Liana Glew is this year’s co-winner of the History of the Human Sciences Early Career Essay Prize. We spoke to her about her research and her winning essay ‘Documenting insanity: Paperwork and patient narratives in psychiatric history’.

HHS: First of all, congratulations on winning the History of the Human Sciences Early Career Essay Prize for your essay ‘Documenting insanity: Paperwork and patient narratives in psychiatric history’. To begin I wonder if you could briefly introduce and summarise your essay and say a little about what inspired you to write it.

Liana Glew: Thank you for the honour of the prize. The essay examines paperwork from US psychiatric hospitals in the late 19th and early 20th centuries. My purpose in this examination is to develop methods of reading that center patient agency and disability identity. The inspirations for piece were twofold. Firstly, it was inspired by a trip to the Oregon State Archives where they’ve done a really beautiful and careful job archiving this challenging history. That’s where a lot of the the material comes from. Second, it was inspired by a graduate seminar taught by Ebony Coletu, which is where I first started thinking critically about bureaucracy and paperwork.

HHS: Before I ask more about the piece itself I wonder if you could briefly talk about your PhD thesis project and how this article relates to your research more broadly?

LG: The article represents the third chapter of the dissertation, edited to stand on its own. Each chapter covers one genre of text about life inside asylums in the 19th and 20th century. So the first chapter is about fiction, the second about memoir-exposes which is a sort of hybrid genre that I’ve identified to talk about the journalistic and memoir pieces coming out around that time about life in an asylum. This third chapter covers the same paperwork material as this essay, then the fourth chapter is on archival patient writing. I’m taking writing to be a really big category, so it includes different types of artistic expression, house organs, personal journals, letters, and more.

HHS: Your essay discusses medical paperwork –what is distinctive about this kind of medical text? Does it make sense to talk about paperwork in terms of genre?

I think it does, yes. I think we’re used to looking through paperwork to get to the content of it and we don’t see the form itself. And so, by framing paperwork as a type of narrative just like other types of narratives, by placing it alongside these other genres, I think we are able to see some of the mechanisms of power at work inside these bureaucracies in a way that would be almost invisible if we weren’t taking the time to stop and look at the writing of paperwork as a genre of writing.

HHS: To rephrase a question you ask in your introduction, how did you go about reading these kinds of documents ‘while centering patients’ agency’? In what ways does paperwork repress  agency?

LG: To start, I think I would define that term patient agency as a person’s power to make decisions about their treatment and to control the stories told about them during the course of their treatment and after. I specifically chose the word agency, rather than something like independence, taking a cue from disability scholars. Sometimes decision-making happens in conversation or in groups, but I wanted to honour the person’s desires and political drives and needs, etc. The type of paperwork I’m looking at often frames a person’s narrative as evidence of ‘madness’ – madness or insanity are the terms they would use – rather than as a valid representation of what they were experiencing. When a patient spoke, the only time their words would end up in that paperwork was often to prove that they were mad. So as a narrative tool, paperwork really subsumes patient agency within its grasp.

HHS: In discussion of mediation and agency in relation to these documents where or how do you position yourself as a historian?

LG: I’m doing my PhD in English Department—even though this project is historically situated, narrative is my primary lens. As I’m developing these methods for reading, I try to be very aware of my own positionality and follow scholars like Gail Hornstein by leaving room for a diversity of madness narratives. I’m constantly checking myself to make sure that I’m not, for example, just replacing a pro-psychiatry narrative with an anti-psychiatry narrative. I’m trying to create these methods for reading that can encompass a really broad array of lived experience and while I’m doing this, I’m also noticing the roles of narratives, stigma, disability, etc, in how we understand history.

HHS: Why were you particularly interested in hospitals built according to Thomas Story Kirkbride’s architectural plans for psychiatric institutions?

On the surface level, they had a more unified and formalized record keeping practice so it was easier to find some of these archives. Although they were still not especially easy to find, as many of them have been destroyed, lost, or taken up by private collectors. On a more theoretical level, I’m interested in how Kirkbride’s vision for architectural design parallels the way that administrators fashion their own role within this bureaucracy. Kirkbride saw very little distinction between architectural design and therapeutic practice so he thought about how each design element would reflect or influence the humane treatment that he hoped patients would receive. Once the construction of the hospitals were set in motion by the Kirkbride Plan, they were set in the context of eugenic America and became sites of overcrowding and abuse. I believe that administrators’ bureaucratic moves demonstrated and reflected the sort of underlying punitive or eugenic ideology of the hospital, just as Kirkbride’s design reflected his underlying utopian vision of the hospital. I think there’s some some parallel work happening there.

