The Supervision of Patient Occupation

Abstract

Mental nurses and attendants spent more time with patients than any other members of mental hospital staff. The professionalism, experience and skills of the mental nurses influenced the type of occupation that could be prescribed by psychiatrists and how patients responded to it. Through an analysis of the skill sets of those supervising patient occupation, Freebody highlights the disparity in levels of training and professionalisation between English and French mental nurses during the interwar period. Training schemes and opportunities to gain qualifications were more widely available in England than in France. French psychiatrists complained that their nurses were uneducated, lacked commitment to the role and were incapable of supervising occupation at more than a rudimentary level. In England, nurses were more likely to hold a nursing qualification and their efforts to supervise occupation were supplemented by a new group of professionals, the occupational therapists. Others involved in supervising the occupation of patients included the workshop managers, whose skills in dealing with the mentally disordered were questioned by some doctors.

The experience and level of professionalisation of the staff who oversaw patient work and occupation influenced the type of occupation that could be prescribed by psychiatrists and the success of its application. Those who spent the most time with patients on a daily basis were the mental nurses. They had a significant impact on the management and treatment of patients in mental hospitals, and thus on patient occupation. Whether patients received adequate supervision, or were encouraged in their work depended on whether nurses had sufficient time, in addition to their regular duties, had received the requisite training and were temperamentally suited to the role. As John Crammer has emphasised, mentally ill patients could be “unpredictable in behaviour, restless, impossible to reason with, uninhibited in aggression when thwarted or frightened [and] incomprehensible in feelings and reactions”.¹ The role of socialising and re-educating patients, encouraging them to fit in and co-operate with others on the wards took considerable patience and skill.² Psychiatrist Charles Mercier commented in 1894 that “the happiness and welfare of the patients … depend far more on the character and conduct of the attendants [male nurses] than on those of all the rest of the asylum put together”.³ So, who was attracted to a career in mental nursing and how similar was the profession in France and England? The calibre of the mental nurses supervising occupation had a significant impact on a patient’s willingness to engage with, and derive benefit from, a task. This chapter examines the roles of those who, in addition to the mental nurses, were involved in the supervision of patient occupation, including the new group of professionals, the occupational therapists.

Mental Nursing: Professionalisation and Training

By 1918, the professionalisation of mental nursing had developed further in England than in France in terms of the availability of training, the existence of a standardised manual, and the establishment of nationally recognised qualifications. That said, professional training and qualifications were not obligatory in either country and the quality of mental nursing attracted criticism in both France and England during the 1920s. Montagu Lomax, for example, was highly critical about the standard of English mental nursing at the Prestwich Asylum. He accused attendants of lacking “patience, tact, sympathy, and an understanding of the insane mind”.⁴ Whilst an “attendant’s character and disposition” were paramount, he also believed that “certification or registration should be compulsory upon all attendants, male and female”.⁵ His remarks led to an enquiry by the Board of Control’s Committee on Nursing in County and Borough Mental Hospitals. Published in the Journal of Mental Science in 1925, the report resulting from the enquiry recommended a “national nursing service … a service in which the same qualifications are recognised and required at all institutions for the same positions”.⁶ The Committee emphasised that quality nursing depended upon “adequate training” based on theoretical and practical instruction by qualified teachers.⁷ This was already available; the MPA had produced a handbook for mental nurses (first published in 1885) and established a standardised, national training scheme. From 1891, trainees could sit an examination resulting in a Certificate of Proficiency in Nursing the Insane. By 1899, 100 asylums were participating in the training scheme, the duration of which was extended to three years in 1908.⁸ In 1919, the General Nursing Council established its own training programme for mental nurses, resulting in parallel training schemes based on almost identical curricula.⁹ The availability of such instruction, however, did not obligate nurses to undertake it, nor hospitals to provide or insist upon it.

Deficiencies in the English system were also underlined by the Macmillan Report of 1926 which emphasised that nurses should be carefully recruited and properly trained.¹⁰ There appeared to be a considerable difference between the quality of nurses working at the Maudsley, Bethlem and Littlemore hospitals, where nurses were given proper training and where the pay and conditions were relatively good, and the other public mental hospitals at which the criticisms were directed. At the Maudsley Hospital, when it opened in 1923, the Board noted that all senior nurses were required to hold a certificate representing at least three years’ training at a general hospital or a diploma from a recognised nursing school. All the sisters and most of the staff nurses also possessed experience at either mental or neurological hospitals.¹¹ Pay and conditions, considered crucial to attracting a high calibre of nurse and maintaining high standards, were considerably more favourable in city institutions, such as the Maudsley and Bethlem Hospitals.¹² At the Maudsley, nurses’ accommodation was described as “excellent” in 1923, while at Bethlem, the pay for probationer nurses was described in an article in The Hospital in 1921 as “far in excess of that usually accorded to learners”.¹³ Nursing care at the Maudsley was praised in the Board of Control’s annual inspection reports. In 1926, the Board remarked that “everything is being done not only for the restoration to health but for the comfort of the patients”.¹⁴ The nursing care was described as “excellent” in 1935.¹⁵ A nine-month course in handicrafts was established for nurses in 1935; nurses attended voluntarily in their free time. Thirty nurses had joined the two classes, for which craft teachers were supplied by the London County Council.¹⁶ Maudsley nurses who underwent such training could therefore assist in the provision of occupational therapy for patients.

