Special Episode: Antonia Hylton & Madness

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Hi, I'm Erin Welsh, and this is This Podcast Will Kill You.

Welcome to another episode of the TPWKY Book Club, where I bring on authors of popular science and medicine books to ask them all about their latest work.

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It is 2025.

We are a quarter of the way into the 21st century, and we are still failing in many ways to deliver mental health care to those in need.

Stigma, shame, dismissal, sexism, and racism are all embedded in the way we view and treat mental health issues, affecting who is deemed worthy of receiving care and what type of care they receive.

And as the police have increasingly and inappropriately been called on to respond to mental health crises, Black Americans and other people of color experiencing a crisis are disproportionately more likely to be harmed or killed by police, imprisoned, rather than given the help and mental health resources that white Americans are more likely to receive.

The roots of these inequalities, which are ingrained in our current medical and carceral systems, stretch back generations.

To make lasting and effective changes in the way we approach mental health in this country, we need to turn to the past to understand its role in shaping our present.

In Madness, Race and Insanity in a Jim Crow Asylum, author Antonia Hilton explores the story of Crownsville Hospital, a segregated asylum in Ana Rundle County, Maryland, built in 1911 by its first patients, 12 black men.

Over the decades of its operation, during which it grew into a compound housing thousands of patients, Crownsville became, in many ways, a microcosm of the dynamics between race, mental illness, medicine, and the civil rights movement playing out across the United States.

Expertly blending oral histories with archival materials, Hilton, who is an Emmy Award-winning anchor and correspondent for MSNBC and NBC and New York Times best-selling author, presents a nuanced and moving examination of an overcrowded, understaffed Jim Crow institution that shaped the lives of those who lived or worked there.

Hilton also reveals how the shift in focus from asylums to prisons and jails was reflected in Crownsville's operation.

Madness is an urgent, necessary, and powerful work that sheds much needed light on the intersections between race, racism, and mental illness.

I'm really excited to share this conversation with you all, so let's take a quick break and get started.

Antonia, thank you so much for joining me today.

Thank you for having me.

I'm so excited to do this.

In your book, Madness, you tell the truly haunting and heartbreaking story of Crownsville Hospital, which is one of the last segregated asylums in the U.S.

How did you first come across this story?

Well, I first came across the story of Crownsville my freshman year of college.

And it was

there's sort of two origin stories I always tell people about how I came to this place.

The simple one is, it's my freshman year.

I'm trying to figure out who I want to be and what I want to study.

And I stumble into a class called Madness in Medicine that I didn't even know was, you know, something that could exist.

A course all about the history of mental health care treatment in Europe and in the United States.

And I learn all about the development of the asylum, the development of medications to treat mental health challenges.

And as I grow deeper and deeper into the course, there's this thing gnawing at me, which is that I'm learning about the history of mental health care mostly from the perspective of European or white American people.

And I knew something was wrong with that, not just from basic instinct, but because I have family members who were very deeply impacted by the system themselves in the U.S., a history of mental health challenges in my family.

And so I knew that there were black people, black patients, black providers who worked in these spaces, who contributed and tried.

And I just went looking for a way to learn more about that at first.

And so I go looking to find out about the asylums, the institutions that worked with black patients.

And what I found was a system of segregated asylums built in the decades after slavery came to an end in the U.S.

And many of them closed down, were the subject of scandal, burned, files destroyed.

There's one asylum that a great-grandfather of mine spent some time in that has been turned into a kind of Halloween theme park sort of experience.

Yeah, I made the same face when I first found that out.

Wow.

And

so in many cases, I just kept hitting these like dead ends.

Okay, not much here, or there's just a paragraph about it here.

And then I found Crownsville.

And Crownsville is unique and not unique in a number of ways.

Unique in that it is one of the only ones that were part of this network, a segregated asylum with existing records, living people and patients who had been at this place, and a campus.

that is still standing, even to this day.

In fact, it's in really the heart of Maryland in Anarundal County.

And the county and the state is engaged in a massive sort of rehabilitation and reimagining project as we speak.

And so there was this opportunity to feel the place, to see it, to walk through it, to talk and sit with people who knew it intimately, and then to also petition the state of Maryland for access to its records.

And that was unlike really any other opportunity.

I'd say there's one similar place in Virginia called Central State that there's a similar opportunity there, but this was so rare.

And so I just dove in and I became obsessed.

The longer story, and perhaps the more true story, is that

when I was 11 years old, I had a conversation with my father about,

you know, cousins, and my cousins had just been visiting our house.

And I asked my dad, you know, I guess something must have clicked in my head, hey, why haven't I met any of your cousins?

