Reading the Room

Situational awareness has become a popular concept in today’s rapidly changing workplace. Originating in military operations, the term simply means to understand the elements within your environment, then use that information in real-time to inform your approach. But what does this look like in practice?

Let’s look to Dorothea Dix, whom many remember for her role as the Superintendent of Army Nurses for the Union Army during the Civil War. Dix was also a major force working on behalf of the indigent mentally ill, her efforts drastically changing mental health treatment in our country. But change was hard won. The Victorian ideal of “separate spheres” confined women to the private domains of home, family, and morality, and many argued that political engagement would undermine this “perfect social order.” Working carefully within this construct, Dix partnered with powerful male allies to limit her political exposure. She also adjusted her approach when her efforts met with failure.

A Brief History.  Prior to Dix’s advocacy, the vast majority of America’s mentally ill were hidden away in family attics and basements, or worse, thrown into prisons with violent criminals. Treatment was limited to exorcism by a local priest, and most mentally ill prisoners lived manacled to floors or walls or kept in cages to try to manage their behavior. Following the pervasive belief that the mentally ill couldn’t feel pain, cold or hunger, patients were often beaten, stripped of their clothing, kept in damp, unheated cells, and given scraps of food for sustenance. Frequently, wardens supplemented their income by charging entrance fees to allow citizens to gape at the patients as if they were animals.

In March 1841, a ministerial student familiar with Dix’s work as a Sunday school teacher, invited her to teach a class for female prisoners at the East Cambridge jail in Massachusetts. What she encountered there shocked her. Mentally handicapped children and adults were not segregated from violent criminals, their quarters were nauseatingly filthy, and the entirety of the jail was unheated. Working with the male seminary student, Dix immediately secured a court order to provide heat and sanitation for the jail. Within weeks, she embarked upon one of our nation’s earliest social research projects, touring the jails and almshouses across Massachusetts and documenting their treatment of the mentally ill.

A Promising Start.  During her tour, Dix met Samuel Gridley Howe, a physician and powerful advocate for the blind. She convinced him to tour the jails and almshouses in eastern and southern Massachusetts with her, then help her publish a commentary to expose the deplorable treatment and conditions. The two became friends, and when Howe won the election to the Massachusetts House of Representatives, he asked Dix to complete her documentation so he could present it at the opening session of the 1843 legislature. Her finished report, a 32-page, unflinching documentation, contained accounts of the “cages, closets, cellars, stalls and pens that the insane are kept in,” and provided her eyewitness account of “the chained, naked [prisoners], beaten with rods and lashed into obedience.” Dix filled her report with political rhetoric and a call to the religious commitment of protecting and caring for those who could not care for themselves.

The response was mixed. Some reacted with incredulity, setting out to conduct their own investigations, which soon proved the truth of her words. Other opponents strongly objected to Dix’s religious fervor, believing emotion has no place in public policy. In spite of these tensions, the report was successful, securing funds for the expansion and improvement of the State Mental Hospital at Worchester, which Dix helped plan.

Failure in New York.  In early 1848, Dix set out on a 10-week tour of New York’s almshouses, insane asylums, and jails, creating a report very similar to what she presented in Massachusetts. Having learned from her critics, Dix removed any mention of religion or emotionality from her report, providing a dispassionate, objective documentation of her findings and suggesting a nonmedical care model, based on the successful Antwerp Hospital in Belgium. The medical community exploded, arguing that all institutions for the insane should be under the direct control of physicians. Dix’s report met with abject failure, but she learned another valuable lesson: get the stakeholders on your side and understand the opposition.

Adapting Her Leadership Strategy.  With a refined plan, Dix traveled throughout New Jersey and Pennsylvania, documenting her findings. She carefully researched prevailing medical views on the mentally ill, and common objections to recent requests for funds from a variety of sectors. Dix incorporated ideas to please all sides, arguing that insanity is a condition of the brain (rather than “demons of the mind”), that prompt medical therapy cured many cases of insanity, and that building new hospitals administered by physicians would save taxpayer dollars by removing cured patients from public assistance. Her report met with resounding success, and New Jersey and Pennsylvania passed legislative funding bills to construct mental hospitals across both states.

Although Dix paused her advocacy to serve the Union Army during the Civil War, she resumed her fight, and by 1880, was directly responsible for establishing 32 of the 123 mental hospitals across the United States at that time. Designing her leadership approach to work within the social construct of her environment, and adjusting to difficulties and failures in real-time, Dix’s situational awareness allowed her to adapt and lead with remarkable success. Sometimes a shift in approach is all we need to succeed.
 
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