patients developed a fatal blood disorder called agranulocytosis. Especially after long-term use,
patients frequently began exhibiting involuntary, writhing movements affecting the trunk, arm,
facial, and tongue muscles. Termed tardive dyskinesia, this difficult-to-reverse sequela was first
recognized in the late 1950s and not generally accepted until the late 1960s and early 1970s.
Treatment of Psychotic and Nonpsychotic Patients With ECT and/or
Antipsychotic Drugs at Stockton State Hospital Before and After January 1,
We systematically sampled patients from Stockton State Hospital using the date of
final admission. Restricting that sample to patients whose final admission occurred
between January 1, 1940, and December 31, 1964, resulted in a sample of 251 patients
(183 psychotic, 68 nonpsychotic). Of these patients, 62 psychotic patients and 16 non-
psychotic patients were in the hospital prior to January 1, 1954, and 159 psychotic patients
and 61 nonpsychotic patients were in the hospital on or after January 1, 1954. We assessed
patients in each of these subsamples for whether they were treated with ECT and/or
antipsychotic drugs during the relevant time period (prior to January 1, 1954, in the first
subsample, and between January 1, 1954, and December 31, 1964, in the second sub-
sample). ECT ? electroconvulsive therapy.
16945 28 74 47
182STARKS AND BRASLOW
As another psychiatrist more succinctly put it, chlorpromazine had a place in
“most types of mental disorder” (Kinross-Wright, 1954, p. 298). It was not until
the mid-1960s that psychiatrists winnowed down the drug’s many indications
primarily to psychotic disorders and that the term antipsychotic replaced the more
generic designation of major tranquilizer (Caldwell, 1970, pp. 150–151). During
the years in which hundreds of patients entered state hospitals with new, nonpsy-
chotic illnesses, therefore, antipsychotic drugs were still a versatile, all-purpose
biological tonic for what ailed one psychologically, whether one was psychotic or
simply anxious. However, even when employing the same biological treatment
irrespective of diagnosis, clinicians employed very different therapeutic rationales
depending on the disease they sought to treat.
Psychiatric Treatment and Therapeutic Rationales
All therapeutic practices entail a vision of what counts as disease and what
constitutes its effective treatment. This “therapeutic rationale” (Braslow, 1997) is
a rough-and-ready way of understanding disease in the context of the proposed
intervention—one that simultaneously defines both the illness and the desired
therapeutic outcome. In the study of psychiatric therapeutics, understanding these
rationales helps us to make sense of the therapeutic world of doctors and patients
and underscores the interdependence between doctors’ understandings of an
illness and the treatments they employ to cure it. In our look at psychiatric care
in the mid-20th century, we focus on this intersection between disease and cure,
examining the therapeutic rationales that governed the treatment of psychotic and
nonpsychotic patients before and after the introduction of antipsychotic drugs as
well as the implications of these new drugs for how doctors and patients under-
stand and treat these disorders.
As mentioned above, antipsychotic drugs were the first class of therapeutic
drugs introduced in psychiatry. They often are credited with the end of lobotomy
as well as with playing a role in the deinstitutionalization of psychiatric patients.
However, though these new drugs were revolutionary in the treatment of psy-
chotic patients, the therapeutic rationale that governed their use was not very
different from that of somatic cures such as lobotomy and ECT. In this sense, state
hospital usage of antipsychotic drugs with psychotic patients was very much
linked to psychiatry of the past. However, clinicians also used these drugs to treat
nonpsychotic patients and, in doing so, employed a very different therapeutic
rationale than the one that governed their treatment of psychotic patients. It is the
treatment of nonpsychotic patients and the linking of this rationale with a
psychotropic medication that most meaningfully laid the groundwork for much of
contemporary psychopharmacology. In what follows, we examine the therapeutic
rationales that governed the treatment of psychotic and nonpsychotic patients,
both before and after the introduction of antipsychotic drugs, and reflect a bit on
the long-term implications of what happened following their introduction.
