Money and Management

Abstract

Tensions between the therapeutic value and the financial benefits of patient work were exacerbated by the difficult financial climate following World War I and during the Great Depression. In France, prefects and asylum directors were keen to maximise the use of patient work to offset institutional running costs, which did not always sit comfortably alongside its therapeutic remit. The transformation of the Asile Clinique into a hospital for acute patients was delayed because it involved losing the asylum’s incurable and chronic patients, who were its best workers. In England, the economic contribution made by patient work was downplayed, in the light of accusations of exploitation, while the curative role of occupation was emphasised. Occupational therapy added to, rather than offset, institutional running costs, but this was justified by its role in active treatment. The budget for entertainment was another contested area; whether expenditure in this area could be justified on the grounds of therapy.

Patient labour saved asylums money. Those in charge of institutions for the mentally ill recognised that the work carried out by patients, originally conceived as therapy by the moral therapists, could also contribute to institutional running costs. By the late nineteenth century, the economic rationale for patient work had begun to take precedence over (although not supplant) its perceived value as therapy. As Geoffrey Reaume observed, asylum work programmes had become cost-saving measures created “under the guise of moral therapy”.¹ The work carried out by calm, chronically ill and convalescent patients (those who required minimal supervision) around the asylum, its grounds and workshops, and on the asylum farm reduced the requirement for paid staff, thereby making savings on the budget for personnel. Furthermore, much of the fresh food and other essential items, such as clothing and bedding, were produced in situ using patient labour instead of needing to be purchased. Before World War I, the asylum authorities in both England and France praised the cost savings generated by patient labour. The straitened financial circumstances brought about by the war rendered the economic contribution made by patient work even more valuable to those trying to balance the asylum accounts, particularly in France where the post-war financial situation was especially challenging. But during the 1920s, attitudes towards patient occupation began to change as asylums were accused of exploiting patients. This chapter examines the response of those concerned with asylum management in England and France to the financial challenges of the interwar period in the light of such criticisms and the emergence of new approaches to occupation. Could asylums survive if patient work was re-organised in a way that might compromise its economic contribution to institutional budgets? How did a patient’s perceived curability, and the management structure of institutions affect decisions regarding the occupation of patients?

The Financial Situation After World War I

Financial pressures following the war meant that hospital budgets were extremely tight, while post-war inflation caused prices to rise unpredictably for essential items such as food. French losses during the war were particularly heavy; the industrial north-east of the country was occupied by enemy forces who laid waste to factories, towns and agricultural land as they retreated. 1.31 million Frenchmen were killed and 1.1 million were severely wounded with permanent work incapacity. France lost 7.2% of its human capital, 25% of its domestic assets and 49% of its overseas assets and 31% of its GDP was spent on the war.² Britain avoided the level of devastation experienced by France, although 715,000 British servicemen died and more than twice that number were wounded. Britain lost 3.6% of its human capital; 10% of its domestic and 24% of its overseas assets were destroyed; and over 25% of its GDP was spent on the war effort between 1915 and 1918.³ Whilst healthcare budgets were strained in Britain, the severity of the French economic devastation resulted in even greater pressure on public finances. Budgetary restrictions not only influenced attitudes towards patient work but also affected the resources available for entertainment and improvements to the material comforts of patients.

Asylums in both France and England were in state of disarray following the cessation of hostilities in 1918. Many patients had been transferred to other asylums following the requisition of their original institutions by the military.⁴ This had resulted in overcrowding, poor nutrition, fewer staff, lower standards of hygiene and the increased incidence of disease (such as tuberculosis and dysentery) in the establishments receiving the transferred patients. The consequent increase in patient mortality led to a reduction in numbers in both French and English asylums during the war.⁵ The situation was exacerbated by the influenza epidemic of 1918–1919, which in France killed over 2500 asylum patients in the Seine department alone.⁶ Despite this reduction in patient numbers, a return to pre-war levels of overcrowding was predicted by Parisian psychiatrist Édouard Toulouse. He envisaged an increase in the incidence of mental illness amongst the general population whose resistance had been eroded by years of wartime privation and anxiety.⁷ After the war, expenditure on health and welfare had to be tightly controlled as the French and English economies struggled to recover. While the Board of Control’s report of 1918 indicates that the post-war condition of English asylums was poor, the General Council of the Seine’s report suggests that French asylums were in an even worse state. It might be expected, therefore, that the contribution made by patient work to asylum finances became even more of a priority than it had been during the late nineteenth century.

The Financial Contribution of Patient Work in France and England

France

In France, this contribution remained an essential aspect of asylum finances during the interwar period. Because of the management structure of French asylums, the financial imperative of patient work made it an area of potential conflict between the asylum director and chief medical officer.⁸ According to the legislation of 1838/1857, asylum management was split between a chief medical officer, responsible for all medical decisions, and an asylum director, responsible for all administrative and financial issues.⁹ The asylum director was at pains to keep asylum maintenance costs down and deliver the cost savings demanded by the local prefecture, while the chief medical officer’s priority was the treatment of patients. Pressure from the asylum director to maximise the economic advantages of patient work could compromise the wishes of the chief medical officer to insist on a primarily therapeutic agenda for patient work. Toulouse was anxious to avoid this type of conflict and insisted on being appointed “medical director” of the Henri Rousselle Hospital, which put him in charge of both medical and administrative matters. This meant he had overall control of patient work.

