From Alienism to Psychiatry

Abstract

Freebody demonstrates how the divergent pathways to professionalisation taken by French and English psychiatry generated different views regarding the causation and treatment of mental disorders, and the therapeutic value attributed to work and other occupations. French psychiatry’s close links to neurology led to an adherence to a physiological interpretation of mental disorder, and to the persistence of a custodial model of care, or “alienism”, in the provinces, and to a preference for biological methods of treatment in the capital. After their experiences of treating “shell shock” during World War I, English psychiatrists (and a small group of Parisian psychiatrists) began to see the causes of mental disorder holistically, the result of psychological, social or environmental factors, or a combination of these and physiological factors. For these psychiatrists, occupation and psychotherapy became useful tools in the active treatment of curable patients, not simply the preserve of calm, chronic, incurable and convalescent patients.

Throughout the nineteenth century, the origins of, and the treatment for, mental disorder were perceived similarly by psychiatrists in both France and England. In both countries, moral treatment had been embraced as the answer to curing the scourge of mental disease. Later, disenchantment with moral treatment and a move towards a physiological interpretation of mental disorder, based on theories of heredity, occurred in both countries at roughly the same time. Attitudes towards patient work and occupation followed similar paths, in line with these changing views. But after World War I, psychiatry in France and England appeared to diverge. This chapter explores the nature and causes of this divergence and its effect on how French and English patients were occupied during the interwar period. It is argued that different models of care evolved in each country after the war. Divergent pathways to professionalisation taken by French and English psychiatry and the different emphases placed on the psychological and physiological causes of mental disorder led to the persistence of an alienist, or custodial, model in one country and to the evolution of a psychiatric model in another.

The Professionalisation of Psychiatry

In England, psychiatry and neurology were separate disciplines. Neurology had a centre of excellence in London at the National Hospital, Queen Square, which opened in 1860.¹ As psychiatrist David Henderson put it, neurologists dealt with “nerves” and knew “nothing about the disorders of the mind”.² In his view, their rigid and objective training led them to think solely in terms of structure and pathology. Neurologists were able to rule out the existence of an organic lesion, but that was the limit of their usefulness to psychiatry.³ British neurologists did not tend to become involved in asylum medicine and, unlike in France, neuropsychiatry did not develop as a combined major specialty.⁴ While neither specialist training nor a qualification in mental medicine were essential requirements for medical superintendents in English mental hospitals (although they had to be qualified doctors), the Medico-Psychological Association (MPA) sought to introduce professional standards with its Certificate in Psychological Medicine, established in 1885. It was never very popular, and was based on vocational rather than academic knowledge, but by 1896 some 240 doctors held the certificate.⁵ In 1892, the MPA, aware of the shortcomings of the Certificate, established an Educational Committee to explore options for expanding and improving training and qualification.

The Diploma in Psychological Medicine (DPM) was created in 1908–1910, and universities were invited to participate. The DPM involved written and practical tests in psychology, anatomy and physiology, together with questions on asylum administration and legislation.⁶ The examination could only be taken two years after medical qualification and following at least three months’ clinical experience in a mental hospital. The first DPM examinations were first taken at Leeds University in 1911 and at Cambridge and Edinburgh Universities in 1912, following courses of instruction at those institutions.⁷ Candidate numbers remained small before the outbreak of World War I, and it was not until the opening in 1923 of the Maudsley Hospital, which offered a six-month course of intensive lectures and demonstrations delivered by high-profile teachers, that the DPM began to attract candidates in double figures.⁸ Nonetheless, the qualification, while it did not become a pre-requisite for a post in a mental hospital during the 1920s and 1930s, marked a significant step in the professionalisation of psychiatry in Britain and its establishment as an independent, academic discipline.

In France, there were no specialist academic courses of instruction, nor any qualifications in psychiatry until after World War II.⁹ Asylums were staffed by full-time physicians appointed by the Ministry of the Interior and a system of internship ensured the transmission of psychiatric knowledge. Medical students entered the asylum as an “interne” in their final year of study.¹⁰ The fact that psychiatrists were unable to identify the alleged physiological causes of mental disorder, or to effect successful cures, led to frequent attacks on the profession by the press from the 1860s.¹¹ Journalists cited therapeutic failure, inappropriate sequestration and the neglect of patients. Morale among alienists plummeted and asylums fell into disrepair. Forging links with the more prestigious, scientifically advanced specialism of neurology was a means of countering this criticism.¹² Neurologists, benefiting from advances in microscopy, improved laboratory techniques and experimental methods, had enhanced their understanding of neuroanatomy and neurological disease during the latter half of the nineteenth century. These developments led to neurology’s reputation as the leading medical specialty in fin-de-siècle France, with alienism its poor relation.¹³ Alienism and neurology overlapped in many ways. Both interpreted mental disorder from an organicist perspective, and it was possible for doctors to switch from one to the other with ease as professional qualifications were yet to be established in either specialism.

