Patient Work before World War I

Abstract

Freebody situates the origin of using work as a medical therapy in moral treatment, which emerged during the early nineteenth century. Work was incorporated as an integral part of moral treatment, which provided the medical and managerial framework for the asylums of England and France. Work was believed to help patients develop self-control and boost their self-esteem. As faith in the efficacy of moral treatment waned in the second half of the nineteenth century, the nature of patient work changed. From work programmes designed to suit the needs of individual patients, work became routinised and bureaucratised. While still percieved as beneficial for the mentally disordered, the financial value of patient work to institutions could outweigh its therapeutic value for patients, as the French psychiatrist Auguste Marie emphasised in 1905. Freebody demonstrates how the evolution of patient work highlights changing medical perceptions of mental disorder as well as prevailing socio-economic conditions.

The health benefits of activity and exercise have been understood since Graeco-Roman times, but it is only relatively recently (in the last two hundred years) that work has been medically prescribed for mentally ill patients. During the early modern period, physicians emphasised the importance of balancing the six “non-naturals” to remain healthy in mind and body. These non-naturals included air (as in the freshness of the air), food and drink, exercise and rest, sleep and waking, repletion and evacuation, and the passions and emotions, over which an individual had some control. Exercise might involve walking, dancing, sport or manual labour.¹ Such recommendations for exercise and labour also informed the views of non-medical writers. Robert Burton (1577–1640), Oxford scholar and cleric, recommended bodily exercise, labour, industry and keeping active as antidotes to melancholy.² Burton referred to idleness as “the bane of body and mind”.³ Philosopher John Locke (1632–1704) also extolled the benefits of labour, which he believed protected people from the “ills of idleness or the diseases that attend constant study in a sedentary life”.⁴ Pangloss in Voltaire’s Candide (published in 1759) maintained that, “man was not born to repose”.⁵ Denis Diderot (1713–1784), editor of the French Encyclopédie, believed that man owed “his health, his subsistence, his peace of mind, his good sense, and perhaps his virtue” to daily occupation.⁶ But it was not until the late-eighteenth century, when new ways of treating the mentally ill emerged from the humanitarian teaching of the Enlightenment, that work was incorporated as a therapy for the mentally ill under the umbrella of moral treatment.⁷

The introduction of work in asylums may have been linked to the beginnings of important and far-reaching changes to the economy associated with the transition from pre-industrial to industrial economic organisation. These changes began in the mid-eighteenth century in England, and the mid-nineteenth century in France, prompting the emergence of new attitudes towards work and workers. The independence and autonomy enjoyed by artisans were gradually sacrificed as workers were brought together in a factory or workshop and subordinated to the control of their employers. Technological advances led to the division of labour as work became more specialised, leading to the de-skilling and fragmentation of the workforce. Industrial workers had to adapt from a task-oriented approach to work, involving bursts of intense labour followed by periods of rest, to one which was governed by the clock. Employers expected long hours, six days per week of hard, disciplined labour, uninterrupted by opportunities to converse, run an errand or take a break. Irregular working rhythms were replaced by the discipline of clock time, rigorously enforced by employers.⁸ Whole families, including women and children from the age of six, began to spend more time working. In England between 1750 and 1800, annual working hours increased by at least one fifth.⁹ A new class of urban labourer was emerging whose labour was their only source of income. This made workers vulnerable to the vagaries of the marketplace and led to poverty on an unprecedented scale.

Poverty was putting increasing pressure on the English Poor Law by the early nineteenth century, leading to calls for a radical reform of the old system. Thomas Malthus’ Essay on the Principle of Population (1798) criticised the existing system, claiming that the provision of generous allowances subsidised the work-shy and would result in even larger families unable to feed themselves. Debates raged over whether poverty was the result of “indolence” or “improvidence” and whether paupers were deserving of relief. Reformers agonised over how to combine compassion with “incentive-compatibility”.¹⁰ In 1832 a Royal Commission concluded that the system was too expensive and morally flawed in allowing men capable of work to claim relief. The resulting Poor Law Amendment Act of 1834 (the New Poor Law) abolished outdoor relief for able-bodied indigents and instituted a system of workhouses where only the most destitute would be fed and housed. The system was undoubtedly harsh; conditions inside the workhouse for the able-bodied pauper were designed to be worse than those of the poorest-paid labourer living outside. The aim of the 1834 Poor Law, according to Peter Bartlett, was to “root out and dismantle a culture of poverty, perceived in terms of immorality, intemperance and promiscuity, and replace it with a culture of self-help, respectability, sobriety and hard work”.¹¹ The prospect of entering the workhouse was to be a humiliating last resort, designed to discourage those capable of working. For Foucault, the existence of English workhouses provided “a certain ethical consciousness of labour” and a moral symbol affirming the value of work.¹² Whilst training in the habits of work was considered important, especially for children entering the workhouse, the real ‘value’ of the institution was its symbolic presence as a place of degradation and brutality that awaited those who failed to work.¹³ The message was clear; the able-bodied were expected to work for their living and idleness was not to be tolerated. Such attitudes provided the backdrop to the establishment of the English asylum system.

New theories about work and the role of labour were developed by political economists who studied the changes taking place in the way wealth was created and distributed in capitalist economies. They sought to “understand, control and predict both the economics and the politics of the market”.¹⁴ One of the earliest political economists, Adam Smith (1723–1790) claimed, in his famous work the Wealth of Nations (1776), that work was “the real price of everything” since it was the “toil and trouble” of labour that enabled an individual to acquire goods or services.¹⁵ James Mill (1773–1836) agreed. As he expressed in his Essay on Government (1820), labour—although “painful” to perform—was the key to obtaining happiness, since it enabled the individual to make or procure what they desired.¹⁶ Smith maintained that “the annual labour of every nation is the fund which originally supplies it with all the necessaries of life which it annually consumes”.¹⁷ It was not “gold and silver” that was responsible for generating the original “wealth of the world”, but labour.¹⁸ The notion that labour was central to national and individual prosperity provided the backdrop to the development of the asylum system. It made sense to ensure that work formed an integral part of institutional life, equipping the recovering mental patient or prisoner with the attitudes and skills necessary to make their economic contribution to society and to earn their living.