Treatment of Psychotic Patients
Before the introduction of antipsychotic drugs in 1954, psychotic state hos-
pital patients were treated with a range of somatic therapies: hydrotherapy, insulin
coma therapy, the convulsive therapies (including metrazol and ECT), and lobot-
183 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
omy. In this article, we look primarily at lobotomy, a treatment of last resort that
disappeared after the introduction of antipsychotic drugs, and, to a lesser extent,
at ECT, a treatment that continued to be used alongside the new medications.
Lobotomy arguably ranks as one of most the notorious medical interventions
spawned in the 20th century. It represented the culmination of a half century of
therapeutic endeavors—from hydrotherapy in the 1900s to ECT in the 1940s—
that increasingly located the cure of diseased behaviors in a patient’s body and,
ultimately, the brain. In performing lobotomy, physicians acted directly on the
brain, drilling a small hole in the front of the patient’s head and then severing the
axon fibers that connect the cortex and lower brain structures. The surgery was
virtually abandoned over 40 years ago, but it continues to be a potent symbol of
the potential dangers of psychiatric medicine (Shutts, 1982; Valenstein, 1973,
1986). Ironically, though, researchers in the late 1940s considered it the most
scientific of psychiatric interventions (Pressman, 1998). In 1949, only 14 years
after he directed the first modern lobotomy, Egas Moniz was awarded the Nobel
Prize in Physiology and Medicine for his efforts (Moniz, 1937, 1956).
At the time of lobotomy’s introduction, state hospital physicians and staff
largely defined treatable psychiatric illness as refusal to behave and identified
behavioral control as the purpose of most therapeutic endeavors. This therapeutic
rationale was deeply indebted to the enormous and understaffed nature of state
hospitals, a persistent reality that contributed to the negative reputation of state
hospitals as human warehouses. In 1946, for example, Stockton’s seven physi-
cians had 4,400 patients in their care (California Department of Mental Hygiene,
1935–1960, year ending June 30, 1949, p. 19). Within such a setting, physicians
located disease in behaviors that subverted order within the asylum, and they
policed that order using the therapies at their disposal (e.g., hydrotherapy and
ECT) as well as the organization of the hospital wards.
In keeping with the needs and nature of the hospital, patients were assigned
to wards not on the basis of diagnosis but rather according to how well they
followed the hospital’s rules. The ward taxonomy—including wards for the
“acutely excited,” “chronic quiet,” “chronically disturbed,” and “convalescing”—
transformed a social appraisal (desirable vs. undesirable behavior) into a physical
reality (the ward) that held both medical and therapeutic meaning. Once a patient
fought, kicked, or bit his or her way onto the chronically disturbed ward, for
example, he or she stood little chance of ever leaving the institution: The physical
reality of the ward stamped the patient with a medical reality—“chronically
disturbed”—and thus with a nearly hopeless prognosis that entailed the abandon-
ment (by physicians, family, and patient) of all hope of recovery. The ward system
helped to enforce order in the hospital, and it also helped to create, sanction, and
reinforce behavioral control as the major measure of therapeutic effectiveness
It was into this therapeutic and disciplinary context that physicians introduced
lobotomy as their most modern and scientific, though also most drastic, means of
quelling diseased, out-of-control behaviors. As the California Department of
Mental Hygiene (1935–1960, year ending June 30, 1949) candidly acknowledged
184 STARKS AND BRASLOW
in a 1949 annual report, lobotomy was “used chiefly to pacify noisy, assaultive,
and uncooperative patients” (p. 21). This was not, however, control for the sake
of control. Pacifying behavior was a therapeutic endeavor above all else, guided
by a therapeutic rationale in which these behaviors signaled a diseased brain that
could be cured by surgical intervention.
