The Medical Prescription of Patient Occupation

Abstract

Analysis of the different attitudes of English medical superintendents and French chief medical officers towards patient occupation provides an insight into the different conceptions of mental disorder and its treatment held by French and English psychiatrists during the interwar period. It also highlights the different management structures of French and English institutions. Authority for running French institutions was shared between a chief medical officer, in charge of medical matters, and an asylum director, responsible for administration and finance. In England, medical superintendents were in sole charge of their hospitals and had the authority to make decisions regarding all matters concerning management and medical treatment, including patient occupation. Psychiatrists' training, professional networks, and attitude towards innovation and risk all contributed to their vision of what constituted effective treatment. In France, this vision could be compromised by the asylum director’s need to maximise the productivity of the patient workforce.

This chapter focuses on the role, authority and therapeutic preferences of the medical practitioners prescribing patient occupation. The attitude of individual medical superintendents and chief medical officers towards the therapeutic value of occupation for patients, and its suitability for certain types of patients, played an important role in whether the new methods of occupational therapy were adopted in French and English mental hospitals. They oversaw how patient work was organised and to whom it was allocated. This raises questions over whether French and English psychiatrists shared similar views regarding treatment and what other effective treatments for mental disorder existed during the interwar period. What influenced psychiatrists’ responses to these different treatment methodologies? The matter of autonomy was also a significant issue; did both French and English psychiatrists enjoy sufficient authority within their institutions to impose their preferred treatment regimes, or were there others in the chain of command to whom they had to defer?

Management and Authority

Different asylum management structures, affecting the levels of authority enjoyed by English and French psychiatrists, originated in the legislative frameworks established to support the emerging national asylum systems in France and England. It is worth pausing to consider the legislation that developed. English local authorities were empowered to raise a county rate for the purpose of building an asylum for the county by the County Asylums Act of 1808; the Lunacy Act of 1845 made this a requirement. Although the asylums were to provide “constant” access to “medical assistance”, there were no regulations regarding treatment.¹ Asylums were run by a medical superintendent, who was expected to be medically qualified and an able administrator. The standards of care that asylums should provide, including the application of moral therapy, and standards referring to food, cleanliness, exercise and occupation were indicated by the Report of the Select Committee on Pauper Lunatics in Middlesex and on Lunatic Asylums, published in 1827.²

The report included a questionnaire for asylum superintendents intended to assess their asylum’s performance in these areas. The questionnaire included an inquiry into the provision of manual labour and activities for patients designed to “engage the attention to external objects” such as drawing, painting or gardening.³ It asked whether “innocent amusement[s]”, such as music, looking after poultry or domestic animals, or gardening were provided for patients whose conditions were severe, or whether intellectual pursuits were available for “patients of a superior description”.⁴ The questionnaire was sent out to the asylum authorities, but there was no law at that time requiring them to complete it, nor to comply with its implicit recommendations.⁵ The principle of inspecting asylums, and of holding the medical superintendent to account, was introduced by the County Asylums Act of 1828. The Lunacy Act of 1845 made it a requirement for every county to provide an asylum for its pauper insane. The Act also established the Lunacy Commission, which was replaced by the Board of Control in 1913. These organisations were responsible for issuing directives concerning the internal regulation of institutions for the mentally disordered and the treatment of patients.⁶ The Board of Control made it clear in 1932 that responsibility for the direction of the medical and scientific work of each hospital lay with the medical superintendent.⁷ The introduction of occupational therapy was therefore in his gift since all administrative and medical decisions rested with him. The English medical superintendent may not have been in control over admissions to a public institution, but he held the ultimate authority over the policies and procedures within it.

In France, legislation regarding care of the mentally disordered in asylums, initiated in the early 1800s, was delayed until 1838 due to successive political regime changes, a lack of finances and ongoing debates over whether asylums were to be considered as hospitals or as institutions of detention.⁸ A requirement for each department to provide, or ensure access to, an asylum for the mentally disordered was established by the law of 30 June 1838.⁹ Further legislation created on 18 December 1839 set out the principle of shared responsibility for asylum management between an asylum director and a chief medical officer.¹⁰ The chief medical officer was responsible for all matters concerning the treatment of patients, while the asylum director took charge of finance and administration.¹¹ Detailed regulations regarding how a model institution should function were the subject of the ministerial order of 20 March 1857. The order included instructions concerning the medical service, administration, the daily regime, dietary, and the provision of work and occupation for patients. The Minister responsible for the order declared that it completed the law of 1838 and was based on 18 years’ experience of asylum management in France and on observation of the workings of asylums overseas.¹² This order, together with the original legislation of 1838, provided the legal framework for the management of asylums for the first half of the twentieth century. A noticeable difference between the French and English legislation was the level of detail. The French Bulletin of 1857 specified very precisely how asylums should be managed and how patients should be treated. In England, the role of the medical superintendent, and the precise nature of patient occupation, was not codified in the same way.

