Keywords

Occupation has been a feature of asylum or mental hospital regimes since the early nineteenth century. The rationales for its prescription to patients have varied in time and space, but occupation itself has been a constant. The comparison of patient occupation in French and English institutions during the interwar period has revealed very different attitudes towards the therapeutic value of occupation not only between the two countries, but also between metropolitan and provincial institutions. In addition, the value attributed to therapeutic occupation in France and England has shone a light on the different perceptions of mental disorder held by psychiatrists, and the different models of care associated with each, in the two countries at that time. Comparing how patients were occupied has also highlighted the varied influences at play, such as attitudes towards labour, poverty and welfare, national competitiveness, professional pride, and the effects of war on both the psyche and the economy. The comparison accentuates the importance of personal relationships, professional networks, and the beliefs, training and aptitudes of those prescribing and supervising patient occupation. It draws attention to the different levels of resources available to metropolitan and rural institutions and the effect this had on the adoption of innovations in treatment. It has demonstrated that medical theories do not necessarily develop in a linear direction and that treatment methods discarded decades previously can be re-imagined and brought back into use.

Belief in the curative potential of occupation followed the acceptance and rejection of psychological interpretations of mental disorder. As this study has demonstrated, psychiatry has been torn between by two different and competing explanatory models, one focusing on the mind (the psychological model) and one on the body (the somatic or organicist model) throughout the nineteenth and early twentieth centuries. The Anglo-French moral therapists understood mental disorder in terms of the mind. For them, occupation in the form of work and recreational activities was curative. The moral therapists believed that taking a patient away from their usual environment, engaging them in a regular daily routine and providing carefully selected activities that distracted their minds and tired their bodies, would lead to a recovery. As the psychological model lost favour in the mid-nineteenth century, and the organicist model gained primacy, psychiatrists lost faith in the ability of occupation to “cure” mental disorder. Their efforts were focused on finding a somatic explanation and a biological cure for mental disease. Patient work had become an established part of the asylum regime by this time. It had proved to be a useful means of managing the now large numbers of patients packed into the public asylums and of off-setting institutional running costs. Occupation was still considered beneficial for patients, but not curative. Individually designed and supervised work programmes were replaced by a routinised bureaucratic system of work allocation that catered as much for the needs of the institution as the patient. Work was no longer considered suitable for acute-stage patients, and was restricted to calm, chronic and incurable cases and convalescent patients who required little supervision. The records indicate that between 30% and 55% of French and English patients worked as cleaners, or on the asylum farm, or in the grounds, workshops, laundry, and kitchen. The work was described as “mere drudgery” by psychiatrist David Henderson. Patient work continued to be organised in much the same way in France and England until the outbreak of war in 1914.

Acceptance of a “psychobiological” approach, which framed mental illness as a failure of adaptation to the human environment, led psychiatrists to regard mental disorders as “correctible maladjustments”, rather than incurable diseases.Footnote 1 This approach restored psychiatrists’ faith in the curative powers of occupation. Psychobiological theory was advanced by the influential American psychiatrist Adolf Meyer and informed the principles of the Mental Hygiene Movement (co-founded by Meyer). It struck a chord amongst progressive English psychiatrists, and a small group of Parisian psychiatrists, after World War I. These psychiatrists, who returned to the idea that mental disorder could have a psycho-social origin, sought to “re-educate” their patients to help them adapt more effectively to their environment. Their methods included psychotherapy and occupation. The (allegedly) new ideas regarding occupational therapy that emerged just before and during World War I in Germany and the USA therefore fell on fertile ground amongst these psychiatrists.

The transfer of these new ideas concerning occupational therapy demonstrates the importance of international personal connections and of the role played by political and scientific rivalries between nations. Clifford Beers’ autobiographical account of his experiences led to a personal friendship developing between American former patient Beers and French psychiatrist Édouard Toulouse, and to Toulouse’s introduction to the Mental Hygiene Movement. The personal connections developed between the co-founder of the Mental Hygiene Movement, Adolf Meyer, and the young British doctors who worked with him in Baltimore during their training, both before and after World War I, were responsible for the transfer of American theories of occupational therapy to Britain. Scottish psychiatrist David Henderson’s enthusiasm for the American style of occupational therapy inspired his English colleagues, as did study visits to asylums at Gutersloh and Santpoort organised by the Royal Medico-Psychological Association in the late 1920s and early 1930s to see Hermann Simon’s more active therapy in action. The latter also impressed a small group of French psychiatrists who visited Santpoort, but their positive reaction was not shared by their colleagues. The reception of German ideas in France was fraught with on-going feelings of revanchisme following defeat of France by Germany in the Franco-Prussian War of 1870–1871 and by the devastation of French territory caused by German forces during World War I. There was also resentment regarding the German usurpation of France’s pole position in the ranks of continental psychiatry. Promotion of Hermann Simon’s methods in France fell on deaf ears. “Traditional hostility towards anything German” felt by the French goes some way to explaining this, but another major factor was the on-going organicism of most French psychiatrists.Footnote 2