Although finances were tight, there was intense pressure on French asylums to cure as many patients as possible so that they could be returned to the labour market. The country needed individuals to resume their duty as productive citizens since France’s “human capital was so diminished” by the war.¹⁰ Successful treatment of patients was hampered, however by the state of provision for the mentally ill in the aftermath of the war. Psychiatrists complained that services were far behind those of “other great countries” and asylums were embarrassingly ill-equipped.¹¹ They described the post-war state of French asylums as “deplorable”, with poor general hygiene; cramped, undifferentiated quarters; a lack of outdoor space; and poor facilities. Entertainments, sport and other forms of recreation, considered so important for patients whose conditions were beginning to improve, were practically non-existent.¹² Treatment for curable patients was compromised by the mixing of curable and incurable patients in the same quarters, and by ratios of over 400 patients per doctor, resulting in most patients being merely “overseen” rather than receiving “modern” treatment. Furthermore, most asylums lacked facilities for laboratory testing and the equipment necessary for delivering modern treatments, such as hydrotherapy, UV-ray treatment, electrotherapy and radiography. Many patients, who, in more favourable conditions, might be cured or improved, remained in asylums far longer than was necessary, adding to the costs of their care and depriving the nation of their labour.¹³

The French Asylums’ Medical Society, led by Toulouse, put forward proposals for post-war reforms to services for the mentally ill, including the separation of acute, recent cases of mental illness and incurable or chronic patients; an admission’s system for recent or incipient cases of mental illness to asylums or mental hospitals that avoided the usual legal formalities; and improvements to support for recently discharged patients in order to avoid a relapse of their symptoms.¹⁴ It was understood by the French Asylums’ Medical Society that the reforms would be costly, but the provision of separate care for incurable and chronic patients, who did not require intensive medical treatment or specialist facilities, would save money in the longer term. General Councillor Dausset suggested that more could be done to enhance the economic value of patient work by ensuring that the work carried out by patients was “really productive,” and by engaging more patients in the process.¹⁵

While Dausset accepted that patient work was primarily a means of therapy (as the law stipulated), he felt that its therapeutic benefits should not be allowed to overshadow the economic advantages. He quoted the nineteenth-century moral therapist Jean-Baptiste-Maximien Parchappe (1800–1866), who had declared, “I do not believe that it is against the principles of humanity, or morality, to expect the work of patients to benefit the establishments that offer them refuge”.¹⁶ Parchappe believed that it was perfectly legitimate to organise the work in “the double interest of patients and establishments”.¹⁷ But by 1918, patient work in Parisian asylums was not sufficiently well organised to fulfil either objective. Dausset observed that “a few women were employed in the laundry, in the ironing and sewing rooms, or in the kitchen, and that some men were engaged in cultivation or gardening, but the great majority of patients remained unoccupied in their quarters”.¹⁸ This was not the case in the service for “difficult” patients organised by Henri Colin at the Villejuif asylum, however, where work was organised in a methodical, rational manner. Nor was it the case in provincial asylums, such as the Asile de la Sarthe in Le Mans, from whom Dausset felt much could be learned.¹⁹ Here, he claimed, one found both asylum farms and workshops that were genuinely productive. Ironically, he added that many of the best workers in those workshops were calm, chronic and incurable patients who had been transferred to the provinces from the Seine.²⁰ The Asile de la Sarthe, where the maintenance charge was cheaper than that of the Parisian asylums, received around six patients each year from the Seine, part of an arrangement with several provincial institutions designed to relieve overcrowding in the metropolitan asylums.

Dausset recommended that the Seine asylums extended their use of market gardening, which required a much smaller area than agriculture. Market gardening had the potential to employ a large and easily surveyed patient workforce. From the economic point of view, it was very profitable because the products harvested could be consumed by the asylum population. While few Parisians were used to such work, Dausset maintained (perhaps disingenuously) that being able to grow their own fruit, vegetables and flowers was a “dream” for many.²¹ At the provincial Asile de la Sarthe the asylum director made frequent references to the cost savings made by “agricultural exploitation”. In 1920, the asylum director commented that farming had given good results that year, saving the asylum considerable sums. Farming was the second largest employer of patient labour, surpassed only by housework. Produce from the market gardens, piggery and poultry farm were evaluated at 85,971F, which, after deducting costs of 47,253F, generated a “profit” of 38,718F.²² The products, including bacon, eggs, chicken, fruit and vegetables, were all consumed on the premises. Nothing was wasted. The asylum director—echoing Parchappe—saw the cultivation of food stuffs as a means of improving the condition of patients, from which the establishment could also benefit.²³ The ongoing importance of this food production to the asylum’s finances was demonstrated in 1936 when the asylum director commented that there was no question of building additional accommodation on the land devoted to market gardening, despite overcrowding. The four hectares of land under cultivation was barely enough to supply the required quantities of fresh produce for the swelling asylum population; losing this land would have serious financial consequences.²⁴

The price fluctuations of essential goods, such as food, in France in the mid-1920s resulted in economic difficulties for asylums in both urban and provincial asylums. In Le Mans, the asylum director had warned the prefect in 1924 of the asylum’s precarious financial circumstances caused by rising prices.²⁵ It is perhaps no coincidence that 1925 saw the highest proportion of patient workers indicated for the entire interwar period.²⁶ In the same year, the escalating costs of maintaining the Seine’s mentally ill population,²⁷ forced the General Council to look at ways of reducing the numbers of paid asylum employees.²⁸ The work provided by patients was crucial, serving to “lighten the maintenance costs which weighed so heavily on the collective purse”.²⁹ This helps explain the hostile reaction of the General Council to a proposal to replace patients working in the kitchen with three paid kitchen assistants at the Asile Clinique in 1925. Following an accident, the kitchen was deemed too dangerous for patients by medical staff. The Council argued that patients should be given tasks that were not dangerous, leaving the riskier work to existing employees.³⁰ If every Seine asylum decided not to use patient labour in their kitchens, the cost implications of employing staff for them all would be huge (an estimated 170,000F).³¹ Furthermore, patients were not to be denied the opportunity to work since it was a means of therapy. In the interests of both patients and budgets, it was recommended that kitchen staffing levels remained as they were, and that more effort was made to employ patients safely.³²