Stockton physicians lobotomized 232 patients between March 8, 1947, and
June 16, 1954. One of these patients, Edward Wheeler, was admitted to Stockton
in 1948 and diagnosed with dementia praecox, catatonic type. He refused to
accept his fate as a psychiatric patient, and he fought not only the attendants,
whom he believed to be his captors, but also his fellow patients. As a result, he
was branded almost immediately in two very enduring ways: first, by his behav-
ior, as chronically and incurably insane, and, second, by his ensuing relegation to
the hospital’s back wards, as a permanent resident of the hospital. From then on,
his medical record chronicled a progressive descent. A typical entry reads:
“Patient Wheeler attacked patient Smith for no apparent reason. Patient Wheeler
is very disturbed and combative, therefore he was put in seclusion for benefit of
cottage.” Five days later, Edward’s physician noted another outburst: “Patient
Wheeler has been very noisy and was cursing everyone near him all afternoon.
For no apparent reason he hit patient Jones in the face.” Finally, in May 1953, the
ward physician ordered a lobotomy:
This patient has had over 200 EST [electroshock] treatments. Despite frequent
maintenance treatments, patient is continually hyperactive and combative. He is
delusional and these impel him to strike others. Seclusion is frequently indicated.
The patient has had the benefit of . . . somatic therapy. Recommend lobotomy.
This decision was the culmination not only of 5 years of violent behavior but also
of numerous unsuccessful attempts at behavioral control.
As Edward’s case suggests, physicians generally did not take the decision to
lobotomize a patient lightly. Stockton clinicians performed the surgery only 245
times (on 232 patients—13 patients were lobotomized twice) over the course of
7 years. The surgery was irreversible, entailed the destruction of seemingly
normal brain tissue, and could have devastating side effects (for more on the
effects of lobotomy, see Braslow & Starks, in press). As a result, state hospital
physicians usually employed the surgery only on their most refractory patients,
most of whom carried a diagnosis of dementia praecox (now called schizophre-
nia).4This psychotic illness is characterized by delusions, hallucinations, and
social withdrawal and is considered the most severe of psychiatric disorders. Not
only did individuals with this diagnosis make up the bulk of state hospital
residents, they also frequently experienced little benefit from other interventions,
such as ECT, and so were more likely than other patients to be considered for the
admittedly drastic intervention of lobotomy (Grob, 1994, pp. 165–190).
Most lobotomies were performed in state hospitals between the end of World
War II and the introduction of antipsychotic drugs. The surgery’s spread had been
4The diagnostic breakdown of the 232 patients lobotomized at Stockton was as follows:
dementia praecox, 160 (69%); manic–depressive psychosis, 14 (6%); mental deficiency with
psychosis, 13 (6%); central nervous system syphilis, 7 (3%); involutional melancholia, 6 (3%);
dementia, 6 (3%); and other/unknown, 26 (11%).
185 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
hindered by financial considerations during the Depression and the war, but the
number of lobotomies performed rose dramatically after 1945, and by 1951 U.S.
physicians had performed nearly 20,000 lobotomies (Kramer, 1954). This spec-
tacularly rapid rise in popularity was matched by an even faster abandonment.
After the introduction of chlorpromazine and reserpine in 1954, doctors quickly
forsook the surgery in favor of these new drugs. By the 1960s, only a few true
devotees continued to perform the operation.
Stockton physicians performed their last lobotomy on June 16, 1954, probably
not knowing that it would be their final surgery. Lobotomy disappeared from
Stockton not because physicians suddenly found it to be ineffective at therapeu-
tically disciplining patients but rather because chlorpromazine quickly proved
itself to be equally or more effective at quelling unruly behaviors. Like lobotomy,
antipsychotic drugs were introduced into a hospital setting in which behavioral
control was a paramount therapeutic concern, and the therapeutic rationale that
governed their use was the same as that behind the use of somatic therapies such
as hydrotherapy, ECT and, as a last resort, lobotomy. As shown in Table 2,
antipsychotic drugs gradually took the place of ECT, but the use of ECT
continued, often in patients who also received drugs. Whereas 63% of psychotic
patients had been treated with ECT prior to 1954, after the introduction of
chlorpromazine, 37% of psychotic patients received ECT, and 75% received
drugs (9% of received ECT alone, 28% received ECT and drugs, and 47%
received drugs alone).