Many of the alienists who worked in the Seine asylums had studied neurology at the Salpêtrière before taking up their asylum posts. The post of Chair of Mental Disorder, based at the Faculty Clinic at Ste Anne’s, was given to individuals with a predominantly neurological background, including Benjamin Ball (1833–1893), Alexis Joffroy (1844–1908), Gilbert Ballet (1853–1916), Ernest Dupré (1862–1921) and Henri Claude (1869–1945).¹⁴ From 1894, neurologists were included in the annual alienists’ conference, which became known as the Congrès des aliénistes et neurologistes.¹⁵ Ballet, who became Chair of Mental Disorder in 1909, was instrumental in developing the alliance between neurology and asylum medicine. Ballet founded a new journal, L’Encéphale (meaning “brain”), in 1906, with the aim of overcoming psychiatry’s isolation from the rest of medicine and highlighting the many commonalities between neurology and the treatment of mental illness.¹⁶

Neurology’s high status in France was in part due to the work of Jean-Martin Charcot (1825–1893), the first Professor of Clinical Diseases of the Nervous System at the University of Paris (from 1882). Practising at the Salpêtrière hospital, Charcot pioneered a systematic approach to the clinical analysis of many neurological conditions, but was most famous for his research into hysteria, one of the so-called ‘functional nervous disorders’. Charcot, who supported the theory of hereditary degeneration prevalent in the late nineteenth century, attributed hysteria to the psychical effects of traumatic events on a degenerate individual.¹⁷ In other words, the underlying cause of hysteria was physiological, linked to a weakness of the central nervous system, while the symptoms were psychological, triggered by a traumatic experience.¹⁸ No physical lesion could be found to indicate a physiological weakness, however, prompting consideration of alternative, non-organic conceptualisations of the condition by the next generation of neurologists.

The Emergence of More Psychological Approaches to Psychiatry

A new discipline—that of psychology—emerged in Europe and the USA in the last quarter of the nineteenth century. Initially, the study of psychology remained academic, a branch of philosophy, and its findings were not applied to the “conduct disorders” that constituted psychiatry.¹⁹ For many years, alienists were indifferent to psychology.²⁰ This period of indifference was ended by the famous German psychiatrist Emil Kraepelin (1856–1926). Kraepelin adopted a multiple approach to psychiatry that incorporated not only neurology and brain anatomy, but also experimental psychology and a thorough investigation of a patient’s life history.²¹ The Swiss psychiatrist Eugen Bleuler (1857–1939), who developed new theories regarding schizophrenia, also sought to introduce greater psychological understanding in the treatment of mental patients between 1890 and 1900.²² As medical director of the Rheinau, and later the Burghölzli Mental Hospitals, Bleuler developed psychological treatment regimes that included occupation, which he considered essential to a patient’s health. Bleuler pioneered the approach that would later be developed by the Swiss-born, American psychiatrist, Adolf Meyer, one of the founders of the Mental Hygiene Movement.²³ Psychodynamic theories were most famously developed by the Viennese neurologist, Sigmund Freud (1856–1939) and the Swiss psychiatrist Carl Jung (1875–1961), who had worked as Bleuler’s assistant. Freud’s ideas were not greeted favourably by his contemporaries, however, with the notable exception of Bleuler.²⁴ Less well-known were the psychoanalytic theories of French psychiatrist Pierre Janet (1859–1947). In fact, Janet developed the concept of psychological analysis seven years before Freud, although it was Freud who coined the term “psychoanalysis” in 1896.²⁵

Whilst far from mainstream, psychological interpretations of mental disorder were therefore in circulation on the continent, and in France and England, before World War I. Experimental psychology laboratories were established in Paris (1889) and Cambridge (1897); national psychological societies were founded in both countries in 1901; and journals dedicated to psychology in 1904. While the evolution of psychology appeared to follow similar trajectories in France and Britain, significant differences lay in the pre-war familiarity with psychoanalysis and in the impact of psychology on asylum medicine. Freud’s theories were being read in England well before 1914, whereas in France they were almost unknown until after World War I. Traditional French hostility to Germanic scholarship, coupled with linguistic barriers and a preference for physiological explanations, may explain this.²⁶ The English psychiatrist David Eder read a paper on Freud’s methods to the British Medical Association in 1911; Freud’s Papers on Psycho-Analysis were published in Britain in 1912 and the London Society of Psychoanalysis was founded in 1913.²⁷ Bernard Hart (1879–1966), who, before World War I worked at the Long Grove Asylum with Edward Mapother, published The Psychology of Insanity in 1912 that included references to the works of Freud, Jung and Janet.²⁸

Despite Pierre Janet’s development of a similar psychodynamic approach to that of Freud, psychoanalysis and other psychological approaches to treating mental disorder did not impinge upon French psychiatry or asylum medicine before World War I. In England, notably at the new Long Grove Asylum in Epsom, Surrey (founded in 1907), psychiatrists responded more favourably.²⁹ The English psychiatrist Charles Mercier (1851–1919) anticipated the psycho-biological approach that would characterise psychiatry in England after World War I in his work on conduct disorders published in 1911.³⁰ A psychodynamic approach was influential in the development of treatment for traumatised British, but not French, soldiers during World War I. This would have implications not only for the introduction of occupational therapy and the practice of patient work, but for the development of psychiatry in each country between the wars.

The Influence of World War I

During World War I, approaches to treating soldiers suffering from war neuroses (the term “shell-shock” was only used in Britain) reflected the different psychiatric traditions of each of the combatant countries.³¹ They also depended on the physicians’ previous training and social networks.³² The different experiences of French and English physicians in these areas led to different emphases on the use of occupation as a treatment for war neuroses in France and England. The treatment of war neuroses as a purely neurological problem by French psychiatrists, and the greater willingness by English psychiatrists to treat shell-shock with psychotherapy, appeared to affect the readiness of psychiatrists in each country to adopt new methods of occupying patients after the conflict.

Conventional historical accounts hold that before World War I, all British psychiatrists were “physicalists” who regarded war neurosis as a “functional nervous disease”, the underlying cause of which was physiological and linked to notions of hereditary degeneration, and that by the end of the conflict, psychiatrists had become psychologists, incorporating the methodology of Freud and psychoanalysis.³³ This interpretation rightly emphasises the role of the war in boosting the subsequent spread of depth psychology, but as Chris Feudtner argues, it oversimplifies the situation.³⁴ Partly physical and partly psychological diagnoses of traumatic hysteria and neurasthenia occurred before 1914.³⁵ Physicians who were known to have a strong physical, neurological view of war neurosis, such as Frederick Mott, also recognised the psychological aspects of the condition, while some psychologists, such as William McDougall, linked mental disorders with underlying physiological issues. There was no “crisp dividing line” between the physicalists and the psychologists; the reality was more nuanced.³⁶ There were also variations in the types of treatment that constituted “psychological” therapy, which included techniques of persuasion and psychoanalysis.

