Introduction

Abstract

This comparative study of patient work and occupation throws new light on a topic that has only recently attracted scholarly attention. Patient work emerged in the context of moral treatment in the early nineteenth century in both France and England and was used similarly in both asylum systems until World War I. After the war, the approach to patient work and occupation diverged, as Freebody demonstrates using three institutional case studies from each country. An overview of the historiography, not only of patient work and occupational therapy but also of the history of work and working practices, welfare, the emergence of the asylum system, psychiatry, mental nursing and the patient experience, puts Freebody’s analysis in context. Criticism of the use of patient labour in 1918 by asylum medical officer Montagu Lomax provides a benchmark for developments during the interwar period.

“It is my day for visiting the workshops, laundry and farm, and I will ask the reader to accompany me. Leaving the airing court, I turn down past the female ward blocks and the female hospital and enter the first workshop. There are four workshops in this block: the coir-picking shop, the tailor’s shop, the bootmaker’s shop, and the painter’s shop. … There are some dozen male patients working in the coir-picking shop, picking the coir, or cocoa-nut fibre, with which most of the mattresses used by the patients are stuffed. It is unpleasant, unhealthy work, reminiscent of oakum-picking to those who have been in jail or worked as “casuals” in workhouses, and patients with weak chests or a tendency to bronchitis should not be employed at it, as the dust given off causes considerable bronchial irritation. But it is very useful work from the point of view of the asylum authorities, for it saves them much expense. In the tailor’s shop some half a dozen patients are now employed under the superintendence of the asylum tailor, who is also a part-time attendant. In the bootmaker’s shop only one patient is at present employed, for not many lunatics can be trusted with sharp tools.

“From the workshops we cross over to the laundry, which provides one of the most important and useful employments to which patients are put, women equally with men. The laundry is the stepping-stone to liberty for more patients than any other workshop. For only the best and most trustworthy patients are employed there, and few decline to take the job, though it is not a particularly healthy one, because they know that in many cases it is the half-way house to freedom. There are a score or more employed there this morning under the charge of the laundryman attendant, and I stop to chat with three or four, whom I am sending up for discharge at the next meeting of the Board, to satisfy myself as to their mental progress. From the laundry, I cross over to the boiler-house and thence to the engineer’s shop, where three or four of the more intelligent patients are working. Two of these are also on my list for the next discharge, one of whom, an old man of about sixty, has been in the asylum for twenty-three years, and from all accounts has been fit for discharge for many years past, had anyone ever taken the trouble to interest himself sufficiently in his case.

“As I pass down the road on my way to the farm … I encounter a string of patients garbed in white overalls, who are wheeling boxes on barrows under the charge of an attendant. This is the “closet-barrow gang”, and numbers twelve in all, and it has been at work, with an interval for breakfast, some four and a half hours. Theirs is the most unpleasant and unhealthy work of all. … The work of emptying the asylum closets must, of course, be done by somebody, and it is much cheaper to employ asylum labour than to get it done outside. Emptying earth-closets is a class of labour which, though unpleasant, is common enough in various parts of the country [and in France], and the particular type of patient employed in this instance is certainly not likely to suffer from undue fastidiousness. Were there no alternative to the earth-closet system there would certainly be no harm in employing healthy lunatics to empty the earth-closets, if they were not averse to the job, provided also that they were well fed, well clothed, and properly compensated, and that every care was taken to make the work as little exhausting and unhealthy as possible. As a matter of fact … none of these conditions were complied with.”¹

The same year that Montagu Lomax’s gloomy account of how patients were occupied at Lancashire’s Prestwich Asylum was published, the American psychiatrist Dr Adolf Meyer (1866–1950) gave a lecture on “The Philosophy of Occupation Therapy” at the fifth annual meeting of the National Society for the Promotion of Occupational Therapy in Baltimore, USA. Lomax’s description, based on his experiences as a medical officer between 1917 and 1919, is borne out by remarks made by Meyer about the occupation of patients in English asylums during the late nineteenth century. Meyer observed that work in the “industrial shops and work in the laundry and kitchen and on the wards [were] very largely planned to relieve the employees.”² Meyer was also critical of occupation in American institutions. At the hospital in Kankakee, Illinois to which Meyer was appointed in 1893, “there was little in the atmosphere to foster interest in occupation” and where work was organised “merely from the point of view of utility”.³ His words could equally apply to the situation in French asylums. Meyer’s lecture then turned to the new conception of occupation, developed in the USA just before the outbreak of World War I, that involved a “blending of work and pleasure—all made possible by a wide supplementing of centralisation by individualisation and a kind of de-centralisation.” This new approach, which included a range of more interesting craft activities, such leather work, basketry and book-binding, generated amongst patients, “a pleasure in achievement … and a happy appreciation of time”.⁴

The two sets of observations, made by Lomax (1860–1933) and Meyer in 1921, raise the question of what had happened to the individualised, therapeutic work programmes that had formed the cornerstone of moral treatment in early nineteenth-century France and England? Why did the nature of work allocated to patients change in the late nineteenth and early twentieth centuries, while asylums continued to operate within the framework of moral treatment? This study will explore what happened within psychiatry, and wider society, to foster a type of patient work that appeared to benefit the institution as much, if not more than the patient. It will identify the combination of medical, economic and social factors in the wake of World War I that caused a re-appraisal of psychiatry, patient work and occupation in England, and amongst a small group of Parisian psychiatrists. Was the approach outlined by Meyer in his lecture really new, or was it merely a re-fashioning of moral treatment? How helpful was it to those hoping to re-join the labour force after leaving hospital? Analysis of factors such as the fiscal crises following World War I and the Great Depression, changing attitudes towards work and welfare, the influence of contemporary notions of class and gender on work, and the changing nature of industry and working practices will help to explain the differences in approach to patient occupation that developed in France and England between 1918 and 1939. Fundamental to this discussion are the divergent professional trajectories of French and English psychiatry and disparate views concerning the origin, curability and treatment of mental disorder.

Selection of Countries and Institutions

The historical parallels in the development of the French and English asylum systems were marked. Theories regarding the moral treatment of mental illness developed by the English William Tuke (1732–1822) and the French Philippe Pinel (1745–1826) emerged contemporaneously in the early nineteenth century and became the model of treatment to which physicians on both sides of the Channel aspired. Work formed a key element of moral treatment and the type of work given to patients, such as farm work, work in the workshops, kitchen and laundry, was similar in French and English asylums. Fast-forward one hundred years, and patient occupation had taken on a different character in the two countries. This divergence in approach, after a century of close alignment, prompted the selection of France and England for study during the interwar period. French and English psychiatrists (or alienists as they were called) had collaborated during the nineteenth century, visiting each other’s institutions and reporting on developments in psychiatry in each other’s countries. Despite this professional collaboration and shared history, work therapy developed differently in each country after World War I, an anomaly that warranted further investigation.

The four metropolitan institutions selected for study all specialised in the treatment of acute-stage, presumed curable cases of mental illness, while the two provincial institutions cared for a mixed clientele of curable and incurable cases. The selection facilitates a comparison of the different approaches to occupation in French and English institutions, between institutions admitting patients at the onset of their symptoms and those only accepting certified patients, and between metropolitan and rural institutions. Ste Anne’s in central Paris included both the Asile Clinique (established in 1867) and the Henri Rousselle Hospital (1922). In London, the two hospitals specialising in acute, curable cases were the Maudsley Hospital, which opened for civilian cases in 1923, and Bethlem Royal Hospital, which had been in existence since the thirteenth century. The Henri Rousselle and Maudsley hospitals were similar in that they were both established for the specific purpose of treating mild, incipient cases of mental disorder that did not warrant certification. They were the only public mental institutions in France and England where the poorest members of society could be admitted voluntarily, before their symptoms became entrenched.⁵ The institutions, founded by Édouard Toulouse (1865–1947) and Henry Maudsley (1835–1918), both became important centres of psychiatric research and provided models for the mental hospitals of the future, offering a blend of in-patient and out-patient care.

