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Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South
There is a complicated history of racism and psychiatric healthcare in the Deep South states of Georgia, Alabama, and Mississippi. The asylums of the Jim Crow era employed African American men and women; served as places of treatment and care for African Americans with psychiatric illnesses; and, inevitably, were places of social control. Black people who lived and worked in these facilities needed to negotiate complex relationships of racism with their own notions of community, mental health, and healing.
Kylie M. Smith mixes exhaustive archival research, interviews, and policy analysis to offer a comprehensive look at how racism affected Black Southerners with mental illness during the Jim Crow era. Complicated legal, political, and medical changes in the late twentieth century turned mental health services into a battlefield between political ideology and psychiatric treatment approaches, with the fallout having long-term consequences for patient outcomes. Smith argues that patterns of racially motivated abuse and neglect of mentally ill African Americans took shape during this era and continue to the present day. As the mentally ill become increasingly incarcerated,Jim Crow in the Asylum reminds readers that, for many Black Southerners, having a mental illness was—and still is—tantamount to committing a crime.
Kylie M. Smith mixes exhaustive archival research, interviews, and policy analysis to offer a comprehensive look at how racism affected Black Southerners with mental illness during the Jim Crow era. Complicated legal, political, and medical changes in the late twentieth century turned mental health services into a battlefield between political ideology and psychiatric treatment approaches, with the fallout having long-term consequences for patient outcomes. Smith argues that patterns of racially motivated abuse and neglect of mentally ill African Americans took shape during this era and continue to the present day. As the mentally ill become increasingly incarcerated,Jim Crow in the Asylum reminds readers that, for many Black Southerners, having a mental illness was—and still is—tantamount to committing a crime.
330 pages, Kindle Edition
Published January 13, 2026
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October 4, 2026
Before beginning, I want to acknowledge the limits of my perspective. As a white American man, I cannot fully understand the violence and suffering endured by African Americans under slavery. I can, however, approach this history with humility and recognize that its psychological harm did not end with those who experienced enslavement directly, but continued to affect families and later generations.
In my English Language Arts classes, my students and I are currently analyzing “To My Old Master,” an 1865 letter by Jourdon Anderson, a formerly enslaved man living in Dayton, Ohio. Anderson wrote the letter in response to his former enslaver, Colonel P. H. Anderson, who asked him to return to work on his Tennessee plantation. I mention the letter here because Anderson recalls witnessing the abuse of other enslaved people on that same plantation and makes clear that protecting his own children from similar violence mattered more than returning. He writes, “I would rather stay here and starve—and die, if it come to that—than have my girls brought to shame by the violence and wickedness of their young masters.”
In Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South, Kylie M. Smith compassionately centers the experiences of African Americans confined within psychiatric systems in Alabama, Mississippi, and Georgia. She shows that institutional racism operated through more than individual prejudice: segregation shaped hospital policies, Black patients received fewer resources and poorer conditions, and psychiatric authority could turn racial assumptions into diagnoses and treatment decisions. These practices denied patients dignity and care while giving discrimination the appearance of medical legitimacy. Smith thus makes a persuasive case that Southern psychiatric institutions often reproduced the racial order outside their walls rather than providing refuge from it.
During the Jim Crow era, state psychiatric hospitals held a painful and complicated place in African American life. Although they provided care and employment for some, they also reinforced a racial system that denied many people safety, dignity, and compassion. In segregated Southern institutions, harsh treatments—including electroconvulsive therapy without anesthesia, lobotomies, and insulin comas—were often administered unequally or used as punishment, compounding the suffering of patients who were already vulnerable. Even after civil rights legislation in the 1960s, Southern states strongly resisted desegregating mental health facilities. Smith connects this history of neglect and dehumanization to present-day systemic disparities, including the incarceration of people living with mental illness, reminding us that humane care must begin by recognizing each person’s dignity.
JCITA shows how the daily lives of Black patients in Southern psychiatric hospitals often continued the exploitative patterns of plantation slavery, sharecropping, and forced labor instead of providing genuine care. In segregated institutions across Georgia, Alabama, and Mississippi, patients were routinely required to perform exhausting farm work and institutional chores, often without pay or meaningful choice. This labor benefited white-run institutions and reflected the racist belief that Black people were suited mainly for hard physical work. By presenting Black patients as incapable of benefiting from treatment, Southern psychiatry gave these prejudices medical authority and turned confinement into a form of social control. The result was a system that treated vulnerable people as a source of labor while denying them the dignity, compassion, and therapeutic care they deserved.
