Work and Support for Patients Outside Hospital

Abstract

This chapter examines whether the rehabilitative remit of patient workhad decreased in importance during the interwar years compared to during the nineteenth century. Despite the need to rebuild their respective economies after World War I, and the high unemployment of the Great Depression, patient occupation in French and English asylums did not appear to prepare patients for the modern workplace, as Freebody’s comparison of the work available locally to the work provided in linstitutions demonstrates. The work around the hospital tended to be based on outmoded artisanal techniques in France, while in England, occupational therapy, in the form of arts and crafts, was the antithesis of modern working practices, such as those associated with “scientific labour management”. Freebody attempts to explain this anomaly in terms of  a focus on the "active treatment" of patients, rather than vocational rehabilitation, and increased levels of support for patients post-discharge in England, and to the emphasis on the financial contribution made by patient labour to asylum budgets in France.

This chapter examines whether the occupations undertaken by patients in mental hospitals and asylums prepared them for a return to the workplace after discharge, either by helping them to maintain their pre-admission skills or by teaching them new ones. Preparing patients for the workplace had been one of the objectives of patient work in the context of moral therapy, and in the early nineteenth century the type of work prescribed for asylum patients equipped them well for work outside the asylum. Working on the asylum farm was familiar to many, given the high proportion of the English and particularly French populations employed in agriculture at that time.¹ The artisanal workshops of the asylum, such as the shoemakers’, stonemasons’, or tailors’ workshops provided employment similar to that which was available in most French and many English towns. One hundred years later, the economies and working methods of both countries had changed significantly (even more dramatically in England) due to industrialisation, raising the question of whether the work offered to mental hospital patients had kept pace with those changes. Were the new methods of scientific labour management and assembly line production introduced into asylums work schemes? Could the American style of occupational therapy, with its focus on arts and crafts, which encouraged creativity and involvement in all stages of the production process, from design to finishing, claim to prepare patients for the modern workplace? Further questions arise concerning the support available to patients after leaving hospital, such as help with finding employment or somewhere to live, or access to ongoing treatment as an outpatient. Were patients left to fend for themselves after discharge or how was support organised? Record levels of unemployment in the immediate aftermath of war and during the Great Depression made the situation for recently discharged patients particularly precarious. The stress associated with unemployment threatened their already fragile mental health as well as their ability to support themselves.

Rehabilitation or Therapy?

New ways of working, by adopting the principles of “scientific labour management”, were developed in the USA before World War I by the American mechanical engineer Frederick Winslow Taylor (1856–1915) and automobile manufacturer Henry Ford (1863–1947). Their methods generated interest amongst British and European manufacturers, who were keen to improve the efficiency of their own enterprises. This interest increased as the need for efficiency and productivity escalated during World War I and afterwards, as economies recovered. Scientific labour management encouraged business owners to undertake a systematic evaluation of all the labour processes involved in their business, with the aid of a stopwatch, and to maximise efficiency by subdividing tasks.² The resulting de-skilling of the workforce and a loss of worker discretion and autonomy was taken to extremes by Charles Bedaux, (1886–1944), a French-born American management consultant.³ Bedaux’s methods were particularly effective in industries using assembly lines, such as the automobile industry and were adopted in around 250 of Britain’s largest manufacturing firms.⁴ This quest for efficiency was unpopular with workers, however, who resented the loss of control, the close links between effort and earnings, and the stringent monitoring of performance.⁵

There was opposition to scientific management methods by skilled workers in France too. Patrick Fridenson highlights the issue of boredom, fatigue and resentment of managerial control amongst French automobile factory workers, leading to absenteeism, the slowing down or limiting of production, and the disruption of work schedules.⁶ During the Depression, the French government intervened directly in the economy, introducing employment regulations and systems for industrial negotiation, and attempting to modernise production methods beyond the automotive industries.⁷ The methods of Taylor and Bedaux, pioneered by Renault, Citroen and Peugeot, were promoted as a means of raising labour productivity and “rationalising” employment. Unpopular and perceived as a threat to traditional French working hierarchies, the imposition of such methods generated a wave of strike action in Paris in 1936.⁸ The new methods struck at the very core of a French worker’s identity, which was based on the established pattern of progress from journeyman to skilled petit entrepreneur and master of one’s own destiny.⁹ Automobile manufacture played an important role in the economies of all the towns and cities where the hospitals in this study were located, namely London (Ford), Paris (Renault and Citroen), Oxford (Morris Motors) and Le Mans (Bollé and later Renault). Bedaux’s methods, whilst unpopular, could not be overlooked if patients were to be prepared for the local labour market.

On the other hand, work satisfaction in a hospital setting could not be ignored either, since one of the purposes of work for patients was to promote well-being and a sense of agency, as Waltraud Ernst has emphasised.¹⁰ The deleterious effects of the division of labour and the “deskilling” of workers had already been recognised by political economists Adam Smith in the eighteenth, and Karl Marx in the nineteenth centuries. In The Wealth of Nations (1776) Smith argues that a man spending all his time performing the same tasks had no need to “exert his understanding or exercise his invention” to solve problems, rendering him “stupid and ignorant”.¹¹ Karl Marx was also highly critical of the division of labour, which he claimed “attacks an individual at the very roots of his life” and could eventually lead to what he termed “industrial pathology”.¹² Describing factories as “mitigated jails”, he argued that the narrow, specialised functions associated with the division of labour reduced workers to a “fragment” of their former selves.¹³ Marx claimed that work under capitalism, divided up into meaningless repetitive tasks, was the opposite of purposeful activity. Marx believed that purposeful activity, such as the work of the skilled watchmaker creating a complete watch, was necessary for the “realisation of the full humanity of the individual”.¹⁴ While Smith and Marx were referring to the new factory conditions introduced during the first industrial revolution, their remarks are perhaps even more relevant to the very exacting methods of scientific management. The loss of autonomy and control, and the sheer monotony of the work, could be damaging to a worker’s mental health and self-esteem. But the factory and the assembly line—rather than the artisan’s workshop—had become the new working environment for which patients left the asylum ill-prepared.¹⁵