The management structure of the French public asylum was quite different to that of an English institution. In England both medical and administrative decisions were taken by one person, the medical superintendent. Although the French chief medical officers had control over medical matters, patient work was both a medical and an administrative concern. Work was supposed to be prescribed by the chief medical officer as therapy for patients, according to the Bulletin of 1857,¹³ but it also fulfilled an important financial role in controlling maintenance costs, which was the concern of the asylum director. The Bulletin specifically highlighted the fact that the “product” of patient work belonged to the establishment.¹⁴ The departmental prefect was supposed to settle any disagreements between the asylum director and chief medical officer, such as those that might arise over the question of patient work. Since neither the asylum director nor the prefect was medically qualified, the medical perspective was in danger of being overruled, despite the regulations regarding the medical prescription of work. M. Reyrel, for example, appointed asylum director of the Asile Clinique in Paris in 1918, was a former a cabinet minister at the Ministry of the Interior and Prefect of the Seine. He was an experienced negotiator and financial manager, but not medically trained.¹⁵

Compared with their Dutch colleagues, as Seine psychiatrists Paul Courbon and A. Porot observed, French psychiatrists lacked authority. They were not respected, either by their staff or by the public and local authorities.¹⁶ Dissatisfaction with services for the mentally ill had not abated since the anti-psychiatry movement of the late 1890s had branded French asylums as “modern Bastilles”.¹⁷ As Coffin has suggested, psychiatrists in the 1920s felt “under attack” because asylums were so overcrowded that it was difficult to provide any proper treatment.¹⁸ A lack of respect was also a consequence of French psychiatry’s subordinate position in relation to neurology and the dearth of effective biological cures for mental disorder. The combination of a lack of authority and the combined administrative might of the asylum director and the prefect, may have rendered the chief medical officer powerless to instigate changes to the way patient work was organised.

It was noted by General Councillor Louis Dausset in 1918 that all the Seine asylums had workshops, but the number of patients working in them had diminished each year, despite the fact that many patients were artisans—mechanics, electricians, locksmiths, painters, stone-masons, and shoe-makers—whose skills had not been completely lost as a result of their illness.¹⁹ The reason for the reduction in the numbers of patient workers was not addressed in this 1918 report, but pre-war reports had indicated that disagreements between doctors and technical staff, over how patients were managed, had deterred the medical teams from sending their patients to the workshops.²⁰ Such disagreements were exacerbated by the management structure of French asylums, since the workshop managers reported to the asylum director, whose agenda was financial, while the chief medical officers’ priority was therapy. The situation did not appear to have improved by the 1930s. As doctors Maurice Legrain (chief medical officer of the Seine’s Villejuif Asylum) and Georges Demay (chief medical officer of the Clermont Asylum in the Oise Department, northern France) wrote in a report commissioned in 1934 by the French government’s Superior Council for Public Assistance (published in L’Aliéniste français in 1936), “it is clear that patient work is regarded differently by the economic and technical services and by the medical services”.²¹ They observed that for the Administration, patient workers were divided into two groups, good workers and the rest, while for the medical team, productivity was not the main aim of the work.²²

Dr Édouard Toulouse (1865–1947) was keen to avoid such conflicts and insisted on the role of “medical director” when appointed to manage the Henri Rousselle Hospital in 1922, combining the functions of asylum director and chief medical officer.²³ Toulouse is pictured with his team at the Henri Rousselle in Fig. 6.1 (above). As medical director, he had control over both administrative and medical matters. Toulouse, like his English counterparts, could focus on the therapeutic aspects of work and occupation when prescribing them to patients. General Councillor Henri Rousselle noted in his 1923 report that patients “were not to be subjected to any work, but were recommended to occupy themselves”.²⁴ While work was available for patients (for which they would be paid), it was stated in the Henri Rousselle regulations that the sole aim of this work was therapy.²⁵ In other words, there was no obligation for patients to contribute to institutional running costs, but keeping busy was advised. While Toulouse, and the English medical superintendents, still had to deliver a balanced hospital budget, their decisions were not constrained by the agenda of an asylum director who was not medically qualified and whose priority was management efficiency rather than treatment. Decisions made by the chief medical officers of the Asile Clinique and the Asile de la Sarthe regarding patient work were subject to negotiation with the asylum administration.

Fig. 6.1

Édouard Toulouse, Medical Director (front row, with the long scarf), and his staff, Henri Rousselle Hospital, Paris. (© Collection Musée d’histoire de la psychiatrie et des neurosciences, GHU Paris, photographie Direction de la communication du GHU)

As Demay highlighted in 1929, it was perfectly legitimate for the work carried out by patients to benefit the asylum and help reduce running costs, but the interests of the patients were always to take priority. The concepts of work-as-therapy (“le travail-traitement”) and work-for-profit (“le travail-rendement”) should not be mutually exclusive, but problems of interpretation could arise. A medical director, he argued, invested with both medical and administrative authority, would be able to balance the interests of patients and asylum management.²⁶ Hermann Simon (1847–1945), the German psychiatrist who developed “more active therapy”, was also adamant that asylums should be medically directed to ensure that work was oriented towards a therapeutic rather than an economic goal.²⁷ The matter of medical control of the asylum was also raised by Dr Ferrio who criticised the French law of 1838 in an article appearing in the Annales Médico-psychologiques. Ferrio insisted that “the director of the psychiatric hospital must be a doctor, exclusively a doctor”.²⁸ This, he believed, was the only way of achieving harmony between all the various hospital services. Ferrio supported Toulouse’s assumption of the role of both asylum director and chief medical officer at the Henri Rousselle Hospital, insisting that this was the only way forward.²⁹ Only a medical director had the authority to see through reforms and ensure the primacy of a therapeutic agenda. In England, the medical superintendent, who was in sole charge of the hospital, had this authority.

Although the English medical superintendent did not have to contend with the aims and objectives of an asylum director, Peter Bartlett argues that his authority was compromised by the close association between the poor law and county asylums. Bartlett maintains that the asylum system was created out of the poor law administrative infrastructure; the county asylums and the other poor law institutions were thus parts of the same system, administered by the same people. ³⁰ Asylum doctors, according to Bartlett, had little say in how asylums would be constructed, nor in the admission or discharge of pauper patients. The medical professionals, far from being autonomous, were simply part of an administrative network comprising local justices of the peace and poor law officials overseeing provision for the poor. The latter might receive “outdoor” relief or be admitted to the workhouse or county asylum.³¹ Whilst it is true that the medical superintendent lacked control over the confinement of pauper patients, once admitted, patients were subject to his medical regimen. The level of care and the nature of the treatment they received were decided upon by the medical superintendent. It was up to the medical superintendent to “balance the books” by deciding how much to spend on personnel, treatment and pharmaceuticals, entertainments and recreation, and on the basic necessities such as food, fuel and clothing. His remit included the decision on whether to employ an occupational therapist and whether patients should be engaged in occupational therapy or work around the hospital.