Although physicians continued to contemplate lobotomy even after receiving
their first shipment of chlorpromazine in early 1954, we were unable to find a
single instance in which doctors chose to perform a lobotomy after first trying a
course of antipsychotic drugs. For example, when Emily Ames’s doctors con-
vened a “lobotomy clinic” to discuss her case on January 19, 1955, she had been
a patient at Stockton since 1942. She had arrived at the hospital agitated,
delusional, and combative, and numerous courses of ECT had been of little avail,
which resulted in the doctors’ decision to lobotomize her in 1948. The surgery
proved relatively successful in eliminating her most disruptive behaviors, but
continued episodes of violent outbursts led Emily’s physicians to contemplate a
second lobotomy 7 years later—a time at which “another method” was available
to improve Emily’s behavior:
This is a 39-year-old woman, hospitalized here since 1942. She has had a previous
prefrontal lobotomy and has seemed to have responded fairly well to it. At the
present time she has occasional periods of aggressive behavior, apparently acting
upon paranoid ideas of reference. The risk involved in a second prefrontal
operation would not seem to merit the amount of improvement we could possibly
obtain. Another method of possibly giving the patient high doses of Thorazine
might be equally successful.
As this excerpt makes clear, the same constellation of symptoms led physi-
cians to employ antipsychotic drugs as had previously led them to prescribe
lobotomy. Emily’s “aggressive behavior,” once having precipitated a series of
186 STARKS AND BRASLOW
unsuccessful ECT treatments followed by lobotomy, was now the primary indi-
cation for her treatment with Thorazine. For patients with severe mental disorders,
what counted as disease (aggressive behavior) and its effective treatment (elim-
ination or control of that behavior) changed little with the introduction of anti-
The staying power of this therapeutic rationale is evident in the hospitalization
of Nancy Evans, who entered Stockton for the first of five times in 1974, 2
decades after Thorazine’s introduction. On her admission form her physician
wrote, “reason for hospitalization: out of control—inappropriate—cursing and
yelling.” His conception of illness differed little from that of his predecessors.
Like them, he saw a relatively simple relationship among behavior, disease, and
its effective treatment. While Nancy’s doctor was able to select from among a
much wider array of drugs, the rationale that led him to prescribe the antipsychotic
fluphenazine (brand name Prolixin) differed little, if at all, from Emily’s doctors’
decision to lobotomize her and then, when that too failed to control all of her
outbursts, to give her Thorazine.
Implications of Antipsychotic Drugs for Psychotic Patients
Because the nature of the state hospital and of psychosis remained essentially
the same, it is not surprising that clinicians used the same therapeutic rationale in
treating psychotic patients with antipsychotic drugs as they had with lobotomy.
However, the persistence of this rationale does not mean that the introduction of
antipsychotic drugs had no impact on the care of these patients. The drugs made
it possible for physicians to treat many more patients, with much less hesitation,
than they could with lobotomy or even ECT. They also made it possible for
doctors to begin calming patients’ behavior and overt psychotic symptoms the
moment the patients entered the hospital, which might have meaningfully changed
the nature of subsequent clinical encounters and increased doctors’ hopes of
treating the patient through more than just behavioral control. Antipsychotic drugs
also made it possible to consider treating psychotic patients in the community
rather than in the hospital, though of course the need for behavioral control was
a factor in the community as much as in the hospital. It is important to keep in
mind that this article looks only at the very early years of antipsychotics,
immediately following their introduction into a hospital setting that was charac-
terized by the need for social order and the control afforded by somatic cures.
Treatment of Nonpsychotic Patients
When nonpsychotic patients first began entering state hospitals, their treat-
ment was likely to consist of some blend of psychotherapy and somatic cure, most
often ECT. Though physicians frequently ordered psychotherapy, it is difficult to
know what such therapy entailed or whether the patient actually received any such
treatment. The use of ECT was more remarkable because it represented the
application of a biological cure to internal psychological suffering, thus cementing
these new diseases as ones amenable to biomedical solutions. Even more notable,
however, was the use of antipsychotic drugs after their introduction in 1954.