It is hard to understand why, at a time when considerable research was being carried out into working practices by the very psychiatrists and psychologists who were treating patients with mental disorder, there appeared to be little crossover. Édouard Toulouse, medical director of the Henri Rousselle and co-founder of the French League for Mental Hygiene, was passionate about workforce productivity and measures to improve occupational health, writing extensively about the need to manage work scientifically.¹⁶ He had established research laboratories investigating what he termed the “psychobiology of labour” in 1900 at the Villejuif Asylum, where he then worked as a chief medical officer, and these laboratories had moved with him to the Henri Rousselle Hospital in 1922.¹⁷ These included the Laboratory of Physiology, which conducted research into muscular fatigue and reaction times, and the Laboratory of Experimental Psychology, which performed various intelligence, perception and memory tests on school children and machine operators to ascertain their suitability for various professions.¹⁸

Toulouse claimed that the laboratories fulfilled both clinical and social functions. On the clinical side, doctors from the Henri Rousselle Hospital sent patients to the Laboratories of Psychology and Physiology to obtain precise information on their mental functioning which aided the doctors in diagnosis and treatment.¹⁹ The results of tests carried out on patients, when compared with the average behaviour of “normal” subjects, enabled doctors to identify diminished functionality. Yet it did not appear that his findings informed how work was organised for patients either at the Henri Rousselle Hospital or at the neighbouring Asile Clinique. One explanation may lie in the fact that experimental psychology was a relatively new area, only emerging from the long-established discipline of philosophy at the end of the nineteenth century; it did not impinge upon asylum medicine until much later in France. Furthermore, Toulouse’s research was aimed at the prevention of mental disorder, in line with the principles of the Mental Hygiene Movement, and so the focus of his work in this area was on work outside, rather than inside, the mental hospital.

In England, research into how to minimise “industrial fatigue” and maximise output by workers began before World War I and escalated during the conflict as the war-time requirement of long hours and intense, sustained effort took their toll on the health of munitions workers.²⁰ This research was continued after the war by the Industrial Fatigue and Industrial Health Research Boards, established in 1918 and 1928 respectively.²¹ Experts in fatigue, nutrition, psychology and physiology subjected the human body’s movements and rhythms to detailed laboratory investigations in a quest to achieve greater productivity.²² By rationalising the physiological and psychological performance of the worker’s body, scientists sought to eliminate fatigue, overwork and wasteful motion, thereby improving the health, efficiency and productivity of workers. Their recommendations referred to the hours and physical conditions of work (such as temperature, humidity, ventilation and lighting) and personal factors such as vocational selection and guidance, as well as clothing and seating arrangements, which were all found to influence productivity.²³ But these recommendations did not appear to influence how work was organised in mental hospitals. That said, the Mental Hygiene principle that work should be purposeful and satisfying to perform was reflected by the introduction of occupational therapy in English institutions.

The activities comprising American-style occupational therapy were quite different to work on the factory floor in London’s expanding industrial sectors. Instead of performing work for which little or no skill was required, patients were taught a craft and how to make aesthetically pleasing objects from scratch. The teaching of arts and crafts to patients inherent in American-style occupational therapy was influenced by the Arts and Crafts Movement, which encouraged the creation of hand-made goods in place of machine-made uniformity. Craftsmanship was considered to be spiritually uplifting quality and to have a “regenerative power”.²⁴ In other words, arts and crafts were perceived as an antidote to modern factory production methods. Elizabeth Casson, who founded the Dorset House School of Occupational Therapy in 1930, maintained that crafts activities were designed to “arouse curiosity and the desire to achieve”.²⁵ The therapeutic benefits of occupational therapy were related to the pride taken in the patient’s work, the care and attention to detail invested, and the fact that the patient was responsible for the whole task, not just one tiny aspect of production. While occupational therapy developed concentration and self-esteem, it was not rehabilitative in an economic sense—except for the few Maudsley patients who managed to turn arts and crafts into a paying hobby or became occupational therapists themselves.²⁶

One of the criticisms of occupational therapy and institutional work made by contemporary psychiatrists after World War II, as Vicky Long has highlighted, was that they failed to prepare patients for the modern workplace.²⁷ This anomaly was eventually addressed in the 1950s with the introduction of “industrial therapy” (IT) into English mental hospitals. The IT units incorporated industrial features such as factory lighting and seating, conveyor belts and time sheets. Work was supplied by local firms and involved simple tasks, such as folding cardboard boxes, for which patients were paid a low hourly rate.²⁸ Whilst arguably less satisfying than arts and crafts, IT prepared patients more effectively for the type of work they would find outside the hospital. This “social readjustment” was important at a time when institutional care was gradually being replaced with care in the community.²⁹

Welfare Measures in France and England

The rehabilitation of patients was an important rationale for the prescription of work to mental hospital patients in France and England since there were few “safety nets” for those unable to find work in the early days of the asylum system. In nineteenth-century England, ensuring that patients were self-sufficient on leaving hospital was accorded high priority, as the workhouse offered the only source of assistance for the destitute. Poor relief was provided by the New Poor Law of 1834, designed, according to Peter Bartlett, to “root out and dismantle a culture of poverty, perceived in terms of immorality, intemperance and promiscuity, and replace it with a culture of self-help, respectability, sobriety and hard work”.³⁰ Unemployment was considered a moral failing and idleness frowned upon. English attitudes towards the unemployed began to change in the early twentieth century, with joblessness no longer viewed as an individual’s “fault”, or a matter of choice, but as a social problem that called for increased state intervention.³¹