The importance of the medical superintendent’s role was recognised by the Board of Control, who remarked that how a hospital was managed “depends more on the personality, the outlook and the experience of the Superintendent than on anything else”.³² The medical superintendent was “the inspiration” behind the medical and scientific work of the hospital and needed to be the “physician in chief” and not just a good administrator.³³ In other words, if the medical superintendent or chief medical officer believed that patient occupation was important, this would be prioritised (although the converse was equally true). It was up to the medical superintendent to make the necessary staffing, financial and practical arrangements to facilitate occupational therapy. The Board of Control insisted that occupation should be supervised by doctors and used throughout the hospital as “a socialising factor or as a method of cure”.³⁴ The Board were keen that medical officers “direct the course of occupational therapy in every phase”, watching the patients in their classes, the occupation centre, the gardens and recreational hall, or wherever they may be. They should study the effect of the treatment on different types of patients, using their observations to prepare prescriptions to guide staff and “ensur[e] that every occupation and recreation is used therapeutically”.³⁵

The Views of Psychiatrists in Paris and London

The priority accorded to occupation by doctors depended on the availability of, and the doctors’ faith in, alternative treatments, such as biological remedies. Modern treatment, as identified by the French Asylums Medical Society in 1918, comprised hydrotherapy, isolation, UV-ray treatment, electricity, radiography, psychotherapy, work and distractions. Of these, the only really modern mode of treatment was psychotherapy, but this was not accepted by psychiatrists outside Toulouse’s circle in Paris.³⁶ Experiments with a variety of biological remedies were carried out during the 1920s, including treatment with organ extracts, hypnotics, barbiturates and anti-syphilitic drugs, but these did not provide the breakthrough that psychiatrists had hoped for and were regarded with scepticism by many English psychiatrists. French psychiatrists, desperate to find a “scientific” treatment for mental disorder that would elevate their status amongst the rest of the medical profession, viewed them more positively. Great claims were made for malaria therapy, found to be an effective treatment for some sufferers of neurosyphilis or general paralysis of the insane (GPI) in 1917. Malaria therapy came into general use in the mid-1920s. Its safety and effectiveness were questioned by some, particularly in England, and it was only effective for one condition (despite attempts to use it for other conditions). GPI became the first treatable brain disease causing serious psychiatric symptoms and malaria therapy marked the beginning of physical therapies for mental disorders.³⁷ It was not until the late 1930s, however, that shock treatments (such as insulin coma therapy and electroconvulsive therapy) and surgical interventions (focal sepsis and leucotomy or lobotomy) emerged on the scene. In other words, during the 1920s, as Jones et al. emphasise, psychiatrists had “little to offer in the way of treatment”.³⁸

In Paris, Toulouse’s interest in the use of therapeutic occupation, like his understanding of heredity, was atypical of his French colleagues. He believed that social; psychological; moral; physical and pathological factors could stimulate an inherited disposition towards mental illness. Crucially, however, he did not believe that mental illness itself could be transmitted through heredity. He was critical of such theories, held by French alienists since they led to a fatalistic tendency to regard all mental illness as incurable. Toulouse was clear that in his view mental illness was both curable and preventable.³⁹ Influenced by contact with American psychiatry through the Mental Hygiene Movement, Toulouse adopted a more psychobiological stance after World War I. He advocated psychotherapy for both in- and out-patients, as well as biological and physical treatments, all of which were available at the Henri Rousselle Hospital. Toulouse’s use of drugs is indicated by the steep rise in expenditure by the Asile Clinique pharmacy (the Henri Rousselle Hospital was administratively dependent on the Asile Clinique until 1926). Between 1921 and 1922 (when the Henri Rousselle Hospital was founded) expenditure rose from 43,000F to 58,000F, despite the Henri Rousselle having just one fifth of the number of patients as the Asile Clinique.⁴⁰ Although clearly not averse to prescribing biological remedies, Toulouse also expected his hospital patients to keep themselves busy and ensured that the facilities were available for them to do so.

Psychiatrists at the Asile Clinique did not consider patient work a suitable treatment for patients at the acute stage of their illness. When the Asile Clinique became an acute service, only convalescent patients in the treatment sections worked. Doctors preferred “active” biological treatments for acute-stage patients, resulting in another significant rise in expenditure by the pharmacy in 1927.⁴¹ In 1928, the pharmacist remarked that not only was the cost of medicines rising, but so was their use by the various services within Ste Anne’s.⁴² Although work was not considered suitable for patients at the acute stage of their illness, once passed this stage patients were able to work. Treatment of GPI with malaria therapy and Stovarsol, an arsenic-based drug, at the Asile Clinique, following the transformation of the Asile Clinique’s services in 1927, was reported to have enabled several patients to take up work once more, either within the hospital as convalescent patients, or after discharge. In 1928, for example, Dr Leroy reported that eight of his GPI patients had been able to leave the asylum in a condition that allowed them to re-enter la vie sociale and take up their professions once more.⁴³ In the women’s first section, which became the Malaria Therapy Centre in 1930, 20 patients were discharged “cured” and able to resume their previous professions.⁴⁴ In 1935, Dr Marchand discharged four more GPI patients from the Men’s First Division, following treatment with Stovarsol, who also returned to productive work.⁴⁵ After discharge, GPI patients who had been treated with malaria therapy or Stovarsol as in-patients of the Asile Clinique continued to receive treatment (twice or three times per week) as out-patients at the Henri Rousselle Hospital, under the therapeutic direction of Dr Barbé.⁴⁶