Do I know any of your cousins?

You must have some.

And he said, well, you know, there's an uncle who you think is an uncle, but he's technically a cousin, but you call him uncle.

And that's something that I know many people can relate to.

And then he said, and then, you know, some of my cousins have lost touch with them.

One was incarcerated.

And then one was killed by a police officer in the middle of a mental health episode.

And we don't talk about him very much.

And that was my first time ever learning that my dad had had a cousin named Maynard growing up, who he had loved and admired.

He kind of wanted to be Maynard.

And in many ways, he actually did follow in that cousin's footsteps.

My dad is a lawyer.

Maynard was a lawyer when my dad was little.

And

he developed schizophrenia and

was killed by a police officer during an interaction in public on the steps of a federal building in Mobile, Alabama in the 70s.

And I was too young at the time to talk to my father about that.

I didn't really know how to ask good questions.

But then I became older and I asked a little bit more.

I became a journalist.

I became a pest.

And I started to understand who Maynard was and just how much his death had transformed my family.

And I think that in a way, for me, this story really goes back to my childhood, to the discovery that there had been all these stories in my family, these experiences, people who had tried and failed to seek treatment in this system that set me on this path, made me so curious in my bones to try to understand this, that it set me up to be in a place where then when I am this young student, it all kind of clicked together.

And so that's why I always tell both of those stories, because there's this sort of surface level story, but then there's like

the

what at times has felt for me like this like familial mission I have been on, almost like I don't know so much that I had a choice.

It just sort of feels like all these things fell into place and they were right and they were the thing I had to do.

And that is what brought me to Crownsville and to this unbelievable story.

I mean, there are so many elements to the story that you tell and in your book that it's not just the effects of Crownsville echo today.

It's that they, you know, have dictated, they have made the world that we have today in terms of mental health care.

And I think it really helps sort of contextualize how today we are still failing in many respects to provide adequate mental health care.

And I want to go through the full story, but I want to touch on something that you mentioned early on, which is the difficulty in obtaining source materials.

And I'd love to hear more about your research method and your process for incorporating these different types of source materials together.

Like which elements do you pull from?

What was that entire experience like for you?

Oh boy.

It was a lot.

It's a short answer

because I was so young.

So keep in mind, you know, I begin this process as a literal teenager.

I'm like 19 years, 18, 19 years old.

There's a lot I did not know about the world and how all of this worked.

And so my first real task at working with, I was really lucky to have Evelyn Hammonds at Harvard as my thesis advisor.

I had her help and some other people in the Harvard History of Science Department really guide me through this.

I don't know that I would have gotten it done without them, but the process of going through

institutional review board, human subjects research approval, and getting the state of Maryland to give me permission to come to the state archives and access records that they typically refuse to share.

In fact, it's a point of contention for many people in the black community in Maryland who have routinely asked for access to these records and been denied it.

And so I think I didn't appreciate how hard it was going to be.

I thought, okay, there's some rules on this website.

I'm going to follow all the rules.

I'm going to take the tests they tell me to take, and then they're going to let me go.

But, you know, there were some politics that got into the way and some people that dragged their feet.

And so it was helpful to have the backing of that institution to come in and sort of apply some pressure to make sure that I could get in there and get my work done.

And so that was, to me, I thought like, holy grail, I'm going to go into the state archives and everything will be there.

I will know everything about this place as soon as I can get my hands on these primary source documents.

And then I finally do.

And it is incredible.

Let me not downplay what's in there.

I mean, there were monthly reports.

There were writings and letters that superintendents who ran the institution had written to themselves or privately to other state leaders.

There were

certain patient records, but there was a whole lot of patient records missing.

And I very quickly realized this wasn't the holy grail that I thought it was going to be.

That most of what happens when an institution of that nature, you know, closes down and people preserve what remains is the sort of clinical perspective,

and the leadership perspective is preserved.

But the patient story, that is

not respected, that's not maintained, that's not preserved as well.

And in fact, as I later learned in my journey, I didn't know this at the time, employees of the institution alleged that there was a systematic effort to destroy a lot of the patient stories because there was a fear from the state, in their view, that perhaps lawsuits could come from that, that it would be more trouble than it was worth and so i realized even as a very young person sitting there in the maryland state archives oh wow i'm going to need to launch like a big oral history project i need to go talk to people i need to meet people i'm going to need to make up for the voices that are missing in this place and find them elsewhere and that took a long time because Humans are human and you have to build trust with people.

You have to

call them, write them snail mail.

I mean, a lot of the former employees,

they were at the time and they still are quite elderly.

And so I couldn't text them and DM them on Instagram or something.