Limited measures to alleviate poverty were introduced in England by the Liberal administrations of 1906–1914.³² These measures included the Labour Exchanges Act of 1909 that created a national network through which the unemployed could search for work, and the National Insurance Act of 1911 that provided compulsory, contributory insurance for most employed individuals against the financial consequences of sickness, disablement, maternity, and short-term unemployment.³³ In France, widespread social reform legislation was not forthcoming until the late 1920s. Until then, “initiative and prudence” were supposed to protect the working man and his family from the consequences of accidents, illness, disability, old age and unemployment.³⁴ Between 1928 and 1932, social insurance laws providing similar protection to that afforded by the British legislation, were introduced.³⁵ The mass unemployment generated by the Great Depression resulted in an extension of the British welfare benefits, including the establishment of an Unemployment Assistance Board in 1934.³⁶ In France, further welfare measures were introduced under Léon Blum’s Popular Front government of 1936–1938.³⁷

These initiatives demonstrate that in both England and France, the state assumed increasing responsibility for citizens’ welfare, and acknowledged that individuals were not to be blamed for unemployment and other social misfortunes. The evolution in the provision of state aid for the poor began some twenty years earlier in England. Late nineteenth-century English psychiatric texts made frequent references to the “creation of useful members of society” who could earn their own living after discharge and not pose a burden on society. But, as Sarah Chaney observes, this type of rhetoric became far less common after World War I.³⁸ It is therefore plausible to assume a corresponding lowering of the priority accorded to ensuring self-sufficiency amongst patients. Indeed, the Macmillan Report of 1926 stressed that the purpose of occupation for the patients of mental hospitals (as opposed to the institutions caring for the “mentally deficient”) was purely therapeutic, whether this comprised work around the hospital or arts and crafts activities in the occupational therapy workshop.³⁹ In France, where the social reforms came later, there did not appear to be any downgrading of the need to rehabilitate patients for the labour market. Here, an ability to work was one of the criteria for discharge.⁴⁰ Furthermore, France was in desperate need of capable workers after World War I. An acute labour shortage was the result of a very low birth rate and the death of so many working-age men during the conflict. The urgent need to rebuild France’s workforce was emphasised by Édouard Toulouse who claimed in 1920 that “the nation’s biggest problem was the re-establishment of its human capital”.⁴¹

During the Great Depression, unemployment was rife in both countries and welfare measures were stretched to breaking point. The economic crisis led some patients to choose to remain in French asylums as workers, despite being eligible for discharge. This was an “unofficial” means of support offered by chief medical officers who were aware of the unemployment situation outside the hospital. Equally, impoverished families were slow to collect their cured or improved relatives from hospital, knowing that work was hard to find particularly for those bearing the stigma of internment.⁴² In 1935, Dr. Marchand of the Men’s First Section of the Asile Clinique, reported that an additional 10 patients could have been discharged that year, but had elected to remain at the Asile Clinique as workers and to continue their treatments as in-patients. These patients had been out of work when they were admitted and were unlikely to find work in the current economic climate.⁴³ Marchand remarked the following year that previously unemployed patients who had been allowed to remain made excellent workers.⁴⁴ A similar situation emerged at the Henri Rousselle Hospital. Former patients who had been unable to find work after discharge, returned to the hospital where they were employed as clerks, or in such tasks as locksmithing, plumbing, stone-masonry and painting.⁴⁵ A sum of 43,196F was spent on remunerating these patients in 1936.⁴⁶ This unofficial support for patients was no doubt a life-line for some, but successful longer term rehabilitation depended on whether the activities undertaken by patients in hospital prepared them for the type of work available in their local community.

The Local Relevance of Work within Institutions

The types of occupation offered to patients in both French and English institutions did not equip patients with the skills required in the modern workplace, although it was appropriate for those returning to more traditional trades. Patient occupation continued to be based on institutional requirements in France, and on a blend of institutional requirements and arts and crafts in England. The type of work performed within the Asile Clinique or the Asile de la Sarthe did not evolve to reflect developments in local employment during the interwar period, while the arts and crafts activities comprising occupational therapy at Bethlem, the Maudsley and the Littlemore hospitals were not vocational. These occupations may have equipped patients with the skills required in traditional sectors of employment, such as tailoring or furniture-making, but they did not prepare patients for work in new industrial sectors, such as the automotive sector or electrical goods’ manufacture. John Burnett highlights the plight of an unemployed skilled woodcarver who had worked for thirty years on high-quality furniture. In the 1920s he found that “machine-turned furniture and machine-carved wood have put us out of business”.⁴⁷ Furthermore, the occupations offered to female patients failed to reflect the increasingly diverse employment opportunities open to women after World War I.

While traditional industries persisted in the city centres, new industries mushroomed in the suburbs, many of which were based on modern management and production techniques, such as the assembly line. In Paris, for example, the traditional sectors of publishing, haute couture and jewellery remained in central Paris, while the suburbs became host to large-scale enterprises in new industrial sectors, such as automobiles (the Citroen plant was established in 1919) and chemicals.⁴⁸ In London, too, major industrial growth took place in the suburbs (the Ford Motor Company arrived in Dagenham in 1931) but almost 37,000 factories involved in clothing, furniture, food and drink, printing and engineering remained in London’s old industrial centre.⁴⁹ Industries deploying new technology showed the most spectacular growth in interwar London. Between 1925 and 1937 the numbers employed in the manufacture of electrical goods rose from 48,000 to 113,500, an increase of 138%.⁵⁰ The other major growth area in both Paris and London was the service sector. In Paris, between 1906 and 1931, employment in banking and business grew by 52% and in administration and retail by 77%.⁵¹

The categories of asylum workshops (namely plumbing, stone-masonry, carpentry, locksmithing, painting, mechanical work, laundry and ironing services, shoe-making, tailoring and needlework) at the Asile Clinique had not changed since 1900, with the exception of an electricity workshop added in 1924.⁵² The latter only employed two or three patients, and therefore did not permit the widespread acquisition of skills in this new growth area. Some of the occupations carried out in the traditional workshops mirrored the artisanal aspect of Paris’ dual economy. Patients leaving the Asile Clinique having worked in the tailoring, needlework, carpentry or shoe-making workshops might still find work in these sectors, but they were not showing the rapid growth of the new industries. Many, such as shoe-making, were switching to modern machine production methods not used in hospital workshops.