Prior to the opening of the Maudsley, the only other English mental hospital that specialised in acute, curable cases, and admitted voluntary as well as certified patients, was the Bethlem Royal Hospital. Bethlem was a registered hospital and therefore not subject to the same jurisdiction as county and borough mental hospitals; it admitted poor patients (although not paupers) voluntarily on a charitable basis. Bethlem had operated a policy of restricting admissions to patients in “a presumably curable condition” since the mid-nineteenth century.⁶ This acceptance of curable patients on a voluntary basis, coupled with its long history, made Bethlem an interesting institution to compare with its near neighbour and rival, the modern Maudsley Hospital.⁷ Despite their similar admissions policies, the treatment offered at the two institutions differed significantly. The various factors that contributed to these differences are analysed, such as Bethlem’s links with the specialist neurological National Hospital for Nervous Diseases in Queen Square, the pervasiveness of a traditional approach to treatment, and the social class of patients. Treatment at the Maudsley, the early plans for which were based on Emil Kraepelin’s clinic in Munich, drew on the latest psychiatric thinking. Occupational therapy was introduced as soon as the Maudsley opened in 1923, while it was only provided at Bethlem from 1932. Both Bethlem and the Maudsley had a medical school, but Bethlem’s foundered in the mid-1920s in the face of competition from the Maudsley school. Bethlem’s move from south London to Kent in 1930, and a lack of high-profile research sealed the fate of the medical school, which ceased in 1937.⁸

As well as the “deserving poor”, who were not expected to pay fees, Bethlem also admitted an increasing number of private patients who could afford to contribute towards the costs of their care, but not the exorbitant fees of a private asylum. The occupations of these middle-class patients, for whom manual work was an anathema, facilitated a comparison with those of the private patients of the Asile de la Sarthe, which accepted both pauper and paying patients. Occupation was considered important at Bethlem, but the focus was on sport and recreation rather than work. The Asile de la Sarthe’s pauper patients were obliged to work, while private patients were exempt. The French asylum lacked the extensive programme of leisure activities provided at Bethlem and did not offer occupational therapy, but a small proportion of the paying patients engaged in some form of work. The variation in the way patients were occupied in the different classes (pauper, poor or working-class and middle-class) in France and England offered interesting points of comparison.

When it was established in 1867, the Asile Clinique catered for a mixed clientele of acute, curable and incurable cases. Since its opening, there had been calls for it to become a hospital exclusively for acute, curable patients. These plans were resurrected in 1918, although the transformation was not fully completed until 1927.⁹ As a hospital for acute cases, the Asile Clinique was expected to provide the most up-to-date psychiatric treatment by doctors at the peak of their profession.¹⁰ Most patients still had to undergo the process of certification before they could be admitted to the Asile Clinique, thereby delaying the commencement of treatment. Others were brought directly to the Admissions Office by their families (an arrangement made possible by special legislation passed in 1876) which meant that treatment could begin earlier.¹¹ Discharge rates after 1928 indicate that many patients were believed to have recovered. The active treatment delivered at the Asile Clinique was heavily influenced by neurology, a characteristic shared with Bethlem. Psychiatrists at the Henri Rousselle Hospital, and some of the junior doctors at the adjacent Faculty Clinic, adopted a more holistic approach, treating patients psychologically as well as biologically. These differences raise the question of the extent to which occupation was used therapeutically in the various institutions, and whether certain approaches attached greater importance to therapeutic occupation. The differences in approach of divisions within the same complex (Ste Anne’s) offered interesting territory for exploration and demonstrate the importance of the treatment preferences of individual psychiatrists.

The two provincial institutions, the Littlemore Hospital in Oxford and the Asile de la Sarthe in Le Mans, both catered for a mixed clientele of curable and incurable cases. Both institutions were situated in or near provincial towns that served the surrounding rural populations of the county of Oxfordshire, England, and the department of La Sarthe, France. Established in 1846 and 1828 respectively, both institutions had been managed according to the principles of moral therapy during their early incarnations. Both institutions were able to provide patients with a plentiful supply of farm work (considered so important by the moral therapists) on the land surrounding the asylums. By the end of the nineteenth century much of the agricultural land near the Asile de la Sarthe had been built on, while the farm at the Littlemore remained a significant aspect of asylum life throughout the interwar period. This raises interesting questions regarding each asylum’s priorities in terms of providing therapeutic work for patients on the one hand and offsetting costs on the other. The financial importance to each institution of growing fresh produce for consumption by patients and staff, or for sale, are assessed in Chap. 5.

A crucial difference between the Littlemore and the Asile de la Sarthe was the Littlemore’s access to the medical students who studied at Oxford University and the Radcliffe Infirmary. Le Mans did not have a university (the University of Maine was founded in 1977) which limited the Asile de la Sarthe’s ability to recruit interns. A shortage of medical staff compromised the ability of the chief medical officer to deliver treatment. The medical superintendent at the Littlemore enjoyed the assistance of medical students and junior medical staff. It was far more feasible for the Littlemore superintendent to deliver active treatment, such as psychotherapy or malaria therapy, than it was for the Asile de la Sarthe’s chief medical officer to deliver any form of treatment. The English Mental Treatment Act of 1930 permitted institutions outside London, like the Littlemore, to admit patients voluntarily, without the need for certification. This meant they could begin treatment at an earlier, potentially curable, stage of their illness. This legislation instigated a gradual change in the proportion of curable patients at the Littlemore, setting it apart from the Asile de la Sarthe where no such changes took place. The approaches to treatment taken by the medical superintendents of the Littlemore and the chief medical officers of the Asile de la Sarthe were markedly different. These differences, examined in Chap. 6, were highlighted by the psychiatrists’ attitudes towards the occupation of patients.

Analysis of patient work and occupation in each of the institutions studied demonstrates how occupation was associated with different psychiatric traditions and approaches to mental disorder. The presumed curability of the patient and stage of their illness, a patient’s class and gender, the institution’s rural or urban location, the availability and quality of staff, and the treatment preferences of individual psychiatrists were also important factors. The selected institutions were not necessarily representative of psychiatric care in their respective nations, but their use of occupation highlights differences between “modern” and “traditional” institutions and signposts the future development of mental hospitals in France and England. A comparison of occupation in these institutions advances and adds a new dimension to themes identified by the existing historiography of patient work and occupational therapy and throws new light on approaches to psychiatry during the interwar period.

Sources

The annual reports of the six institutions formed the main source material for this study. The nature of the reports varied, with some including administrative, “moral” and medical reports and others written solely by the medical superintendent, but they incorporated similar information and statistics on the workings of each institution, its patients and staff, treatment regimes, facilities and financial situation. Whilst these reports provided the details essential for conducting an investigation into patient work and occupation, it must be remembered that they were written to present a certain image to the outside world. As Kathryn McKay notes, the annual reports of medical superintendents in British Columbia, Canada, included carefully balanced accounts of patient labour that overcame the inherent “tension between exploitation and therapy”.¹² It has been important to try and “read between the lines” of the annual reports to piece together what life was really like in these institutions, and to use other sources to put them into context.

The reports of the Board of Control (England) and the Commission de Surveillance (France), the bodies that oversaw the provision of institutional care for the mentally disordered, were consulted for their reports on individual institutions and to ascertain their stance (and therefore that of government) on patient work and occupation. In the case of the French Commission de Surveillance, the contents of the reports tended to focus on practical matters, such as sanitation and building works. The Board of Control reports were more policy-driven, with sections dedicated to “lunacy” (or mental illness) and “mental deficiency” (or intellectual impairment), as well as inspection reports on individual institutions.¹³ The Board of Control, which reported to the Ministry of Health after the latter’s formation in 1919, formed a link between the mental hospital system and the state and acted as a conduit for government policy towards the mentally disordered.¹⁴ It could not enforce compliance but highlighted the standards expected of institutions. In France, asylum directors and chief medical officers reported to the General Council (Conseil Général) of the department, an elected body responsible to the Prefect who, operating under the Ministry of the Interior, represented the state at local level.

The professional psychiatric journals of each country, the Journal of Mental Science (established in 1855) and the Annales Médico-psychologiques (founded in 1843), were consulted to gain a sense of the important contemporary issues within psychiatry and to ascertain the level of interest amongst psychiatrists in therapeutic occupation. These two publications were associated with the Medico-Psychological Association (the MPA became the Royal Medico-Psychological Association, or RMPA, in 1926) in England, and the Société Médico-psychologique in France. As such, they were the “official” voice of French and English psychiatry. Articles advocating new approaches to patient work written by French psychiatrists also appeared in L’Aliéniste français, which was produced by the Association amicale des Médecins des établissements publics d’aliénés de France, an association for doctors working in public asylums founded in 1907, and L’Hygiène Mentale, the journal of the French League of Mental Hygiene, edited by Édouard Toulouse, co-founder of the French league. L’Hygiène Mentale was therefore supportive of the principles of mental hygiene, which included the re-education of patients through occupation, while L’Aliéniste français was in favour of asylum reform. Other key sources included the reports from government enquiries, such as the Macmillan Report of 1926, and legislation, such as the Mental Treatment Act of 1930 and the French Ministerial Circulars of 1937 and 1938. These give further insight into government thinking on the use of occupation within the overall contexts of institutional management and psychiatric treatment, revealing occasional differences between central policy and local practice.

