Chapter 3 in Democracy in Captivity: Prisoners, Patients, and the Limits of Self-Government (University of California Press, 2023)

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Chapter overview

This chapter offers a historical case study of patient self-government at St. Elizabeths Hospital in the 1940s and 1950s, asking what “democracy” meant inside a maximum-security psychiatric ward. Through archival research—including patient-authored newspapers, administrative records, and interviews—it reconstructs the rise of group therapy sessions, Patient Administrative Groups (PAGs), and eventually a hospital-wide patient federation. These institutions were justified as therapeutic: deliberation was said to foster “reality testing,” civic responsibility, and preparation for life outside the asylum.

Yet patient self-government proved politically ambivalent. Democratic forms—elections, bylaws, committees, representation—both empowered patients to press claims about food, privileges, and ward conditions and enabled administrators to contain dissent through procedure. The chapter conceptualizes this dynamic as a feedback loop between democracy as therapy and democracy in therapy. When tranquilizing drugs and administrative retrenchment shifted the institutional landscape, the hospital-wide federation was dismantled. The case illuminates how democratic practices can simultaneously expand agency and stabilize custodial authority, reframing debates about power, care, and participation in psychiatric institutions.

Core contributions

  • Provides a detailed archival account of patient self-government at St. Elizabeths Hospital, including the creation of PAGs and a hospital-wide patient federation.
  • Distinguishes democracy as therapy from democracy in therapy, clarifying how participatory forms can both empower wards and extend custodial control.
  • Identifies a feedback loop between institutional processing of patient claims and the reshaping of hospital authority.
  • Shows how democratic procedures (elections, representation, constitution making) can function as tools of containment as well as vehicles for collective action.
  • Connects mid-century psychiatric reform to contemporary debates about mental health activism, therapeutic communities, and democratic legitimacy in care institutions.

Where this chapter fits

The chapter engages sociological accounts of “total institutions” (including Erving Goffman), histories of moral treatment and therapeutic community models, and democratic theory’s concern with voice under conditions of dependency. It also anticipates later mental health activism and the consumer/survivor movement by highlighting how patients themselves used the language of democracy and legitimacy to challenge custodial authority. Substantively, it bridges political theory and the history of psychiatry, offering a new lens on institutional power in mental health care.

Keywords

patient self-government; therapeutic community; St. Elizabeths Hospital; Howard Hall; Patient Administrative Groups (PAGs); patient federation; democracy as therapy; democracy in therapy; psychiatric reform; institutional power; tranquilizing drugs; parens patriae; mental health activism

How to cite

Chicago (author-date)

Berk, Christopher D. 2023. “Mad Politics.” In Democracy in Captivity: Prisoners, Patients, and the Limits of Self-Government. Oakland, CA: University of California Press.