Early in his medical career, Erich Lindemann grew interested in patients who had lost a part of themselves: those with amputated legs, failing eyesight, organs that had been surgically removed. In 1941, the psychiatric unit where Lindemann worked at Massachusetts General Hospital ran a study on patients who had undergone hysterectomies, or the removal of the uterus.
Several of these women responded to their operations with levels of distress that surprised and confused them: They became furious with their doctors, generally disliked people more, couldn’t stand movie scenes depicting violence. Suddenly, one woman with seven children developed a tendency to break glass and china after her operation. “I sometimes have an irresistible impulse to smash something,” she explained. In another case, a patient, against her conscious will, knocked her surgeon to the floor.
The psychiatric unit decided to run a study comparing these patients to those who had undergone cholecystectomies — the removal of the gallbladder — and found similar reactions of anguish.
Lindemann told this story to a group of huddled nurses and doctors one February morning in 1972. He wanted to teach them about loss, and this seemed to be the simplest way to do it: by starting with the loss of parts. Lindemann and the group of medics stood in a small, windowless room in the basement of Stanford Medical School. A few years earlier, he had retired from his position as a Harvard psychiatry professor and the chief of psychiatry at Boston’s Massachusetts General Hospital.
Lindemann had spent much of his career researching loss. He soared to national prominence after conducting a historic study of bereavement in the wake of the deadly fire at Boston’s Cocoanut Grove nightclub on Nov. 28,1942. His work — on Cocoanut Grove and beyond — would reshape the way the medical world understood grief and redefine the landscape of mental health treatment in the United States.
“Partial death,” Lindemann called the instances of organ removal he studied a year before the fire in 1941. The body part’s literal function was defunct. The person was now a different person, one without the part. The new person had to rethink how they could relate to a constellation of altered social ties. And they had to figure out what to do with their sorrow.
This was the cause of the patients’ distress, Lindemann explained to the group of medics — being forced into figuring out this new life without the missing thing.
There’s a photo from 1942 of the northwest corner of the Melody Lounge that looks pretty innocuous — funky, with its zebra-striped couch and walls made of palm-stems and unfinished wood — until you notice everything pictured is scorched.
The Melody Lounge was the basement of Boston’s Cocoanut Grove, located in the city’s Bay Village. Witness testimonies said this was where, around 10:15 p.m. on Nov. 28, a sailor unscrewed a lightbulb so that the corner, usually dimly lit, would become pitch-black and he could kiss his girlfriend in private. A busboy lit a match to find the missing bulb. He screwed the bulb back in and stamped out the match under his shoe. Soon after, bystanders saw sparks in the kissing corner. They saw the plastic palm tree fronds that reached along the starry sky-painted ceiling begin to blur red at the edges. A fire spread rapidly across the Melody Lounge, then up the stairway throughout the whole nightclub.
The Cocoanut Grove nightclub fire is America’s deadliest nightclub fire, and, until 9/11, it was the second-deadliest single-building fire in United States history. It was the night of the Boston College-Holy Cross football game at Fenway Park. It was the weekend after the Harvard-Yale game. Families and couples were gathered at the club. That night, it was uncomfortably cold outside and uncomfortably hot inside, especially since the club was at nearly two times its human capacity — more than 1,000 people were crammed inside. An estimated 492 people died in the fire or its aftermath. The next day, in the midst of the Second World War, the front pages of American newspapers belonged to Cocoanut Grove.
One patron that night was a national celebrity, the Hollywood western actor and bona-fide Montana cowboy Buck Jones. He boasted nearly 120 country-western credits to his name, but, over the preceding years, singing cowboys had come to dominate on the national stage — and Buck Jones did not sing. He had come to Cocoanut Grove on a promotional tour through Boston meant to put more traditionally stoic cowboys back in the spotlight. A 17-year-old singer named Dotty Myles was also chasing fame that night. Despite being too young for the venue, she was hired for a four-week slot performing at Cocoanut Grove, her first professional gig. Her four weeks were nearly up whent he blaze started.