Proposals to transform the Asile Clinique from an asylum for all types of patient into a “hospital” for acute, curable cases had been discussed at intervals since the establishment of the institution in 1867. Specialising in acute cases meant incurring the loss of incurable and chronic cases and thus the majority of the patient workforce (made up almost exclusively of calm, incurable and chronic patients). The anticipated financial consequences of this loss had resulted in the repeated postponement of the transformation from asylum to hospital. A feasibility study had been requested by the General Council in 1913, but the war had intervened and approval for the project was delayed until 1923.³³ The process of gradually transferring incurable and chronic patients out of the Asile Clinique to colonies or other asylums to make room for the acute cases, began in 1927.³⁴ Replacing the incurable and chronic patient workers with paid members of staff was not financially feasible, and there were unlikely to be sufficient numbers of convalescent patients to carry out the work. The decision was taken to create a special division for working patients within the Asile Clinique, separate from the treatment sections. Two pavilions were constructed for the 120 male and 50 female incurable and chronic patient workers who would be able to fulfil the tasks around the hospital that acute patients were deemed incapable of performing.³⁵ The transformation of the service was completed in 1928, with all patients in the treatment quarters at the acute stage and therefore presumed curable, while the patients in the separate workers’ pavilions, who were assumed to be incurable, did not receive active treatment. The economic contribution made by these patient workers became even more important than before the transformation because of the additional personnel and pharmaceutical costs associated with caring for acute-stage patients. Two additional chief medical officers, four additional interns and 34 extra nurses were employed, whose salaries added to the maintenance charge.³⁶

The Great Depression put renewed pressure on asylum finances, rendering the economic contribution made by patient workers even more important to the Asile Clinique. While the impact of the Depression on France was minimal at the outset, its arrival was merely delayed.³⁷ The crisis reached France in 1931 and its effects persisted until 1938, continuing despite the upturn of the world economy in 1935. French economic activity during the interwar period peaked in 1929, but from 1931 France was engulfed by economic, political, social and moral malaise.³⁸ The Seine’s departmental budget was particularly stretched as the cost of unemployment benefit rose from 1.5 million Francs in 1931 to 191 million in 1932 and was set to rise again to 210 million in 1933. Councillor Fiancette called for a reduction of 3 million Francs in the budget for maintaining the mentally ill of the Seine.³⁹ This demand was extremely challenging since the asylum population expanded during the early 1930s, adding to the costs of care.⁴⁰ A fall in the discharge rate was blamed on the economic crisis. Doctors hesitated to discharge recovered patients, knowing that they would struggle to support themselves in the exceptionally difficult economic climate of the early 1930s.⁴¹ The economic crisis was therefore contributing to overcrowding in the Seine’s asylums.⁴² Furthermore, as psychiatrist Aubrey Lewis noted with regard to England and historian Richard Warner observed in relation to the USA, cases of mental disorder rose as a result of the anxiety caused by unemployment and financial hardship.⁴³ The increased costs of care, coupled with demands for further cost-savings, increased the importance of productive patient work to the Asile Clinique budget.

French patients, unlike their English counterparts, were incentivised to work by the prospect of a nominal daily wage, known as a pécule, paid to all pauper patient workers, as set out in the Law of 1857.⁴⁴ The payment of French patients underscores the essential nature of their work to the asylum, even though the amount paid was a fraction of what an ordinary worker would receive outside the asylum. The precise amount varied according to the gender of the patient, the type of work and, in Paris, the skill of the labourer. The pécule paid to women was less than that paid to men, reflecting pay structures outside the asylum. In 1927, for example, male and female workers in the Asile Clinique’s laundry undertook similar work but men were paid 1.20F per day while women earned 1F per day. Male patients working in the tailors’ workshop earned 0.80F per day, while women in the sewing rooms earned between 0.63F and 0.70F per day. The male patient assisting in the mechanics’ workshop was highly skilled and received the maximum pécule of 2.5F per day.⁴⁵ At the Asile de la Sarthe, there were just two rates of pay. Most tasks, including working in the laundry or knitting, were attributed a value of 1F per day, while more skilled work, such as clerical work, stonemasonry, painting, carpentry, locksmithing, and shoemaking, was evaluated at 1.50F per day.⁴⁶ Women were assigned less skilled roles in the lower wage category. The work performed by patients, in terms of days or half-days, and the type of work performed were carefully recorded by the asylum bursar. This record enabled the bursar to work out not only how much each patient should be paid, but also the value of the contribution made by patient work for inclusion in the asylum accounts.

The annual value of patient work to the asylum (referred to as the produit du travail des aliénés) was calculated at three times the total amount paid to patients. The value of the produce harvested from the farm or market gardens, or made by patients, appeared in the accounts as the produits recoltés. For example, at the Asile de la Sarthe, the items made in the sewing room during 1923 included 190 pillowcases, 470 sheets, 67 mattress covers, 360 men’s shirts, 499 women’s blouses, 238 dresses, 152 pairs of trousers, and 1622 handkerchiefs, each of which was assigned a monetary value.⁴⁷ Dresses were valued at 4F, pillowcases at 0.50F and handkerchiefs at 0.10F each. The produit du travail and the produits recoltés constituted the total financial contribution made by patients to the asylum maintenance budgets. At the Asile de la Sarthe this amount represented between 5% and nearly 12% of the total maintenance budget [see Table 5.1]. The Asile Clinique’s city centre location meant that the land available for cultivation was limited, so receipts from the produits recoltés were modest compared with those of the provincial asylums, such as the Asile de la Sarthe [see Table 5.2], and those of other Seine asylums located on the outskirts of Paris. In 1930, the value of vegetables and flowers grown at the Asile Clinique was estimated at 59,278F, while the value of produce from the Maison Blanche was 262,404F.⁴⁸

Table 5.1 Table to show the value, in French Francs (F), of goods produced or harvested; the value of patient labour; and the total value of goods and labour expressed as a percentage of total expenditure at the Asile de la Sarthe, Le Mans, 1919–1939

Table 5.2 Table to show the value, in French Francs, of goods produced or harvested, and of patient labour, at the Asile Clinique, Paris, 1920–1939

At the Henri Rousselle Hospital, patient work was organised rather differently to that at the Asile Clinique and the Asile de la Sarthe. All patients at the Henri Rousselle Hospital were in the unique position (in France) of being admitted voluntarily to a public institution at the early, acute stage of their illness, and able to leave the hospital at any time (on giving 72 hours’ notice), as were patients at the Maudsley Hospital in London. Patients were not expected to work to contribute to the costs of their care. They were advised to keep busy and were paid a pécule for their labour if they chose to work, but this was optional. Patient work was not evaluated and did not appear in the hospital accounts as it did at the other French institutions. This different approach to patient work was made possible by the fact that there was just one person in overall charge of the hospital, the medical director. Toulouse was able to instil a therapeutic priority for occupation because he did not have to comply with an asylum director’s financial demands from patient work.