In France, most psychiatrists outside Paris rejected the psychobiological approach and remained wedded to the somatic model. This insistence on the exclusively physiological nature of mental disorder is explained by the way psychiatry had developed as a profession in France. French psychiatry had always been closely aligned with neurology, which enjoyed a high profile and great respect within medical circles. While in England, neurologists did not have much involvement in asylum medicine, in France, the opposite applied. Psychiatry had yet to develop independently of neurology and many chief medical officers of asylums were neurologists, who saw mental disorder solely in terms of physiology, and sought biological methods of treating it. They were sceptical about treatment methods that could be perceived as “unscientific” by their medical colleagues. Biological and physical treatments, that were being used with increasing success in other areas of medicine, were more likely to enhance the psychiatrists’ scientific credentials and professional standing. The biological treatment of acute patients was preferred by the chief medical officers at the Asile Clinique and Asile de la Sarthe. Here, only chronic, incurable and convalescent patients were given work, the nature of which was unchanged since the late nineteenth century.

The profession of psychiatry in England had evolved rather differently, becoming an independent discipline far sooner than in France. This allowed English psychiatrists to break free of the rigidly organicist interpretation of mental disorder far more readily than their French colleagues. The theories of Freud, Janet and James were known—although not widely circulated—by English psychiatrists before World War I. This knowledge was crucial to the development of psychological treatments for the huge number of soldiers suffering from war neuroses during the conflict. The efficacy of these psychological methods broadened English psychiatrists’ understanding of mental disorder and paved the way for acceptance of the psychobiological approach developed by Meyer. The French response to war neuroses relied on neurological methods of treatment since most psychiatrists were trained neurologists. The French experience of war neuroses reinforced, rather than challenged, organicist thinking and led to the divergence between French and English approaches to psychiatry during the interwar period. This divergence was highlighted by the acceptance of new thinking about the curative use of occupation in England, and its rejection in most of France.

Paris proved an exception to this rule. The Parisian psychiatrist Édouard Toulouse denounced the rigid organicism of his French colleagues and developed his own version of psychobiology, which he called la biocratie. Toulouse supported the preventative agenda of the Mental Hygiene Movement and founded the French League of Mental Hygiene in 1920. Toulouse, an active socialist, was convinced that mental disorder was often linked to poverty and the psychological stress caused by deprivation. His acceptance of psychosocial factors as potential causes of mental disorder put him at odds with French psychiatrists outside the capital and many within it. The Asile Clinique, for example, continued to be led by neurologically oriented psychiatrists, although younger members of staff who joined in the 1930s, such as Jacques Lacan (1901–1981), were more psychologically inclined. In contrast to the mainly biological treatments dispensed at the Asile Clinique, the Henri Rousselle Hospital established by Toulouse, offered psychotherapy and occupational therapy including art classes. All patients were encouraged to keep busy at the Henri Rousselle, but work was voluntary and was not evaluated in the same way as at the Asile Clinique or the Asile de la Sarthe, where the financial contribution made by patient labour was calculated and appeared in the asylum accounts. Toulouse’s attitude to occupation marked a departure from the late nineteenth-century asylum system of patient work that remained in place in provincial asylums and highlighted the difference in his overall approach to mental disorder. The Henri Rousselle Hospital had much more in common with London’s Maudsley Hospital, where psychotherapy and occupational therapy were also offered, than with other establishments in France.

Both the Maudsley and the Henri Rousselle were unique in their respective countries in providing a combination of voluntary admission, both inpatient and outpatient facilities, research laboratories and psychiatric social services, and for their focus on acute, incipient cases of mental disorder. These public hospitals represented a new model of care, based on that of the general hospital and informed by the principles of the Mental Hygiene Movement. Inpatients were admitted voluntarily, enabling them to avoid the often-lengthy process of certification and to start active treatment at the onset of their symptoms. Outpatient clinics allowed patients to seek treatment without ever being admitted to a mental institution, or to continue their treatment after discharge. Patients could carry on with their regular lives and work whilst still receiving treatment. The employment of professional psychiatric social workers gradually began to replace an uneven patchwork of voluntary service provision in England, while in France the concept was quite new. As well as providing vital information to psychiatrists about their patients’ domestic situation, the psychiatric social worker helped patients adjust to life outside hospital, and assisted with finding employment, training, or access to welfare support. The care at the Maudsley and Henri Rousselle was considered “state of the art” and it is noteworthy that the active treatment recommended for acute patients included occupational therapy. Occupational therapy had become the hallmark of a modern hospital.