Both performers made it out of the club. Myles even continued her singing career after receiving extensive operations from Dr. Varaztad H. Kazanjian, the first professor of plastic surgery at Harvard Medical School. Jones died in the hospital in December.
As victims flooded Boston hospitals, Harvard Medical School professors temporarily joined medical staffs. Harvard students and instructors arrived at the scene of the fire before midnight to serve as stretcher bearers and hospital orderlies — and to help identify the dead and injured. This last task was especially difficult when it came to women; in the chaos many had been separated from their handbags and therefore from their identification.
At Radcliffe, administrators scoured the sign-out books that Radcliffe women had to fill out before leaving for any given evening to see who had gone into the city that night. City desk phones rang off the hook with calls from school officials at Boston’s many colleges. School officials’ phones rang off the hook with calls from anxious parents.
Cocoanut Grove first opened in 1927 during Prohibition. It was dreamed up by a pair of orchestral musicians, but its financial backers had ties to the mob and soon opened a speakeasy in the space. A Russian mob boss named Charles “King” Solomon bought the club in 1931. A few years later, King was shot in the men’s room of the Cotton Club in Roxbury, and his lawyer Barney Welansky took over and kept managing Cocoanut Grove right up until the fire.
Welansky, in the style of his former boss, kept side doors locked shut so patrons would not leave without paying. During the fire, the front revolving door jammed due to the mass of people trying to push through. In what proved to be a fatal design flaw, other swing doors opened inward, so the weight of people trying to exit prevented the doors from opening. Following the fire came an onslaught of fire code and safety standard reforms, in Boston and across the U.S.
On Nov. 28, the day of the fire, Welansky was at Massachusetts General being treated for an unrelated heart condition. After the fire, he was convicted for manslaughter when police investigations found that he had neglected safety codes. Boston Mayor Maurice J. Tobin was reportedly friendly with Welansky and had enabled his negligence. (Three-and-a-half years into Welansky’s 12 to 15-year sentence, Tobin would grant him a pardon from his new perch as Governor.) Bostonians had enough familiarity with crooked politics to smell cronyism, and the public was outraged: they felt the politicians responsible for their safety had failed them.
The fire came at a strange moment in Harvard’s history, a time when life at the University was saturated with war. “We must rearm at once,” Harvard President James B. Conant said in 1940 in a nationally broadcast radio address endorsing the war effort. “We will gain the inevitable triumph so help us God,” President Roosevelt said in 1941, the day after the Pearl Harbor bombing, and 1,200 students gathered in Sanders Theater heard him declare it over the radio. They heard Conant pledge Harvard’s full support for the Allies. After that, ROTC members ran drills in Memorial Hall; researchers broke codes and developed radar jamming and night vision and napalm. A naval communications school was installed — four of its students died in the fire. So did one from Harvard’s Navy Supply school, three from its Laboratory Radar school, two from the Business School, seven alumni, and five students at Harvard College.
John J. Rizzo was 21 years old and waiting tables at the club on the night of the fire. He escaped through a window and managed to help 15 others exit, too, by hoisting them up from a bartop. Rizzo testified in the investigations immediately following the fire, at one point responding to a line of questioning posed by the Boston Fire Commissioner William A. Reilly:
Q. The first you saw of the fire [was] a commotion in the lobby near the Piedmont Street front door, and you went that way thinking it was a fight?
Q. And you saw it was a fire?
Q. Would you say the fire spread along the ceiling or along the walls?
A. It was right in the middle of the room just like a forest fire, coming right down along the aisle.
The story of the Cocoanut Grove fire has been well documented by Boston historians. Boston talk radio pioneer Paul Benzaquin published a narrative version of the story in 1959. In 2005, Boston journalist Stephanie Schorow published “The Cocoanut Grove Fire,” which detailed the disaster’s pivotal role in Boston history. The same year, a New York-based consumer protection attorney named John C. Esposito published “Fire in the Grove: The Cocoanut Grove Tragedy And Its Aftermath.”