England

In England, there were also different levels of expectation regarding the financial contribution made by patient work, and towards the costs of occupational therapy. The Littlemore was typical of the traditional English asylum, in that it catered for a mix of curable, incurable and chronic cases, with pauper patients’ maintenance fees paid out of the local rates. Bethlem, a registered institution, was England’s only mental hospital specialising in acute cases until the state funded Maudsley Hospital opened in 1923. Bethlem was financed charitably through a mix of charitable donations and income from investments. The physician superintendent had to answer to a Board of Governors regarding the maintenance charge rather than a local authority. Bethlem catered for the “deserving poor”, working people on low incomes or who found themselves in straitened circumstances without being paupers. Some of the Bethlem’s patients were received “gratuitously” and did not have to pay for their care, while others paid fees, depending on their circumstances. The proportion of Bethlem’s patients who paid fees steadily increased during the interwar period. Manual labour was an anathema for this increasingly middle-class clientele.⁴⁹ The Maudsley was a public hospital that accepted both pauper and paying patients (c.25% of total admissions paid for their care). Like the Henri Rousselle Hospital in Paris, the Maudsley was in the unique position in England of receiving pauper patients on a voluntary basis, facilitating the treatment of the poorest patients at the onset of their illness without the delays caused by the lengthy process of certification.⁵⁰

Before 1913, English public asylums, which at that time cared for a mix of both chronic, incurable and acute, curable patients (with the exception of Bethlem which only admitted acute, curable patients), were expected to ensure that a high proportion of patients were “usefully employed”.⁵¹ As in France, it was the calm, incurable and chronic, and convalescent patients who performed “useful” work around the asylum that offset institutional running costs. This was the case at the Littlemore before the outbreak of World War I. As discussed in chap. 2, the Mental Deficiency Act of 1913 was intended to provide for the separate accommodation of the intellectually impaired and chronic patients in colonies, enabling asylums to concentrate their efforts on treating patients who were presumed curable. Plans to build colonies had to be scaled back as a result of the financial challenges presented by World War I, so the Act was not as far-reaching as had been originally intended.⁵² Nonetheless, the planned separation of the curable and incurable led to the divergence of rationales for patient occupation.

From 1913, the Board of Control reports were divided into two sections, one focusing on institutions specialising in “mental deficiency” (the colonies) and the other on those specialising in “lunacy” (the asylums, or mental hospitals as they became known). The two sections of the Board’s reports revealed very different aims for the occupation of patients. In the “mental deficiency” section, the Board was keen to emphasise self-sufficiency and the productive work of inmates in the colonies. In the “lunacy” section, the emphasis was on therapy for curable patients. In reality, however, the mental hospitals continued to house many chronic and incurable cases simply because there were insufficient places for incurable patients in the colonies.⁵³ Some mental hospitals attempted to retain their incurable and chronic working patients (rather than recommending their transfer to a colony) in order to keep maintenance costs down, although this attracted the Board’s disapproval.⁵⁴ The result was that within the same institution, there could be different rationales for occupation, depending on whether the patient was curable or incurable, as Mary Macdonald, principal of the Dorset House School of Occupational Therapy, recognised.⁵⁵ She maintained that as well as keeping the incurable patient healthy and “as near normal as possible”, work “enables those who would otherwise be a burden on society to contribute in some measure to their maintenance”. In her view, occupational therapy should be aimed at the curable cases who were expected to make a recovery.⁵⁶

The emphasis placed on the financial contribution made by patient work in mental hospitals began to be downplayed, while it remained an important consideration in the colonies. The economic viability of the Caterham Imbecile Asylum, for example, depended on patient work and was expected to be a “self-sufficient site”.⁵⁷ The Board of Control’s 1917 report emphasised that a significant proportion of “mentally deficient” patients in the colonies could be “trained to contribute towards their own support” instead of being a “dead weight upon the community”.⁵⁸ The phrase “usefully employed” gradually disappeared from the lexicon of the annual and inspection reports of mental hospitals, which emphasised therapeutic occupation rather than work that was “useful” to the institution. At Bethlem, for example, inspectors recorded the numbers of “usefully employed” patients for the last time in 1928. In the long-term it was deemed more cost-effective to provide curable patients with effective therapeutic occupation that would expedite their recovery and increase discharge rates.⁵⁹ This would enable greater numbers of patients to spend shorter periods in hospital, thereby saving money and freeing up beds for others. The recovered patients would then be able to re-join the labour market outside hospital.

The negative publicity surrounding the exploitative nature of patient work generated by publication of Montagu Lomax’s The Experiences of an Asylum Doctor (1921) and the subsequent government enquiry prompted a re-appraisal of the financial benefits of patient work. The Board was keen to distance itself from the pre-war pre-occupation with its monetary value and emphasised a commitment to patient occupation “as a curative agent and as a means of promoting the contentment and well-being of [hospital] patients” in its annual report of 1923.⁶⁰ The Macmillan Report of 1926 reinforced the need to deliver active treatment to curable patients; occupational therapy formed an important aspect of such treatment.⁶¹ The Board began to criticise the provision of occupations for patients in most hospitals, noting that for many, the only available employment was ward work. The commissioners recommended the appointment of an “occupations officer” who would ensure that patient occupation was organised therapeutically.⁶² Such an appointment would obviously add to the maintenance charge, but the Board considered it money well spent. Occupations officers were appointed at the Maudsley in 1924 and at Bethlem in 1932. At the Littlemore, the medical superintendent chose not to employ a specialist occupations officer; instead Littlemore nurses were expected to learn a craft that they could teach to patients.⁶³ In 1928, the Board highlighted the “gratifying results” obtained in some hospitals where occupational therapy had been developed, and admitted that, “in the past there has been a tendency to concentrate on the employment of those patients who readiness to work was spontaneous … and upon work which was of some economic value to the institution”.⁶⁴ The Board’s Memorandum on Occupation Therapy (1933) emphasised that “the economic value of occupation need not be stressed” and that “the object of occupation is primarily therapeutic”.⁶⁵ The aim of occupational therapy was “not … a means of providing commodities for use in the hospital at a low cost”.⁶⁶ There should not be “too much stress … laid on output and finish”.⁶⁷ Patients were not to be expected to produce “articles of high artistic merit or of commercial value”.⁶⁸ As Adolf Meyer had maintained, the most effective aspect of occupational therapy was the “actual doing, actual practice” (that is, the process of making something) rather than the finished item.⁶⁹