Stockton doctors treated more of their nonpsychotic patients with drugs than
they had with ECT: Forty-nine percent of nonpsychotic patients received anti-
187 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
psychotic drugs (with or without ECT) after 1954, whereas 31% had been treated
with ECT prior to the drugs’ introduction (see Table 2). More important, the new
drugs had vast potential for use outside the hospital as well, so it was through their
use (and later through that of newer classes of psychotropic drugs, e.g., antide-
pressants and antianxiety drugs) that the therapeutic rationale governing the
biological treatment of nonpsychotic patients carried forward into an expansive
outpatient psychiatry. In the cases that follow, we look at three dimensions of this
rationale: the biological treatment of internal psychological distress, the need for
agreement between physician and patient, and the balance between medical
attributions and moral responsibility.
Biological Treatment of Internal Psychological Distress
The treatment of nonpsychotic patients with ECT and antipsychotic drugs
marked a major change in psychiatric practice. Not only did it give final confir-
mation that these patients’ troubles had attained the status of treatable psychiatric
illness—a status already apparent from the growing presence of nonpsychotic
diagnoses in state hospitals and the DSM—but it entailed a belief that psycho-
logical distress could be the object of biological treatment. This belief fundamen-
tally separates current psychiatric practice from that which governed the treatment
of psychotic patients in state hospitals, whether with lobotomy or with newly
introduced antipsychotic dugs. When physicians recommended lobotomy, they
saw little or no difference between the uncontrollable, “psychotic” behavior and
the ostensible disease the surgery aimed to treat: Irrespective of the psychological
states that might have accompanied a patient’s behavior, it was behavior above all
else that determined his or her candidacy for surgery. However, when doctors
employed antipsychotic drugs on their nonpsychotic patients, their attention (as
well as the treatment) was focused not on observable behavior but on internally
experienced psychological difficulties.
In the 1964 hospitalization of Fred Willits we see how, as nonpsychotic
patients increasingly sought hospitalization for troubles of everyday life, psychi-
atrists found themselves prescribing treatment in response to their patients’
internal distress. During his intake interview, an exasperated Fred revealed his
desperate desire for treatment, telling physicians that he had “been trying to get
into this hospital for over 2 years.” Fred was 40 years old and had no obvious
signs of psychiatric disorder but, when questioned, complained of an unrelenting
anxiety that prevented him from working: “works steadily until he gets too
nervous and then has to quit.” His life had become an accumulation of thwarted
attempts to keep a steady job, attempts that he claimed numbered in the hundreds,
and the ensuing desperation had driven him to the hospital. “He is quite appre-
hensive about his future,” wrote the admitting physician, “and wonders if we can
help so he can get back to work.” The physician diagnosed Fred with a “psycho-
neurotic reaction” and placed him on an antipsychotic drug: not as a means of
disciplining his behavior, for he was an ideal patient, but rather to soothe his
Because of the internal nature of psychological distress, treating such troubles
required that patients disclose their private suffering. Though in Fred’s case his
physicians arguably could have determined his need for treatment simply from his
188 STARKS AND BRASLOW
tumultuous job history, other patients’ troubles were less apparent. When a
Stockton physician diagnosed Kyle O’Neill with depression and anxiety and
prescribed Thorazine as an antidote, he did so not on the basis of any behavioral
observations but rather on the basis of Kyle’s own reports: of feeling “like my
body is sinking” and as if he were “ebbing away” and “dead inside,” and of an
inexplicable fear that gnawed at his mind to such an extent that he was no longer
able to work. Self-disclosure was also required for doctors to treat Wendy
Johnson, who was given antipsychotic drugs, ECT, and psychotherapy to treat her
reported “guilt feelings about infidelity on her part while her husband was in the
Merchant Marine during the war.” Similarly, when physicians ordered that
George Hammond be started on antipsychotic drugs, their belief that he required
such a cure was a direct response to his self-critical disclosures: “I’m still in love
with my wife who left me. . . . Without my family my life has been a complete
failure. I’m a zero.”