The different training and networks of those involved in treating shell-shocked soldiers led to different approaches. Historian Eric Leed identified two different techniques in the British treatment of shell-shock, “disciplinary” and “analytic”, which were “rooted in two different conceptual frameworks and visions of human nature”.³⁷ The disciplinary method, or “quick cure” was the preferred method in the French military. It was based on a ‘moral’ view of war neurosis as a form of malingering. In England, this method was associated with the neurological National Hospital at Queen Square where a specialist unit had been opened for severe cases of shell-shock, such as mutism or paralysis. The treatment comprised a mix of high pressure techniques of persuasion; shouted commands were accompanied by the use of strong, painful electric shocks (faradisation), icy showers and isolation.³⁸ The analytic method, associated with psychologists based at the Red Cross Hospital, Maghull, including W.H.R. Rivers, T.H. Pear and William McDougall, won the “grudging support” of the military authorities towards the end of war, and the Maghull was given responsibility for training military psychiatrists.³⁹ This method, which included re-education and psychotherapy, involved paying close attention to the whole patient and their state of mind, while the disciplinary method focused solely on their neurological symptoms.⁴⁰

The emphasis placed upon the re-education of the patient, a key aspect of which was the prescription of work and occupation, contributed to the greater interest shown in therapeutic occupation in England during the interwar period. The emphasis on occupation is revealed in a number of English publications produced during or just after the war. Elliot Smith and T.H. Pear’s Shell Shock and its Lessons (1917), for example, advocated therapeutic work for the shell-shocked patient to prevent him from “dwelling upon his subjective troubles”.⁴¹ A “suitable occupation” should be identified comprising “useful work” to stop the patient from feeling that he was a burden, reflecting contemporary notions of usefulness, efficiency and duty. The work should be interesting and occupy the patient’s mind, not just his body, and combined with attempts to identify the root cause of his trouble through psychotherapy.⁴²

A report by American psychiatrist, T.W. Salmon, who visited British treatment centres in France before the US entered the war in 1917, believed that “re-education by physical means is a valuable adjunct to treatment” and that this was best achieved by occupation.⁴³ While the British facilities for treatment were quite limited, the Americans introduced a range of clinical interventions, which included the provision of psychotherapy and occupational therapy workshops.⁴⁴ Activities could be conducted in bed (such as basket-making, net-making, polishing and sand-papering), indoors (such as carpentry, wood carving, metal work, printing, book-binding and cigarette making) or outdoors (including farming, gardening, animal care and building work).⁴⁵ Salmon emphasised that “shell-shock” was a disorder of “will” as well as function and that “progressive achievement” was the only means by which “manhood and self-respect” could be restored.⁴⁶ Patients were encouraged to undertake physical tasks such as the cultivation of farmland, wood cutting and road construction, and art therapy which helped them come to terms with their traumatic experiences.⁴⁷

British physician Millais Culpin, who had treated British troops in France in treatment centres established by the British military, also emphasised the value of work for shell-shocked patients in The Psychoneuroses of War and Peace (1920). Work and hobbies formed part of a programme of psychotherapy and re-education in which “all methods converge[d] and overlap[ped] in order to make the patient efficient again and to enable him to cope with himself and his environment”. Doctors sought to re-establish patients’ self-confidence, which was usually “painfully lacking”, by assigning chores and small projects that fostered a sense of achievement.⁴⁸ Work helped the patient feel that he was capable of “taking part in the world again” and provided a “useful gauge of his progress towards active citizenship”.⁴⁹ The War Office Committee agreed, maintaining that at the re-education stage of treatment, “the patient should be occupied consistently and not allowed to slip back into unprofitable habits by neglect or lack of mental diversion”.⁵⁰ At the Maudsley Hospital, under the direction of Frederick Mott, “an atmosphere of cure” was emphasised through “purposeful activity”.⁵¹ Occupational therapy and social activities were encouraged; soldiers grew vegetables in the hospital grounds and constructed a poultry house to provide a supply of fresh produce. Patients were taught carpentry and woodwork in a large, fully equipped workshop (see Fig. 3.1). Mott donated a piano and advocated choral singing as an “uplifting mental diversion” which he believed would promote “that sense of wellbeing so essential for mental and bodily recuperation”.⁵² These re-educative methods involving occupation were rare in French military psychiatry.

Fig. 3.1

Carpentry Workshop at the Maudsley Hospital, London, 1918. During World War I the hospital was used by the Royal Army Medical Corps to treat soldiers suffering from “shell shock”. (© By permission of Bethlem Museum of the Mind, HPC-19)

The French Army’s Service de Santé equated war neuroses with hysteria, the condition made famous by the flamboyant French neurologist Jean-Martin Charcot (1825–1893). The authorities regarded the incidence of such functional disorders as highly contagious, posing a threat to the morale of the army that needed to be contained.⁵³ The “disciplinary” approach to treatment, associated with neurology (the dominant medical specialty in France and with which psychiatry had sought to align itself) was preferred by the French military authorities. Military neuropsychiatric treatment centres were established in the main cities and run by neurologists. In Paris, for example, neurologists Jules Dejerine and Pierre Marie assumed responsibility for the military neurological department at the Salpêtrière Hospital; Joseph Babinski and Jules Froment took over the military unit at the Pitié; Gilbert Ballet at the Maison Blanche and Achille Souques at the Paul-Brousse Hospital.⁵⁴ Neuropsychiatric centres were also established near the Front, overseen by neurologist Gustave Roussy.

