Mental health nursing: The working lives of paid carers in the nineteenth and twentieth centuries 9781784992156

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MENTAL HEALTH NURSING The working lives of paid carers in the nineteenth and twentieth centuries Edited by

Anne Borsay and Pamela Dale

Mental Health Nursing

This series provides an outlet for the publication of rigorous academic texts in the two closely related disciplines of Nursing History and Nursing Humanities, drawing upon both the intellectual rigour of the humanities and the ­practice-based, real-world emphasis of clinical and professional nursing. At the intersection of Medical History, Women’s History and Social History, Nursing History remains a thriving and dynamic area of study with its own claims to disciplinary distinction. The broader discipline of Medical Humanities is of rapidly growing significance within academia globally, and this series aims to encourage strong scholarship in the burgeoning area of Nursing Humanities more generally. Such developments are timely, as the nursing profession expands and generates a stronger disciplinary axis. The MUP Nursing History and Humanities series provides a forum within which practitioners and humanists may offer new findings and insights.  The international scope of the series is broad, embracing all historical periods and including both detailed empirical studies and wider perspectives on the ­cultures of nursing. Previous titles in this series: One hundred years of wartime nursing practices, 1854–1954 Edited by Jane Brooks and Christine E. Hallett ‘Curing queers’: Mental nurses and their patients, 1935–74 Tommy Dickinson Who cared for the carers? A history of the occupational health of nurses, 1880–1948 Debbie Palmer

MENTAL HEALTH NURSING THE WORKING LIVES OF PAID CARERS IN THE NINETEENTH AND TWENTIETH CENTURIES EDITED BY ANNE BORSAY AND PAMELA DALE

Manchester University Press

Copyright © Manchester University Press 2015 While copyright in the volume as a whole is vested in Manchester University Press, c­ opyright in individual chapters belongs to their respective authors, and no chapter may be reproduced wholly or in part without the express permission in writing of both author and publisher. Published by Manchester University Press Altrincham Street, Manchester M1 7JA www.manchesteruniversitypress.co.uk British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data applied for

ISBN  978 0 7190 9693 8 hardback First published 2015 The publisher has no responsibility for the persistence or accuracy of URLs for any ­external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Typeset by Servis Filmsetting Ltd, Stockport, Cheshire Printed in Great Britain by TJ International Ltd, Padstow

Contents

List of contributors  page vii Foreword: the struggle is never over  ix   Mick Carpenter Acknowledgementsxiv List of abbreviations xv   1 Mental health nursing: the working lives of paid carers from 1800 to the 1990s  1 Anne Borsay and Pamela Dale   2 Psychiatric nurses and their patients in the nineteenth century: the Irish perspective  28 Oonagh Walsh   3 A duty to learn: attendant training in Victoria, Australia, 1880–1907  54 Lee-Ann Monk   4 ‘Who are these?’ Nursing shell-shocked patients in Cardiff during the First World War  75 Anne Borsay and Sara Knight   5 Discourses of dispute: narratives of asylum nurses and attendants, 1910–22 98 Barbara Douglas   6 ‘Surely a nice occupation for a girl?’ Stories of nursing, gender, violence and mental illness in British asylums, 1914–30123 Vicky Long

v

Contents   7 Reassessing staffing requirements and creating new roles for nurses during a period of rapid change at the Royal Western Counties Institution, 1927–48 Pamela Dale   8 ‘The weakest link in the chain of nursing’? Recruitment and retention in mental health nursing in England, 1948–68 Claire Chatterton   9 Wardens, letter writing and the welfare state, 1944–74 John Welshman 10 Learning disability nursing: surviving change, c.1970–90 Duncan Mitchell 11 Between asylum and community: DGH psychiatric nurses at Withington General Hospital, 1971–91 Val Harrington

145 169 190 213 235

Index259

vi

Contributors

Anne Borsay, who sadly passed away during the final stages of the production of this book, was Professor of Healthcare and Medical Humanities based in the College of Human and Health Sciences, Swansea University. She was working on a Wellcome Trust Programme Award, ‘Disability and Industrial Society: A Comparative Cultural History of British Coalfields, 1780–1948’. Mick Carpenter recently retired from his position as Professor of Social Policy at the University of Warwick but remains research active, pursuing his commitment to progressive change and the need to tackle issues of social justice and inequality. Claire Chatterton trained as a general and mental nurse before taking masters degrees in social policy and historical studies. She works as a staff tutor for the Open University in the North West and is chair of the Royal College of Nursing’s History of Nursing Society. Her chapter draws on PhD research completed at the University of Salford, Manchester. Pamela Dale is an Honorary Fellow attached to the Centre for Medical History at the University of Exeter. Her chapter draws on doctoral research undertaken at the Centre that was generously supported by the Exeter University Foundation and the AHRB. She has also worked on Wellcome Trust funded projects exploring the history of health visiting and stress.

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Contributors

Barbara Douglas is a counselling psychologist, having previously worked as a psychology lecturer. Her chapter draws on doctoral research undertaken at the Centre for Medical History, University of Exeter. Val Harrington was until recently a post-doctoral fellow at the University of Manchester. Her doctoral studies, conducted at the Centre for the History of Science, Technology and Medicine and supported by the Wellcome Trust, examined the post-war history of mental health services in Manchester and Salford. Sara Knight completed her PhD in Wales and is now an independent scholar. She works as a senior archivist for Archives New Zealand in Wellington. Her contribution to this volume draws on doctoral research exploring nursing in Cardiff during the First World War. Vicky Long is a senior lecturer at Glasgow Caledonian University and is the author of Destigmatising Mental Illness? Professional Politics and Public Education in Britain, 1870–1970 (Manchester: Manchester University Press, 2014). Duncan Mitchell has a nursing background but is now a Professor at Manchester Metropolitan University where he is one of the conveners of the Learning Disability Research Group based in the Research Institute for Health and Social Change. Lee-Ann Monk is the author of Attending Madness: At Work in the Australian Colonial Asylum (Amsterdam: Rodopi, 2008). She is a Research Associate in the history program at La Trobe University, Melbourne. Oonagh Walsh is Professor of Gender Studies at Glasgow Caledonian University and has published widely on gender and medical history with a particular interest in the nineteenth-century history of Irish psychiatry. John Welshman is a senior lecturer in the Department of History at Lancaster University. His research interests are at the interface of contemporary history, social policy and public health. viii

Foreword The struggle is never over Mick Carpenter

Nursing, as we know, is seen as only marginally interesting by history in general, except for a few famous figures, previously Florence Nightingale and subsequently Mary Seacole (who in fact recently had to fight posthumously to keep her place within the English school curriculum).1 Either we have the history of medicine or the history of health care. At best nurses creep on to the margins of the pages of these histories, just as in the real health care system nurses metaphorically and literally carry the heaviest loads, but remain scarcely visible. Of course, this unjust neglect has been challenged over the past forty years, most notably alongside the rise of feminist and labour history, and a substantial corpus of work on nursing history has emerged. Yet even so nursing’s claim to be recognised within history at large is still largely ignored: in such ways, scholarship imitates life. That, however, is nursing generally, by which I definitely don’t just mean general nursing. So what of the history of mental health nurses? They remain substantially neglected in the history of nursing, and certainly in the history of mental health services. While there is a very strong critical history of psychiatry, the asylum and its successor, the mental hospital, from Foucault onwards, it tends to ignore nurses or give them a minor ‘subplot’ in the drama. Psychiatry and psychiatrists are deemed to play the leading role and while they are highly important in shaping and driving the mental health system, they are much less important in ensuring that all the daily work of caring and tending and controlling and, yes, sometimes even assisting recovery is actually done. Thus the mental health system has become a complex and ever-changing division of labour, and within it is a large body of people who do much of the paid work and are called ix

Foreword

and call themselves ‘nurses’, who intersect and interact with the smaller cohort of professionals including psychiatrists, psychologists, occupational therapists, dieticians and others. They also liaise with cleaners, cooks and porters, and deal with relatives, and also, let’s not forget, coexist with and deal intimately, often on a round-the-clock basis, with the minds and bodies of those who are called ‘patients’. That is itself only part of the story, because nurses themselves are not a homogeneous group but are hierarchically organised in terms of trained and untrained staff, managers and operational staff, students and qualified, as well as being socially differentiated in terms of criteria such as gender, nationality and ethnicity. However, despite all this cross-cutting complexity (which I have only started to describe), one thing has remained a constant, which is that the nurse (and the attendant previously) has remained the pivot around which the mental health system revolves, carrying the prime responsibility but not exercising the prime power. The setting for this has changed dramatically. For a long time it was played out primarily in institutions, initially the large asylums on the building of which the Victorians lavished enormous expenditure, though they increasingly skimped on the funds required to run them when the instant curative effects expected of institutional regimes failed to materialise. The people originally most trapped by this were the inmates, but in a sense the staff were also confined: geographically by the location of the institutions, socially by the stigma of madness and the asylum that rubbed off on them, and economically in a labour-intensive service by the fact the prime economies sought were on the costs of staff who were expected to work long hours with little pay under onerous discipline. The stigma did not just affect the ‘attendants’ but also the ‘mad doctors’. One of the myths that needs to be dispelled is that the asylum system was a settled field that did not essentially change until the 1950s shift to ‘community care’ which essentially – after a prolonged delay – spelled its doom. It is a myth partly because the asylum system itself was never monolithic and unvarying, but mainly because even as it was established it came under concerted challenge. With the benefit of hindsight we can see that there were three sets of challenges. The first, under the banner of ‘liberty’, asserted the rights of patients, initially against ‘wrongful confinement’ but increasingly, following x

Foreword

the deterioration of already poor conditions in asylums in the First World War, as a result of scandals about abusive treatment, eventually morphed into the mental health users’ movement in the modern era. The second, under the banner of ‘the medical model’, sought to transform lunacy into mental illness, asylums into mental hospitals, mad doctors into psychiatrists, attendants into nurses, inmates into patients, and confinement into treatment. The third, under the union banner of ‘workers rights’, sought to acknowledge that most asylum workers were subordinated paid employees and should therefore collectively mobilise and combine with other workers to do something about it. These three movements intersected and clashed at various times, and waxed and waned in relative degrees of influence. However, they each in their different ways have had significant effects on the mental health system in general and the history of mental health nursing in particular. Since I argued above that mental nurses were the axis around which mental health care pivots, this is not surprising. The distinction I would make, however, is that while the first two movements reshaped ‘daily’ mental health care from the outside and often from above, the third originated from within and below. I have dealt with some of these issues at greater length in various publications over the years, so I won’t elaborate in detail how all this played out. I will, however, indulge myself by pointing out that I was a ‘pioneer’ who was one of the first to map out the terrain in a chapter for a landmark collection which sought to ‘rewrite’ nursing history.2 In the process I was able to stake a claim for three things which needed saying then and I believe are still relevant today. The first is that any account of nursing history worthy of its name needs to recognise that mental nursing, by a complex political process that is worth unravelling, has been included in the family of nursing occupations and needs to be recognised rather than ignored as a poor and embarrassing relative. Second, that mental nurses pioneered the campaign for workers’ rights to decent employment conditions, pay and prospects in ways that subsequently benefited all health care workers and ultimately users, often in the face of opposition from professional organisations that until recently treated such concerns as demeaning. Third, and perhaps most important, nurses are people in all their interesting and flawed complexity, not simply stereotypical public projections xi

Foreword

of saints (usually general nurses) or demons (usually mental nurses). The full story of the lives they lived and how they tried to shape their destinies deserves to be told. The chapters in this book in a diverse set of ways take up these themes, and I therefore feel privileged to be asked to write the Foreword to such a fine collection. There is still plenty of room in this area to dig deeper into the historical archives to broaden the narratives, and also to bring the stories up to date. The book starts with a useful survey of the field by Anne Borsay and Pamela Dale, which effectively sets the scene for the exceptionally interesting, wellresearched and thought-provoking set of chapters that follow. My hope is that this book will help to broadcast loudly the importance of conducting scholarship in this field, its importance to understanding the situation of nursing and nurses, and also how this intersects with key service and policy issues in the health care system and wider society. In the process it will hopefully inspire others to research this still woefully neglected field. Of course, no one would claim that overcoming the Cinderella status of mental health nursing history will itself change its status within the nursing constellation, or the continuing public neglect of the mental health services. Another constant factor, or in political science jargon path-dependency, is that despite the efforts of the three social movements I briefly outlined above, mental health services are still clearly vulnerable to judgements that they are less important than other public priorities. In a period of increasing austerity, rising demands and more exacting public expectations, they are easy targets. For example, despite formal government commitment in principle to the idea that mental and physical health services are of equal status, it became clear in March 2014 that the NHS funding and regulatory agency Monitor was effectively seeking to cut expenditure on mental health services to pay for nurse staffing increases in acute general hospitals in the wake of the recommendations the Francis Report into the South Staffordshire Hospital scandal – in other words robbing Peter to pay Paul.3 So if, as far as the mental health services are concerned, Cinderella is still waiting to go the ball, it was ever thus. The struggle in tandem for a better history and better society must therefore continue. xii

Foreword

Notes 1 K. Rawlinson, ‘Another Gove u-turn: Mary Seacole will remain on the curriculum’, The Independent, 7 February 2013, http://www.independent.co.uk/ news/uk/politics/another-gove-uturn-mary-seacole-will-remain-on-the-­curri​ culum-8485472.html. 2 M. Carpenter, ‘Asylum nursing before 1914: a chapter in the history of labour’, in C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980). 3 D. Campbell, ‘Mental health funding changes in NHS will put lives at risk, say charities’, The Guardian, 12 March 2014, http://www.theguardian.com/ society/2014/mar/12/mental-health-funding-changes-lives-risk.

xiii

Acknowledgements

This volume originated in a history of nursing workshop hosted by the Centre for Medical History, University of Exeter, 2–3 July 2009 (see report in The Gazette (Society for the Social History of Medicine) 48, August 2009). The event was generously supported by the Wellcome Trust and attracted an international audience of scholars, students and practitioner-historians. Their thoughtful contributions have shaped this volume at all stages of production and are much appreciated. We are indebted to Dr Deborah Palmer who coorganised the conference and Claire Keyte who handled the administration. Thanks are also due to Professor Joseph Melling, Professor Mark Jackson and other Exeter colleagues who offered their generous support, as well as Professor Steve King whose advice proved invaluable. We are also grateful for the warm assistance received from the team at Manchester University Press.

xiv

Abbreviations

AOA Asylum Officers’ Association AWA Asylum Workers’ Association BNA British Nursing Association CNO Chief Nursing Officer COHSE Confederation of Health Service Employees CPN Community Psychiatric Nurse DGH District General Hospital DHSS Department of Health and Social Security DOH Department of Health ECT electroconvulsive therapy EEG electro-encephalography EVIAs English Voluntary Idiot Asylums FSU Family Service Unit GNC General Nursing Council HAS Health Advisory Service MDA Mental Deficiency Act MDCT multi-disciplinary clinical team MPA Medico-Psychological Association MTA Mental Treatment Act NAWU National Asylum Workers’ Union NHS National Health Service QAIMNS Queen Alexandra’s Imperial Military Nursing Service RCN Royal College of Nursing RHA Regional Health Authority RMN Registered Mental Nurse RMO Resident Medical Officer RMPA Royal Medico-Psychological Association xv

Abbreviations

RNMH SJAA SRN TFNS VAD

Registered Nurse Mental Handicap St John Ambulance Association State Registered Nurse Territorial Force Nursing Service Voluntary Aid Detachment

xvi

1

Mental health nursing: the working lives of paid carers from 1800 to the 1990s Anne Borsay and Pamela Dale

At the beginning of the twenty-first century mental health issues are being debated at a local, national and international level.1 Positively, there is an argument that the global promotion of mental well-being will deliver benefits ranging from personal fulfilment to improved public health. Yet there remain significant concerns about the social and economic costs of mental illness, which fall on individuals, families and communities. Interestingly, recent international and country-specific policy documents outlining the future of mental health provision have also offered an historical analysis to explain the current configuration of services and their limitations.2 What has often been missing from these discussions is any mention of paid staff and their contribution to providing and transforming different models of care. We argue that this important omission is explained by both the traditional powerlessness of rank-and-file caregivers and the fragmented state of the historiography. The history of care has had relatively little to say about paid carers,3 and within the history of nursing mental health tends to be neglected. Writing in 2009, Peter Nolan was only able to identify six significant historical studies of mental nurses and these included a thesis, three journal articles, Mick Carpenter’s Working for Health and his own classic history from 1993.4 There are other publications that touch on relevant issues, but these can offer a misleading picture of the role and achievements of the mental nurse. Compared to other branches of nursing, the mental health sector lacks even celebratory histories of Victorian/Edwardian nursing personalities and autobiographical 1

Mental health nursing

accounts of working as a twentieth-century nurse. Scholars have identified a lack of detailed understanding about the recruitment,5 training and working lives of paid carers as both a serious problem and a vital agenda for future research.6 This volume develops new research questions by drawing together a concern with exploring the class, gender, skills and working conditions of practitioners with an assessment of the care regimes that staff helped create and patients’ experiences of them. The chapters are arranged chronologically and concentrate on care in Great Britain and Ireland. This geographical coverage follows established literature conventions for the Victorian and Edwardian periods,7 and the transfer of personnel and ideas continued throughout the twentieth century. It is, however, not our intention to offer a detailed survey of legislative developments in either country. Similarly, Lee-Ann Monk’s chapter explores a colonial perspective on British models of staff training rather than providing an overview of psychiatric services in Australia. The aim is to focus on the rank-andfile staff whose role is often overshadowed by historical assessment of contributions from policy-makers. Staffing issues have received most attention in the mental health sector, but significant insights have also been developed from the care of people now understood to have learning disabilities. Over time there have been significant changes in the language used to describe patients in both sectors but, to retain the focus on carers, tracing the evolution of terminology is not a central theme of this volume. Instead all the contributors have used language appropriate to their case studies, and here we apologise for any offence caused by obsolete words. Across the volume the term ‘mentally disordered’ is used inclusively to extend coverage from carers of patients with a formal diagnosis of a major mental illness to a variety of care settings where staff supported a range of service-users. Where it is necessary to distinguish between the sectors we have adopted the language of mental health/illness and learning disability services but it is important to remember that efforts to alleviate the distress of individuals were not confined to the care of people who had received a formal diagnosis or were following a conventional patient career. John Welshman (chapter 9) examines the care provided in hostels, concentrating on  the Brentwood Recuperation Centre for Mothers and Children. 2

Introduction: mental health nursing

The warden’s role in offering comfort and support, building resilience and rehabilitating clients in the community parallels many other contemporary mental health projects while also revealing the perceived benefits of smaller-scale facilities and personalised services. The therapeutic value of relationships established between staff and residents, emphasised in chapter 9, arguably applied in all the care settings described in this volume. Such a conclusion helps integrate the recently restated concerns of nursing historians,8 perhaps preoccupied with the priorities of general nursing, with ongoing research exploring the care of the mentally disordered from a variety of perspectives. Classic history and social history of nursing texts by Brian Abel-Smith,9 Celia Davies,10 Christopher Maggs11 and Dingwall, Rafferty and Webster12 provide a framework for understanding the earliest origins of nursing; the evolution of different branches of nursing; attempts to define and improve nursing knowledge and practice; efforts to improve training and raise standards as a pre-requisite for professional recognition; the aspirations of nurse leaders; the consolidation of nursing organisations; and the changing place of the nurse in society.13 Scholars from different backgrounds have contributed to the historiography, but although collective knowledge has widened and deepened since the 1980s, they have generally worked within the established parameters of nursing history. This approach has served to prioritise certain topics at the expense of others, with care of the mentally disordered often neglected despite evidence of public concern about the past, present and future of these services. The emergence of modern nursing is usually dated to the mid nineteenth century. It is generally agreed that its complex evolution and international variations were shaped by the relationship between nursing and the state, religious influences, economics, a concern with social welfare, class and gender issues, scientific innovation, medical change, the reform of hospitals and the development of a distinct body of nursing knowledge.14 Such analysis, in the UK, tends to prioritise the experiences of the general nurse in institutional and community settings with special status conferred on military nurses and the religious.15 It also foregrounds the goals elite nurses pursued through nursing organisations that claimed jurisdiction over rank-and-file practitioners but whose 3

