In its 150 years, St. Elizabeths Hospital has mirrored the best and worst
of the history of American psychiatry. The great reformer Dorothea Dix founded"
The Government Hospital for the Insane," dreaming that the
government might provide, in her words, "the most humane care and
enlightened curative treatment of the insane of the Army, Navy and the
District of Columbia," said Kenneth P. Gorelick, M.D., a clinical
professor of psychiatry at George Washington University and a historian of the
institution. Situated on a tract of land in the southeast quadrant of the
city, the hospital opened its doors in 1855, and its original buildings are
now a National Historic
In reality, said Gorelick at the sesquicentennial celebration of the
hospital's birth last month, "St. Elizabeths was bedeviled by having to
do too much for too many with too little."
Gorelick spoke at a symposium organized by program chair Liza H. Gold,
M.D., a clinical associate professor of psychiatry at Georgetown University
School of Medicine. The symposium was sponsored by APA, in conjunction with
the Medical and Professional Society of St. Elizabeths Hospital. A number of
local mental health organizations provided support, including the psychiatric
societies of Maryland, Virginia, and Washington, D.C., as well as the
Chesapeake Bay Chapter of the American Academy of Psychiatry and the Law.
Coordinating the symposium for APA was the Corresponding Committee on History
and Library, chaired by Avram Mack, M.D., with the assistance of APA's
director of Library and Archives, Gary McMillan.
The hospital's first quarter century saw the initial fulfillment of Dix's
dream. She played a role in establishing 30 of the 60 mental asylums built in
the United States during her lifetime. Active psychosocial treatment and
decent accommodations helped stop mentally ill persons from being locked up in
attics and jails or from wandering the countryside.
The hospital's first superintendent, Charles Nichols, M.D., built pleasant,
detached buildings based on the Kirkbride model, which called for symmetrical
wings of asylum buildings to be stepped back in a shallow V-shape. Patients
worked in greenhouses as part of their therapy, growing flowers for the
Later, the psychological and emotional casualties of the Civil War found
their way to St. Elizabeths during and after that conflict.
During this era, St. Elizabeths also began its association with notorious,
criminally mentally ill individuals—of whom Ezra Pound and John Hinckley
were the most prominent 20th-century examples. Richard Lawrence, who tried to
assassinate President Andrew Jackson on January 30, 1835, was found not guilty
by reason of insanity and spent 20 years in a Maryland hospital before
becoming patient number seven at St. Elizabeths.
In 1885 the trial of Charles Guiteau, the assassin of President Chester
Alan Arthur, saw dueling psychiatric witnesses, including superintendent
William Godding, M.D., argue over the culpability of the accused. Guiteau was
found guilty and hanged. Godding then attended Guiteau's autopsy, which
revealed changes in his brain caused by tertiary syphilis.
Increasing rates of neurosyphilis through the 19th century probably
contributed to the rising number of people who became mentally ill, according
to medical historians. Partly as a result of his experience with the Guiteau
case, Godding hired neuropathologist Isaac W. Blackburn, M.D., to investigate
the biology of psychopathology in the first pathology laboratory in a U.S.
The hopes of this early age of idealism remained, but social and financial
support for care was lost, overwhelmed by the number of chronic patients
accumulating in the absence of curative treatments, said Gorelick. By the end
of the 19th century, St. Elizabeths had become a warehouse for the insane,
with patients sleeping on straw pallets and working on the hospital farm to
provide funds for the institution. The arrival of William Alanson White, M.D.,
in 1903 began a new era.
"White embraced psychoanalysis as early as 1908," said
Gorelick. "He was open-minded but saw no panaceas coming from the
biological side. Thus, he tilted to a new hope of understanding through the
thoughts and feelings and stories of patients."