The disciplinary approach, similar to that adopted at the English neurological hospital at Queen Square, was championed by neurologist Joseph Babinski, Charcot’s former pupil. It was this approach that came to dominate French treatment of war neuroses.⁵⁵ Babinski’s methods were “virile and correctional”, sometimes involving the use of electricity to produce intense pain. This technique, which became known as torpillage (from the French word torpille meaning electric eel) was controversial and some soldiers refused treatment.⁵⁶ These disciplinary methods did not treat the underlying psychological causes of the trauma, but were effective in removing, in the short-term at least, physical symptoms such as mutism or an inability to walk. Recidivism was common, however. It has been suggested that in countries where the fighting was on home territory, such as France, firm physical methods of treatment predominated, while elsewhere (such as Britain) patient management was focused on longer-term psychological methods.⁵⁷ French physical methods of persuasion, whether or not they involved the more extreme measures of torpillage, were based on a medical-military attitude that sought the rapid return of soldiers to the Front to defend French territory.⁵⁸ Physical therapies were preferred in France, although some doctors, such as Dejerine, did opt for more psychological methods.

A French military treatment centre for soldiers who had sustained physical injuries, such as the loss or paralysis of a limb, rather than for those suffering from war neuroses, used occupation therapeutically. At the neurological centre in Montpellier, Dr Villaret developed a programme of “professional re-education” involving a form of occupational therapy (ergothérapie).⁵⁹ Agricultural work, artisanal activities such as metalwork, leatherwork, woodwork and upholstery formed part of a programme that included training in typing, accounting and languages. Recovering patients assisted the nurses with training new patients.⁶⁰ A film made at the centre in 1919 shows soldiers with paralysed hands looking after the pigs and learning agricultural skills.⁶¹ Agricultural work was also used to rehabilitate those who had suffered severe facial injuries during the war. These individuals, known as les gueules cassées (or broken faces) found their disfigurement a barrier to returning to their former employment, and in some cases to their families. In 1921, a group of veterans established L’Union des blessés de la face et de la tête that organised work on farms for such individuals, enabling them to support themselves whilst coming to terms with their transformed appearance and avoiding public stigma.⁶²

By the end of the war, British servicemen suffering from war neurosis were more likely to receive holistic treatment that focused on their psychological condition as well as their physical symptoms than their French counterparts. The psychodynamic treatment offered at the Maghull was perceived as the most effective, long-term method of treatment.⁶³ The British, influenced by the Americans, who established sophisticated occupational therapy workshops within their treatment centres near the Front, recognised the value of in-depth psychotherapy coupled with re-educative techniques involving work and occupational therapy. In France, the disciplinary or quick cure, based on physical treatment methods, was preferred. These did not incorporate work therapy or occupational therapy and did not deal with the underlying psychological causes of the traumatic response. The different approaches to dealing with war neuroses by French and English psychiatrists drew on the different psychiatric traditions of each country; these traditions led to divergent responses to new theories of therapeutic occupation emerging after World War I.

The Mental Hygiene Movement

The war highlighted the need for services where mildly troubled former soldiers and traumatised civilians could be treated without the threat of internment in an asylum.⁶⁴ The psychological effect of the war on civilians was particularly noticeable in France, where so many homes and livelihoods had been destroyed as a result of the fighting. The cure of these individuals was essential to revitalise the French nation. Reformers, such as Édouard Toulouse, called for the establishment of new, medicalised psychiatric facilities.⁶⁵ The post-war period in both France and England saw the introduction of social hygiene measures to improve the physical health of their populations, including strategies to tackle tuberculosis, alcoholism and syphilis, and thereby boost the productivity of their workforces.⁶⁶ Efforts to improve the populations’ mental health (or “mental hygiene”) were stimulated by the Mental Hygiene Movement. The movement originated in the USA, where Clifford Beers, aided by the professional expertise of psychiatrist Adolf Meyer, co-founded the National Committee for Mental Hygiene in 1909. Beers’ experiences in three different mental hospitals in the early 1900s had persuaded him to devote his energies to campaigning for improved services for the mentally ill. The movement spawned national organisations in France and England in 1920 and 1922 respectively. The chief purposes of the movement, as reported by the Journal of Mental Science in 1923, were to conserve mental health; promote the study of mental disorders and intellectual impairment; to obtain and disseminate information regarding mental health; raise standards of care and treatment; and co-ordinate the activities of national organisations.⁶⁷ The movement was associated with the growing interest in psychology and an awareness of the importance of conserving the mental health of a population to the national economy.⁶⁸ It emphasised the important role that psychiatry had come to play in the social life of the community.⁶⁹

Adolf Meyer, co-founder of the Mental Hygiene Movement in the USA, was an early adopter of occupational therapy at the Henry Phipps Clinic in Baltimore. Meyer defined mental disorder as a form of “maladjustment” or a state in which individuals were no longer able to respond adequately to their environment.⁷⁰ His approach was holistic. He believed that the causes of mental disorder could be physiological, psychological, social or environmental. He used the term “psychobiology” to describe this approach, which enabled him to overcome the great divide between “mind” and “body”, or between an organicist and a psychological approach to mental illness.⁷¹ His views on the causation, treatment and prevention of mental disorder informed the International Mental Hygiene Movement and influenced the approaches taken by national mental hygiene organisations. The model of treatment advocated by Mental Hygiene Movement included the establishment of outpatient clinics, where patients could receive treatment such as psychotherapy without admission to a mental hospital; the provision of social services for the support of patients both in hospital and at home; child guidance clinics; and facilities for the voluntary treatment of patients at the early stages of their illness (or “open” services, as they were known in France). This model of treatment, and Meyer’s teaching, also informed the English Macmillan Report of 1926. This report maintained that “there is no clear line of demarcation between mental and physical illness”.⁷² Physical illnesses could have a “mental concomitant” just as mental disorders could have a “physical concomitant”, and in many cases it was hard to ascertain whether mental or physical symptoms predominated.⁷³ The notion that mental disorder could be the result of a “medley” of different causes became known as the “continuity of mental disorder”, a phrase coined by Edward Mapother of the Maudsley Hospital.⁷⁴