In contrast to the Maudsley, where all senior nursing staff were qualified, at Bethlem, during the mid-1920s, approximately 65% of male nurses and 30% of female nurses were registered or certificated. Despite the fact that training was incentivised at Bethlem by the offer of an additional two shillings per week for those obtaining the MPA Nursing Certificate, the numbers of trainees fell.¹⁷ By 1934, the percentage of certificated nurses had fallen to 48% of male nurses, and 19% of female nurses.¹⁸ Although nurses at Bethlem were not involved in instructing patients in occupational therapy (introduced in 1932), they were expected to encourage patients to take exercise and “to enter into amusements”.¹⁹ Bethlem’s “Rules and Orders”, prepared in 1932, stated that “the Nurses shall devote the whole of their time during the day to the Patients, and shall execute with diligence all the direction they shall receive respecting their treatment, medicine, food, dress, occupation, exercise and amusement”.²⁰ There was no mention of work around the hospital in the Rules, but one nurse remembers that “we tried to keep everyone occupied…they [the patients] played cards, table tennis, did knitting [and] sewing”.²¹

Although Bethlem’s Rules and Orders did not emphasise the benefits of manual labour, in other respects they appeared to be closely aligned with the principles of moral therapy, and with the practices recommended in the mental nursing handbook produced by the MPA. The first edition of the handbook was published in 1885 and remained in circulation until 1902.²² Numerous subsequent editions (the seventh appearing in 1923) were produced between 1902 and 1978. Early editions of The Handbook encouraged staff to train patients to adopt “proper healthy habits”, by adhering to the daily routine of the asylum with its “regular hours for rising, taking food, work, exercise, amusement and retiring to bed”.²³ Occupation in the form of work was reported as having “a most salutary effect on both the body and the mind”.²⁴ Housework, work in the gardens or workshops, on the farm or in the laundry, needlework, drawing or writing, or whatever work was “congenial” to the individual, diverted the attention away from “morbid fancies” and helped patients to focus on healthier matters. It was the attendants’ or nurses’ duty to ensure that patients were properly engaged with the work and not allowed to “lounge about idly” to ensure the maximum benefit was derived from the activity. It was also made clear that “the willing must not be over-tasked”.²⁵ The value of providing amusements for patients in the form of dancing and games was also highlighted, and nurses were to encourage patients to participate.²⁶ Although the first edition of the handbook was produced some forty years after the heyday of moral therapy, the passages relating to occupation bore a marked resemblance to the teaching of the moral therapists. The wording did not change significantly in subsequent editions produced during the interwar period.

As in England, standards of nursing care in French asylums attracted widespread criticism. Formal training in mental nursing was rare in France in the immediate aftermath of World War I, despite the efforts of psychiatrists Théodore Simon and Georges Daumézon to professionalise mental nursing and improve instruction.²⁷ Training was provided in some departments, including the Seine, where a mental nursing school had been established at Ste Anne’s in 1882 and at other Seine asylums in 1907, but provision outside the capital was patchy.²⁸ A State Diploma, requiring a year’s training (increased to two years in 1924), was introduced in 1922, but it was not compulsory. The general education of those nurses who took the examination compromised their chances of success. In the Seine, 28 out of 40 student nurses failed the diploma in 1922, as a result of poor communication skills.²⁹ Thirteen years later, Daumézon found that the level of education achieved by mental nurses was still extremely poor. Only 5% of mental nurses held a certificate of primary education in 1935, and some were illiterate.³⁰ Manuals were available, including Roger Mignot and Ludovic Marchand’s Manuel technique de l’infirmier des établissements psychiatriques (first published in 1912, with a second expanded edition appearing in 1930), and Antony Rodiet’s Manuel des infirmiers et infirmières des hôpitaux et des asiles (1928) which were based on “modern republican medicine”.³¹ But the manuals’ usefulness depended on the nurses’ ability and inclination to study them. The Mignot and Marchand manual indicated that work for patients was a distraction and helped to maintain a level of intellectual activity. It also highlighted that in many asylums, patient work generated important cost savings.³² The influence of moral therapy can be detected in the notion of work as a distraction and a stimulus to the intellect, while its benefit as a means of making cost savings can be linked to a concern for economy that grew in importance after c.1850. Neither of the later editions of the manuals advocated the more sophisticated techniques of occupational therapy.