Industrialisation began later in France, in part due to the political, social and economic upheaval generated by the French Revolution (1789) and the Napoleonic Wars (1803–1815). Following the redistribution of land after the Revolution of 1789, France became a nation of small farmers. In 1862, 85% of French farms were under 10 hectares.¹⁹ This had enduring social and economic consequences, including labour shortages throughout the economy, the persistence of craft industries and a “household economy” whereby family members held other jobs, such as hand-weaving, as well as working on the smallholding.²⁰ Coal mines and factories were often viewed as means of earning money during bad weather or agricultural slack periods, rather than as a labourers’ only source of income.²¹ Significant industrial development did not occur until the onset of a period of relative political stability following the establishment of the Third Republic in 1871.²² Industrialisation, therefore, was not the context from which moral treatment and work therapy emerged. However, in post-revolutionary France, good citizenship involved working hard, supporting oneself and contributing to the new Republic. Idleness, which was associated with the aristocracy, was shunned.

It was in this context of economic and political change that the asylum system developed. For the pioneers of moral treatment, William Tuke (1732–1822) in England and Philippe Pinel (1745–1826) in France, work was a fundamental aspect of their therapeutic regimes, helping patients to master their symptoms and enabling them to maintain their professional skills and thus their means of subsistence. As asylums proliferated during the early nineteenth century, the principles of moral treatment became the ideal to which most asylum superintendents and chief medical officers aspired. Work programmes for patients were introduced in the context of moral treatment at a time when work was expected of the inmates of most institutions (including prisons, workhouses and orphanages) and when there were no other successful remedies for mental disorder.²³

Moral Treatment

Moral treatment represented a significant departure from previous methods of treating the mentally disordered. Before the mid-eighteenth century, it was believed that mentally disordered individuals were possessed by the Devil or, having lost their reason, reduced to wild beasts, rather than as people who were ill and in need of compassion and support. Earlier methods of treatment infamously included the use of mechanical restraint; intimidation, coercion and fear; regular bloodletting, the administration of emetics and laxatives; cupping and blistering; cold baths or showers; and a restricted diet. “Lunatics” were regularly beaten and were thought to be insensitive to the cold. In France, a nationwide survey of institutions for the mentally ill was undertaken in 1817 by the physician Jean-Étienne Dominique Esquirol (1772–1840), former student of Pinel. His report revealed the grim conditions endured by mental patients: “I have seen them naked, clad in rags … coarsely fed, lacking air to breathe, water to quench their thirst, wanting the basic necessities of life. I have seen them at the mercy of veritable jailers, victims of their brutal supervision. I have seen them in narrow, dirty, infested dungeons without air or light, chained in caverns where one would fear to lock up wild beasts…”.²⁴ Esquirol sought to establish an asylum system in France where Pinel’s teaching would be implemented.

According to the principles of moral treatment, the mentally disordered deserved compassion and should be treated as human beings who were still capable of rational behaviour, albeit intermittently. Corporal punishments, harsh treatment and indiscriminate physical remedies were not to be used. The creation of a clean, comfortable, homely environment, the provision of nutritious food and decent bedding, and the establishment of a regular daily routine were key aspects of moral treatment. Removal from the patient’s home was considered essential since it separated the patient from the difficulties that may have caused their mental illness, such as family problems, business or financial worries, intemperance or religious fanaticism.²⁵ The orderly, structured environment of the asylum was believed to be curative in itself. The asylum grounds and setting were considered important aids to recovery, the landscaped gardens and surrounding countryside affording plentiful opportunities for exercise, fresh air and exposure to nature.²⁶ Patients were encouraged to develop self-control through a system of rewards and the withdrawal of certain privileges. Work was considered a particularly effective means of instilling self-control; it distracted the patient from their troubles, focused their attention on the fulfilment of a task and provided opportunities for social interaction and cooperation with staff and other patients. A patient’s day was scheduled to include regular hours for work, balanced with periods for recreation and amusements.²⁷

While there is some debate amongst historians of medicine over the precise origins of moral treatment,²⁸ its teaching was most famously and comprehensively outlined in England by Samuel Tuke’s account of his grandfather’s methods, published in 1813, and in France by Philippe Pinel’s Traité of 1800.²⁹ Tuke described the moral treatment practised at the Retreat at York, which opened in 1796. Here, he claimed, “it has [been] demonstrated, beyond all contradiction, the superior efficacy, both in respect of cure and security, of a mild system of treatment in all cases of mental disorder”.³⁰ Tuke rejected the “drugs and medicaments” that were trialled initially because a “moral regimen” that helped a patient control themselves, proved more effective. Pinel warned against all forms of violence towards or physical punishment of patients, not simply because they were inhumane, but because they exacerbated the patient’s condition.³¹ Both Tuke and Pinel regarded treating the insane rather like rearing children. Tuke spoke of restraining patients from certain activities and encouraging them in others, while Pinel observed that when children were at play, they ceased to be lazy and disobedient and became active, focused and keen to obey the rules. Patients who were engaged in some form of activity were distracted from their morbid thoughts.³²

Moral treatment acted on the mind, encouraging patients to behave in a way that enabled them to fit in with the rest of society. As such it was a psychological method of treatment, although the term “psychological” was not in use at that time. However, as Roy Porter reminds us, moral treatment should not be confused with modern psychotherapy since neither Tuke nor Pinel were interested in “talking cures” or in “working through” problems.³³ They sort to influence behaviour by making patients “want to be good”.³⁴ Tuke and Pinel’s theories were similar, although interpretation of the word “moral” in Tuke’s “moral treatment” and Pinel’s “traitement morale” differed in emphasis, as Louis Charland explains.³⁵ At the Retreat, the term “moral” had an ethical dimension linked to the Quaker faith of the institution’s founder, William Tuke. The non-medical Tuke believed that all individuals were imbued with a “moral sense”, an innate sense of right and wrong, and that the mentally disordered could be persuaded to control themselves by appealing to this moral sense. Pinel’s traitement morale was designed to act on the passions, sentiments, and emotions.³⁶ As a qualified physician, whose beliefs were firmly rooted in the sectarianism of revolutionary France, Pinel was not influenced by religious concerns. That said, in early nineteenth-century France, the emotions were considered closely linked to ethics and morality.³⁷ The aim of both versions of moral treatment was to influence behaviour without the use of drugs, physical treatments or mechanical restraint, but at the Retreat, ethics and religion played a particularly important role.³⁸