HHS: What was the value of Ann Laura Stoler’s injunction to read ‘along the archive grain’ for your project?

LG: Stoler’s work for me was a really good starting place for working with this material because it teaches us to see and notice how groups and power constructed narrative, as well as the real life effects that those narratives can have on the people experiencing life in the hospital. Stoler provides a starting point, the first place that I go before developing the argument and methods further. Put altogether I think the methods more readily reflect

Marisa J. Fuentes’s approach of reading along the bias grain. Not to overcomplicate the metaphors here, but just as Stoler moves along the archival grain which involves following wood grain, Fuentes talks about cutting fabric on the bias, which makes it stretch. My examination of paperwork shows where these narratives stretch—what’s missing, where patients push back against the institutional narrative, etc. Stoler’s work is a good starting point, but then I move out towards this more elastic understanding of the archive.

You describe finding some empty forms in the archive that struck you as significant for identifying the ‘archival grain’ – how so?

LG: That’s an anecdote I go to because it was one of the first times I started realizing how we’re trained to think about paperwork. I was working on a really tight schedule in an archive and I had this really thick folder of paperwork that I had brought to the desk. I worked with this really wonderful, helpful archivist who scanned the documents for me; I came back a few hours later and I realized she had only scanned about half of the papers. She said she didn’t scan the others because they were “blank.” And this led to such a generative conversation between the two of us in realizing that we are trained to see forms as blank, even when they contain plenty of text. It was this moment where it clicked for me that this is something that’s really worth looking at and something that we’re so trained to see as invisible.

HHS: What key historical shifts in psychiatry were evident from studying these documents?

LG: I’m hesitant to make broad claims about psychiatry as a whole, because my access to archives has been limited to the US and limited to really two or three hospitals. But I have noticed within that scope a shift more towards family history, so in the late 19th century, a lot of these forms were more about the person’s individual history: when they started exhibiting behaviours that were non-normative, etc. And then the paperwork that I’m looking at around the 1920s starts moving towards asking more questions about family history. The other thing that I noticed was a shift in where authority was located in the intake process, the process of a patient being admitted into the hospital. Around the 19th century, so many of these forms just reference the fact that a physician has done an exam on this patient behind closed doors, that the physician declares this patient is insane and that they should be hospitalized, and so the reader of the form is supposed to just trust the doctors’ authority. In the 20th century, these intake forms went from being about three pages to about ten pages. A community member or a friend (whoever brought the patient to the hospital that day) was expected to fill out the form and provide a detailed family history. The authority started residing in the bureaucratic process itself rather than in the individual physician.

How does this essay bring together approaches from disability studies and medical humanties?

I think they work together. In this essay in particular I’m interested in some questions borrowed from medical humanities, such as how medical practices operate, how decisions are made at the top, how power flows, how power operates in doctor-patient encounters etc. But as someone who has come to this from the perspective of disability studies, I feel that we can’t answer those questions without also answering questions about how one self identifies with disability or doesn’t, how stigma and ableism operate in these hospitals and how we can centre the lived experiences of disabled people. These questions, for me, are are part and parcel, they really can’t be separated. We can’t answer the questions about how bureaucracy operates without answering questions about the effects on people’s lived experiences.

HHS: How do you go about disentangling different ‘layers of voices’ in these documents?

It’s often a really complicated process. I tried to be transparent about the ambiguity, about the impossibilities of disentangling some of those voices when I’m writing about the documents.

I work with one document, for example, that’s just called ‘Case notes continued’. It’s typed up but it’s completely unclear to me as a 21st century reader whether this was dictated by a physician to another worker to type up after interviewing a patient, if some other worker in the hospital read the patient’s file and then summarized it in this type of document, or something else. I don’t know how this document came to be or what the process behind it was. I don’t know whose voice is leading it, but it’s written in this almost omniscient scientific voice. I think that the ambiguity builds that scientific authority so that it reads not as the voice of an individual, but as the voice of the hospital or the voice of science. The patient’s voice is buried really, really deep in there. In this particular document, they say that the patient claims that her husband is abusive, just as she claims to hear the voice of God; these claims are immediately followed by a diagnosis of paranoia. So, as I said before, her voice just becomes evidence of her madness. This is significant because her voice is completely subsumed by this medical narrative. I think noticing those ambiguities and the work of those ambiguities is important.

HHS: Could you say more about Mrs H’s story and what seemed significant or intriguing about it?

