Epilogue
“An Experiment in the Social Basis of Psychotherapy”
The black man’s is a strange situation; it is a perspective, an angle of vision held by oppressed people; it is an outlook of people looking upward from below. It is what Nietzsche once called a “frog’s perspective.” Oppression oppresses, and this is the consciousness of black men who have been oppressed for centuries,—oppressed so long that their oppression has become a tradition, in fact, a kind of culture.
Richard Wright, foreword to George Padmore’s PAN-AFRICANISM OR COMMUNISM, 1955
Maybe the history of the Clinic is a more important experiment than the Clinic itself.
Dr. Fredric Wertham to Richard Wright, May 12, 1953
Fredric Wertham and his colleagues at Lafargue not only fashioned a conceptual framework for addressing the social basis of mental illness among an oppressed people, but also institutionalized that framework and applied this social psychiatry therapeutically in a way that touched the lives of thousands of everyday people. This book has shown how this intervention distinguished the Lafargue Clinic in the history of American psychiatry. Lafargue’s emergence was of course the product of a widespread American concern with the mental health of its citizens, but it went further than any other therapeutic institution by linking race and class oppression as a source of mental disorder and personality problems. Moreover, the clinic’s founders and supporters argued that mental health care for African Americans was an extension of democracy into the fundamental institutional life of the nation. The Lafargue Clinic became a key site in the battle for the desegregation of American society.1
The social context of New York City at midcentury was ripe for producing in African Americans a considerable degree of anxiety about their basic survival in a constricted ambit characterized by hostile competition for living space, jobs, health, recreation. Extraordinary measures were required of black people just to attain the material necessities and those intangible human needs of status and recognition and feelings of personal safety.2 This book has sought to provide a window onto a world in which the mental health of African Americans was either an invisible, underground absence or something over which many professionals in the human sciences obsessed. This is the striking paradox at work in the research and thinking of early post–World War II social scientists, government officials, and mental health professionals. In this context, the Lafargue Clinic was indeed unique, even exceptional. But its work—Wertham called it “an experiment in the social basis of psychotherapy”—was part of something larger than itself. The clinic sat at the intersection of major intellectual, political, and institutional developments in the early postwar period: the social scientific study of the effects of discrimination on minority groups; liberal antiracist social policy; and the push to move mental health care “from asylum to community.”3 Most important, though, the clinic addressed the vital issue of what healthy African American minds should look like, in practical terms, through practical means.
In his 1952 classic study, Black Skin, White Masks, which blurred the genres of scientific analysis, autobiography, and philosophical treatise, Martinican psychiatrist Frantz Fanon argued for a sociogenic approach to the origin of psychological structures of “the black living in an antiblack world.” Fanon noted that Freud, “reacting to the constitutionalist tendency of the late nineteenth century,” introduced the ontogenetic (individual) as a substitute for the phylogenetic (group/family) theory of human psychology. “It will be seen,” declared Fanon, “that the black man’s alienation is not an individual question. Beside phylogeny and ontogeny stands sociogeny.”4
Fanon’s work was contemporaneous with Wertham’s attempts to fashion a social psychiatry whose basic orientation was sociogenic. This psychiatry considered the lives and thoughts of the patient within a social context, within the quotidian experience of modern society. In a December 1946 lecture, Wertham explained that “in every mental disorder social factors are operative. It has to be determined if they are etiologically predominant, in which case we speak of sociogenic; or if they merely color the symptomatic manifestations in form or content, in which case we use the term socioplastic.”5 Wertham was convinced that psychiatry had to move beyond its binary emphasis on either somatic/constitutional determinants or individual psychopathology rooted in childhood trauma. Like Fanon, Wertham was a practicing psychoanalyst, someone whose critique of what he called “old-style conservative” psychoanalysis was an internal argument for transforming the field both philosophically and scientifically.
Race sat at the center of both Fanon’s and Wertham’s projects as the exemplary variable in the sociogenesis of mental disorders among modern “Negroes.” And while Richard Wright himself was no clinician, he too argued that the psychosocial alienation that blacks experienced, especially in the urban North, engendered among many a type of free-floating anxiety that threatened their mental health. Wertham never produced an extended study on what constituted mental health, but he persistently referred to the notion of the “will to survive in a hostile world” as the ideal state of mind for his patients who came to the Lafargue Clinic. Coming from Wertham this was of course an idea that moved beyond individual survival to consider the survival of a whole community. Thus the mental health, the psychic health of black people or any other human population, could be gauged by the presence or absence of thoughts and/or behavior directed to self-harm or violence against other community members.