For non-conformists, including Quakers, work was a social duty, a source of dignity and moral worth, as Max Weber (1864–1920) observed in his essay The Protestant Ethic and the Spirit of Capitalism (1904–1905). The accumulation of wealth was morally acceptable provided it was combined with a sober, industrious career and not squandered on dissolute living.³⁹

Weber observed that thrift, industriousness, self-discipline and sobriety characterised the growing class of non-conformist entrepreneurs. This observation led him to believe that the non-conformist or puritan outlook “stood at the cradle of modern economic man.”⁴⁰ The philanthropist William Tuke was a successful wholesale trader of tea, coffee and cocoa, remaining in business until the age of eighty-six. No stranger to hard work, Tuke was also a patron of the Bible Society, treasurer of the York Society of Friends, a campaigner for the abolition of the slave trade and the founder of three schools.⁴¹ Hard work, as opposed to aristocratic idleness, and the duty of citizens to be useful members of society, were post-revolutionary principles that influenced Pinel’s theories too. Work, for both Tuke and Pinel, was key in encouraging the mentally disordered to restrain themselves. Pinel regarded manual labour as one of the “most effective and reliable means of restoring reason”. He added that aristocrats who rejected this form of therapy were merely perpetuating their condition.⁴² Pinel noted that when his patients at the Bicêtre were provided with appropriate work, they immediately became calm, responsive and lucid. He insisted that all asylums for the insane should provide employment for their patients and that even the “furious” should be given some sort of physical work. Idleness exacerbated symptoms, while physical work fixed the attention and helped maintain self-control. Farming, or working a plot of land, was a particularly effective form of labour, given “the pleasure man derives from growing his own food and providing for his own needs”.⁴³

In a similar vein, Tuke maintained that “indolence has a natural tendency to weaken the mind and to induce ennui and discontent”. Activities, such as walking, reading, conversation and physical exercise were all effective ways of diverting a patient’s attention away from “their illusions”. Tuke’s frequently cited remark that “of all the modes by which patients may be induced to restrain themselves, regular employment is perhaps the most generally efficacious”, particularly employment that involved “considerable bodily action”, shows him to be in accord with Pinel.⁴⁴ Tuke emphasised the role of work in promoting self-esteem. The latter, Tuke insisted, was a far more powerful tool than fear in encouraging patients to control their behaviour.⁴⁵ It was up to the attendant to ascertain the type of work or amusements most appropriate for the patient, such as “active and exciting” activities for the melancholic and more sedentary occupations for the “maniacal class”. There were no hard and fast rules, but the “inclination of the patient” should guide the choice of employment unless it appeared to exacerbate his or her condition.⁴⁶ Tuke described how the condition of one patient, a gardener by profession, was greatly improved by involving him in the management of the asylum grounds, and worsened when this form of employment was no longer available.⁴⁷ For Tuke, work or amusements were to be tailored to suit the patient, based on the nature of their condition, their preferences and previous occupation, and on whether the choice of occupation proved beneficial. The successful allocation and supervision of occupation required that the attendant know the patient well and had the time to oversee the activities.

The Adoption of Moral Treatment in French and English Asylums

The basic principles of moral treatment, as set out by Tuke and Pinel, influenced how the mentally disordered were treated in asylums for the next c.150 years. The teaching of Pinel and Tuke informed subsequent generations of psychiatrists, including Jean-Étienne Dominique Esquirol and Guillaume Ferrus (1784–1861) in France, and Sir William Charles Ellis (1780–1839) and John Conolly (1794–1866) in England. In England, the Select Committees of 1815 and 1827, established to investigate care of the mentally disordered in institutions, recommended the adoption of moral treatment methods. As Kathleen Jones highlights, Tuke’s system “was set as the ideal” and was regarded by members of the 1827 committee as key to “creating an environment in which patients could live with some personal satisfaction and dignity”.⁴⁸ The report produced by the 1827 Select Committee included an Appendix that set out what asylums should provide, including manual labour, intellectual pursuits, and hobbies. The report stated that, “In the moral treatment of the patients, it is considered an object of importance to encourage their own efforts of self-restraint…”, thereby underlining the psychological nature of the treatment.⁴⁹ The campaign to establish the French asylum system and the drafting of the 1838 legislation regarding how asylums should be managed was led by Esquirol. He ensured that the legislation (refined but not substantially changed in 1857) was based on the principles of moral treatment and included the provision of work for patients.⁵⁰ The law stipulated that work and other occupations should be prescribed for patients by a doctor as a means of therapy.⁵¹

In England, the “non-restraint” movement of the 1830s and 1840s, owed much to Tuke and Pinel. The campaign to abolish mechanical restraint, pioneered by Robert Gardiner Hill (1811–78) and John Conolly, was based on the aim of replacing strait jackets and other methods of physical restraint with the introduction of elaborate patient work programmes to encourage self-restraint.⁵² Gardiner Hill, who abolished restraint at the Lincoln Asylum, declared, “I wish to complete what Pinel began”.⁵³ As a result, many English asylums became “hives of activity” in the mid-nineteenth century. Echoing Tuke, Sir William Charles Ellis, who took over stewardship of the Hanwell Asylum in 1831, shortly before the New Poor Law was passed, maintained that “nothing is found so efficacious as employment”. He advocated the provision of workshops in all asylums for the poor, where “patients may perform different branches of mechanical labour to which they have previously been accustomed”.⁵⁴ Failing that, patients could be taught a new skill, such as shoemaking or twine spinning.