Mental health nursing

historic policies discriminated against those who were not white, female, middle-class, London-based and trained in a prestigious voluntary hospital. Within these discussions the asylum attendant (later registered mental nurse (RMN) or psychiatric nurse, or registered mental handicap nurse (RNMH) or learning disability nurse) tends to be overlooked or described in a way that suggests inferiority to the general trained nurse. An early account of mental nursing within the history of nursing written in the 1930s drew a distinction between the few trained nurses in the sector and the many untrained attendants. The trained nurses were further divided into those who had completed a threeyear course leading to admission to the supplementary register of mental nurses and those who had taken Royal Medico-Psychological Association (RMPA) qualifications.16 Similar themes inform Dingwall, Rafferty and Webster’s 1988 survey. Although they make the interesting point that ‘the fortunes of mental nursing have been intimately linked to those of the mental sector as a whole’, their presentation of asylums and their staff as both marginal to the concerns of the wider nursing profession and something of an embarrassment to health care providers imposes its own restrictions.17 It is certainly a perspective that neglects to consider the appropriateness of general hospital attitudes and practices to the care of the mentally ill, the special qualities and specific skills that might be demanded of the asylum attendant/nurse,18 and the distinctive problems ­presented by their working environment over more than two centuries. Under the modern imperative to remove barriers between health and care services it is helpful to re-evaluate the historical contribution of those caring for the mentally disordered and break some of the shackles of traditional nursing history; this might be characterised as too • concerned with the story of professionalisation; • preoccupied with elite figures and national organisations; • focused on the female nurse and the ambiguous position of the male nurse; • stereotypical when discussing class and race; and • Whiggish. 4

Introduction: mental health nursing

Such organising points also speak to the institutional/psychiatric histories that have tended to neglect individual staff to concentrate on staffing problems. Within these debates the staff generally remain anonymous and are often treated as a homogeneous group. Contributors to this volume instead suggest that caregivers had a variety of experiences that depended on time, place, institutional politics and their personal place in various hierarchies.19 Current concerns about both the costs and public-safety implications of supporting large numbers of vulnerable people in the community provide a useful backdrop to a reassessment of historical models of care and the important, though changing, contribution of the mental nurse and other paid carers. The idea that nurses’ needs and experiences can shape their responses to patients, and thus wider care regimes, is only just gaining credence in the historiography but is the starting point for this collection of essays.20 Throughout this volume there is a focus on struggle and unresolved tensions. The asylum attendant/mental nurse confronted many of the same issues driving the development of modern general nursing, but often differently. Relationships with local and central government were unusually important, and so was the style of medical management operating in the asylums. These themes have been central to the study of asylums, but within this historiography caregivers tend to be overlooked, with only brief discussions about their status as victims (of poor working conditions) and oppressors (of patients).21 It is, however, difficult to argue that mental nurses achieved any of the ‘three main attempted transformations’ of nursing described by Carpenter.22 They were not nurses in the Nightingale model, nor were they straightforwardly part of the later professionalisation or new professionalism agendas. Concerned commentators have identified that mental nurses are at great risk of workforce deskilling because of both their historical position at the margins of the profession and the content of their work, which pushes them towards a posture of providing care and control rather than cure.23 Similarly, in an overview of staffing in the learning disability sector, Mitchell and Welshman place workforce issues ‘in the shadow of the Poor Law’ and highlight continuities between past and present obstacles to developing a well-trained workforce.24 Such themes resonate strongly in all the case studies that follow, but nevertheless it is helpful to highlight different eras. 5

Mental health nursing

In the beginning Caring for the mentally disordered is an issue that faces all societies, but the institutional paradigm is so dominant that the history of mental nursing often begins with this model. Nolan is one of many scholars whose survey of UK provision starts with the care offered by monks and nuns before the dissolution of the monasteries.25 Positive connotations are attached to the refuge offered by these religious communities and he is not the only commentator who views their loss with regret. The problem is tracing what happened afterwards, as care of the mentally disordered, such as it was, is not well understood until the eighteenth-century rise of the private madhouse created a new institutional locus of care and concern. Such commercial provision ranged from the excellent to the purely exploitative, but early efforts to reform institutional care underlined the importance of good management and attention to staffing issues as the best guarantor of compassionate care for patients from all walks of life. Such concerns informed the development of public asylums, although patient numbers, financial constraints and staffing problems challenged the lofty aspirations of their founders. Historians from many disciplines have highlighted the complexity of the asylum world, drawing attention to both problems of internal organisation and the difficulties imposed by external social, economic, political and demographic pressures.26 Yet many medical superintendents regarded themselves as reformers, seeking enlightened as well as efficient models of patient care. Therefore close attention was paid to recruiting, training, deploying and disciplining staff conceived as keepers, attendants and finally nurses. Perhaps to a greater extent than in any other branch of nursing, the asylum attendant is seen as the creation, even prisoner, of his or her institutional context. Yet employing men and women to provide care for mentally disordered people was commonplace before a network of large public asylums was created, and the operation of these facilities always depended on ongoing arrangements for community care. While it is easy to denigrate the motivations of paid carers and the quality of their care, they were nonetheless important. It is probable that many of these caregivers were originally domestic servants who offered care alongside or as an alternative to undertaking 6

Introduction: mental health nursing

other household duties. The gradual specialisation of the role is highlighted by the way Poor Law authorities and societies providing the first cohorts of district nurses employed ‘nurses’ to care for the mentally disordered.27 This work developed after 1850, but historians usefully identify an earlier tradition of ‘mad nursing’.28 R. A. Houston was struck by the number and variety of people, of both sexes, receiving payment for caring for mentally disordered individuals during the long eighteenth century. He argues that these individuals ‘performed a role which blended the abilities of school teachers, jailers and lodging-house managers’.29 The demands made on such carers were clearly considerable but social historians have been more concerned with assessing the burdens placed on relatives and factors that encouraged them to seek extra-familial support. It is the rise of the asylum that dominates the historiography and while this had an obvious impact on those seeking employment as caregivers, it seems unsatisfactory, in the light of the discussion above, to simply assert, as Kelly and Symonds do, that keepers ‘responsible for the containment of the mad … were seen as being of a dangerous nature themselves’.30 It is important to differentiate between the experiences of senior staff, enjoying wide-ranging responsibilities, and policies affecting rank-and-file caregivers who were understood to require careful supervision to compensate for alleged personal and known organisational deficiencies. While staffing difficulties emerge as a perennial problem in asylum histories it is important to acknowledge the care that was taken with staffing issues. Most new public and charitable asylums started with the deliberate intention of recruiting a cohort of experienced senior staff from reputable institutions. These individuals must have brought with them attitudes and practices learnt from past service and even formal training. Nolan highlights the contribution of W. A. F. Browne (medical superintendent at the Royal Edinburgh Asylum) who he credits with introducing a pre-Nightingale nursing school.31 The personal example and writings of John Conolly (medical superintendent at Hanwell Asylum, Middlesex), who Steven Cherry credits with identifying the therapeutic potential of the mental nurse,32 also influenced practice in the UK and abroad (chapter 2). In the learning disability sector, the famous Earlswood institution provided a source of staff when provincial groups established similar 7

Mental health nursing

facilities. Personnel appointed to new or reconfigured services were also sent to leading institutions for periods of training. These imported and/or specially trained senior staff then instructed their juniors, who had opportunities to develop their careers by progressing through an institutional hierarchy, moving to another asylum in search of promotion, or utilising their skills and experience in other settings. David Wright captures the sophistication of the asylum labour market in Victorian London,33 although historians concerned with rural institutions have been less enthused by the quality of available recruits, noting that into the twentieth century most newcomers were fairly raw domestic servants and farm labourers. The lack of trust these staff commanded is revealed by the care taken to enforce asylum rules (chapter 2) and sanction workers who challenged their employers (chapter 5). The surveillance exercised over junior staff was at least as intense as the watch kept over patients; indeed the former served to guarantee the latter. Obedience was seen as a necessary virtue for all nurses but the culture of suspicion that infected the asylums was a distinctive feature of a unique working environment that was as attractive to some as it was repellent to others. Analysis of British asylum work continues to focus on power and its abuse, although few commentators go as far as Shula Marks’s devastating critique of asylum nursing in South Africa.34 This leads to questions about what would attract people to work in such environments. While a sense of vocation, and a determination to care for others regardless of cost to self, imbues accounts of general nursing, mental health nursing has always been associated with an economic imperative. Yet this does not imply that practitioners had no alternative employment options. The decision to embark on what for many was intended as a career rather than simply a temporary job was a matter of deliberation and the careful cultivation of appropriate attitudes as well as the acquisition of valuable skills and experience. Far more attention needs to be paid to who was nursing at different times, and how this influenced their practice in terms of relations with patients and relatives and other health professionals, as well as caregivers’ views of themselves both individually and collectively. Notions of a shared experience enjoyed or endured by patients and staff, whose backgrounds were often surprisingly similar, are only just 8

Introduction: mental health nursing

beginning to be explored. This means potentially illuminating concepts such as the idea of shared or transferred stigma and discussion about the fear of the contagious nature of mental illness have not been fully exploited. Even where a theoretical discussion is introduced, personal testimony is often lacking. The historiography arguably needs to be more imaginative in terms of themes, approaches and sources.35 Oonagh Walsh (chapter 2) emphasises the importance of language and culture as well as economic factors in shaping both demand for care and care regimes. Evidence that violence towards self and others was a factor encouraging resort to institutional care serves to reinforce the idea that paid carers took over at the point where care/control needs were most difficult to meet. Yet decisions about when and how to seek assistance, and the form any help might take, were heavily dependent on local factors that determined access to different institutions. Walsh’s interest in national politics as a framework for the provision of care contrasts with the often narrower scholarly assessment of the politics of nursing and nurse organisations.36 Chapter 3 moves from the national to the trans-national and contributes to growing interest in international comparative work on the care of the mentally ill.37 Lee-Ann Monk examines the influence of British models of care on a doctor-led initiative to professionalise the asylum attendant in late nineteenth-century Australia. Arguing that ‘attending’ is better understood as an occupation in its own right, rather than a precursor to the later profession, she discusses how the development of the occupation, itself influenced by earlier notions of ‘governing’ the attendant, shaped the attendant response to training and questions what benefits it had for staff or the people in their care. Using international case studies to highlight the strengths and weaknesses of UK models of nursing as well as to consider their utility in different national contexts has already proved illuminating. Judith Godden and Carol Helmstadter make a number of important observations about Nightingale nursing in the light of contested attempts to transport it to colonial Australia and Canada.38 Mental nursing opens a rich new field of enquiry but it is important to retain a focus on its distinctive features. These arguably became more important, and certainly received more scrutiny, in the early twentieth century. Contributors to this volume draw attention to the unusual gender 9

Mental health nursing

composition of the workforce, the rise of trade unionism and the opportunities and constraints that followed from the traditionally close relationship between asylums and the state. The First World War and its aftermath A series of UK case studies (chapters 4–6) explore a crucial turning point in the history of nursing at the start of the twentieth century. At this time the general nurse was in the ascendancy, a cause and effect of the battles over nurse registration, and class and gender conflict was particularly acute. Wartime conditions 1914–18 threatened (through the use of Voluntary Aid Detachments) but ultimately consolidated the position of the general trained nurse.39 In the mental health sector the suffering and sacrifice of asylum staff during the war years (chapter 4) fed industrial discontent (chapter 5) and the rise of trade unionism (chapter 6). In most accounts the attendants are treated as unremarkable with few clues given about their identities or personalities. This makes the personal testimony offered by Barbara Douglas (chapter 5) particularly valuable as she reveals how the Exeter strike, which sought to promote unity within the asylum workforce, resulted in disproportionate penalties for the long-serving male staff. Gendered aspects of asylum work have been persistently, though somewhat problematically, highlighted in studies of both asylum and nursing history. When contrasting asylum and general nursing, the presence of significant numbers of male staff has been both noteworthy and associated with distinctive work cultures, attitudes and practices. In particular male staff have been linked to a commitment to trade unionism, which embodied a collective identity that was different from the corporatism offered by the Royal College of Nursing.40 Vicky Long (chapter 6) draws attention to growing tension between evoking sympathy for staff and patients on the basis that both groups had to share an unacceptably grim environment and the idea that attendants deserved improved pay to compensate them for the inhumanity of their charges. Ideas of shared citizenship were therefore deeply problematic and an obstacle to achieving the aspirations for better care that lay behind the 1930 Mental Treatment Act. Ambivalence about the aims and methods of treating mental illnesses 10

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in traditional or new ways was not confined to rank-and-file attendants or leading figures prominent in trade union and professional bodies. It also deeply infected the medical profession in a way that was highly problematic for all asylum staff. There was a danger that professional ambitions could either nullify the benefits of therapeutic innovation or endanger patients. Edgar Jones and Shahina Rahman critically reviewed claims that plans to make the Maudsley a pre-­ eminent centre for postgraduate medical education took precedence over meeting the needs of local people requiring mental health services.41 Unfortunately, they had little to say about how nurses adapted to the possibilities and constraints embodied in this new facility, but at the Maudsley, and elsewhere, the contested introduction of new physical therapies impacted on both the daily work and career prospects of mental nurses before and after the creation of the National Health Service (NHS). The increasing resort to physical therapies, such as insulin coma or ECT, from the 1930s is associated with a requirement for mental health nurses to adopt the techniques and intensive nursing regimes previously associated with the care of the physically ill. These developments were accompanied by staff changes, with more dual-­qualified nurses entering the mental hospitals and taking senior positions. This unsettled traditional hierarchies, while stifling debates about the distinctive needs of the mentally disordered and their carers. It also undervalued the skills of experienced mental health practitioners. Asylum staff had always monitored the physical and mental condition of their patients and managed difficult conditions such as epilepsy. They also understood the importance of nutrition and the therapeutic use of drugs and alcohol. Frank Crompton reminds us of the curative potential of the Victorian asylum and the vital contribution nursing care made to the treatment as well as the welfare of individual patients.42 Debates about who should care and what that care should entail were played out in the interwar learning disability sector as well as the mental hospitals. Here the early development of community care programmes conflicted with trends towards a more medical and custodial approach.43 Pamela Dale (chapter 7) explores how plans to offer more treatments placed new demands on male and female staff from the late 1930s. As the nursing staff expanded, new hierarchies 11

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were created and there were opportunities to import nurses and nursing knowledge from general and mental hospitals. This did not necessarily improve patient care, and staff turnover and disciplinary cases noticeably increased. These interwar tensions were exacerbated by wartime disruptions and reorganisations following the 1946 National Health Service Act. The National Health Service Despite its unifying national structures, the NHS did little to challenge the isolation of the mental hospitals while perhaps making them less central to what Joan Busfield terms ‘social networks of care and custody’. She identifies a four-stage development of welfare regimes in the mental hospitals from 1890–2004, characterised by calls for voluntary admissions (1890–1929), the Mental Treatment Act’s emphasis on more active therapeutic interventions (1930–53), a new reliance on psychotropic drugs and first steps to community care (1954–73), and the retreat of the state in the face of privatisation since 1974.44 Nationally, nursing staff tended to respond to rather than initiate these developments. Yet these changing and often problematic contexts for service delivery led to almost continuous discussions about who should nurse and what skills practitioners required. The NHS began at a time of severe staff recruitment and retention problems. Claire Chatterton (chapter 8) notes that the crisis in mental nursing was more severe and protracted than the oft-discussed shortages of general nurses. This point has also been highlighted by Starns who suggests that not only was insufficient care paid to maximising the recruitment and retention of people (especially men) with relevant wartime skills and experience, but arrangements to provide qualifying courses actively discriminated against those wishing to work in the mental health sector.45 Many commentators drew attention to the armed forces as an important route into nursing for male staff in the decades after the Second World War, echoing nineteenthcentury asylum recruitment patterns that had provided a supply of fit and disciplined recruits well-placed to make a long-term career in the sector. However, the arguments put forward in the 1960s and 1970s to suggest that more men should be recruited into general nursing confirmed their second-class status based on gender, pre-training 12

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experiences and association with mental hospitals.46 No effort was made to delineate any special skills they might bring to the role despite an earlier debate about this in the USA.47 Yet only a few years later it was noted that male nurses across all branches of nursing were enjoying career progression and success as nurse managers.48 These issues kept gender discrimination, against women as well as men, on the nursing agenda through the 1970s and 1980s but did nothing to raise the status of mental hospital work.49 From the beginning of the NHS era services for the mentally disordered had been destabilised by administrative and financial reforms that problematically interacted with the legacy of service provision, changing therapeutic dynamics and a need for legal reform. These issues came to prominence at different times but a perennial problem was staffing difficulties, which negatively impacted on both patient care and efforts to recruit and retain quality personnel. Mental nursing was not immune from the social and economic forces undermining traditional nurse recruitment strategies and suffered from the fact that its most modern and technologically advanced treatments could be perceived by patients to be abusive rather than therapeutic. This critical narrative imbues the historiography,50 but an interesting personal account of receiving such treatments c.1950, informed by the author’s own nursing experiences and her obvious sympathy for both staff and patient perspectives, is offered by Claire Rayner.51 Other practitioners have come forward to share personal experiences of being a nurse, then a patient, and then attempting to resume a career after treatment for mental health problems. The fact that many chose to do so anonymously points to the stigma and difficulties they encountered.52 Even today it is noteworthy that while nurses are seen as an important resource when promoting mental health and caring for the mentally ill, nurses are also understood to be vulnerable to episodes of mental illness and have a known occupational risk of suicide linked to access to drugs.53 Stress has been identified as a major twentieth-century problem for nurses as well as their patients.54 Since the 1950s a voluminous historiography has laid bare the challenges faced by nurses as members of a caring profession,55 but also sought to individualise many of the suggested coping strategies rather than address underlying workforce issues. Service to others was strongly associated with self-sacrifice during and immediately after the Second 13

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World War and nurses-in-training were not expected to complain about their own conditions or on behalf of their patients.56 Starns has usefully identified cultural and organisational problems in the newly created NHS that burdened junior staff with both excessive workloads and bullying seniors.57 Over time, however, it became understood that the altruistic goals of the NHS were underpinned by the exploitation of certain staff and the neglect of vulnerable patient groups. Concerns about ‘Cinderella’ services emerged in the 1960s, with debates about services for the mentally disordered given urgency by a series of hospital scandals,58 but the problems had long antecedents. Staffing difficulties, especially endemic recruitment and retention problems, have been seen as a cause and effect of both wartime labour controls59 and a series of failed efforts to reform all branches of nursing following the recommendations of the Lancet (1932), Athlone (1937), Horder (1943), Wood (1946), Goddard (1953) and Platt (1964) reports.60 The NHS gave increasing attention to manpower planning, but this did little to alleviate nurse shortages or definitively determine staffing requirements.61 In the mental health and mental handicap sectors problems were arguably more serious, and made worse by the way the special needs and qualities of their staff were often overlooked. American nursing journals had published a number of articles exploring these themes in the 1940s, identifying the successful male psychiatric nurse’s character, leadership skills and insight into nature of self and others.62 British research in the 1950s and 1960s concentrated, however, on exploring the alleged immaturity and excessive sensitivities of young women attracted to the idea/ ideal of nursing but repelled by its realities.63 A concern to exclude physically and emotionally frail would-be general nurses did not lead to greater appreciation of the strength and resilience of male mental nurses flagged by other researchers,64 but only served to underline differences between the two sectors. Similarly, the career-mindedness and long service of male nurses was noted rather than celebrated in discussions about young women dropping out of training courses. Male nurses were unable to escape the view that their service owed much to economic imperatives and a search for job security despite surveys revealing more men explained their nursing careers in terms of interest in the work and a desire to serve the community.65 14