Market-gardening was not an activity associated with the Parisian economy, but this occupation made an important contribution to the asylum’s supply of food. Physical work in the open air had been considered particularly beneficial for patients since the early nineteenth century.⁵³ Farm work in particular, which gave patients the satisfying experience of growing their own food, had been recommended by Pinel in his Traité of 1800.⁵⁴ The restricted nature of this activity at the Asile Clinique (market gardening occupied between just seven and 12 patients each year) was due to the availability of land in a city-centre institution, rather than a reflection of the scope for employment in market-gardening in Paris. The large numbers of patients employed in the laundry reflected the fact that a hospital of over 1000 patients produced a significant amount of laundry, rather than size of the laundry sector outside the hospital. The workshops only occupied approximately one third of the Asile Clinique’s working patients [see Table 9.1]. A breakdown of how the other patient workers were occupied was only indicated for the years 1937 and 1939 [see Table 9.2], but these figures show that roughly two thirds of patients (32% of male and 43% of female patient workers in 1937) were allocated housework or cleaning duties. This unskilled work was essential to institutional maintenance. In 1937, clerical work was allocated to 10% of male and 5% of female patient workers, while in 1939 these figures had decreased to 8% of males and 4% of females [see Table 9.2]. Hospital employment in clerical work was therefore contracting, whilst outside hospital it was expanding. What is not clear from the tables is which (convalescent) patients were from the treatment divisions, and therefore soon to be discharged, and which (incurable) patients were from the workers’ pavilion, who were unlikely to leave the asylum. 

Table 9.1 Table to show a breakdown of the work performed by patients in the various workshops at the Asile Clinique, and the average daily wage (“pécule”) paid to patients for each type of work, in 1925 and 1932

Table 9.2 Table to show a breakdown of the work performed by patients at the Asile Clinique 1937–1940

The provincial institutions of the Littlemore and the Asile de la Sarthe catered for both curable and incurable patients. Rehabilitation for work outside hospital was particularly important for the curable who, on leaving the institution, would have to support themselves. Incurable patients were likely to spend the rest of their lives in hospital. Rehabilitation for the labour market was less of an issue for these patients, but making a contribution to institutional running costs (and therefore to the costs of their care) was a priority for the authorities. In England, the Mental Treatment Act of 1930 meant that the movement of patients was greater, although the numbers of patients discharged “recovered” was still outnumbered by those remaining in hospital. An ability to work was considered one of the criteria for discharge at the Asile de la Sarthe, where a patient with no means of support (either by working or living with family) was to be retained (the phrase à maintenir appeared in their records).⁵⁵ A patient who was working well in the asylum was deemed capable of doing so outside it and therefore able to be self-sufficient and not a drain on society. The knowledge that his liberty depended on his capacity to work led one patient to write to the asylum director requesting employment in the asylum gardens [see Fig. 8.1].⁵⁶

At the Asile de la Sarthe, the types of work offered to patients inside the asylum during the interwar period were identical to those offered before World War I [see Tables 9.3 and 9.4]. The tasks had been engineered to serve the needs of the asylum in the mid-nineteenth century and had not evolved to prepare patients for changes in the local economy. Farming, however, as the second largest category of employment within the Asile de la Sarthe for men, after cleaning, was useful preparation for patients seeking work in the local community. Although the numbers employed in agriculture were declining in the department of La Sarthe (22,000 Sarthois agricultural workers left the countryside in 1922 alone), 67% of the population still lived in rural areas in 1936.⁵⁷

Table 9.3 Table to show a breakdown of the work performed by male patients (paying and pauper) at the Asile de la Sarthe in 1925; 1929; 1934 and 1937. The figures represent the number of days worked in each category

Table 9.4 Table to show a breakdown of the work performed by female patients (paying and pauper) at the Asile de la Sarthe in 1925; 1929; 1934 and 1937. The figures represent the number of days worked in each category

The third largest category of male employment was work in the laundry, but, as in Paris, this was indicative of institutional need. The only type of work available in the asylum that represented a growth area in the local economy (metallurgy) was tin-plate-making, but this involved very few patients. Metallurgy flourished in Le Mans, with the opening of La Maison Chappée, a new foundry producing radiators, which serviced the growing motor industry in the town. The latter employed 2000 workers in 1920 and 17,000 in 1933.⁵⁸ Another firm involved in metalwork was Carel et Fouché, which produced metal construction materials for the railways. Le Mans’ artisanal activities, such as shoe-making, saddlery, brickmaking, ceramics, and tanning were in decline while food processing prospered.⁵⁹ It was the artisanal occupations, notably shoe-making, that employed patients within the Asile de la Sarthe.

For women, the largest employment categories in the asylum were housework and sewing. Whilst textiles had been an important aspect of the local Sarthois economy in the nineteenth century and earlier, this industry was in sharp decline during the interwar period. Needlework, housework, ironing, knitting or working in the kitchen, were tasks with which women were familiar in a domestic context. So, whilst the work available to women was not representative of the changing local economic profile, nor of the expansion in the range of work opportunities for women, it could be construed as rehabilitative for those returning to a domestic role. The employment of female patients in the farmyard also provided a useful and familiar task for those returning to work on the family small-holding. On the one hand, the work for women had changed little since the nineteenth century, while on the other, its emphasis on women’s domestic role was reflective of contemporary measures to discourage women from working outside the home amid concerns regarding France’s low birth-rate and high levels of infant mortality.⁶⁰

At the Littlemore, the occupation undertaken by the largest group of patients prior to admission was labouring, which occupied c.20% of male patients between 1926 and 1939. “Labouring” could be interpreted in a variety of ways, and it is unclear whether patients were agricultural labourers, workers on a building site or casual labourers. The building industry in Oxford was expanding, stimulated by the requirement for new housing, factories and extensions to the university colleges.⁶¹ Brickmaking at the Littlemore was therefore a useful skill to develop. Agriculture, on the other hand, was in sharp decline in Oxfordshire. Between 1921 and 1931, the percentage of agricultural workers in the county fell by 32%, compared to a fall of 17% nationally.⁶² By 1931, just 6% of the nation’s working population were involved in agriculture (compared to 36% in France).⁶³ Work on the hospital farm was not, therefore, particularly useful in terms of future employment prospects, but agricultural work had been considered a valuable therapy since the early nineteenth century, and was a useful means of producing food for the asylum.