Esquirol supported Pinel’s view that every asylum should have a farm where patients could work the land and emphasised the moderating effects of manual labour on the passions. His female patients at the Salpêtrière Hospital benefited from tending the garden or engaging in domestic chores.⁵⁵ Esquirol’s protegés, whom he helped to become chief medical officers in the new provincial asylums, adopted his methods and became “missionaries” for his version of moral treatment.⁵⁶ Camille Bouchet, for example, who became chief medical officer of the asylum in Nantes, maintained that work alone could “provide a ‘sustained distraction from delirious impressions and thoughts’”.⁵⁷ Another physician influenced by Esquirol’s methods, Gustave-François Étoc-Demazy (1806–1893), became chief medical officer of the Asile de la Sarthe in 1834, remaining there until his retirement in 1872. Étoc-Demazy had trained under Guillaume Ferrus at the Bicêtre hospital. Ferrus’ commitment to patient work was demonstrated by his foundation of La Ferme Ste Anne, where patients from the Bicêtre could engage in agricultural work.⁵⁸ Throughout his long career, Étoc-Demazy maintained his belief in the psychological origins of mental disorder and remained committed to moral treatment, including the provision of work for his patients. He was not swayed by the growing prevalence of physiological interpretations of mental disorder based on heredity towards the end of his tenure.⁵⁹

In England, the first annual report of the Littlemore (produced in 1847) suggested that great importance was attached to the occupations made available to patients. The medical superintendent, Dr William Ley noted that around half of the patients worked. In suitable weather, men worked “in the garden or in some other outdoor occupation” while patients of both sexes were employed “in the domestic work of the House”.⁶⁰ Three tailors and a carpenter had been admitted for whom work in their respective fields had been found. Ley noted that it was not always possible to find work for patients that matched their previous professions. He could not, for example, find work ideally suited to the soldier, butcher, hawker, fellmonger, schoolmaster, clerk, bookbinder, wheelwright, linen draper and “more than one medical man” who had been admitted, although many patients were happy to work in the garden. For women, needlework, working in the laundry and housework seemed to bring satisfaction, particularly from a social perspective.⁶¹ Ley observed that patients welcomed the opportunity to have “their hands and eyes occupied in what they retain a certain knowledge of”. Patients took “much interest” in the yield of the crops they cultivated and “also contemplate with pleasure the participation in the fruits of their labour.” Ley also highlighted his patients’ enjoyment of the music and dancing that formed part of the asylum’s entertainment programme.⁶² Patients of both sexes attended reading classes with the Chaplain.⁶³

Treatment practices at Bethlem changed dramatically after the damning evidence gathered by the 1815 Select Committee. This revealed that cramped, unsanitary conditions devoid of any comfort, widespread use of mechanical restraint, inadequate staff numbers, and a catalogue of abuses were the norm at Bethlem.⁶⁴ Committee members noted how unfavourably Bethlem compared with the Retreat at York. Bethlem’s move to new premises shortly after the enquiry, and a change of personnel, resulted in the introduction of moral treatment, although it took several years before therapeutic work was provided for patients.⁶⁵ The 1830s saw the addition of eleven workshops and patients were encouraged to help with household chores. The 1843 hospital report maintained that work had proved beneficial, but that its use was limited because Bethlem did not possess extensive grounds.⁶⁶ Sport and recreation were added to Bethlem’s regime following the 1815 Select Committee report; patients were able to play football, battledore, trap-ball and cricket outside while cards and dominoes were provided indoors.⁶⁷ By the 1820s, Bethlem’s reputation had improved so much that physicians were being sent to Bethlem and the Retreat at York to observe best practice.⁶⁸ Not everyone agreed that this reputation was deserved. The physician Alexander Halliday observed in 1827 that, despite the adoption of some aspects of moral treatment, “there is too little space for exercise and employment for it [Bethlem] ever to prove an efficient hospital” and that there existed “too rigid a system of quackery”.⁶⁹ It was not until the arrival of superintendent William Charles Hood (1824–70) in 1852 that Bethlem’s practices were brought fully in line with “modern sentiments and requirements”.⁷⁰ Hood was a firm believer in moral treatment and in the benefits of work for his patients’ mental and physical health. He found it “lamentable to see strong and healthy men, in the prime of life, idling away their time from morning till night, lounging listlessly about the wards, doing nothing.”⁷¹ Hood improved the recreational facilities, food and general living conditions at Bethlem and introduced excursions to places of interest.

Unlike the long-standing Bethlem, Ste Anne’s was only established in 1867. Ste Anne’s was the flagship institution, which incorporated the Asile Clinique, in Baron Haussmann’s plans for reorganising provision for the mentally disordered in the Paris region. Despite being created some thirty years after its heyday, the asylum was designed according to the principles of moral treatment set out by psychiatrist François Leuret (1797–1851). Leuret, a former pupil of Esquirol, has been described as France’s “last moral therapist”.⁷² He did not adhere to the new ideas that attributed mental illness to a somatic disorder and remained committed to psychological treatment. As a result, Ste Anne’s had plenty of green spaces where patients could take exercise, enjoy recreation in the fresh air and work in the orchards and gardens.⁷³ Patients also worked in the various workshops. Intellectual pursuits were encouraged; there was a library; and musical and theatrical performances were organised.⁷⁴

Initially, moral treatment was deemed highly effective. Its initial success led to a general sense of therapeutic optimism regarding the curability of mental disorder, regardless of the social status, age or sex of the affected individual, as long as treatment began soon after the onset of symptoms.⁷⁵ Some historians have attributed this optimism to the inaccurate early reporting methods of asylum superintendents, keen to demonstrate their success, and others to the higher proportion of patients with favourable prognoses admitted to asylums in the first half of the nineteenth century, before institutions became overcrowded with chronic and incurable cases.⁷⁶ The efficacy of moral treatment, and thus of patient work, was barely questioned until the middle of the century.⁷⁷ By this time, a modus operandi had been established and asylums in both France and England were managed according to the framework provided by moral treatment. Patient work formed part of the daily asylum routine that included regular hours for waking, meals, exercise, recreation and social activities, and sleeping (Figs. 2.1 and 2.2).

