Dorothea Dix and the Trade in Lunacy

Dorothea Dix, Harvard University Houghton Library

Dorothea Dix was a leading US and international mental health reformer. She knew how to wield her quill pen and do her own reporting to advocate for positive changes. We still have a lot to learn from her.

Starting in 1830 with her investigative reporting on the deplorable conditions of inmates at a Cambridge, Massachusetts jail, Dorothea Dix quickly spread her mental health advocacy efforts with inspections of prisons and insane asylums throughout Massachusetts and other states, then internationally to England and Scotland (petitioning Queen Victoria for reforms), France, Italy (petitioning Pope Pius IX), and Turkey (trying unsuccessfully to meet with and petition Florence Nightingale at the end of the Crimean War).

After Dix’s controversial stint as Superintendent of Women Nurses for the Union Army during the American Civil War, she again took up her mental health reform efforts extending them to the Far West, visiting California, up through Oregon, to Washington Territory. Remarking on the natural beauty of Washington, including snow-capped Mt. Rainier, she described in a letter to her British Quaker reform friends, the Rathbones of Liverpool, that she was favorably impressed by the Pacific Northwest’s “humane and liberal” prisons and insane asylums. She attributed their excellence to how newly settled the area was, a newness that allowed for more progressive thinking than in either European or the American East Coast cities.

Dix was involved with political debates raging in England and Scotland where local parishes used the contract system, paying for their insane poor to live and work in private, for-profit insane asylums. Many of the asylum proprietors cut costs and increased their profits by shackling patients inside unheated rooms and depriving them of food and medical care. Known as the “trade in lunacy,” once the truths of the trade were uncovered, the practice was a source of widespread moral outrage and calls for reform.

In America, there were claims that treatment of insane incurable paupers in state-run insane asylums was a more humane approach. Proponents claimed it would save money in the long run, given economies of scale and since patients could avoid being sent to higher-cost jails and prisons.
Early reports from institutions such as the Worcester Insane Asylum claimed high success rates of “curing” patients of their insanity, by citing high patient discharge rates. What they failed to mention were the equally high rates of readmission of these patients to the same or similar institutions within short periods of time. Once forced to face these statistics, proponents of insane asylums, including Dorothea Dix, began to point to “seasonable care,” meaning that successful treatment and cure rates occurred when patients were identified early in their illness and were provided with appropriate treatment at insane asylums. Early in their illness was typically defined as treatment within the first year of onset of their symptoms.

Public and private debates in America were raging as to whether paupers–insane or not–brought on their own plights through immoral acts such as intemperance, specifically in terms of alcohol consumption, and the duty of the state to care for such people. Calvinist work ethics and conceptions of sin and salvation colored these debates. Women with children “out of wedlock” and prostitutes were labeled as sinners and as undeserving poor. Leading reformers such as Dorothea Dix declared that the duty of society was the same whether insanity or destitution resulted from “a life of sin or pure misfortune.”

Sources:

Dorothea Lynde Dix, Asylum, Prison, and Poorhouse: The Writings and Reform Work of Dorothea Dix in Illinois (Carbondale, Ill.: Southern Illinois University Press, 1999).

Thomas J. Brown, Dorothea Dix: New England Reformer, Harvard Historical Studies ; v. 127 (Cambridge, Mass.: Harvard University Press, 1998).
Dix, Asylum, Prison, and Poorhouse.

Legislative Assembly of the Territory of Washington, “An Act Relating to the Support of the Poor.”

Tamonud Modak, Siddharth Sarkar, and Rajesh Sagar, “Dorothea Dix: A Proponent of Humane Treatment of Mentally Ill,” Journal of Mental Health and Human Behaviour 21, no. 1 (2016): 69, https://doi.org/10.4103/0971-8990.182088.

Dorothea Dix, “‘I Tell What I Have Seen’—The Reports of Asylum Reformer Dorothea Dix,” American Journal of Public Health 96, no. 4 (April 1, 2006): 622–24, https://doi.org/10.2105/AJPH.96.4.622.

Dorothea Lynde Dix, The Lady and the President: The Letters of Dorothea Dix & Millard Fillmore (Lexington: University Press of Kentucky, 1975).

When Nursing Bores Me to Tears

While there is much that I love about nursing and about being a nurse, there are times when it bores me to tears, times when I feel I have been dropped down a rabbit hole time warp, times when I despair for its future. My current list includes:

  1. When the Cult of Florence Nightingale is invoked as the one and only true vision of modern nursing;
  2. When busy (and boring) Powerpoint slides are used as props to make any and all (mostly vacuous) statements;
  3. When nurse academic-types staunchly defend an old, tired, narrow-minded, biomedical model of ‘nursing research’ as the one and only true version of research;
  4. When older, privileged white women (who seemingly are blithely unaware of their privilege) are nursing’s chosen leaders and spokespersons.