Between c.3% and 13% of Littlemore patients were engaged in factory work prior to admission. This was a rapidly growing sector in Oxford. As in Le Mans, car manufacture and metallurgy developed rapidly in Oxford during the interwar period. In 1923, Morris Motors employed 1650 workers and by 1927 this number had grown to c.5000.⁶⁴ Pressed Steel’s workforce grew from 546 in 1926 to 5250 in 1939. Morris Motors, Pressed Steel and Osberton Radiators between them employed 30% of Oxford’s insured population in 1939.⁶⁵ Other major employers in Oxford included the many breweries, such as Morrells, print works, Cooper’s Marmalade Factory, the Oxford and District Gas Company, the Oxford Electric Company and the railway.⁶⁶ There was no work within the Littlemore Hospital that would have prepared patients for the type of work involved in these industries. Between 4% and 9% of Littlemore patients were previously employed in traditional trades such shoe-making, carpentry, stone masonry and tailoring. Although these artisanal activities were in decline in Oxford, they were still viable, so work within the hospital in these areas could be conceived as rehabilitative. Domestic service was a large employer within Oxford due to the continued growth of the university. 23% of Oxford’s workforce in 1931 were employed in domestic service, compared with the national average of 13%.⁶⁷ Between 4% and 14% of patients admitted to the Littlemore between 1926 and 1939 were employed in some form of service.⁶⁸ Work around the hospital, such as cleaning and helping in the kitchens or laundry, would have been useful preparation for this type of work. It is not clear whether Littlemore patients were offered any form of clerical work (as some patients were at the Asile de la Sarthe), but this was another expanding sector in Oxford. The numbers employed in local government and the civil service increased dramatically, from fewer than 500 in 1911 to over 2700 in 1931.⁶⁹ Approximately 6% of patients admitted to the Littlemore in 1926, and 11% in 1937, held a clerical or business role.

It appears that neither the work around the hospital nor occupational therapy were engineered towards preparing patients for work in the local economy. If the tasks allocated in hospital happened to be relevant to the type of work available locally, it was more by happy coincidence than by design. In France, the emphasis was on work to contribute to hospital maintenance, while in England, where psychiatrists placed a greater premium on the therapeutic properties of occupation, the emphasis was on therapeutic occupation. Whilst both work around the hospital and occupational therapy developed discipline and concentration, and some of the workshop activities promoted artisanal skills still in existence in local economies, patients did not leave hospital with experience of modern workplace methods. For the many incurable patients in the provincial asylums, this was not so important since they were unlikely ever to leave the institution, but curable patients would have to support themselves outside hospital. Their ability to cope with living and working independently, particularly in the busy cities of London and Paris, was aided by the support provided for patients after discharge, where this was available. The Board of Control in England emphasised the need for “after-care” for patients in 1928, observing that the transition from “the ordered and sheltered life of the hospital to the stress and competition of the work-a-day world is too sudden and too severe for the convalescent”.⁷⁰ Psychiatrists, such as Aubrey Lewis (medical superintendent of the Maudsley from 1937), recognised that patients who left hospital without the prospect of employment or support were more likely to suffer a relapse of their mental symptoms as a result of anxiety and loss of self-esteem.⁷¹ John Burnett highlights how unemployed men during the early 1930s spoke of “feeling ‘lost’ without work”, and of the “hopelessness” of being unable to find a job. Research revealed that psychoneuroses increased with the duration of unemployment.⁷²

Support for Patients Outside Hospital

Whilst welfare measures to support the poor had been introduced in the 1910s in England and the late 1920s in France, the legislation provided uneven cover and individuals who had not been in a position to pay National Insurance contributions were excluded. There was, however, limited support for recently discharged mental hospital patients in both countries. Before World War I, this support was charitable, provided by a network of Lady Almoners and the Mental After Care Association (MACA) in England and the Sociétés de patronage des aliénés guéris (Patronage Societies for Cured Mental Patients) in France. Provision by these organisations was patchy in both France and England, but particularly so in France. French patients, however, had the benefit of leaving the asylum with a small sum of money, earned whilst in the asylum.

English patients who worked in the various hospital departments were not paid; they merely received additional food rations, such as an extra portion of bread and cheese, or cup of tea for their trouble.⁷³ French patients, in contrast, were paid a nominal daily wage, or pécule, for their work in the asylum, a principle established by the law of 1857.⁷⁴ Their wages accumulated during their stay and enabled them to leave with a small “nest-egg” or pécule de sortie, given to them on discharge. A minimum amount was set by law (and reviewed periodically) for the leavers’ nest-egg. It was only after this amount had been earned and put aside that a patient was allowed to use their earnings to buy small luxuries such as chocolate, tobacco, or soap from the asylum shop. If the patient had not managed to earn the full amount before departure, this was made up by the asylum. During the interwar period, the value of the nest-egg varied between 15FF and 30FF. For the completely destitute among patients from the Seine, there was also recourse to the Fondation André, a legacy that had been invested for the purpose of giving small lump sums to the poorest asylum patients on discharge. It was divided between the institutions of the Seine; 300FF per annum was received by the Asile Clinique for distribution to its most needy patients.⁷⁵