The key issue here is that of irrationality or loss of control. While the notion of rationality is of course fraught with issues of racialized normativity, as generations of antiracist writers have demonstrated, the concept is useful here as a distinguishing feature of individual thought and action that threaten one’s or another’s survival.6 Wertham had a progressive faith in reason as both faculty and mechanism for helping everyday people identify the sources of mental conflict, such as anxiety or disorganized thinking. This notion becomes relevant when applied to black people living under the pressures of racism and class subjugation. The aim of Wertham’s approach was not to mold African Americans into embodiments of normative rationality. Rather, Wertham’s goal was to direct his patients toward the roots of their mental conflicts that connected deep into the social order of racial capitalism, as Cedric Robinson would later term the articulation of white supremacy and the capitalist mode of production.7
Cultural Competency and the Lafargue Clinic
It helps to place the antiracist work of Lafargue in conversation with the push for cultural competency in contemporary mental health care. The Lafargue Clinic’s emphasis on its Harlem patients’ intersecting statuses as black, largely poor, and disempowered, rather than on their “culture,” in treating mental disorders or problems of everyday living eschewed the framework of culture as a psychic determinant and offered a model of psychotherapy that was “radical” in the etymological sense: that is, of seeking answers and interventions in the roots—the social origins—of anxiety and other mental health problems.
We are in a moment in the West where scholars and laypeople alike explain human behavior, that of both individuals and collectives, through the language of “hard wiring,” of “evolutionary foundations,” of “Darwinian adaptations.” It is a return to the constitutionalism of a century ago that was thought by many to be defeated with the fall of eugenic ideology in the Allied-Axis war. What is lost in this deference to the gene, to hereditarian fixity, is the social—the world of human activity and thus contingency. The neglect of the social, of sociality as such, in the “normal science” of research in a wide array of fields enshrines matter/bodies at the expense of understanding complex causality in the shaping of human substance.8
Yet it has also become a commonplace within academia to proclaim race to be a social construction. In this formulation, race is really just a misguiding shorthand for explaining human difference based upon symbolic cues, read contextually, which have no fundamental bases in verifiable biological entities such as genes. And yet, the commonplace claim of race as social construction has hardly permeated the commonsense institutional life of so many spheres of contemporary activity, including that of psychotherapy. As historian and psychiatrist Jonathan Metzl has recently argued, “To a remarkable extent, anxieties about racial difference shape diagnostic criteria, health-care policies, medical and popular attitudes about mentally ill persons, the structures of treatment facilities, and, ultimately, the conversations that take place there within.”9
These anxieties about racial difference intersect with entrenched social-structural inequities in modern U.S. society to generate a range of racialized disparities in the access to care, diagnosis, treatment, and outcome in the area of mental health care.10 Changing the fundamental structure of an unequal social order is difficult, to say the least. So contemporary workers in the mental health care field turn to culture, to the culture of their patients and, to a lesser degree, the culture of the fields within which they work. Many practitioners and policy makers propose a concept and practice of cultural competency as a remedy to both the anxiety of encounter and the disparity in care.
From the office receptionist to the chief executive, the attainment of cultural competency has become imperative among clinical staff at all levels. Promoters of cultural competency argue that an important step in reducing disparities is for health care systems and providers to become not only aware of cultural differences among their clients and patients, but to adopt strategies for incorporating that difference into their diagnostic and treatment protocols. Professional organizations, including the American Psychiatric Association, along with individual hospitals and clinics, have devised specific guidelines that signal to their members what to be aware of when treating members of different “ethnic” and “cultural” groups, that is, what to know about “African Americans,” “Asians,” “Latinos,” and “Native Americans.”11 In their best versions, cultural competency guidelines promote awareness among the caregivers of their own possession of a culture, as well as the distinct culture of the treatment environment—the clinic, hospital, or office, for example. What cultural competency advocates hope to emerge from this stew of “cross-cultural” awareness is a reduction in miscommunication, misunderstanding, and ultimately misdiagnosis and mistreatment.
Culture, as word and concept, emerged over the last century as a placeholder for mental health professionals, policy makers, and socio-behavioral scientists for that which used to evoke or be applied to race—race as those embodied, intrinsic, fixed, and heritable traits/qualities within a population group and each one of its members.12 In contemporary discourse seeking to address disparities in the context of psychotherapy as it relates to the wider field of mental health care, cultural difference has emerged as a proxy—a stand-in for racial difference. Race becomes culture becomes race in a reflexive, circular interaction through the demand that the psychotherapist read and interpret the visible and aural signs of difference that are indeed marked by embodied difference—reading culture becomes reading race, and that process of reading is governed by a fundamental, long-embedded ensemble of associations and expectations of what it means to be X type of person.
Within the clinical encounter, the shift from race to culture has historically been a well-intentioned, often antiracist, attempt to address problems of alterity. Yet the consequences of this well-intentioned shift from race to culture are profound evasions of the persistent significance not only of racial identification and identity, but of racism as a determining force in constituting psychic health. And what is at stake in these evasions is nothing less than the very meaning of health and pathology, questions that will shape—that are no doubt shaping—the contours and substance of modern therapeutic cultures.