Despite the Board’s exhortations to the contrary, some items for institutional use were produced by the occupational therapy departments, but the purpose of the activities was primarily therapeutic. At the Littlemore, brickmaking was introduced in 1926. Dr. Good observed that this activity provided effective “assistance in treatment” and the bricks were used to build a new mess room. The Board’s inspectors were enthusiastic about the new activity and wondered if patients might be taught how to make concrete curbing for the paths in the ward gardens.⁷⁰ Littlemore’s female patients were given the task of making cotton-wool swabs for use at the Radcliffe Infirmary. Male patients made a complete set of folding tables for the Littlemore’s Recreation Hall.⁷¹ At the Maudsley, wireless sets, bedside tables, lampshades and mortuary trolleys were among the items destined for hospital use produced by patients undergoing occupational therapy. These activities, although they saved the hospitals money, were not evaluated financially. The one aspect of productive patient work that was ascribed a monetary value was the food produced by the Littlemore’s farm. The sums raised by the sale of farm produce, and the value of food supplied to the hospital, featured in the hospital accounts, and offset maintenance costs [see Table 5.3]. The value of patient labour involved in the food production was not evaluated, however.

Table 5.3 Table to show the value, in GBP, of farm goods supplied to the hospital; the income generated from the sale of surplus farm goods; and the total value of the goods expressed as a percentage of total expenditure at the Littlemore Hospital, 1923–1939

While occupational therapy was not intended as a means of raising funds, hospitals were expected to keep the net costs of the craft activities that comprised occupational therapy to a minimum, particularly during the testing economic climate of the Depression. The Board maintained that “the best work can often be done with the simplest and cheapest materials”, so “no great outlay” was required. They recommended the use of waste materials, claiming that “a little ingenuity … solves many problems”.⁷² The cost of materials for handicrafts was usually covered by sales of the finished goods within the institution. This was the case at Bethlem, where the physician superintendent was proud to announce in 1933 that the work produced by the occupational therapy department (established the previous year) had “found a ready sale amongst patients and their friends and articles to the value of £70 have been sold”.⁷³ At the Maudsley, many items produced by the occupational therapy department were sold in the hospital canteen, which also sold tobacco, sweets, stationary and toiletries to patients, visitors and staff.⁷⁴ The medical superintendent was keen to point out in 1930 that occupational therapy continued to be run on a self-supporting basis; patients who wanted to keep the items they made bought the materials themselves at a reduced price.⁷⁵ Reporting on occupational therapy at the Littlemore in 1929, the Board’s inspectors remarked that, “It is pleasant to hear that the periodical sales of work are remunerative”.⁷⁶

Even though some items were sold, and other items may have been used in the hospital (such as the decorative lampshades made by Maudsley patients), the arts and crafts that comprised occupational therapy could be considered as based on hobbies. This was certainly the view of Wilhelm Mayer-Gross, Eliot Slater and Martin Roth, whose 1954 textbook, Clinical Psychiatry, described British occupational therapy as “being more of pastimes and hobbies than of rough manual work, as on the European continent.”⁷⁷ As such, occupational therapy fell somewhere between work and recreation. Patients were not rewarded for engaging in occupational therapy (as they were for work around the hospital) and, even if sales of items covered the expense of raw materials, the employment of an occupational therapist represented a cost to the hospital budget.

Entertainment—Therapy or a Drain on Resources?

The provision of entertainment for patients also represented a cost to French and English institutions. The resources allocated for entertainment varied between France and England and between metropolitan and provincial institutions. As he made plain in 1918, Toulouse was strongly in favour of “distractions” or entertainment for patients, which he believed were an essential aspect of treatment.⁷⁸ As the medical director of the Henri Rousselle Hospital, he was responsible for deciding how much to spend on these activities. At the Asile Clinique and the Asile de la Sarthe, decisions regarding the amount to be spent and the content of the programme, were taken by the asylum director. The latter also negotiated the costs—or the supply free of charge—of the entertainments. Not all French psychiatrists believed in the therapeutic value of entertainments, but the law of 1857 stipulated that “distractions” and “intellectual occupations” should be provided for patients.⁷⁹ Although there were only 80 beds at the Henri Rousselle Hospital, the entertainments budget was increased from 4000F (or 50F per capita) in 1925 to 10,000F (or 125F per capita) in 1928, indicating the priority attributed to this area by Toulouse. A piano, wireless and gramophone were available for patients to use,⁸⁰ and creative afternoons were organised with visiting artists.⁸¹ Games, books and writing materials were also provided [see Fig. 5.1].⁸²

Fig. 5.1

Recreation room at the Henri Rousselle Hospital during the 1930s. (© Collection Musée d’histoire de la psychiatrie et des neurosciences, GHU Paris, photographie Direction de la communication du GHU)