From Reconstruction through the Jim Crow era, the divide between custodial and therapeutic hospitals reflected the racial divide between Black and white patients. Custodial institutions emphasized housing, feeding, and social control rather than medical cure, confining many vulnerable people—especially Black Southerners—indefinitely in neglected, underfunded conditions. They relied on physical restraint, forced agricultural labor that echoed plantation life, and punishment rather than psychiatric healing. Therapeutic hospitals, by contrast, claimed to offer rehabilitation and clinical care designed to ease or treat mental illness, using methods such as electroconvulsive therapy, insulin comas, lobotomies, and later Thorazine. Yet racism shaped these institutions too: Black patients were often denied advanced care while being disproportionately subjected to violent physical treatments or custodial confinement. The distinction was therefore not simply medical; it reveals how institutional racism determined who was treated as a patient deserving compassion and who was managed as a problem to be controlled.
In Georgia, Alabama, and Mississippi, institutional racism was built into psychiatric care through policies and practices that systematically disadvantaged Black patients. Hospitals served as instruments of social control as well as places of treatment, using segregation, confinement, and medical authority to police Black behavior within the Jim Crow order. Emotional distress could be recast as deviance or criminality—a pattern that continues in modern mass incarceration—while racist assumptions contributed to disproportionate schizophrenia diagnoses when Black patients expressed anger. Many were confined to overcrowded, neglected sections of institutions such as Central State Asylum in Milledgeville, showing how “separate but equal” produced profoundly unequal care. Even within these conditions, Black patients and staff created spaces of dignity, community, and mutual care. After the civil rights era, de facto segregation and unequal funding preserved many of the same disparities, while reliance on police during mental-health crises extended institutional control beyond the hospital and deepened the medical mistrust rooted in this history.
Smith presents Alabama as a key battleground in the struggle to reform the Jim Crow South’s abusive psychiatric system. Institutional racism was built into the system itself: white patients were largely sent to Bryce Hospital in Tuscaloosa, while Black patients were confined at Searcy Hospital in Mount Vernon, where segregation determined access to resources, living conditions, and meaningful care. Black patients who received treatment could face psychosurgery, electroconvulsive therapy, or early antipsychotic drugs such as Thorazine, often with little oversight or concern for their well-being. Smith argues that psychiatric authority gave racial control a medical appearance: diagnoses could label resistance or distress as illness, while unequal treatment and confinement reinforced the wider social order. Civil rights lawyers and the NAACP Legal Defense Fund eventually forced desegregation, but the state failed to build adequately funded community care, leaving many former patients without support. This pattern—racialized confinement followed by institutional abandonment—helps connect Jim Crow asylums to today’s mass-incarceration crisis, in which jails and prisons have become primary sites of confinement for many Black Americans living with mental illness.
In JCITA, Smith traces how institutional racism operated across a connected Mississippi network: Ellisville State School for children with developmental disabilities, the state hospital at Whitfield for adults with mental illness, and local jails. Black patients were often moved among these institutions throughout their lives, showing that Jim Crow segregation did more than separate facilities—it directed Black people into an underfunded system where disability, mental illness, and criminality were deliberately blurred. By withholding community care, relying on forced labor, and embedding racial assumptions in diagnoses such as schizophrenia, the state gave unequal treatment the appearance of medical necessity and left families with lasting trauma and mistrust. These patterns were not isolated abuses but features of Jim Crow-era institutions that used confinement to preserve racial hierarchy. Later underfunding of community services, combined with mass incarceration, carried this logic forward by treating mental illness among Black Southerners as a matter of criminal control rather than compassionate care.
The Milledgeville facility in Georgia grew into one of the nation’s largest psychiatric institutions, yet its scale did not translate into equal or compassionate care. The hospital enforced strict racial segregation and depended heavily on African American workers and patients to keep it running under deeply unequal conditions. Smith shows that aggressive procedures—including electroconvulsive therapy without anesthesia, lobotomies, and insulin comas—could become tools of racial discipline and behavioral control rather than genuine treatment. Black patients and workers were therefore caught in a painful double bind: they built forms of community and care within an institution governed by the paternalistic demands of Jim Crow bureaucracy. By tracing this history, Smith connects psychiatric policing and systemic neglect to today’s mass incarceration and criminalization of mental illness, showing how institutional racism can persist even as its settings change.