Insulin shock treatment and Cardiazol were used in all the services of the Asile Clinique in 1938.⁴⁷ The judicious application of shock treatments was responsible for a “considerable reduction” in the length of a patient’s stay in hospital, which was good for the patient (who could convalesce at home) and for departmental finances.⁴⁸ Treatment of GPI with malaria therapy and arsenic had continued, apparently with good results. Dr Guiraud had noted, by following patients’ progress since 1934, that the results were not transitory, but definitive in most cases provided the treatment was continued for a long period after discharge.⁴⁹ UV-ray and electrical treatment had also been continued.⁵⁰ The report was optimistic, suggesting that the increasingly varied treatment offered at the Asile Clinique emphasised its role as a “proper hospital”, where all acute patients were given appropriate medical care.⁵¹ In the same report, the patient workforce was described as “practically non-existent” (à peu près nulle). The work of the general services and technical departments had been performed by the permanent and auxiliary personnel, rather than by patients.⁵² This underscores the reluctance of doctors to prescribe work to acute patients. The apparent lack of interest in psychological methods of treatment, such as psychotherapy or occupational therapy, that were not even mentioned by doctors at the Asile Clinique, contrasted with the approaches taken by Toulouse at the Henri Rousselle Hospital (which was literally next door) and Edward Mapother (1881–1940), medical superintendent of the Maudsley Hospital in London. Mapother, in particular, was far more cautious with regard to biological and physical treatments than his French counterparts.

Both Toulouse’s and Mapother’s understanding of mental illness evolved during their careers. Mapother’s early papers (1911–1914) were strongly neurological in tenor, although he worked with some of the leading names in psychology (including Bernard Hart) at the Long Grove Asylum before World War I. During the conflict, Mapother served in the Royal Army Medical Corps, and completed the three-month course in military psychiatry at the Maghull Hospital in 1917. Immediately after the war he was appointed to the Maudsley Hospital whilst it was operating as a Ministry of Pensions specialist treatment centre for soldiers suffering from severe war neuroses. ⁵³ These wartime and post-war experiences led Mapother to become interested in psychopathology. He maintained that “in all properly investigated cases of insanity, it is found that it is the result of the summation of multiple causes, effective in combination, though inadequate singly”.⁵⁴ He declared futile the controversy between those who believed mental disorder had a psychogenic origin and those for whom its origin was physiological.⁵⁵ Mapother stressed the “continuity of all forms of mental disorder and for the compatibility of treatment … of all grades of it”.⁵⁶ His policy at the Maudsley was “to encourage an unprejudiced trial of every form of treatment offering a reasonable prospect of benefit rather than harm”.⁵⁷ Wary of the latest biological and physical treatments, Mapother maintained in 1925 that “certain long-established measures still form the foundation of any successful treatment of neuroses and psychoses”. These he identified as “suitable feeding, fresh air and sun, the regulation of rest, exercise and occupation, [and] the procuring of sleep”, reminiscent of the balanced “regimen” of the six non-naturals.⁵⁸

This preference for “long-established measures” did not preclude the Maudsley’s experimentation with organotherapy, as Bonnie Evans and Edgar Jones have shown, but this, and other biological treatments, were blended with efforts to help a patient to adapt more effectively to their environment through psychotherapy and occupation.⁵⁹ The Maudsley’s approach was “interdisciplinary” and “pragmatic” and drew on Adolf Meyer’s methodology. It incorporated “psychology, biology, evolutionary theory, and even the moral and social sciences”. Each patient’s personal circumstances and family histories were integrated with their symptoms to develop a coherent understanding of their problems.⁶⁰ Mapother (pictured below in Fig. 6.2) recognised the need to “elucidate both recent and remote sources of mental trouble” through psychotherapy but felt this was better achieved after the patient’s emotional state had been improved by established measures outlined above, and by the removal of the patient from home, which was often at the heart of a patient’s anxieties.⁶¹ He acknowledged that psychotherapy was the most effective means of combating mental stress in cases of “functional disorder”, following his experiences in World War I. In this therapeutically tolerant atmosphere, occupational therapy, which had the advantage of doing no harm to patients (unlike many of the treatments of the 1930s) was able to flourish. Mapother first reported employing an occupational therapist in 1925.⁶² A school of occupational therapy was established at the Maudsley in 1932, underlining its perceived importance by the superintendent.

Fig. 6.2

Edward Mapother, Medical superintendent of the Maudsley Hospital, London. (© By permission of Bethlem Museum of the Mind, EM-01)

The discovery of insulin shock treatment for schizophrenia in Vienna in 1936 generated international excitement at a time when the Board of Control were starting to despair of ever seeing “any noticeable improvement in the discharge rate”.⁶³ The procedure was not without risks, however, and the following year, an alternative, safer method of shock treatment, by injections of the drug Cardiazol, was introduced. Cardiazol became the most widely used somatic treatment for schizophrenia and affective disorders in British public mental hospitals.⁶⁴ Mapother was wary of the new shock treatments.⁶⁵ Until their safety and efficacy could be proven, he opposed their use. In line with Mapother’s commitment to avoiding treatment that could cause his patients harm, clinical trials of Cardiazol were banned at the Maudsley because the convulsions generated could cause extreme anxiety and fear. Similarly, Mapother delayed the introduction of insulin coma therapy until November 1938 owing to the medical risks posed to patients.⁶⁶ While these shock treatments were being greeted with caution by Mapother, the provision of occupational therapy was expanding at the hospital, following the department’s relocation to larger quarters after the hospital was extended in 1936. That year, a male occupation officer was appointed to provide carpentry classes for male patients; a dedicated carpentry workshop was planned for the hospital’s second extension in 1939.⁶⁷