At the Asile Clinique, where an average of 1100 patients were accommodated, expenditure per capita on entertainments was much lower, increasing from 5788 F (or 5.3 F per capita) in 1921 to 10,100 (or 9.18 F per capita) in 1930 [see Table 5.4]. Concerts, such as those given by the ensembles “L’Harmonie de la Préfecture”, the brass band “La Sirène, “Musique et poésie à l’Hôpital” and “L’Harmonie Municipale de la Ville de Paris”, took place in the asylum gardens in summer and in the Salle des Fêtes (recreation hall) in winter approximately once a month.⁸³ Stars from the Parisian music-hall gave performances at the Asile Clinique free of charge, and in winter there was a fancy-dress ball for the women patients.⁸⁴ Music for the latter was provided either by the hospital band, or by phonograph, and therefore did not incur a cost. Patients could play tennis and boules and there was a games room, well used by the working patients, where billiards was particularly appreciated.⁸⁵ Christmas celebrations involved a party organised by the asylum director’s wife and a Christmas tree from which gifts donated by the managers of large Parisian stores were distributed to patients. In 1932, 450 items of various kinds were donated, including 80 kg of sweetmeats, jewellery, undergarments, smoking apparatus, toiletries and tobacco.⁸⁶

Table 5.4 Table to show the annual expenditure in French Francs (F) on entertainments, and expenditure per patient, by the Asile Clinique 1921–1937

The events, whether paid for or free of charge, attracted criticism from the General Council for their infrequency.⁸⁷ Noting the wide variation in the sums allocated to distractions, the Commission de Surveillance recommended that a minimum sum of 15,000F be included in all the Seine asylum budgets, to allow a complete programme of therapeutic entertainments to be offered to patients, including the very popular film showings and the installation of wireless equipment.⁸⁸ The Asile Clinique’s budget was duly amended [see Table 5.4]. In 1932, two wireless sets were installed in the workers’ quarters, which were reported as greatly appreciated.⁸⁹ In 1933, apparatus for showing “talkie” films was purchased and film showings were organised each month.⁹⁰ What is unclear from the records is the rationale for these events. The provision of entertainments could simply have been to comply with legislation, to avoid accusations of inhumane treatment, to reward the patient workers, to encourage social skills amongst convalescent patients, or the programme could have been perceived as curative by psychiatrists who viewed entertainments in the same light as Toulouse.

At the Asile de la Sarthe, provision of distractions was much more limited than in the capital. Before World War I, a programme of entertainments for patients had been itemised in the asylum director’s reports. These had included picnics in the countryside, walks into town, concerts, watching the town fireworks on 14 July and celebration of the Fête-Dieu, a Catholic festival that took place 60 days after Easter, organised by the chaplain. These events had not incurred any costs to the asylum; the cost of travelling on the tram to local beauty spots for picnics was deducted from the patients’ pécule. No such events were mentioned in the post-war reports. This is not to say that they did not occur, but they were not discussed in the annual reports. A budget for “distractions and games for patients” appeared in the asylum accounts for the first time in 1934, and continued to do so until 1939 (expenditure varied between 215F and 377F; see Table 5.5). This indicated that some forms of entertainments were provided, at least from 1934 onwards, although the sums allocated were very small. Prior to 1934, the asylum director may have continued the pre-World War I policy of organising free entertainment.

Table 5.5 Table to show expenditure on entertainments, and expenditure per patient, in French Francs (F), by the Asile de la Sarthe, 1934–1939 (no figures appeared in the Asile de la Sarthe accounts for entertainments prior to 1934) 

The three French asylums demonstrate different levels of financial expectation from patient work and different attitudes towards expenditure on entertainments. The acute patients admitted to the Asile Clinique’s treatment divisions after 1927 were not expected to work, but this left a “gap” in the hospital’s finances. A solution to this problem was the creation of separate quarters for incurable and chronic, working patients who required minimal supervision and custodial care rather than active treatment. Although work was deemed unsuitable for the acute patients, entertainment for them and for the working patients, was encouraged by the General Council. The asylum director committed increasing amounts to the budget for amusements and negotiated the provision of some forms of entertainment and even Christmas gifts at no charge. At the Asile de la Sarthe, where there was a mix of acute, incurable and chronic, pauper and private patients, work continued to be performed by the calm, incurable and chronic pauper patients who were expected to contribute to the costs of their care. Work was organised in much the same way as it had been before World War I. Entertainment was minimal and the budget tiny in comparison to that of the Asile Clinique. Occupation at the Henri Rousselle Hospital was organised on a voluntary basis; no monetary value was attributed to any work carried out by patients; and the budget for amusements was particularly generous here. These varied policies concerning the value of patient work and expenditure on entertainment reflect the different management structures existing at the Henri Rousselle Hospital and the other two asylums; the attitudes towards occupation of those in charge; and the different financial circumstances of metropolitan and provincial institutions. On this last point, certain similarities between the situation in France and England can be seen.

In England, the Board of Control encouraged hospitals to provide “objects of interest and amusement” for patients.⁹¹ The levels of expenditure committed to this area varied considerably. Bethlem had the most lavish budget for entertainment out of the three hospitals [see Table 5.6]. For physician superintendent Dr. John Porter-Phillips (1877–1946), Bethlem’s entertainment programme constituted “one of the most potent factors in treatment” and was a more appropriate diversion for his middle-class patients than manual work.⁹² As studies of both private and public institutions before World War I by Louise Hide and Anne Shepherd have shown, middle-class patients tended to prefer leisurely pursuits over manual work.⁹³ Bethlem’s programme was curtailed during World War I, but by 1923 was back up to speed with a full schedule of dances, theatrical performances, concerts, sewing parties and lectures.⁹⁴ The Christmas Eve Fancy Dress Ball was a regular feature, constituting “a prominent landmark in the domain of winter entertainment [that] affords much enjoyment and comfort of mind to those whose mental horizon may be tinged with pessimism or clouded with unhappiness.”⁹⁵ Visits to the Boat Race and Epsom Races, and picnics in the countryside, were scheduled in the summer months. Patients were taken out for drives or for accompanied walks each week, and those who were well enough could leave the hospital “on parole”. Considerably more patients attended the entertainments (an average of 79 patients between 1920 and 1929) than were “usefully employed” (an average of 64 patients between 1919 and 1928).