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While the full (and still expanding) mental hospitals and mental deficiency institutions offered some hope of job security for nurses and ancillary staff in the early years of the NHS, a number of threats were emerging. Chatterton (chapter 8) draws an interesting link between efforts to resolve the early NHS staffing crisis in mental hospitals (informed by parallel initiatives across other branches of nursing) and the emergence of a distinctive critique of the asylum as a past, present and future locus of mental health care that had no counterpoint in discussions about other hospital facilities. It is, however, evident that the institutional model of care remained dominant, with the 1960s and early 1970s paradoxically seeing both a commitment to alternative models of service delivery and major investments in new and newly reconfigured services built on traditional lines. At this time many large-scale, long-stay mental and mental handicap hospitals finally secured the resources needed to enact long-cherished improvement programmes. Capital programmes delivered new and refurbished patient accommodation and staff facilities. Nurse education received a boost from investment in both nursing schools and post-qualification courses, and on the wards staff benefited from reduced hours and improved staffing ratios. Attention was also paid to managing nurses on individual wards and through the hospital hierarchies, with some institutions finally integrating their male and female staff.66 Such developments were associated with claims of improvements for staff (and by implication patient care) deriving from modernisation and professionalisation,67 although managerialism is also apparent,68 as is a failure to really transform services. Institutional actors had anticipated that hospital provision would be reinvigorated by the new investment, operating both in support of community care and as beacons of excellence that would provide specialist services including all necessary staff training.69 However, the limitations of the now significantly more expensive model of institutional care encouraged alternative provision. David King, an NHS manager, explained that he advocated hospital closures after becoming disillusioned by how little costly refurbishment programmes had achieved in Devon mental and mental handicap hospitals.70 Evidence from contemporary descriptions and photographs suggests that hospital life changed only slowly despite greater emphasis on research and treatment. 15

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In the mental health sector physical therapies for a range of mental illnesses were pursued with increasing enthusiasm from the 1930s. Cherry notes these early experiments but dates ‘modern treatment’ to the period 1948–64.71 He goes on to discuss staff reactions to both the new therapies and the changing institutional cultures they were associated with, arguing that the use of tranquillising drugs reduced ward disturbances and made realistic a gradual shift towards community care. Staff training emerged as an obstacle to progress with senior doctors and nurses wedded to traditional programmes while students sought more varied experiences relevant to their likely future roles.72 In the 1980s there was particular concern about the correct balance between academic knowledge and caring skills,73 but critical commentators highlighted that neither the debate nor its content was new and suggested caution about falling victim to ‘fads and fashions’ that left underlying problems with recruitment and training unresolved, and the distinctive skills of the psychiatric nurse undervalued and misunderstood.74 De-institutionalisation The accelerating pace of institutional change is captured in a case study of services in the Exeter area.75 Beds at the old asylums had slowly reduced (from a 1949 total of 2,070) since the 1950s but day hospitals and community psychiatric nurses only really appeared in the 1970s. In the 1980s the three large-scale hospitals closed and total psychiatric in-patient provision was reduced to 545 beds in 1990 across a number of Devon sites. These facilities were then gradually closed as community provision developed, with in-patient beds reduced to 100 in 1996 and just 40 in 2006. This transformation of services clearly had implications for staff. At the start of the de-institutionalisation process many of those caring for the mentally disordered remained chronically overworked and undervalued. Some workers in specialist institutions still needed encouragement to fully embrace the identity of a nurse rather than custodian.76 Practitioners as well as managers began to question the role of the nurse, making the profession vulnerable to encroachment from social workers and care assistants. These discussions arguably went furthest in the mental handicap sector. Duncan Mitchell 16

Introduction: mental health nursing

(chapter 10) highlights the potential to develop community roles,77 but learning disability nurses faced growing insecurity. Some staff embraced new care programmes while others led resistance to them. Although often dismissed as self-interested defenders of old-­ fashioned facilities, they articulated a concern for patient welfare that was sometimes lacking from documents presenting the economic case for change. A 1985 report from the House of Commons Social Services Committee challenged the myth that staff were resistant to working in the community, but also identified practical problems and argued that staff would need consideration and support as services were reconfigured.78 Writing about the reconfiguration of services in Devon, Chris Williams discussed the importance of moving on from the ‘closure of a hospital’ (the Starcross facility introduced in chapter 7), which he likened to the dissolution of the monasteries, to ‘the development of a locally based support system’. However, he revealed that many of the 198 staff struggled to make the transition. More than one quarter were entirely lost to the sector (one died, twenty-one retired and twenty-eight found other employment), while half (ninety-nine) had transferred to other large-scale hospitals, nineteen had moved to local support units and twenty-six to staffed group homes. None were employed by learning disability services run by local authorities or voluntary sector organisations and only four had joined community mental health teams.79 In 1989 the Audit Commission explored some of the reasons why NHS staff, especially the senior and experienced people needed to support the transitional arrangements, were so reluctant to transfer to community learning disability services run by local councils. They used a case study of Somerset as an example of good practice, but showed that insurmountable difficulties around pay, pensions, recognition of qualifications and status issues meant enhanced redundancy packages were the preferred option for many.80 Transforming the mental health sector was no easier. Staff with concerns about the impact of service reconfiguration struggled to get their voices heard and have been sidelined by contemporary and historical research that has suggested nurses opposed de-institutionalisation for their own ends,81 were marginalised by the process,82 or disappeared altogether leaving patients to act as their own carers.83 Identification of positive roles for staff during 17

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the de-institutionalisation process84 allows consideration of nurses’ contributions to earlier reform programmes. The large-scale longstay facilities were never as monolithic as hostile commentators have assumed, and an increasing array of alternative facilities, including hostels (chapter 9), encouraged innovative approaches to staffing and patient care long before hospital closures.85 Unfortunately the increasing pace of change meant that many experiments were shortlived and often overlooked by the historiography. Models of nursing practice pioneered in post-war British therapeutic communities were once praised in the American nursing press,86 but are now just a footnote to brief discussions about the rise and fall of therapeutic communities. These and other innovative programmes deserve more attention. Val Harrington (chapter 11) explores an important episode in psychiatric care based not in the asylum but in a district general hospital. This experimental programme paralleled contemporary initiatives in other parts of the UK and Europe, where practitioners similarly reported phases of optimism and crisis.87 The co-location of services for the mentally and physically ill theoretically offered many benefits, but also created difficulties for nurses and patients.88 Many general hospitals had first developed out-patient services for the mentally disordered in the interwar period. Such moves, associated with leading institutions like the Maudsley, encouraged the inclusion of psychology and psychiatry in nurse training programmes from this date, although the UK appears to have lagged behind the United States and Europe.89 This is not the entire picture, however. Practitioner-historians usefully highlight the contribution public health nurses have made since the first decades of the twentieth century to the promotion of mental hygiene. These nurses fall outside the scope of this volume but merit further study. So do other nursing staff seeking ways to innovatively discover and meet patient needs. Rob Irwin is doing interesting historical work on the promotion of psychosexual health by nursing and other staff within family planning clinics.90 The care of rape victims has been another field where nurses’ ability to deal with physical and psychological trauma has supported changing models of best practice.91 In the field of post-natal depression important work to raise awareness and encourage women to come forward for treatment has been carried out by midwives and health visitors as well as nursing and other staff tasked 18

Introduction: mental health nursing

with supporting patients experiencing mental health crises. From the 1980s community psychiatric nurses (CPNs) were an important component of multi-disciplinary teams but much of their work falls outside our study period and as yet their role, and its limitations, remains under-explored. Writing about services in Northern Ireland in 1989, Kader Parahoo highlighted the potential value of these highly qualified staff (all RMNs and many with other nursing qualifications and many years of experience) but also problems organising services to allow appropriate and timely interventions with clients.92 Reflecting a new health consumerism, government publications since the 1990s have emphasised improving the patient experience and encouraging choice. Ensuring the availability of staff with appropriate skills was an important underlying theme, but it was not always made explicit who these workers were or might be in the future. The employment of nurses within community mental health and crisis intervention teams in the recent past has as yet attracted limited attention from historians, but there have been a succession of negative stories in the media about patients harming themselves and/or other people, including staff concerned with their care. There have also been scandals where abuses once associated with the worst days of the asylum have been perpetuated in new institutional facilities. Care homes for elderly people suffering from dementia and private hospitals for people with learning disabilities have recently come under scrutiny. Concerns have also been raised about the way NHS hospitals struggle to meet the mental and physical health needs of vulnerable older people. Worried relatives frequently raise questions about nursing care, not realising that only part of the workforce are trained nurses with professional qualifications.93 In these circumstances nurses and nurse managers (with and without specialist responsibilities for the mentally disordered) are vulnerable to criticism with regard to their own clinical practice, information-sharing with colleagues/regulators, maintenance of minimum care standards and/or staffing ratios, and the management of subordinate care staff. Official reports and media coverage from the present will surely provide a rich resource for future historical study. The themes addressed, including the need to monitor/discipline staff to maintain standards of care and facilitate suicide prevention, resonate strongly with those already being explored by social historians in earlier periods.94 19

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The case studies presented in this volume address discrete topics but coherence is achieved through shared themes and common approaches. Following the practice of quality institutional histories, attention is paid to contextualising the micro-histories, providing links to other relevant studies, and drawing on different strands of the historiography.95 Nursing history has particular relevance to this volume. It has proved both helpful to, and neglectful of, efforts to understand the role of caregivers in the evolution of care for the mentally disordered. Surprisingly there have only been two major recent studies of asylum nursing, neither of them dealing with the UK.96 With scholars concentrating on other branches of nursing, institutional studies, psychiatric innovation and/or the patient experience, staffing issues remain elusive. This volume deliberately includes all paid carers even while making an historical assessment of the place of mental nursing within nursing at different times. Recruitment and retention issues, training and professional qualifications all form an important part of the discussions that follow, but we argue that using developments in general nursing to understand the provision of mental health care is also limiting. For this reason staffing issues are understood broadly, and a concern with relationships between different groups of nurses and nursing organisations is never allowed to overshadow wider questions about the care provided. The volume extends coverage from the institutional care of those suffering from major mental illnesses (chapters 1–6, 8 and 11) to the staff and facilities tasked with caring for people we would now understand to have learning disabilities (chapters 1, 2, 7 and 10) and other groups of service-users (chapter 9). It argues that paid carers (not limited to mental nurses) were central to the provision of care for mentally disordered people in the UK throughout the study period and therefore merit careful attention. Notes   1 S. Sturdy, R. Freeman and J. Smith-Merry, ‘Making knowledge for international policy: WHO, Europe and mental health policy, 1970–2008’, Social History of Medicine, 26:3 (2013), 532–54.  2 Department of Health (DOH), Closing the Gap: Priorities for Essential Change in Mental Health (2014); DOH, The Mental Health Strategy for

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Introduction: mental health nursing England (2011); DOH, Saving Lives: Our Healthier Nation (Cm 4386, 1999), pp. 95–104.   3 K. Jones, Asylums and After: A Revised History of the Mental Health Services from the Early Eighteenth Century to the 1990s (London: Athlone Press, 1993).   4 P. Nolan, ‘History of mental health nursing and psychiatry’, in R. Newell and K. Gournay (eds), Mental Health Nursing: An Evidence Based Approach (Edinburgh: Churchill Livingstone, 2nd edn, 2009), pp. 21–38; M. Carpenter, Working for Health: The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988); P. Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993).   5 C. Chatterton, ‘Recruitment into mental health nursing: a historical perspective’, paper presented to Nursing History: Profession and Practice (hereafter P&P) conference, University of Manchester, 18 November 2005.  6 Useful methodologies are set out in S. Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (London: Routledge, 2010).   7 An approach adopted by J. Andrews and A. Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam; Rodopi, 2004); and P. Bartlett and D. Wright (eds), Outside the Walls of the Asylum: The History of Care in the Community 1750–2000 (London: Athlone Press, 1999).  8 B. Mortimer, ‘Introduction’, in B. Mortimer and S. McGann (eds), New Directions in the History of Nursing: International Perspectives (London: Routledge, 2005), pp. 1–21.   9 B. Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1960). 10 C. Davies, Rewriting Nursing History (London: Croom Helm, 1980). 11 C. Maggs, The Origins of General Nursing (London: Croom Helm, 1983). 12 R. Dingwall, A. M. Rafferty and C. Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988). 13 M. Lorenzton and J. Bryant, ‘The professional development and status of nurses in war and peace: analysis of Nursing Times extracts, 1905–1945’, International History of Nursing Journal, 6:1 (2001), 27–34. 14 For a useful literature review, see Mortimer, ‘Introduction’, and J. E. Lynaugh, ‘Common working ground’, in Mortimer and McGann (eds), New Directions in the History of Nursing, pp. 194–202. A more critical account appears in A. Crowther, ‘Review of Containing Trauma: Nursing Work in the First World War’ (review no. 972), www.history.ac.uk/reviews/review/972 [last accessed 24 May 2013]. 15 A. Summers, Angels and Citizens: British Women as Military Nurses 1854–1914 (London: Routledge, 1988); P. Starns, March of the Matrons: Military Influences on the British Civilian Nursing Profession, 1939–1969 (Peterborough: DSM, 2000).

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Mental health nursing 16 A. E. Pavey, The Story of the Growth of Nursing as an Art, a Vocation and a Profession (London: Faber and Faber, 1938), pp. 325–6. 17 R. Dingwall, A. M. Rafferty and C. Webster, ‘Mental disorder and mental handicap’, in Dingwall, Rafferty and Webster, An Introduction to the Social History of Nursing, pp. 123–44 (p. 143). 18 D. Mitchell and P. Smith, ‘Learning from the past: emotional labour and learning disability nursing’, Journal of Intellectual Disabilities, 7:2 (2003), 109–17. 19 An interesting contrast between staffing arrangements at the Brookwood Asylum and the Holloway Sanatorium is provided in A. Shepherd, Institutionalizing the Insane in Nineteenth-century England (London: Pickering and Chatto, 2014), pp. 48–62. 20 Christine Hallett explores nurses’ physical, emotional and moral containment of patients together with their work to maintain their own physical and emotional integrity. C. Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009). 21 For an unusually patient-centred account of daily life for inmates and staff in a Canadian asylum, see G. Reaume, Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane, 1870–1940 (Oxford: Oxford University Press, 2000), pp. 54–100. 22 For discussion of Mick Carpenter’s 1993 model, see A. Borsay and B. Hunter, ‘Nursing and midwifery: historical approaches’, in A. Borsay and B. Hunter (eds), Nursing and Midwifery in Britain since 1700 (Basingstoke: Palgrave Macmillan, 2012), pp. 1–20 (pp. 8–9). 23 A. Kelly and A. Symonds, The Social Construction of Community Nursing (Basingstoke: Palgrave Macmillan, 2003), pp. 135, 179. 24 D. Mitchell and J. Welshman, ‘In the shadow of the Poor Law: workforce issues’, in J. Welshman and J. Walmsley (eds), Community Care in Perspective: Care, Control and Citizenship (Basingstoke: Palgrave Macmillan, 2006), pp. 187–200. 25 Nolan, ‘History of mental health nursing and psychiatry’. 26 J. Melling and B. Forsythe, The Politics of Madness: The State, Insanity and Society in England, 1845–1914 (London: Routledge, 2006), pp. 1–12, 55–61. 27 V. Heggie, ‘Health visiting and district nursing in Victorian Manchester: divergent and convergent vocations’, Women’s History Review, 20:3 (2011), 403–22. 28 J. Andrews, ‘Identifying and providing for the mentally disabled in early modern London’, in D. Wright and A. Digby (eds), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996), pp. 65–92. 29 R. A. Houston, ‘“Not simple boarding”: care of the mentally incapacitated in Scotland during the long eighteenth century’, in Bartlett and Wright (eds), Outside the Walls of the Asylum, pp. 19–45 (p. 39).

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Introduction: mental health nursing 30 Kelly and Symonds, Social Construction of Community Nursing, p. 16. 31 Nolan, ‘History of mental health nursing and psychiatry’, p. 27. 32 S. Cherry, Mental Health Care in Modern England: The Norfolk Lunatic Asylum/St Andrew’s Hospital, 1810–1998 (Woodbridge: Boydell Press, 2003), p. 122. 33 D. Wright, Mental Disability in Victorian England: The Earlswood Asylum 1847–1901 (Oxford: Clarendon Press, 2001), pp. 99–119. 34 S. Marks, ‘The microphysics of power: mental nursing in South Africa in  the  first half of the twentieth century’, in S. Mahone and M. Vaughan (eds), Psychiatry and Empire (Basingstoke: Palgrave Macmillan, 2007), pp. 67–98. 35 Local history groups are making personal photographs, biographical notes and other memorabilia available on websites alongside more traditional archival material. 36 See also J. Campbell, ‘Mental health policy, care in the community and political conflict: the case of the integrated service in Northern Ireland’, in Bartlett and Wright (eds), Outside the Walls of the Asylum, pp. 227–43. 37 R. Porter and D. Wright (eds), The Confinement of the Insane: International Perspectives, 1800–1965 (Cambridge: Cambridge University Press, 2003). 38 J. Godden and C. Helmstadter, ‘Women’s mission and professional knowledge: Nightingale nursing in colonial Australia and Canada’, Social History of Medicine, 17:2 (2004), 157–74. 39 Summers, Angels and Citizens, p. 278. For the contrast between experiences of general and mental nurses at this time, see D. L. Palmer, ‘Who Cared for the Carers? A Study of the Occupational Health of General and Mental Health Nurses 1890–1948’, PhD dissertation, University of Exeter, 2009. 40 Carpenter, Working for Health; S. McGann, A. Crowther and R. Dougall, A Voice for Nurses: A History of the Royal College of Nursing, 1916–90 (Manchester: Manchester University Press, 2009). 41 E. Jones and S. Rahman, ‘Framing mental illness 1923–1939: the Maudsley Hospital and its patients’, Social History of Medicine, 21:1 (2008), 107–25. 42 F. Crompton, ‘Needs and desires in the care of pauper lunatics: admissions to Worcester Asylum, 1852–72’, in P. Dale and J. Melling (eds), Mental Illness and Learning Disability since 1850: Finding a Place for Mental Disorder in the United Kingdom (London: Routledge, 2006), pp. 46–64. 43 M. Thomson, ‘Community care and the control of mental defectives in interwar Britain’, in P. Horden and R. Smith (eds), The Locus of Care: Families, Communities, Institutions and the Provision of Welfare Since Antiquity (London: Routledge, 1998), pp. 198–216. 44 J. Busfield, ‘Class and gender in twentieth-century British psychiatry: shell shock and psychopathic disorder’, in Andrews and Digby (eds), Sex and Seclusion, pp. 295–322. 45 Starns, March of the Matrons. pp. 75–6.

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Mental health nursing 46 J. G. Rosen and K. Jones, ‘What makes men become nurses in general hospitals; and how can we set about attracting more?’, New Society, 9 March 1972, 493–4. 47 L. N. Craig, ‘Opportunities for male nurses’, American Journal of Nursing, 40:6 (1940), 666–70; A. B. Linton, ‘Men and women nurses’, American Journal of Nursing, 40:10 (1940), 1152. 48 L. K. Hardy, ‘Career politics: the case of career histories of selected leading female and male nurses in England and Scotland’, in R. White (ed.), Political Issues in Nursing: Past, Present and Future, Volume 2 (Chichester: John Wiley, 1986), pp. 69–82. 49 L. Swaffield, ‘Is it still jobs for the boys?’, Nursing Times, 84:30 (1988), 17; J. Sims, ‘Unequal opportunities’, Nursing Times, 85:20 (1989), 19. 50 D. Gittins, Madness in its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998). 51 C. Rayner, How did I get here from there? (London: Virago, 2003), pp. 182–90. 52 V. Rippere and R. Williams (eds), Wounded Healers: Mental Health Workers’ Experience of Depression (Chichester: Wiley, 1985). 53 DOH, Saving Lives, pp. 95–104. 54 C. L. Cooper and P. Dewe, Stress: A Brief History (Oxford: Blackwell, 2004); M. Jackson, The Age of Stress: Science and the Search for Stability (Oxford: Oxford University Press, 2013). 55 R. R. Kilberg, P. E. Nathan and R. W. Thoreson (eds), Professionals in Distress: Issues, Syndromes and Solutions in Psychology (Washington, DC: American Psychological Association, 1996); S. F. Jacobson and H. M. McGrath (eds), Nurses under Stress (Chichester: John Wiley, 1983); A. Pries and E. Aronson, Career Burnout: Causes and Cures (London: Collier Macmillan, 1988). 56 Autobiographical accounts offering thoughtful insights into these issues include L. Fairley, The Midwife’s Here (London: Harper Collins, 2012); E. Cotterill, Nurse on Call (London: Ebury Press, 2010); B. McBride, A Nurse’s War (London: Sphere, 1979); and Rayner, How did I get here from there? 57 Starns, March of the Matrons, chapter 3. 58 Richard Crossman, The Diaries of a Cabinet Minister. Volume Three: Secretary of State for Social Services 1968–70 (London: Book Club Associates, 1977), pp. 408–13, 418–20, 425–30, 685. 59 A. M. Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996), p. 172. 60 A. Hull, with A. Jones, ‘Nursing, 1920–2000: the dilemma of professionalization’, in Borsay and Hunter (eds), Nursing and Midwifery in Britain, pp. 74–103. 61 N. W. Chaplin (ed.), Health Care in the United Kingdom: Its Organization and Management (London: Kluwer Medical/Institute of Health Service Administrators, 1982), pp. 389–94.