Fig. 2.1

“Les Services Techniques” or Technical Services Workshops, Asile Clinique, Paris, 1900. (© Collection Bibliothèque Henri Ey (don Gérard Proust), GHU Paris, photographie Direction de la communication du GHU)

Fig. 2.2

Attendants and patients working in the grounds, Littlemore Hospital, Oxford, 1910s. (© Oxfordshire County Council, Oxfordshire History Centre, POX0571824)

Changing Views Regarding the Curability of Mental Disorder

Doubts about the efficacy of moral treatment began to creep in as the numbers of individuals detained in the asylum system, notably those with incurable or chronic conditions, kept increasing each year. Moral treatment did not seem to be as successful as it first appeared. Such doubts were compounded by changes in the way mental disorder was perceived. During the early nineteenth century it was generally accepted that individuals who had been mentally disordered since birth; had developed mental disease in old age (such as senile dementia); or had suffered a mentally debilitating physical injury or illness (such as syphilis), were unlikely to improve significantly. Other cases were believed to stand a good chance of recovery if treated early. This therapeutic optimism was widespread, as Joan Busfield emphasises. Asylum reform in the early nineteenth century was based on a “cult of curability”, the belief that asylums could achieve a high rate of cure.⁷⁸ William Browne, medical superintendent of the Montrose Asylum, remarked in 1837 that certain physicians were claiming an ability to cure 90 in every 100 cases, “proving” that mental disorder was “the most curable of all diseases”.⁷⁹ This impressive claim only applied to recent cases, Browne added, those whose conditions had existed for three months or less before they began medical treatment. For these cases, the chances of recovery were high, regardless of the age, social rank or sex of the patient.⁸⁰

Early institutional treatment was considered economically prudent since an increased likelihood of cure lessened the chance of long-term dependency. Len Smith reports that throughout the 1820s and 1830s, medical superintendents complained that parish officials tried to save money by delaying the transfer of the mentally disordered from workhouse to asylum. But waiting until cases had descended into chronicity was far more costly in the longer term since chronic patients would end up staying far longer in the asylum (possibly for life) and their families would soon became pauperised.⁸¹ As W.J. Gilbert, an Assistant Poor Law Commissioner in Devon observed in 1839, it was ill-advised to allow the insane patient’s condition to linger without proper treatment since the disease would soon become “inveterate and recovery hopeless”.⁸²

As asylums became overcrowded with incurable patients in the late 1840s, they became places of detention rather than cure. The sheer numbers of patients made it hard for doctors to treat those whose conditions might be curable, leading to doubts about the curability of mental disorder.⁸³ Theories claiming that mental disease was a condition of the mind lost ground. Psychiatrists began to regard mental disorder solely as an organic disease, a physiological condition of the brain and central nervous system, rather than as a problem of the psyche. This physiological interpretation of mental disorder was reinforced by the circulation in the late 1850s of theories of heredity, developed by the French psychiatrist Bénédict-Augustin Morel (1809–1873). He believed that the majority of cases of mental disorder were caused by a hereditary “defect” to the brain or central nervous system. Mental disorder was inherited either directly as “mental deficiency” (or intellectual impairment in today’s parlance), in which case individuals were impaired from birth, or indirectly as a “predisposition” towards developing some form of mental illness in the future. If the latter, this would worsen or “degenerate” with each generation.⁸⁴

The widespread influence of Morel’s theory of heredity, both in England and France, encouraged psychiatrists to turn away from psychological modes of treatment, such as moral treatment, and towards trying to identify a biological cure. From the mid-nineteenth century, articles in the Journal of Mental Science and L’Aliénation Mentale increasingly focused on the search for physical causes of mental disorder and on the quest for successful biological remedies. Moral treatment and patient work were considered outmoded as methods likely to bring about a cure. In 1887, an author writing in The British Medical Journal observed that “the physical treatment of insanity is put prominently forward”. He added, “Formerly we heard much about the moral treatment of insanity; nowadays it is rarely mentioned”.⁸⁵ In 1900, in an article in the Journal of Mental Science referring to the provision of farm-work for patients, the author remarked that “It was late in the day to advocate that primitive measure”.⁸⁶ In France, Pinel’s son, the physician Scipion Pinel (1795–1859), attempted to divert attention away from his father’s reputation as the founder of moral treatment by focusing on Pinel’s alleged breaking of the chains from patients at the Bicêtre.⁸⁷ This supposedly heroic gesture, for which there is little evidence, became legendary. According to Dora Weiner, perpetuation of the myth was motivated by Scipion’s embarrassment at his father’s emphasis on the psychological causes and treatment of mental illness. Scipion himself was convinced that mental illness was caused by physiological factors.⁸⁸

The Decline of Moral Treatment

In line with this change from a psychological to a physiological orientation, the practices associated with early nineteenth-century moral treatment evolved.⁸⁹ Anne Digby observes that at the York Retreat, the increasing size of the institution resulted in the introduction of more formal rules and codes of behaviour. Patients began to be treated less as individuals and more as “inmates in a bureaucratic regime”.⁹⁰ The framework provided by moral treatment remained, while faith in its ability to cure mental disorder had diminished. The more bureaucratic, disciplinarian methods, associated with a custodial model of care, became an effective means of managing large numbers of patients in an efficient and humane way. Patient numbers, particularly in the large public asylums, prevented the allocation of work according to individual needs, preferences, or previous professions. The provision of work, exercise and amusements for the more tractable patients did not equate to an adherence to the principles of moral treatment, as Busfield has highlighted.⁹¹ This required individual attention from staff and a response to the needs of each patient, rather than the imposition of a uniform, regimented routine.⁹² The work performed by patients represented a considerable cost-saving for the asylum, but the nature of work in the late nineteenth century was, as Dr David Henderson remarked, often “mere drudgery”.⁹³ Over half of working patients in both French and English establishments were engaged in ward work (essentially cleaning), the potential of which to stimulate a patient’s creativity, intelligence or self-esteem was limited. Far from being a “cornerstone” of moral therapy prescribed according to patient need, work had simply become part of the daily asylum routine, organised to supplement the smooth-running of the institution, to distract calm, chronic and incurable patients and to prepare convalescent patients for life outside the institution.⁹⁴ Unlike during the early nineteenth century, psychiatrists’ “interest in the therapeutic value of … employment was minimal”.⁹⁵ Textbooks, such as Daniel Hack Tuke’s two-volume Dictionary of Psychological Medicine (1892), continued to recommend work and other occupations but devoted far less attention to them than to physical or biological remedies.⁹⁶ By the last quarter of the nineteenth century, the benefits of patient work to the institution appeared at least as important as its benefit to the patient (as discussed in Chap. 5).