The Board of Control chastised Bethlem for its lack of occupational therapy provision, maintaining that Bethlem did not deserve its reputation as a progressive institution without making occupational therapy available to patients. The delay in establishing an occupational therapy department was in part due to the enduring organicism of Bethlem’s physician superintendent, John Porter-Phillips, who remained committed to identifying the physical causes of mental disorder. Occupational therapy was eventually provided at Bethlem in 1932 following complaints of boredom by patients.Footnote 3 Porter-Phillips’ conservatism was in marked contrast to the progressive views of Thomas Saxty Good of the Littlemore Hospital. Good, who became convinced of the efficacy of psychotherapy during World War I while treating soldiers suffering from war neuroses, was an early adopter of occupational therapy. He rarely prescribed sedative drugs, while these were routinely used at Bethlem. Good’s patients were trusted to take trips into the village or into Oxford for shopping, and to wander freely in the grounds. Very few of the Littlemore wards were locked, a measure applauded by the Board of Control. This “open door” policy represented a significant step towards the opening up of asylums that followed the Mental Treatment Act of 1930. Such measures were unknown in provincial France where asylums remained “closed” institutions. At the Asile de la Sarthe security was tight and work in the open air was limited for fear that patients might escape. Neither psychotherapy nor occupational therapy were offered at the Asile de la Sarthe. Chief medical officer Henry Christy’s self-professed enthusiasm for neuropsychiatry and biological methods of treatment for acute patients meant that work remained confined to the chronic, incurable and convalescent patients. The preferences of the individuals in charge of mental hospitals were thus of fundamental importance to the nature of treatment provided. Even within hospitals, there could be differences of approach. At the Maudsley, for example, Edward Mapother’s foremost concern was that psychiatry should “do no harm”. He responded far more cautiously to the emergence of the shock treatments than some of his colleagues, such as Eliot Slater.Footnote 4

As well as support from those in charge of mental hospitals, the successful adoption of occupational therapy depended upon well-trained, dedicated nursing staff or occupational therapists. As Good remarked, “the greatest essential to any hospital’s success is the human element, i.e. the staff and the way it fits in and pulls together”.Footnote 5 Hermann Simon’s more active therapy (MAT) required a cultural change within the hospital and the involvement and support of all members of staff. Nurses played an essential role in supervising patients in their various tasks; they needed to be well trained and fully committed. The American style of occupational therapy required practitioners to have expert skills in arts and crafts. Mental nurse training was available nationwide in England, but in France its provision outside the capital was uneven. Even in Paris, mental nursing failed to attract high quality candidates. While pay and conditions were slightly better than those of provincial asylums, they compared unfavourably with other types of work available in the capital. Inadequate educational attainment (many French mental nurses were illiterate even in the 1930s) compromised the ability of nurses to take advantage of training. The few French psychiatrists who were in favour of occupational therapy, such as Paul Courbon, had little confidence in the ability of their nurses to deliver it.Footnote 6 In England, becoming qualified in mental nursing was not obligatory in most hospitals (although it was for senior staff at the Maudsley), but all hospitals provided training and encouraged nurses to sit the mental nursing examinations set by the Royal Medico-Psychological Association or the General Nursing Council.

At the Littlemore, nurses enhanced their mental nursing skills by spending three months training at the Radcliffe Infirmary, to gain experience of general nursing. Mental nurses were expected to learn a craft that they could then teach to patients, enabling them to deliver occupational therapy, thereby avoiding the expense of employing an occupational therapist. Good ensured that nurses were relieved of administrative duties so they could spend more time developing relationships with patients and engaging them in activities. The calibre of nurses at the Littlemore was very different to that of nurses at the Asile de la Sarthe. In Le Mans, male nurses had little experience of any form of nursing. Their ineptitude was a source of anxiety for the chief medical officer. Whilst the sisters who provided nursing care on the female side were diligent, the fact that nursing was still being delivered by nuns, so long after the secularisation of most public institutions in France, suggests that methods were old-fashioned. The delivery of occupational therapy by nursing staff therefore offers an insight into the different levels of professionalisation of mental nursing in France and England, and between metropolitan and provincial institutions.

