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Response to Review of Mental Health Nursing: The Working Lives of Paid Carers in the Nineteenth and Twentieth Centuries

I would like to thank Niall McCrae for his very interesting and wide-ranging review. It certainly encourages reflection about past, present and future approaches to the history of mental health nursing within both the history of nursing and the histories of the different services and facilities such nurses staffed. My personal research has concentrated on asylum histories but I have always thought that the best of these seek to bring particular institutions to life as places where people lived and, crucially, worked. It was arguably in the personal interactions of patients and paid carers that the purposes of the asylum were either realised or frustrated. This seems an important starting point for those keen to evaluate the caring, even therapeutic, potential of the asylum as well as those concentrating on its controlling functions. Yet, to date there has been a tendency to overlook the contribution of rank-and–file staff (be they keepers, attendants, or nurses) to concentrate on elite figures in the asylum world; the lay and medical administrators and the professional networks that sustained and expanded their influence. In a rejection of this top down approach other scholars have self-consciously looked from the bottom up but efforts to capture the patient experience have similarly tended to neglect the staff most intimately involved with their care.

It seems strange that there are so few major studies of asylum nursing. When this edited collection was published in 2015 there were no monographs tracing the development of mental health nursing in the UK. This significant gap in the historiography has started to be addressed (1a), but Niall McCrae and Peter Nolan would probably be the first to agree that a lot more needs to be done to fully understand mental health nursing in the periods before, during, and after the asylum age. Yet the picture is perhaps not as bleak as it seems. The archival record is good, and anyone interested in staffing issues at particular institutions potentially has an embarrassment of riches at their disposal. These local case studies are highly amenable to comparative work and the gradual development of nursing organisations and trade unions for nurses provide voluminous records offering additional and alternative commentary designed for a national and even international audience. Services were more fragmented before and outside of the asylum but imaginative scholars continue to locate, and find new ways of using, relevant source material. The early modern period is becoming more accessible to nursing historians, and mental health topics aren’t entirely forgotten within this literature. In a different way deinstitutionalisation and the rise and fall of alternative models of service-delivery present similar challenges to historians of the recent past (2a), although authors with personal experience of working as nurses have been particularly astute at keeping pace with developments and providing contemporary as well as historical insight into them. Here scholars such as Peter Nolan and Mick Carpenter have not just argued against the marginalisation of mental health nurses but set an interdisciplinary agenda for future work. Researchers with backgrounds in medicine as well as medical history and the social history of medicine have been quick to adopt their conclusions and in so doing widen and deepen the reach of their own studies.(3a)

The voluminous historiography exploring the rise and decline of the asylum in different places at different times presents challenges, but the vibrancy of the field continues to surprise and delight. I’ve worked on institutional histories since 1997 but there is always something new. Quality monographs continue to use evidence from previously under-researched facilities to ask new research questions and add nuance to ongoing debates.(4a) Anna Shepherd, for example, contrasts experiences of patients at the Brookwood Asylum and Holloway Sanatorium while paying careful attention to staffing issues and throwing new light on previously neglected topics such as child/adolescent admissions and suicide prevention.(5a) A strength of the discipline has always been a sense of common purpose, reinforced by the generous sharing of information at seminars and conferences. Some of the most powerful contributions to the field have been multi-authored works and edited collections which have been organised thematically. Just recently Waltraud Ernst’s new volume successfully moves consideration of patient work from the margins of existing studies to the centre of analysis.(6a) It is now hard to think casually about patient work, and I am conscious of rereading older studies differently. I hope and suspect that recent efforts to foreground staffing issues in specialist monographs as well as edited collections will encourage future asylum studies to consider paid carers, in the UK and other countries, in far more detail. We should also revisit existing publications as there are many excellent studies that do, however briefly, discuss the many and varied roles of keepers/attendants/nurses and these ideas also need to inform future work and aid the extension of its chronological and geographical coverage. A useful starting point, not just for the relatively neglected early 19th century, is Len Smith’s particularly sensitive account Cure, Comfort and Safe Custody.(7a)