In 1925, General Councillor Chausse referred to the need to eliminate “useless” staff from Seine asylums.³³ Nurses’ salaries had been raised in an attempt to recruit competent, devoted staff who could give their patients the best care, but this had not had the desired effect.³⁴ French nurses were compared unfavourably with their Dutch counterparts by Seine psychiatrist, Paul Courbon. After visiting the Dutch asylum at Santpoort in 1929, Courbon observed that Dutch nurses regarded the profession as a vocation, rather than just a job, and they were recruited from a more highly educated and cultivated class than in France.³⁵ Similar observations were made by Daumézon in 1935. He noted that nurses tended to be recruited from peasant or labouring stock and lacked a vocational calling to their profession.³⁶ From 1930, a new five-year training scheme was offered to nurses, but this was optional and did little to improve overall standards.³⁷ The need for nurses to be highly trained and committed to their role was essential for the successful introduction of Simon’s “more active therapy”, since, as Legrain and Demay highlighted in their 1934 report, the application of therapeutic work rested with the nurses.³⁸ Nurses needed to have the skills to motivate patients, to direct the activity of distracted or confused patients, to intervene if a patient became agitated and to modify the work according to how a patient was coping. They needed to be familiar with their patients’ conditions, interests and capabilities, and able to handle them with patience and tact.³⁹ French mental nurses, including those in the Seine department, lacked the training and experience to direct patient work effectively, particularly when dealing with more challenging patients.⁴⁰

Édouard Toulouse was keen to address these shortcomings. He drew up a proposal for a school of mental health, to be established within the Henri Rousselle Hospital. The aim was to provide technical, theoretical and practical training to mental nursing staff, laboratory assistants and social workers. The course was aimed at those who already had a basic knowledge of anatomy, physiology and hygiene; it was designed to complement, rather than replace, that which was taught at nursing school. Instruction in psychiatry and mental health would be taken by everyone, followed by specialist classes in nursing, social work and laboratory work.⁴¹ Although the school was described as in the “process of being created” in 1931,⁴² Toulouse’s plans do not appear to have been realised. His intentions, however, are indicative of the general dissatisfaction with mental nursing standards at that time.

Standards of nurse training and skills differed quite markedly at the rural Littlemore and the Asile de la Sarthe. They were of a much higher standard at the Littlemore (although standards here were not typical of all English provincial mental hospitals). Dr Thomas Saxty Good expected every Littlemore nurse to learn a craft that they could teach to patients. By developing a rapport with patients, nurses were able to encourage them to take up the craft in which they specialised. As Good put it, a patient’s attachment to a nurse “will often induce them to start that nurse’s particular craft”.⁴³ Nurses in both the male and female divisions were expected to learn and teach handcrafts to patients. The Board of Control was impressed that this interaction with patients enabled them to produce “detailed and helpful notes … on the behaviour and conversation of patients” which aided the doctors in their treatment decisions.⁴⁴ Doctors discussed each case fully with the senior nurses and involved them in decisions regarding treatment.⁴⁵ The hospital did not suffer from overcrowding (attributed to the existence of the outpatient clinic) so the nursing staff were able to maximise the amount of time spent with patients, engaging them in conversation and helping them with their craft activities.

At the Asile de la Sarthe, on the other hand, it was difficult to find reliable, experienced male nursing staff who could supervise patient work at all but the most rudimentary level. Staff shortages were compounded by overcrowding, which meant that nurses had less time to spend with patients. In 1920 the Asile de la Sarthe had barely enough staff to give nurses a rest day every week.⁴⁶ Despite a salary rise in 1920 which put the Asile de la Sarthe on a level with other, similar establishments, few male applicants were able to satisfy the Asile de la Sarthe’s requirements for nursing experience gained at other local hospitals or asylums.⁴⁷ Those who were recruited did not remain long in post, which was unsettling for patients.⁴⁸ It had not been possible to institute the eight-hour day for nurses in 1919 (although it had been applied to administrative staff) because recruitment was so difficult. Splitting the nursing teams into three would have been impossible, since the existing two teams were rarely complete. The asylum director, who was in charge of recruitment, rather disparagingly observed that “a good nurse, let us say, is the exception” and that it was probably unwise to allow nurses 16 hours of liberty because they would probably abuse it!⁴⁹ These comments lend weight to the criticisms of nursing staff made by Paul Courbon in 1929.⁵⁰

