“Meeting on The Same Errand”—Origins of Mental Hygiene

They were an unlikely pair: the asylum messiah and the taciturn, Swiss-born psychiatrist. 

Clifford Whittingham Beers, a former mental patient, did not seek treatment from Adolf Meyer when they met in the fall of 1907. Instead, Beers wanted the esteemed psychiatrist to review an 80,000-word manuscript he’d written called A Mind That Found Itself. The book described Beers’ two-year odyssey through the primitive and brutal insane asylums of the day. 

At their meeting, each had his own agenda: Beers was crusading for institutional reform; Meyer wanted to broaden society’s approach to mental health by treating and possibly preventing disorders on a community-wide basis.Their brief collaboration would draw unprecedented public attention to mental health and launch a national organization. Ultimately, their ideals, and particularly Meyer’s vision, would inspire others to found the Department of Mental Hygiene at the School and place mental hygiene on the public health agenda.

“We both felt equally keenly the opportunity of the hour,” Meyer would later write. “Active psychiatry and public sentiment seemed to be meeting on the same errand.”

Born to middle-class Connecticut parents in 1876, Beers graduated from Yale and worked in a New York City insurance office. Increasingly obsessed with his epileptic brother’s death, Beers suffered a breakdown in 1900 and returned to his parents’ New Haven home. On June 23, in a half-hearted suicide attempt, he dropped himself feet-first from his fourth-floor bedroom window. He landed in front of the dining room window as his family was eating lunch. “Naturally that dinner was permanently interrupted,” Beers wrote. 

Shuttled from one asylum to another as his parents struggled to pay for his care, Beers suffered inhumane treatment by “typical eighteen-dollar a month attendants.” His book details how he was  laced so tightly into a straitjacket that he suffered intolerable pain and had difficulty breathing; locked in an airless and filthy padded cell; and choked, knocked down, and cursed regularly.

It would be difficult to find someone more different from Beers than Meyer. Born in 1866, in Nieder-weningen, near Zurich,  Meyer studied medicine at the University of Zurich and wrote a thesis on the reptilian forebrain. He arrived in the United States in 1892.Small in stature, with a direct, clear gaze and thinning black hair, Meyer wore a bushy goatee and spoke heavily accented English. Trained as a neurologist and a neuroanatomist, Meyer worked at the University of Chicago, the Worcester (Mass.) State Hospital—where, among other things, he studied patterns of alcoholism among the Irish—and at the New York State Hospitals for the Insane at Wards Island. Meyer believed that clues to the reasons for psychotic reactions could be found in a thorough review of a patient’s history, community, and environment—the patient’s life experience. “To Dr. Meyer, this was not just an intellectual insight; it was a burning conviction and a practical program of action,” recounted Hopkins psychiatrist John C. Whitehorn in a 1950 tribute to Meyer.

In Beers, Meyer found a man overflowing with life experience and the desire to share it. Beers, Meyer recalled, was “a man with a vivid appeal and a fervid devotion to a cause.” He could also be useful in Meyer’s quest for greater acceptance of the concept of mental hygiene.

Meyer was an early advocate of looking at the individual within the context of his or her home and social environment, and, on the flip side, looking to that community as a potential source of mental disorders. He believed that psychiatrists should work with community leaders and organizations to promote mental health. The concept was labeled “mental hygiene”.

When Meyer agreed to help Beers edit his book, he encouraged the younger man to soften the harsh portrayal of individual doctors and other professionals, redirecting blame toward understaffing and lack of funds. He also encouraged Beers to shift the emphasis to prophylaxis. Daily letters and express packages shuttled revisions between the pair, according to Eunice E. Winters who edited Meyer’s collected papers.

Beers wrote to Meyer: “Your suggestions (for which I thank you)…now appear in my final version.” The book remains, however, a very personal memoir, chronicling Beers’ harsh, and at times sadistic, treatment. It’s hard to imagine him having “softened” his portrayal of the doctor he referred to as Jekyll-Hyde.

“On many things we saw alike; there were others, perhaps, on which our points of view were somewhat different,” Meyer tactfully said years later. Meyer did succeed in helping redirect Beers’ passions from institutional reform only to a focus on a national mental hygiene movement that called both for preventive services based on a public health approach and the improvement of the care of the seriously mentally ill. The book, published in 1908, was an immediate success and helped to forge public support for the mental hygiene movement.

The following year, Beers, Meyer, and others launched the National Committee on Mental Hygiene (see sidebar). By late 1910, however, Meyer would resign from the committee. The energetic, excitable Beers proved to be a dynamo that the reserved psychiatrist could not control. Beers, a natural fundraiser who sometimes referred to himself as the “high priest of mental hygiene,” had grand ideals but no specific plans. Meyer wanted the organization to tackle small projects and build a base of scientific research. Beers’ erratic finances also worried Meyer, whose resignation was inevitable.