Themes and Historiography

The prescription of work for patients originated in the context of moral treatment and the emergence of the asylum system. Its prescription was influenced by a range of factors that varied across time and space. The contemporary economic climate; the nature of industry; the provision of welfare; notions of class and gender; psychiatric ideology; and the professionalisation of psychiatry, mental nursing and occupational therapy, all had a role to play. These topics have their own specialist histories, but few (with the obvious exception of occupational therapy) are linked to institutional patient work. This study draws these various influences together to enrich our understanding of the rationale for patient work and occupation. It highlights the tendency of psychiatry to encroach upon areas of everyday social life and to “medicalise” the concept of employment. In so doing, it reveals our changing and often ambivalent attitudes towards work, its perception as a moral good, as a means of subsistence, as a source of identity and personal satisfaction, and as the basis of national wealth and competitiveness. Conversely, this study also draws attention to ways of thinking about unemployment, as a moral failing or as a social problem to be solved, and about the responsibility of the state towards those without work or income. These issues were particularly relevant during the political and economic uncertainty of the interwar years.

Work and Working Practices

The devastation of the economies of Europe by World War I and by the Great Depression of the 1930s, have been well documented by economic historians.¹⁵ The direct and indirect effects of this devastation on the practice of patient work and occupation in institutions have attracted less attention. Both the war and the economic precarity of the 1930s had a significant effect on the mental health of individuals, on how they were treated and occupied in institutions, on the budgets available for healthcare and on the work that might be available outside those institutions to discharged patients. As well the premature death of ten million people, massive migration and the redrawing of national borders, the war caused major disruptions to markets and industry. After the conflict, industry had to re-adjust to peace-time conditions. In France, industries in the north-east destroyed during the conflict had to be reconstructed. It was estimated in 1919 that the war had left France short of three million men from its labour force, necessitating the recruitment of immigrant workers.¹⁶ In Britain, the government had to decide how to redeploy some five million servicemen, and a similar number of civilians (including c.700,000 women) who had been employed in war-related work.¹⁷ The war had encouraged women to leave sectors traditionally associated with female labour, such as textiles, clothing manufacture or domestic service and to move into clerical work, shopwork and factory work.¹⁸ Whether such changes were reflected by the work provided in asylums is an area addressed in Chap. 9.

During the process of recovery from these war-induced challenges, the profile of industry was changing. Coal-powered steam engines were gradually being replaced by electric motors in manufacturing, and electricity and diesel threatened the use of locomotives in rail transport.¹⁹ The new sectors of electrical engineering, rayon production and automobile manufacture were poised for growth after the war. There remained, however, pockets of traditional, artisanal occupations, that coexisted alongside the newer industries, and the extent and nature of industrial development varied regionally, in both France and Britain.²⁰ The percentage of the work force employed in industry remained stable between 1913 and 1930 at c.46% in Britain and c.33% in France.²¹ The agricultural sector continued to shrink in both France and Britain, although in France the proportion of workers remaining on the land was much higher. In Britain, one of the least agricultural countries of Europe, just 10% of people were employed in agriculture in 1913, and by 1930 this percentage had decreased to 6%. In France, 41% were employed in agriculture in 1913, and 36% in 1930.²² The services sector, however, increased in both countries, with a modest rise in Britain from 45% in 1913 to 48% in 1930, and in France from 26% in 1913 to 31% in 1930.²³ This sector comprised shipping; rail and road transport; financial services; distribution; education, medical and social services; and religious and domestic services.²⁴ These factors had implications for what might constitute rehabilitative work within asylums and raise questions over the ability of asylums to provide work that prepared individuals for the labour market outside. Was agriculture, for example, an area to encourage given the declining numbers employed in the sector?

As Geoffrey Searle has highlighted, attempts were being made by the British to maximise productivity before the outbreak of World War I, amid concerns regarding “national efficiency” and maintaining Britain’s reputation as “the workshop of the world”.²⁵ The war accelerated these efforts and stimulated innovation in working methods. Research into how to minimise “industrial fatigue” and maximise output by workers increased, as the war-time requirement for long hours and intense, sustained effort took their toll on the health of munitions workers.²⁶ The war, as Roger Cooter and Steve Sturdy have maintained, acted as a catalyst for the development of scientific management techniques to maximise productivity and efficiency.²⁷ The new methods, developed in the USA and often known collectively as Taylorism, involved the breaking down and subdivision of tasks involved in the production process. This resulted in a de-skilling of the workforce; tighter controls over workers; a loss of worker discretion and autonomy; closer links between effort and earnings; and more stringent monitoring of performance.²⁸ The routinised and fragmented working practices, analysed by Anson Rabinbach, were not only unpopular with workers but could be perceived as harmful to their mental health.²⁹ According to the Mental Hygiene Movement’s preventative agenda, work should be satisfying and well-suited to the aptitudes of the individual worker. This raises the question over whether work for patients was aimed at preparing them for the labour market, whilst exposing them to potentially harmful working practices, or at protecting their mental health by providing satisfying occupations that failed to equip them for the modern workplace. Equally damaging to mental health was the anxiety, loss of self-esteem and sense of hopelessness generated by being unemployed.³⁰ Arguably, recently discharged patients might be more prone to unemployment if they did not leave the institution with a marketable skill.

Welfare and Unemployment

Much has been written on changing attitudes towards unemployment and poverty, and on the beginnings of state welfare provision in both France and England.³¹ Poverty and joblessness, regarded as a moral failure and a matter of individual fault for most of the nineteenth century, gradually came to be seen as a social problem in the late nineteenth and early twentieth centuries. Measures to tackle the root causes of poverty, such as old age, sickness and unemployment, were introduced in England in the decade before World War I, but not until the late 1920s in France. The existing literature does not explore the relationship between these changes taking place in society and their effect on patient care and how patients were occupied in mental institutions, a lacuna addressed by this study. The existence of the twenty-year time lag between the introduction of significant welfare measures in England and France raises questions about the impact of these measures on the way patients were prepared for life outside English and French institutions. Did the existence of welfare measures in post-war England enable psychiatrists to focus more on using occupation therapeutically, rather than as a means of ensuring patients’ employability, than in France? Late nineteenth-century English psychiatric texts made frequent references to the “creation of useful members of society” who could earn their own living after discharge, as Sarah Chaney observes, but this type of rhetoric was far less common after World War I.³² Was the development of self-sufficiency amongst patients no longer a priority for mental hospitals, despite the economic uncertainty of the period?

The problem of unemployment grew very rapidly after World War I, as Bernard Harris observes.³³ Between 1921 and 1938 in Britain, the average number of unemployed people never dropped below one million and remained above two million during the first half of the 1930s, peaking in 1932 as the Great Depression took its toll.³⁴ In France, the effects of the Depression lasted longer than in Britain, causing widespread hardship between 1931 and 1938.³⁵ High levels of unemployment during the Depression put increasing strain on existing welfare provision, as well as on health budgets. In England, the poor law buckled under the strain. The Boards of Guardians were abolished, and the 1929 Local Government Act saw responsibility for the poor transferred to the local authorities, who were obliged to set up Public Assistance Committees.³⁶ This study examines how such pressures outside mental institutions affected the occupation of patients inside them. As Richard Warner notes, in the USA, increased levels of admissions for schizophrenia were observed during economic slumps, and recovery rates were significantly lower during the Great Depression.³⁷

The Emergence of the Asylum System and Moral Treatment

The history of Western psychiatry has tended to focus on the late-eighteenth and nineteenth centuries, a period characterised by the rise of the asylum and by new ways of treating the insane according to the humanitarian principles of the Enlightenment.³⁸ “Moral treatment” became the method to which most asylum doctors aspired, and its principles provided the administrative and medical framework for the emerging asylum systems in both France and England. The therapy concentrated on the rational and emotional, rather than the organic causes of insanity, aiming to build up patients’ self-esteem and self-restraint, thereby equipping them with sufficient self-discipline to master their condition.³⁹ Integral to moral treatment was giving patients some form of work, such as assisting the attendants with their duties or working in the fields or gardens.⁴⁰ Patient work was, according to Andrew Scull (1993), a “major cornerstone” of nineteenth-century moral treatment, while Leonard Smith (2007) describes it as “a rationalised central element of therapy and rehabilitation in public lunatic asylums”.⁴¹