The nursing situation was rendered more complex at the Asile de la Sarthe, because as was the case in many French provincial asylums, nursing on the female side was provided by nuns from the Charité d’Evron. This was the result of a long-standing arrangement between the Prefect of La Sarthe and the Mother Superior of the religious order dating back to 1870.⁵¹ In Paris and other large cities, where republican values predominated, the secularisation of asylum personnel took place in (or before) 1905,⁵² when all state institutions officially became secular.⁵³ In the provinces, however, particularly in areas where support for the Church remained strong, institutional secularisation was piecemeal and occurred much later.⁵⁴ Secularisation of the nursing staff did not occur at the Asile de la Sarthe until the 1960s.⁵⁵ Fears were expressed by the secular psychiatrists of the Seine that employing nuns as nurses created a “state within a state” and impeded the introduction of modern methods.⁵⁶ Although Dr Christy had come to Le Mans from the republican city of Lyon, such criticisms did not appear to trouble him. He regularly praised the diligence and devotion to duty of his nursing “sisters” and did not regard them as an impediment to his pursuit of modern treatment methods. ⁵⁷

The nursing situation on the male side of the Asile de la Sarthe contrasted with that at the Littlemore, where nurse training based on the RMPA syllabus was given by Dr Good, his medical officers, the matron and head male nurse. Approximately 40–45% of Littlemore nurses (pictured taking a break from their duties in Fig. 7.1, below) were registered or certificated. Examination results were highlighted each year by the medical superintendent in the hospital’s annual report. For example, in 1936, nine male nurses and 16 female nurses were reported to have passed their preliminary examinations, while six women and one man passed their finals, one woman gaining a distinction.⁵⁸ General training was supplemented at the Littlemore by a system of nurse exchange between the Littlemore and the Radcliffe Infirmary, Oxford’s general hospital, enabling Littlemore nurses to gain experience of physical illness and Radcliffe nurses to learn something of mental nursing.⁵⁹ The Board of Control remarked that nurse training at the Littlemore was “calculated” to ensure that nurses could provide “valuable co-operation” in the treatment of patients.⁶⁰

Fig. 7.1

Nurses relaxing at the Littlemore Hospital, Oxford, 1930s. (© Oxfordshire County Council, Oxfordshire History Centre, POX016605)

An important aspect of developing a rapport with patients was continuity of care. Frequent staff changes were unsettling for patients. At the Littlemore, patients were able to establish stable, trusting relationships with their nurses because so many of the latter remained in post for a long time. In 1929, the medical superintendent announced that the Deputy Head Male Nurse, Henry Shattock, was retiring after 41 years of service. Four other male nurses also retired that year after working for between 30 and 35 years at the Littlemore.⁶¹ Good praised the “general excellence and almost universal good behaviour of the Staff” which he attributed to the “keenness and efficiency” of the Matron and Head Male Nurse.⁶² The Board’s inspectors noted in 1934 that “the [senior] nurses with whom we spoke showed both knowledge and interest in their patients and the general standard of nursing appeared to us to be high.”⁶³ Bethlem also appeared to inspire devotion to duty and long-service amongst its senior nursing staff. In 1925, Nurse Eva Scott retired after 21 years of service and in 1927 Male Nurse William Redaway retired after 41 years.⁶⁴ In 1935, the physician superintendent, John Porter-Phillips, noted that two of the nursing sisters had achieved 25 years of service, and in 1938 he congratulated Sister Neave on her retirement after 33 years at Bethlem.⁶⁵ He remarked in 1929 that “…it is gratifying to note that the senior members of the Nursing Staff continue to give us loyal and faithful service”.⁶⁶ He also commented on the “appreciation and gratitude” expressed by patients and their relatives for the “sympathetic care, kindness and devotion” of the nursing staff.⁶⁷ Continuity of care was not something that the Asile de la Sarthe could offer. On the male side, it was difficult to recruit sufficient nurses, and many did not stay long. On the female side, the requirements of their religious order meant that the nuns were continually being replaced.