Every French department was encouraged to create its own patronage society, subsidised by the prefecture, although many departments did not have one. Where they existed, the societies fulfilled a similar function to that of MACA in England. A patronage society was only established in La Sarthe in 1933, after Dr. Bourdin retired from the Asile de la Sarthe and beseeched his successor, Dr. Schultzenberger, to make it a priority.⁷⁶ The department of the Seine’s patronage society, founded in 1886 and subsidised by an 8000FF annual grant from the General Council, aimed to assist indigent patients who had recently left a public asylum or hospice. Its function, however, was described by the Council as “incomplete and insufficient”.⁷⁷ It was agreed that more comprehensive support for discharged patients was required, to avoid their return to the asylum. Many patients failed to secure work because employers were often reluctant to employ ex-asylum patients. They soon fell into poverty, causing their symptoms of mental illness to return. Families frequently rejected discharged relatives, owing to the stigma attached to mental disorder.⁷⁸

In England, the Mental After Care Association (MACA) had been founded in 1879 by Rev. Henry Hawkins, chaplain of the Colney Hatch Asylum, to provide an alternative to the workhouse for pauper patients discharged from asylums. MACA was a national organisation, but most of its services were concentrated in the south-east. Former patients were assisted with lodging, money and clothing and helped to find suitable work. In the 1920s and 1930s, MACA provided cottage homes for convalescent patients, who stayed for a short period of between a fortnight and three months.⁷⁹ The Board of Control applauded the work of MACA, but felt that the larger hospitals should do more themselves in respect of providing after care.⁸⁰ The Board recommended the appointment of a full- or part-time psychiatric social worker.⁸¹ Some English hospitals had a Lady Almoner, a voluntary role whose remit included after-care and visiting patients’ homes.⁸² When the Maudsley first opened, a Lady Almoner collected “useful and important knowledge” for the medical staff, supported patients whilst in hospital and helped them find work after discharge.⁸³ The medical superintendent, Edward Mapother, reported that a “great deal of time and thought” went into “re-establishing former patients in normal life again” in relatively stress-free situations that were unlikely to cause a relapse of their symptoms.⁸⁴ During 1925, he reported that 98 Maudsley patients had been assisted by the Lady Almoner.⁸⁵

During the interwar period, support for recently discharged patients started to become professionalised, with the provision of paid psychiatric social workers taking over the role of the volunteer Lady Almoners in the more “progressive” city institutions.⁸⁶ The importance of the role of the psychiatric social worker (or PSW) to modern psychiatry had been recognised by American psychiatrists, notably Adolf Meyer, since the early twentieth century. By 1920, knowledge of a patient’s social environment was considered vital to an understanding of individual behaviour and the PSW was regarded as an indispensable partner to the psychiatrist, gathering information on patients’ family and community environment.⁸⁷ In 1929, a psychiatric social worker (PSW) replaced the Lady Almoner at the Maudsley Hospital, pre-empting the Board of Control’s call for “well-trained social workers” to be attached to mental hospitals and clinics, as they were at US hospitals.⁸⁸ Edward Mapother cited as one of the most important developments during the Maudsley’s first five years of operation, the increasing co-operation between PSWs and the hospital.⁸⁹ The investigations into a patient’s social situation made by a PSW and the PSW’s ongoing support of discharged patients were seen by Mapother as an “indispensable condition of … progress in tackling mental illness”.⁹⁰ “For modern institutional psychiatry” to function effectively, he maintained, the co-operation of specially trained PSWs was essential.⁹¹

The employment of a PSW was a luxury that not many English provincial mental hospitals could afford, despite the Board of Control’s advocacy of such a service. At the Littlemore, a volunteer social worker assisted the medical team for two months during 1937, obtaining full case histories from patients on admission and making arrangements for patients who were about to be discharged. Her services were much appreciated by staff, leading Dr. Armstrong to observe that “a permanent psychiatric social worker will eventually be considered a necessity at this as well as many other mental hospitals”.⁹² By 1938, in the absence of a permanent social worker, the Littlemore relied upon the City Mental Health Visitor and her assistants for help with obtaining information regarding new patients and for arranging after-care for discharged patients.⁹³ A temporary part-time social worker, Miss Leslie, was appointed to the hospital staff on 1 January 1940.⁹⁴

In France, the services of a PSW were regarded as essential by Édouard Toulouse, who ensured that a social services unit was attached to the Henri Rousselle Hospital.⁹⁵ The PSW, directed by the doctor, acted as a liaison between the hospital and the patient’s family, providing advice, ensuring that treatment guidelines were being followed, and researching information about the patient’s circumstances that might aid the doctor treating a patient in an outpatient facility or in hospital.⁹⁶ Mental crises, or relapses, were often caused by irregular life-styles, overwork, lack of work, domestic difficulties or the breakdown of family relations; the PSW could investigate these issues.⁹⁷ PSWs also helped patients find work that was appropriate for their condition, and to identify suitable employers.⁹⁸ To facilitate the “best use” of the individual, the social worker could call upon the Service of Professional Orientation (also part of the Henry Rousselle Hospital) which identified the most suitable (and unsuitable) types of work according to an individual’s characteristics.⁹⁹ For those who were unable to work, the PSW found alternative means of support, such as placement in a family colony, hospice or retirement home.¹⁰⁰ Toulouse described the social assistants as “indispensable collaborators” from the doctors’ perspective and as “precious guides” and “advisors” from that of patients.¹⁰¹ A PSW service was not provided outside Paris during the interwar period (despite its recommendation to all departmental Prefects by the Ministry of Health in 1937), emphasising the difference in approach between the Henri Rousselle Hospital, which was heavily influenced by the American model of psychiatric care and the mental hygiene movement, and the traditional “closed” asylums, which remained custodial institutions. The Asile de la Sarthe was no exception to this rule and did not have a PSW service.