In contrast with the holistic approach of Mapother, John Porter-Phillips, physician superintendent of the Bethlem Royal Hospital from 1914 until 1944, maintained a predominantly physicalist approach to treating acute-stage patients for most of his tenure at Bethlem. When the hospital was amalgamated with the Maudsley in 1948, his treatment methods were denounced as “old-fashioned” by Aubrey Lewis, who became the Maudsley’s superintendent in 1939.⁶⁸ The records indicate that sedation, bed-rest, a milk diet and electrotherapy were the preferred methods of treating acute patients during the interwar period at Bethlem.⁶⁹ All patients, whatever their condition, were sedated on admission (sulphonal and paraldehyde were the sedatives most commonly used), a custom established in the late nineteenth century.⁷⁰ The use of mechanical restraint was regularly reported by the Board of Control’s inspectors. For example, in 1929 they noted that two women had been mechanically restrained on 11 occasions for a total of 62 hours “to prevent self-injury”.⁷¹

Porter-Phillips’ initial focus on the “physical side of mental illness” was indicated by the Medical School’s neurological orientation and by his particular interest in focal sepsis. The latter became a significant method of treatment at Bethlem after the appointment of dental surgeon William Bulleid to Bethlem in 1922.⁷² In his annual report of 1926, Porter-Phillips stressed the importance of treating “the large number of patients … admitted with marked dental disease” given the “possible role this focal sepsis plays in the causation of mental disorder”.⁷³ Although more concerned with focal sepsis and other physical or biological remedies, Porter-Phillips appointed a psychologist in 1923 as he felt that psychology should be included in the medical school’s syllabus. Psychology at Bethlem, however, was limited to the psychometric testing of patients and there was little cooperation between the psychology department and other departments of the hospital.⁷⁴ Psychotherapy was not widely used at Bethlem until after World War II.

A lack of enthusiasm from Porter-Phillips, coupled with the Bethlem Governors’ unwillingness to set aside the requisite funds, delayed the introduction of occupational therapy until 1932. That said, Porter-Phillips was committed to the provision of a comprehensive programme of entertainment and recreation. The programme of plays, operas, dances, whist drives, and fancy dress ball at Christmas, and the carriage drives into London, visits to see the Boat Race and to Epsom Races, sporting activities, walks and picnics in summer, formed, in Porter-Phillips’ opinion, “one of our most potent factors in treatment”.⁷⁵ He claimed that the programme helped patients “focus their attention in a healthy manner and thus readjust themselves to our so-called normal social life”.⁷⁶ The Chaplain gave lantern-slide lectures; patients were provided with a piano and a library; contributions to the hospital magazine Under The Dome (renamed Orchard Leaves after the hospital’s move to Monks Orchard in 1930) were encouraged. Classes in Swedish Drill, Morris and Country dancing were introduced in the mid-1920s, from which patients were said to derive “enormous benefit in mind and body”.⁷⁷ These activities were well suited to the Bethlem’s increasingly middle-class clientele.

The early nineteenth-century moral therapists had long since recognised the value of entertainment and recreational activities that diverted the patient’s attention and encouraged social interaction (just as they had advocated the therapeutic potential of work). The programme at Bethlem was not novel, although it was far more lavish than the entertainment offered in public asylums. Porter-Phillips also realised that “employment in the open air”, which had been highly recommended by Pinel and Tuke, could provide a “great auxiliary to the medical treatment” particularly amongst patients in “late adolescence or early manhood” (despite that fact that manual work was unsuitable for many of his middle-class patients).⁷⁸ Porter-Phillips’ evaluation of entertainment and work appeared to be rooted in the nineteenth-century concept of moral therapy rather than in modern notions of occupational therapy. Patient complaints of boredom eventually persuaded the Governors that occupational therapy should be introduced, and an occupational therapist was duly appointed in 1932.⁷⁹ A photograph of the new occupational therapy department was included in the hospital prospectus in 1932 (see Fig. 6.3), which boasted of the range of arts and crafts on offer.⁸⁰ Although supportive of occupational therapy once it had been introduced, no doubt encouraged by its popularity amongst staff and patients, Porter-Phillips remained committed to searching for the physical causes of, and biological treatment for, mental illness.⁸¹

Fig. 6.3

The arts and crafts department at Bethlem Royal Hospital, Monks Orchard. (© By permission of Bethlem Museum of the Mind, ECB-07)

Only a few GPI patients were admitted to Bethlem, owing to its policy of restricting admission to curable patients, and Porter-Phillips was not enthusiastic about malaria therapy, believing it only offered “a slight hope of complete cure”.⁸² At Bethlem in the 1930s, patients continued to be sedated, with hyoscine prescribed to deal with head-banging and other destructive habits. Barbiturates, such as the hypnotics veronal and medinal, were increasingly used at this time to calm patients and promote sleep. Depressed patients were prescribed stimulants, including Benzedrine, that produced a sense of euphoria.⁸³ Staff often ignored the complaints of patients that the drugs made them feel “drunk” and relied on sedation to keep patients calm and manageable.⁸⁴ Porter-Phillips remained unconvinced by the “experimental” shock treatments emerging in the late 1930s.⁸⁵ He observed that “each method after trial appears to be withdrawn in favour of some other therapeutic agent more suitable and promising”.⁸⁶ The results of insulin shock treatments delivered at Bethlem were inconclusive, but Porter-Phillips conceded that they led to a definite alteration in the mental state or attitude of patients which made their management by the nurses much easier.⁸⁷ This was also noted by the Board of Control inspectors who recorded in 1938 that no seclusion or mechanical restraint had been used in the previous 12 months.⁸⁸ Mechanical restraint was not a method associated with modern psychiatric practice.