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Introduction: mental health nursing 62 Craig, ‘Opportunities for male nurses’. 63 I. E. P. Menzies, The Functioning of Social Systems as a Defence Against Anxiety: A Report on a Study of the Nursing Service of a General Hospital (London: Tavistock Institute of Human Relations, 1967). 64 R. G. S. Brown and R. W. H. Stone, The Male Nurse (London: G. Bell and Sons, 1973), pp. 13–14. 65 Rosen and Jones, ‘What makes men become nurses in general hospitals’. 66 Royal Albert Hospital, Lancaster, 1868–1968 (commemorative brochure published by Morecambe and Heysham Times Ltd); A. B. Rowland, No Epilogue to the Saga: A Study of a Hospital and its Role in the Care of People with Learning Difficulties (Dawlish: Rowland, 1992), pp. 30–1. 67 A similar strategy of linking improved conditions for nurses and patients had been pursued in interwar municipal general hospitals. S. Kirby, ‘Marketing the municipal model: the London County Council nursing service recruitment strategies 1930–1945’, International History of Nursing Journal, 4 (1998), 17–23. 68 R. W. Revans (ed.), Hospitals: Communication, Choice and Change (London: Tavistock, 1972). 69 Royal Albert Hospital, p. 9. 70 D. King, Moving on from Mental Hospitals to Community Care: A Case Study of Change in Exeter (London: Nuffield Provincial Hospitals Trust, 1991). 71 Cherry, Mental Health Care in Modern England, pp. 243–73. 72 T. Archer, ‘Student power’, Nursing Times, 84:42 (1988), 49–51. 73 E. Shanley, ‘Inherently helpful people wanted’, Nursing Times, 84:3 (1988), 34–5. 74 P. Burnard, ‘Fads and fashions’, Nursing Times, 85:2 (1989), 69–71. 75 A. Knox and C. Gardner-Thorpe, The Royal Devon and Exeter Hospital 1741–2006 (Exeter: Knox and Gardner-Thorpe, 2008), pp. 90–8. 76 In the late 1980s learning disability charities raised concerns about the orientation of nurses in special hospitals, while the Forensic Psychiatric Nurses Association debated membership of the Prison Officers Association and/or the Royal College of Nursing. G. Crabbe, ‘Care or custody’, Nursing Times, 84:28 (1988), 19; M. Vousden, ‘Slamming the door’, Nursing Times, 84:46 (1988), 16–17. 77 For a contemporary practitioner perspective on the benefits of embracing community care, and the training implications of this, see P. Massey, ‘Sticking to the status quo’, Nursing Times, 84:28 (1988), 65; and R. Oliver, ‘Out and about’, Nursing Times, 84: 28 (1988), 63–4. 78 House of Commons, Second Report from the Social Services Committee, Session 1984–85, Community Care: With Special Reference to Adult Mentally Ill and Mentally Handicapped People, volume 1 (London: HMSO, 1985), paragraphs 174–83.

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Mental health nursing 79 C. Williams, ‘“Dissolution of the Monasteries”: an analogue for community care’, paper presented at the Annual Conference (1987) of the British Psychological Society for the Division of Clinical Psychology Special Interest Group in Mental Handicap, p. 26. 80 Audit Commission, ‘Developing community care for adults with a mental handicap’, Occasional Papers, 9, October 1989, p. 7. 81 King, Moving on from Mental Hospitals to Community Care. 82 Rowland, No Epilogue to the Saga; Campbell, ‘Mental health policy’. 83 S. Payne, ‘Outside the walls of the asylum? Psychiatric treatment in the 1980s and 1990s’, in Bartlett and Wright (eds), Outside the Walls of the Asylum, pp. 244–65. 84 Matthew Godsell, ‘Transition to Community Care: Stoke Park Hospital’, paper presented to P&P conference. 85 John Adams suggests that once given a lead by a reforming medical officer, nursing staff played a crucial role in a ‘social therapy’ experiment at Fulbourn Psychiatric Hospital. Some were enthusiastic innovators, although nurse resistance was one of a number of factors encouraging a return to a more biological approach. J. Adams, ‘“Patients are telling people what to do!”: conflict and consensus in FPH, 1950–1980’, paper presented to P&P conference. 86 For review of the contemporary literature, see L. Stearns, ‘Changing concepts in nursing supervision: a supervisor discusses frankly the problems she faced in modifying her own role when new concepts of treatment were introduced on the psychiatric service’, American Journal of Nursing, 59:1 (1959), 63–5. 87 J-C. Coffin, ‘Review of J. Pedroletti, La Formation des Infirmiers en Psychiatrie: Histoire de l’École Cantonale Vaudoise d’ Infirmières et d’Infirmiers en Psychiatrie, 1961–1996 (ECVIP)’, Medical History, 50:4 (2006), 539. 88 House of Commons, Second Report from the Social Services Committee, Session 1984-85, Community Care, volume 1, paragraphs 76-9. 89 Anon, ‘The psychiatric nurse: what the psychiatrist expects of her’, American Journal of Nursing, 40:1 (1940), 23–8; Pavey, The Story of the Growth of Nursing, pp. 325–6, 393–406. 90 R. Irwin, ‘To try and find out what is being done to whom, by whom and with what results: the creation of psychosexual counselling policy in England, 1972–79’, Twentieth Century British History, 20:2 (2009), 173–97. 91 L. Regan, J. Lovett and L. Kelly, ‘Forensic nursing: an option for improving responses to reported rape and sexual assault’, Home Office Development and Practice Report, 31 (London: HMSO, 2004). 92 K. Parahoo, ‘A survey of CPNs in Northern Ireland’, Nursing Times, 85:20 (1989), 75. 93 It is nonetheless interesting that nurses and nursing organisations were criticised by inquiries (2009–13) into problems at Stafford Hospital led by Robert Francis. See ‘Stafford Hospital: Q&A’, www.bbc.co.uk/news/health21275826, 25 March 2013 [last accessed 20 May 2013].

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Introduction: mental health nursing 94 S. York, ‘Alienists, attendants and the containment of suicide in public lunatic asylums, 1845–1890, Social History of Medicine, 25:2 (2012), 324–42. 95 J. Andrews and A. Digby, ‘Introduction’, in Andrews and Digby (eds), Sex and Seclusion, pp. 7–44 (p. 30). 96 L. Monk, Attending Madness: At Work in the Australian Colonial Asylum (Amsterdam: Rodopi, 2008); G. Boschma, The Rise of Mental Health Nursing. A History of Psychiatric Care in Dutch Asylums, 1890–1920 (Amsterdam: Amsterdam University Press, 2003).

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2

Psychiatric nurses and their patients in the nineteenth century: the Irish perspective Oonagh Walsh

The nurse carries significant cultural capital in the Western world. Her image has altered over the years, but historic representations have always been class and period specific, and have had a powerful resonance. The gentle and selfless ‘Lady with the Lamp’ embodied a popular revulsion over the unnecessary suffering of soldiers in the Crimea, and approval of woman’s innate capacity to succour and heal.1 Over the course of the nineteenth century consistently positive attitudes towards this diverse group developed, cementing commonly held perceptions of appropriate gender roles.2 But not all nurses were equally regarded. The psychiatric nurse is fixed in modern popular consciousness as Nurse Ratched from One Flew Over the Cuckoo’s Nest, a steely-eyed subversion of the caring stereotype who bullied her vulnerable charges into suicidal submission. Earlier ­representations were rather more ambiguous, but consistently lacked the positive aura that surrounded the general nurse. This chapter seeks to explore the reality of the district asylum nurse in Ireland, and examine the manner in which both her representation, and the reality of her experience, altered throughout the nineteenth century. Male nurses, or ‘keepers’, are also a fascinating cohort but they did not fulfil the same gender-specific, nurturing brief. Their experiences are not the focus of this chapter although their work and contribution to mental health care is examined in chapters 1, and 3–11. This chapter draws upon the records of the Connaught District Lunatic Asylum (CDLA) in Ballinasloe, County Galway, one of the earliest and most important of the regional district asylums.3 Opened in 1833 with a 28

Irish psychiatric nurses in the nineteenth century

150-patient capacity, it encapsulated the early and optimistic phase of moral therapy in Ireland. Conceived on generous lines, set in lawns and sited close to the edge of the town, it stood in marked contrast to the prevailing architectural style of low thatched cabins and the modest townhouses of the local elite. The hope of large-scale cures proved illusory, however, as the institution was rapidly overwhelmed by admissions, which led to chronic overcrowding, understaffing and a political apathy that endured well into the twentieth century. The district asylum nurse The district asylum nurse did not in the early years differ significantly from her general nursing fellows, in that at the start of the nineteenth century each were equally untrained and generally regarded with suspicion. Many nurses in workhouses and infirmaries had been inmates of these institutions, and after their care were allowed to remain in exchange for assistance with ill and infirm residents. Although graced with the honorific ‘nurse’, these women had no formal training or specific medical skills and were the object of some suspicion, accused by the physicians who oversaw them of hindering recoveries through ignorance and indifference.4 Well into the nineteenth century there remained a vague association between nursing and immorality, underpinned by an increasing rigidity in gender roles. As women’s lives narrowed, especially in the middle classes, nursing assumed a rather disreputable aura, which was not relieved until Florence Nightingale initiated professional training and demonstrated through her own impeccable antecedents that nurses could be intimates of the body, but retain middle-class respectability.5 However, this newly elevated status did not embrace the asylum nurse. As nursing became increasingly professionalised, asylum nursing staff were specifically excluded from membership of the general nursing associations on the grounds that they represented an inferior category of carer. Mrs Bedford Fenwick, the founder of the British Nursing Association, was absolutely opposed to the admission of asylum nurses to the BNA, declaring ‘one can hardly believe that their admission will tend to raise the status of the Association’.6 Indeed, there was even some debate over whether they should be permitted to title themselves ‘nurses’, as the old asylum taint of discipline 29

Mental health nursing

and restraint clung to the psychiatric nurse, in contrast to the modern scientifically trained hospital nurse. The hostility towards asylum nurses was not, however, shared by physicians in the institutions themselves, who recognised the centrality of good nursing care in patient recovery. In 1828 William Ellis of the Hanwell Asylum had emphasised the importance of not merely humane nurses, but professionally trained staff who could properly implement moral therapy. He argued that their remuneration should include a ‘premium’ that reflected the specific dangers they faced as a matter of routine: And, in estimating what is a fair reward for their labour, it ought to be remembered, that their lives are constantly exposed to be attacked by those whose insanity has not diminished the influence of their evil passions, but who have sense enough to know that however violent or fatal the outrage they may commit, their disease exempts them from all liability to punishment.7

Ellis’s remarkably forthright analysis of the relationship between nurses and patients is unusual in its recognition of the problems faced by staff, who were required to accept patient misbehaviour and offer no retaliation. Recruiting and retaining nurses in the Irish district asylums proved a Sisyphean task. Until the latter years of the nineteenth century they were a motley body of women, many unreliable, prone to drunkenness and insubordination, and barely capable of fulfilling even the more basic of their duties. Concerns about the quality of staff existed in similar institutions in Britain, though better economic conditions there may help to explain the poor quality of nurses when other employment options were available. There were consistent problems in the recruitment of nurses to the North Wales Lunatic Asylum, for example, as women chose to work as servants in England rather than at the asylum, using the new and efficient railway system to broaden their opportunities.8 Only those unable or unwilling to enter domestic service entered the asylum as nurses. But there were no such glittering prospects for Irishwomen, especially in rural areas. On the contrary, conditions in the west of Ireland for the poor were unimaginably precarious and squalid. In Ballinasloe, periodic food shortages rapidly tipped families into starvation and utter destitution, ‘forcing 30

Irish psychiatric nurses in the nineteenth century

them to sell their shirts and shifts and other cotton wearables as rags to the paper-stuff buyers for the purposes of stopping the ravages of hunger’.9 One land agent gave some old rugs to a widow because ‘these days herself and her children will starve for want of clothing, [the rugs] will be sufficient, to take her out to beg with them’.10 The absolute poverty to which individuals were reduced, such that they could not even beg because they had no clothes, might lead one to expect that the asylum’s opening in 1833 would represent an employment godsend, but this did not prove to be the case. The first staff came largely from Dublin, where they had worked in institutions including St Patrick’s Asylum. This might suggest that skilled and experienced nurses were being deliberately selected in order to launch the institution on a professional footing, but the results were disappointing. One of the senior nursing staff, Nurse L, was eventually dismissed following innumerable complaints to the asylum board from the matron, warnings regarding her drunkenness and unreliability, and vague suggestions of the abuse of patients.11 The problems with unsuitable staff went beyond the nurses, however, and may reflect the relatively low status of the Irish district asylums. The first visiting physician had also come from Dublin, where he had had a brief (September 1830 to June 1831) and undistinguished stint as manager of the Richmond Asylum. Discharged from his post because of a damming report by the asylum inspectors, he was nevertheless appointed to Ballinasloe on the recommendation of the Richmond board. His work at the CDLA was unremarkable, and was abruptly terminated in 1848 following his admission that he had made one of his patients pregnant.12 Thus, when even the most senior medical staff were themselves of poor quality, it is less surprising that nurses were not of the highest grade. The behaviour of the asylum nurses in the first decades of the institution’s history would seem to conform to the worst excesses of Sairey Gamp and her drunken, untrustworthy nature.13 Much board time was consumed in discussing the most recent excesses of the nurses, and hearing the increasingly pitiful recital from the matron on the difficulty of maintaining even the most basic standards of behaviour. The post-Famine years were especially poor in terms of the quality of staff. Emigration from the west of Ireland was consistently high, leaving a traumatised and scanty population from which the asylum 31

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drew its nurses. The province of Connaught had the sharpest drop in population of the entire country as a result of death and emigration, losing almost one-third of its inhabitants between the census years of 1841 and 1851.14 It was alleged by several contemporary commentators that the most resilient and resourceful of the Irish made up the majority of emigrants, leaving behind the dross who became a millstone round the necks of their landlords or the state: For some years the emigration of labourers and small farmers has been considerable, but, unfortunately for Ireland, they have generally been the most industrious, well-behaved, and in most cases the most monied of their class, thus leaving the worst, and all the riff-raff, as an increased burden on the country.15

Although it may be tempting to explain the poor standards of nurses on these grounds, this would be to ignore the comparably weak staff available to similar institutions throughout Britain in the same period. A more likely explanation is the fear and dislike of association with lunatics that persisted in the local population, despite an enthusiastic use of the asylum by the community for care and incarceration. ‘Respectable’ daughters would not be encouraged to seek employment there if emigration, marriage or domestic service were available as an alternative, and the residential nature of asylum nursing, coupled with a ban on marriage for female attendants, made it a less attractive occupation for young Irishwomen. Originally intended as a means of preventing liaisons between staff, the ban on married nurses meant the periodic loss of valuable staff to the institution: ‘Read Manager’s report stating that Charles C. night watch had married Bridget C. Deputy in No. 3 division who consequently by the rule of the House is disqualified from remaining a deputy.’16 An examination of the behaviour of the Ballinasloe nurses provides an insight into the reality of power relations in the asylum. The prevalent view of nurses as handmaidens to the high-status, highly educated physician is upheld in the asylum rules, which strictly delineated a nurse’s capacity for independent action (none). The nurses’ role was to pass information to the physician, and carry out his instructions without comment: They [nurses and keepers] are in their communications with the Physician to state to him all the circumstances relating to each Patient within their

32

Irish psychiatric nurses in the nineteenth century knowledge; and they are strictly to obey his orders relative to the patients, and conduct themselves towards him with the utmost respect.17

The ideal nurse was indeed a woman who lived to serve, a caring automaton who did not criticise or comment. It was a widely accepted concept, emphasised even in texts on household management: [A nurse] must begin her work with the idea firmly implanted in her mind that she is only the instrument by whom the doctor gets his instructions carried out; she occupies no independent position in the treatment of the sick person.18

But this is not to assume that the ideals enshrined in asylum rule books and popular manuals were accurate reflections of reality. In an environment in which good nursing staff were difficult to recruit, the asylum physician, manager and matron were forced to accommodate themselves to a rather more bawdy version of the angelic nurse, or find themselves without staff. The minutes of the board of governors reveal a nursing cohort that required constant check and reprimand, and one that was aware of the relative degree of power they could exercise while still retaining their positions. From the administrators’ perspective it is equally revealing that sanctions were slowly and cumulatively applied, with nurses given substantial opportunities to redeem themselves before the ultimate sanction of dismissal was applied. The minutes from late 1855 to 1857 show an unexpected level of accommodation of poor behaviour by the board, and hint at a more complex social and professional life for the resident nurses than might be expected. The relatively poor quality of the nursing and other staff had been a cause for concern for some time, with the asylum physician, Frederick Thornton, noting with timid hope in 1853 that: The wages of the Servants have been raised in accordance with the recommendation of Dr White, Inspector General of Lunatic Asylums, for the purpose of securing a better class, and the general superiority of the persons recently appointed supports his opinion.19

This cautious optimism was not borne out by the subsequent conduct of staff, however. In 1856 the manager was forced to dismiss the cook for incompetence: 33

Mental health nursing Bridget W., Cook, on the 10th inst. violently attacked Kate P. Deputy Nurse and attempted to put her out of the kitchen by force when she went to receive the supper for the patients. The Cook appears to be very ill tempered, and from her stupidity is quite unfit for the situation, under the circumstances he had advertised for candidates for the situation.20

Previously, in December 1855 the board ‘Read [the] Manager’s report describing gross irregularities in the Servants’ bedroom occupied by Anne C., M. B., C. G., & A. M. Ordered: That Anne C. be fined 11/, C. G. 3/, A. M. 2/.’21 Given that the nurses earned an average salary of £6 per annum in 1855, an eleven-shilling fine was a substantial deduction, suggesting that the unspecified ‘gross irregularity’ was a serious one. But there was a high level of tolerance for poor behaviour, born out of a realisation that even poor-quality staff were difficult to replace. Even an outright failure to undertake one’s duties did not necessarily result in dismissal. On 7 February 1856, the board Read [the] Matron’s report stating that Ellen P. night nurse had grossly neglected her duty on the 30th January in leaving a servant who was in a most dangerous state without seeing her the whole night, and also refusing to attend the Infirmary where there were 13 patients very ill; when spoken to she was very impertinent. Also stating that Mary McD. servant appointed deputy nurse last Board day was totally unfit for her situation. Ordered: that Ellen P. be reduced to Deputy Nurse, and Mary McD. be dismissed.