I had to really do some like shoe leather reporting work.

And in some cases, there were some people I was able to meet very quickly.

Paul Lurs, for example.

Paul Lurs worked at the institution for 40 years, social worker who dedicated his life to children at Crownsville.

He was very quickly willing to speak, but so many people had been affected, had been traumatized in some cases by what they experienced at Crownsville.

And so it took a while to build their trust.

There are people in this book who took three, five, seven years to decide to talk to me.

And I had to be really patient with that and respect that.

There were people who didn't want to talk on the phone, but they were willing to talk if I came and I knocked on the door and I sat on their porch.

And so the level of investment and patience that comes with that, I really grew into it in a way.

I started out as this young person who was just calling people up.

And I should be grateful that anyone answered a 19-year-old's phone calls, first of all, let me say that.

But then I became an adult and a professional journalist, and I got the resources to be able to do the sort of real, like sitting in the community and being present work.

And that is what

transformed everything.

I think those stories, those memories, they are the richest part of this book.

You know, the records, they are fascinating, they are valuable.

I worked with so many of them in the story, but it's so helpful to have the sort of sights, smells, sounds, and stories from people who were so personally impacted by all this, whether they were the patients or they were the providers.

And in many cases, they really fill in critical gaps or you know, the records in some cases actually confirmed some of the stories that were found out in the community.

And with an institution like Crownsville, it's huge.

For anyone listening who lives in the Maryland area, like it is worth driving by and seeing this place because you'll get a sense of just the immensity, the number of people who were touched by this place over the almost 100 years that it was in operation.

And what comes with that is there's an amount of community rumor and storytelling and all of that that you have to wade through.

And having the community and having the trust in the community and then having the records and bringing those complementary pieces together, it allowed me to find a way to tell a story that had either been both sort of simultaneously pushed under the rug, but also sort of festered as a mythological thing for a really long time.

And it was the ability to do both of those things that helped me find the truth, the core of what happened there.

And I see the record, the sort of painstaking archival and research process as being just as important as the oral history endeavor too

let's take a quick break and when we get back there's still so much to discuss

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Welcome back, everyone.

I've been chatting with Antonia Hilton about her book, Madness, Race and Insanity in a Jim Crow Asylum.

Let's get back into things.

What emerges is this really rich, sweeping perspective, like the storytelling of asylums and the representation of asylums that happens often in popular media, like movies, is very one-sided, one-dimensional, or just one perspective.

And that's one of the things I really appreciated about your book.

And I would love to turn sort of to the beginning.

Why was this institution institution and other institutions like it?

Why was it built?

And how did its surrounding context, both the time period in which it was established and the location that it was established in, how did that shape what it would become?

The context is everything.

Crownsville is created.

It is founded in 1911.

And this is a fascinating time in the United States.

We're a couple decades after the end of slavery.

And there have been these immense contradictions in American society.

I mean, black people have in some cases, they've become lawmakers.

They've started incredibly successful towns and communities in places like Tulsa, Oklahoma.

And they're gaining ground.

But then there is a massive backlash and backsliding that starts to steal some of that ground back.

And there's an effort, and a lot of that effort actually begins in Maryland.

A lot of people don't know this.

You know, Maryland passed one of the first segregation ordinances in the entire country.

If not, I think the very first segregation ordinance, in fact.

So there is this effort to try to put black people back in their place.

But there also is, for the black people who haven't found the tulsas, who haven't maybe found their footing yet, there's this sort of incessant writing going on in white intellectual circles.

So doctors, lawyers, politicians, who are really obsessed with what they describe as this problem of Negro insanity, Negro alcoholism, Negro waywardness.

They are observing that there are all these black people who seem to be traumatized and struggling and unable to adjust to life post-enslavement.

And, you know, looking back on it for us now, that perhaps doesn't seem so surprising that people found that experience, you know, hundreds of years of enslavement to be traumatizing for their families.

But at that time, you would think they thought that everyone would get over it in a year or two.

And that just simply hadn't been the case.

So

they're writing these letters to each other, or they're publishing in medical journals these observations that were incredibly dehumanizing.

On the other hand, then they're expressing pity and saying, well, we need to do something about it.

We got to do something about it.

But what they decide to do is create a place to treat them, but they must be separate from white people.

Because these antebellum attitudes that black people are inherently different, they seeped into everything.

I mean, I think people understand, okay, separate water fountains, separate schools, but they forget it.

I mean, mean, it went into healthcare treatment.

It went into basic conceptions of how the mind in different people would work.

And so they make the decision that there need to be these separate places for treatment, and Maryland takes it one step farther.

They decide that they're going to create this asylum, but they don't really want to pay for it.