As well as providing care, nursing staff in English mental institutions had been expected to supervise and participate in the programme of leisure activities and entertainments for patients ever since the advent of moral therapy in the early nineteenth century. As Jocelyn Goddard highlights, the ability to play a musical instrument or demonstrate proficiency in one or more sports continued to be highly valued attributes amongst English mental nursing staff until the 1950s. One former nurse at the Littlemore remembered, “when the male staff were enlisted, they had to either be good at some sport or a musical instrument”. Such attributes were even stipulated in the advertisements for nursing positions.⁶⁸ The Littlemore’s cricket, hockey, football, badminton, and table tennis teams regularly played other hospital teams, travelling as far as Birmingham and Portsmouth for matches.⁶⁹ Bethlem also boasted hospital teams in all sports; match schedules and results were included in the hospital magazine, Orchard Leaves. For example, in the summer of 1935, it was reported that 28 cricket matches were played, of which Bethlem won 12, lost eight and drew five, while three had to be abandoned due to bad weather. Eleven tennis clubs sent teams to play at Bethlem, and the contests were described as “very keen”.⁷⁰ A Sports Club was established in 1933.⁷¹ The matches provided spectator sport for those patients who were not included in the teams. Hospital orchestras played at the weekly dances for patients, until music was provided by phonograph in the 1930s.⁷² The involvement of staff in the provision of entertainment was not such a feature of French institutions. This may have been related to a lack of accomplishments amongst the nursing staff, or lack of staff time, or to the fact that entertainments were organised by the asylum director, rather than the medical staff.

How much time staff had to supervise patient occupation, and thus the extent to which occupation could be used as a curative agent, depended to a large extent on the ratio of nurses to patients. This was particularly important in institutions where there were no occupation officers or occupational therapists, as at the Asile Clinique. Ladame and Demay observed that in most French asylums there was usually one nurse to every ten patients.⁷³ This ratio was similar, according to the Board of Control to that of most English mental hospitals where the ratio was one nurse to nine or ten patients.⁷⁴ Ratios at the metropolitan hospitals of Bethlem, the Maudsley and the Henri Rousselle hospitals, which were all dedicated to the care of acute patients, were far more favourable. At Bethlem and the Maudsley the ratio was two nurses to every five patients, and at the Henri Rousselle Hospital it was one to seven. At the Faculty Clinic, however, Professor Claude complained in 1922 that nurse numbers were so inadequate, particularly during the holiday season, that he was unable to use his isolation rooms for lack of nurses to supervise them.⁷⁵ The Asile Clinique’s ratio improved following transformation into an acute hospital and the “doubling” of the services in 1927. This resulted in one chief medical officer becoming responsible for c.200 cases instead of 400, and the addition of 34 medical and nursing staff who were recruited to provide the more intensive care required for acute patients undergoing biological treatment, such as malaria therapy.⁷⁶ However, even in the 1930s there were still complaints regarding staff shortages at the Asile Clinique. Dr Marchand, for example, noted in 1931 that nurses had to take patients from the First Quarter, where there was no bathroom, over to the general baths, leaving acute patients unattended on the ward.⁷⁷ At the Seine’s Villejuif Asylum, the “sister” institution to Ste Anne’s, one chief medical officer claimed that “moral treatment” [sic] had become almost impossible since patient surveillance and routine tasks took up all the nurses’ time and they had no time to talk to patients.⁷⁸ If nurses had no time to talk to patients, they were unlikely to have time to supervise patient occupation on anything other than a rudimentary level.

At the Asile de la Sarthe, an insufficient quantity of nurses and junior medical staff compromised treatment. In 1933, the new chief medical officer Dr Schutzenberger highlighted that although “on paper” there might be an appropriate number of patients per nurse, in reality, the number of nurses was insufficient. Nurses were often required to be somewhere other than the patients’ quarters, such as supervising bathing, and days off and holidays had to be taken into consideration. In the Men’s Division, there were 335 patients and 42 nurses, but only 26 of these were on the wards at any one time, giving a ratio of one nurse to 13 patients. On the women’s side, there were 496 patients and 43 sisters, but one worked in the pharmacy and two more supervised bathing, giving a ratio of one nurse to 12 patients. Lack of continuity of service amongst the sisters added to the problems caused by the patient to staff ratio. The introduction of the 40-hour week in 1937 forced the Asile de la Sarthe to increase the number of male nurses from 46 to 125. Many of the new recruits had no experience of nursing and none were qualified.⁷⁹ The chief medical officer, Dr Christy, was compelled to organise courses for all male nurses, including elementary instruction in anatomy, physiology and hygiene, since he could achieve little if his staff lacked any understanding of patient care and had scant interest in their work.⁸⁰ Until then, there was no formal mental nurse training at the Asile de la Sarthe. On the female side, however, the majority of the nuns were qualified. In 1928, a third of the nuns had gained nursing diplomas from the general hospital in Le Mans, and half held a “certificate of professional capability” recognised by the Ministry of Hygiene.⁸¹ There was therefore a significant imbalance in the qualifications held by nurses at the Asile de la Sarthe. Male nurses were unlikely to have the time, knowledge or inclination to become involved with patient occupation, other than delivering the patients for whom it had been prescribed to their places of work, while the nuns may not have had the time between their nursing and religious duties.