Outpatient clinics were another service for the mentally ill that emerged during the interwar period. They were of benefit to recently discharged patients, who could continue their treatment as an outpatient, as well as for those with mild symptoms who did not require admission. Although they had been recommended by the Medico-Psychological Association in their 1911–1914 report, and by Édouard Toulouse in his report to the Prefecture of 1913, outpatient services for the mentally ill were extremely rare in England and France before the end of World War I. In England, outpatient facilities were established in 1918 in Oxford and in London in 1919, as part of the Bethlem Royal Hospital. The Oxford clinic for nervous disorders, while established and managed by Thomas Saxty Good of the Littlemore Asylum, was attached to the Radcliffe Infirmary, a general hospital. This arrangement helped circumnavigate the law regarding the certification of mental patients that pertained until 1930. Good was also responsible for establishing Oxford’s City Education Clinic for children with learning difficulties or behavioural problems.

A steady increase in the number of outpatients attending both the clinics during the interwar period corresponded with a reduction in the numbers of admissions to the Littlemore, particularly amongst young adults. The latter were able to remain living, and working, in the community while receiving treatment, mainly in the form of psychotherapy. The Board of Control noted in 1936 that the two outpatient clinics were “providing for a large section of the mentally sick, who, under other circumstances, would be mental hospital patients” and that many children were being “saved from becoming psychotics in later life”.¹⁰² Both clinics continued “to serve a useful function” after Good’s retirement in 1936, and attendances remained high.¹⁰³ Dr. Armstrong, Good’s successor at the Littlemore, remarked on recent praise for “Out-patient Clinics in the treatment of early mental conditions of both children and adults”, noting that Oxford had “long been amply served by both types of Clinic” thanks to the enlightened policy of Dr. Good.¹⁰⁴ By treating so many cases of nervous disorders as outpatients, before symptoms became entrenched, the Littlemore avoided the overcrowding suffered by many provincial mental hospitals.

The outpatient department at Bethlem was the first to be established at a London mental hospital.¹⁰⁵ Dr. Porter-Phillips, Bethlem’s physician superintendent, felt that an outpatient department was an important addition to the hospital because, according to Jonathan Andrews, it was a “progressive policy” expected of “high status” institutions.¹⁰⁶ When the department opened in November 1919, the treatments offered included massage, X-ray and electrical treatment.¹⁰⁷ Speech therapy and the services of a Lady Almoner were added later. Porter-Phillips also saw the clinic as a means of identifying cases of “mental deficiency”, an area in which Dr. A. F. Tredgold, appointed in 1920, specialised.¹⁰⁸ Although the clinic was considered a success in terms of the numbers of patients treated and added “great value” to the education of students (the University of London, for example, was impressed with its performance), the clinic closed in 1927.¹⁰⁹ Porter-Phillips felt that too many patients were of “a chronic order with a history of attendance elsewhere”, rather than the incipient cases for which the service had been established.¹¹⁰ Many of the war veterans referred by the Ministry of Pensions were found to be incurable and “quite unsuitable for treatment”.¹¹¹ The closure of the clinic was perceived as a backwards step for Bethlem, since as Dr. Tredgold emphasised, “the whole tendency of modern medicine is to remove the stigma of Insanity, by breaking down the artificial barriers which has so long existed between the different forms of disease and disorders of the nervous system”.¹¹² But the patients treated at Bethlem’s clinic did not appear to be well enough to carry on with their daily lives and work whilst receiving treatment, and in this they differed from the Maudsley’s outpatients.

Outpatient departments were incorporated into the Maudsley and Henri Rousselle hospitals from the outset and fared rather more successfully. The outpatient services worked in tandem with the main hospitals, referring cases that warranted in-patient treatment, but also treating some patients for long periods as outpatients. This enabled patients to continue with their regular work outside hospital, and thus to remain productive, whilst receiving treatment. At the Maudsley, the main treatment offered was psychotherapy, while at the Henri Rousselle patients a range of specialist treatments, including hydrotherapy, electrotherapy, UV-ray treatment, physiotherapy, organotherapy and vaccinations, as well as psychotherapy, were offered. These treatments could be accessed without admission or following discharge from either the Henri Rousselle or the Asile Clinique. At both the Maudsley and the Henri Rousselle hospitals, demand for outpatient services increased rapidly. Between 1923 and 1935, the number of new outpatients registered at the Maudsley rose three-fold, the total number treated four-fold and the number of attendances 13-fold.¹¹³ By 1935, the outpatient facilities were deemed “grossly inadequate” for the numbers of patients wanting to use them and were therefore extended in 1936.¹¹⁴ Between the opening of the Henri Rousselle outpatient facilities in 1922 and 1934, the number of consultations given annually at the outpatient department rose tenfold from 3289 to 31,817.¹¹⁵

The success of the outpatient facilities at the Henri Rousselle prompted the Minister of Health, Marc Rucart, to encourage their provision nationwide in 1937. The Minister issued a Circular in which he proposed the reorganisation of care for the mentally ill, along the lines already established by the Henri Rousselle Hospital in Paris.¹¹⁶ Acknowledging that measures to combat mental illness had not been pursued as vigorously as those taken to fight other social scourges (such as tuberculosis), Rucart set out similar proposals for reform to those put forward by the English authorities over a decade earlier. He stressed the “therapeutic, economic and social importance” of early treatment and maintained that pauper mental patients, “easily curable” at the start of their illness, became a danger to themselves and others if their condition was left untreated.¹¹⁷ By the time their condition had deteriorated to the point where the law intervened, they faced the prospect of long-term internment in an asylum, perhaps for life, for which there was a heavy cost to society, both in terms of the patients’ care and their lack of productivity.¹¹⁸ Rucart wanted to see the provision of “open services” for the voluntary admission of those with mild symptoms, outpatient facilities, social services and assistance for “abnormal children” in all departments.¹¹⁹ These recommendations were followed by another ministerial Circular, issued in 1938, which attempted to modify (but did not supplant) the regulations set out in 1857. They sought to re-orientate the care of patients in “closed” asylums, such as the Asile de la Sarthe, towards a focus on treatment rather than custodial care.¹²⁰ Henceforth asylums were to be known as “psychiatric hospitals” to emphasise this new focus, although as psychiatrist Paul Balvet observed, the change was in name only.¹²¹