And they're going to ask.

not ask, they're going to force these patients to build it for themselves.

So it begins with 12 black men who are brought from almshouses, poor houses around the state, brought into a forest.

And if you know the Maryland area, it's sort of the modern Bacon Ridge natural area.

And there's nothing there, nothing, not a place to sleep, no cabins.

And they are told they have to get to work.

Build yourself an asylum, move railways, move tracks, construct roads, clear ground.

I mean, really monumental labor.

They're working side by side with contractors hired by the state, but the patients did an immense amount of the backbreaking, really physical labor.

And weeks go by as they're doing this, and they bring new patients in and new men in,

and actually also boys.

There are state records describing

putting boys who are about 10, 12 years old, who are disabled, physically disabled, to work and being proud that they were able to get them to carry pails of water or other items around and get them to contribute to this effort.

And the sort of tone is always that they should be grateful that they're given this work, that it must make them feel better,

and that once this project is done, they'll march into the rooms that they just built and they'll become its first patients.

So that is how Crownsville begins.

And that is the racial and political context.

At the time, how was mental health, like was mental health a concept?

How was mental health different than mental illness?

And what were the prevailing ideas around treatments or therapies?

And, you know, what options were available to, for instance, a black person in 1911 in Maryland that if they were experiencing a crisis, where could they go?

Could they go anywhere?

I really appreciate this question.

Actually, you might be the first interviewer to ask me that in that way, because because I think it gives me the chance to make an important point, which is that I think often, you know, in 2025, we look back at a time like 1911 and we think, well, people just didn't know anything.

Like it was all pretty horrible.

And look, a lot of the mental health care treatment, the majority of what was available was terrible for everybody.

I mean, if you actually talk to psychiatrists and

biochemists and to therapists and people who work in the space today, they'll still tell you that we may be in the dark ages of understanding how the mind works at this current moment.

So certainly nobody's going to argue that what was available in 1911 was incredible and

that there were quick fixes all around.

No, not for anyone.

But there were ways in which leaders made very deliberate decisions to give people of color the absolute worst of what was available.

You know, for example, they knew that tuberculosis was an incredibly dangerous disease that impacted people's physical and mental health, but they were careful to create separate quarantined wards for that at all white institutions.

They refused to do that, however, at Crownsville.

They knew that this disease would kill or physically and permanently disable all kinds of people

in Crownsville, but they allowed it to fester anyway.

That was a price, a sort of just...

a reality they were willing to accept, despite writing and openly knowing that to do the opposite was the right thing for another set of patients.

And the other interesting thing I should say, too,

is a lot of these therapies are complicated to talk about because they may sound horrible at first, but there are clinical arguments that have been made for them.

For example, electroshock.

A lot of people are horrified by the concept of electroshock, but there are still people doing electroshock to this day, and there are patients that will tell you that they love it.

And so, you know, while at Crownsville, there are a lot of stories of abuse of patients through electroshock.

There are stories of clinicians believing that it was a valuable tool that helped them gain insight and make treatment breakthroughs with patients at places like Crownsville, too.

Hydrotherapy is another example.

Hydrotherapy is a tool that for some patients could be incredibly relaxing.

It was the experience of being submerged up in water in a tub, sort of up to right under your chin.

And you would be either in incredibly hot or incredibly cold water for a period of time.

That period of time could be a couple hours.

It could be up to three days at Crownsville.

Now,

spending a couple hours in a very warm tub for some patients was apparently, in some cases, very relaxing.

Spending three days in a very hot or a cold tub, some would call that torture.

And so

every single one of the sort of modalities available, you can pause or you can do the reading and see a completely different way of looking at its application and the potential for harm.

And so there's sort of the baseline story of what was available and how difficult and how dark the treatment of the mind was at that time.

But then there's also just sort of the need to understand that as you look at the different kinds of facilities,

that always what you saw was the same pattern repeated, not just in Maryland, but certainly that's the place that I studied, that the black patients were going to get the worst of what was out there and were going to have the fewest sort of clinicians and aides available to support them.

I write at one point about records that I found that showed that as the state rehabilitated a bunch of the different asylums in the state, that they sort of consciously made the decision to build less therapy space at Crownsville.

So sort of this idea that there was going to be room for patients to even just have space to talk, to reflect, to work with, and be in conversation with a provider, you see the way in which sort of attitudes are reflected in expenditures and structural decision-making.

I know people don't love talking about structural racism anymore,

but you see a lot of it very obviously in the story of Crownsville.

And so it's complicated because there are these moments in this story where people are able to do genuinely great work with patients at Crownsville, especially after integration and more members of the community are able to get the chance to take care of people who look like and who know them.