When historians discuss the fire, they often bring up the developments in burn treatment that sprang up in its aftermath, or how it changed building design and safety codes. But there is another outcome of the fire that rarely gets mentioned outside of academic texts. Under the scrutiny of psychiatrists working at Massachusetts General Hospital and Harvard University, the fire reshaped how we understand grief.
Dr. Erich Lindemann moved to the U.S. from his native Germany in 1929 to conduct psychology research at the University of Iowa. He came to Harvard on a research fellowship in 1935. By 1942, Lindemann was the chief of a psychiatric outpatient department at Massachusetts General Hospital, where emergency personnel rushed 114 patients the night of the fire at Cocoanut Grove.
Surgeons treating burn trauma in the wake of the fire found treatment paths that were original, effective, and immediately useful — not only in Boston but for the medical needs of the Allied forces in the war. They also found themselves perplexed, confronted with problems for which they had no vocabulary. A number of patients were not grateful — they were angry. They tore off their medical devices and yelled at their doctors and kicked their nurses.
“You had a problem that didn’t even have its own experts yet,” explains Anne Harrington, a professor of the History of Science at Harvard who studies the history of psychiatry and neuroscience. “So they bring in psychiatrists because that’s the closest they can think of.”
Lindemann was the psychiatrist they chose. The angry patients, he found, were in fact the ones who had lost loved ones in the fire, and the feeling they displayed was much more than anger. It was grief — which, at the time, was not considered by the medical establishment to count as a psychiatric issue.
“And [Lindemann] says, well maybe we don’t think of acute grief as requiring psychiatric help, but I trade under psychiatry and I think I can help,” Harrington says.
Lindemann recorded his observations in a paper titled “Symptomatology and Management of Acute Grief.” The paper would become a foundational document in standards of psychological care after disasters. It spawned the field of crisis theory. It was an early signpost in the long road to understanding trauma.
As Lindemann described it in his findings, “acute grief” looked like this: the patients’ throats were tight. They couldn’t help sighing. Their muscles were weak. They felt physical pain in waves that lasted for up to an hour. A mention of the deceased, a visit from a friend, or an offer of sympathy could elicit any of these symptoms. They tended to repeat certain phrases:
“It is almost impossible to climb up a stairway.” “Everything I lift seems so heavy.” “I can’t walk to the corner without feeling exhausted.” “The food tastes like sand.” “I stuff the food down because I have to eat.”
One man whose daughter died in the fire kept picturing her calling his name from a telephone booth. The sound become so loud and the scene so vivid that he often forgot his immediate surroundings. A navy pilot found an imaginary companion in a friend he’d lost, and went on eating and discussing life decisions with him. Some patients embodied their dead loved ones, walking or talking like the deceased, or taking on their interests. One woman, the wife of a deceased insurance agent, wrote elaborate letters offering her services to insurance agencies.
Loss of social habits was common, as were hostility and guilt. One man’s family returned him to the hospital in January after he began to express immense guilt over having fainted before he could help his wife in the fire. “I should have saved her or I should have died too,” he would say. “Nobody can help me. When is it going to happen? I am doomed, am I not?”
On his fourth day in the hospital, the man finally grew calm. Doctors were pleased with his progress and said they anticipated a full recovery. On the sixth day the man leapt through the room’s closed window to his death.
These grieving patients, Lindemann believed, were not dissimilar from those he’d seen before, those who had seen their uteruses or gallbladders removed and lashed out at their medics. He proposed that losing a human relationship, especially one central to a person’s social structures, was like losing a part of oneself.
The way to recover the self, Lindemann wrote, was through something called “grief work, namely, emancipation from the bondage to the deceased, readjustment to the environment in which the deceased is missing, and the formation of new relationships.” And the task of the psychiatrist, as imagined by Lindemann, was to share in the grief work: to help extricate the patients from their ties to the deceased and help them find fulfilling new social patterns, ways of living in their new world.
