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

A popular exhibition at the Wellcome Trust in London, running for three months from October 2016, Bedlam: the Asylum and Beyond promised to ‘reimagine the institution, informed by the experiences of the patients, doctors, artists and reformers who inhabited the asylum or created alternatives to it’. Something was missing in the promotional message, and indeed in the exhibition itself: nursing was barely mentioned. Despite constituting the great majority of care staff, having the closest contact with patients, and running the wards day and night, nurses are little more than a footnote in the history of mental health care as presented by psychiatrists.

Meanwhile, the history of mental health nursing is growing into a corpus of scholarly literature, immersed in personal narratives with a sociological orientation. The book reviewed here, edited by Anne Borsay and Pamela Dale, is a valuable contribution. Yet it is also a strange collection. Of 11 chapters, four are not on mental health nursing: three focus on institutions for learning difficulties (at the time known as mental handicap), and one on a hostel for families with social problems. The book has a strong Mancunian flavour, which is no shortcoming: Manchester was very important to the history of mental health nursing in Britain, being the origin of the National Asylum Workers Union, the Prestwich Asylum scandal of 1921, and the progressive relocation of psychiatric services to district general hospitals from the 1950s onwards. Except one chapter on Australia, all others are from the British Isles, including an account of nursing at an asylum in Galway, during the reign of Queen Victoria.

Several chapters are based on PhD research, with untapped primary sources carefully examined. In a chronological order, the period most covered is the early 20th century, including a chapter on nursing psychological casualties of the First World War at Cardiff War Hospital (an asylum requisitioned by the military authorities). This volume does not offer a comprehensive history of mental health nursing, unlike the earlier book by Peter Nolan and the more substantial text by Nolan and I, but overarching themes give the work coherence.(1)

Transcending the chapters are tensions, not least between professionalisation and organised labour. It should be acknowledged that while doctors instituted a formal training scheme for attendants in the late 19th century, their aim was not primarily to create a new profession, but to raise standards and to maintain medical control. The most valued trait in a nurse was obedience. The priority for nurses, meanwhile, was to keep order amidst potential chaos by all means permissible, while averting disciplinary sanction or a black eye.

Developments in British asylums were mirrored in the colonies, as shown in Lee-Ann Monk’s study of nurse training in the state of Victoria in Australia. The first asylum, Yarra Bend, opened in 1848. Four further asylums were built in Victoria by the end of the century, mostly led by doctors who had emigrated from Britain or Ireland. In 1887, Doctor O’Brien introduced lectures on nursing for ‘male warders’ at Kew Asylum. Lectures emphasised the somatic basis of insanity, assimilating it to physical disease. Patients thus needed hospital treatment, not custodial care. Two years earlier a manual for nursing the insane had been written by W. C. Williamson in neighbouring New South Wales. However, the manual that became popularly known as the ‘Red Book’, first published in 1885 by the Medico-Psychological Association (MPA) in London, was distributed to Victoria staff. This followed the launch of a training scheme by Doctor McCreery, after he was promoted from medical superintendent at Kew to the state inspector of asylums. A series of 25 lectures was based on the ‘Red Book’, with the first year focusing on physiology and basic nursing, and the second on care of the insane. McCreery wanted the course to be compulsory, but attendants resisted this, initially by not putting themselves forward, and (when pushed to do so), by petition to the Public Service Board. One reason was the lack of incentive, but also men with long experience of dealing with the mentally disturbed resented being told how to do their job by junior doctors. The Lunacy Act of 1903 enabled full implementation of training, making its completion a requisite for permanent employment, increments and promotion.  

Wherever they were built, the story of the asylums is of demand exceeding supply, with rising admissions compounding an accumulation of chronic cases. Monk’s chapter suggests that progress in mental nursing in Australia matched that in old Albion, as did the impoverishment. E. Cunningham-Dax, who had made his name as medical superintendent at Netherne Hospital in Surrey, went to Victoria in 1952 with the mission of resocialising the denizens of this lost world. Dreadful conditions at Yarra Bend and Kew were described in his book From Asylum to Community, which featured grotesque images of the kitchens and toilets. He found it ‘difficult to imagine how any service was allowed to deteriorate to this extent’.(2) But mental hospitals in Yorkshire and around London were plagued by the same problems of overcrowding, understaffing and dilapidation.