Apart from the workshop managers, there were no other members of staff who could have supervised occupational therapy (or administered biological treatments, for that matter) at the Asile de la Sarthe. Dr Schutzenberger highlighted that it was impossible for a single chief medical officer to treat c.850 patients without either a medical assistant or interns.⁸² Christy admitted that he had only achieved modest results in the treatment of GPI with malaria therapy because there were insufficient staff to carry out all the necessary procedures.⁸³ Until the mid-1930s, the chief medical officer had been the only medically qualified member of staff. Le Mans was a small town without a university (at that time), which made the recruitment of interns difficult, although one had been engaged for a short period.⁸⁴ In this, the situation of the Asile de la Sarthe was quite different to that of the Littlemore, which was located in the university town of Oxford, where there existed an abundance of medical students. Dr Christy was delighted to have a medical assistant in 1937 but having been without an intern for several months he had been forced to abandon some of the more labour-intensive therapies that he had begun. He concluded that without interns, he could not offer the modern treatments that he would like to use, particularly as he was also running courses for the male nursing staff.⁸⁵

Unlike Le Mans, the existence of the university in Oxford, made the recruitment of medical students for the Littlemore much easier. As the Board of Control highlighted in 1928, “Dr Good’s recent appointment as lecturer of psychiatry … will undoubtedly benefit this Hospital, as the periodical introduction of keen medical students has always been found to be a stimulus to high class work”.⁸⁶ In addition to medical students, the medical superintendent was supported by two assistant medical officers throughout the interwar period. The ratio of nurses to patients was also more favourable at the Littlemore, with one nurse to between seven and nine patients, while at the Asile de la Sarthe the ratio was one nurse to 12 patients. This meant that both medical and nursing staff had more time to spend with patients, and more time to supervise patient occupation. The medical superintendent highlighted the fact that Littlemore nurses were very dedicated and keen to further the work of the medical staff.⁸⁷

Nurses at the Bethlem and Maudsley hospitals had more to offer their patients in terms of time, training and aptitudes than those at the Asile Clinique, and the English hospitals also benefited from the existence of trained occupational therapists. The Henri Rousselle Hospital enjoyed a more generous nurse to patient ratio than other French hospitals, but there was no occupational therapist here either. French nurses, even in the capital, where training was more readily available than in the provinces, lacked the requisite skills to deliver occupational therapy. In the English provincial hospital at Littlemore, most of the nursing staff were dedicated and genuinely interested in their patients according to Dr Good’s article in the Journal of Mental Science and the hospital’s annual reports. Both male and female nurses were willing to learn a craft that they could teach to patients, and in this they were encouraged by the medical staff who recognised the benefits of keeping patients “of all grades” occupied. At the Asile de la Sarthe, male nurses lacked the time and the knowledge to become involved with patient occupation, and this was not an area that appeared to be prioritised by the asylum’s chief medical offers. The latter were more concerned with focusing their limited resources on biological treatments for acute cases.

The New Profession: Occupational Therapy

One of the fundamental differences between French and English mental hospitals was the employment of an occupational therapist. In France, because the new approaches to occupational therapy had not been championed by chief medical officers, there was no requirement for occupational therapists and the profession had not developed. Patients working in the hospital workshops, as they had done in the nineteenth century, were supervised by the workshop managers. Nurses supervised patients working on the wards. There were no opportunities to train as an occupational therapist during the interwar period and the position of occupations officer or occupational therapist did not exist in France at that time. The first schools of occupational therapy (ergothérapie) opened in Paris and Nancy in 1954. Craft activities were not taught to patients at the Asile Clinique, although at the Henri Rousselle Hospital local artists gave art classes to patients.

In England, during the early 1920s, the Board of Control encouraged every large hospital to employ an occupations officer, to put the organisation of patient occupation “on a better footing”.⁸⁸ From 1933, they recommended the employment of a trained occupational therapist, someone with “considerable knowledge of the theory and practice of occupation therapy and who has the education and mentality to interpret the doctors’ instructions in the widest therapeutic sense”.⁸⁹ David Henderson, who had introduced occupational therapy to Scotland in the 1920s, recommended in an article appearing in the Lancet in 1924 that occupational therapy would suit “a well-educated and intelligent, refined type of girl”.⁹⁰ The “refinements” to which Henderson alluded may have been the arts and crafts taught to many middle-class girls and young women in the late nineteenth and early twentieth centuries. Mary Macdonald, principal of the Dorset House School of Occupational Therapy, wrote that the success of occupational therapy depended on the “tact, sympathy and power of understanding the patient’s mental state and individual needs” of the therapist, on “a thorough knowledge of the crafts and occupations she employs”, and finally on her “common sense”.⁹¹ A rather different set of skills was therefore expected of occupational therapists to those held by regular nursing staff, although at an RMPA conference in 1934, it was observed that “a good matron was, ipso facto, an occupational therapist”.⁹² The Association of Occupational Therapists (formed in 1936) defined an occupational therapist as:

Any person who is appointed as responsible for the treatment of patients by occupation, and who is qualified by training and experience to administer the prescription of a Physician or Surgeon in the treatment of any patient by occupation.⁹³

When the Maudsley first opened, patients confined to bed were given activities by the assistant matron, but she soon became “too busy”.⁹⁴ An occupations officer was therefore engaged in 1924. Her working hours were extended from three afternoons per week to five in 1925, and she became full-time in 1929.⁹⁵ She was assisted by seven volunteers during 1925, one of whom had trained as an occupational therapist in the USA.⁹⁶ In 1924, the medical superintendent claimed that patients were engaged in household duties, needlework, clerical work, gardening, carpentry and upholstery.⁹⁷ The occupational therapist also supervised the new occupational therapy centre that opened in 1931, where patients who were fit enough could carry out a wider range of crafts than those practised on the wards. The occupational therapist was assisted by occupational therapy students and nurses who had received training in occupational therapy.⁹⁸ Although there was only one occupational therapist employed by the hospital by 1936, patient occupation was also supervised by trained volunteers, nurses and students.

The Maudsley Hospital was one of three English institutions offering training in occupational therapy during the interwar period.⁹⁹ Initially, it was offered on an informal basis. Those who wished to take up a career in supervising occupations for the mentally disordered could gain practical experience through working with the Maudsley’s occupations officer, appointed in 1924.¹⁰⁰ From 1932, the Maudsley offered a regular six-month course in occupational therapy in conjunction with the Royal College of Nursing; the course was extended to 12 months in 1935. Camberwell School of Arts and Crafts provided the technical training in weaving, rug-making, basketry, bookbinding, cardboard construction, leather-work, sewing, embroidery and design.¹⁰¹ Nurses were encouraged to join some of the practical training. In this way, the nurses could become a “useful supplement to any possible provision for the instruction of patients by more highly skilled occupational therapists”.¹⁰² At Bethlem, the physician superintendent’s report of 1936 indicated that “the training of new students in Occupational Therapy has become a regular feature of the Department” enabling “work to be done on a much wider field”.¹⁰³ Bethlem did not become a recognised school of occupational therapy, suggesting that this training was carried out on an informal basis.

Workshop Staff: Managers or Therapists?

In England, occupational therapists were not involved with the work performed by patients around the hospital; their time was spent supervising ward activities and arts and crafts in the occupational therapy department. The Board of Control recommended the employment of one occupational therapist on “each side” (that is, the male and female sides) of a hospital for c.1,000 patients.¹⁰⁴ A therapist responsible for 500 patients would not have time to supervise work as well as arts and crafts. The supervision of patients undertaking office work, gardening or work in the kitchen at the Maudsley was not mentioned; it may have been the responsibility of nurses, or the regular hospital staff. There is no indication that the regular staff received any training, but all ultimately reported to the medical superintendent. It was good practice for doctors to complete an occupational therapy prescription, either for the occupational therapist or for whoever was supervising the patient, so this may have helped workshop staff in their management of patients. The prescription used by the American Occupational Therapy Association was recommended by John Ivison Russell, medical superintendent of the North Riding Mental Hospital, in his book on occupational therapy. The form included details of the patient’s diagnosis, mental traits or characteristics, previous employment, special aptitudes or interests, the results desired, and the duration and frequency of treatment.¹⁰⁵

In France, Demay observed in 1929 that workshop managers, who reported to the Bursar and ultimately the asylum director, appeared unaware of the nature of mental illness and many showed neither kindness nor patience towards the patients working in their workshops.¹⁰⁶ They were overly concerned with productivity and failed to prioritise the therapeutic, re-educative purpose of patient work. Patients were sometimes excluded from workshops for being disruptive, or too placid, or for showing a “lack of respect” for an employee. Demay recommended (as Dr Marie had done in 1913) that each workshop manager should undergo a period of training in medical services. At the very least, the doctor needed to give the workshop staff precise instructions regarding the patients conferred to their care.¹⁰⁷ Between 25% and 45% of the Asile Clinique’s patient workforce were employed in the workshops, so this daily interaction with workshop staff affected a significant proportion of working patients.