Changes to the perceived curative value of moral treatment and patient work took place at different times in different locations, depending on the views of the medical superintendent or chief medical officer, patient numbers, the extent of overcrowding and the proportion of patients with poor prognoses. At the Littlemore, it was clear from the dearth of comments about moral treatment or the therapeutic value of occupation from the 1870s onwards that these were no longer priorities. This can be linked to Dr Ley’s retirement in 1868 and to the fact that patient numbers at the Littlemore had increased from 286 in 1850 to 527 in 1870 without a proportionate increase in staffing levels. Work was only mentioned in the Committee of Visitors’ report where the standard phrase, “Employment for the Patients capable of being engaged, is found the House, Garden, and Grounds of the Asylum; besides work in certain Trades at which they are from time to time enabled to work”, was repeated each year.⁹⁷ Although Littlemore patients continued to be employed during the last quarter of the nineteenth century, as Table 2.1 indicates, the work did not appear to be allocated on the basis of patient preference or need. The type of work (such as cleaning and hair-picking) suggested that it was geared to the needs of the institution. As the Commissioners in Lunacy noted in 1910, the amount and type of work provided for patients depended on the “the extent to which the medical superintendent … takes a real and lively interest in these matters so essential to the care and treatment of the insane”.⁹⁸ Entertainments, an essential aspect of the therapeutic arsenal in the eyes of the moral therapists, also seemed to be neglected at the Littlemore by the end of the nineteenth century. The Commissioners in Lunacy noted in 1901 that only one recreational event had been held that year, apart from the regular dances.⁹⁹ Concern was expressed in 1908 that almost half the patients were confined to the airing courts for fresh air and exercise.¹⁰⁰ Requests to provide more reading material to Littlemore patients “whereby their lives may be greatly brightened at a comparatively trifling cost” cropped up in 1901, 1910 and 1912, suggesting that this form of amusement was not a priority for the superintendent.¹⁰¹

Table 2.1 Table to show the number and percentage of male and female patients who worked at the Littlemore Asylum, Oxford, 1870–1895 and 1900–1913

At the Asile de la Sarthe, belief in the effectiveness of moral treatment appeared to have lasted considerably longer. The rules for staff set out in the Règlement of 1893 demonstrate a routine closely aligned with the principles of moral treatment, with set times for meals, work, prayer, recreation and the doctor’s daily visit. Echoing the legislation regarding patient work compiled in 1857, the rules stated that, “Work is provided in the asylum as a means of treatment and distraction for patients”.¹⁰² Which patients were given work, the nature of that work and the length of time each patient was to spend on it were to be decided by the chief medical officer. The types of work, both indoor and outdoor, that patients were permitted to perform were indicated in the Règlement; for example, patients should not be given work that relied solely on muscular force, such as operating the pumps or carousel.¹⁰³ The working day was limited to eight hours in winter and nine hours in the summer.¹⁰⁴ These regulations suggest that patient work was conceived as a therapeutic activity, but it was also made clear that the product of the patients’ labour belonged to the asylum.¹⁰⁵ “Intellectual occupations”, games and physical exercises were also to be provided for patients, as directed by the chief medical officer and supervised by the nurses and attendants (Fig. 2.3).¹⁰⁶

Fig. 2.3

Plan of the Asile de la Sarthe, Le Mans, 1891. The plan shows the areas allocated to market gardening (“jardin potager et frutier”) and the workshops (“Maison centrale pour les services généraux”). (© Arch. Dép. Sarthe, 4 N 158/8)

In his 1899 and 1901 annual reports, Dr Petit (chief medical officer of the Asile de la Sarthe from 1898 to 1904) highlighted patient work and entertainments as the most effective therapies. These methods were considered more important than pharmaceuticals, described as simply an “accessory” to moral treatment.¹⁰⁷ However, while Dr Petit may have considered moral treatment his preferred methodology, his ability to deliver it, as the sole doctor for 865 patients (the number of residents at the Asile de la Sarthe in 1903) is questionable. Furthermore, it seems that financial considerations overruled the desire to provide therapeutic farm work at the Asile de la Sarthe. By the end of the nineteenth century, much of the agricultural land near the Asile de la Sarthe had been built on, so a small farm had been rented near the asylum to provide work for patients. The decision was taken in 1903 not to renew the lease because the farm was deemed too costly to run.¹⁰⁸ Many of the patients who had worked on the farm were redeployed as ward cleaners since opportunities to work on the small market garden within the asylum grounds were limited. Dr Bourdin, the chief medical officer appointed in 1911, appeared less enthusiastic about moral treatment. He described pharmaceutical treatments, such as sedatives, in considerable detail in his medical report of 1911, while “moral treatment” only received a brief mention.¹⁰⁹ The reports of 1911–1913 no longer featured the previously regular section on patient work, indicating that work was less of a therapeutic priority, even though the records indicate that patients continued to work (See Tables 2.2 and 2.3).