LG: This is a true story. It is both the heart of the essay and the thing that I was most hesitant to include. The case file that I was just referencing is actually hers—her husband brought her to the Oregon State Hospital. The first forms that we see are filled out by the husband and by the doctor, and they declare that she’s heard the voice of God, that she has religious insanity etc. And then, in that case notes file we get this little glimmer where she says, ‘no my husband is abusive I shouldn’t be here’. But then that becomes evidence of her paranoia. She was there for about a month or two before the hospital received a petition signed by 150 of her friends, church members, community members, etc. These signatures attested to her sanity and to the fact that her husband is an awful abusive man.

What I can glean from the case file – there are a few carbon copies of letters that the doctor sent after receiving this petition to the judge, to the husband, and to the friends of this patient – is that the doctor came to believe her story. He sent her home into the care of friends and he told her husband he should have nothing to do with her anymore. It’s a really moving story.  It’s triumphant, it’s this example of community power, of people coming together and achieving this thing. But it also is in no way representative of most of these files, and so I was hesitant to include it because it’s so spectacular and I didn’t want it to be distracting. I think that’s the limit of case studies, but I think it’s also important to untangle some of the narrative voices in a story like this. It’s intriguing, it’s captivating, it’s triumphant and it’s also a little bit distracting from the patients who came to the hospital but whose voices don’t seem to bubble up in their paperwork nearly as much as Mrs H’s. Her story is important and it’s also challenging because I want to be very careful not to let it represent the whole of people’s experiences in these hospitals.

HHS: How do you define ‘archival excess’?

Archival access is the third mode of reading that I get to at the very end. Other people have used this phrase before but not quite in this context. I’m using it to reference how material spills out over these prescribed bureaucratic boxes. One example is marginalia. I have another example in the essay of a discharge notice that’s written on an edge of a piece of paper, it seems a doctor ripped it off and said, ‘if this woman’s fit to go home then send her home, if not keep her here’. That’s all it says, and that was her discharge notice. This sort of haphazard ephemera I think of as archival access. It could also be something like a patient’s answer to a question that the form didn’t ask, but the patient thought was important information to convey at the bottom of the form. I think archival access is one of those windows into seeing the form as a genre and as a piece of writing. It helps show the limitations of the form, what story that hospital is trying to tell and what story the patient felt was important to tell back. I find it a useful tool for reading.

HHS: Is there something specific about working with the archives of psychiatric institutions that might provide insights into working in archives more generally?

LG: I went back and forth between wanting to make a claim about disability and archives generally, and these very specific archives. US psychiatric archives tend to have vanished or gone into private collections or been shredded or something else, but there are places like the Oregon State Archive that have have really stewarded this history. But those places are few and far between and I think there’s something to how closely guarded so many of these archives are. I also came up against some challenging ethical questions regarding anonymity; I chose to make all of these forms anonymous in my own writing. That was a choice I made with some hesitation because I’ve seen some really excellent work on the history of disability that deanonymizes these stories to tell stories with names and faces to them. I think that’s important work, but the patients whose stories I’m looking at—stories that have been heavily mediated by paperwork and institutional narratives—never had the option to say if they wanted to be part of this project of destigmatizing mental illness, for example, and so I try to honor that and by making all of these stories anonymous.

But a choice like that is a choice that’s really specific to the archive, and it’s really specific to the history that I’m trying to tell. Psychiatric archives open up a set of questions that are relevant to archiving more generally, but I don’t want to claim any of these these choices, like my choice to anonymize my sources, are a prescription for how all archiving and all archival research should work.

HHS: Your essay explores the ‘structural relationship between bureaucratic institutions and disabled people’ – could this relationship be linked to the distinction you make in your conclusion between ‘spectacular, unsettling, disturbing’ narratives and ‘mundane, undisturbed, and undisturbing’ paperwork?

LG: Absolutely. The sort of spectacular stories, like Mrs H’s triumphant story of getting out of the hospital, are few and far between. More frequently we get stories of institutional violence that are made to seem really mundane and so at the end of the essay I start talking about paperwork that represents the forced sterilization of people who are in these institutions. This paperwork refers to violent murderous eugenic history and practice but the paperwork makes it seem so mundane and so unchallenged. It’s yet another reason to look really closely at this paperwork to see what stories are being told, to see what stories are not being told, and to centre the lived experiences of disabled people when we’re talking about this kind of medical history and practice, because the stakes of the issue can be obscured if we were just reading the story that that paperwork wanted to tell us.

Liana Kathleen Glew is a PhD candidate in English at Penn State University where she teaches writing and an Introduction to Disability Studies course. Her dissertation, “Ravings: Reading, Writing, and Psychiatry in the American Asylum” examines four genres of texts by and about psychiatric patients in the US between 1860 and 1940: fiction, memoir-exposés, paperwork, and archival patient writing. Her work can also be found in J19: The Journal of Nineteenth-Century Americanists and the C19 Podcast.

Interview conducted by Hannah Proctor