Most French provincial institutions lacked either the finances or the will to instigate the proposals set out by Rucart before the outbreak of World War II in 1939. This lack of reform within provincial institutions led historians Postel and Quetel to observe that the further French asylums were from cities the more they remained locked into psychiatric conservatism. They point to a cleavage between the Parisian Henri Rousselle Hospital where the principles of mental hygiene were adopted, under Toulouse’s influence (including the establishment of “open” services, outpatient clinics, social services and research facilities), and provincial institutions that were effectively left behind.¹²² Their distance from the capital and the reformist agenda of Toulouse and his colleagues, together with their isolation from the rest of medicine, meant that many psychiatrists in French provincial asylums continued to run their asylums on a custodial basis.

There was no outpatient department at the Asile de la Sarthe, nor was it able to open its doors to voluntary patients. That said, as Dr. Christy (chief medical officer of the Asile de la Sarthe from 1935 to 1938) observed, “open” services might not have been appropriate in the department of La Sarthe whose high proportion of rural inhabitants rarely sought medical advice. The occupation and life-style of peasant farmers, in Christy’s opinion, meant that they were less likely to seek help for mental illness voluntarily than urban dwellers.¹²³ Christy supported the idea of early treatment, particularly for cases of GPI and dementia praecox, which would benefit from the early administration of malaria therapy and shock treatments respectively, but he recognised that the delivery of any form of treatment was almost impossible at the Asile de la Sarthe with only one doctor for 900 patients.¹²⁴ Despite Rucart’s recommendations, the Asile de la Sarthe remained a “closed” institution, overcrowded and dominated by incurable and chronic cases, until after World War II. This had consequences for patient occupation, which also remained unchanged throughout the interwar period. Routinised work, organised to fulfil institutional requirements, remained the main means of occupying calm, chronic and incurable inmates and the few convalescent patients who made a recovery. The latter could not benefit from the services of a psychiatric social worker to help them secure employment, nor could they continue receiving treatment as an outpatient while pursuing their regular employment.

Had Rucart’s recommendations been acted upon before the outbreak of World War II, the French system of mental health provision might have appeared altogether more uniform and more in line with the American system, but the American model remained the preserve of the Henri Rousselle Hospital. Although the English mental healthcare system might have been considered more “advanced” than the French in terms of the national distribution of outpatient facilities, educational and preventative work, psychiatric social work and support for discharged patients, provision was nonetheless piecemeal. Services varied across the country and were provided by a mixture of charitable and public organisations whose activities were poorly co-ordinated. While at one end of the scale, the Maudsley Hospital provided a model of best practice, there were parts of the country where there was no support at all for patients outside hospital. Mindful of these shortcomings, the English Ministry of Health set up a committee, led by Lord Feversham, to investigate. The Feversham Committee reported in 1939, recommending that in the interests of efficiency all the different bodies providing mental healthcare should be amalgamated.¹²⁵ The committee believed that “Mental Health should be recognised as a single concept” and this belief dictated the tone of the report.¹²⁶ The report also highlighted the “encouragement of community care” resulting from the Mental Treatment Act (1930), an early indication of how mental healthcare provision would develop.¹²⁷ The report recommended that every Local Authority should appoint a Mental Health Committee to deal with all matters relating to mental welfare, thereby bringing the control of institutions, early treatment of mental disorders, establishment of clinics, community care and education of the public under one co-ordinating body that would operate like the Public Health Committees.¹²⁸ The Feversham Report, like Rucart’s Circular, was not acted upon before World War II, but its recommendations had considerable influence after the conflict.¹²⁹

Conclusion

French patients, unlike their English counterparts, left the asylum with a small “nest-egg”, money earned whilst working in the hospital, but in general support for patients outside hospital was more limited in France than in England. The Henri Rousselle was the only institution of its type in the capital, and its social service and outpatient facility could not provide support for all those who needed it. The increasing levels of demand for the Maudsley’s outpatient facility were met by an expansion of the service and the opening of additional facilities in north London. This did not happen in Paris, where the Henri Rousselle remained the only provider. Édouard Toulouse and his associates in Paris were unique in their support for the holistic, American model of psychiatric care, which took longer to attract support from French psychiatrists. It was not until 1937 that the Health Minister, Marc Rucart, saw fit to recommend the services comprising the Henri Rousselle Hospital to other institutions in the capital and the provinces. This was not forthcoming until after World War II, however. In England, on the other hand, support for the American model was more widespread. Its principles had been recommended by the Macmillan Report of 1926. The Mental Treatment Act of 1930, which provided for the widespread introduction of the outpatient system and the relaxation of the laws regarding admission, paved the way for greater fluidity between hospital and community in England. Psychiatric social work services were embryonic during this period, but their emergence demonstrated the beginnings of a transition from voluntary to professional service provision. Psychiatric social workers were regarded as an “essential” aspect of modern psychiatry by English psychiatrists and by Toulouse in Paris. Their role in helping discharged patients find work outside hospital was a lifeline for some, particularly since the occupations allocated to patients in hospital did not prepare them for local employment opportunities or modern working practices in either England or France. Work around the hospital was anachronistic, remaining similar in character to the work provided in the early days of the asylum system. Occupational therapy, on the other hand, provided patients with an experience that was the opposite to that which they would encounter in a modern factory. This anomaly would eventually be addressed by the introduction of industrial therapy in England in the late 1950s, the same decade that occupational therapy was being introduced in France. Patient occupation could thus be regarded as a “barometer” of developments within psychiatry.