Individual nurses came repeatedly to the board’s attention, and on 8 May 1856 Mary L made the first of several appearances. The manager indicated that ‘Mary L. (Deputy Nurse) had been careless and inefficient in her duty, but recommend[ed] that she should be continued on trial for a short time’. The next board brought encouraging news: ‘Read: Manager’s report stating that Mrs Callan [the former matron, still resident and working in the asylum] on behalf of the Matron reported that Mary L. Deputy Nurse has been diligent in her duty, and is likely to improve and recommended her to be continued’. The following month, however, she had deteriorated again: Manager’s report stating that Mary L. Deputy No. 1 division had been absent from her duty the most part of the month in consequence of a sore knee, she has lately quarrelled with the Cook, and was insolent to Mrs.  Callan; she has given me warning to resign. Ordered: If disorderly conduct be repeated, Mary L. be immediately dismissed.22

34

Irish psychiatric nurses in the nineteenth century

Infractions involving quarrelling, incapability and drunkenness were a mere matter of routine. Thus ‘Mary G. attendant No. 5 Ward, and Brigit C. Deputy in No. 8 division [were fined] 2/6 each for quarrelling with other servants’,23 while ‘Maria G. was quite unfit for her situation, being untidy and stupid also Anne C. … is thoroughly idle and dirty’.24 On other occasions ‘Evelyn C. [ was reported] for general irregularity and negligence’,25 and ‘Anne M. Night Nurse came in tipsy on the evening of the 10th and being incapable for duty, she neglected going round as watch during the night’.26 Repeated instances of neglect and incapacity were dealt with by moving nurses to other duties (often on the night watch, an unpopular shift) in the hope that they would improve, but further problems were more often the result. At the 12 October 1857 board, Deputy Nurse Mary C was officially reprimanded for neglect. She was moved to the night watch, whereupon she and a colleague, Rose C, were the subjects of a further complaint by the matron. They were brought before the November board, where Rose C was reprimanded and Mary C was dismissed. However, the minutes also indicate a significant degree of responsibility towards staff whom the board (on the advice of the manager, matron and physician) felt had given good service, even when it was under no legal obligation. Thus the board funded recuperative trips for valued staff: Manager’s report stating that Mary C. Head Nurse, having been seized with her annual attack of spasmodic asthma, the Medical Officer had recommended she go to the sea side, and that he had given her leave of absence for 10 days.27

The board also approved pension payments that were not part of contracts of employment: ‘Recommended: that Bridget M. an attendant keeper, 23 years in the House, be allowed £8 per annum superannuation pension, being debilitated from active duty’.28 The board distinguished between those whom it regarded as deserving cases, and those who had not made a significant contribution to the asylum. In the case of Anne M, little sympathy was shown for her chronic illness. The Manager had reported that Anne M. Deputy Nurse had been confined to the Infirmary for the last six weeks with severe opthalmia, to which she was subject formerly in the Workhouse, there appears to be little hope that

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Mental health nursing she will be able to return to the duties of her situation. Ordered: That she be served with notice of dismissal.29

Nurses and the labour market Part of the difficulty in recruiting high-quality nurses was the limited range of individuals seeking employment locally. The reality was that the nurses at the CDLA came from a similar socio-economic background to the patients who thronged the institution throughout the nineteenth century. They were the daughters of farm labourers and domestic servants, their formal educational standards were low and although they improved steadily as the decades advanced, they shared for the most part a common religious faith and cultural outlook that tended, especially in the later years of the century, towards the socially conservative.30 They were not, for the most part, the children of strong farmers, or the aspirational middle or lower-middle classes: those women were drawn towards hospital nursing or the Church. The heads of religious congregations in Ireland, as elsewhere, were usually from affluent backgrounds and well educated. For example, Mother Mary Aikenhead, head of the Sisters of Charity in Ireland, was the daughter of a Cork physician.31 Nuns brought a dowry with them, and the hierarchy within the convent was established to a significant degree upon the dot they endowed the order with. In secular institutions, the middle-class profile of the general and hospital nurse was underpinned by the fact that nurse probationers in the Dublin hospitals had to be relatively well educated before entering the profession and had to pay a fee for their training.32 This social difference was to have a detrimental impact upon the status of Irish asylum nurses, and their efforts to professionalise and advance their position was undermined by the enduring sense that they were as much custodians as carers. But the relatively lowly position of the asylum nurse had an unexpected benefit. A post at the asylum offered rates of pay far in excess of any other employment open to unskilled and ill-educated countrywomen. The Poor Law Enquiry of 1833–36 exposed the miserable wages generally available for female labour in rural Ireland: in County Mayo domestic servants were considered fortunate to secure 5–6 shillings plus board per quarter, and high-quality spinsters might hope to 36

Irish psychiatric nurses in the nineteenth century

earn 4d a day.33 With a starting rate of £2–3 per annum with board in 1833, rising to £8 for a head nurse, asylum salaries were exceptionally high for west of Ireland women. Moreover, despite a somewhat inferior status, asylum nurses received comparable salaries to their general hospital peers. This fact may be explained by the highly gendered nature of general nursing, and its vocational nature. Nursing salaries were traditionally low, and many hospitals held firmly to the belief (readily accepted in the wider community) that the occupation was its own reward. In Ireland, this position was strengthened by the large-scale entry of nuns to the nursing profession who laboured for little or no monetary reward. Asylum nurses were on the contrary difficult to recruit, and their salaries reflected the popular perception of asylum nursing as a potentially dangerous and rather undesirable occupation. Moreover, the cost of living in nineteenth-century rural Ireland was considerably lower than in Dublin, leaving the district asylum nurses better off than their urban counterparts. Asylum nurses’ wages at Ballinasloe increased steadily from the middle of the century, reflecting both a growing sense of professionalisation and the more onerous duties of a greatly expanded institution. It is useful to compare asylum wages with those available to hospital nurses, and it provides some insights into the manner in which a highly gendered view of nurses as ministering angels resulted in almost static wage rates and poor remuneration. In the early years there was a significant disparity in regional wage rates, with general nurses in the Royal Hospital Kilmainham, Dublin receiving far higher salaries than those paid at the CDLA. In 1853 nurses at Ballinasloe were paid an average wage of £6 per annum, with an additional £6 expenditure by the institution on ‘rations’, and just over £2 on clothing per staff member.34 By contrast, the Kilmainham nurses in 1857 received wages ranging from £19 to £23, depending on seniority, and were also provided with bed and board.35 Male keepers at Ballinasloe enjoyed comparable wages to the Dublin nurses, with a 1857 recommendation by the board of governors that ‘the minimum salary of £10 be adopted for all newly appointed [Keepers], and that the Head Keeper have a salary of £20 with clothes etc’.36 By the 1880s the wage gap had narrowed, with a head nurse at Ballinasloe receiving a salary of £24, and ‘Rations, Furnished Residence, Fuel, Light and Soap’ to the value of another £26 per annum: a night nurse and 37

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a ‘1st Class Attendant’ were each paid £14 with bed and board.37 A senior nurse at Kilmainham in the same year received a salary of £28, with her more junior colleagues earning between £19 and £23.38 By the end of the century Ballinasloe head nurses had a wage of £30 per year, and ‘furnished apartment, rations, fuel, light, soap and clothes’ to the value of £29, plus 18 shillings cash ‘for boots’, while nurses at the prestigious Sir Patrick Dun’s Hospital in Dublin had to campaign for an increase in salary for senior nurses from £25 to £30 plus board. While the salaries paid to the asylum nurses were infinitesimal when compared with that of Ballinasloe’s resident medical ­superintendent – £725 salary per annum, with an additional £150 in kind as ‘partly furnished residence, garden, fuel, light, washing, bread, milk, vegetables [and] keep of a horse’ – the asylum nurses were not the ‘poor relations’ in the broader nursing profession, at least in terms of remuneration. Moreover, ambitious nurses could secure an enhanced wage by improving their qualifications. In 1898 three male keepers and four female attendants were ‘paid £2 per annum extra, in consideration of their having obtained the Certificate of the MedicoPsychological Association for proficiency in Mental Nursing’. Duties and responsibilities The work of an asylum nurse may not have been intellectually challenging, especially in the early years, but it was certainly laborious and time-consuming. The working day began at 6 a.m. and ended at 10 p.m. (precisely the hours of a domestic servant) and commenced with helping infirm patients to rise and dress. Patient registers had to be completed and checked (noting any illness, restlessness or disturbance in the night), the new shift briefed, and beds turned back and changed if soiled. Nurses assisted those unable or unwilling to eat at breakfast, and then organised patients into work parties or groups for exercise. They were responsible for counting the bed linen and clothing to and from the laundry, feeding and attending to the bedridden inmates, giving the patients their twice-weekly baths and cutting their hair. Throughout the day they supervised sewing groups, received food from the kitchens, prepared the dining room for meals, read to the pacific recuperative patients and walked them in the grounds, cleaned and tidied the wards (with the assistance of wardsmaids) and 38

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made the beds after the compulsory eight-hour airing. All of this was before the nurse implemented any sort of therapy on the orders of the physician. The domestic duties of the female nurse conservatively doubled her workload, compared with the keepers. The duties of male employees were to a significant degree supervisory: they took responsibility for work parties (assisted by numbers of convalescent and trustworthy patients), intervened in physical disputes between patients, accompanied potentially dangerous inmates on their journeys around the asylum and harmless inmates on excursions beyond the walls. They also undertook night duty, but only on the male wards, and supervised suicidal patients of both sexes (a duty shared with a nurse if the patient was female). Nurses therefore carried a heavy burden of responsibility and an onerous list of duties that filled every moment of the working day. Their terms of employment were overlain with a system of punishment, but not reward, for work, and their responsibilities went far beyond the implementation of the therapeutic orders of the physician. There are important gender implications in the division of labour between female nurses and male keepers which persisted until the 1960s.39 Despite the rhetoric of medical professionalism employed by the Board of Guardians when considering the qualities necessary for a good nurse, the reality is that women were hired on the basis of their domestic skills: nursing the mentally ill back to health was a secondary consideration.40 Indeed the principal means of securing promotion in the asylum, before the recognition by the Medico-Psychological Association of nursing competence in 1890, was through domestic and not nursing skills: Assistant keepers and Nurses are to be considered as appointed to carry into effect the regulations which are laid down for keepers and nurses, they are to clean the corridores [sic], day rooms, sleeping-rooms, yards &c., of their respective divisions and have them ready for inspection at the appointed hours – their promotion to the places of keepers and nurses is to depend on the manner in which their duties are performed, and their conduct is accordingly to be reported in the daily statement books.41

Training became an increasingly important element in the asylum nursing system as the century advanced, and became a significant means of distancing the institutions from the taint of custody. However, in an era when medical education was itself undergoing 39

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a contested move away from a hereditary business and systems of apprenticeship to a university-trained profession, there was a struggle to maintain boundaries based on the possession of specialist knowledge.42 From the early nineteenth century, asylum medical superintendents had published observational findings on the origins of mental illness, using an increasingly sophisticated and exclusive language to delineate causes, manifestations and cures for insanity.43 Although nurses had a far greater degree of interaction with patients, and continually monitored their behaviour, they did not formulate treatment regimens or suggest alternative treatments for individual cases. They ‘were responsible for maintaining institutional efficiency, delivering humane standards and mediating between policy and practice. The work of attendants determined precisely how, and with what success, alienists’ theory was implemented in everyday practice.’44 Even while physicians noted the need for specialist nurses, they were reluctant to permit any degree of latitude to the staff that might threaten their own professional positions. Thus, the approved manual of instruction, Winslow’s Handbook for Attendants on the Insane (1877), steered carefully around any suggestion that nurses required specialist knowledge of either the body or the mind.45 Rather their role was to ‘combine, in their character and disposition, firmness and gentleness; and they should be able, by their education and habits, to superintend, direct, and promote the employment and recreation of the patients’.46 As the constant companion of the patients, the nurse often had significant insights into their cases, but were sternly admonished against presenting themselves as experts: ‘Never express any opinion to the relatives or friends of the patient as to the progress of the case, but refer them to the medical officer, who alone can give a correct opinion.’ From the publication of Winslow’s textbook onwards, the emergence of specialisms within medicine, including psychiatry, fostered a strict delineation of expertise between the skilled physician with his scientific knowledge of the brain, and the largely domestic, unskilled nurturing role of the nurse.47 Even when a revised and greatly extended Handbook for the Instruction of Attendants on the Insane was prepared by the Medico-Psychological Association with the specific intention of preparing asylum attendants for examination, it placed emphasis upon the practical elements of patients’ physical needs – there were chapters on The Body, Nursing the Sick, 40

Irish psychiatric nurses in the nineteenth century

Mind and its Disorders, Care of the Insane and the General Duties of Attendants – and kept the increasingly scientific discourse of psychiatry in the hands of medically trained men.48 In common with the practice in Holland, a similarly sized country with a comparable asylum system, resident medical superintendents in Irish asylums developed a somatic treatment system for nurses, ensuring that female attendants adhered to an old-fashioned and generally feminised caring role, and did not even benefit from the anatomical and dispensing training of the general nurse.49 Historians of general nursing have pointed to the manner in which nurses were forced to embrace a narrow representation of their profession, in order to secure a degree of status: One reason nurses may rely so heavily on the virtue script is that many believe this is their only legitimate source of status, respect, and self-esteem. For the past 150 years nurses have been told that only physicians really need scientific training. Deprived of status and respect that stems from a standard university education, nurses were taught the way to gain social respect was to establish themselves as the most devoted, altruistic, and trustworthy members of the health care team … Opinion polls reinforce the belief that nurses are generally prized for their virtues, not their knowledge.50

Irish asylum nurses could not access this definition quite so easily, given the nature of their work and the impossibly high ideal presented by another type of Irish nurse – the nun. Nuns and nurses: an impossible ideal The presumptions that informed popular conceptions of the ideal nurse – calm, discreet, self-sacrificing – were broadly the same in Ireland as in Britain. But there was one significant difference that further undermined the status of the Irish asylum nurse. When nursing became an acceptable vocation for women, it was less the respectable middle classes seeking independence who flocked to the profession, and rather more women in religious orders who flooded into hospitals and institutions for the sick. The firm hold that the Catholic Church would exert on Irish society only began in the post-Famine years: prior to 1850, society in general had been far less conservative and devout, with erratic church attendance and a general acceptance of pre-marital pregnancy and other social lapses.51 But from the 1850s onwards nuns formed a veritable vanguard of 41

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religious incursion into the private lives of Irish lay men and women, teaching in schools, nursing in hospitals and staffing charitable institutions for the care of unmarried mothers, the elderly and the destitute. The determined move by nuns into nursing was not surprising, given the stereotypical qualities associated with the nurse. But their presence had a damaging effect upon its professional status. Although they validated the occupation for middle-class women, stamping it with irreproachable respectability, they also crowded it out and had a detrimental effect upon salaries. They laboured willingly for nominal pay – a token £20 per annum for the services of two nuns in Ennis workhouse in 1884, for example – and embodied an obedient ideal. Thus they cemented the belief in Irish minds that nurses worked selflessly for the satisfaction of the job itself, and not for professional advancement. Moreover, they made distinctions between the types of nursing that could appropriately be undertaken by respectable women. They did not for example do night nursing, attend maternity cases, or in the early years nurse male patients: There are services the Sisters cannot perform themselves – as modesty must never be wounded … particular discretion and caution are necessary to the Sisters nursing in male wards … We should ever bear in mind that ‘charity is not only kind, but doth not behave unseemly’.52

Some Irish Sisters of Mercy had nursed alongside Florence Nightingale during the Crimean War, and while they unofficially faced religious and ethnic suspicion as to their motives, they were publicly praised for their efforts. Nightingale herself was at pains to emphasise the inherently feminine aspects of their contribution – ‘I always wondered at your unfailing patience, sweetness, forbearance and courage under many trials’53 – while studiously ignoring their professional nursing skills. The image was, however, one that Irish nursing nuns themselves embraced. Arguably this had a significant impact upon the reputation of asylum nurses. The district asylum system is unique in Irish cultural and medical history in that it did not become a specific ‘target’ for the Church. Every other key sphere of life saw a steady Catholic encroachment, including general hospital nursing, education, local government, welfare and allied areas, but the Church remained largely outside the asylum walls. Although Catholic priests, along 42

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with Anglican ministers, were appointed to each of the regional asylums, with the exception of Belfast,54 to minister to the spiritual needs of the inmates, they did not take a leadership role in the running of the institutions. This is a major aberration in Church history and arguably reflects a sense of unease with regard to the inmates. Mentally ill patients were unpredictable, often ungrateful or violent, and certainly far from the pliant recuperative hospital patient. The asylum nurses at Ballinasloe were frequently the targets of physical,55 and sexual,56 assault and exposed to sexually explicit language and inappropriate displays.57 Patients often suffered from religious delusions,58 believed themselves to be divine, or behaved blasphemously on the instructions of the devil.59 This was utterly at odds with the self-, as well as popular, image of the nursing nun. Their reluctance to expose themselves to the moral, spiritual and physical dangers implicit in nursing mentally ill patients ensured that asylum nursing retained the stigma of earlier years, while general nursing rose in terms of status, if not remuneration. Any respectable parent might encourage their daughter to train at one of the prestigious Dublin hospitals, but would baulk at the prospect of entry to the local asylum: truly a place ‘where angels fear to tread’. It is significant that Irish nuns did dominate one field related to mental health, however. They assumed responsibility for the care of intellectually disabled children, becoming by the start of the twentieth century the main providers of care for this group. Such patients represented the epitome of religious fulfilment: they were permanently dependent and child-like, never reaching (or allowed to reach) full adult sexuality. In 1892 the Daughters of Charity took over the North Dublin Union workhouse, and began a century of almost exclusive provision for the intellectually disabled. There had long been an argument regarding the unsuitability of district asylums for those who did not suffer from mental illness, but little available alternative care. From the end of the nineteenth century, nuns fulfilled this vital role, but shied away from any specific association with the insane. It was, and remains, common in Ireland to refer to an intellectually disabled individual as ‘touched’, the full phrase being ‘touched by the hand of God’. The imperative to care for those who would never grow up was a powerful one, but sufferers who were closer to demonic rather than divine possession did not fall within this ambit. 43

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Nursing surveillance The asylum system was hierarchically organised, with a top-down model predicated upon professional qualification, social status and, as the century advanced, political and religious patronage.60 Nurses occupied the lower strata, below the keepers and the various administrators and office bearers, which included the matron, apothecary, clerks and gate and hospital porters, and only above the most junior of domestic servants (the wardsmaids). An examination of Irish asylum nursing reveals many restrictions, and a profession underpinned with the most conservative interpretations of gender limitations. But there was of course a great deal of manoeuvre within the system, and from a different perspective, especially that of the patient, the nurse was an extremely powerful agent. Although therapeutic decisions lay increasingly with the asylum physician, and the magical powers of discharge and detention were exclusively in his hands, the nurse was the essential conduit for information upon which those decisions were based. In modern psychiatry, anxiety has been expressed regarding the use of electronic surveillance of patients, and the Foucauldian implications of what one might call ‘distant monitoring’ in ensuring that patients are under continual observation.61 In the nineteenth century, this role was effortlessly undertaken by the nurses, who despite the regulatory restrictions placed upon them had a great deal of latitude with regard to movement within the asylum, and individual action. They were enabled to oversee all aspects of the patient’s daily life and record changes in behaviour and health as well as individual idiosyncrasies. Indeed, it was a specific requirement of their employment that they note and relate every conceivable action on the part of their charges direct to the physician, and that their all-seeing eye covered every area in the asylum. The ‘Bye-Rules and Regulations for the Government of the Connaught District Lunatic Asylum’ outlined 30 specific instructions for nurses and keepers, and laid a particular emphasis upon surveillance and reporting: Keepers and Nurses are to remain constantly in charge of their respective patients, and by no means absent themselves, unless permitted to go out by a written Pass, signed by the Manager, and shall take care that each Patient in their charge shall be under constant observation (rule 4) … they are in their communications with the Physician to state to him all the

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Irish psychiatric nurses in the nineteenth century circumstances relating to each Patient within their knowledge (rule 10) … During the time that the keepers or nurses are in charge of patients, they shall not be engaged in any employment or work that might divest them from the sole duty of watching patients (rule 17).