Noting foundational racism in medicine, academic journals like CHOICE and the Journal of the History of Medicine and Allied Sciences praise the book for demonstrating that racism was not an incidental bias but a foundational element of American psychiatric history. Reviewers on the Mississippi Books Page highlight how the author uses painstaking research, personal letters, and testimonies to make a difficult history deeply personal. Writing in USIH, historian Andrew Scull characterizes it as a powerful moral indictment of psychiatry's complicity in abuse, though he argues the text leans heavily on systemic denunciations with fewer novel evidentiary breakthroughs. Readers on platforms like The StoryGraph emphasize the book's success in connecting historical psychiatric practices to the modern pipeline between mental illness and criminalization.
Smith argues that Southern asylums often reproduced plantation structures, using Black patients for forced farm labor while presenting exploitation as therapy. In JCITA, she shows how psychiatry pathologized Black resistance—especially through racialized schizophrenia diagnoses—to justify confinement and abuse, a pattern that helped link mental illness with criminalization. Across major hospitals in Alabama, Mississippi, and Georgia, segregation and Black labor sustained unequal systems of care. Yet Black mental-health professionals and advocates, including Dr. Prince Barker, Dr. Eugene Dibble, Vera Chandler Foster, and Ethel Harvey, created more humane forms of community care through efforts such as the Tuskegee Mental Hygiene Clinic. Their work, together with NAACP Legal Defense Fund advocacy and Judge Frank M. Johnson’s 1969 desegregation ruling, challenged a system that had long denied Black patients dignity and meaningful treatment.
Longstanding beliefs that treated Black activism and emotional distress as signs of illness helped create disparities that remain visible today, including the disproportionate misdiagnosis of Black patients with schizophrenia. Generations of segregation, medical experimentation, and abuse in state hospitals across Georgia, Alabama, and Mississippi also left many African American communities with a deeply understandable mistrust of psychiatric and medical institutions. When desegregation and deinstitutionalization were not matched by adequate, integrated community care, many people with mental-health disabilities were pushed toward jails and prisons rather than treatment. This history continues to shape an underfunded public mental-health system in which racial and ethnic minority communities face unequal access to services, showing how institutional neglect can endure long after formal segregation ends.
This history leaves me deeply troubled, especially because such systemic injustice has too often been overlooked. I recognize the limits of my own perspective, but I am grateful that Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South brings these experiences into clearer view and challenges readers to consider how institutional racism continues to shape mental-health care. The book offers both a necessary historical reckoning and a call to pursue more humane, equitable systems. I highly recommend it.
In my English Language Arts classes, my students and I are currently analyzing “To My Old Master,” an 1865 letter by Jourdon Anderson, a formerly enslaved man living in Dayton, Ohio. Anderson wrote the letter in response to his former enslaver, Colonel P. H. Anderson, who asked him to return to work on his Tennessee plantation. I mention the letter here because Anderson recalls witnessing the abuse of other enslaved people on that same plantation and makes clear that protecting his own children from similar violence mattered more than returning. He writes, “I would rather stay here and starve—and die, if it come to that—than have my girls brought to shame by the violence and wickedness of their young masters.”
In Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South, Kylie M. Smith compassionately centers the experiences of African Americans confined within psychiatric systems in Alabama, Mississippi, and Georgia. She shows that institutional racism operated through more than individual prejudice: segregation shaped hospital policies, Black patients received fewer resources and poorer conditions, and psychiatric authority could turn racial assumptions into diagnoses and treatment decisions. These practices denied patients dignity and care while giving discrimination the appearance of medical legitimacy. Smith thus makes a persuasive case that Southern psychiatric institutions often reproduced the racial order outside their walls rather than providing refuge from it.
During the Jim Crow era, state psychiatric hospitals held a painful and complicated place in African American life. Although they provided care and employment for some, they also reinforced a racial system that denied many people safety, dignity, and compassion. In segregated Southern institutions, harsh treatments—including electroconvulsive therapy without anesthesia, lobotomies, and insulin comas—were often administered unequally or used as punishment, compounding the suffering of patients who were already vulnerable. Even after civil rights legislation in the 1960s, Southern states strongly resisted desegregating mental health facilities. Smith connects this history of neglect and dehumanization to present-day systemic disparities, including the incarceration of people living with mental illness, reminding us that humane care must begin by recognizing each person’s dignity.