Bethlem’s physician superintendent, Porter-Phillips, was conservative in his approach, continuing to rely on sedation, isolation and restraint (until the advent of shock treatments) as the main means of calming turbulent patients, rather than prescribing occupational therapy or work around the hospital. The lavish programme of sport and entertainment, designed to appeal to a middle-class clientele, had changed little since before the war. Occupational therapy was only introduced after patients complained of boredom. Porter-Philips remained committed to finding a physical cause of mental disorder and never embraced the possibility of a psycho-social cause. At the Maudsley, on the other hand, Mapother introduced occupational therapy from the outset. He believed that mental illness might have a psycho-social origin, and that psychotherapy and occupational therapy could help patients re-adjust to their environment. In this, Mapother was similar in outlook to Toulouse at the Henri Rousselle Hospital. Toulouse also adopted a holistic stance, using psychotherapy and advocating some form of occupation for his patients, as well as biological treatments. The latter were the preferred methods of treatment for the psychiatrists of the Asile Clinique. Here, the active treatment of acute patients was just as much a priority as it was at the Maudsley and Henri Rousselle hospitals, but the emphasis was on delivering physical and biological treatments. Occupation was not deemed appropriate for acute cases.

The Views of Psychiatrists in the Provinces

The long-standing medical superintendent of the Littlemore and the successive chief medical officers of the Asile de la Sarthe had quite different therapeutic approaches, which were related to the different pathways of professional development taken by French and English psychiatry discussed in Chap. 3.⁸⁹ The different approaches were reflected in their prescription of patient work. Dr Thomas Saxty Good, (1870–1945), medical superintendent of the Littlemore from 1906 to 1936, put great faith in psychotherapy, following his experience of treating shell shock during World War I.⁹⁰ The chief medical officers of the Asile de la Sarthe took a more “biological” approach. Psychotherapy became the main method of treatment at the Littlemore after 1922, when the hospital re-opened for civilian use after the war, along with hydrotherapy, “work therapy” and amusements.⁹¹ The Board of Control commented on Good’s “judicious exercise of psychotherapy in conjunction with close study of physical conditions”.⁹² While drug treatments were not eschewed, the Board of Control noted with approval the Littlemore’s “sparing use of sedatives”.⁹³

Good confirmed in 1930 that sedatives, narcotics and hypnotics were only used for extreme cases. He claimed that 15 female patients (or 2% of the average daily number resident), but no males, were given paraldehyde (a hypnotic drug used to treat insomnia) continuously throughout the year, while bromides (used to control the seizures associated with epilepsy, a neurological condition) were given in 48% of male epileptic cases and 38% of female epileptics. Two dozen tablets of “dial” and an equal number of “didial” were administered during the year, but no other barbiturates. Hydrotherapy was used for cases of confusional excitement.⁹⁴ Good maintained that as a “matter of practice” all methods of treatment were tried at the Littlemore, but he had found that “mental analysis” was the “most certain”.⁹⁵ Occupation complemented this psychological approach.

Good used psychotherapy not only in his treatment of patients, but also in his dealings with members of staff.⁹⁶ Psychotherapeutic principles permeated Good’s management style. Because he believed that all departments of the hospital, including the kitchen, laundry, stores and offices, contributed to the well-being of patients, Good insisted on close communication between them. While units operated independently, there was “frequent discussion amongst the various head of units”. In this way, “every person in the hospital staff has an opportunity of hearing the ideas of others, and therefore perceives not only the effect of his own unit, but of others”.⁹⁷ This was an important factor when patients were working all over the hospital, assisting in various departments where they might not be medically supervised. As for the nursing staff, Good ensured that nurses were freed from administrative duties in the laundry and kitchen so that they could spend more time with patients.⁹⁸ He made it a priority that nurses were not only able to deal with physical aspects of illness, but also to “sympathise with the psychological disposition of the individuals under their care”.⁹⁹

Described by the British Medical Journal as “one of the pioneers of modern psychiatry”, Good’s approach was endorsed by his appointments as lecturer in psychiatry and nervous disorders at the University of Oxford in 1928, as President of the Royal Medico-Psychological Association in 1930 and of the British Medical Association’s Section on Neurology and Psychological Medicine in 1936.¹⁰⁰ Good’s approach was continued by Dr Robert William Armstrong after the former’s retirement in 1936. During the late 1930s, many more biological treatments were beginning to be explored, raising the question of whether psychotherapy, together with occupation, remained an important means of therapy. From the Littlemore’s annual reports, it appears that Dr Armstrong was keen to trial new treatments, but psychotherapy and occupational therapy remained a priority at the Littlemore. Armstrong reported in 1938 that malaria therapy was being continued and had produced very satisfactory results in several cases.¹⁰¹ Good had mentioned in 1926 that the effects of malaria therapy on cases of GPI and encephalitis had been trialled by his medical team,¹⁰² but he did not mention it in subsequent annual reports, nor in his history of the Littlemore. Armstrong’s comment, however, suggests that its use had been on-going. The 1938/1939 report also referred to the use of shock therapy in the treatment of schizophrenia. Cardiazol had been used at the Littlemore and Armstrong hoped to try other forms of convulsive drugs such as Triazol.¹⁰³ He had not attempted insulin therapy due to a shortage of medical staff, but this was planned following the appointment of a third assistant medical officer.¹⁰⁴ This appointment, the Board of Control believed, was justified in the light of the number of acute patients being admitted on a voluntary basis; the need for thorough and sometimes prolonged investigation; and the time taken up with psychotherapy at the Littlemore.¹⁰⁵ The latter comment suggests that psychotherapy remained a significant method means of therapy.