Need for Agreement Between Physician and Patient
Self-disclosure was not the only form of cooperation required of the patient.
For treatment to succeed, he or she needed not only to confess the presence of
illness and assent to its prescribed treatment but also to have an insight into the
cause of the illness that meshed with the interpretation held by his or her
physician. The importance of such insight is exemplified by the case of John
Cowley, a patient who, like so many others, sought the asylum as an escape from
his crumbling life. Though his voluntary admission showed that he and his doctors
agreed as to the necessity of hospitalization, he could not be discharged as
“recovered” until he agreed with his doctors’ interpretations as to the source of his
John’s doctors described his illness as the consequence of an irresolutely lived
life, characterized by his “chronic inability to engage wholeheartedly and be
persistent in carrying through activities, that is, schoolwork, employment, many
reconciliations in marriage.” His marital difficulties took center stage in his
woeful tale and, according to the hospital staff, were of his own creation. His wife,
wrote the social worker, “has put up with a good deal during the marriage and it
appears she is willing to put up with more, but feels she needs some help in doing
so.” Even the manner of his hospitalization was symptomatic of these inadequa-
As is his custom, the patient decided to leave town and get a job. He came to
Stockton, obtained work, but apparently became fed-up with it and somewhat
depressed. He simply entered the hospital as a voluntary admission and then wrote
his wife a letter saying he had done so.
After arriving at a complete picture of John’s difficulties (and, not incidentally,
after developing a significant degree of sympathy for John’s wife, not only for the
precarious financial situation in which he had so often left her but also for his long
string of infidelities), the staff set about attempting to effect a cure.
John’s treatment plan initially included two antipsychotic drugs, but, when
those failed, his physicians discontinued them in favor of ECT. Both treatment
decisions were directly linked to John’s lack of insight into what his doctors
189 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
believed to be the true origin of his illness, namely his inability to live up to his
responsibilities. They noted that John, rather than owning up to his failings,
preferred to blame his wife:
Tells of years of discord with wife who is always accusing him of infidelity. He
feels she is mentally ill but has never done anything about seeking psychiatric aid
for her. . . . Recently became panicky and came here . . . will put on Thorazine and
Serpasil combination. . . . Basically is a dependent, immature individual who has
not been able to accept adult responsibilities.
Six days after starting medications, John steadfastly held to his theory that his
wife, not he, was the root of his ills. As the medications had failed to bring about
any improved insight, John’s physician decided to start what was, according to
both doctor and patient, a necessary and successful course of ECT:
Interview: Patient requests explanation for why he was “ill” and why he feels
“better” now. He states he is improved tremendously. Feels relaxed now. Admits
that his wife was correct in saying he was “sick,” and so forth. Realizes he was
“running away,” avoiding people, not being articulate, “being a failure in anything
he did, and so forth.” Patient appears to be much improved.
On the day of his discharge, the physician wrote that John “now wishes to
return home and start work. . . . Has shown beginning insight” (emphasis added).
By its definition this insight not only required that John and his doctor share a
common therapeutic vision but also signified his cure.
Moral Judgments and Biological Cures
As John’s case suggests, the fact that an individual’s failings were now seen
as biologically treatable did not erase the moral dimensions of these failings. Ideas
of right and wrong were (and continue to be) central to patients’, families’, and
doctors’ determinations of whether a patient had lived up to prescribed obliga-
tions. Though the act of hospitalization and diagnosis lent medical meaning to the
patient’s failings, this medicalization did not free the patient from moral respon-
For example, when Steven Harris sought help for his frequent bouts of
nervousness by admitting himself into the hospital in the summer of 1956, the
examining physician soon found Steven’s anxiety to be inextricably tied up in his
failure as the family’s breadwinner:
Patient states that for the past 5 years he has not been able to hold any job for more
than 6 months. Each time he starts on a job for two or 3 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.
