Chapter: 2

Clinicians at Morningside at midcentury were utilizing the 1st Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1), engaging with the promise and the limits of standardized psychiatric diagnosis. Published in 1952 by the American Psychiatric Association (APA), the DSM-1 first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The DSM-I was developed with what its authors called a simple, user-friendly structure, aimed in part for use by hospital administrators who needed a more robust classificatory system for tracking patient diagnosis and treatment. The DSM-I was the first official manual of mental disorders to focus on both clinical and statistical use, including a glossary of descriptions of diagnostic categories. In developing the DSM-I, the APA drew on earlier classificatory systems developed by the U.S. Army and the Veterans Administration in the post WWII period, which were influenced by the large numbers of veterans suffering from war-related distress, the “war-related neuroses” or traumas. The DSM-I also sought to align its diagnostic system with the International Classification of Disease, to make cross-population statistical comparisons possible.

The DSM reflects what anthropologist Tanya Luhrmann has termed the “two minds” of American Psychiatry, referring to the competing influences of psychoanalytic and biomedical approaches to mental disorder. In the mid-20th century, however, it was not yet clear which approach would come to predominate; thus, exploring the tensions surrounding diagnosis at Morningside reveals how psychiatrists encountered the limits of biomedical treatment models and sought to implement more humanistic, patient-centered care. One avenue of analysis this project follows is examining how psychiatrists prescribed available treatment modalities, including electroconvulsive shock therapy and thorazine, as well as prosocial therapies such as occupational and vocational rehabilitation. This chapter examines how psychiatrists at Morningside applied these treatments differently based on their narrative rendering of patients’ symptoms or their perceptions of patients as racialized, gendered, and classed subjects. The chapter thus historicizes psychiatric practice within the local space of an inpatient hospital, carefully reading available archival materials for certainty and doubt in the diagnostic enterprise, characteristics that may suggest alternative paths of mental health care treatment in the past and in the present.

While informed by Foucauldian approaches to psychiatry as a mode of social control, the analysis here seeks to complicate a straightforward view of biopower or biopolitics by elucidating the complex positionality of psychiatrists themselves as imperfect human actors in broader dramas of midcentury US mental health care. As they tacked back and forth between political interests, concerns for patients, new diagnostic tools, and limited therapeutic options, psychiatrists exercised a constrained control over patients, constituted through the on-the-ground, complicated relations of coercion and care. Mirroring and precipitating the broader trends surrounding the deinstitutionalization of US mental health care later in the 20th century, clinical and financial practices at Morningside come under increasing critique and scrutiny, eventually forcing the hospital’s closure. The story of Morningside is thus also a story of the end of the zenith of the American ‘asylum,’ illuminating the challenges of institutionalized psychiatric practice and the difficulty of implementing alternative, community-based, mental health programs. This project speaks to these challenges, using historical analysis to re-imagine how mental health institutions might better reflect psychiatry’s humanistic tendencies and foster patient-centered care.

Although the DSM-I was developed to minimize inconsistency in diagnostic categories and to foster standardization in American psychiatry, scholars have debated the extent to which the DSM-I reflected an emerging biological view of mental disorders or a longer-standing psychodynamic explanatory model. While biogenetic approaches may have taken over by the late 20th and early 21st centuries, during the 1950s, in the wake of the publication of DSM-1, psychiatrists were very much deliberating and negotiating these various influences over professional practice. If the DSM-I has received relatively little scholarly attention, scholars have asserted this may be precisely because the first edition of the Manual largely reflected psychoanalytic approaches to mental distress. Conceiving of DSM-I as psychoanalytically-oriented has diminished its professional importance and led to the Manual “being dismissed as a mere artifact of a long-gone era.” However, Cooper and Blashfield (2016) argue, DSM-I is as much influenced by “Kraepelian as Freudian approaches” (p. 449), focused heavily on the categorization of observable symptoms into scientific categories as an attempt to standardized both diagnosis and treatment. Tracing the discourse of psychiatrists who used the DSM-I in the period after its publication offers insight into the actual practice of how mental health professionals utilized these newly emerging standardized diagnostic categories.

Of course, psychiatrists engage with diagnostic criteria within the constraints of institutionalized mental health care. The 1950s may be characterized as the apex of the institutionalization of psychiatric care in the United States, with much mental health care delivery focused on inpatient hospitals during this period. DSM-1 was in fact designed to aid in the hospital-based delivery of psychiatric care, responding to the needs of US hospital administrators to collect standardized statistical data on patient treatment and service delivery. In the introduction to DSM-1, the authors and editors of the manual make clear that a driving influence for the revision to psychiatric nomenclature was standardizing language for clinical practice, research, and statistical information -gathering across sectors of American psychiatry, including: the Veterans Administration, military psychiatrists, public mental hospitals and public outpatient clinics.

Despite the prevalence of inpatient psychiatric care in the 1950s, few extant studies have documented how hospital-based psychiatrists actually utilized DSM-1 criteria in this period. In this chapter, we use primary source archival materials from 1955-58 from Morningside Hospital to document the ways in which psychiatrists engaged with the new DSM-1 diagnostic categories, particularly those designed to categorize the common ailments of schizophrenias and mood disorders, but also to describe behaviors found among alcohol users or survivors of sexual assault and brain trauma. Drawing on the minutes of regular staff meetings from the DeWitt Burkes collection (UO Special Collections and University Archives), wherein attending psychiatrists, nurses, and clinical and administrative staff of the hospital met to discuss patient cases, we engage with the following overarching questions: first, are diagnoses of mental disorders applied systematically or consistently across the hundreds of patients hospitalized at Morningside during this period, or how were diagnostic labels assigned in ways patterned by patients’ origin, race/ethnicity, gender, or other sociodemographic characteristics? Second, how do psychiatrists’ narrative comments about patients reveal the limits of diagnostic categorization and the slipperiness of diagnostic categories? And, third, how does this diagnostic uncertainty impact mental health care at Morningside and plans for discharge and treatment of patients after hospitalization?