The year 1939 was reported as “exceedingly active” from the point of view of the medical treatment of patients. A “large number” of patients were treated with various forms of shock therapy and “nearly a dozen” with insulin therapy resulting in “a few striking successes and a great many disappointments”.¹⁰⁶ More success had been achieved using continuous narcosis, which Armstrong believed was “definitely a useful addition to the therapeutic armamentarium”.¹⁰⁷ On balance, however, he considered that these “heroic measures of treatment” were “unlikely to realise the high hopes with which they were introduced”.¹⁰⁸ His ongoing commitment to occupational therapy, on the other hand, was indicated in the reports from 1936/1937 to 1939/1940. These revealed that provision of occupational therapy had expanded both in terms of the numbers of patients involved and the range of items produced. He confirmed that this “important form of treatment” was being provided for “all grades of patients” including those at the agitated, acute stages of their illness.¹⁰⁹ Occupation was therefore being used to treat curable cases as well as to distract the more turbulent, incurable patients. Armstrong appeared equally supportive of occupational therapy as his predecessor.

The Littlemore had just two superintendents during the interwar period; Good and Armstrong, both of whom valued psychotherapy and occupation. Although Armstrong was more open to modern biological interventions, he remained committed to occupational therapy. In contrast, while the Asile de la Sarthe enjoyed continuity of medical leadership until the retirement of Dr Victor Bourdin in 1931, during the 1930s three chief medical officers were appointed in fairly rapid succession. None of these chief medical officers mentioned psychotherapy and all appeared to favour biological interventions for curable cases, in line with their organicist principles. Bourdin’s reports were dominated by his trials of new medicines, such as Borosodine to treat epilepsy, and the hypnotic somnifène, but the results were not promising.¹¹⁰ The families of some GPI patients had asked Bourdin to experiment on their relatives with anti-syphilitic treatments based on bismuth or arsenic, but he felt that, apart from being very expensive, these drugs were risky to the patient and only gave temporary relief. Bourdin prescribed them if relatives insisted, however.¹¹¹ The fact that patient work was not mentioned in Bourdin’s reports, while his use of various drugs was paid significant attention, suggests that Bourdin preferred biological to psychological methods of treatment, in keeping with French psychiatric tradition. The records appended to the Asile de la Sarthe accounts, however, indicated that patient work was occurring on a similar scale to before World War I. It can be assumed that this patient work was carried out by calm, chronic and incurable patients and the few convalescents who had made a recovery (as was the practice before the war). There is no indication that occupation was being used to treat acute patients.

When Dr. Schutzenberger arrived in Le Mans from the Asile Clinique in Paris, becoming chief medical officer of the Asile de la Sarthe in 1932, he was keen to offer “complete, effective and modern treatment” using the full range of therapeutic methods available.¹¹² His comments suggest that he found the treatment deployed at the Asile de la Sarthe old-fashioned and inadequate. He was able to obtain additional funds from the asylum director that enabled him to purchase the equipment required to perform blood tests, lumbar punctures and the examination of fluids that would allow biological tests, such as the Bordet-Wassermann test for syphilis, to be undertaken.¹¹³ Schutzenberger, taking advice from his former senior colleagues at the Asile Clinique, Drs Guiraud and Truelle, introduced malaria therapy to the Asile de la Sarthe in 1933.¹¹⁴ Henceforth, he maintained, this method would be used to treat all GPI sufferers. Rates of cure and improvement for 1933–1935 did not increase significantly, however. Schutzenberger’s medical report of 1933 was the first interwar medical report to mention patient work, itemising the numbers of days worked in each category, and the breakdown of work between male and female patients.¹¹⁵ It is interesting that he chose to mention work, given his background at the Asile Clinique where work was not undertaken by patients in the acute, treatment wards. Schutzenberger’s report did not discuss the work in therapeutic terms, however, so it may be that its prescription was limited to incurable, chronic and convalescent patients. Schutzenberger’s strong views on the extent of overcrowding at the Asile de la Sarthe brought him into conflict with the prefect and he did not remain long in post.

When Dr Henry Christy took over as chief medical officer in 1934, his first report was designed to impress upon the prefecture the “scientific trends” that guided his treatment methodology.¹¹⁶ His emphasis on the scientific nature of his methods is indicative of French psychiatrists’ desire to be taken seriously by the rest of the medical profession. Christy divided patients into two categories, the intellectually impaired, who were incurable, and the mentally disordered, who responded to treatment. The two categories required different therapeutic techniques. The intellectually impaired required treatment for any physical ailments; support; comfort; and the moral discipline provided by work. The mentally disordered, on the other hand, required “aggressive biological treatment”.¹¹⁷ The two types of treatment required different skill sets of the doctors. When treating the intellectually impaired, the doctor had to be a psychologist, while the skills of a neuro-psychiatrist were required to treat the mentally disordered.¹¹⁸ Christy’s preference for a neuro-psychiatric approach towards treatment of acute cases underscores French psychiatry’s lack of independence from neurology. Christy made it clear in 1936 that he was more interested in neuro-psychiatry than psychological medicine.¹¹⁹ He wanted to focus on treating acute cases, but the demands of modern (biological) medicine made this difficult with so many patients under the care of just one doctor.