Despite Meyer’s departure, the movement was achieving the kind of recognition he had long sought for mental hygiene. Ever since a late 1890s meeting of the Child Welfare League, Meyer had been convinced of the ubiquitous nature of mental disorders and the need for a population-based approach to prevention—at that point focusing on protecting children. He came to Baltimore in 1910, appointed as the first director of the Henry Phipps Psychiatric Clinic at Johns Hopkins Hospital. 

At Phipps, Meyer continued to refine his theory that studying patients in their cultural or social settings was as important as examining brain lesions or other physiological defects. Meyer also felt that psychiatrists should work with teachers, ministers, and others in the community to promote mental health, according to Elizabeth Fee’s 1987 history of the School, Disease and Discovery. “In Meyer’s view, mental hygiene was the social agent of psychiatry and a civic responsibility,” Fee wrote.

Thomas W. Salmon, the first medical director of the National Committee, agreed with Meyer’s views and envisioned a “new psychiatry” that would move from institutions to the world at large. Psychiatry began to move into the community, and psychiatrists began to pay closer attention to statistical analysis. 

When the School was founded in 1916, the country had only just begun to see mental health within the context of public health. In the 1840s, a physician named Edward Jarvis began analyzing disease-related data gathered by the census bureau and categorizing mental disorders.

However, it wasn’t until the 1920s that doctors and epidemiologists began to look seriously at conditions in a community—economics, education, employment, family situation—as risk factors that could predict delinquency and behavioral problems in children, substance abuse, schizophrenia, and other psychiatric disorders.

By 1918, “social and mental hygiene” was listed in the School’s course catalog as an area for study.  Dr. Esther Loring Richards, chief physician at the Phipps clinic, was appointed lecturer in mental hygiene in 1926, the first faculty appointment in the field.

One of the School’s first laboratories was in its own neighborhood. A one-square-mile area adjacent to the School was established as the Eastern Health District in 1932. It was jointly administered by the Baltimore city health department and the School. A 1933 survey of the district involved 56,044 poor and middle class individuals. Within this group, Dr. Ruth Fairbank, the psychiatrist in charge of the mental hygiene portion of the study, reported that 3,881 persons “presented problems of mental ill-health of sufficient severity to have them recorded by some agency or institution.” The issues included psychotic cases, school and social problems, and juvenile and adult delinquency. There were also 1,444 people who were labeled “maladjusted individuals,” including alcoholics, those with suicidal tendencies, and people with sexual, marital, or adjustment problems. In a 1937 presentation, red and black pins on maps of the district marked the residences of psychotics, delinquents, and the maladjusted. They clustered on the district’s western and southern areas, which were full of saloons, brothels, and gang hangouts.

These data represent one of the country’s first organized epidemiologic studies of mental health conditions. In a 1938 report, Fairbank detailed the response to the community’s mental health needs: Mal-adjusted individuals received psychiatric consultation at the Phipps Clinic; mothers met with medical students to discuss “questions of habit training and social adjustment”; and, Fairbank wrote, “We are working towards the establishment of Nursery Schools and ‘Community Centers’ in some of the Public Schools in the District.” 

By the early 1940s, Adolf Meyer was in his mid-70s and ready to retire. Clifford Beers was still battling his own demons. Although he had succeeded in making his cause a national one—and raising at least $4 million for it—he was never completely free of mental disorders.

As medical historian Roy Porter recounts, Beers died in a mental asylum in 1943, depressed, near catatonic, and convinced the doctors attending him were all impersonators. Meyer, some months after suffering a stroke, died in May 1950. He was lauded by John Whitehorn, his successor at Phipps, as “a legendary figure—the idealized combination of immense erudition and practical common sense… He gained for psychiatry a high measure of respect.”

Before Meyer’s retirement, one of his students, Paul Lemkau, began working on the mental hygiene study at the Eastern Health District. Described by one colleague as looking like “Gary Cooper—tall, lean, handsome—at the same time warm and humble,” Lemkau became convinced that mental disorders could be studied in the context of epidemiology. His Eastern Health District studies would stand for decades as the most reliable basis for estimates of the number of people with mental disorders in the country. 

After writing the first textbook on mental hygiene and public health and serving in government in Maryland and New York, Lem-kau was named chair of the School’s new Department of Mental Hygiene in 1961. “It was Lemkau’s vision and activities [that] actually helped create the institutional structures, which turned Meyer’s ideas into practical reality,” notes Wallace Mandell, a professor emeritus in the department.

In addition to honoring Lemkau’s work, the 1961 creation of the Department of Mental Hygiene—still the only department of its kind in a school of public health in the nation—served another purpose. It was a vindication of sorts for Adolf Meyer and his erstwhile collaborator Clifford Beers, who had both believed the discipline to be an essential public health mission almost six decades before.