But

there's also the element of horror.

There's also an absolute reality of abuse.

And all of those things existed and coexisted and could happen on any given day at the very same time.

Let's take a quick break here.

We'll be back before you know it.

Welcome back, everyone.

I'm here chatting with the wonderful Antonia Hilton about her book, Madness.

Let's get into some more questions.

The way that this plays out is such a nuanced way, where you have these prevailing notions about how the mind works, how mental illness works, and then also you have this racism that's baked into so much of the way that that is informing a lot the physicians, for instance, who are providing the treatment and so on.

And of course, funding and all of that.

And initially, it seems like for at least a period of time, Crownsville's predominant role was not to necessarily, or maybe it was in combination, to provide care for those with mental illness, but also to exploit those individuals for their free labor.

How did this factor into how long someone was held at Crownsville or was lived at Crownsville?

And when did awareness of this sort of mistreatment or these instances of mistreatment seep into the surrounding communities?

The question of exploitation is a really important one because it is there from the very beginning.

I mean,

the story of its creation, it's almost like when I tell people the story, it almost sounds like biblical or mythological to them that these 12 men are in the woods and they hear the news that they have to build themselves a hospital.

So the exploitation begins before the hospital has any sort of physicality to it.

And then when the hospital opens and its operations start, that is really just the beginning of very long workdays for the majority of the patients there.

Unless you were essentially completely physically disabled, you were expected to offset the cost of your own care for many decades, the first essentially three, four decades at Crownsville.

There is this massive pressure on patient labor there in areas that

were unusual to.

So, in the 20th century, there was a very common concept, actually, even before that, of this idea that having vocational training for patients, for people struggling with their mental health, would be good for them.

It would mean that when they get out, they get great jobs, or they have an apprenticeship, they have opportunity, or at least they can be helpful to their families if they're staying at home.

And so, lots of asylums had jobs, programs, or chores that patients needed to do.

And Crownsville was no different in that respect.

But the hospital had an entirely other layer of labor expectations, unlike anything seen in Maryland or really most of the institutions I've ever studied.

Crownsville expected patients to run a highly modern and productive farm with modern irrigation practices.

They farmed tobacco.

They worked with cattle.

Women were expected to basically constantly be working with food and produce or in the kitchen or in the laundry.

And

it was

to such a powerful extent that this is remarked upon consistently in state records, really as a point of pride, that we're able to keep the costs down at this place because we make the patients run the place themselves.

They were proud of how much they were able to get them to do it.

And then, even they take it, again, another step too far.

They are extracting from creative patients, so people who create rugs or did basket weaving.

They start to sell their goods, and none of that money comes back to the patient themselves.

It's used again to offset the cost of their care.

They send items that patients at Crownsville made out to competitions, and the superintendents would display and brag about them as if they were almost theirs.

And so there is this sort of constant air of exploitation there.

And it doesn't start to shift until

really,

I mean, I guess it depends on your idea of what a shift looks like.

If it's the rumor mill, if it's awareness in the community, the black community became aware of a lot of this very early on.

There were a number of patient murders.

I write about one.

The father of civil rights icon, Polly Murray, her father, William Murray, murdered by an allegedly, pretty openly racist guard at the hospital.

Stories like that, they spread among black community members of Annapolis and Baltimore.

They didn't necessarily get the attention they perhaps deserved in the papers like the Washington Post or Baltimore Sun, but they certainly were known about.

But real action begins, say, in the 40s, when there are these sort of budding civil rights movements.

There are lawyers and growing, budding associations like the NAACP that are starting to sort of demand access, demand meetings with state leaders and the superintendents of Crownsville, and get in there and actually start taking testimony from patients.

And then, to give a little credit to my field, there are reporters who start asking questions at all the major papers.

There is a series of exposés, but there's also some incredible work done.

I have to shout out the Afro-American newspapers because those reporters consistently published diary entries of patients on the first pages, unlike anything any of the other papers were doing.

And they allowed patients to tell their own stories in their own voices and weren't always taking the word of, say, the police or the superintendent above theirs.

And so there's a lot of richness there in the record that you can find by looking at some of the alternative or minority media at that time.

And so that's when the sort of consciousness, I guess, starts to shift is in that period in the 40s.

And in a way, it's it's no surprise.

America is engaged in a horrendous world war.

The hospital is starting to receive and welcome in Jewish men and women who are fleeing the Nazis and who are coming to restart their lives in the United States.

They come to work at places like Crownsville, and they too are outraged by what they see there because they've seen this.

They just escaped a system of extinction.