There are effective antidotes to this despair and I will share my list in a follow-up post.

Stories Beget Stories

Stories beget stories, so be careful of the ones you tell—or listen to or share.

This past week I was a participant in the StoryCenter‘s webinar “Defining Compassion in Nursing” based on the Nurstory digital storytelling project founded by Dr. Sue Hagedorn from the University of Colorado School of Nursing. I was intrigued by the title of the webinar as well as by the opportunity to learn how digital storytelling is being used in nursing education and advocacy.

Digital storytelling (DS) refers to short video segments (typically 3-5 minutes in length) personal narratives that incorporate digital images, music, and voice-over narration by the person making the video. They are typically created within a workshop-based process that includes a Story Circle to share, critique, and refine stories-in-progress. Developed in the early 1990s by media/theater artists Dana Atchley and Joe Lambert and promoted through their StoryCenter (formerly the Center for Digital Storytelling), DS has been used for public health research, training, and policy campaigns (such as the powerful Silence Speaks global women’s health/human rights campaign); community building (such as the now archived BBC Capture Wales program); literacy programs; and reflective practice with health science students. DS is increasingly used as an innovative community-based participatory method that is especially effective at informing program planners and policy makers about the lived experiences of marginalized people.

Besides the fact that not all stories can or should be told in a nice, neat, linear 3-5 minute format, there are numerous ethical issues to consider. A brief overview of some of the ethical issues with DS is included on the StoryCenter website under “Ethical Practice in Digital Storytelling.” And, with their permission, here is an excellent overview by Kelsen Caldwell (formerly in the University of Washington School of Medicine, Health Sciences Service Learning and Advocacy group) of ethical considerations of storytelling in health advocacy work with communities: “The Ethics of Storytelling.”

I have worked with groups of people experiencing homelessness, as well as with health science students working on community-based service-learning projects that include homeless people, and have helped them to make some of their own DS videos. I completed a participatory digital storytelling video workshop in August, 2015 with a group of homeless youth through the Zine Project Seattle (sadly, no longer in existence). With their permission I share links to two of their videos here: “Harm Reduction is Good” and “Tug of War.”

“Soul Stories: Homeless Journeys Told Through Feet” is a DS video I made to accompany a show of my photographs and poems/prose that then became the book, Soul Stories: Voices From the Margins (2018). Also from this book, I made “Listen, Carefully” (at 7 minutes a bit long for a DS). In a StoryCenter workshop at the University of Washington, Bothell campus during the summer of 2016, I made my “Homeless Professor” digital storytelling video which was based on a portion of my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (2016). My very first DS video I made was “My Story of Community Health Nursing” that I continue to use in teaching population/community health nursing. In reviewing these DS videos, I am struck by their staying power and relevance for me. Although technically rough in places, they tell stories I want to share.

I have concerns about how empathy and compassion are defined by nursing and how we as nurse educators have our own unpacked, unexamined, uncritically looked at stories of what nursing should and should not be. Who gets to decide what is a “proper” nurse story of compassion? Shouldn’t it more properly be Nurstories instead of the singular Nurstory? That said, after viewing all of the DS videos on the Nurstory website, I am struck by how powerful and even subversive several of them are. Rawaih Faltatah’s “Circle of Care” is an ode to her older sister, a nurse, and the effects of her caring and compassion on her own life and choice of a career in nursing. A more difficult to watch and listen to, yet subversive and important DS video is “Invisible Touch” by Kate Clayton-Jones.

Feminist Nurse: Not An Oxymoron

Nurses Build Trust Not Walls. Women’s March on Seattle, 2017.

One of my first patients was a suffragette poet. She was 102 in 1981 when I cared for her in a Presbyterian nursing home in my hometown of Richmond, Virginia. I was a recent Harvard Divinity School drop-out working full-time as a nursing assistant, wrestling with the decision of whether or not I wanted to be a nurse. I was—and still am—a feminist. I was not sure I could be both a feminist and a nurse. Nursing seemed anti-feminist, steeped in the traditional subservient roles to which women were relegated.

I’ll call her Lillian because in my memory she stands out as steely kind and sharply intelligent as I imagine Lillian Wald, the founder of public health nursing, to have been. As a young woman “my” Lillian had met and worked with Susan B. Anthony. “My” Lillian had marched in suffragette demonstrations in Washington, DC and had written suffragette tracts and poetry and lobbied hard for passage of the Nineteenth Amendment in 1920 that finally granted women full voting rights. She never married and spent the rest of her life as a Presbyterian missionary in various African countries. Being a missionary was one of the few acceptable roles for single women at that time, along with nursing and teaching. (The drawing below is from my paternal grandmother’s 1919 college journal showing the “choices” she was considering for her life—ranging from Old Maid to Bride.)