As Good recognised, nurses played a crucial role in the happiness and general wellbeing of patients. Clifford Beers had experienced brutality and a total lack of empathy from his nurses in the 1900s. It can be assumed that where nurse training was prioritised, as at the Littlemore, the patient experience was far better than where nurses had only rudimentary skills and little interest in their work, as on the male side of the Asile de la Sarthe. The damning remarks made by Lomax had prompted an enquiry into nursing standards in England, and fed into the Macmillan Report of 1926, both of which helped to raise standards in England. The implementation of occupational therapy, whether based on Hermann Simon’s method or the American style, would have improved patients’ experience of work from the grim description given by Lomax, quoted at the beginning of this book. The individualised programmes of activity that characterised occupational therapy—where they were implemented—were a far cry from the conditions endured by Lomax’s “closet barrow gang”. For the French patients at the Asile de la Sarthe, however, the nature of work for the incurable and convalescent patients did not change a great deal. The lack of occupation for acute-stage patients here and at the Asile Clinique contrasts with the activities devised for patients at this early stage of their illness in English mental hospitals. In England, the middle-class patient’s experience of occupation at Bethlem, where sports and leisure activities, and arts and crafts in the occupational therapy department (from 1932) comprised the main forms of occupation, was very different from that of the private patient at the Asile de la Sarthe, where the only option was manual labour. The latter, of course, was considered unsuitable for the middle classes, and made occupation less accessible for them. Patients experienced occupation differently according to the rationale for its prescription.

The varied rationales for occupying patients have provided insights into the financial circumstances of institutions, national and local labour requirements, and attitudes towards individuals with different types of mental disorder. As we have seen, the economic rationale for patient work was bound up with the need for asylums to offset their running costs. Budgets were tight, particularly during the challenging economic climate of the interwar period. Employing patients to perform many of the tasks that would otherwise have incurred significant expense made financial sense, particularly since engaging patients in work could be justified as therapy. The necessity of using patient labour was particularly apparent in France, where plans to transform the Asile Clinique to a hospital for acute patients were delayed due to concerns regarding the loss of patient workers. Here, and even more so at the Asile de la Sarthe, patient work contributed significantly to the asylum budgets, both in terms of labour costs and in terms of the products made or grown by patients, throughout the interwar period. Pressure exerted by the asylum director to meet institutional labour requirements affected decision-making regarding the allocation of patient work. The asylum director’s role has been compared to that of a company Chief Executive Officer, managing the workforce to maximise profits.Footnote 7 It was for this reason that Édouard Toulouse was keen to become medical director of the Henri Rousselle Hospital (and not chief medical officer), as this dual role put him in charge of both administrative and medical matters.

The economic contribution of patient work was viewed positively by the French authorities who saw it as helping to reduce the burden on the public purse of caring for the mentally disordered. In English mental hospitals, on the other hand, the economic contribution made by occupation was downplayed. The emphasis here, expressly stated in the Macmillan Report of 1926, was on providing active treatment, including occupational therapy, for curable patients. The Board of Control’s Memorandum also spelled out that occupation was for the purpose of therapy and not for saving money on the production of commodities for the hospital. This was justified on the grounds that focusing on active therapy would enable curable patients to recover faster and to leave the hospital sooner, which would be cheaper in the long term. The attitude towards the work undertaken by incurable, or “mentally deficient” patients was quite different. The work carried out by incurable patients who remained in a mental hospital (as many did at the Littlemore), or who had been placed in specialist institutions, was supposed to make a financial contribution to institutional running costs. So, if a patient’s condition was curable, the rationale for occupation was therapy, while if incurable, the primary rationale was economic. Examined from this perspective, the rationale for work for incurable patients was similar in France and England.