The merits of moral treatment, and thus of patient work, have been the topic of vigorous debate among historians. Psychiatric practitioners writing the history of their profession in the 1930s, 1940s and 1950s, extolled the virtues of moral treatment as the harbinger of a new compassionate era that witnessed a transformation of the profession of psychiatry from “cruelty and barbarism to organised, institutional humanitarianism, and from ignorance, religion and superstition to modern medical science”.⁴² These progressivist, internalist accounts became known as Whiggish histories.⁴³ They were challenged by Michel Foucault in his Histoire de la Folie (1961), in which he questioned the alleged benign nature of moral treatment, and rejected the notion of liberal humanism in nineteenth-century psychiatry, medicine and penal reform. In his view, moral treatment merely replaced physical abuse with mental abuse. Seen through Foucault’s lens, the asylum was a means of moulding inmates into willing, acquiescent workers, ready to contribute to the state’s economic requirements. Foucault characterised work within the asylum as “a constraining power superior to all forms of physical coercion” due to the regularity of the hours, the need to pay attention, and the obligation to produce results.⁴⁴ Work carried out by inmates was “deprived of any productive value”, imposed as a “moral rule, a limitation of liberty, a submission to order, an engagement of responsibility” designed to rid the mind of “of all exercises of the imagination” and supplant “delirious illusions”.⁴⁵ Foucault’s critical account, together with those of Erving Goffman, R.D. Laing and Thomas Szasz, prompted a series of revisionist works on the history of psychiatry, including those by Klaus Doerner, David Rothman, Robert Castel and Andrew Scull.⁴⁶ According to Scull, writing in the late 1970s, the asylum system was designed to “repair damaged human capital”, to instil bourgeois values of self-control, self-sufficiency and productivity through a programme of “moral therapy”, and to “warehouse” those unable to support themselves.⁴⁷

A new generation of scholars turned away from revisionist arguments focusing on negative aspects of social control to embrace what Joseph Melling has termed a late-Whiggish position on the nineteenth-century asylum, suggesting its function was more benign.⁴⁸ Leonard Smith, Akihito Suzuki and David Wright, contributors to Melling and Forsythe’s edited volume (1999), present the asylum as a therapeutic establishment that responded to community needs.⁴⁹ In their study of the Welsh asylum at Denbigh, Pamela Michael and David Hirst assert that “the operational philosophy of the asylum was based on the ‘rule of kindness’”.⁵⁰ These more recent studies, based on the detailed study of institutional practices, indicate that the pendulum has swung back towards a more compassionate interpretation of the asylum. The present study of patient occupation helps to clarify the extent to which the mental hospital fulfilled a political aim of turning pauper patients into productive workers, and whether the primary rationale for the prescription of patient work was to offset institutional running costs, or to provide therapy for the benefit of the patient.

Psychiatry and Ideology

Other areas of the history of psychiatry that have attracted the attention of historians include the period between c.1870 and 1914,⁵¹ the war neuroses experienced by soldiers during World War I,⁵² the history of psychoanalysis and the teaching of Sigmund Freud,⁵³ and aspects of psychiatry after 1945, such as the “pharmaceutical revolution” of the 1950s and 1960s.⁵⁴ In England, the process of de-institutionalisation after 1959, and in France the reforms taking place within psychiatry in the aftermath of World War II, have been particular foci for recent scholarship.⁵⁵ The interwar period has received less attention, with the exception of studies of the Mental Hygiene Movement; the effect of eugenic ideology on psychiatry; and the introduction of shock treatments and psycho-surgery in the late 1930s.⁵⁶ The interwar period in France has been dismissed by some historians as “immobile” or “frozen”, as Isabelle von Bueltzingsloewen observes.⁵⁷ This notion is challenged by the present study which demonstrates that, while by no means nationwide, new approaches to psychiatric care were being developed in France (albeit limited to Paris) and England during the interwar period, and it was during the interwar years that occupational therapy emerged in England. The present study’s focus on patient work and occupation highlights what Mark Micale has described as the competition between “two explanatory models” of mental disorder that characterised psychiatry in the twentieth century.⁵⁸ One model is based on a psychosocial theory of insanity as an “illness of the mind or spirit” that emphasises external factors, such as family upbringing, personal history, and environmental factors, and the other on organic or somatic theories based on the view that mental disorder as “a cerebral disease with physical determinants such as heredity, foetal milieu, hormonal environment, and brain anatomy, physiology, and chemistry”.⁵⁹ The two explanatory models are associated with different models of care. The somatic model is often associated with a custodial model of care known as “alienism”, while the psychosocial model is indicative of the move towards modern “psychiatry” (a term that was rarely used before 1900) that involved the active treatment of patients.⁶⁰

The adoption and rejection of these models took place at different times in different locations. Adoption of the psychosocial model in England was stimulated by the experiences of psychiatrists who treated soldiers suffering from war neuroses during World War I. The conflict had a profound effect on English psychiatrists’ attitudes towards the causation and treatment of mental disorder. Although it would be naïve to assume that all English psychiatrists made this ideological shift, they were much more likely to accept that mental disorder had a psychological or social origin after the conflict than before the war, as Chris Feudtner has observed.⁶¹ The fact that the war did not have the same impact on French attitudes towards mental disorder, and did not therefore prompt the move from a custodial to a psychosocial model of care, affords an interesting angle for comparison. This difference in approach is highlighted by the type of occupations assigned to patients, and the type of patients to whom it was assigned. In custodial institutions, such as those found in provincial France, only the calm, chronic and incurable patients and convalescent patients, who required little supervision, were given work around the hospital. At institutions where the psychosocial model had been adopted, such as the Maudsley Hospital, carefully supervised occupational therapy or work was prescribed to all patients, including those at the early, acute stage of their illness.

Professionalisation of Psychiatry and Mental Nursing

The ideological shift from a physiological to a psychosocial approach is linked in the present study to levels of professionalisation in French and English psychiatry. It is argued that psychiatry followed very different professional trajectories in France and England. French psychiatry remained closely aligned with the more prestigious profession of neurology and did not develop as an independent discipline until after World War II. Psychiatry in England, on the other hand, developed independently of neurology, and the two disciplines diverged after World War I.⁶² While there exists extensive literature on the professionalisation of medicine, there are fewer studies of the professionalisation of psychiatry.⁶³ Many tend to focus on the stages of development in training and professional organisations, rather than on the ideological shifts taking place within the profession, that occurred at different times in different places.⁶⁴ The present comparative study links the different stages of ideological and professional development in England and France, which are emphasised by the prescription of occupational therapy by psychiatrists.

The professionalisation of mental nursing is another key area addressed by the present study, since, in the absence of professional occupational therapists, the successful application of occupational therapy depended on the skills, competence and training of mental nurses. Peter Nolan traces the development of mental nursing in England from its origins in the eighteenth century to the end of the twentieth century. He highlights the goal of self-sufficiency through the use of patient labour in the nineteenth-century asylum, but pays scant attention to the role of mental nurses supervising occupation in the 1920s and 1930s. Nolan acknowledges, however, that mental nurses felt threatened by the new profession of occupational therapy.⁶⁵ An edited volume by Anne Borsay and Pamela Dale examines the changing role of mental nurses in Britain, Ireland, Wales and Australia, addressing such issues as training, the move from asylum to community, gender, violence, recruitment and retention, but does not focus on the supervision of occupation.⁶⁶ The history of the mental nursing profession in France, which attracted considerable criticism from interwar French psychiatrists, is addressed by Alexandre Klein, Patrice Krzyzaniak and Benoît Majerus.⁶⁷ Their studies highlight the paucity of training and education received by nurses during the early twentieth century, but are not focused on the role of mental nurses in supervising occupation, a role for which contemporary psychiatrists found them lacking. The history of Dutch mental nursing profession is discussed in a monograph by Geertje Boschma.⁶⁸ Mental nursing in Holland attracted educated, middle-class women, for whom training was available from the 1870s.⁶⁹ These nurses were better equipped with the skills required for delivering occupational therapy, than their working-class, poorly educated colleagues in France, as this study highlights.

Patient Work and Occupation

The specific nature of the work and occupation prescribed for mental hospital patients has only recently attracted scholarly attention in its own right; more frequently it is described in studies focusing on individual asylums or on moral treatment (see footnote 37). Studies by historians that put patient work centre-stage include an edited volume by Waltraud Ernst (2016) and works by Véronique Fau-Vincenti (2014), J-P. Arveiller and Clément Bonnet (1991); Jennifer Laws (2011); Vicky Long (2013, 2006); and Geoffrey Reaume (2006).⁷⁰ These studies examine the relationship between the meaning of work inside the asylum and the socio-economic, cultural and political contexts outside. A number of similar themes emerge from the existing literature, which are taken forward by the present study, such as the relationship between economic exploitation and therapy inherent in patient work, whether work offered an effective means of rehabilitation, and the influence of the socio-economic and political climate on work within mental institutions. Few focus on the interwar period,⁷¹ and none offer a direct comparison between patient occupation in one country and another.