Meyer’s influence was apparent in Paris, where the League of Mental Hygiene was founded in 1920 by psychiatrist Édouard Toulouse, supported by Joseph Briand and Georges Génil-Perrin.⁷⁵ Toulouse developed a personal friendship with Clifford Beers after reading his book, A Mind That Found Itself, published in 1908, and became greatly interested in the new approach taken by Meyer at the Henry Phipps clinic.⁷⁶ Toulouse has been described as an “organiciste tempéré”.⁷⁷ At the beginning of his career, Toulouse was an organicist, but the more he focused on the preventative agenda of the Mental Hygiene Movement the more he became convinced of the role played by social factors in causing mental disorder. Toulouse maintained in 1926 that, “For historical reasons, [psychiatrists] have remained organicists for too long … it must be remembered that mental illness is also affected by the social character of the individual”.⁷⁸ He maintained that the organicists did not pay sufficient attention to problems of “maladaptation” to a patient’s social situation and was adamant that social factors should not be overlooked in the genesis of psychosis.⁷⁹ His views were far more in tune with those of Adolf Meyer than they were with French psychiatrists outside Paris, most of whom dismissed his theories. Like Meyer, Toulouse and his Parisian colleagues took a holistic view of mental disorder. One such colleague, Ernest Dupré of the Faculty Clinic at Ste Anne, concluded in 1919 that “mental illnesses are diseases of the personality”, suggesting a much broader concept of mental disorder than that held by most French psychiatrists.⁸⁰ Toulouse developed a similar concept to Meyer’s “psychobiology” that he termed “la biocratie”.⁸¹ For Toulouse, it was still essential to conduct thorough investigations into potential physical factors, such as the metabolism of the brain, or anatomical changes within the nervous system, but the life-style and character of an individual were equally important considerations.

The British National Council for Mental Hygiene (NCMH), founded in 1922, was not driven by one man’s vision in quite the same way as the French League. The British NCMH included a cross-section of founder members, including eminent psychiatrists Sir Frederick Mott, Hubert Bond, Hugh Crichton-Miller and Alfred Tredgold; psychologists Charles Myers and W.H.R. Rivers; neurologist Henry Head; and philanthropist and businessman Sir Courtauld Thomson, the Council’s first president.⁸² As members of the Council of the Eugenics Education Society, Mott and Tredgold were in favour of segregating the intellectually impaired and of pursuing the policies set out by the Mental Deficiency Act of 1913. Henry Head, like Toulouse, was concerned by industrial fatigue and worker efficiency, maintaining that “much industrial unrest was due to the worry and fatigue induced by unsatisfactory working conditions”.⁸³ Hubert Bond was an active campaigner for voluntary treatment and President of the Association of Occupational Therapists from 1937, while Hugh Crichton-Miller’s wartime experiences of treating shell-shock led him to found the Tavistock Clinic for nervous disorders in 1920.⁸⁴

Psychologist Charles Myers, after serving as consultant psychologist to the British Army in France during World War I, founded and became the director of the National Institute of Industrial Psychology in 1922.⁸⁵ He was committed to the Mental Hygiene principle that “a man should have pleasure in his work and a feeling that it is worthwhile” and believed that psychiatrists could assist in the “difficult task of fitting men to the jobs they can best do, and jobs to the men they need”.⁸⁶ W.H.R. Rivers’ speciality was applied psychology; an advocate of psychotherapy and psychoanalysis, his treatment of traumatic experience were influential during World War I. Although the movement lacked the drive and passion of its forceful proponent in France, the NCMH members’ varied interests and spheres of influence ensured that the principles of the Mental Hygiene Movement had a broader reach in England than in France. The Mental Hygiene Movement effectively took psychiatry out of the confines of the asylum and into the community, thereby bringing to an end the era during which psychiatrists were only concerned with asylum cases, and individuals were considered either ‘sane’ or ‘insane’.⁸⁷ Fundamental to mental hygiene principles was belief in the curability of mental disorder.

Transformation of the Asile Clinique

Plans to transform the Asile Clinique into a hospital specialising in curable cases had been mooted at intervals since the asylum opened in 1867. These plans were resurrected in 1918. It was proposed that the Asile Clinique should provide the most up-to-date psychiatric treatment and care by doctors at the peak of their profession.⁸⁸ Patients admitted to the Asile Clinique would be those defined as “acute”. In his 1927 report Dr Marie, head of the Admission Service at Ste Anne’s, provided a summary of what was meant by “acute”.⁸⁹ First and foremost were patients considered “curable” on examination by doctors within the Admissions Service, such as those at the early stage of their illness, preferably not more than six months (or twelve at the outside) from the onset of symptoms, since the evidence suggested that treatment had the greatest chance of being effective during these first few months. This included any case of mental illness (whether confused, toxic or infectious), as long as the case had not been clinically diagnosed as incurable, and patients suffering from emotional states such as phobias or obsessions. At the Asile Clinique, “acute” also included incurable patients who were in need of significant care, even if they were not receiving active treatment, as well as those exhibiting episodes of extreme agitation or depression who needed active medical treatment, or who were dangerous, such as those in the early stages of dementia praecox or chronic delusional states.⁹⁰ Incurable cases who were excluded from the Asile Clinique were those whose conditions would not benefit from active treatment, such as later-stage dementia praecox cases; melancholics and maniacs who were not considered dangerous; “organic cases” such as the senile, those suffering from tertiary syphilis; the intellectually impaired; and patients whose condition had deteriorated into chronicity.⁹¹