In the 1930s and into World War II, the landscape of psychiatry in the U.S. was “a kind of uneasy detente,” Harrington says. Some professionals strictly followed Freud’s psychoanalytic theories. Others reworked psychoanalysis, many of them attempting to humanize the approach by attending to people’s lived experiences instead of just the happenings of their unconscious. Proponents of the American Mental Hygiene Movement emphasized a “positive mental health” approach that applied to everyone, not just sick people. Other doctors swore by electroconvulsive therapy and endocrine research.
Lindemann’s homeland of Germany was a wellspring of psychoanalysis, and he was well-trained in its study, but what he’d found in his career made him grow disenchanted with the notion of the individual psychiatrist who seeks to plumb the unconscious mind of the suffering individual. He’d determined from his grief study that it is necessary to reconnect the bereaved individual with the living world, and that this is impossible without the cooperation of the living world.
Recovery, then, would require the whole community.
Ironically, Freudians on the front lines of World War II were producing results around the same time that mirrored Lindemann’s grief study. While looking after soldiers suffering from what came to be called battle fatigue or neurosis, these doctors found that the soldiers experienced acute grief and isolation. During treatment, taking the soldiers away from their platoons hampered recovery, but — if they were treated on site, if they understood that they would be re-embedded in their communities as soon as possible — they were more likely to recover.
At Harvard, Lindemann searched for methods in social sciences like anthropology, sociology and social psychology, which had long used community-embedded approaches. He mapped out a plan to integrate these fields into mental health education and research. Ever since conducting his grief study, he wrote, he had become increasingly concerned with the effect of human relationships on health and illness, and with “the possibility that certain individuals might operate as pathogenic agents for others.” In other words, it wasn’t only viruses and wounds that could worsen health. Other people could, too.
The logic that human relations could be pathogenic extended smoothly into a set of political implications for Lindemann’s work: if disrupted social structures could set into motion a psychiatric crisis for an individual — well, communities were embedded in social structures, too, and surely the disruption of those could take similar psychiatric tolls.
Lindemann looked to research conducted by Dr. Heinz Haefner at Germany’s University of Heidelberg. Haefner, researching mostly Jews after World War II to learn about the psychosocial effects of racial and political persecution, indeed found evidence of psychiatric disturbance among the persecuted group. Surprisingly, members of the racial group who had not lost significant family members showed the same symptoms as those who had.
“It appears that community behavior includes reactions quite similar to those experienced in individual crises,” Lindemann wrote. “Massive emotional responses can be seen as panic or apathy. The manifest danger may be denied or altogether overlooked.”
For the rest of Lindemann’s career, community psychiatry would remain his main preoccupation. When a large-scale urban renewal project evicted residents from Boston’s working-class West End and replaced the neighborhood with high-rise buildings, Lindemann, along with a slew of social scientists and other medical professionals interested in public health, decided to study the effects of the relocation.
Lindemann wrote, “3000 families are being forcibly relocated and thrown out of a context in which they have established reasonably satisfactory networks of interaction... What kind of families, from what kind of origin, will be damaged most by this process?”
People needed their communities to recover from grief, and grief could take place at the level of the community, so people needed to be treated in their communities. This was the foundation of a movement called Community Mental Health, and in 1948 Lindemann founded the Wellesley Human Relation Service, the nation’s first community mental health center.
In Lindemann’s vision, the community mental health centers would emphasize preventive care to promote the wellness of the community at large, rather than the illness of a few. Lindemann imagined community participation in the centers. He imagined excellent psychotherapy; modified care programs, like halfway houses; workshops for occupational training; and educational outreach to disadvantaged people. “There might be a breakthrough on some forms of schizophrenia (I think schizophrenia is a collective name for probably some 50 conditions),” he wrote.
At that moment, he believed, people held an image of healthcare that looked like this: “There is the hospital, the castle, and there it is all being done.” He offered this image in its place: “It’s done right where you sit, in your own family, in your own factory, in your own school, and so on. What arrive at the castle are the long-neglected casualties.”