A rehabilitative rationale for patient work was evident in the English asylum system in the early nineteenth century. Asylum work programmes, whilst modelled on the teaching of the moral therapists, were created in the context of debates concerning the Old Poor Law and its ability to provide for an ever-increasing number of paupers. An ethos of productivity and self-sufficiency, inherent in the New Poor Law of 1834, informed the asylum system. Medical superintendents like Sir William Charles Ellis were keen for patients to have a professional skill that they could use to secure employment after leaving the asylum. The jobs around the asylum, from shoemaking to gardening, were similar to the type of work that could be found outside the institution. In France too, where being a productive citizen was de rigueur after the Revolution of 1789, asylum work programmes reflected the work available in the community. Work and working practices in asylums failed to evolve with the changing profile of local and national industry. The type of work offered in mental institutions after World War I did not equip patients either for the emerging new industries, such as the manufacture of automobiles or electrical goods, nor for the modern working practices that were associated with them, such as assembly-line production. Occupational therapy, with its focus on arts and crafts, represented the antithesis of working practices in the modern factory associated with scientific labour management. This failure to provide vocational training, or work designed to replicate local labour market conditions, can be explained in terms of the emphasis on active therapy for curable patients. It was no longer incumbent upon mental hospitals to prepare patients for the workplace. The goal was to cure and expedite discharge. This was particularly true of the Maudsley and Henri Rousselle hospitals, which specialised in treating acute, curable patients and where support with finding employment was available from a psychiatric social worker. For incurable patients who were destined to remain in an institution for the rest of their lives, such as the majority of patients at the Asile de la Sarthe, the question of rehabilitation did not arise as they were unlikely to have to find work outside the asylum.

The need for occupation to fulfil a more rehabilitative remit in English mental institutions was expressed in the late 1950s as deinstitutionalisation loomed. During the interwar period, the main goal of occupational therapy had been to restore mental health, rather than to provide vocational training. As the locus of patient care began to shift from the hospital to the community after 1959, former in-patients were required to support themselves and needed the skills to do so. Despite the alleged potential of modern working practices to compromise mental health, “industrial therapy” (IT) was introduced in the late 1950s. Factory-style workshops were recreated in many mental hospitals, as Vicky Long has outlined, either in addition to, or in many cases, replacing occupational therapy workshops.Footnote 8 Work on the assembly line was monotonous, mundane and offered little satisfaction. It was “alienating” in the Marxist sense and could be psychologically damaging. While industrial therapy prepared patients for the working environments they were likely to encounter outside hospital, whether it could accurately be described as “therapy” is debatable. A therapeutic rationale for occupation had ceded “pole position” to a rehabilitative one in response to changing mental health policies rather than new psychiatric ideology.

As occupational therapy was being replaced by industrial therapy in many English mental hospitals in the 1950s, occupational therapy was emerging as a new profession in France. A major re-assessment of care for the mentally disordered took place after 1945, prompted by revelations of the neglect and ill-treatment of asylum patients during World War II.Footnote 9 The re-assessment led to the introduction of “institutional psychotherapy”, promoted by a group of young, militant psychiatrists known as L’information psychiatrique. This group included the influential post-war psychiatrist François Tosquelles, who was inspired by the work of both Sigmund Freud and Hermann Simon.Footnote 10 Institutional psychotherapy was based on a return to the founding principles of modern psychiatry, as laid down by moral therapist and creator of French asylum legislation, Jean-Étienne Dominique Esquirol, pupil of the revered Philippe Pinel.Footnote 11 This marked a renewed acceptance of a more psychological interpretation of mental disorder by French psychiatrists and an attempt to “rehumanise” psychiatry. Tosquelles sought to transform patient work from the way it was practised in most French asylums (which he regarded as having nothing to do with therapy) to occupational therapy. The latter became a key aspect of “institutional psychotherapy”. Occupational therapy services were provided by those who had trained in Anglo-Saxon schools until two French schools of occupational therapy were established in 1954, one in Paris and one in Nancy.Footnote 12 A national association of occupational therapy was created in 1961 and a diploma in 1970.Footnote 13

French psychiatry had operated in the shadow of neurology for so long that it had lost sight of the “mind”. Psychiatry’s return to the founding principles of the profession after World War II saw the “mind” return. As it did so, the benefits of using occupation therapeutically were re-evaluated and its curative potential recognised once more. A similar transformation occurred in English psychiatry after World War I, as psychobiology took the place of organicism, re-introducing the psychological perspective to psychiatry. In the wake of this ideological shift, occupational therapy replaced the routinised patient work of the late nineteenth century for curable patients. Occupational therapy was not really new, however. It was a re-imagined, more sophisticated version of moral treatment. It represented a return to prioritising a therapeutic agenda for patient occupation, whether this involved work around the hospital, or the production of arts and crafts. Its remit was formalised and professionalised, but the basic principles were the same as those of moral treatment. Both occupational therapy and work in the context of moral treatment provided a distraction from a patient’s troubles, instilled regular habits and boosted self-esteem. Both encouraged patients to control their symptoms and behave in a way that corresponded to contemporary social norms. This in turn helped patients to adapt more effectively to their environment. Both were based on an individualised approach designed to suit the needs, interests and condition of the patient. These transformations in theory and practice emphasise the cyclical nature of the paradigms underpinning psychiatry and occupational therapy.