Table 2.2 Table to show the number and percentage of male and female pauper patients who worked at the Asile de la Sarthe, Le Mans, 1900–1913

Table 2.3 Table to show the number and percentage of male and female paying patients who worked at the Asile de la Sarthe, Le Mans, 1900–1913

At Bethlem, the use of mechanical restraint, greatly reduced under Hood’s leadership, re-emerged after his resignation in 1862. This was justified on the grounds of the acute nature of many of Bethlem’s cases but was seen as an abandonment of the principles of non-restraint and moral treatment. Chemical restraint in the form of sedatives also became popular at Bethlem in the late 1870s. The use of sedatives and stimulants continued to characterise treatment at Bethlem into the 1930s.¹¹⁰ By 1914, an average of 40%—or less than half—of Bethlem’s patients worked. In addition to a preference for using sedatives to calm acute-stage patients, the figures can be linked to the class of Bethlem’s patients and its metropolitan location. For the middle-class patients at Bethlem, manual labour was an anathema. As superintendent George Henry Savage complained in 1882, “we are no nearer solving the problem of occupation for the middle-class insane”.¹¹¹ Entertainments, sport and other leisure activities were more appropriate occupations than work for this class of patient. As Oswald has argued, psychiatrists recognised that, to be effective, occupations had to be suited to the class of patient, as well as their condition.¹¹² In the private section of the Asile de la Sarthe, just 17% of paying patients worked during the first decade of the twentieth century (Table 2.4).

Table 2.4 Table to show the number and percentage of patients who worked at the Bethlem Royal Hospital, London, 1900–1913 (no gender breakdown available)

Like Bethlem, the Asile Clinique was located in a city centre where the availability of land for farm work was limited. Other forms of work were available but were only being prescribed to a relatively small proportion of patients. In 1907, General Councillor Henri Rousselle felt compelled to remind the medical staff that it was “perfectly legitimate” to expect patients to work “to lessen the enormous cost of their care”.¹¹³ He argued that a balance needed to be reached enabling doctors to reconcile “the needs of humanity with those of an efficient administration”.¹¹⁴ The Asile Clinique doctors’ apparent unwillingness to prescribe work for their patients may have been linked to a preference for alternative methods of treatment, such as continuous bedrest, the method introduced in 1896 by Valentin Magnan, the revered psychiatrist in charge of the Admissions department at Ste Anne’s from its opening in 1867 until 1916.¹¹⁵ In the decade before the outbreak of World War I in 1914, an average of just 29% of Asile Clinique patients worked. This contrasts with over 60% of pauper patients at the Littlemore and the public section of the Asile de la Sarthe, where there was a high proportion of chronic and incurable cases (Table 2.5).¹¹⁶

Table 2.5 Table to show the number and percentage of male and female patients who worked at the Asile Clinique, Paris, 1900–1913

Psychiatrists at the Seine’s Villejuif Asylum, who included the reformers Édouard Toulouse (1865–1947) and Auguste Marie (1865–1934), were greatly in favour of patient work as a means of therapy. They disagreed with colleagues who claimed that there was “no scientific evidence” for its efficacy and who maintained that “the best exercise was rest”. ¹¹⁷ Marie emphasised in his report of 1905 that “the main purpose of work in asylums is the well-being of the patients; its usefulness as a means of production should be entirely subsidiary.”¹¹⁸ There needed to be a clear distinction between therapeutic work and work-for-profit. Unfortunately, this principle was all too often misunderstood. Marie warned that the “profit motive” could cloud the judgement of asylum physicians and administrators and push the goal of medical treatment into second place.¹¹⁹ All staff, including the director, the bursar and their employees, needed to understand that the work carried out by asylum patients was therapeutic, not a means of making or saving money.¹²⁰ French asylums, Marie maintained, were often regarded by the public, the administrative authorities and by the patients themselves as “work colonies”, rather than as hospitals where people were treated for mental illness.¹²¹ In the colonies, patients were expected to work to contribute to the costs of their care whilst benefiting from a healthy activity in the fresh air.¹²² In an asylum, on the other hand, doctors needed to consider the patients’ preferences and aptitudes, and assign work that was relaxing and agreeable.¹²³ Toulouse agreed, insisting in 1905 and again in 1913, that the occupations and amusements provided for patients should be increased in frequency and variety, as these activities were essential to recovery (Table 2.6).¹²⁴

Table 2.6 Table to show the average number of male and female patient workers per institution, 1900–1913

Separation of Curable and Incurable Patients

Reformers argued that separating curable and incurable patients would lead to greater clarity in terms of establishing the rationale for prescribing patient work. It would also facilitate more effective treatment of curable cases, and more efficient allocation of limited financial resources. Calls for the separate treatment of curable and incurable cases had begun soon after the establishment of the asylum system. Psychiatrists recognised that treating curable cases separately would allow doctors to focus their attention on those most likely to make a recovery. An accumulation of chronic and incurable patients, who were likely to have to spend the rest of their lives in the asylum, would inevitably lead to overcrowding. In England, this situation had been foreseen by Thomas Bakewell who launched a twenty-year campaign for the establishment of an alternative system of state-run hospitals for curable patients.¹²⁵ Bakewell, proprietor of the Spring Vale private asylum in Staffordshire, maintained as early as 1814 that it was essential to separate the recent, curable cases from the chronic and incurable. A large public asylum, which was obliged to accept all types of patient, was “a great deal more calculated to prevent recovery than to promote it”.¹²⁶ The campaign to treat curable and incurable patients separately was stimulated towards the end of the nineteenth century by Morel’s theory of heredity and concerns regarding degeneration.