The lengthy rules 18, 19 and 20 address the need for nurses to maintain written records regarding improvements in health, any seizures, excitement or violence, and to ensure patient welfare and security at night, and in the exercise yard during the day. These rules also placed the nurse in a position of continual observation of behaviour and inclination: ‘Each attendant will be expected to report at least once in each week such patients as may be filthy or addicted to any disgusting or improper habit.’ In recent years, the role of nurses in the Foucauldian paradigm has attracted increasing attention. From analysis of nurses as victims of a culture of violent surveillance,62 through their role in objectifying and controlling the patient body,63 to the negotiation of power between staff and patients,64 the focus has shifted somewhat from the largely presumed culpability of physicians to the more fluid position of the nurse. Critics including Sam Porter have argued that, particularly in a modern setting, nurses are relatively powerless in the face of patient intransigence.65 He pinpoints in particular their inability to apply penalties for a refusal to cooperate, and the lack of officially sanctioned violence in support of their actions as undermining Foucault’s fundamental premise. In asylum history the threat, or even implied threat, of violence was an element in the nursing relationship. However, although Foucault’s often sweeping assertions regarding power have been challenged in recent years, his fundamental premise that ‘power is exercised at innumerable points in the interplay of nonegalitarian and mobile relations’ is nonetheless largely true in the nurse–patient relationship at Ballinasloe.66 Nurses at the Ballinasloe Asylum had, as had their peers elsewhere, significant degrees of authority over their patients. The exercise of this authority is evident in periodic cases of reported abuse, serious enough to warrant an investigation by the national asylum inspectors as well as the matron and manager of the institution. Most of these related to accidental deaths, where the keepers in particular were investigated for ‘excessive force in restraint’ of patients that resulted in death. There were four such cases between 1870 and 1890 and in all of them the staff 45

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were ‘exonerated’, a favoured phrase in almost every unusual death in the asylum. It is noticeable that staff were more readily dismissed in cases when a patient was seriously rather than fatally injured, suggesting perhaps that there was a tendency to close ranks and protect the reputation of the asylum in extreme cases: the fact that the patient concerned was no longer available to give evidence also tended to produce a verdict that was more favourable to the institution. In one case of suicide, a night nurse was formally investigated for neglecting to check regularly on a known suicidal patient. I regret having to report the death by suicide of a patient named Catherine B. who was found by the night nurse at 6.45 am on the 3rd inst. suspended by a piece torn from a sheet and tied to the window shutter, she was then quite dead.67

In this case, as in several others, there was concern regarding the relative laxity of night nurses. This nurse found the patient only when her shift had officially ended, suggesting that she had failed to check on a known suicidal patient once per hour throughout the night as was required. Nurses at Ballinasloe were often charged with neglecting suicidal and ill patients at night, arguing in more than one case that it was too unsettling: ‘Nurse Ellen P. stated “You’d be afeared to go to No. 4 alone at night”.’68 But the nurses had an additional power over many of the patients in the nineteenth century, through which they could exercise the utmost control. The CDLA originally catered for pauper patients from the whole province of Connaught, which included the counties of Galway, Mayo, Sligo, Roscommon and Leitrim. Until the Castlebar Asylum opened in 1866, and took both new admissions and relocations from Sligo and Mayo, the Ballinasloe institution had included large numbers of monoglot Irish-speaking patients from the western seaboard in particular. The asylum, however, conducted itself through the exclusive medium of English, which was the language of all administrative records, instructions, board negotiations and official affairs. Many patients in the early years declared themselves to be at least semi-literate, and as the century progressed and the national education system took effect, most admissions were recorded as literate.69 Given that the national school system was conducted in English, it would be reasonable to assume that most patients were at 46

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the least bilingual. However, the reality was that there were significant regional variations in the spread and use of English, with communities such as the Claddagh in Galway, as well as populations in the far west and islands, that remained predominantly Irish-speaking until the 1930s.70 Thus from 1833, when the asylum opened, there was a substantial proportion of the patient body who spoke only Irish. There were also individuals who, although fluent in English, chose to communicate in Irish, some as a result of their illness and others as a form of protest. The senior staff in the asylum, including, crucially, the physician, spoke only English. It was the nursing staff who bridged the linguistic gap, translating for the physician when he interviewed patients on admission, and at intervals when updating case notes. Thus nurses were a key conduit between patient and physician, with both sides dependent upon their honesty for an accurate rendition of events and symptoms. As the literal mouthpiece for the patient, the nurses’ authority far exceeded these few formal encounters. If an inmate sought release, or wished to see the physician, make a complaint or even simply have a change in mental state recorded, they relied upon the nurse to accurately represent their case. This did not always happen. Case notes reveal an anxiety about whether patient testimony is translated accurately, and if nurses are reporting upon mental changes as required. One patient admitted in 1896 made consistent complaints to the physician about his treatment at the hands of the nurses – ‘he asks me to see that the nurses do not strip and hose him’71 – and some Irish-speaking patients tried to by-pass the nurse entirely and speak directly to the physician, without success: [He] is much improved physically and mentally is clearer and brighter and answers readily but does not understand English and is apparently incoherent though not really so [1896, 4 months after admission] … he insists on his capacity to talk English in which he is quite unintelligible, and will not trust the nurse to speak for him [1902] … has still his supposed capacity for talking English [1904] … speaks in Irish only … when looked at he wriggles about after the manner of a dog who is in doubts as to whether he will jump into the water or not [1906].

Nurses were often recorded as being ‘dismissive’ of patients who could not converse easily in English, and the physician noted a somewhat suspicious use of stock phrases by nurses who translated for 47

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patients. Indeed there were moments at which the physician sought to translate not only the patient’s speech, but also non-verbal clues: ‘This patient looks at me earnestly while his plea is made by the nurse: his evident air of disappointment when she finishes suggests he had other intentions and hopes.’72 Conclusion On an obvious level, then, nurses operated as straightforward exemplars of Foucault’s ‘omnipresent power’, compelling patients to behave through the implied threat of inaccurate reports to the asylum physician, who could order continued detention, restraint, segregation or even physical punishment in the guise of treatment.73 As the century progressed they also conformed to what Nelson describes as an increasingly regulated and structured process that regimented the casual and allegedly more humane patient–nurse interaction: Nurses [had originally] played a major role in the regulation of poverty through the supervision of the poor in workhouses and in the community … Epidemic nurses assisted in the management, training and supervision of the poor. Nursing then became governed by standardised training regimens and registration procedures. Nursing also became part of the process of government.74

From within and outside the institution, then, it would appear that an increasingly rigid conception of both nurses and the profession was emerging. But it is important to recognise another, all too often neglected element in the nurse–patient dynamic. Every asylum holds records of patients who lived their lives within its walls, unvisited, abandoned by family, with no prospect of discharge. What is less often noted are the many asylum nurses who also lived, and died, in the institution, sharing every aspect of the patients’ lives with the exception of their illness. They lived in the same buildings, ate the same food and were bound by the same routines, with marriage and motherhood possible only on relinquishing their post. It is important not to ignore the importance of friendships that grew from this close proximity over time. The nursing profession was, and remains, one in which women occupy a fluid status between remote practitioner and intimate friend. 48

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A convalescent patient, necessarily dependent upon strangers for care, often forges an intense if short-lived bond during which the nurse may exercise an exceptional degree of authority. Jane Austen’s Nurse Rooke understood the unique relationship struck up between the patient and the woman who relieves their pain: ‘Everybody’s heart is open, you know when they have recently escaped from severe pain, or are recovering the blessing of health, and Nurse Rooke thoroughly understands when to speak.’75 Asylum nurses had far longer-term relationships with their charges, which often extended over not merely years but decades. Moreover, the day-to-day ­responsibility of the asylum nurse was very different from that of the monthly or hospital nurse. Patients were often in good physical health, not requiring the continual changing, wound dressing and pain relief that those with physical illness needed. In the era before the distribution of prescribed medication became a central role, the asylum nurse was a peculiar compound of domestic servant and genteel companion, leading groups of pacific patients in needlework and embroidery, accompanying them on walks in the asylum grounds and reading ‘improving literature’ to those capable of understanding it. They were also, in many cases, friends. Despite the complaints regarding drunken and dissolute nurses throughout the nineteenth century, strong bonds often formed between staff and patients. The establishment of the Monaghan Asylum Soviet in 1919 was one dramatic expression of nurse and patient solidarity, but on a routine level there were many friendships forged over years of contact that endured into old age. Poignantly, the only faithful visitors many of the patients had were the retired nurses who had cared for them all their lives. For both, it was a reflection of the most meaningful of their life-long relationships. Notes   1 P. T. Clements and J. B. Averill, ‘Finding patterns of knowing in the work of Florence Nightingale’, Nursing Outlook, 54:5 (2006), 268–74.  2 The dichotomous representation of nurses attracted early attention from scholars of women’s history. See J. Muff, ‘Battle-axe, whore: an explanation into the fantasies, myths and stereotypes about nurses’, in J. Muff (ed.), Socialization, Sexism and Stereotyping: Women’s Issues in Nursing (London: Mosby, 1982).

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Mental health nursing   3 The records of Connaught District Lunatic Asylum (hereafter CDLA) have been transferred to the National Library of Ireland but are not yet available for general consultation.   4 The women received no pay, but were granted extra rations in exchange for duties including washing patients, changing bed linen and accompanying inmates to the exercise yard. M. Luddy, ‘“Angels of Mercy”: nuns as workhouse nurses, 1861–1898’, in E. Malcolm and G. Jones (eds), Medicine, Disease and the State in Ireland, 1650–1940 (Cork: Cork University Press, 1999), p. 103.   5 It remains a problematic area today, especially with regard to the nurse’s ‘touch’: a central part of a nurse’s duties but one that transgresses social and cultural boundaries. J. Lawler, Behind the Screens: Nursing, Somology and the Problem of the Body (Sydney: Sydney University Press, 2006), chapter 4. In the nineteenth century, Irish nurses who were also professed religious simply avoided nursing that raised these issues; Luddy, ‘Angels of Mercy’, p. 109.  6 Quoted in P. Nolan, A History of Mental Health Nursing (Cheltenham: Chapman and Hall, 1993), p. 69.   7 W. C. Ellis, A Treatise on the Nature, Symptoms, Causes and Treatment of Insanity: With Practical Observations on Lunatic Asylums, and a Description of the Pauper Lunatic Asylum for the County of Middlesex at Hanwell, with a Detailed Account of its Management (London, 1838), p. 10.   8 P. Michael, Care and Treatment of the Mentally Ill in North Wales, 1800– 2000 (Cardiff: University of Wales Press, 2003), p. 66.  9 Freeman’s Journal, 4 June 1822. 10 Letter from land agent Henry Comyns to the landlord, Ross Mahon, 3 November 1822. Quoted in C. McNamara, ‘The monster misery of Ireland: landlord paternalism and the 1822 famine in the west’, in O. Walsh and L. Geary (eds), Philanthropy in Nineteenth Century Ireland (Dublin: Four Courts Press, forthcoming). 11 She was provided with three months’ pay in lieu of notice, her clothing allowance and her train fare back to Dublin. CDLA, Minutes of Board of Governors (hereafter MBG), 11 May 1848. 12 See O. Walsh, ‘A perfectly ordered establishment: Connaught District Lunatic Asylum (Ballinasloe)’, in P. Prior (ed.), Asylums, Mental Health Care and the Irish:  Historical Studies 1800–2010 (Dublin: Irish Academic Press, 2012), p. 251. 13 The monthly nurse in Charles Dickens’ Martin Chuzzlewit (1844), Gamp has become a shorthand for drunken, untrustworthy nurses worldwide. 14 J. Lee, The Modernisation of Irish Society, 1848–1918 (Dublin: Gill and Macmillan, 1973), p. 2. The population declined by over 28 per cent, although this is believed to be an underestimate of the total lost. 15 Testimony from the Barony of Balrothery, County Dublin. Quoted in G. Davis, ‘“Shovelling out paupers?”: emigration from Ireland and the s­outh-west

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Irish psychiatric nurses in the nineteenth century of England, 1815–1850’, unpublished proceedings of the ‘Westward Ho: Movement and Migration’ conference, University of ­Exeter, 2003. 16 MBG, 2 July 1857. 17 CDLA, Bye-Rules and Regulations, Rule 10. 18 J. McGregor-Robertson, The Household Physician (London: Gresham Publishing, 1902). Quoted in L. Fagin and A. Garelick, ‘The doctor–nurse relationship’, Advances in Psychiatric Treatment, 10 (2004), 277. 19 CDLA, Annual Report for 1853, p. 5. 20 MBG, 4 September 1856. 21 MBG, 11 December 1855. At this same meeting, two keepers handed in their resignation, which was accepted without comment. 22 MBG, 3 July 1856. 23 MBG, 3 July 1856. 24 MBG, 3 September 1857. The women were discharged, ‘both being incompetent’. 25 MBG, 8 July 1858. 26 MBG, 3 July 1856. She was discharged from her post for drunkenness, the board noting that this was not the first such incident. 27 MBG, 3 July 1856. 28 MBG, 7 May 1857. 29 MBG, 4 September 1856. 30 R. M. Rhodes, Women and the Family in Post-Famine Ireland: Status and Opportunity in a Patriarchal Society (New York: Garland, 1992). 31 D. S. Blake, Mary Aikenhead (1787–1858): Servant of the Poor, Founder of the Religious Sisters of Charity (Dublin: Caritas, 2001). 32 A. Hyde, M. Lohan and O. McDonnell (eds), Sociology for Health Professionals in Ireland (Dublin: Institute of Public Administration, 2004), p. 232. 33 Report of the Commissioners for Inquiring into the Conditions of the Poorer Classes in Ireland (HMSO, 1836), Appendix D, xxxi. 34 CDLA, Annual Report for 1853, ‘Abstract of Expenses’, p. 15. 35 M. H. Preston, Charitable Words: Women, Philanthropy and the Language of Charity in Nineteenth-Century Dublin (Westport, CT: Praeger, 2004), p. 141. 36 MBG, 7 May 1857. 37 CDLA, Annual Report for 1883, ‘Wages and Allowances of Attendants and Servants’, p. 23. 38 Preston, Charitable Words, p. 141. 39 A. J. Sheridan, ‘Mental health services in Ireland’, in N. Brimblecombe and P. Nolan (eds), Mental Health Services in Europe – Provision and Practice (London: Radcliffe, 2012), p. 161. 40 Joseph Reynolds has described the nurses’ duties as domestic service rather than skilled care, and this is certainly true of the earlier years of Irish asylums. J. Reynolds, Grangegorman: Psychiatric Care in Dublin since 1815 (Dublin: Institute of Public Administration, 1992).

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Mental health nursing 41 CDLA, Bye-Rules and Regulations, Rule 13. 42 P. J. Corfield, Power and the Professions in Britain, 1700–1850 (London: Routledge, 1995), p. 160. 43 The most influential works, which went into multiple printings, included J. Conolly, An Inquiry Concerning the Indications of Insanity with Suggestions for the Better Care and Protection of the Insane (London, 1830); J. C. Bucknill and D. H. Tuke, A Manual of Psychological Medicine (London, 1858); and W. A. F. Browne, What Asylums Were, Are and Ought to Be (1837). Browne’s text was not a medical manual, but had a tremendous impact upon medical and lay responses to the mentally ill. 44 S. York, ‘Alienists, attendants and the containment of suicide in public lunatic asylums, 1845–1890’, Social History of Medicine, 25:2 (2012), 324–42 (p. 326). 45 This was the standard textbook in Irish as well as British asylums in the nineteenth century. 46 L. S. Forbes Winslow, Handbook for Attendants on the Insane (London, 1877), p. 6. 47 G. Weisz, Divide and Conquer: A Comparative History of Medical Specialization (Oxford: Oxford University Press, 2006), p. 57. 48 A. Campbell Clark, C. MacIvor Campbell, A. R. Turnbull and A. R. Urqhart, Handbook for the Instruction of Attendants on the Insane (1893). 49 G. Boschma, ‘Creating Nursing Care for the Mentally Ill: Mental Health Nursing in Dutch Asylums, 1890–1920’, PhD dissertation, University of Pennsylvania, 1997, pp. 93–135. 50 S. Gordon and S. Nelson, ‘An end to angels: moving away from the “virtue script” toward a knowledge-based identity for nurses’, Australian Journal of Nursing, 105:5 (2005), 67. 51 S. J. Connolly, Priests and People in Pre-Famine Ireland, 1780–1845 (Dublin: Gill and Macmillan, 1982). 52 Luddy, ‘Angels of Mercy’, p. 109. 53 Letter from Florence Nightingale to Mary Clare Moore (leader of the Mercy sisters in the Crimea), 1863, in T. C. Meehan, ‘In the shadows of nursing history’, Reflections on Nursing Leadership, 31:2 (2005), 32–3 (p. 33). 54 The board at Belfast refused to appoint ministers of any religion for fear that proselytising of vulnerable patients would take place. See P. Prior and D. Griffiths, ‘The chaplaincy question: The Lord Lieutenant of Ireland versus the Belfast Lunatic Asylum’, Eire-Ireland 33:2/3 (1997), 137–53. 55 CDLA, case note, number 3902, 12 April 1900. ‘He often assaults [the nurses] owing to the force of his delusions.’ 56 CDLA, case note, number 3849, 25 September 1888. ‘He says Nurse N__ “bewitched” him and that is why he did it.’ 57 CDLA, case note, number 1964, 1 April 1891. ‘The nurses complain of his constant masturbation and habit of lunging towards them without warning: has had to be repeatedly blistered as a consequence.’

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Irish psychiatric nurses in the nineteenth century 58 CDLA, case note, number 4428, 26 November 1888. ‘He says that God speaks to him through the window at night, and tells him what he must do.’ 59 CDLA, case note, number 4702, 23 February 1900. ‘At Mass last Sunday he tore his clothes and ran to the altar and nearly knocked the Priest aside.’ 60 The rise of nationalist parties in Ireland at the end of the nineteenth century saw an increase in politically influenced appointments. In 1904 a Catholic physician was appointed instead of a better-qualified Protestant doctor, in specific response to pressure from Catholic board members. 61 D. Holmes, ‘From iron gaze to nursing care: mental health nursing in the era of panopticism’, Journal of Psychiatric and Mental Health Nursing, 8:1 (2001), 7–15. 62 I. St-Pierre and D. Holmes, ‘Managing nurses through disciplinary power: a Foucauldian analysis of workplace violence’, Journal of Nursing Management, 16 (2008), 352–9. 63 A. Henderson, ‘Power and knowledge in nursing practice: the contribution of Foucault’, Journal of Advanced Nursing, 20 (1994), 935–9. 64 M. Johnson and C. Webb, ‘The power of social judgement: struggle and negotiation in the nursing process’, Nursing Education Today, 15 (1995), 83–9; R. Whittington and D. Balsamo, ‘Violence: fear and power’, in T. Mason and D. Mercer (eds), Critical Perspectives in Forensic Care: Inside Out (London: Macmillan, 1998), pp. 64–84. 65 S. Porter, ‘Contra-Foucault: soldiers, nurses and power’, Sociology, 30:1 (1996), 59–78 (pp. 62–3). 66 M. Foucault, The History of Sexuality, Volume 1: An Introduction (London: Allen Lane, 1979), p. 93. 67 MBG, 11 August 1890. 68 MBG, 12 May 1891. 69 The national system of education began in 1831, but it was principally towards the end of the century through the compulsion of the 1880 School Attendance Act that Ireland achieved high levels of literacy. D. H. Akenson, The Irish Education Experiment: The National System of Education in the Nineteenth Century (London: Routledge, 1970), p. 9. 70 G. Ó Tuathaigh, ‘Language, ideology and national identity’, in J. Cleary and C. Connolly (eds), The Cambridge Companion to Modern Irish Culture (Cambridge: Cambridge University Press, 2005), pp. 45–50. 71 CDLA, case note, number 3904, 16 September 1908. 72 CDLA, case note, number 3947, April 1884. 73 There are instances at Ballinasloe where treatments such as blistering appear to have been used as much to control behaviour (preventing masturbation, for example) as to treat an illness. See the discussion of blistering in the case of a recidivist self-abuser in Walsh, ‘A perfectly ordered establishment’. 74 S. Nelson, ‘Humanism in nursing: the emergence of the light’, Nursing Inquiry, 2 (1994), 39. 75 Jane Austen, Persuasion (Leicester: Blitz editions, 1993), p. 130.