English psychiatrists began to question the efficacy of activities based on arts and crafts in the 1960s, considering them too unscientific and insufficiently evidence based.Footnote 14 While arts and crafts still comprised a significant aspect of occupational therapy training in the 1960s and 1970s, they were used less and less in hospitals. Ironically, and a further indication of the cyclical nature of treatments, art therapy, music therapy and drama therapy developed as an independent disciplines after World War II, filling the gap left in these areas by occupational therapy.Footnote 15 Most recently, music therapy has been found to be particularly helpful in the treatment of dementia and schizophrenia.Footnote 16 “Social prescribing” is another recent nonclinical intervention aimed at improving mental health and wellbeing.Footnote 17 Patients can be referred by their general practitioner to local community based organisations for access to support and advice on such topics as loneliness, social networking, volunteering and opportunities to engage in arts and crafts, and other creative activities, as well as healthy eating, legal advice and debt counselling.Footnote 18 Estimates that around 20% of patients consult their general practitioner for social issues have prompted a proliferation of social prescribing and have led to its description as the “topic of the moment” by one group of researchers.Footnote 19 The aim of social prescribing to apply the “common knowledge that people’s health is largely determined by socioeconomic factors” resonates with the preventative agenda of the Mental Hygiene Movement.Footnote 20 Art, music, drama, and social activities have all featured in therapeutic occupation since the early days of moral treatment, resurfacing at intervals right up to the present day.

Occupation of some form, or perhaps the lack of it, has been at the heart of the mental patient’s experience in England and France since the early nineteenth century. Activities that patients enjoyed, such as arts and crafts, or work that was satisfying (rather than “mere drudgery”), such as gardening, were more likely to be provided to patients who were deemed curable in English mental hospitals during the interwar period than in French institutions. Curable French patients, other than those at the Henri Rousselle Hospital, were either unoccupied whilst undergoing biological treatments, or, if convalescent, obliged to perform work around the hospital about which there appeared to be little choice, but for which they were paid. Occupation did not appear to reflect the individual tastes or aptitudes of patients in French institutions; rather, it was allocated according to the needs of the institution. Whilst occupation (or idleness) was fundamental to the patient experience, so too were the institution’s urban or rural location, and whether it was publicly or charitably funded. The living conditions, the recreational facilities, the number and quality of staff were all superior at the charitably funded Bethlem which catered for a middle-class clientele. In France, provincial institutions enjoyed significantly fewer resources that metropolitan hospitals; innovations that occurred at the centre rarely reached the periphery. Patients in French provincial institutions, where the model of care remained custodial during the interwar period, did not enjoy the same degree of liberty as their counterparts in England. The Littlemore patient who could wander into town to do some shopping must have experienced hospital life very differently to the patient kept under lock and key at the Asile de la Sarthe. The knowledge that someone could leave the institution at will—as patients could at the Maudsley and Henri Rousselle hospitals—must have made an enormous difference to the overall experience. This freedom (also available to voluntary patients after 1930 in England) must also have changed a patient’s attitude towards work. Even if a patient disliked the occupation prescribed for them, it was not something that had to be endured forever, or for as long as a doctor decreed. The voluntary patient had far more agency, knowing they could leave the institution at any time.

This study has revealed the interwar years as a dynamic period for the profession of psychiatry, a period that witnessed the beginnings of a diversification of services for the mentally ill and an “opening up” of institutions in England and Paris. The period was characterised by experimentation with a range of treatments, from malaria therapy to organotherapy, from the shock treatments to occupational therapy. Patients began to be treated as individuals with complex needs. But however innovative the interwar years were, they also revealed that “even in medicine, history repeats itself” as David Henderson observed in 1939.Footnote 21 He was talking about putting the “mind” back in psychiatry, which occurred in England and Paris after World War I but not until after World War II in the rest of France. Henderson was keen to stress the “close correlation” between anatomical, physiological and psychological factors.Footnote 22 It was acceptance of the psychological dimension of mental disorder that enabled the moral therapists of the early nineteenth century and psychiatrists of the mid-twentieth to recognise the curative potential of occupation. The use of occupation as a medical tool may have waxed and waned over the past two hundred years, but the centrality of work and occupation to an individual’s humanity and wellbeing have never been in doubt.