And now they come to this place and they see the patient labor and the exploitation for what it is.

And so you have all these factors that are coming together in that period that are leading to these new coalitions that are getting ready to transform this place.

This broader shift, you know, not just within the recognition of Crownsville, but this shift in the mid-20th century that you describe in the way that the general public and medicine begins to see mental health and psychiatric hospitals.

These views, of course, the shifts in these views are not consistent across the race of the patients, right?

And you point out the differences in this framing where white patients are said to, oh, well, we need to rehabilitate, but black patients said, oh, well, we need to manage.

How did this play out at Crownsville?

This is, again, actually where some of the most valuable records were the work of reporters because they would talk to community members and kind of publish their unvarnished thoughts about what should be done about places like Crownsville or similar pure white institutions like Spring Grove or Springfield in the state.

What I found was that, just as you mentioned, there's this movement after there are scandals in the asylums and reporters are starting to get the story out there, lawyers are starting to make demands, there's this growing movement in the United States that begins in the 40s and really extends for decades onward to reinvest in community care, to bring people home, to have more empathy for the patient, to be willing to hear their side of the story and to share their narratives in the paper, in media, and movies, really, there was a sort of explosion.

But then what I found is that when it came to black patients, the communal response was very different.

There was a fear about release.

There was a fear about what it would mean to welcome them back into the community and that often reporters in my field then they made a lot of mistakes.

They over-exaggerated and sort of misreported the extent of, for example, escapes or riots at a place like Crownsville as compared to what was happening at pure white institutions.

And I found records of even superintendents who

none of the patients would have described as their ally.

They would acknowledge that Crownsville, the amount of violence or escapes at that site were being sort of unfairly highlighted or featured in the papers, even when pretty much equivalent events were happening elsewhere.

I spent some time going through just some of the language, the adjectives used by reporters at the time, too.

That when they would talk about a white patient who escaped, they would often describe sort of the person's melancholy, how fearful they were.

I remember, I don't think I included it in the book, but I remember reading one paper describing a white male patient escaping one institution.

And the paper was kind of making jokes about the red fluffy slippers that he escaped into the woods wearing.

Whereas, and I do include these in the book, I write about some of the young black male patients who are written about as though they are any minute now going to come into the suburbs surrounding the institution and rob, rape, and terrify people.

And there are descriptions of people saying, you know, after they've heard about an escape, that guns are going out onto porches tonight.

And people are sort of fantasizing about this fear of their wives being left home alone.

And there's this sort of juxtaposition always between sort of white domestic life and the threat of the people inside Crownsville.

Again, even though at the same time, the same number of patient escapes are pretty routinely happening at pure white places as well.

And so there is a perception that follows then, of course.

And what follows from the conversation, the cultural conversation, the perception is political action.

People start advocating to build a wall around Crownsville.

So if that sounds familiar to anyone, I don't know.

Yep, maybe.

They advocate for more lock-and-key policies.

They want to bar patients from being able to visit communities.

There's this massive carceral push to keep them behind bars at all costs, even as clinicians keep saying.

We know from the evidence, from the work we're doing with these patients, that what they need is actually more community support.

We need to be able to hire more people.

They need therapists.

There are patients every week getting zero time with therapists or psychiatrists at the hospital.

Basically, they're just like sleeping there and working there all day long.

They're not actually getting the treatment and rehabilitation that this place was supposed to provide.

And so there's the people who sort of know the people in the place begging for one thing, but the community, because of what they've grown to fear and believe, pushing for the exact opposite.

And in many cases, the community and the sort of people filled with this false perception, they went out.

And one of the tragedies of Crownsville, and I often use Crownsville to help people understand concepts around structural racism and sort of the ways in which our past informs always our present moment, is that because of what happened in Crownsville's founding, the state always wanted to spend less money on it.

They never invested in its building.

completely.

They never invested in employees.

They never invested in making sure there were good doctors and clinicians there.

They didn't want to build the proper amount of therapy space.

They barely had food and soap available during World War II when patients there were literally suffering and dying.

Even when this sort of civil rights movement gets some wins, there's integration and there are changes coming and there's sort of new standards and rules by which all these places have to operate, Crownsville is operating at a deficit.

They're never given back the money they were never provided.

And so all these new sort of institutional and

legal and health care related laws and regulations come into place.

There are these high expectations of the place after integration, like, okay, let's see what you all can do.

But

they don't have money.

They're operating with an institution never built with what it needed to properly survive.

And so they end up kind of stuck in this heads you lose, tails you lose situation.

And it's heartbreaking for the institution and it haunts it from the period we're talking about all the way until its closure in 2004.