Another tension was between the male and female sides of the institution, where strict segregation was applied as rigidly to staff as the patients. Elaine Showalter’s seminal The Female Malady (3) has been criticised for imposing feminist ideology on the history of asylums, as evidence does not support the thesis of a system designed or run simply to control women.(4) Nonetheless, disadvantage is readily apparent in staffing ratio on the wards, while male attendants were paid considerably more than their female counterparts (as was the general rule in society at the time).

The Asylum Workers Association (AWA) was established in the 1890s, but it appeared too close to the authorities, with paternalistic input from medical superintendents and lay managers. Although AWA lobbying for a pension succeeded with legislation in 1909, the contributory scheme actually reduced the pay of workers in some counties. This spurred the formation of a new, more militant organisation in 1910. The National Asylum Workers Union (NAWU) rapidly overtook the AWA in membership, and with growing strength it threatened industrial action at several asylums. After a hiatus due to emergency legislation in the First World War, the struggle resumed. Barbara Douglas’ chapter on the growth of trade unionism in asylums is contextualised by the broader labour movement and class consciousness. She describes unrest at the Exeter Mental Hospital, quoting from a sympathetic patient’s poem (p. 99):

Let’s hope the band on sports day

Will play God Save the King

And finish with the Marseillaise

And hear the nurses sing

Douglas’ account is complemented by the following chapter by Vicky Long, who considers the gender aspect of trade unionism. George Gibson, general secretary of the NAWU, deserves recognition as an important figure in the history of mental health nursing. But as Long shows, the union was more tuned to the needs of male attendants. Men returned from the Western Front to hospitals to face a serious threat to their jobs: women working on their wards! This had been a pragmatic response to wartime exigency, but a precedent had already been made in a Scottish asylum, where medical superintendent George Robertson (5)had openly declared his preference for female nurses. In Robertson’s experience, women were more naturally caring, and male patients responded with chivalry to motherly behaviour.

Gender stereotypes abound in primary documentary sources on the traditional asylum system. They are based on social realities of the time, and there may be a grain of truth in perceived gender dispositions, despite their rejection by contemporary scholars. Certainly, stark contrasts may be drawn between the culture of the male and female sides. Whereas the matron ran a regime similar to that of a general hospital, with due attention to cleanliness and appearance, the environment headed by the chief male attendant was akin to military barracks. Male attendants used brute force, and wrote candidly about their role in the NAWU magazine, one likening his job to a lion-tamer. There was none of the niceties of an evening sing-along around the piano, or homemade decorations to soften austere dormitories. However female nurses could be insensitive too, Long (p. 127) giving an example of one describing her patients as ‘unpleasant, abusive, filthy in habits’. Despite being in ‘hospital’, patients were not necessarily seen as ill, but as antisocial. Indeed, the difficulties of dealing with such patients was used in the argument for better pay.

Although the NAWU was initially dominated by men, by 1920 almost half of the membership was female. Long portrays the union as protectionist, with strong hints of misogyny. Gibson, in a report to the Labour Party, argued that women could not manage the violence and sexual depravities of male patients. Quoting from the ‘Red Book’, he opined that the male wards were no place for a girl. The NAWU suspected that women would be favoured because they were cheaper, but according to the Nursing Times, the organ of the College of Nursing, female nurses should not be criticised for caring for men. Nursing is nursing, wherever practised. Long’s account shows that women were the drivers of professionalism in mental nursing, while men were immersed in the pursuits of organised labour. Male nurses were barred from the state register until 1949, and from the College of Nursing until 1960.

Although titled ‘The weakest link’, the chapter by Claire Chatterton is the backbone of this book. For all the promise of the National Health Service, with free treatment for all, there was little change to the perception and provision of the psychiatric system. The former asylums were fearsome places to the public, and mental nursing was not an appealing option for a school-leaver. With work opportunities in shops, factories, offices or training for the police or teaching, why choose a stigmatised gloomy institution, with long hours, low pay and Victorian attitudes to mixing of the sexes? Not surprisingly, the persistent staffing shortage in mental hospitals became a crisis.