A key theme addressed by the present study is the balance between justifications for patient work and occupation as a means of therapy, rehabilitation and offsetting institutional running costs. None of these justifications were mutually exclusive, but the priority accorded to each changed over time and varied between France and England. The view that patient work was a means of “repairing damaged human capital” designed to mould the mentally ill into productive citizens, expressed by Andrew Scull (1979), has been challenged by contemporary historians.⁷² But questions remain over the justifications for patient work during the interwar period. Was it to prepare recovered patients for employment after discharge, ready to assist with the rebuilding of the economy after the devastation of World War I? Or was the main purpose to save on employment costs by using patient labour to perform the tasks necessary for the smooth-running of the institution? Or were work and occupation deemed curative and therefore primarily deployed to expedite the recovery of the patient? Linked to the theme of rehabilitation is that of “idleness”. Were work and occupation introduced into the asylum regime to prevent “malingering” and to instil a work ethic? The present study demonstrates that how patient work and occupation were justified by psychiatrists varied regionally and across time, in response to a range of factors both internal and external to the asylum.

A moral justification for patient work, as a means of combating idleness, is noted by several authors in relation to the late nineteenth century. The Board of Control’s annual reports from the late nineteenth and early twentieth century refer to the provision of “useful employment” for patients, reflecting an expectation that patients would contribute to the costs of their care. Sarah Chaney notes that patients refusing to engage with work around the asylum were “regarded with suspicion”.⁷³ James Moran, in his study of patient work in New Jersey, maintains that work in the asylum was “synonymous with the mid-nineteenth century middle-class ideal of productivity”.⁷⁴ Towards the end of the nineteenth century, combating idleness was increasingly emphasised in asylums in British-held territories in South Asia, as Ernst notes, replacing the early rhetoric of patient work that was linked to moral therapy.⁷⁵ This focus on combating idleness persisted into the interwar period in Germany, where productivity was seen as the route to economic recovery and restoration of national pride after defeat in World War I. A desire to re-establish Germany as a “resurgent and aspiring nation”, put greater emphasis on labour and resulted in a significant increase in the number of German psychiatric patients engaged in work, as Monika Ankele observes.⁷⁶

Under the National Socialist regime, as Thomas Mueller reports, labour and the ability to work were placed “at the centre of decision-making”.⁷⁷ Following a re-interpretation of psychiatrist Hermann Simon’s “more active” work therapy during the late 1930s, those patients who failed to respond to his treatment regime were dismissed as “hopeless cases”. In a tragic and extreme example of politics influencing psychiatry, medical staff were made responsible for selecting patients who were unable to work, and therefore deemed “unworthy of living”, for euthanasia.⁷⁸ In Argentina, those unable to work were considered a “burden to the state” during the economic crisis of the 1930s that put extreme pressure on the Argentinian welfare budget.⁷⁹ As a result, Yolanda Eraso notes that Hermann Simon’s “more active” work therapy was implemented in asylums and adapted to ensure the institution’s material needs were met with a minimum of financial input from the state.⁸⁰ Whilst there is no suggestion that such extreme measures were adopted in England or France during the interwar period, the present study questions whether the idea of work as moral duty still had traction. France, it must be remembered, was occupied by the Germans in World War II and from 1940 conditions in mental institutions took a sinister turn, as Isabelle von Bueltzingsloewen outlines.⁸¹

Studies by Ernst, Reaume, McKay and Moran highlight the increasing economic importance of patient work, revealing that as asylum budgets became increasingly restricted towards the end of the nineteenth century, patient work offered a means of making substantial cost-savings. This became as important as the therapeutic benefit of work to the patient.⁸² This was certainly the case in Ontario, Canada, as Geoffrey Reaume observes. “Moral therapy”, according to Reaume, “when stripped of its therapeutic veneer, was in reality a public works programme run on the ‘free’ labour of people confined in insane asylums”.⁸³ Between 1841 and 1900, he notes, patients undertook an ever-increasing array of work duties, from knitting to digging and from masonry to nursing. On the one hand, psychiatrists downplayed the extent to which patient labour constituted real productive work, while promoting the cost-savings achieved by it on the other.⁸⁴ Such contradictions were also evident British Columbia, Canada, as Kathryn McKay’s account demonstrates. The emphasis placed on economy or therapy in superintendents’ annual reports varied according to prevailing medical ideology and socio-economic conditions.⁸⁵ This point is highlighted by the comparative nature of the present study, in which English psychiatrists’ attempts to downplay the economic contribution of patient work are contrasted with the French focus on its importance as a cost-saving measure.

Occupational Therapy

The development of the para-medical professions, including occupational therapy, is addressed by historian Gerald Larkin.⁸⁶ Larkin emphasises the influence of social, technical and cultural forces, as well as the impact of developments within medicine, that gave rise to the para-medical professions.⁸⁷ Jean-Philippe Guihard is more specific; he maintains that the decision to include or exclude occupational therapy in psychiatry’s therapeutic arsenal rested with psychiatrists.⁸⁸ In other words, the development of the profession of occupational therapy was driven by psychiatric demand for the specialty. These views resonate with the arguments presented in this study; in locations where psychiatrists saw a value in prescribing occupational therapy (such as England) the profession developed, whereas in areas where psychiatrists preferred prescribing biological remedies for curable patients (such as France), it did not.

Most histories of occupational therapy (rather than patient work in institutions) have been written by practitioners of the profession. As with histories of psychiatry written by psychiatrists, it is important to consider whether these histories constitute “Whiggish” accounts, offering a “purely descriptive reporting of facts” rather than a critical analysis, or an interpretation that “studies the past with reference to the present”.⁸⁹ As Scull warns us, histories portraying a “triumphal procession towards the rational and humane practices of today” often fail to take account of alternative perspectives.⁹⁰ Foucault’s view of patient work as a means of disciplining the unruly and of enforcing compliance to behavioural norms—of replacing physical shackles with mental ones—can seem abhorrent to occupational therapists. They can find it hard to believe that their profession could be rooted in coercion or in any practices that could be considered inhumane or unkind. As Laws highlights, Foucault is rarely cited in histories of occupational therapy written by practitioners.⁹¹ The danger of accepting “taken-for-granted” versions of events, even if this “threatens the accepted historical narrative” is highlighted by Brid Dunne, Judith Pettigrew and Katie Robinson, who aim to encourage other occupational therapists to delve into the history of their profession.⁹² The authors explain how to use historical research to gain a deeper critical understanding of the profession of occupational therapy, using primary and secondary source material.⁹³ This may be a tacit acknowledgement that many histories of occupational therapy lack critical engagement.

Few monographs have been dedicated to the history of occupational therapy, although works by Ann Wilcock, former president of the International Society of Occupational Scientists, and Catherine Paterson, director of occupational therapy at the Robert Gordon University, Aberdeen (1990–2002), are two important British exceptions. Wilcock’s detailed, two-volume account of occupational therapy in the UK traces the roots of using occupation therapeutically back to the ancient Greeks, through the teaching of the moral therapists to the emergence of the profession in the twentieth century, and its early adoption by Dr D.K. Henderson and Dr Elizabeth Casson.⁹⁴ Paterson has performed a similar task for the profession in Scotland,⁹⁵ while Virginia Quiroga has documented the earliest years of the profession in the USA.⁹⁶ Quiroga emphasises the holistic approach taken by the early occupational therapists. Margaret Drake, an occupational therapist in the USA for 30 years, has written a fictional account of the experiences of an American occupational therapist coming to France with the US Army in World War I. It offers an insight into daily life at the Front, the difficulties encountered by female practitioners of fitting into a male-dominated Army hospital, as well as the treatment of shell-shocked soldiers.⁹⁷

Many histories of occupational therapy written by practitioners appear in the professional journals,⁹⁸ or in chapters devoted to the profession’s history in occupational therapy textbooks.⁹⁹ The annual Elizabeth Casson Memorial Lectures, given at the Annual Conference and Exhibition of the College of Occupational Therapists in England, the Eleanor Clarke Slagle Lectures in the USA and the Doris Sym Memorial Lecture in Scotland have frequently been devoted to historical reflection.¹⁰⁰ Professional anniversaries have also afforded opportunities to look back.¹⁰¹ A number of themes emerge from this literature, including the use of arts and crafts in the early days of the profession and how that impacted on the subsequent reputation of occupational therapy; the “identity crisis” that seems to have plagued the profession in the second half of the twentieth century; and occupational therapy’s struggle to be seen as scientific. It is argued in this study that the rejection of occupational therapy by French psychiatrists during the interwar period was linked to a perceived need to demonstrate their scientific credentials (addressed in Chap. 6). They sought to do this by focusing on biological remedies for the curable and dismissed occupational therapy as unscientific.