Though Steven’s inability to hold a job was seen as a part of his illness, his
wife did not absolve him of personal responsibility: “Mr. Harris has always relied
on my position, money from his parents or aid from mine. . . . He has financial
problems only because of his attitude and refusal to meet his outstanding obli-
gations.” She believed that Steven was willfully irresponsible, but she neverthe-
less agreed that he required not moral exhortation but medical intervention,
190 STARKS AND BRASLOW
through which she optimistically saw the possibility “that he could be self-
supporting.” A month later, after a successful course of chlorpromazine and
psychotherapy, his doctors believed that he had recovered sufficiently—measured
by his willingness “to leave and get a job”—to be discharged. For Steven, his
wife, and his doctors, the social and moral meaning of his eventual willingness to
get a job was inseparable from its medical meaning as a measure of chlorprom-
Stockton physicians also attributed moral and medical meaning to the troubles
of Wendy Johnson, who first admitted herself to Stockton in 1951. Like Steven,
Wendy was seen as irresponsible to the point of immorality, though her particular
failings were as a wife and mother:
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’s sense of moral failing undoubtedly was reinforced by her physi-
cians, who described her as “an acute actor-outer” who “has had repeated affairs
with other men, abortions, though she does have the decency to get depressed
about it,” and who treated her first with psychotherapy and ECT and later with
Implications of Antipsychotic Drugs for Nonpsychotic Patients
When nonpsychotic patients began streaming into state hospitals, their treat-
ment foreshadowed many aspects of contemporary psychiatry: the medicalization
of social failings, the doctor–patient relationship of today’s consumer psychiatry,
and the biological treatment of internal distress. Though physicians prescribed
ECT and antipsychotic drugs more or less interchangeably for their nonpsychotic
patients, ECT was a treatment with little possibility for use outside the hospital.
Antipsychotic drugs, conversely, could be (and were) used to treat a much larger
population of individuals whose difficulties were unlikely to merit hospitalization.
Their introduction facilitated the widespread biological treatment of the kinds of
distresses and failings presented by these new, nonpsychotic patients and thus laid
the groundwork for contemporary psychiatric practice and culture.
The histories of these Stockton patients show the remarkable extent to which
the influx of nonpsychotic patients into state hospitals marked the beginnings of
a contemporary psychiatry characterized by voluntary outpatient care, the phar-
macological treatment of a wide range of disordered behavior and psychological
distress, and a doctor–patient relationship and cultural acceptance of disease that
allows psychiatric patients to identify themselves as consumers. The introduction
of the first psychotropic drugs was fundamental to the spread of this new
psychiatry: first, by cementing a medical, biological view of psychological dis-
tress and, second, by treating both psychotic and nonpsychotic patients in such a
way that the new therapeutic rationale used in treating nonpsychotic patients
could gradually make its way into the treatment of psychotic patients as well.
191 MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1
External judgments about behavior and fulfillment of societal expectations remain
essential aspects of the diagnosis and treatment of both psychotic and nonpsy-
chotic patients, but so do the elements of the new rationale that emerged with the
treatment of nonpsychotic state hospital patients in the mid-20th century.
These shifting therapeutic rationales and their legacy raise important ques-
tions about the role of culture in the diagnosis and treatment of psychiatric
disorder. Whether they are grounds for moral judgment or for medical diagnosis
and treatment, disordered behavior and failures of everyday life both are measured
by societal standards, as are the outcomes of the biological treatments that aim to
remedy them. Thus, regardless of the diagnosis, treatment, or therapeutic ratio-
nale, cultural judgments play an elemental role in the identification and treatment
of psychiatric disorder. In the second article in this series, we look at how one
aspect of culture, gender, intersected with diagnosis, treatment, and rationale to
shape the treatment of psychotic and nonpsychotic patients before and after the
introduction of antipsychotic drugs (Braslow & Starks, in press).
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Received April 15, 2002
Revision received January 1, 2005
Accepted January 24, 2005 y y
193MAKING OF CONTEMPORARY AMERICAN PSYCHIATRY, PART 1