In England and Wales, entrants to mental nurse training fell from 3204 in 1948, to 1594 six years later. These two years are milestones: the first for the birth of the NHS, and the second for the peak of the mental hospital population in England and Wales. Recruitment campaigns presented mental nursing as a modern, clinical profession with exciting career prospects, but the contrast between ideals and reality was stark. The student nurse (the term ‘probationer’ was discarded) may have looked forward to spending time talking to patients, and to learning about psychotherapies and physical treatments, but the first visit to a ward may have dispelled such notions. A typical ‘back ward’ dormitory was entirely filled with beds, inches apart, with merely a narrow gangway to the hopelessly inadequate sanitary facilities at the rear. The odour was thick with sweat, paraldehyde, floor polish, boiled cabbage and frequently-blocked latrines. Some patients stared vacantly at the newcomer, while others talked to themselves in their delusional world. ‘Abandon hope, all ye who enter here’.

Reprieve from the monotonous, stultifying regime could be found in the social club, the nurses’ home, sporting and musical endeavour, and in the camaraderie among colleagues. However, this was not enough to lure local workers. As Erving Goffman described in his study of a huge state hospital in Washington (6), stigma was attached to staff as well as patients. Overseas recruitment drives were economic with the truth, hiding the type of hospital from naïve Nigerian or Jamaican school-leavers. Many felt duped on arrival at a mental institution instead of the prestigious general hospital that they had imagined, but at least they would have a certain job on qualifying. A trickle became a flood, and by the end of the 1960s, the workforce of many mental hospitals around London and other conurbations was staffed by a foreign legion from all parts of the faded empire.

The final chapter is a particularly important contribution to the narrative of mental health nursing. Val Harrington presents a case study of a psychiatric unit in a district general hospital, a much neglected area in the history of mental health services. It has been tempting for historians to focus on the traditional mental hospitals and their eventual replacement by care in the community, but not only was the creation of these units a radical venture at the time, they are now the main location of the dwindling number of psychiatric beds in Britain.

The Manchester environs are the ideal location for this chapter, because it was here that psychiatry established a foothold outside the former asylums. Doctors in mental hospitals had struggled to gain credibility as a specialty of medicine, tending to be regarded as governors of social institutions, but the Mental Treatment Act of 1930 was a poignant move in unifying mental and physical health. Voluntary admission was introduced, and for this purpose admission blocks were built at mental hospitals, physically and culturally separated from the old block. Shock treatments forged a more clinical atmosphere, although their effectiveness failed to fulfil initial promise. Yet these new buildings, labelled as ‘nerve clinics’ to distinguish from public perceptions of insanity, were within the old asylum estate, and could not avoid being tainted.

Although much overlooked in historical accounts, there was another location of mental treatment prior to the National Health Service. The mental observation wards of Poor Law infirmaries enabled distressed or disturbed persons to be assessed and to receive brief treatment without certification, although those who failed to recover were dispatched to the distant mental hospital under the 1890 Lunacy Act. In Lancashire, however, the health administrators opened large psychiatric departments within general infirmaries, obviating the need to transfer patients for longer-term care. The first opened in Oldham in 1950, and its purpose was not only acute admission but the full array of psychiatric treatment, thereby beginning to relieve the severe overcrowding of the conventional mental hospitals of that county.

In 1961 Minister for Health Enoch Powell delivered his famous ‘water tower’ speech on the proposed rundown and eventual closure of the mental hospitals, but less remembered was his department’s Hospital Plan of the following year. This policy decreed that the plethora of specialist fever, eye, ear nose and throat, maternity and children’s hospitals would be replaced by a comprehensive district general hospital. Multi-storey concrete blocks were erected throughout the land, among them Withington Hospital in Manchester. Opening in 1971, the large psychiatric unit at Withington had ten wards for a total of 170 patients, with five consultant psychiatrists’ ‘firms’ and 120 nurses. With bright furnishing and therapeutic optimism, it was incomparable to the decaying institutions such as Prestwich. Hundreds applied for nursing jobs, enabling managers to pick and choose. Most of the elite who were appointed had qualification in general as well as mental nursing.