Aaron Ross Powell, this period of time too, as I find this so interesting, the shift in the framing of how we're viewing mental illness and then also sort of the weaponization of diagnosis that still happens today where you get these shifts in or these changes in the way that certain conditions are labeled.

Or, you know, for instance, schizophrenia is one that you discuss in your book.

And of course, there's another book, The Protest Psychosis, that goes into this as well, where it starts out as this sort of this diagnosis of mothers, homemakers who are burnt out, and then it transforms into this opportunity to pathologize young black men in particular, especially during this period of time.

What was happening at Crownsville as far as that goes?

Or like, was that bleeding into there as well?

Oh, absolutely.

And I have to give a shout out to Jonathan Metzel, the author of the protest psychosis.

He was so helpful to me when I was an undergraduate trying to learn how to do all of this stuff.

And we have been so supportive of each other's work since.

And so I cite him a lot in the book.

And that's, you know, no mistake.

Like, I couldn't have done a lot of this work without his help and his feedback at many points.

Crownsville absolutely reflects that story.

You see it in the records, but you also see it in really, and what I found most interesting was the recollections and the testimony of the people who were there.

There's this really

just fascinating transition coming out of really the civil rights movement, where you start to see all of these clinical changes that they're starting to change that labeling, as you just spelled out.

So, schizophrenia is becoming more of something that is about paranoia and aggression and all of these assumptions around

black men and masculinity.

And it's shifting from

being sort of pictured or illustrated as as a disease mostly of, I guess, being withdrawn into yourself.

And so it's sort of seen as this explosive thing.

I even show in the book some examples of psychiatric ads and ways in which the conversation and the depiction of who suffers from schizophrenia shifts.

at the same moment that these movements, these protests are happening.

There's one psychiatric ad that I'll never forget that depicts a black man like hanging from fiery bars and looks like he's in the middle of like a protest that's burning some kind of city to the ground.

And he is the image that is accompanying a medication to treat schizophrenia and other diseases.

And so you see that.

And if you're a person of that time, that is absolutely when you're talking about a time in which there were massive protests.

I mean, Martin Luther King murdered and that impacted Crownsville.

People there processed that in real time.

Staff members, patient family members, they attended the March on Washington.

I mean, all of this is interrelated.

It's all part of the cultural context to the story.

So you see it from the clinical perspective, but also I enjoyed hearing the memories of people who could describe it for you less as this sort of academic pattern and more as just the real thing that they saw every day at work.

Like I spent a lot of time with this psychiatrist who actually still lives and works in Ann Arundel County, Maryland to this day, named Dr.

Brian Sims.

He was one of the first black psychiatrists.

He really helped pioneer trauma-informed care at Crownsville.

And this is in the latter part of the book.

And he writes about seeing police bringing a boy who's about six years old to the hospital in a karate uniform.

He's misbehaved in karate class, and he's brought there.

He and many others described to me seeing patients, you know, chained to poles while they waited to find out where they were going to be sent within the institution.

the sort of constant flow of court-committed patients who judges sort of decided were one week maybe they would go to the jail, the next week they were fit for Crownsville, and how doctors like him had to get on the phone and battle it out with judges and try to explain to them what was and wasn't appropriate, what was a clinical necessity and what wasn't, and that it was an exhausting sort of unpaid part of their labor.

And that they saw a lot of it as incredibly racialized, that kind of the second they saw a black person with pain and confusion and who had perhaps committed a low-level crime, that to them there was this sort of fear of derangement and a desire to have them stuck at a place like Crownsville.

And that was really heartbreaking for the people who worked there.

And the way that they tell those stories, they capture it so much better, I think, than a journalist or an academic even can.

And so I tried my best to retell those stories in their voices.

But you absolutely see it play out.

And the doubly heartbreaking part is that those same doctors then respond by trying to create sort of a community-based solution.

So, okay, we're going to create a program where we ourselves drive to visit our patients out in the community.

We're going to make sure they stay on their medications.

We're going to make sure they don't go back to court.

Because a lot of patients, they end up on what's essentially sort of the mental health equivalent of like probation, where

any missed appointment could send you back to the hospital.

And so these doctors are committed to trying to get people out of that cycle cycle because, I mean, who among us hasn't missed a doctor's appointment?

To be told for five years that you can never miss an appointment, it put people at immense risk.

So they sort of put a lot aside in their day-to-day jobs and drove out there into Baltimore, into all these other neighborhoods to make sure their patients made it anyway.

And

after seeing immense success, seeing the recidivism rate drop precipitously, They're told by the state that this isn't a good use of their time and that the program needs to disband.