The project to transform the Asile Clinique into an acute service was finally approved in 1923, although the transformation was not fully completed for another five years. Chronic and incurable patients were gradually transferred to the colonies or other asylums in the Seine department or the provinces during 1927 and 1928 to make way for acute cases. The men’s and women’s divisions were each divided into two sections, with their own medical and nursing teams, to provide the more intensive care required by acute patients. The discharge rates after 1928 indicate a marked change in the movement of patients, demonstrating that the Asile Clinique was indeed operating as a service for acute, curable cases, as Dr Truelle observed in 1931.⁹² At the Asile Clinique, “alienism” had given way to psychiatry, although the brand of active treatment practised here was biological, rather than psychosocial.

The effect of the transformation of the Asile Clinique on patient occupation was marked. Most French psychiatrists did not consider work or any form of occupation an appropriate treatment for acute patients. Work was for calm, chronic and convalescent patients; these were the patients who were transferred out of the Asile Clinique. The numbers of patients provided with work in the new treatment divisions of the Asile Clinique dwindled following the transformation to a hospital for acute patients. Patients with acute conditions were initially prescribed bed-rest, sometimes for several weeks, according to the teaching of the Dr Valentin Magnan (1835–1916), the long-serving head of the Admissions Service at Ste Anne’s before World War I, and then treated biologically.⁹³ The financial implications of this policy for the Asile Clinique, which lost its chronic and incurable patients and therefore the majority of its patient workers, are explored further in Chap. 5.

Voluntary Treatment

Separating the curable and incurable allowed a greater focus on treating the curable, but, as had been recognised since the early nineteenth century, the mentally ill needed to receive treatment as soon as possible after the onset of their symptoms for it to be effective. Undergoing the time-consuming and stigmatising process of legal commitment to an asylum or mental hospital delayed treatment and jeopardised a patient’s chance of recovery.⁹⁴ In England, calls for the provision of treatment for incipient cases of insanity on a voluntary basis had been ongoing throughout the nineteenth century, but they intensified at the turn of the twentieth. Parliamentary bills were introduced in 1899, 1900, 1904 and 1905, but these had been withdrawn through lack of debating time.⁹⁵ Henry Maudsley, a “sharp and persistent critic” of the English system of lunacy legislation and incarceration throughout his long career, was particularly critical of the delay to treatment caused by the certification process.⁹⁶ The lack of legislative progress to address this issue led him to make a bequest in 1907 for the establishment of a hospital to focus on the “early treatment of cases of acute mental disorder”. This gave the London County Council the impetus, and half the funds, to build an institution that would enable the voluntary admission of poor patients.⁹⁷

Maudsley and his collaborator, Frederick Mott, believed that only by studying mental disorder at its early, acute, yet curable stage could knowledge be generated about its causes. They planned a hospital, named after its benefactor, with facilities for postgraduate training based on Kraepelin’s clinic in Munich.⁹⁸ Parliament granted the Maudsley Hospital special administrative freedoms to avoid the difficulties surrounding certification. The London County Council (Parks etc) Act of 1915 allowed the Maudsley to “receive and lodge as a boarder and maintain and treat … any person suffering from incipient insanity or mental infirmity”. ⁹⁹ The Maudsley, however, only opened to civilians in 1923 since as soon as it was ready to receive patients in 1916, following various delays due to planning and construction issues, it was taken over by the War Office as a clearing hospital for shell-shocked soldiers, and then by the Ministry of Pensions to treat veterans with severe neuroses.¹⁰⁰

Admission to the French public asylum system, established by the law of 1838, was by official committal, a system known as placement d’office. It was restricted to those who posed a danger to themselves or others, or who threatened public order. The system was administered by the local police, who sent individuals to a special infirmary, usually located next to the police cells, for assessment, certification and referral to an asylum. The process was lengthy, complicated and degrading. In the department of the Seine, there was another, allegedly more humanitarian admission procedure known as placement volontaire, that had been introduced in 1876.¹⁰¹ Individuals could be brought by their families directly to the Admissions Office at Ste Anne’s for assessment and referral to one of the Seine asylums. The term volontaire is misleading, however, since, once certified, the patient had no rights and was not considered capable of informed consent.¹⁰² Édouard Toulouse sought to create a truly voluntary system, or “open” service, that would be available to all without certification, enabling the early treatment of individuals with acute symptoms or those at the early, mild stage of mental illness, before their conditions deteriorated.¹⁰³ After witnessing the Scottish “open door” system in 1897, he attempted to persuade the General Council of the Seine of its merits in lengthy reports written in 1898 and 1913.¹⁰⁴ A revision to the law requiring that patients had to be certified to gain admission to public asylums was proposed in 1914, but World War I broke out before this could be debated.¹⁰⁵

The war bolstered Toulouse’s arguments for reform by highlighting the need to strengthen the mental health of war survivors, many of whom (both military and civilian) were traumatised by the experience of war and by the economic instability of its aftermath.¹⁰⁶ The French League of Mental Hygiene provided a useful launch pad for Toulouse’s campaign to establish an “open” psychiatric service in Paris. He obtained the support of several politicians, notably Councillor Henri Rousselle and Health Minister Justin Godard, but many psychiatrists remained opposed to the project.¹⁰⁷ Despite opposition from colleagues, the Service Libre de Prophylaxie Mentale (later named the Henri Rousselle Hospital) opened in 1922 in the grounds of Ste Anne’s.¹⁰⁸ The service comprised an outpatients facility (or dispensary); a hospital (where patients were at liberty to discharge themselves voluntarily); various research laboratories; and a social services department. For the first time, poor patients could access free psychiatric treatment, as “in-patients” or “out-patients”, without having to be certified.¹⁰⁹ Toulouse recognised the benefits of psychiatric social work and its role in helping patients to secure employment after leaving hospital; this comprised an essential service at the Henri Rousselle Hospital.¹¹⁰