Professor of psychiatry Neil Kessel (7) lauded Withington as the future of psychiatry. However, while this was an obvious advance, as a fully-equipped clinical setting integrated with community services, the problem was that it made the large mental hospitals more isolated and a dumping ground for chronic and psychogeriatric cases. Sadly, the most vulnerable patients did not attract the best nurses. Nursing students were sometimes horrified by what they saw, and despite the efforts of hospital managers and trade unions alike, the truth was leaking out. A series of scandals rocked the system in the 1970s, hastening the demise of the large hospitals. Perhaps the most shameful exposé was at Whittingham in Lancashire, where a government enquiry found evidence of widespread abuse and embezzlement.

Meanwhile psychiatric units were never fully accepted in general hospitals. Harrington quotes from nurses who were exposed to condescending or contemptuous attitudes from general nurses; for example, when taking a patient for X-ray. At my local general hospital, the psychiatric annexe was known as ‘Fraggle Rock’, after the crazy television cartoon show, and I remember repeated remarks by nurses on the medical wards that one could not tell the staff from the patients. Harrington’s account ends in 1991, when the Withington unit had lost its lustre. The 1960s construction was not built to last, and the positive energy had dissipated.

This final chapter shows another perpetual tension: is the primary function of mental health services to treat illness, or is to provide sanctuary and support for people with ‘problems in living’? Both may be necessary, but arguably the latter is neglected in favour of a biomedical model reinforced by the most powerful profession and the pharmaceutical industry. Recently in Malta I met mental health commissioner John Cachia, who is gradually closing the wards at the old institution of Mount Carmel, which was built in the mid-19th century as a copy of the Wakefield Asylum in Yorkshire. At Mater Dei, the general hospital, Cachia plans to open a floor for psychiatry, without any labelling as such. It will simply be another ward for treating people who are unwell, with full access to the medical technology. Holistic care is the rationale, but somehow it didn’t convince me. Inpatient care is for a brief period, entailing containment and drug treatment followed by discharge home under the watch of a community team. Studies have persistently shown a lack of therapeutic engagement in acute psychiatric wards, and sometimes this is excused on the grounds that patients are too unwell, and the medication too blunting. The system must change, enabling more psychological and social intervention.

There is little to criticise in the standard of writing throughout this book. A minor point, however, is the inconsistent adherence to the language of the time, this being a convention in historical work. ‘Psychiatrists’ lurk in early chapters, but while this term was introduced by a German writer in 1808, British asylum doctors were known as ‘alienists’ throughout the 19th century, and their field was ‘psychological medicine’ until at least the 1950s. As noted previously, this book has no pretence as an encyclopaedic treasury of the history of mental health nursing. Missing or mentioned in passing here are some major developments such as the therapeutic community model, shock treatments and psychosurgery, the dramatic cultural changes to the institutional regime in the 1960s, and the scandals that followed. However, the chapters provide original and useful contributions to understanding the profession and how it got where it is today. It is a pity that this work, and others on nursing, were missing from the bookshelves at the aforementioned Bedlam exhibition.

Notes

1. P. Nolan, A History of Mental Health Nursing (London, 1993); N. McCrae and P.  Nolan, The Story of Nursing in British Mental Hospitals: Echoes from the Corridors (London, 2016).Back to (1)
2. E. Cunningham-Dax, Asylum to Community: the Development of the Mental Hygiene Service in Victoria, Australia (Melbourne, 1961).Back to (2)
3. Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830–1980 (London, 1987).Back to (3)
4. Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry, ed. J. Andrews and A. Digby (Amsterdam, 2004).Back to (4)
5. George M. Robertson, ‘The employment of female nurses in the care of insane men in asylums’, Journal of Mental Science, 52 (1906), 116–29.Back to (5)
6. Ernest Goffman, Asylum: Essays on the Social Situation of Mental Patients and Other Inmates (Harmondsworth, 1961).Back to (6)
7. Neil Kessel, ‘The district general hospital is where the action is’, in Policy for Action: a Symposium on the Planning of a Comprehensive Psychiatric Service (London, 1973), pp. 53–64.Back to (7)