Clare Hocking explores the philosophical foundations of occupational therapy in rationalism and Romanticism. In a series of three articles, she argues that an individual’s sense of themselves is expressed through the items they own and use, an idea that strongly influenced the interwar pioneers of occupational therapy in England.¹⁰² Hocking also examines how early British occupational therapists perceived themselves and their practice, focusing in particular on their use of craft activities and how to demonstrate the efficacy of their methods.¹⁰³ Ann Wilcock and Beryl Steeden examine the influence of the Arts and Crafts Movement on the profession of occupational therapy. They emphasise the importance of creativity to health and wellbeing, and to fulfilling people’s potential for “doing, being and becoming”.¹⁰⁴ Exploring the same topic, Ruth Ellen Levine considers the similarities between the beliefs of the founders of occupational therapy in the USA and advocates of the Arts and Crafts Movement. Both, she argues, expressed contempt for mass-produced goods, and lauded the almost spiritual sense of satisfaction and the calming effects of making items by hand. This preoccupation with the spiritual made the occupational therapists vulnerable to criticism when required to explain the value of their activities to medical practitioners.¹⁰⁵ Kathlyn Reed also delves into the history of the profession and regards the Arts and Crafts Movement as a “means of revitalising the ideas of moral treatment in a new rationale”.¹⁰⁶ The close links between moral treatment and occupational therapy are highlighted in this study.

The history of the profession is frequently used in attempts to identify occupational therapy’s core beliefs or philosophy. Hélène Polatajko looks back to 1933, when the first issue of the Canadian Journal of Occupational Therapy was published, during the Great Depression.¹⁰⁷ The lead article lamented the “disease of unemployment” and the need to “remedy human dissatisfaction and mental unrest” by providing tasks to keep minds occupied and bodies healthy. Providing occupation has been at the core of occupational therapy since its beginnings, although the rationale for its provision has changed over time. Polatajko claims that occupation has been variously conceived as diversion, therapy, rehabilitation and re-education, all of which are apparent in this present study. Polatajko does not mention the economic benefits of patient occupation for institutions.

Robert K. Bing used his Eleanor Clarke Slagle lectureship in 1981 to draw lessons from the past, such as treating the individual holistically.¹⁰⁸ He traces the roots of occupational therapy back to the moral therapy of Tuke and Pinel. He highlights the “disappearance” of moral treatment in the late nineteenth century, and its re-emergence and development in the early twentieth as occupational therapy, led by the American pioneers, including Adolf Meyer and Eleanor Clarke Slagle (1870–1942). Bing then discusses the contribution of “second generation” occupational therapists in elaborating, codifying and applying the initial theory in the late 1920s and 1930s.¹⁰⁹ Kathlyn Reed also highlights the philosophy of occupational therapy and finds that the philosophical beliefs of one of the profession’s founders, Eleanor Clarke Slagle, are still relevant to the profession today (in 2019). These included the belief that, through individualised activity programmes, occupational therapy could help people with mental health issues to change their habits and routines to improve their ability to integrate socially and function in society.¹¹⁰ Reed’s analysis of the core beliefs underpinning occupational therapy could equally apply to those of the moral therapists, as this study demonstrates.

French histories of occupational therapy, or ergothérapie, are more recent, which is unsurprising given that the profession in France is some 30 years younger than it is in the UK. M.C. Morel-Bracq et al. discuss the conceptual paradigms that underpinned the French profession of occupational therapy at various stages of its development, observing the parallels between the holism of the early French occupational therapists and that of the moral therapists.¹¹¹ This view supports the thesis presented in this study, which links holism within psychiatry as a pre-requisite to the adoption of occupational therapy. Lisbeth Charret and Sarah Thiébaut Samson also emphasise the holism of French occupational therapy in the late 1940s.¹¹² However, they also highlight the fact that by the time that French schools of occupational therapy were established in the mid-1950s, the prevailing conceptual paradigm had become biomedical (as it had been in the 1920s and 1930s), supporting the belief that human beings were an agglomeration of disparate structures and functions.¹¹³ Only in the 1980s, Charret and Samson argue, did occupational therapy begin to reunite biological, psychological and social factors, and to consider all the needs of an individual trying to live in and interact with their environment.¹¹⁴

Jean-Pierre Goubert and Rémi Remondière situate the origins of occupational therapy in the recommendation of work for patients by Pinel, Esquirol and Jean-Baptiste-Maximien Parchappe (who was impressed by the work undertaken by patients in British asylums), and in the French asylum legislation of 1839 and 1857.¹¹⁵ The authors also emphasise the influence of gymnastics, introduced into French schools in the 1850s, citing the benefits to the brain of making muscles move. Goubert and Remondière note that the vocational training offered by American occupational therapists in World War I acted as a stimulus to the profession of physiotherapy, while occupational therapy did not develop in France until after World War II.¹¹⁶ Gabriel Gable examines the history of occupational therapy from 1900, when it was first conceived in the USA, citing the influence of psychiatrists John Hall, Adolph Meyer and William Rush Dunton and others including Eleanor Clarke Slagle, Susan Tracy and George Edward Barton. ¹¹⁷ Like Goubert and Remondière, Gable emphasises the role of American occupational therapists in returning physical function to injured soldiers in Paris during World War I. The interwar period did not see the development of the profession in France; this occurred after the re-assessment of psychiatry following World War II and the exposure of abuses in French asylums during the conflict.¹¹⁸

Most of the French histories of occupational therapy address the American influence on the origins of the profession, while few mention the contribution of the German psychiatrist, Hermann Simon (1867–1947). Isabelle Pibarot is an exception.¹¹⁹ In her account, she links moral therapist Philippe Pinel’s theories to the methods advocated in works by chief medical officer Charles Ladame (1908 and 1926) and German psychiatrist Hermann Simon (1929).¹²⁰ Pibarot quotes the Spanish psychiatrist François Tosquelles (1912–1994), who sought refuge in France during the Spanish Civil War (1936–1939). Tosquelles, a keen advocate of French psychiatric reform after World War II, praised Hermann Simon’s methods in his influential book of 1967.¹²¹ Both Pibarot and Tosquelles see Simon as a key figure in the development of the therapeutic use of occupation and of the profession of occupational therapy.

Studies of occupational therapy by historians include those by Mark Jackson and John Hall. Jackson focuses on the links between prevailing attitudes towards work, leisure, unemployment and poverty on occupational therapy, with particular reference to an institution for children and adults with learning difficulties (the Sandlebridge Colony). He argues that it is the strength of the ideological and pragmatic links between therapy, health and work, rather than a rigid biomedical explanation of disease, that has constituted the basis for the professional expertise of occupational therapists.¹²² This view resonates with the argument presented in this book that support for occupational therapy by English psychiatrists depended upon their adoption of a holistic approach to mental disorder after World War I. In France (outside Paris), a biomedical conception of mental disorder remained firmly in place and psychiatrists were unwilling to adopt a therapy based on a broader conception of mental disorder.

John Hall, a historian and clinical psychologist, focuses on the administrative frameworks that underpinned development of the profession of occupational therapy in the UK from the end of World War I.¹²³ Hall highlights the foundation of the first school of occupational therapy in England in 1930 and the formation of the Association of Occupational Therapists in 1936. His account, which extends to 1959, identifies the shift from the early hospital-based provision of occupational therapy, with its focus on arts and crafts, to the incorporation of more rehabilitative activities after World War II that were designed to prepare patients for life in the community. Hall’s account emphasises the influence of the American style of occupational therapy on British practice that led to the focus on arts and crafts, as opposed to the work practices that characterised European asylum regimes. Hall’s observation corroborates the findings of this study in its comparison of occupation in England and France.