In highlighting the efforts of cultural competency to confront the significance of racial and ethnic difference in the clinical setting, I wish to suggest that the emphasis on the patient’s “culture” and the clinician’s capacity to read and accommodate that patient’s difference tends to elide the larger structures of inequity that perpetuate not race, but racism. And beyond that I wish to suggest that the focus on cultural competency evades the very fundamental issue of how racial difference structures how pathology is recognized, diagnosed, and treated.13
By contrast, Lafargue was a modestly radical, local effort to confront directly the individual and social effects of intersecting racial and class oppressions in the mid-twentieth-century United States. By taking concrete, institutional measures to address the anxiety of the black individuals and communities living in New York, Lafargue had chipped away at the edifice of Jim Crow in the North. While it anticipated the community mental health movement of the 1960s, the clinic did not shake up the entire system of mental health care in America, or even New York City, for that matter. Yet the very existence of Lafargue forced city officials, and at least some psychiatrists, to take seriously black people’s need for humane and accessible psychiatric services.
The End of an Experiment
In 1954, the same year that Seduction of the Innocent was published and the Supreme Court overturned “separate but equal,” the State of New York passed a law that seemed to bode well for the future of the Lafargue Clinic. The Community Mental Health Services Act represented the postwar shift in mental health care policy toward public health measures based on localized efforts to prevent serious mental illness. The act established community mental health boards in cities and counties of fifty thousand or more residents. Each local board would now be responsible for dispensing considerable funds allocated by the state to licensed providers of mental health care. Some of the clinic staff had always hoped they might be able to operate on a full-time, all-day basis, and the new law rekindled that hope. In its first eighteen months, the seventeen mental health boards across New York State dispensed approximately $4 million to outpatient clinics, inpatient general hospital psychiatric services, and a variety of psychiatric rehabilitation and remedial education programs. Kenneth and Mamie Clark’s Northside Center received over $72,000 of the New York City Community Mental Health Board’s total allotment of $436,000.14
The Lafargue Clinic applied to the state and city for funding under the 1954 act but was summarily denied. In letters to the state commissioner of mental hygiene and to New York City’s director of mental health services, Lafargue physician-in-charge Hilde L. Mosse appealed the rejection for funding. She challenged the mental health board’s finding that Lafargue did not qualify under the new law. She characterized the clinic as fulfilling a community need that no other mental hygiene clinic in Harlem had done. “As you know,” Mosse wrote to the state commissioner, “the Northside Center restricts it cases to children, and Harlem Hospital is not able to take care of the needs of the community. Our long waiting list proves this conclusively.” Moreover, the Lafargue Clinic’s contribution to pioneering clinical research had already far exceeded anything one might expect from an institution subsisting on low fees and piecemeal donations. Citing a list of studies conducted at the clinic, Mosse concluded her letter: “It is my feeling therefore that our research work also qualifies us for inclusion in the Mental Health Act.” Lafargue fit the model perfectly of locally based outpatient mental health services imagined under the 1954 act. But clearly the die had been cast long before the new legislation; no amount of persuasion or pleading could undo the calumny Wertham had directed against the psychiatric establishment or his reputation as a self-important nuisance. And so the Lafargue Clinic, Wertham’s “experiment in the social basis of psychotherapy,” never received any of the new money for community mental health care.15
The Lafargue Clinic’s failure to secure government funding coincided with the impending retirement of its most important supporter, Rev. Shelton Hale Bishop. In 1957, Bishop announced his retirement, and the board of St. Philip’s Episcopal Church announced its selection of Rev. Dr. M. Moran Weston, a graduate of Columbia University and Union Theological Seminary in New York City, to replace him. Like Bishop, Weston was committed to the mental health care needs of the Harlem community, but his opinion of Wertham and the Lafargue Clinic’s approach to social and psychological problems remains unknown. In the first year of his rectorship, Weston transformed the St. Philip’s community center and parish house, where the Lafargue Clinic had been housed since its opening, into a clearinghouse for community services and new health programs directed by a doctors’ committee he appointed. The men and women who executed the new programming represented medical professionals drawn from the St. Philip’s congregation.
Weston’s health initiative was not a slight directed at Wertham and the Lafargue Clinic. Rather it reflected a changing of the guard and perhaps the desire to place the health needs of the central Harlem community in the hands of black professionals. As if the leadership change at St. Philip’s were not enough to affect the Lafargue Clinic’s survival, several members of the clinic staff had died in the past year, and a few others were suffering from severe illnesses. And so, on November 1, 1958, the Lafargue Clinic staff held their last therapy and counseling sessions with thirty or so men, women, and children who represented the thousands that over the past twelve years had descended into the parish house basement.16