And so

you saw that lack of compassion and the way in which the attitudes you have about a certain community create a kind of permission structure and a sort of attitude from the top down, where anything that would actually solve the problem you claim to be so alarmed about isn't worth spending money on.

But the one thing consistently we're willing to do is behind bars, behind bars, behind bars.

And

it is absolutely a part of the Crownsville story.

And it's something that stuck with so many of the people who worked there for decades onward.

Crownsville acted as almost like a place of dual purpose, where you have it as a psychiatric facility on one hand, but then this unofficial detention site on the other.

And this also, as you describe in your book, sort of plays out on the national scale where you have this decline in psychiatric hospitals just as you see this expansion of the prison system in the U.S.

Can you tell me a little bit more about that?

Yeah,

what I'm arguing in that section of the story is really that it's not such a simplistic story where, you know, the asylum disappears and everyone goes to prisons, but that

you have to see these institutions as being in conversation with each other and as sharing DNA, being part of the same genealogical timeline, and that it isn't a coincidence.

that at the moment that we are starting to disband this massive institution that at one point was the dominant institution in the United States.

In the mid-20th century, the asylum was much more prevalent and powerful.

There were more people there than there were in our prison system.

And so you see the decline of that place and this explosion in the other.

And Crownsville is a fascinating window into that because again,

you can see how it worked in real time and in day-to-day human interactions.

I write at one point about a report that breaks down

what was essentially going on inside of peer-white institutions and Crownsville, which at that point had been desegregated but was still majority black, as they were trying to transition patients out of the institution back to the community.

Sort of a simple government study trying to look at what was available to those people in those different groups as that process unfolded.

What they found was that at a peer-white institution, there were vocational trainers available.

There were counselors and teachers and family members present at these hearings, essentially, where someone would get approved to go home or not go home.

And they would be connected with opportunities and resources afterward.

The report found that at Crownsville, there were juvenile probation officers present.

There were often no educators.

nobody hiring out in the community, no vocational support.

And so there was much more common that there would be someone who had a tie to the prison and jail industrial system.

And a lot less likely that there would be somebody who was about to connect that person with a bright future, a job opportunity, and an appointment to make sure that they stayed on their care schedule.

And so even then, as this is happening in real time, there is a knowledge that it's not happening the same for everyone.

This whole idea that we had become so empathetic and interested in supporting patients and bringing them home was not applied evenly to all populations.

And so it's no surprise then that our prisons and jails are full of black people, many of whom clinicians,

you know, COs will tell you they think actually need mental health care treatment and support and are likely regressing in a carceral setting like that.

And it's the kind of maddening moment we're living in right now.

I mean, I think about it a lot in particular as we look at what's unfolding in Washington, D.C., and we see this big push to just get the homeless out of there, just push them out.

Like the president basically saying that he doesn't care where they end up and where they go, but they can't be here.

And the idea that, well, okay, you either find yourself a shelter or something you're going to do or you're going to end up in jail.

That attitude,

it came from somewhere.

And we saw all these shifts.

And in many ways, I describe basically the black patient as sort of the linchpin that held these negotiations together through which you can see how so many of these decisions and disparate actions were taken.

And that's really one of the key lessons from Crownsville, I think.

You know, people, they often ask me like, how hard it must have been for me to write this story and how dark some parts of it are.

And I, of course, agree, and I needed to take a lot of breaks while I did this work.

Absolutely.

But the piece of it for me that's actually incredibly hopeful, not just the amazing people that you meet along the way in this book, but also my belief that if you see where we went wrong and you see how some of these

systems were set up, that now in our current moment, as so many Americans of every background want a better mental health care system, that this is a story that can provide us a window, like, oh, hey, this was a poor decision.

This wasn't necessary.

Perhaps we should listen more to what advocates and doctors are trying to tell us in this moment.

And I think that this, when you look at Crownsville through all these different eras, you can see windows of opportunity and for change.

And that to me is actually a piece that, as strange as it may sound to others, actually gives me hope.

I can appreciate that.

We just, it's having the will to implement these changes and to

hear the lessons from the past.

Yeah, right.

That's that's separate.

Well, Antonia, this has been, I mean, such an enlightening and important conversation.

I am so happy to talk with you today, and I really appreciate you taking the time to chat.

Thank you.

So great to join you.

A big thank you again to Antonia Hilton for taking the time to chat with me.

If you enjoyed today's episode and would like to learn more, check out our website, thispodcastwillkillYou.com, where I'll post a link to where you can find Madness, Race, and Insanity in a Jim Crow Asylum.

The paper book is now out, by the way.

As well as a link to Antonia's website where you can find her other incredible work, including the podcasts South Lake and Grapevine.

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