Class, Gender and Patient Work

Another important theme in this study is how class and gender influenced the type of work allocated to patients. As Joan Busfield has emphasised, class and gender are “embedded” in psychiatry, impacting on both aetiology and treatment, and thus on patient occupation.¹²⁴ She maintains that psychiatric practice cannot avoid “reflecting, incorporating, reproducing and sustaining class and gender divisions”, since the aim of psychiatry was to return individuals to their place in society.¹²⁵ Busfield’s observations are corroborated by studies focusing on the nineteenth century. In the early Victorian period, as Levine-Clark maintains, poor women were expected to work to stave off pauperism, and the work ascribed to male and female patients at Yorkshire’s West Riding Asylum reflected the “expectation of society that work itself was gender- as well as class-specific”. ¹²⁶ In the late Victorian and early Edwardian era, normative concepts of masculinity and femininity remained very rigid, as Louise Hide observes. Patients at the Bexley and Claybury asylums were allocated work suitable for their sex and class, skills, previous occupation and physical and mental abilities.¹²⁷ Women were assigned work that reflected their domestic duties, while men were employed in more varied productive roles in the grounds or workshops, or on the farm. At the private Holloway Asylum, entertainment and “genteel occupations” were considered more in keeping with middle-class life than physical exertion through work.¹²⁸ Hide notes that, although they were encouraged to do so, few private patients at Bexley or Claybury worked.¹²⁹ These observations of the period before World War I raise the question of whether such rigid gender and class divides were still apparent in interwar mental hospitals, after so many Victorian “social norms” were allegedly swept away by the war.

Diana Gittins’ study of Severalls Hospital includes the interwar period and suggests that narrowly defined concepts of class and gender still governed the assignation of patient work. Long-stay female patients with “no, or few, obvious disorders” were employed in the laundry and sewing room, while those more prone to violence or disruption worked in the ward or scrubbed corridor floors.¹³⁰ Understaffing meant that many female patients requiring supervision had nothing to do.¹³¹ There was a much wider variety of occupations available to male patients, with work in the workshops, on the farm, in the gardens, or in the smithy.¹³² Gittins pays scant attention to the introduction of occupational therapy during the interwar period, although she notes that a small department was established at Severalls in 1922 and nurses were encouraged to take up a handicraft.¹³³ More attention is paid to occupational therapy in the 1960s, by which time the department had expanded considerably but still reflected “a rigid and Victorian stereotype of gender”.¹³⁴ The present study reveals that the traditional asylums tended to be more conservative regarding what was considered appropriate work for women and men than the more recently established hospitals, such as the Maudsley and Henri Rousselle hospitals.

The Patient’s View

Recent research in the history of psychiatry has been able to reveal the views and actions of patients, using letters, notes, poems, art, journals and other written items produced by patients and included in their medical records as evidence of their condition.¹³⁵ Allan Beveridge’s study (1998) of over a thousand letters written by patients admitted to the Royal Edinburgh Asylum between 1873 and 1908 reveal the patients’ frustration and dissatisfaction with institutional life.¹³⁶ Frequent complaints included the monotony of the daily routine, the brutality of the attendants, the behaviour of other inmates, and the prison-like characteristics.¹³⁷ Beveridge notes that the majority of the letters were written by upper-class patients who were not obliged to work, but in one letter a pauper patient complained that, “I’ve knitted stockings for the High persons and done seawing to [sic] … and got no thanks for it”, providing a rare glimpse of attitudes towards work.¹³⁸ In a volume dedicated to the voices of the mad and their carers,¹³⁹ Rory du Plessis uses correspondence and casebooks to create a portrait of patient life in a South African mental institution between 1890 and 1910.¹⁴⁰ His account reveals evidence of racial discrimination, poor diet, a regimen of physical labour disguised as therapy and such personal indignities as a denial of clothing.¹⁴¹ Violence and threats of violence by asylum staff are revealed in Tomas Vaiseta’s account of the lives of mental patients in twentieth-century Lithuania. Patients’ letters described not only brutal treatment, but also their struggle to be seen as individuals.¹⁴²

Using similar sources, Monika Ankele highlights the attitudes of patients towards work therapy at the Hamburg-Langenhorn asylum, Germany, during the Weimar Republic.¹⁴³ Patients complained that they were not paid for their work in the institution, and felt that they should not have to work because they were ill.¹⁴⁴ They asked why they had not been released, since, if they were expected to work inside the asylum, they could also work outside.¹⁴⁵ Whilst patients were not paid, their food rations were linked to the amount and type of work they performed, with certain jobs that were considered more useful to the asylum attracting larger quantities of food. Hard-working patients could also be awarded privileges, such as tobacco or the opportunity to walk in the gardens.¹⁴⁶ Studies by Lee-Ann Monk and Geoffrey Reaume also address the issue of payment for work carried out by patients. Reaume highlights the unpaid labour of patients who constructed the boundary wall round the Toronto Asylum in the late nineteenth century. The architect of the wall, Kivas Tully, was commemorated in the 1970s, but the unpaid patients who constructed it were not.¹⁴⁷ At Kew Cottages, an institution for people with learning disabilities in Australia, patients worked in the workshops, grounds and kitchens and some helped nurse other patients. They were not paid and working conditions were often unsafe, leading to accusations of exploitation.¹⁴⁸ The present study reveals different patient reimbursement policies in French and English institutions. As Reaume has emphasised, the non-payment of patients, or the very low wages, could be explained or excused by referring to the work as therapy.¹⁴⁹

Although patients at the Hamburg-Langenhorn asylum had little choice over whether they worked, they could control how much effort to put into the work, and in some cases, they could influence the type of work they did. Ankele cites the example of a shoemaker who asked to be transferred to a ward where he could work in the cobbler’s workshop, thus enabling him to maintain his skills and his professional identity at the same time as repairing numerous shoes for the institution.¹⁵⁰ At Kew Cottages, the medical superintendent responded to criticism by maintaining that the work carried out by patients was voluntary and never imposed. But, as Monk highlights, patients were committed to the institution by law and had little power to negotiate, compared to the institution’s paid staff or workers outside. Some patients refused to work, although the consequences of refusal are unclear.¹⁵¹

The patient’s role as an actor—rather than as a passive recipient of care—is the focus of several recent studies. Scull (2006), Forsythe (1996), Wright (1998), Walsh (1999) and Michael (2003) dismiss the notion that patients and their families should be regarded as “submissive pawns” pushed about by officials, regarding them instead as active users and manipulators of the asylum system for their own ends.¹⁵² In Australia and New Zealand during the late nineteenth and early twentieth centuries, families actively negotiated asylum care for their insane relatives, and regularly came to the asylum to check on patients’ progress, treatment and welfare, as Catharine Coleborne observes.¹⁵³ In France, Patricia Prestwich notes that, following revision of the admissions procedure to mental asylums in the Seine department in 1876, some families began to take their insane relatives directly to the asylum to avoid the complicated, degrading and often traumatic committal system.¹⁵⁴ She claims that the new procedure shifted the balance of power between the family of these patients (although not the patients themselves) and the asylum.¹⁵⁵

During the Great Depression of the 1930s, as this study reveals, some Parisian families chose to leave their relatives in the asylum despite their having been pronounced ready for discharge, to save on the costs of looking after them in the uncertain economic climate. Some Parisian psychiatrists actively sought to retain certain patients, knowing that they were unlikely to find work outside the asylum and that this could cause a return of their symptoms. One of the roles of the psychiatric social worker, employed by the metropolitan hospitals during the latter part of the interwar period, was to help patients find work after discharge. The high unemployment rate during the Depression was a recurring topic of communication between doctors, patients and family members at the Hamburg-Langenhorn asylum. Numerous patient letters contained requests to remain at the asylum. As Ankele highlights, for many patients and their families the asylum was not just a place of “control, expropriation, authoritarianism and confinement”; it was also perceived as a place of refuge in difficult circumstances, offering security, food, shelter and a sense of belonging.¹⁵⁶

Two patients, one British and one American, whose experiences of asylum life were very negative used their voices to effect change. John Perceval (1806–1876), the son of a British prime minister, and Clifford W. Beers (1876–1943), a Harvard law graduate, both wrote autobiographical accounts of their mental breakdown and treatment. As Richard Hunter observes, published autobiographies by mental patients are rare, in part because few individuals wish to relive their experiences, and in part because they lack the ability to describe their ordeal in an “organised, readable form”.¹⁵⁷ Perceval wrote of his experiences at two private asylums in Bristol and Sussex between 1830 and 1832, and Beers completed a book about his own mental breakdown and subsequent hospitalisation at three different institutions in the USA between 1900 and 1905.¹⁵⁸ Both men claimed to have suffered abuses and harsh treatment, both resisted such abuses, and both successfully campaigned to improve conditions for other sufferers of mental disorder. Perceval’s period of institutional confinement occurred just before the system of non-restraint was introduced; he endured weeks of being restrained in a strait-waistcoat fixed to a chair by day and secured to his bed at night.¹⁵⁹ Perceval helped found the Alleged Lunatics’ Friend Society and was active in forcing the appointment of a Select Committee tasked with enquiring into the care and treatment of “lunatics”.¹⁶⁰