Table 5.6 Table to show the annual expenditure on entertainments by the Bethlem Royal Hospital, and expenditure per patient, in GBP, 1919–1922 (the only years for which figures were available) 

In 1931, Porter-Phillips maintained that “…every form of entertainment and amusement has been encouraged by the Governors for the treatment and happiness of the patients and staff”.⁹⁶ In 1931, the Board of Control remarked that “probably nothing has done more in recent years to add to the happiness and contentment of the patients than the installation of the cinema”.⁹⁷ A “movie-tone” apparatus was duly installed at Bethlem in 1932 to enable the showing of new films. It also had a “Radio-gram attachment” so that gramophone records could be played in the Recreation Hall, “thus obviating the necessity of an Orchestra”.⁹⁸ During an outbreak of chicken pox in 1932, the new technology enabled Christmas celebrations to be broadcast from the Recreation Hall to various wards around the hospital.⁹⁹ In 1935, Bethlem’s library held around 2000 books, mostly fiction, with an additional music section. A circulating system, organised by a male nurse, ensured that parcels of books were delivered every fortnight to the various wards. The stock was replenished every year by the addition of c.50 new books and 60–70 books were repaired annually.¹⁰⁰ Since 1891, Bethlem had published its own magazine, Under the Dome, edited by the Chaplain, to which patients, staff and Governors contributed. It was financed by sales to patients, former patients, and patients’ families and friends. A new, more up-to-date version, Orchard Leaves, appeared in 1934, comprising short articles, quizzes, poems, a crossword, letters, and book reviews as well as details concerning the entertainments programme and sporting events.¹⁰¹ The Governors noted in 1935 that production costs were not covered by sale of the magazine, but Porter-Phillips persuaded them to allow publication to continue, claiming; “The magazine [was] proving a means of interest and pleasure to all types of patients”; patients enjoyed contributing to it; and it “provide[d] a medium which create[d] and encourage[d] a good-will and fellowship amongst guests and staff alike.”¹⁰² In this instance the interests of patients overcame cost considerations.

Porter-Phillips put great emphasis on sport and other activities that kept patients active. The extensive grounds at Bethlem’s new premises at Monks Orchard enabled a variety of sports to be played, including cricket, tennis, bowls, hockey and football. Regular matches were played by the hospital teams, which comprised both patients and staff. For example, it was reported in Orchard Leaves that during the summer season of 1935, 28 cricket matches were played, of which Bethlem won 12, lost 8 and drew 5, while 3 had to be abandoned due to bad weather [see Fig. 5.2]. Eleven tennis clubs sent teams to play at Bethlem, and the contests were described as “very keen”.¹⁰³ A new sports pavilion was completed in 1937, providing Bethlem with “what is generally believed to be one of the best sports grounds for many miles around” and facilitating the entertainment of visiting cricket teams.¹⁰⁴ For the less sportively-inclined, Swedish drill and country dancing were introduced in 1927, providing another “valuable asset in the domain of treatment” from which the patient “unconsciously derives enormous benefit in mind and body”.¹⁰⁵ By 1938, various dance and eurythmic movement classes of different levels, even for the most disturbed patients, were held twice weekly for both sexes.¹⁰⁶ Teaching of these classes by specialist instructors represented an addition cost. Bethlem’s provision of indoor recreations and outdoor physical activities was described by the Board of Control as “plentiful and varied” in 1938, and they were pleased to note that patients were encouraged to pursue their individual hobbies.¹⁰⁷ Bethlem’s programme of entertainment was designed to appeal to a middle-class audience, reflected by its lecture series and the contents of its magazine. The Maudsley’s patients included labourers and the unemployed, as well as clergymen and doctors, and therefore the hospital had to cater for a broader range of tastes.

Fig. 5.2

Physician Superintendent John Porter-Phillips (front row, centre) with the Bethlem Royal Hospital’s cricket team. (© By permission of Bethlem Museum of the Mind, HPC-20)

At the Maudsley, sport was limited, owing to the hospital’s city location, but there were two billiard tables, tennis and badminton courts, and croquet was set up in the gardens attached to ground-floor wards.¹⁰⁸ A hard tennis court was laid in 1928 enabling play to continue all year round.¹⁰⁹ Fortnightly picnics were organised in neighbouring parts of London in summer, and at least one indoor event, either a concert, dance or whist drive, was held each week. Volunteers contributed to patient entertainment in less formal ways, for example, by singing in the wards.¹¹⁰ The hospital was well-supplied with pianos, gramophones, wireless sets, cards and draughts, and its library (run by two nurses in their own time) held over 1000 books.¹¹¹ Weekly singing and dancing classes were introduced in 1924. “Such classes”, maintained Mapother, “not only mitigate the monotony of hospital life and promote cheerfulness but can be made to play a definite part in the re-education of many neurotic patients”.¹¹² A patient choir was established, which gave many successful performances during the winter.¹¹³ The choral instructress, Miss Erhart, gave her services for free. Mapother paid tribute to her in 1926, remarking that “all grades of staff as well as patients are agreed that her work is one of the most useful activities of the hospital”.¹¹⁴ Christmas celebrations included a fancy dress dance and entertainment around the Christmas tree on Boxing Day for child patients or the offspring of patients.¹¹⁵ Attendance at this event grew each year and “strain[ed] the capacity of the hall”.¹¹⁶

In terms of audio-visual equipment, “wireless” sets were provided in two of the Littlemore’s largest wards, and also in the nurses’ quarters, in 1926.¹¹⁷ The Maudsley was similarly equipped in 1928. Music could be delivered to patients’ rooms with headphones provided in every single room, and between each pair of adjoining beds in the dormitories. Loudspeakers were installed at various points throughout the hospital.¹¹⁸ Both the Maudsley and the Littlemore benefited from the installation of a cinematograph in 1927 and 1928 respectively. The Board of Control urged hospitals to invest in the equipment for showing “talkie” films in 1934 because silent films were going out of circulation.¹¹⁹ Sound apparatus for showing “talkie” films was introduced at the Littlemore in 1934.¹²⁰ At the Maudsley, patients had to wait for completion of the extension to the hospital in 1936, which included the provision of a larger recreation hall and new premises for the library.¹²¹

At the Littlemore, many of the events organised for patients did not incur any costs. For example, Dr. Good reported in 1925/1926 that concerts were held “throughout the year [performed] by Staff, both male and female, for the amusement of patients”. He added that “dances have been held in the Entertainment Hall, and in many of the Wards”.¹²² These free events continued throughout the interwar period, as indicated by the reports of 1926/1927 and 1937/1938.¹²³ Dr. Armstrong (appointed in 1936) introduced the practice of sending groups of “the better type of working patients” for charabanc outings to some of the local beauty spots. He noted that several of the older patients had not left the grounds for many years and were very appreciative of this innovation.¹²⁴ Dr. Penton (the new assistant medical officer) introduced folk dancing classes in 1939 and organised concerts given by the patients.¹²⁵ Again, such events organised by staff did not incur additional costs. The Littlemore’s budget for entertainment was a fraction of that of Bethlem [see Table 5.7].