JCITA shows how the daily lives of Black patients in Southern psychiatric hospitals often continued the exploitative patterns of plantation slavery, sharecropping, and forced labor instead of providing genuine care. In segregated institutions across Georgia, Alabama, and Mississippi, patients were routinely required to perform exhausting farm work and institutional chores, often without pay or meaningful choice. This labor benefited white-run institutions and reflected the racist belief that Black people were suited mainly for hard physical work. By presenting Black patients as incapable of benefiting from treatment, Southern psychiatry gave these prejudices medical authority and turned confinement into a form of social control. The result was a system that treated vulnerable people as a source of labor while denying them the dignity, compassion, and therapeutic care they deserved.
From Reconstruction through the Jim Crow era, the divide between custodial and therapeutic hospitals reflected the racial divide between Black and white patients. Custodial institutions emphasized housing, feeding, and social control rather than medical cure, confining many vulnerable people—especially Black Southerners—indefinitely in neglected, underfunded conditions. They relied on physical restraint, forced agricultural labor that echoed plantation life, and punishment rather than psychiatric healing. Therapeutic hospitals, by contrast, claimed to offer rehabilitation and clinical care designed to ease or treat mental illness, using methods such as electroconvulsive therapy, insulin comas, lobotomies, and later Thorazine. Yet racism shaped these institutions too: Black patients were often denied advanced care while being disproportionately subjected to violent physical treatments or custodial confinement. The distinction was therefore not simply medical; it reveals how institutional racism determined who was treated as a patient deserving compassion and who was managed as a problem to be controlled.
In Georgia, Alabama, and Mississippi, institutional racism was built into psychiatric care through policies and practices that systematically disadvantaged Black patients. Hospitals served as instruments of social control as well as places of treatment, using segregation, confinement, and medical authority to police Black behavior within the Jim Crow order. Emotional distress could be recast as deviance or criminality—a pattern that continues in modern mass incarceration—while racist assumptions contributed to disproportionate schizophrenia diagnoses when Black patients expressed anger. Many were confined to overcrowded, neglected sections of institutions such as Central State Asylum in Milledgeville, showing how “separate but equal” produced profoundly unequal care. Even within these conditions, Black patients and staff created spaces of dignity, community, and mutual care. After the civil rights era, de facto segregation and unequal funding preserved many of the same disparities, while reliance on police during mental-health crises extended institutional control beyond the hospital and deepened the medical mistrust rooted in this history.
Smith presents Alabama as a key battleground in the struggle to reform the Jim Crow South’s abusive psychiatric system. Institutional racism was built into the system itself: white patients were largely sent to Bryce Hospital in Tuscaloosa, while Black patients were confined at Searcy Hospital in Mount Vernon, where segregation determined access to resources, living conditions, and meaningful care. Black patients who received treatment could face psychosurgery, electroconvulsive therapy, or early antipsychotic drugs such as Thorazine, often with little oversight or concern for their well-being. Smith argues that psychiatric authority gave racial control a medical appearance: diagnoses could label resistance or distress as illness, while unequal treatment and confinement reinforced the wider social order. Civil rights lawyers and the NAACP Legal Defense Fund eventually forced desegregation, but the state failed to build adequately funded community care, leaving many former patients without support. This pattern—racialized confinement followed by institutional abandonment—helps connect Jim Crow asylums to today’s mass-incarceration crisis, in which jails and prisons have become primary sites of confinement for many Black Americans living with mental illness.
In JCITA, Smith traces how institutional racism operated across a connected Mississippi network: Ellisville State School for children with developmental disabilities, the state hospital at Whitfield for adults with mental illness, and local jails. Black patients were often moved among these institutions throughout their lives, showing that Jim Crow segregation did more than separate facilities—it directed Black people into an underfunded system where disability, mental illness, and criminality were deliberately blurred. By withholding community care, relying on forced labor, and embedding racial assumptions in diagnoses such as schizophrenia, the state gave unequal treatment the appearance of medical necessity and left families with lasting trauma and mistrust. These patterns were not isolated abuses but features of Jim Crow-era institutions that used confinement to preserve racial hierarchy. Later underfunding of community services, combined with mass incarceration, carried this logic forward by treating mental illness among Black Southerners as a matter of criminal control rather than compassionate care.