Alongside evaluation of asylum nursing thought needs to be given to the network of institutions that patients were transferred from and to. The workhouse care of lunatics remains an area of concern despite some excellent studies concentrating on patient experiences and the professionalization of Poor Law nursing.  Other loci of care/control need to be considered, and this historical work needs to engage with studies exploring 21st-century practices and problems such as the multi-disciplinary mental health teams working with the police and in hospital A and E departments. Recent tragedies have highlighted the need for nurses, midwives and other staff to support pregnant women and new mothers experiencing mental health crisis and it is frankly odd that historical studies of puerperal insanity have concentrated almost exclusively on family carers and tensions between obstetricians and asylum doctors. The role of nurses in domestic and institutional settings needs to be assessed more thoroughly. We also should also seek to understand more about the care strategies of wealthier families. Some details of patient-staff interactions at exclusive, private, institutions are familiar thanks to the work of Charlotte MacKenzie (8a), but mental health crises and mental illnesses of longer duration were also managed in domestic settings. Janet Morgan describes a situation where a team of four nurses were assembled at short-notice to provide round-the-clock care for a female patient for a period of months but who these women were, where they came from, what they did, and how their work fitted into the routines of an inter-war country house are never explained.(9a) Yet these are important questions for the history of nursing as well as the history of mental health nursing.   

I am optimistic about the potential for this work but there are still obstacles to overcome and the most important of these seems to be finding ways to better include nurses and practitioner-historians working across the full range of history of nursing topics. To understand what is distinctive about mental health nursing it is important for researchers to fully comprehend but also move beyond the models of general nursing that so often set the parameters for debate. We also need to keep in mind the contribution and experiences of paid carers who are not nurses. I once worked in the social care sector and encountered the alarming story of a young woman offered brief induction training and sent alone to deliver a 30-minute care package to an elderly lady with dementia. The home visit was entirely routine until the client’s husband, and main carer, attempted to commit suicide with a ligature. Such incidents serve as a reminder of the onerous demands placed on the humblest of staff, so often under-appreciated by their employers and overlooked in historical evaluations of services.    


  1. Niall McCrae and Peter Nolan, The Story of Nursing in Mental Hospitals in Britain: Echoes from the Corridors (Oxford, 2016).Back to (1a)
  2. Deinstitutionalisation and After: Post-war Psychiatry in the Western World, ed. Despo Kritsotaki, Vicky Long and Matthew Smith (London, 2016).Back to (2a)
  3. Peter Nolan, ‘Mental Health Nursing’, ‘Psychiatric Nursing’, and ‘Community Psychiatric Nursing’, in A Century of Psychiatry, ed. Hugh Freeman (London, 1999), pp. 93–6, pp. 208–11 and pp. 332–3.Back to (3a)
  4. Louise Hide, Gender and Class in English Asylums, 1890–1914 (Basingstoke, 2014); Debbie Palmer, Who Cared for the Carers? A History of the Occupational Health of Nurses, 1890–1918 (Manchester, 2014).Back to (4a)
  5. Anna Shepherd, Institutionalizing the Insane in Nineteenth-Century England (London, 2014).Back to (5a)
  6. Work, Psychiatry and Society, c. 1750-2015, ed. Waltraud Ernst (Manchester, 2016).Back to (6a)
  7. L. D. Smith, ‘Cure Comfort and Safe Custody’: Public Lunatic Asylums in Early Nineteenth-Century England (London, 1999).Back to (7a)
  8. Charlotte MacKenzie, Psychiatry for the Rich: A History of Ticehurst Private Asylum, 1792–1917 (London, 1992).Back to (8a)
  9. Janet Morgan, Edwina Mountbatten: A Life of Her Own (London, 1992), p. 183.Back to (9a)