Anxiety about degeneration infiltrated all areas of society in both France and England. In England, many of the “social ills” associated with degeneration were attributed to a section of the “mentally deficient” population identified as the “feeble-minded”. Segregation of this part of the population, as argued by Mary Dendy in her 1899 pamphlet, The Importance of Permanence in the Care of the Feeble-Minded, would be beneficial both for society and the feeble-minded individuals themselves.¹²⁷ Segregation would protect the public from the crimes supposedly committed by the feeble-minded; relieve overcrowding in asylums, workhouses and gaols; and prevent the feeble-minded from transmitting their condition to future generations. Ultimately, the measure would save money at the same time as protecting the feeble-minded from themselves and the rest of society.¹²⁸ A Royal Commission on the Care of the Feeble-Minded was appointed in 1904 and reported in 1908. “Mental defectives”, defined as “idiots”, “imbeciles”, the “feeble-minded”, and “moral imbeciles”, were regarded as a “totally distinct and pathological group” whose conditions were “congenital” in character.¹²⁹ The Mental Deficiency Act of 1913, which embodied the Commission’s recommendations, set in motion the establishment of “mental deficiency colonies” as a means of segregating the “mental defectives” from the rest of the population into custom-built, but inexpensive specialist institutions located in sparsely populated areas.¹³⁰ Eugenicists such as psychiatrist Alfred Tredgold, maintained that the segregation of these “mentally defective” (or intellectually impaired) individuals would prevent them from introducing “tainted strains” into the population.¹³¹ Segregation would also facilitate the separate care of the intellectually impaired (in “colonies”) and the mentally ill (in asylums or mental hospitals).¹³² Colonies for the intellectually impaired were to focus on care and self-sufficiency and were to provide a “simple and wholesome life” for inmates. ¹³³ Adults who were capable of work would be provided with agricultural or simple industrial work, as they were at the David Lewis (established in 1904) and the Chalfont (1894) epileptic colonies, where “the labour of inmates produce[d] a considerable profit” and reduced the costs of their maintenance.¹³⁴ There was little time for the Mental Deficiency Act to take effect before the outbreak of the war in 1914, and little money after the conflict for new institutions to be created, but the principle of caring for curable and incurable patients separately had been established. At the same time, the principle of patient work as a means of reducing maintenance costs for incurable—as opposed to curable—patients was also established.

In France, calls for the separation of acute, curable cases and chronic, incurable cases into different institutions intensified in the 1890s amid a torrent of anti-alienist literature criticising asylum conditions and poor prognoses, as well as widespread concerns about national decline and degeneration.¹³⁵ Popular fears about the “quantity and quality” of the French population were expressed in Max Nordau’s book, Degeneration (1892), while right-wing journalist Maurice Barrès warned in 1908 of the “moral feebleness” and “weakening of the will” that were early signs of mental illness and degeneration.¹³⁶ France’s low birth-rate, the lowest in Europe, was also a source of anxiety for which degeneration was believed to be responsible. The population of France grew by just 11% between 1851 and 1901, while that of England and Wales increased by 81% in the same fifty-year period.¹³⁷ Between 1901 and 1911 the population of England and Wales increased by a further 11%, but that of France by only 1.8%.¹³⁸ The French, according to Robert Nye, became renowned for the “sheer obsessiveness” with which they pursued the problems of social deviance, degeneration and national decline.¹³⁹

These fears were exacerbated by the rising number of cases of insanity in France, as noted by General Councillor Navarre in 1908. Asylums in the Seine were overcrowded, despite the existence of colonies for incurable patients just outside the capital. Based on similar principles as the epileptic colony in Britain, institutions for the Seine department’s incurable patients had been established in the rural areas of Dun-sur-Auron in 1892 and at Ainay-le-Château in 1897 by Auguste Marie.¹⁴⁰ However, these institutions could not accommodate all the Seine’s incurable patients. Increasing numbers of incurable and chronic patients were therefore remaining in the Seine asylums, where the costs of care were higher.¹⁴¹ The policy of transferring some incurable patients from Paris to the provinces was being compromised by overcrowding in provincial asylums, which could no longer accept as many patients from the capital.¹⁴² Maintaining incurable patients in asylums did not make economic sense, according to General Councillor Henri Rousselle. He referred to the incurable insane as des non-valeurs sociales; they were never going to be productive citizens, and yet the costs of their care (in the expensive asylums) were roughly equal to the amount earned by a labourer, who worked hard and contributed to society.¹⁴³ Rousselle sought to divide the Seine’s asylums into two groups, one reserved for acute and curable cases, and the other exclusively for chronic and incurable patients.¹⁴⁴ The first group would justify a higher level of investment because patients being treated here would, once recovered, be able to re-join the labour market as productive citizens. Rousselle’s plans would eventually (in 1927, a year after his death) be realised in the transformation of the Asile Clinique into an acute hospital. Édouard Toulouse, one of the Parisian psychiatrists committed to the separation of cases, was also convinced of the curability of mental disorder provided asylum doctors had the opportunity, training and facilities to actively treat those most likely to benefit. His ambitions to establish a hospital for incipient cases of mental disorder would also have to wait until after World War I. Both of these plans would have a significant impact on patient work.

Conclusion

Therapeutic work for mentally ill patients emerged in the context of moral treatment at the end of the eighteenth century. The early moral therapists perceived mental illness in psychological terms and used work and occupation as a means of helping patients to control their symptoms and to adopt behaviours that equated with contemporary social norms. The principles of moral treatment provided the administrative and medical framework for the newly established asylum systems of France and England, so that even when the efficacy of moral treatment was thrown into doubt, work and recreational activities continued to be organised for patients. They became accepted aspects of asylum regimes and in France, their provision was enshrined in law. That said, the nature of occupation underwent subtle changes in emphasis as asylums gradually evolved from places of treatment and cure to custodial institutions, and as the therapeutic optimism associated with moral treatment descended into the pessimism of hereditary degeneration. The benefit of work as a method of disciplining large numbers of patients and of offsetting institutional running costs was given equal or greater priority than its role as a means of therapy. While patient work featured prominently in the early asylum annual reports, it had become almost a footnote in reports at the end of the nineteenth century, with little evidence of work being found to suit patients’ aptitudes or previous occupations. Most late-nineteenth and early twentieth-century psychiatrists supported theories of hereditary degeneration and did not believe that mental illness could be cured. There were some, however, who maintained faith in its curability and campaigned for institutional reform, such as the separation of curable and incurable cases. Only by separating cases could the curable receive the medical attention they required to make a recovery. The need for reform became more pressing after World War I and the war itself led to a reappraisal of the causes of and treatment for mental illness.