The Milledgeville facility in Georgia grew into one of the nation’s largest psychiatric institutions, yet its scale did not translate into equal or compassionate care. The hospital enforced strict racial segregation and depended heavily on African American workers and patients to keep it running under deeply unequal conditions. Smith shows that aggressive procedures—including electroconvulsive therapy without anesthesia, lobotomies, and insulin comas—could become tools of racial discipline and behavioral control rather than genuine treatment. Black patients and workers were therefore caught in a painful double bind: they built forms of community and care within an institution governed by the paternalistic demands of Jim Crow bureaucracy. By tracing this history, Smith connects psychiatric policing and systemic neglect to today’s mass incarceration and criminalization of mental illness, showing how institutional racism can persist even as its settings change.
Noting foundational racism in medicine, academic journals like CHOICE and the Journal of the History of Medicine and Allied Sciences praise the book for demonstrating that racism was not an incidental bias but a foundational element of American psychiatric history. Reviewers on the Mississippi Books Page highlight how the author uses painstaking research, personal letters, and testimonies to make a difficult history deeply personal. Writing in USIH, historian Andrew Scull characterizes it as a powerful moral indictment of psychiatry's complicity in abuse, though he argues the text leans heavily on systemic denunciations with fewer novel evidentiary breakthroughs. Readers on platforms like The StoryGraph emphasize the book's success in connecting historical psychiatric practices to the modern pipeline between mental illness and criminalization.
Smith argues that Southern asylums often reproduced plantation structures, using Black patients for forced farm labor while presenting exploitation as therapy. In JCITA, she shows how psychiatry pathologized Black resistance—especially through racialized schizophrenia diagnoses—to justify confinement and abuse, a pattern that helped link mental illness with criminalization. Across major hospitals in Alabama, Mississippi, and Georgia, segregation and Black labor sustained unequal systems of care. Yet Black mental-health professionals and advocates, including Dr. Prince Barker, Dr. Eugene Dibble, Vera Chandler Foster, and Ethel Harvey, created more humane forms of community care through efforts such as the Tuskegee Mental Hygiene Clinic. Their work, together with NAACP Legal Defense Fund advocacy and Judge Frank M. Johnson’s 1969 desegregation ruling, challenged a system that had long denied Black patients dignity and meaningful treatment.
Longstanding beliefs that treated Black activism and emotional distress as signs of illness helped create disparities that remain visible today, including the disproportionate misdiagnosis of Black patients with schizophrenia. Generations of segregation, medical experimentation, and abuse in state hospitals across Georgia, Alabama, and Mississippi also left many African American communities with a deeply understandable mistrust of psychiatric and medical institutions. When desegregation and deinstitutionalization were not matched by adequate, integrated community care, many people with mental-health disabilities were pushed toward jails and prisons rather than treatment. This history continues to shape an underfunded public mental-health system in which racial and ethnic minority communities face unequal access to services, showing how institutional neglect can endure long after formal segregation ends.
This history leaves me deeply troubled, especially because such systemic injustice has too often been overlooked. I recognize the limits of my own perspective, but I am grateful that Jim Crow in the Asylum: Psychiatry and Civil Rights in the American South brings these experiences into clearer view and challenges readers to consider how institutional racism continues to shape mental-health care. The book offers both a necessary historical reckoning and a call to pursue more humane, equitable systems. I highly recommend it.
July 11, 2026
Dr. Smith does an incredible job of detailing the hidden history of segregation in psychiatric hospitals in the South. This book was very informative and eye-opening. I had to keep putting this book down because I was so disturbed by the content, but Smith's obvious passion for the subject kept me reading.
If you're a doctor, mental health professional, or social worker, this book is a must-read for better understanding the dark history that underpins our careers.
Thank you to the University of North Carolina Press and NetGalley for the ARC!
If you're a doctor, mental health professional, or social worker, this book is a must-read for better understanding the dark history that underpins our careers.
Thank you to the University of North Carolina Press and NetGalley for the ARC!
Displaying 1 - 2 of 2 reviews