Table 5.7 Table to show the annual expenditure on entertainments by the Littlemore Hospital, and expenditure per patient, in GBP, 1923–1932

Attempts were made at the Littlemore in 1937 to increase opportunities for outdoor exercise.¹²⁶ Dr. Armstrong introduced weekly keep fit classes at the Littlemore, conducted by an instructor from the Keep Fit movement, and classes in Physical Training were held regularly for both male and female patients.¹²⁷ Cricket and football teams of male patients were created and a schedule of both home and away matches was organised with patient teams from neighbouring hospitals.¹²⁸ Facilities for hockey and netball were provided for nurses and female patients, and badminton and tennis equipment was provided in some of the women’s gardens. Indoor recreational facilities included table-tennis and darts for the men and table-tennis and card games for the women.¹²⁹ Nurse B, who joined Littlemore in 1936, remembered an annual sports day, as well as a fancy-dress ball at Christmas.¹³⁰ At the Littlemore, it was the Chaplain who managed the hospital library and was responsible for distributing books to patients each month. On hearing from the Chaplain that many books were being destroyed by patients, the Board suggested that such wastage could be reduced by starting a bookbinding workshop, which might also provide an interesting and useful occupation for patients who were not otherwise employed.¹³¹

Out of the three hospitals discussed, the financial implications of patient occupation appeared to be most pressing at the Littlemore. Here the medical superintendent chose not to invest in the services of an occupational therapist and the cost-savings generated by the sale and consumption of produce from the hospital farm continued to feature in the institution’s accounts. Expenditure on entertainments was kept to a minimum through the organisation of “in house” events. Despite the legislation of 1913 and 1930, the Littlemore continued to care for a significant proportion of chronic and incurable patients, many of whom, had they been placed in a colony would have had to contribute to the costs of their care by working. Whilst this is not explicit, it could be that costs per capita were expected to be lower in institutions continuing to care for chronic and incurable patients. Occupation at the Maudsley was organised with therapy as the primary aim for all patients from the outset. By the time the Maudsley opened in 1923, the thinking around occupation had already started to move on from its pre-war pre-occupation with offsetting costs. Although some of the items produced by the occupational therapy department were used by the hospital, none of the products were evaluated for accounting purposes. Patients were engaged in both occupational therapy and work around the hospital. The recreational programme at the Maudsley was varied and the medical superintendent clearly felt it made an important contribution to treatment. Whilst some aspects of the programme, and the facilities required to deliver it, were paid for, the use of volunteers kept costs down. At Bethlem, where institutional finance came from charitable sources or the patients themselves, and where many patients were unaccustomed to manual labour, occupation was focused on recreation rather than labour, hence the high expenditure on sport and entertainments. That is not to say that Bethlem was oblivious to budgetary constraints. The Governors were reported as reluctant to make the initial outlay required to establish the occupational therapy department, which eventually opened in 1932, and questioned whether the patient magazine was really needed when sales failed to cover its production costs.

Conclusion

The different management structures of French and English asylums, coupled with the different levels of economic difficulty experienced after World War I, contributed significantly to the divergent attitudes towards patient work in France in England. They were not the only significant factors but added to the differences in opinion regarding the perceived usefulness of occupation as a means of therapy, particularly for acute patients, discussed in the previous chapter. In France, where the economy was more severely damaged by the war, the emphasis on keeping costs down increased the importance of patient work as a cost-saving device. The prolonged effects of the Great Depression (from which England recovered relatively quickly) also intensified reliance on patient work. Those psychiatrists who wished to change how patient work was organised by introducing occupational therapy, or simply by easing the production targets set by workshop managers, faced potential opposition from the asylum director and prefect for whom financial matters were a priority. The way to overcome such opposition, as Édouard Toulouse demonstrated, was to insist on the role of medical director which put a doctor in sole charge of the hospital, responsible for both medical services and administration. English medical superintendents had this dual responsibility and were able to establish therapeutic priorities for occupation within their institutions. An emphasis on therapy was encouraged by the Board of Control, who sought to downplay the financial contribution of patient work and advocated occupational therapy, despite the additional costs involved. This was in marked contrast to the Board’s attitude towards the incurable patients placed in colonies, from whom productive work was expected. English mental hospital patients were not paid for their work, nor for what they produced in the occupational therapy department, which supported the notion that the purpose of this occupation (as opposed to the work carried out in colonies) was therapeutic. The French pécule system emphasised the transactional nature of patient work, making it appear more like work in the outside world, and, arguably, detracting from its role as therapy.

In terms of the entertainment provided for patients, it is interesting that the types of events in English and French institutions were quite similar, despite their being organised by a medical superintendent in England and an asylum director in France. In both countries, resources for entertainments were far more lavish in metropolitan institutions than in provincial ones. In both countries, efforts were made to secure at least some of the activities free of charge and to use the services of volunteers where possible, even at Bethlem where the programme was accorded such a high priority. The balance between work, occupational therapy and recreation, and the budgetary implications of each type of occupation, was a matter for negotiation between chief medical officer and asylum director in France. In England, the medical superintendent had overall control of patient occupation and the precise nature of the programme depended on his preferences and management style. The roles of these individuals are discussed in more depth in the next chapter.