Lindemann began to receive invitations to speak all over the country. A note came in the mail that read, “Dr. Mead needs a reference to your grief studies, especially your study of the Cocoanut Grove fire.” It came from a secretary of the famed anthropologist Margaret Mead, writing from the American Museum of Natural History in New York City. (Mead later nicknamed Lindemann’s field of work “sociatry.”)
In 1954, he became the chief of psychiatry at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School, where he taught courses that danced between medicine and social science and philosophy. He taught his students from the perspective of existentialist philosophers in order to “find a conception of sick man which would be compatible with the dignity and uniqueness of each specific human being.” He encouraged students to consider a patient “not only as a sick organism but also as a human being caught up in the complexity of the various determinants of his life career, a being which only vaguely perceives who he is and where he is going.”
“It is the essence of life to be intertwined with death and the rhythmical coming and going of generations,” Lindemann wrote in his lesson plans for a seminar on “The Existentialist Approach to Psychiatric Problems.” “It is the essence of life that there be strife among human beings, among populations, and among the organism.”
He wasn’t without critics. “It began to sound very different from what psychiatry was like at the time,” says David G. Satin, who was a student of Lindemann’s throughout the 1950s and 1960s and later went on to work as an assistant professor of psychiatry at Harvard Medical School. “People began to disapprove of this expansion. They felt he was getting into things that were not psychiatric, that were not medical. That were getting into fields that were politics, that were sociology, and physicians should stay out of that.”
Resentment and resistance brewed toward Lindemann, Satin says — “And when he involved non-medical people, in psychology, anthropology, sociology… the medical people were just outraged — letting all these non-medical people into our citadel, and polluting the purity of medicine.”
On a lecture tour in 1951, Lindemann had serendipitously met a British man named Gerald Caplan who’d been independently conducting research on crisis theory in Jerusalem. Caplan joined Lindemann the next year at the Harvard School of Public Health. The two worked and spoke closely on all facets of community mental health. Later Caplan wrote, “My own thinking about these topics was so influenced by Erich that I have never been able to say which of my ideas in those days originated in my mind and which in his.”
Caplan became well known for his work in community mental health, and his work on preventive care inspired and galvanized a man named Robert H. Felix, who was the director of the National Institute of Mental Health. Felix championed community mental health as the model for the nation.
In 1963, less than a month before his assassination, President John F. Kennedy signed into law the Community Mental Health Act, which mandated that the federal government fund centers and research at the national level. The following year, Caplan published a book titled “Principles of Preventive Psychiatry,” which laid out an instructional framework for the many community mental health workers who would start work across the country following the act’s passage. Felix wrote the book’s impassioned forward, calling it “a Bible.”
The community mental health movement gained national momentum not only from Kennedy and Congress, but from increased social and political support offered by Civil Rights and anti-Vietnam War activists.
Meanwhile, in the Harvard medical community, Lindemann’s decriers grew louder. In the later years of Lindemann’s tenure, Satin says, “People at the medical school became much more uninterested and hostile, retrenching to biology, lab research, and illness treatment approaches.” Early in Lindemann’s career, the Medical School curriculum had allocated increased time for psychiatry. Later on, the allotted time contracted, Satin says.
And, in one massively significant way, community mental health failed.
“It should be possible, within a decade or two, to reduce the number of patients in mental institutions by 50 percent or more,” Kennedy said when he signed the bill into law on Oct. 31, 1963. This reduction would come to be called “deinstitutionalization.” It was clear that American mental institutions were understaffed and over capacity, and they offered inadequate and sometimes abusive treatments. Community mental health centers had the potential to provide patients with the personalized care that large institutions could not offer.
But in practice, deinstitutionalization often meant releasing severely mentally ill people in enormous numbers to be treated at community mental health centers that didn’t have the capacity or funding to care for them. Many of these people wound up homeless or imprisoned. These problems were exacerbated by national entrance into a politically conservative era stewarded by Ronald Reagan and Richard Nixon, who both shrank federal funding for community mental health centers.
The budget cuts amplified the inadequacy of the centers, worsening public opinion. By Reagan’s presidency in the 1980s, the movement had lost steam. “‘Community’ kind of became a discredited reference point in psychiatry,” Harrington says.