Clifford Beers’ account is particularly relevant to this study as it led Beers to collaborate with psychiatrist Adolf Meyer and psychologist William James (1842–1910) to found the National Committee for Mental Hygiene in 1909 in the USA. Beers’ book also captured the attention of French psychiatrist Édouard Toulouse, leading to an influential and close personal friendship between the two men.¹⁶¹ Toulouse established the French League of Mental Hygiene in 1921. While Beers’ original plan was to use his book to campaign for the improvement of hospital conditions for the mentally ill, Meyer persuaded him to broaden his remit to include promoting awareness of how to maintain mental health and to prevent the onset of mental disorder, in addition to improving hospital conditions. Meyer coined the phrase “mental hygiene”.¹⁶² The book itself caused a great stir in the contemporary press and whilst Beers’ account was sensationalised by some newspapers, it served to draw attention to the “broad clinical picture” of the pre-war era.¹⁶³ Beers spoke of the crude, often cruel, behaviour of the attendants who showed no sympathy for his condition; the indignity of mechanical restraint; the frustration of the enforced rest-cure; the brutal attempts at force-feeding; the violence exhibited by other patients, attendants and even the medical staff; and the misery of seclusion. Beers does not mention any form of work or therapeutic occupation in his book, although at one of the institutions where he stayed, the Hartford Retreat, there were amusements such as games, reading material (nonfiction only), a piano and the occasional dance.¹⁶⁴ As Norman Dain observes, during the early 1900s there were “no individualised programs to engage patients’ interests and energies” and no other successful treatments had been identified.¹⁶⁵ Beers’ claims regarding his treatment (nearly all of which have been verified by other sources) underscore the deterioration of the early nineteenth-century practices associated with moral treatment, as well as emphasising the difference in approach by psychiatrists such as Meyer.

Aims and Scope

This book compares approaches to patient occupation in France and England, approaches that remained similar during the nineteenth and early twentieth centuries, and then diverged after World War I. As such, it adds to the genre of comparative and transnational histories of psychiatry, such as those featured in edited works by Marijke Gijswijt-Hofstra and Harry Oosterhuis, Olé Peter Grell and Andrew Cunningham; Waltraud Ernst and Thomas Mueller; and Louise Westwood, Volker Roelcke and Paul Weindling.¹⁶⁶ These works demonstrate how modern psychiatry developed as a result of the constant transfer of ideas, perceptions and personnel across national borders. The present study shows how new ideas concerning occupational therapy were transferred from the USA and Germany to England and France but were received very differently in these countries. The book analyses the medical, socio-economic, cultural and legislative factors that caused this divergence. The comparison of patient occupation in England and France highlights the different professional trajectories of English and French psychiatry that led to contrasting understandings of mental disorder during the interwar period.

What is lacking from this study is the views of the patients themselves. Clearly, their opinions on work and occupational therapy would offer valuable insights, since as Roy Porter reminded us nearly forty years ago, histories of medicine should not be written solely from the physicians’ perspective.¹⁶⁷ However, without access to individual patient’s medical records, to which letters, notes and journals are sometimes appended, the voices of patients have remained silent in this study.¹⁶⁸ But as Isabelle von Bueltzingsloewen maintains, it is possible to create a “history from below” using asylum records alongside official sources. ¹⁶⁹ The present study provides a sense of what life was like for patients—such as the daily routines, the asylum environment and living conditions, the type of treatments prescribed, and the attitudes of staff—but does not reveal what patients actually felt about the occupations that were (or were not) allocated to them.

The origins of therapeutic work in the moral treatment of the early nineteenth century, and the waning of its popularity and perceived effectiveness as a cure by the end of the century are analysed in Chap. 2. Patient work was used very similarly by French and English psychiatrists between the early 1800s and the outbreak of World War I. In both countries, what began as a psychological treatment, carefully selected to suit individual patients, evolved into a bureaucratic system that commodified patient labour to suit institutional requirements. The changing perceptions of mental illness following World War I are the focus of analysis in Chap. 3. The reasons for the shift of psychiatric opinion from the organicist or physiological interpretation of mental disorder, that characterised late nineteenth-century psychiatric thinking in both England and France, to a psychosocial understanding of mental disorder that occurred in England and Paris, but not in provincial France, are explored. This ideological shift influenced the nature of occupation offered to patients, encouraging the adoption of occupational therapy. In institutions where a custodial model of care, and an organicist interpretation of mental disorder prevailed, patient occupation continued much as it had done before World War I. The differences and similarities between the new methods of therapeutic occupation that emerged in Germany and the USA before World War I; patient work at the end of the nineteenth century; and occupation in the context of moral treatment, are assessed in Chap. 4.

Chapter 5 addresses the deleterious effects of World War I on the respective economies of England and France, and thus on asylum budgets. Tensions between the important economic role played by patient work, particularly in such straitened times, and the prescription of work or occupation as therapy are analysed. These tensions could be exacerbated by the different management structures in the French and English asylum systems. The issue of medical or administrative authority became key in decisions regarding how patients were occupied. The place of entertainments, which represented a cost to the asylum, could also be contested area. The role of the medical superintendent and chief medical officer, as the doctors who prescribed patient work and occupational therapy, is discussed in Chap. 6. Their therapeutic preferences, and the ideology that underpinned these preferences, were key to the type of occupations they prescribed, or indeed whether patients were occupied at all. The doctors’ preferences were framed by the availability of effective remedies. In the 1920s these were minimal, but the late 1930s saw the introduction of shock therapies and psycho-surgery. As this chapter demonstrates, the French and English psychiatrists in charge of the hospitals in this study evaluated these various treatments, and their relative importance compared to occupation, differently. The psychiatrists who prescribed occupation spent very little time with patients, particularly in the provincial institutions where one psychiatrist was responsible for several hundred patients. The staff spending the most time with patients were the nurses, occupational therapists and workshop managers, whose supervision of the occupation prescribed by the doctors is the subject of Chap. 7. Analysis of staff competence, training, their commitment to the role, and the staff-to-patient ratios reveal marked differences between rural and metropolitan institutions as well as between French and English establishments.

The influence of a patient’s mental condition, physical health, age, and class and gender on the occupation allocated to them in French and English institutions is investigated in Chap. 8. A patient’s assumed curability or incurability, and the stage of their illness, affected whether they were prescribed occupation, and of what type. While the opinions of patients on work and occupation cannot be gleaned, this chapter gives an indication of their experiences of life in French and English institutions. The question of whether patients were being “moulded into productive citizens” is addressed in Chap. 9. Was this facilitated by the occupation prescribed to patients in the institution? Did the occupations inside reflect the types of work available outside it? The preparedness of patients in the metropolitan and rural institutions studied, for the new industries and the modern methods of production introduced in the interwar period, is discussed. Did occupational therapy, with its focus on arts and crafts, provide appropriate rehabilitation for a patient hoping to find work in an automobile factory? The issue of support for discharged patients, both charitable and state-funded, is also addressed in Chap. 9, which highlights differences in the availability of assistance both between England and France, and between rural and metropolitan areas.

The overall thesis of the book, drawn to a conclusion in Chap. 10, is that the nature of occupation prescribed to patients tells us so much more than simply how patients were occupied. The deployment of patient work highlights the financial situation in different institutions, revealing how some were more reliant on its economic contribution than others. It informs about the management structures inherent in different national institutions and how these could impact on the types of therapy prescribed, and about the multiplicity of factors involved in decisions to accept or reject ideas coming from overseas. The numbers of patients involved in work in different institutions suggested variations in the class, gender, age, physical fitness and severity of the mental disorder of patients. The type of occupation allocated to patients was also a matter of the personal preference of psychiatrists, reflecting their training and professional backgrounds. Whether occupation was prescribed at all is indicative of the level of competence of nursing staff and the existence of professional occupational therapists. The extent to which patients were prepared for the labour market in their locality raised questions about the about the rehabilitative value of patient work, and whether this was regarded as important by psychiatrists. But most crucially, patient occupation is indicative of levels of professionalisation within psychiatry, of attitudes towards the curability of mental disorder and its interpretation as an organic disease or a problem of adaptation to an individual’s social environment. In the early days of moral treatment, the topic of Chap. 2, patients were encouraged to adapt their behaviour to enable them to integrate with society and earn their living. Such aims would re-emerge a century later.