The opening of the Henri Rousselle Hospital in Paris in 1922 and the Maudsley Hospital in London in 1923 represented a major reform to treatment of the mentally ill poor in England and France. These two institutions were based on the model of the general hospital and were not subject to the same legislation as asylums. The hospital model was focused on the active treatment of patients who were admitted, and could discharge themselves, voluntarily, in the same way as patients admitted to a general hospital, suffering from a physical condition. Both institutions accepted all classes of patient, including paupers. This meant that the poorest patients could be admitted at the early, curable stage of their mental illness, a facility hitherto denied them. But in 1922/3 these were the only public institutions in England and France where such freedoms existed, and therefore served only a tiny proportion of their respective populations. Outside these two institutions, only those who could afford the fees of private institutions (or in England, those who were eligible for admission to the registered Bethlem Royal Hospital) could access treatment at the early, potentially curable, stage of their illness.

In England after the war, the NCMH and the Board of Control continued the campaign for the extension of voluntary treatment to all public mental institutions. Calls for voluntary treatment peppered the Board of Control’s annual reports throughout the 1920s.¹¹¹ Their case was boosted by the findings of the Macmillan Report of 1926, produced following a Royal Commission on Lunacy and Mental Disorder established by the Ministry of Health in 1924. This radical and influential report declared that no satisfactory distinction between mental and physical illnesses could be identified and concluded that all illnesses should be managed similarly. It stressed the importance of early treatment and stated that “certification was to be the last resort in treatment, not [its] prerequisite”.¹¹² The aim of psychiatry should no longer be the containment and isolation of individuals with the most severe conditions. Anyone suffering from a mental illness, whether severe or mild, should have access to treatment, either at home, at an outpatients’ clinic, in a general hospital or in a mental hospital, depending on the patient’s needs and the availability of facilities.¹¹³ This paved the way for an opening up of psychiatric facilities and for the care in the community measures that would be introduced after World War II.

The Mental Treatment Act was eventually passed in 1930. It provided for the admission of uncertified, early-stage, acute cases to all public mental hospitals on a voluntary or temporary basis, without the need for the lengthy process of certification that delayed the commencement of treatment.¹¹⁴ Medical superintendents were encouraged to transfer their chronic patients to Public Assistance Institutions,¹¹⁵ or specialist institutions for the “mentally deficient” to allow acute cases to have “first call” on mental hospital beds, where they would receive active treatment.¹¹⁶ The Board of Control described the Act as “the outstanding event of the year”.¹¹⁷ As Mathew Thomson put it, the Act “promised to turn the asylum into a place of treatment and cure, rather than of long-term custody”.¹¹⁸ By 1938, nearly 38% of all admissions to English public mental hospitals were voluntary.¹¹⁹ This meant that a greater proportion of patients were admitted at the early, curable stage of their illness, thereby increasing the need for effective treatment. In terms of occupation, this called for carefully supervised occupational therapy rather than the traditional, unstructured and routinised institutional work given to chronic, incurable, and convalescent patients. This in turn, required well-trained, specialist staff capable of supervising and delivering occupational therapy.

In France there was no equivalent to the English Mental Treatment Act. The only “open” public services, other than those at the Henri Rousselle, remained the faculty clinics attached to medical schools, but places were extremely limited. It was only in 1937 that French Health Minister Marc Rucart, issued a Circular in which he proposed the reorganisation of care for the mentally ill, along the lines already established by the Henri Rousselle Hospital in Paris. Acknowledging that measures to combat mental illness had not been pursued as vigorously as those taken to fight other social scourges (such as tuberculosis), Rucart set out similar proposals for reform to those put forward by the English authorities in the Macmillan Report over a decade earlier. He stressed the “therapeutic, economic and social importance” of early treatment and maintained that pauper mental patients, “easily curable” at the start of their illness, became a danger to themselves and others if their condition was left untreated.¹²⁰ By the time their condition had deteriorated to the point where the law intervened, they faced the prospect of long-term internment in an asylum, perhaps for life, for which there was a heavy cost to society, both in terms of the patients’ care and their lack of productivity.¹²¹ Rucart wanted to see the provision of “open services” for the voluntary admission of those with mild symptoms, outpatient facilities, social services and assistance for “abnormal children” in all departments.¹²² These recommendations were followed by another ministerial Circular, issued in 1938, which attempted to modify (but did not supplant) the regulations set out in 1857. They sought to re-orientate the care of patients in “closed”, provincial asylums towards a focus on treatment rather than custodial care.¹²³ Henceforth asylums were to be known as “psychiatric hospitals” to emphasise this new focus, although as one psychiatrist observed, the change was in name only.¹²⁴ Most French provincial institutions lacked either the finances or the will to instigate the proposals set out by Rucart before the outbreak of World War II in 1939, and the new law was not enforced.¹²⁵

This lack of reform within provincial institutions led historians Postel and Quetel to observe that the further French asylums were from cities the more they remained locked into psychiatric conservatism (or alienism). They point to a cleavage between the progressive developments in the area of mental hygiene taking place in Paris, under Toulouse’s influence (including the establishment of “open” services, outpatient clinics, social services and research facilities), and other institutions outside the metropolis that were effectively left behind.¹²⁶ Their distance from the capital and the reformist agenda of the Mental Hygiene Movement, together with their isolation from the rest of medicine, meant that psychiatrists in French provincial asylums, such as the Asile de la Sarthe, continued to run their establishments according to the custodial model of care associated with alienism. The new approach to psychiatric care taken by Toulouse and his colleagues at the Henri Rousselle Hospital was not welcomed by these provincial psychiatrists for whom it represented a threat.¹²⁷ Routinised work continued to characterise occupation for calm, chronic and incurable patients in these provincial institutions, while acute and severely disturbed patients were sedated or isolated.