The Role of the Chaplain

Most English mental hospitals, including the three studied here, had their own chaplain and chapel within the hospital grounds. Patient attendance at church services was encouraged and the numbers recorded by the Board of Control inspectors before World War I. Although attendance details ceased to be recorded after the war, religious observances continued and provided a social activity for patients on a Sunday. The chaplain also played an important role outside the provision of religious services and spiritual guidance, often taking responsibility for the hospital library, as was the case at the Littlemore, accompanying patients on outings, and giving talks and lantern lectures. When, in 1935, the Littlemore chaplain was moved to another post after 26 years, he remarked, “I hope that my ministrations have been the means of brightening the lives of many of the patients and making them happier”.¹⁰⁸ He gave services every Sunday, took communion to patients on the wards who were unable to come to chapel, and distributed books from the library every month. The new chaplain began confirmation classes and baptised an infant born in the hospital during his first year.¹⁰⁹ Roman Catholic patients (of whom there were 62 at the Littlemore in 1935) received ministrations from a Catholic priest, as they did at the Maudsley, where patients also had access to a Jewish Rabbi and a Nonconformist minister.¹¹⁰ At Bethlem, where running the library was entrusted to a nurse, the chaplain edited the hospital magazine, Under the Dome, and his lantern lectures were very popular with patients.¹¹¹

In France, following the secularisation of public services in 1905, provision for religious observances had been phased out in most mental institutions, particularly those in the republican large cities, and the role of chaplain no longer existed. The chapel at Ste Anne’s had been converted into a Salle des Fêtes to provide space for the entertainments programme following the chapel’s decommissioning in 1908, an event described by Henri Rousselle (who had campaigned for the chapel’s conversion for years) as a “victory for republican values”.¹¹² There was, however, an “aumônier” (or chaplain) at the Asile de la Sarthe, where secularisation did not take place until the 1960s. Religious events organised by the Catholic chaplain, such as the Fête-Dieu, a procession that took place 60 days after Easter, punctuated the year at the Asile de la Sarthe and provided a diversion for patients. There was a clear divide between the secular metropolitan and the more religiously orientated provincial French asylums. The English institutions fell somewhere in the middle, with a lower profile of religious observances, administered by chaplains who also fulfilled secular functions.

Conclusion

The successful deployment of occupation as a means of therapy in French and English mental hospitals depended in large measure on the training, skills and number of non-medical staff, including nurses, workshop managers, chaplains and, in England, occupational therapists. The authority and therapeutic preferences of the psychiatrist were crucial, but so too were the means at his disposal to implement those preferences. In England, the medical superintendent, who had sole responsibility for management of the hospital, had the authority to drive through the introduction of the news methods of occupational therapy, but he had to have staff willing and able, and preferably trained, to supervise patients in these new methods. Mental nurse training was more widely available in England than in France, particularly in London, but while mental nurse training emphasised the importance of occupation, it did not necessarily follow that a trained mental nurse would be able to deliver occupational therapy. For the successful introduction of the latter, it was desirable to employ an occupational therapist. The new profession of occupational therapy emerged in England during the interwar period. Formal training in occupational therapy was available in England from 1930, while in France, the profession did not exist until after World War II. Here occupation was supervised by the nursing staff, whose lack of training and competence attracted considerable criticism, and by the workshop managers, who had no training in the supervision of mental patients. While English workshop managers reported to the medical superintendent, in France (other than at the Henri Rousselle Hospital) they reported to the asylum director whose priority was the contribution that patient labour could make to the hospital rather than its therapeutic benefit to the patient.

At the Maudsley Hospital, occupational therapists were supported by well-qualified nurses, trained in the basics of occupational therapy. Workshop managers at the Maudsley and Bethlem were ultimately responsible to the medical superintendent who believed in the curative properties of occupation and could insist on its deployment as therapy. At the Asile Clinique, the workshop managers who supervised c.30% of the patient workforce, were not always sympathetic to patient needs, and most of the acute patients in the treatment divisions were unoccupied. This was as much a matter of the psychiatrist’s choice as it was to do with the competence and availability of staff. The situation at the Asile de la Sarthe was similar, with acute patients remaining unoccupied and the calm, chronic and incurable patient workers supervised by nursing or workshop staff. At the Henri Rousselle, all staff reported to Toulouse, who as medical director, had the authority to prioritise the therapeutic benefits of occupation. There were no occupational therapists here, nor at the Littlemore Hospital. At the latter, occupational therapy was delivered by nurses, who were each expected to know a craft that they could teach to patients. The nurses at the Littlemore, who were of a different calibre to those at the Asile de la Sarthe, were able to pass on useful information to the medical staff as a result of the time they spent with patients undertaking occupational therapy. The fact that the Littlemore did not suffer from overcrowding, and the nurses’ exemption from administrative duties (something the medical superintendent insisted upon) meant that nurses were able to devote time to their patients, a commodity that was impossible to find in most French asylums. The types of activities that patients undertook, supervised by mental nurses, occupational therapists or workshop managers, are examined in the following chapter.