“The centers weren’t really funded to a point where they could handle issues of medication and medication compliance, and these people were really sick and they weren’t just in crisis,” Harrington says. “Community mental health centers was maybe a really good model for people suffering from acute grief. The idea that it should become a model for people suffering from every single distress or disorder probably was a big mistake.”
More recently, Harrington says, there’s been a shift in the world of psychiatry back to the biological — and a burgeoning lack of interest in integrating social scientific research into treatment paths. She calls this “an era when we believe that all forms of suffering [are] ultimately best treated with a prescription for a good antidepressant.”
“I think there has been a profound medicalization of many forms of mental suffering, possibly in ways that have narrowed perceived options for people,” she says. “In a way these are quiescent times for the psychosocial.”
In the basement of Stanford Medical School that February morning in 1972, Lindemann addressed a group of doctors and nurses on the subject of loss, recalling what he had learned from his research on hysterectomies. He was not their chief. He was their patient. The medics standing before him had spent the past six years treating Lindemann for a sacral chordoma, a rare cancer occurring in the lower back.
It is very unusual for a patient facing death to also be an expert on the subject. Lindemann wanted to take advantage of the opportunity to use all his knowledge of loss to explain to the medics what it was like to be confronted with one’s own death.
It was not only a chance for the doctors to learn how to best treat a dying patient, but Lindemann’s chance to test whether he could benefit from his own theories. What he said on that day would become a published essay titled, “Reactions to One’s Own Fatal Illness.”
He talked through the loss he’d observed in patients with missing body parts; and how, in the case of the Cocoanut Grove fire, he’d seen a huge quantity of people stricken by the loss of loved ones.
“Now let us turn away from partial losses and think about losing of oneself in threatening death,” he said. “Some time left, a little time left, a long time left? — how much, one doesn’t know.”
A surgeon had misdiagnosed his cancer for three years, and, when he finally found it, told Lindemann: “Well, you have three or four years now, can you do with three or four years?”
“Then it really hits you,” Lindemann said, “And the thing that hits you is that you are not immortal.”
Lindemann had been adamant throughout his career that the hospital itself is a site of complicated social dynamics. A mentally healthy ward was one that looked out for the emotional wellbeing of all patients, even mentally healthy ones, as well as that of caretakers, who often faced crises of their own while working. One problem that arose in medical institutions, he believed, was that staff felt limited in their time and emotional resources.
Sometimes, he thought, there was an inclination among doctors to consider good patients the ones who don’t show their misery. It was emotionally demanding for a doctor to think of the dying patient as an individual. The easiest thing was to think of the patient as a biological specimen. But this would not work for the patient who, in Lindemann’s view, had one important task remaining.
The bereaved survivors of the Cocoanut Grove fire had needed to reconstruct their social ties to move past their grief. The patient facing death was faced with “constructing a collective surviving image of oneself which still will be there when one happens not to be there any more in the flesh,” Lindemann said.
Some patients might attempt to reconstruct their identity as they approached death by writing a book. Lindemann, by then, had a building named after him in Boston: The Lindemann Mental Health Center. Having a building named after you marked a good — if not widely available — way to ensure that your identity lived on.
In most cases that Lindemann observed, though, dying patients would simply speak to a nurse or friend or family member and tell that person about what kinds of things they had done over the course of their lives. This is what Lindemann called “the core of grieving, which, if it is done well, is apt to become an an admirable process — a fascinating process if one is lucky enough to witness it.”
Once the medic understands that this is the kind of care the patient needs, Lindemann told his doctors, “one can be surprised at how little actual time expenditure is needed to say the right word at the right time, and not too much.”
He thanked his medics for their attempts to save him, for their unusual degree of care. He had two more years and so much work to do.
Correction: Nov. 29, 2018
Due to an editing error, a previous version of this story incorrectly stated that the Cocoanut Grove fire took place Nov. 28, 1928. In fact, it took place Nov. 28, 1942.
— Magazine writer Eva K. Rosenfeld can be reached at email@example.com.