The ongoing cleavage between alienism and psychiatry, which remained marked in France outside the capital, attracted the attention of Aubrey Lewis (who joined the Maudsley Hospital staff in 1929 and was appointed Clinical Director in 1936) during his tour of European psychiatric institutions in 1937. His subsequent report offers a useful insight into the approach of French interwar institutions. While he was in Paris, Lewis observed that “the gulf between the ‘médecins des hôpitaux’ and the ‘médecins des asiles’ [was] wide”.¹²⁸ By this he meant that hospital doctors, such as those practising at the Henri Rousselle Hospital and Henri Claude’s Faculty Clinic, took a more holistic view of mental illness and were engaged in active treatment, including psychotherapy, while asylum doctors were more likely to hold a traditional organicist stance and to offer only custodial care. Lewis maintained that French asylum medicine drew on its heritage of neurology, hysteria and neurosis, and remained intent on identifying physical causes of mental illness.¹²⁹ Furthermore, Lewis observed that there did not appear to be much communication between the various sectors of French psychiatry.

Although psychotherapy and psychoanalysis had begun to make in-roads into French psychiatry in the 1920s, it was very much “on tiptoe”.¹³⁰ Organisations such as the Société de l’Évolution Psychiatrique, the Mouvement Psychanalytique Français had emerged and the Revue Française de Psychanalyse appeared in 1926, but the numbers involved were small and all were based in Paris.¹³¹ Lewis noted that the “more progressive people” were associated with Eugène Minkowski’s Évolution Psychiatrique group (also Parisian), whose main interest was psychopathology.¹³² Rather than trying to explain mental disorder in terms of brain lesions, psychopathologists concentrated on the clinical observation of symptoms, putting them at odds with the neurologists, who regarded the Évolution Psychiatrique group somewhat contemptuously.¹³³ The group mainly comprised hospital doctors (many were attached to the Henri Rousselle, including Georges Heuyer, or to Professor Claude’s Faculty Clinic at Ste Anne’s, such as Jacques Lacan and Henri Ey) and psychiatrists working outside the asylum system. Most asylum doctors, concluded Lewis, had “very little opportunity” to experience “the more psychological side of therapy”.¹³⁴ As French historian of psychiatry Jean Guyotat observes, psychoanalysis did not impinge on neuro-psychiatry, but it had considerably more influence at the psychiatric hospital level, thereby reinforcing the division between the “resolutely” organicist stance of the asylums and the psychosocial psychiatry associated with psychoanalysis, of psychiatrists working in private practice and at the Parisian public mental hospitals.¹³⁵ The organicism of French asylum medicine was at odds with Lewis’ own views; he maintained the psychobiological perspective of most of the Maudsley psychiatrists, who were heavily influenced by Adolf Meyer.

Conclusion

The fact that French psychiatry was slow to develop as a separate discipline, independent of neurology, impeded development of the holistic interpretation of mental disorder that was the prerequisite for the adoption of new methods of occupational therapy. Psychiatrists adopting a holistic approach were more likely to embrace the idea of treating of acute cases with occupational therapy.¹³⁶ It was only in Paris, and more specifically, at the Henri Rousselle Hospital and the Faculty Clinic, that more psychological or psychobiological interpretations developed. When mental disorder was interpreted holistically, psychotherapy and re-educative methods, including occupational therapy, were considered beneficial for acute, curable patients. This interpretation was limited to Paris until after World War II because of the organicist stance of most psychiatrists, who perceived mental disorder in purely neurological terms. Sedation for the agitated and routinised work for the calm were the standard means of controlling the large numbers of incurable and chronically ill patients. For the latter groups, work was a useful distraction. This custodial approach, associated with the term “alienism”, continued in provincial asylums, such as the Asile de la Sarthe, for far longer than those based in the larger cities, such as Paris and Lyon. At the Asile Clinique, where acute cases received active treatment from the late 1920s onwards, the treatment was biological rather than psychological; acute cases were not prescribed work or occupational therapy. At the Henri Rousselle Hospital, on the other hand, Toulouse considered occupation an important aspect of treatment.

In England, psychiatry was more firmly established as an independent discipline. Campaigning by reformists such as Henry Maudsley; the emergence of psychology; the experience of dealing with shell shocked soldiers during World War I; the influence of the Mental Hygiene Movement; and the findings of the Macmillan Report all contributed to bringing about an ideological shift amongst English psychiatrists. Mental disorder was regarded holistically by a greater proportion of English psychiatrists during the interwar period than before 1914. For psychiatrists, rather than alienists, an individual was no longer regarded as simply sane (without physiological disease) or insane (suffering from a physiological lesion of the brain or central nervous system). Varying degrees of mental disorder placed an individual somewhere on a spectrum of normality and pathology and took account of physiological, psychological, social and environmental factors that could all affect an individual’s mental state.¹³⁷ This erosion of the traditional boundary between “sanity” and “insanity”, referred to as the “continuity” of mental disorder, led to a greater focus on active treatment in mental hospitals.¹³⁸ This was facilitated by the separation of curable and incurable cases, and by the passage of the Mental Treatment Act in 1930 that radically changed the rules surrounding admission to public mental hospitals. The move away from a custodial approach to caring for the mentally disordered, where work was routinised and only prescribed for incurable, chronic and convalescent patients, and towards a medicalised approach typical of hospitals, created an environment in which new methods of occupational therapy could gain acceptance as a curative treatment for acute, curable patients.