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3

A duty to learn: attendant training in Victoria, Australia, 1880–19071 Lee-Ann Monk

In late January 1895 Dr J. V. McCreery, Inspector of Asylums in Victoria, Australia, instructed his superintendents to post a notice in the mess rooms of their respective institutions announcing the introduction of a scheme to instruct attendants in the nursing of the insane.2 As the men and women employed to attend the insane in Victoria’s asylums contemplated these changes, it is likely that many of their counterparts in Britain were doing the same, because initiatives to train attendants in Victoria coincided with the movement to establish formal training in Britain.3 The coincidence reflects Andrew Scull’s observation that ‘Australasia was an intellectual as well as a political colony’ whose alienists shared many of the theoretical assumptions of their metropolitan counterparts.4 This was certainly the case with regard to training, the scheme devised in Victoria drawing directly on British initiatives. This chapter explores the first attempts by asylum doctors in Victoria to introduce training in the 1880s and 1890s, and the resistance of asylum workers to those attempts, the latter arguably a consequence of the ways in which the occupation of attending had developed in the preceding four decades. The asylum system and its attendants in Victoria Victoria established its first public asylum, the Yarra Bend, in 1848. Three years later the discovery of gold in the colony saw its population explode. While some found riches, for many the quest for gold created only disappointment and despair. The resulting demand for admission overwhelmed the accommodation at Yarra Bend.5 In 1863, after several inquiries, the government decided to build two 54

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new asylums in the country towns of Ararat and Beechworth, both of which opened in 1867, and a second metropolitan asylum, located in the Melbourne suburb of Kew.6 By the mid-1880s, when doctors in Victoria first began to call for the training of attendants, an additional asylum had opened at Sunbury, some twenty-five miles north-west of Melbourne.7 All were state controlled and funded, a part of the Hospitals for the Insane Department, which was in turn located within the Department of the Chief Secretary, who held ultimate responsibility for their administration. When it opened in 1848, Yarra Bend employed three men and a single woman as ‘keepers’.8 Four decades later, the establishment of the new asylums and an unrelenting demand for admission had seen the number of attendants increase significantly to keep pace. By 1885, 270 attendants (154 men and 116 women) worked in the colony’s five asylums.9 Initially there had been difficulties in retaining staff. In 1857 contemporaries calculated the average length of employment of attendants for the preceding five years at roughly six months for men and nine months for women.10 That year the government adopted an incremental wage scale intended, in the words of the Chief Medical Officer, Dr McCrea, ‘to add to the permanency of their situations in the asylum’. Under this scheme, the wages of men commenced at £85 and rose incrementally to a maximum of £120 a year while women’s wages began at £36 and increased to £50 per year.11 The scale had the desired effect: by 1886, the median length of service for men was 10.4 years and for women 5.25.12 The consequence was the creation of an attendant staff with considerable practical experience in attending the insane; some, like John Cane, the head warder at Yarra Bend, had by then accrued a quarter of a century’s service.13 Coupled with this experience, attendants in Victoria enjoyed a degree of independence within the asylums, in part because of the political system under which the institutions operated. In 1884 the then Inspector of Asylums, Dr Thomas Dick, characterised his authority to a Royal Commission investigating the management of the asylums as ‘for the most part nominal, the Chief Secretary appointing, dismissing, promoting, reducing, or otherwise punishing all employés [sic] in the department, his formal authority required to almost every act of the Inspector’. The medical superintendents, as his subordinates, consequently held ‘minimum authority’.14 While Dick 55

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exaggerated the degree of his and the superintendents’ i­mpotence – permanent appointment depended on a positive report from the superintendent, for example – the system did expose the management of the asylums to political interference, attendants threatened with dismissal appealing to their political representatives to intercede with the Chief Secretary on their behalf. Such interventions were not always successful, however.15 In the latter part of 1883 the government legislated to eliminate political patronage from the civil service generally. The new Public Service Act transferred responsibility for the appointment, promotion, demotion, transfer and dismissal of attendants from the Chief Secretary to the newly created Public Service Board. This change, however, conferred no more power over attendants than previously. Asylum officers could neither fine nor reprimand attendants ‘without reference to the Under Secretary, as permanent head of the Department’. Only he or the Minister could order suspensions. Attendants possessed the right of appeal from any fine. In a letter to the commission in late 1885, Dick complained that the Act thus denied ‘officers who are held responsible for the good management of the asylums that direct control which is essential to the efficient performance of their duties’, concluding that ‘it must surely tend to foster a spirit of indifference to superiors amongst subordinate officers’.16 It was this workforce, many of whom were possessed of considerable practical experience in asylum work and with a degree of independence from the medical officers of the department, that asylum doctors hoped to train. ‘Only the beginning of a strenuous effort to develop the nursing powers of the staff’: training initiatives in the 1880s In 1887, eight years before the posting of the notice with which this chapter began, McCreery was the medical superintendent of the Kew Asylum. In his report on the institution that year, he noted that his deputy, Dr O’Brien, had presented a series of ‘lectures on “Nursing” to the male warders’, which he hoped represented ‘only the beginning of a strenuous effort to develop the nursing powers of the staff’.17 McCreery was one of several progressive medical officers keen to see the training of attendants introduced. Their belief in the need to train 56

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attendants reflected new understandings of insanity as somatic in origin, developed by alienists in the 1870s and 1880s. If insanity was a disease of the brain or nervous system as alienists theorised, and so akin to other physical disease, then it followed that its sufferers ‘should receive the same care and treatment as physically ill patients in the general hospital’. The asylum must become a hospital, and its attendants nurses, trained in the care of the sick.18 McCreery had articulated this view several years earlier, while superintendent of the Ararat Asylum, declaring that ‘an institution like this should be looked upon as an hospital for persons suffering from certain forms of brain disease. Nurses are required to tend, look after, and nurse, and not warders to guard as in a gaol.’19 In 1889 his successor at Ararat, Dr W. Beattie Smith, asserted that: if we in Victoria are to maintain our proper place in dealing with that kind of disease which we set ourselves to treat, some systematic plan of teaching the staff must at once be adopted, and thus bring up insane hospitals nearer to the standard of nursing which exists in general hospitals.20

Their attendance at the second Intercolonial Medical Congress of Australasia, organised by the Australasian Branches of the British Medical Association and held in Melbourne in January 1889, no doubt strengthened their resolve. The training of attendants was the subject of considerable discussion among the members of the recently established Psychological Section of the Association. In his address, the section’s president, Dr Frederick Norton Manning, urged ‘the systematic training of attendants and nurses for their special duties’, adding that such training ‘should include a knowledge of general, as well as special nursing’.21 Manning was also the Inspector-General of the Insane in New South Wales, the colony neighbouring Victoria to the north. Under his administration, steps to train attendants had been underway for several years. In 1885 Dr W. C. Williamson, the medical officer at the Hospital for the Insane at Parramatta, fourteen miles west of Sydney, had written a manual, Lectures on the Care and Treatment of the Insane: For the Instruction of Attendants and Nurses, a copy of which was given to all new attendants and nurses commencing duty.22 In 1887 his colleagues, Dr Sinclair and Dr Chisholm Ross, had delivered ‘a special course of lectures’ to the nurses at the Gladesville Hospital for the Insane in Sydney, after which Williamson 57

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conducted an examination on the subjects taught, those candidates who achieved a satisfactory pass receiving ‘certificates of efficiency’.23 The following year training was extended to the men at Gladesville.24 Both Williamson and Sinclair addressed the Psychological Section. Williamson spoke at length on ‘the training of nurses and attendants in hospitals for the insane’, arguing that the example of general nursing demonstrated both the practicability and advantages of ‘systematic training’ of attendants.25 Sinclair, speaking on ‘the extension of hospital methods to asylum practice’, began his discussion by asserting that: Each year, those who have to do with the insane become more convinced, that the asylum of the future should be a hospital, with powers of detention; that the insane patient should be treated altogether as a sick person; and that the main idea of the hospital for the insane should be medical treatment of disease, not mere detention and separation from society.26

Medical treatment required ‘improved nursing arrangements’ and they, in turn, he suggested somewhat circularly, required attendants to receive ‘some more or less systematic training, to allow of their being able to carry out intelligently, ideas as to improved nursing’.27 In the discussion following Williamson’s paper, all present ‘agreed that instruction of the attendant and nurse was the thing, at the present time, in the further advancement of the curative agencies brought to bear on the insane, and ought to be carried out zealously, as part of the medical officers’ duties’.28 McCreery certainly attempted to see it made so in Victoria. After consulting with some of his medical colleagues in the department, he ‘brought the resolution of the congress under the notice of the authorities and made suggestions for carrying it into effect’ but received a ‘discouraging reply’.29 That reply likely came from Dick, the Inspector of Asylums, who expressed his views on the subject in his report for 1888. Dick was obviously well aware of developments at ‘home’, because he began by discussing the content of the Handbook for the Instruction of Attendants on the Insane, published by the Medico-Psychological Association of Great Britain (MPA) in 1885. This, he explained, embodied information designed to assist attendants in the intelligent performance of their duties. Rules on nursing, and the relations which should exist

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Attendant training in Victoria between patients and those in charge of them, and elementary instruction in anatomy, physiology, and surgery, are amongst the principal features of the work.30

While training had thus far ‘only been very partially adopted in European asylums’, Dick declared there could ‘be little question that, when practicable, it should benefit those who come under its influence’. Nonetheless, he foresaw several obstacles in the way of any unqualified implementation of such a scheme in Victoria. Teaching, he believed, ‘should be compulsory to have its best effect’, but imposing such a condition would conflict ‘with the terms on which many of the senior officers entered the service’. To the suggestion, probably from McCreery, ‘that certificates should be granted to those who have passed a satisfactory examination, and that promotion should depend on the possession of these’, he objected that ‘only a central authority should examine and issue such certificates’. This was ‘a course he considered not readily adaptable’ to the circumstances in Victoria. He also warned that the ability to reply to ‘questions on a text-book’ afforded ‘only indifferent evidence of fitness to be intrusted with the care of the insane. Certain moral and physical qualifications are even more desirable in attendants than mere cleverness, and can only be known to the officers under whom they serve.’ Given all these circumstances, he recommended ‘a voluntary system of teaching and examination, carried out on the lines of the text-book of the MedicoPsychological Association’, as the best resolution of the question.31 By late 1889 Dick had issued copies of the Handbook to the asylums and the medical officers had begun to present lectures and practical demonstrations to supplement its contents, in an attempt to impart to the attendants ‘the principles of nursing, together with some insight into mental and physical disease’.32 Attendants proved none too willing to participate in this new, doctor-led initiative. In 1891 Dick reported that many had ‘failed to take full advantage’ of the opportunity to ‘acquire special knowledge of their duties’.33 Dr O’Brien, now superintendent at the Sunbury Asylum, concluded from his experience that attendance at lectures ‘should be compulsory’, an indication of the degree of enthusiasm with which the attendants there had greeted the new scheme.34 The attendants at the Ararat Asylum were apparently as little inclined to participate as their 59

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Sunbury counterparts, their superintendent declaring that ‘unless attendance on lectures and demonstrations is made compulsory no good will accrue’.35 McCreery apparently had no better luck at Kew. His experience moved him to ‘again suggest that it be made the duty of … the [warders] to learn; and that proper examinations be held to ascertain that warders have learned nursing and the other duties of their position’.36 While their actions in absenting themselves make their reluctance to participate clear, attendants have left no written record to explain it. Historian Mick Carpenter argues that attendants in England possessed ‘an instrumental (i.e. economic) orientation’ to their work.37 The incentives the superintendents advocated to induce attendants to participate assume a similar orientation among attendants in Victoria. O’Brien recommended that both the permanent appointment of probationers and promotion should depend upon participation,38 suggesting that in the absence of any tangible reward (or penalty) attendants were unwilling to participate. ‘A systematic plan for training the attendants as nurses of the insane’: training 1894–1903 In June 1894 Dick retired. Appointed Inspector in his stead, McCreery lost little time in proposing a ‘systematic plan for training the attendants as nurses of the insane’. The scheme he devised, approved by the Chief Secretary in late January 1895,39 was founded on the MPA Handbook, the course extending over two years, with ‘12 or 14 lectures given each year by the Medical Staff of each Asylum, explaining the subjects treated’ in it. The first year of lectures covered ‘Elementary Anatomy, Physiology and general practical nursing’, the second ‘Instruction in the knowledge of special diseases and in more advanced nursing’, with examinations held at the end of each year’s training. Newly appointed attendants were sent initially to the hospital ward to receive instruction ‘in practical work’.40 Two days after receiving the Minister’s approval, McCreery instructed the superintendents to post the notice informing the attendants of the introduction of the scheme and expressing the hope that they would take ‘full advantage’ of it.41 By early 1896, lectures had ‘been given in all asylums and one hundred and ten attendants 60

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and nurses presented themselves for examination’.42 This represented a little over a quarter of the ordinary attendant staff,43 revealing that training continued to meet with considerable resistance, and prompting McCreery to reiterate that if the scheme was to succeed it must be made compulsory or inducements given to the staff to encourage their participation.44 While the notice posted in the mess rooms in January 1895 had warned that ‘appointments after probation, promotions, transfers and increments must in a measure depend on the warders having acquired a proper knowledge of their duties’, this was not in fact the case. McCreery had recommended these provisions as part of his original plan,45 but they required the approval of the Public Service Board, and by late October 1896 the board had agreed only to the first condition, that probationers must pass the first or junior examination before appointment to the permanent staff.46 Crucially, training was compulsory only for newly appointed staff, not for those attendants employed in the service prior to the introduction of the scheme. Both the actions of the attendants in absenting themselves, and the recommendations made by McCreery in response, strengthen the impression that without material reward (or cost) attendants saw no reason to participate. Subsequent events at the Ararat Asylum only reinforce this impression. Since the introduction of the training scheme in early 1895, the superintendent at Ararat, Beattie Smith, had sought to induce his staff to participate, issuing memos each year in which he reminded them of the introduction of the scheme and called for candidates to sit the coming examinations. After the first of these met with an almost complete absence of interest, he conceded senior staff the privilege of attending ‘even if they had not availed themselves of the previous teaching’ so that they might pass both examinations together, but this concession proved no more persuasive. In August 1897, when he called again for candidates to sit the approaching senior examination, only seven women put their names forward. Among the men, there were no applicants.47 Three days later, thirty-one of the forty-four Ararat attendants (all men) wrote to the Public Service Board to query whether ‘retention in the Service, Promotion or increase of salary depends upon our attendance at these lectures and passing the examinations which are being held from time to time’. The men were calling Beattie Smith’s 61

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bluff, because despite his certain knowledge that it was not the case, he had emphasised that ‘appointments, promotions, transfers and increments’ depended on participation. While the men gave no reasons for their resistance, their enquiry provides further evidence that attendants were not willing to participate if nothing material depended on their doing so. However, a demographic analysis of the petitioners suggests there may have been other reasons for their reluctance. In the 1870s and 1880s the department had found it difficult to recruit and retain medical staff.48 Only young doctors very recently graduated were willing to accept posts in the asylums, and then only as interim positions until places ‘in general or medical practice offered’.49 Nor had the pay proved sufficient to encourage medical men to remain in asylum employment. Many attendants, in contrast, had worked in the asylums for considerable periods. Consequently, attendants with many years’ experience found themselves subject to the authority of men much younger and seemingly less knowledgeable than themselves, a situation they resented.50 In 1885 James Beggs, a Yarra Bend attendant for almost eighteen years, wrote to the Royal Commission investigating the management of Victoria’s asylums. In his letter, he complained of the manner in which Dr Smith, appointed to the department two years earlier and then senior deputy medical superintendent, spoke to the attendants. Beggs found Smith’s manner ‘very degrading, although he appears to be under 30 years of age, he will snub men that has been in the service and had done their duty to the satisfaction of their superior officers before he had left the nursery’.51 Beggs was articulating a more widespread antagonism between attendant men and the junior medical officers,52 an antagonism perhaps mostly violently expressed by attendant William Meehan, who in 1880 angrily replied to a reprimand from the resident medical officer at Kew with the retort that ‘He would not be bounced by a boy’, before striking the doctor several times.53 In the early 1890s Australia experienced a severe economic depression that hit Victoria particularly hard. The government responded by paring its spending ‘to the bone’.54 Among the economies instituted in the asylums was compulsory retirement of attendants at age 60 and their replacement by lower-paid juniors.55 Despite this measure, there continued to be men in the asylums possessed of considerable 62

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experience. Among the Ararat men to sign the petition to the Public Service Board in August 1897 was 48-year-old William White. By the time White put pen to paper, he had worked as an attendant for some twenty-six years, since December 1871. His fellow attendant, 42-yearold Roland Hill, whose name headed the list of signatures, had accrued twenty-two years service and a third signatory, W. Stubbings, aged 39, had two decades’ experience to his name. All three men were in charge of the wards in which they worked. In contrast, the junior medical officer slated to give the lectures, Dr James Thompson, was 28 years old and, having been appointed in April the previous year, could boast only a little over a year’s service.56 It is not difficult to imagine that White, Hill and Stubbings, given their considerable experience, might have felt disinclined to be lectured to by a medical officer with considerably less experience and, indeed, in White’s case, by a man who had not ‘left the nursery’ when he began his career as an attendant. Even taking the Ararat signatories as a whole, the median years of service of the thirty-one petitioners was eight-and-a-half, the average almost ten, still considerably more than the man expected to convey to them ‘the proper knowledge of their duties’, as the 1895 notice introducing the scheme expressed it.57 Nor was the situation at Ararat atypical. At Yarra Bend, for example, the junior medical officer had four years’ service, in contrast to the thirty-three years accrued by the longest serving attendant; the median for attendant men as a whole was eleven years and the situation was similar at the other asylums.58 Beattie Smith expected that the men’s petition would spur the Public Service Board to make the sorts of changes he and the other medical officers believed were necessary to ensure the success of the scheme.59 The board’s response must then have proved a sore disappointment. In September 1897, in a letter ‘to certain Male Attendants’, it ruled attendance at lectures and sitting of examinations ‘optional’. The board did add ‘that it would be well for Attendants to consider that by availing themselves of the advantages freely offered for their instruction they may become more competent to perform the duties of their position’.60 However, a spirited defence by attendants against public allegations of inefficiency some years later suggests they were unlikely to heed such advice, believing themselves already entirely competent and in no need of any further instruction. 63

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In July 1902 Dr Joske, Dr Jamieson and Dr Springthorpe, the Official Visitors to the Metropolitan Asylums, met with the Chief Secretary to express their opinions on reforming the administration of asylums.61 Among the changes they advocated was the proper training of ‘nurses and warders, who should be compelled to pass examinations’. When the Age newspaper subsequently reported the meeting, it prompted the ‘attendants in the various Asylums of the State’ to write to the Chief Secretary in protest.62 On the contention that training should be compulsory, the attendants asked: how is it that under present conditions where so much is left to the attendant in the Medical care of the Insane – the doctors interfering but rarely in the practical work – the attendant can be considered incompetent or requiring any further acquirement of matter which we hold is not necessary or consistent with the domain of Asylum labour.63

Much, indeed, was left in the hands of attendants. It could hardly be otherwise, given the very few medical men and the large numbers of patients. At Kew, for example, the medical superintendent, assisted by two medical officers, was responsible for the care of 858 patients. In the country asylums, two medical men were responsible for between six and seven hundred inmates.64 In these circumstances, in which so much care of the patients fell by necessity to the attendants, the latter might ­reasonably consider they did not require ‘any further acquirement of matter’. Nor did they consider the knowledge doctors wanted to convey relevant, as their remark that it was not ‘consistent with the domain of asylum labour’ reveals. Indeed, one of their objections to training was ‘the character of the duties being always foreign to some of the questions’ asked at the examination.65 Attendants in Victoria were not the first to express such a view. In a review of the first edition of the Handbook, the unnamed author ‘questioned whether some of the details of physiology were necessary to attendants’.66 Perhaps, as historian Mark Finnane suggests, he was the author who the following year commended Williamson’s Lectures ‘for omitting “all description of the anatomy and physiology of the brain in a book intended for the use of attendants and nurses”’.67 In Victoria, a consideration of the nature of their duties suggests why many of the attendants considered training irrelevant to their 64