Although Christy emphasised biological treatments for curable patients in his reports, he also made several references to patient work in a rare outline of specific cases presented in 1935. A 19-year-old woman, Berthe, was diagnosed with dementia praecox. She recovered after shock treatment and was reported to have been “docile and working”. Berthe then contracted pleurisy, but on recovering from this illness she returned to regular work within the institution and was soon able to leave the asylum. Patient P.J., aged 21, also suffering from dementia praecox, improved considerably after shock treatment and was currently working at the asylum. His family were going to take him home in a short while. Mme D., 42, suffered from acute depression and had attempted suicide. She was malnourished and deficient in vitamins. She recovered, and after receiving the appropriate food, she returned home and was able to take up her profession as a market trader once more.¹²⁰ The first two cases indicate that Christy prescribed work for patients who were convalescing, following successful shock treatment. The third case indicates that Christy regarded a patient’s ability to return to work as evidence of recovery. An ability to work was considered a requirement for discharge, as indicated by the annual examination records of patients throughout the interwar period. These revealed that if a patient was unable to work and had no-one at home to support them, the patient should remain in the asylum. The phrase “à maintenir” appeared next to their record.¹²¹

Dr Hédouin, who took over from Christy in 1939, agreed that one chief medical officer could only deal with the most pressing cases and that it was impossible to follow the progress of each patient.¹²² Following the outbreak of World War II, patient numbers at the Asile de la Sarthe swelled to over 1,000. Le Mans had been invaded by the Germans and the Asile de la Sarthe was obliged to admit patients evacuated from a neighbouring hospital, Dury-les-Amiens. Hédouin found it impossible to categorise or separate patients. He was obliged to lodge acute psychopaths next to the intellectually impaired and impressionable adolescents with the medico-legal cases.¹²³ The accounts show that patient work continued throughout 1939. It can be assumed that its contribution to asylum maintenance and food production was essential during the Occupation when conditions were harsh and most French mental hospitals were deprived of food and other essential resources.¹²⁴

The focus of the interwar chief medical officers of the Asile de la Sarthe was biological or physical treatment rather than psychotherapy or occupational therapy for acute patients, while patient work was prescribed to the chronic, incurable and convalescent patients. Psychotherapy, as the English Board of Control observed, was time-consuming, and a single chief medical officer in charge of between 600 and 1,000 patients did not have time to deliver it. But neither was psychotherapy an area of interest for the succession of chief medical officers who presided over the Asile de la Sarthe. Christy actually stated his preference for neuro-psychiatry. This preference for biological interventions appears to have influenced the chief medical officers’ views on patient occupation. Christy felt that work was appropriate for incurable patients, while the curable should receive “aggressive biological treatment”, followed by work during their convalescence. There was no question of developing occupations for those who were confined to bed, or for other patients whose conditions precluded work around the hospital. However, the ability of the Asile de la Sarthe chief medical officer to recruit interns and medical officers compromised the provision of biological treatment for patients. By 1939, when Hédouin joined the Asile de la Sarthe, overcrowding and understaffing, as a result of the war, meant that little active treatment of any kind could be delivered.

Psychiatrists at both the Littlemore, and the Asile de la Sarthe after 1932, were striving to provide active treatment for their patients, unlike many provincial establishments (particularly in France) where the model of custodial care remained in place. But each institution’s ways of providing that active treatment were quite different, and in the case of the Asile de la Sarthe, such attempts were thwarted by issues of resources and overcrowding. At the Littlemore, Good’s war experiences had led him to prioritise psychotherapy and occupational therapy, treatments that he would not have considered before the war. Good was also an advocate of treating patients at the early stage of their illness, before their symptoms became entrenched, at the outpatients’ facility he established at the Radcliffe Infirmary in 1918. Christy of the Asile de la Sarthe was quite clear that his preference, as a neurologist, was for the “aggressive biological” treatment of acute cases, and that occupation was the preserve of incurable and chronic patients. The stances of Good and Christy were indicative of the different approaches taken by English and French psychiatrists towards the active treatment of acute cases.

Conclusion

This chapter has shown that the introduction of occupational therapy as an active treatment was intrinsically linked to the outlook and treatment preferences of individual psychiatrists. Those psychiatrists who supported a psychosocial or psychobiological view of mental disorder, as espoused by Adolf Meyer, valued treatments that acted on the psyche of the patient, helping them to re-adapt to their environment and re-establish behaviours that allowed them to function in society. This type of treatment was favoured by those in charge of the Maudsley and Littlemore Hospitals in England, and the Henri Rousselle Hospital in Paris. These psychiatrists all enjoyed therapeutic autonomy. At Bethlem, the physician superintendent retained an organic, pre-war approach to treatment, focused on sedation followed by attempts at re-socialisation through entertainment and sport. Occupational therapy was added almost as an afterthought at Bethlem, in response to the Board of Control’s insistence that occupational therapy was the hallmark of a truly modern hospital, and to patient complaints of boredom. The introduction or absence of occupational therapy highlights the different approaches of the psychiatrists in charge of institutions in the same country, and even the same city.

The Asile de la Sarthe was run along custodial lines between 1918 and 1932, heavily reliant on sedation to calm the turbulent. The arrival of the progressive Dr Schultzenberger, who was keen to introduce the modern therapies for acute patients with which he had become familiar at the Asile Clinique, witnessed the introduction of a more active approach to treatment. Schultzenberger’s successor, Christy, was equally keen to deploy “aggressive biological” treatment methods for acute, curable patients. While innovative treatments such as malaria therapy and the shock treatments were attempted, occupational therapy was dismissed as inappropriate. Occupation was not an option for acute patients, either at the Asile de la Sarthe or at the Asile Clinique where doctors failed to recognise its curative value. Patient work remained restricted to the calm, incurable and chronic patients, just as it had been before the war. “Modern” treatments therefore meant different things to different psychiatrists, depending on their training, professional networks and outlook. The delivery of these modern treatments, whether inclusive of psychotherapy and occupational therapy or not, depended on the quality and quantity of nursing staff and others in supporting roles to provide adequate assistance to the psychiatrists.