In my research this past week I ran into an article written in 1904 in Seattle by a man named Honor L. Wilhelm. In between his serialized stories of his honeymoon to Victoria, BC, and guest articles on Native Americans, he wrote a piece titled “The Girl Alone” that made my feminist blood boil. He stated, “Motherhood is the acme of womanhood. The girl alone is a sinful, selfish, miserable, abhorred, ugly, wretched, hideous creature, whom to know is to shun and to meet is to pass by. She is an outcaste and a social parasite.” (p. 74, The Coast: Volumes 7-10, 1904)

The elderly suffragette poet I was fortunate to have had in my young adult life helped convince me that in becoming a nurse I did not have to trade in my feminist ideals and identity. I mainly worked evening shift at the nursing home. Late at night, once I had completed all my work, I sat beside her bed while she told me stories of her life and read drafts of poems she was working on. She gave me a hand-written poem which I treasure—a talisman of feminism.

A year later when I went back to school for my bachelor’s degree in nursing, I had no feminist nurse professors or role models. The sole feminist nursing student I knew dropped out of school in disgust after our first semester. I wish I had known about the work of feminist nurse Peggy Chinn and her colleagues who had just started Cassandra: Radical Feminist Nurses Network. Dr. Chinn’s work continues, including through her NurseManifest Nursing Activism Project. And the next generation of feminist nurse activists have started the Radical Nurses group.

March on. We still have so much work to do to help make our world a safer, healthier, more equitable place for all.

Empathy Deficit

Tactile Object 2, 1969, Paul Neagu. The Tate Modern Museum, London

Someone asked me recently at a public forum if empathy has been diminishing among nurses (and nursing students). Excellent question. In my answer, I pointed out that empathy is being sorely tried and spread quite thin in our country currently. That goes for everyone, including nurses and physicians, and students and teachers. And writers.

The question was in response to my reading of excerpts of my essay “Walk in My Shoes” included in my recently published book Soul Stories: Voices from the Margins (San Fransisco: The University of California Medical Humanities Press, 2018). In “Walk in My Shoes” I explore empathy, including if it is always a good thing. Empathy is “feeling with” as opposed to the more distancing “feeling for” of sympathy.

We all tend to be more empathetic to people who are similar to us. Climbing the socioeconomic ladder can diminish our empathy for people less well off than ourselves. It becomes easier to blame the poor and the homeless for their situations. Experiencing our own significant traumas can make us more empathetic to people who have experienced similar traumas—but only if we have had the resources to heal sufficiently.

In The Empathy Exams, Leslie Jamison describes empathy as “a penetration, a kind of travel. It suggests you enter another person’s pain as you’d enter another country, through immigration and customs, border crossing by way of query: What grows where you are? What are the laws? What animals graze here?” p. 6

I like this description because it includes the cognitive dissonance, the discomforting disorientation—and humility—that come with travel and with empathy as travel. It also highlights the healthy curiosity required of successful travel, successful empathy. Empathy takes work to gain and to maintain.

Empathy cannot be taught but it can be modeled and it can be nurtured.

Images of Nursing

From a 1989 newsletter of the Radical Nurses Group, UK

What is a nurse? What images of nursing do you have? What images of nursing are portrayed in the media? What images of nursing do we want in the future?

These are just some of the many questions that can—and should—be asked about the profession of nursing. No matter where in the world you happen to be living, a healthy and positive image of nursing matters. Nurses constitute the largest segment of the healthcare workforce worldwide. Valuing the vital work they do—and can do when given the chance—is important for individual and population health.

Do we really want to stay stuck with the image of nursing portrayed by the lady with the (Victorian) lamp, Florence Nightingale? Do we want to stay stuck even further back in time to the monastic orders who provided nursing care? Do we want to stay stuck in the limiting hospital-based image of nursing portrayed our slightly more evolved TV soap operas (from General Hospital) of E.R. and Grey’s Anatomy or even Nurse Jackie?

In reviewing my own—literal—images of nursing that I have collected over the years, it struck me how few I have of hospital nursing. To be precise, I only have one photograph I took of a hospital nurse and that was quite by accident. I was taking a photograph of a shiny-surfaced piece of hospital artwork and a nurse happened to be walking past behind me. In contrast, I have numerous photographs I have taken of nurses providing foot care and health education in homeless shelters, tent encampments, and even under bridges. Intrepid, empathic, fearless nurses. They are my image of what nursing is and what nursing can become. They are from many parts of the world. Here they are and I hope they give you hope for the future of not just nursing. And check out the Nursing Now program, in collaboration with the World Health Organization and the International Council of Nurses, which aims to raise the status and profile (and image I suppose) of nursing.