In the years just before and after World War II, St. Elizabeths housed
nearly 7,000 patients. Under Winfred Overholser, M.D., St. Elizabeths, like
other progressive mental hospitals, became a self-contained therapeutic
community with patient self-government and arts therapies, even as the worst
asylums descended into the "snake pits" that shocked the
In the postwar years, St. Elizabeths' location in the District of Columbia
began to make it more of a city hospital and less of a federal one, as places
for the city's mentally ill citizens declined with deinstitutionalization,
said William Prescott, M.D., a former assistant U.S. surgeon general and the
last superintendent of the hospital under U.S. government control. St.
Elizabeths changed from the equivalent of a large state mental hospital to a
large community mental health center over two decades in the 1960s and
At the same time, the hospital served as the incubator for a wide range of
neuropsychiatric research, said Daniel Weinberger, M.D., now at the National
Institute of Mental Health (NIMH).
"This was the site of a premier schizophrenia research
program," said Weinberger, who worked at St. Elizabeths for 20 years."
Basic and clinical scientists worked side by side."
St. Elizabeths saw the birth of neuroimaging in the United States, he said,
including the first use of CT scans in schizophrenia research, followed by
studies using regional cerebral blood flow, magnetic resonance imaging, single
photon emission computed tomography, and whole brain scans using functional
magnetic resonance imaging. Other milestones included work in frontal lobe
physiology, neurocircuitry models, neurodevelopmental theory, and the genetics
The use of the work of Paul Luisada by St. Elizabeths' NIMH researchers
provided another example of cooperation between clinic and lab at the
institution, said Roger Peele, M.D., a clinical professor of psychiatry and
behavioral sciences at George Washington University and APA's Area 3 trustee.
Peele started as an intern at St. Elizabeths in 1960 and eventually held a
number of positions there, including directing the hospital.
In the early 1970s, Luisada noticed that phencyclidine (PCP) use was
causing a schizophrenia-like illness among his patients at St. Elizabeths.
Weinberger and other NIMH researchers on the grounds of the hospital
facilitated the exploration of phencyclidine's psychotomimetic effects. Today,
said Peele, those effects are known to act on the glutamate system, and future
medications for people with schizophrenia will focus on countering these
In 1973 Armando Saenz, M.D., initiated an outpatient commitment option that
resulted in fewer hospitalizations than comparable approaches, said Peele."
For the next 25 years, St. Elizabeths used the outpatient commitment
option better than anyone. This was ideal for patients and was achieved
without any increase in costs."
The decision to transfer control of the institution in 1987 from the
federal government to the District of Columbia was made too abruptly, and
largely for political reasons, said Prescott. An inexperienced D.C.
government, still finding its footing in the wake of its transition to home
rule and buffeted by a fiscal crisis, was left with layoffs, a deteriorating
infrastructure, and declining patient care at St. Elizabeths, said Martha
Knisley, the director of the D.C. Department of Mental Health.
"We had to fight such a difficult battle on the other side of the
wall to keep providing world-class care and research on the inside,"
The battles included disputes with Medicare and Medicaid over $325 million
that the District had claimed for patient care, outpatient services, and
services for federal prisoners being treated for mental illness. Nevertheless,
the city has put $10 million into the renovation of existing facilities and
will soon start construction of a 300,000-square-foot hospital for evaluation,
patient care, and forensic services. Currently, St. Elizabeths houses 248
civil and 206 forensic patients, said a department spokesperson.
Regardless of the value of community mental health care, there will always
be a need for long-term inpatient care, said E. Fuller Torrey, M.D., associate
director for laboratory research at the Stanley Medical Research Institute in
Bethesda, Md, and a member of the St. Elizabeths' clinical staff from 1977 to
"Deinstitutionalization was not an utter failure—just for 50
percent of the patients," Torrey said. He pointed that out that people
with mental illness are still being institutionalized—but not in
"The largest psychiatric institution in D.C. is the jail," he
said, given that a third of prisoners in the D.C. prison system are taking
Torrey concluded his remarks by pointing out, "There will continue to
be a need for public psychiatric hospitals for the long-term care of a small
subset of individuals with severe psychiatric disorders."
More information on St. Elizabeths and its sesquicentennial is
posted online at<www.seh150.org/index.htm>.▪