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day-to-day work on the wards. In August 1898, three-and-a-half years after he introduced the training scheme, McCreery redrafted the existing Regulations for Attendants and Nurses.68 However, the duties he set out did not differ radically from those described in earlier codes, continuing to emphasise the attendant’s responsibility for the safe and secure care of patients, as had the original regulations of 1848 and their subsequent revisions.69 In 1898, as earlier, the regulations charged attendants to keep the patients from harming themselves or others by securing potentially dangerous objects and medicines, and ensuring that their surroundings were free from hazards. Preventing escape also continued to be the responsibility of attendants, as it had always been. Attendants also continued to be responsible for the personal and bodily care of patients and were expected to examine them regularly for any injury or sign of serious disease and report these to the medical officer. One difference between the 1898 and earlier codes of regulations is the absence of any reference to domestic work. This probably reflected McCreery’s belief that the formation of ‘a first-class nursing service’ depended on the separation of the nurses ‘from the artisans and servants’,70 but in the continued absence of a separate domestic staff, attendants (or patients) must have continued to do the work necessary to maintain the domestic world of the asylum. Only one clause referred explicitly to duties consistent with the training of attendants as nurses, directing them to ‘observe indications of mental or bodily disease and report them to the medical officer, and … carry out such treatment as ordered’. Even this was not entirely new. Earlier regulations had required attendants to observe the patients carefully, so as to be able to report to the Medical Officer the slightest symptom of illness or indication of amendment; they must observe the nature of the excretions, the state of their appetite, the habits of each patient, their mental condition, and any delusions they may entertain.71

Now, however, the standard of observation expected was ‘the ­knowledge and skill that could be acquired by a capable and willing person during the two years of training now given in the asylums, and any special instructions that have been given’.72 This, however, 65

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may have been as much a spur to participation as an objective benchmark. The structure of the scheme also encouraged perceptions of irrelevance. In Victoria, as in Britain, attendants did not receive instruction in the care of the insane until the second year of training, by which time they had been working on the wards for a considerable period. In 1902 the attendants objected to ‘attendants and nurses who performed their work for many months creditably’ being forced to resign because they were subsequently ‘unable to answer a few catchy questions at an oral nursing examination’, particularly when those questions were in their view unrelated to ‘the character of their duties’.73 In these circumstances, as other historians suggest, attendants must have ‘learned the details of their work by word of mouth from colleagues, or possibly by instruction from the head nurse’.74 These circumstances were only likely to have confirmed the relative worth attendants accorded medical knowledge when compared with their own practical experience, and hence their resistance to training. In 1885 James Beggs made their relative merits clear when the Royal Commission asked him to explain why he objected to the appointment of inexperienced ‘boy doctors’: My reasons are that as soon as a young man – a doctor by profession – will get his diploma, he will be immediately appointed to the lunatic asylums. He has perhaps never seen half-a-dozen lunatics in his life. Therefore he will order men to do things, order warders to do things, that that warder knows very well are wrong, and he dare not disobey. Although the warder has only practical experience, the other may have theory. But I would not give an ounce of practical experience for a pound of theory.75

In 1902 the attendants continued to stress the value of their ‘practical experience’. In response to the criticisms of inefficiency made by the Visitors, they emphasised the ‘cheerful and experienced method’ they adopted with patients. Nor, they asserted, were the Visitors in any position to judge their competence, ‘since their visits are rare and spasmodic, and there is no record of any of these gentlemen having during these visits went [sic] into the question of an attendant’s efficiency, where the testing ground should lie i.e. the scene of labour’. In other words, their efficiency should – could only – be gauged on the ground and in practice. Practical experience was also central to their objection 66

Attendant training in Victoria

to the forced dismissal of those attendants who had ‘performed their work creditably for many months’ but were caught out by devious questioning at the subsequent examination. Attendants argued that the repeated replacement of those so dismissed with new appointees threatened to create a ‘floating staff’, a policy they considered ‘very much against the dictates of commonsense’. What was needed, this argument implied, was a settled and, by extension, experienced staff.76 The resistance to training among attendants probably also reflected their suspicion of the medical staff’s motives. In 1902 they concluded their objections to the creation of a floating staff with the warning that while against common sense, this was ‘what will be done should Superintendents control be increased’.77 Asylum doctors had in fact long argued the necessity for their increased control over attendants, but to little avail.78 In 1902 the power of appointment, promotion and dismissal remained with the Public Service Commissioner (the successor to the Public Service Board). In 1903 Springthorpe attributed ‘the present deplorable condition’ of the asylums to the division of authority between the Chief Secretary and the Commissioner and the ‘want of proper control’ consequently exercised by its senior officers.79 A year earlier, he and his brother Visitors had complained to the Chief Secretary that, ‘Under present conditions … there was not sufficient control over the staff. Whether men were found inefficient or not they went on in the stereotyped way in their positions, and promotion depended entirely on seniority.’ It was in this context that they called for ‘properly trained nurses and warders, who should be compelled to pass examinations’.80 Moreover, as Mick Carpenter suggests, the ratio of doctors to patients gave attendants a significant degree of informal power in their day-to-day relations with the medical staff. Doctors, unable to keep in mind the condition of so many patients, relied on attendants for their knowledge of individual patients. Any refusal by attendants to act as intermediaries between the medical officer and the patients threatened ‘to overwhelm the medical staff with work. Thus, in many instances, though doctors “ordered” treatment for individual patients, it must often have been at the behest of attendants.’ Attendants, Carpenter concludes, effectively ‘ran the asylums’.81 Transforming the asylum into a mental hospital and attendants into nurses promised to give asylum doctors in Victoria the power 67

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over attendants that they had long argued was necessary. If attendants were remade as nurses, their control and training must logically fall within the domain of medicine.82 In 1883, when McCreery declared that the asylum should be seen as a ‘hospital for persons suffering from certain forms of brain disease’ and so staffed by nurses, he added that because ‘few persons’ possessed ‘the nursing faculty to any great degree, it therefore follows that the attendants should be selected by skilled persons’83 – in other words, by asylum doctors rather than by the laymen who comprised the Public Service Board. Moreover, as attendants themselves seemed to recognise in 1902, the necessity to pass an examination set by asylum doctors would finally deliver the long sought power of dismissal into the latter’s hands, from which there could seemingly be no appeal to non-medical authorities. Training also promised to rein in attendant autonomy because, in Boschma’s words, it shifted ‘the socialization of asylum personnel under medical control’ and away from attendants themselves.84 In his 1889 address to the Congress, Williamson argued the importance of such a shift. ‘In too many instances’, he declared, ‘the system hitherto has been to allow the raw material to develop of itself, without assistance or instruction worthy of the name from the medical officers.’ While he doubted that experienced attendants bothered themselves with ‘new hands’, he suspected ‘any training or example’ they did provide could not always be said to be what is desirable. Almost invariably a lazy, indifferent senior will spoil the juniors in the same ward by force of example, and the first six or twelve months may well be said to make or mar the future of the probationer. The difference between a trained nursing staff and one allowed to develop of itself, is just the difference between skilled and unskilled labour.85

The training scheme McCreery devised was similar to its MPA counterpart in having all the lectures and examinations conducted by the asylum medical officers, ‘thus ensuring that training remained firmly under medical control’.86 Training, then, was an imposition of medical knowledge,87 of that ‘theory’ the value of which attendants compared so unfavourably to their ‘practical experience’. While for Williamson the difference between the trained and untrained was the difference between the skilled and unskilled, from the attendant 68

Attendant training in Victoria

perspective training undermined the practical experience that was the core of the occupation and forced them to rely on doctors for knowledge. In short, training threatened ‘professional subordination’.88 Conclusion In 1903 the government passed a new Lunacy Act. In his report for the year, the last under the existing system, McCreery considered it appropriate ‘to draw attention to the reforms effected during the last few years’. Among these, he counted the ‘systematic training of the attendants and nurses’.89 This was something of an exaggeration, however. By his own admission, the system had ‘to a great degree broken down’ for ‘want of support’ from the Public Service Board.90 The new Act finally overcame this obstacle, removing ‘control of the Asylum Staff from the Public Service Commissioner, and [giving] the supreme authority, as well as responsibility, to an Inspector-General’.91 Dr W. Ernest Jones, recruited to the position from England in 1905, was consequently able to introduce the kind of training scheme McCreery had sought since the mid-1880s, in which permanent appointment, wage increments and promotion all depended on satisfactory completion of the course.92 The first lectures and examinations under the new scheme were conducted in 1907.93 The history of the changes it wrought to the occupation, and the response of the men and women who were its objects, are yet unwritten.94 For the asylum medical officers, the successful establishment of attendant training was a crucial element in setting the care of the insane on a proper medical footing, but perhaps their achievement came at the expense of other possibilities. By the time the first attempt to train attendants was instituted, the occupation of attending in Victoria was some four decades old. Many of the men and women who worked in Victoria’s asylums had accrued considerable practical experience attending the insane and, by necessity, much of the day-to-day care fell to them. Historian Richard Russell suggests that ‘for a brief time during the later part of the nineteenth century’, attendants ‘were the most vital part of the asylum business’ and as such their ideas and attitudes might ‘have had significant ­consequences for treatment and professional relations’.95 How the care and treatment of the insane might have developed if the a­ lienists’ ambitions to train 69

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their attendants had not finally prevailed is perhaps difficult to know but is a question at least worth asking. Notes   1 This chapter draws from Lee-Ann Monk, Attending Madness: At Work in the Australian Colonial Asylum (Amsterdam: Rodopi, 2008), with the kind permission of Editions Rodopi B.V., Amsterdam, http://www.rodopi.nl.   2 Public Record Office Victoria (hereafter PROV), VPRS 7555/P1, Unit 1, pp. 176–8, re Instruction in nursing to Warders &c.   3 P. Nolan, A History of Mental Health Nursing (Cheltenham: Stanley Thornes, 1993), pp. 63–8; M. Finnane, Insanity and the Insane in Post-Famine Ireland (London: Croom Helm, 1981), pp. 180–1.   4 A. Scull, ‘Review of C. S. Coleborne, Madness in the Family: Insanity and Institutions in the Australasian Colonial World’, Health and History, 12:1 (2010), 130–3 (p. 131).  5 E. Malcolm, ‘Australian asylum architecture through German eyes: Kew, Melbourne, 1867’, Health and History, 11:1 (2009), 46–64 (pp. 47–8).   6 C. R. D. Brothers, Early Victorian Psychiatry, 1835–1905: An Account of the Care of the Mentally Ill in Victoria (Melbourne: Government Printer, 1961), pp. 63–5, 85–90, 97–8.  7 Brothers, Early Victorian Psychiatry, p. 119.   8 PROV, VPRS 19/P, Unit 1909, File 1848/1780, letter, 8 August 1848.  9 ‘Supplement to the Victoria Government Gazette of Friday, 30 January, 1885’, Victoria Government Gazette (hereafter VGG), 12, 31 January 1885, pp. 383–5. 10 Report from the Select Committee upon the Lunatic Asylum (hereafter Yarra Bend Inquiry), 1857–8, Victorian Parliamentary Papers (hereafter VPP), Vol. I, 1857–8, Appendix E. ‘STATEMENT Showing the Average Period of Employment of Servants, at the Yarra Bend Lunatic Asylum, from the 1st January, 1853, to the 31st December, 1857.’ 11 Yarra Bend Inquiry, Minutes of Evidence, Q.989–95, 40. 12 Analysis of PROV, VPRS 7519, Unit 1. 13 Supplement to the VGG, 30 January 1885, p. 380. 14 Royal Commission on Asylums for the Insane and Inebriate (hereafter Royal Commission), 1884–6, VPP, Vol. II, 1886, Report, xxiv. 15 Royal Commission, Minutes of Evidence, Q.8966–7, 364. For an example of such an appeal see PROV, VPRS3991/P, Unit 1237, File 1881/U1059. 16 Royal Commission, Report, xxv. The asylum staff was brought under the operation of the Act at the beginning of 1885. 17 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1887, VPP, Vol. III, 1888, p. 43.

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Attendant training in Victoria 18 G. Boschma, The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums 1890–1920 (Amsterdam: Amsterdam University Press, 2003), pp. 19, 59, 60–1; O. M. Church, ‘The emergence of training programmes for asylum nursing at the turn of the century’, Advances in Nursing Science, 7:2 (1985), 35–46 (p. 36); Finnane, Insanity and the Insane in Post-Famine Ireland, pp. 181–2; V. M. Tipliski, ‘Parting at the crossroads: the emergence of education for psychiatric nursing in three Canadian provinces, 1909–1955’, Canadian Bulletin of Medical History (hereafter CBMH/BCHM), 21:2 (2004), 253–79 (pp. 255–6). 19 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1882 (hereafter Report of the Inspector, 1882), VPP, Vol. II, second session, 1883, p. 27. 20 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1888 (hereafter Report of the Inspector, 1888), VPP, Vol. IV, 1889, pp. 60–1. 21 F. N. Manning, ‘Section of Psychology, President’s Address’, in Intercolonial Medical Congress of Australasia, Transactions of Second Session held in Melbourne, Victoria, January 1889, Vol. II (Melbourne: Stilwell and Co., 1889), pp. 816–33 (p. 832). 22 W. C. Williamson, Lectures on the Care and Treatment of the Insane for the Instruction of Attendants and Nurses (Sydney: Thomas Richards, Government Printer, 1885), p. 3. 23 Inspector-General of the Insane, Report for 1887, Journal of the Legislative Council of New South Wales, second session 1887–88, Vol. XLIII, part IV, pp. 10–11. 24 Inspector-General of the Insane, Report for 1888, Journal of the Legislative Council of New South Wales, first session 1889, vol. XLV, part II, p. 9. 25 W. C. Williamson, ‘The training of nurses and attendants in hospitals for the insane’, in Transactions of Second Session held in Melbourne, pp. 887–95 (pp. 889–92). 26 E. Sinclair, ‘The extension of hospital methods to asylum practice’, in Transactions of Second Session held in Melbourne, pp. 895–8 (p. 895). 27 Sinclair, ‘The extension of hospital methods to asylum practice’, p. 895. 28 Williamson, ‘The training of nurses and attendants’, p. 894. 29 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1889 (hereafter Report of the Inspector, 1889), VPP, Vol. III, 1890, p. 48. 30 Report of the Inspector, 1888, p. 18. 31 Report of the Inspector, 1888, pp. 17–18. 32 PROV, VPRS 7555/P1, Unit 1, Memo No 89/1708, 30 October 1889, 82; Report of the Inspector, 1889, pp. 37, 48, 84; Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1890 (hereafter Report of the Inspector, 1890), VPP, Vol. VI, 1891, pp. 21, 36, 48, 65, 85. 33 Report of the Inspector, 1890, p. 21. 34 Report of the Inspector, 1890, p. 85.

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Mental health nursing 35 Report of the Inspector, 1890, p. 65. 36 Report of the Inspector, 1890, p. 48. 37 M. Carpenter, ‘Asylum nursing before 1914: a chapter in the history of labour’, in C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980), pp. 123–46 (p. 141). 38 Report of the Inspector, 1890, p. 85. 39 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1894, VPP, Vol. III, second session, 1895–6, p. 12; PROV 3992/P, Unit 556, 1894/Y7144, McCreery to the Under Secretary, 27 September 1894. 40 PROV, VPRS 3992/P, Unit 682, File 1897/F9375, McCreery for the information of the Public Service Board, 22 September 1897 Nursing in Asylums; VPRS 7555/P1, Unit 1, pp. 176–8, Memo re Instruction in Nursing to Warders &c, 24 January 1895. 41 PROV, VPRS 7555/P1, Unit 1, pp. 176–8. 42 PROV, VPRS 3992/P, Unit 609, File 1896/C724, Inspector to Under Secretary, 28 January 1896. 43 ‘Persons Employed in the Public Service of Victoria on the 31st December 1895’, Fourth Supplement to the VGG of Friday January 24, 1896, no. 13, 31 January 1896, pp. 15–27. Note that the figure excludes head attendants, matrons and artisan attendants. 44 PROV, VPRS 3992/P, Unit 609, File 1896/C724, Inspector to Under Secretary, 28 January 1896. 45 PROV, VPRS 3992/P, Unit 723, File 1894/Y7144, McCreery to the Under Secretary, 27 September 1894. 46 PROV, VPRS 3992/P, Unit 648, File 1897/E722, Report of Second Annual Conference of Medical Staff, First Ordinary Meeting, 28 October 1896. 47 PROV, VPRS 3992/P, Unit 682, File 1897/F9375. 48 Brothers, Early Victorian Psychiatry, pp. 90, 107. 49 Royal Commission, Report, xxxv–viii; Brothers, Early Victorian Psychiatry, p. 175. 50 Monk, Attending Madness, pp. 216–17. 51 Royal Commission, Minutes of Evidence, Q.9818, 412. 52 Monk, Attending Madness, pp. 201–2, 215–18. 53 PROV, VPRS 3991/P, Unit 1237, File 81/U1059. 54 T. Dingle, Settling (Sydney: Fairfax, Syme and Weldon, 1984), p. 124. G. Blainey, A History of Victoria (Melbourne: Cambridge University Press, 2006), p. 144. 55 Brothers, Early Victorian Psychiatry, p. 165. 56 ‘Supplement to VGG of Friday, January 28, 1898’, VGG, no. 8, 31 January 1898, pp. 21–2. 57 ‘Supplement to VGG of Friday, January 28, 1898’, VGG, no. 8, 31 January 1898, pp. 21–2 and ‘Supplement to VGG of Friday, January 27, 1899’, VGG, no. 8, 31 January 1899, pp. 21–2.

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Attendant training in Victoria 58 ‘Supplement to VGG of Friday, January 28, 1898’, VGG, no. 8, 31 January 1898, pp. 15–27. The exception was the Ballarat Asylum, opened in 1893, where the superintendent had accrued eight years’ service, in contrast to a median of five for the attendant men. The head attendant, however, had twenty-eight years’ service. Its recent establishment perhaps explains the difference. 59 PROV, VPRS 3992/P, Unit 682, File 1897/F9375, W. Beattie Smith to the Inspector, 9 August 1897. 60 PROV, VPRS 3992/P, Unit 759, File 1899/J6851, Secretary, PSB to the Under Secretary, 26 July 1899, and Secretary, PSB to certain Male Attendants, 30 September 1897. It is unclear whether this letter was in reply to the query from Ararat, though the timing suggests it, or a reply to a separate query. No correspondence for the PSB itself survives prior to 1901. 61 PROV, VPRS 3992/P, Unit 892, File 1902/P7455, undated newspaper cutting. 62 PROV, VPRS 3992/P, Unit 892, File 1902/P7455, Attendants in the various Victorian asylums to the Chief Secretary (hereafter petition), 24 July 1902. The surviving petition is unsigned, making it impossible to discover anything about its authors. 63 PROV, VPRS 3992/P, Unit 892, File 1902/P7455, petition, 24 July 1902. 64 ‘Table I Showing the Distribution of the Insane on 31st December 1901’, Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1901 (hereafter Report of the Inspector, 1901), VPP, Vol. II, 1902, p. 2, and ‘Persons Employed in the Public Service of Victoria on the 31st December 1901’, Third Supplement to the VGG, no. 14, 31 January 1902, pp. 17–33. 65 PROV, VPRS 3992/P, Unit 892, File 1902/P7455, petition, 24 July 1902. 66 Finnane, Insanity and the Insane in Post-Famine Ireland, p. 182. 67 Finnane, Insanity and the Insane in Post-Famine Ireland, p. 182, quoting from Journal of Mental Science, 137:32 (1886), 122. 68 PROV, VPRS 3992/P, Unit 723, File 1898/G7010, McCreery to the Under Secretary, 3 August 1898. 69 PROV, VPRS 19/P, Unit 130, File 50/77, Regulations for the Guidance of the Officers, Attendants and Servants of the Lunatic Asylum, Port Phillip; VPRS 3991/P, Unit 752, File 1872/E2729, Hospitals for the Insane: Regulations. For a detailed discussion of attendant duties, see Monk, Attending Madness, pp. 30–2, 63–4, 106–7, 156. 70 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane for the Year, 1885, VPP, Vol. III, 1886, p. 47. 71 PROV, VPRS 3991/P, Unit 752, File 1872/E2729, Hospitals for the Insane: Regulations. 72 PROV, VPRS 3992/P, Unit 723, File 1898/G7010, Regulations for Attendants and Nurses. 73 PROV, VPRS 3992/P, Unit 892, File 1902/P7455, petition, 24 July 1902.

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Mental health nursing 74 Boschma, The Rise of Mental Health Nursing, pp. 158, 193–4; Nolan, A History of Mental Nursing, pp. 154, 156. 75 Royal Commission, Minutes of Evidence, Q.9818–9, 412–13. 76 PROV, VPRS 3992/P, Unit 892, 1902/P7455, petition, 24 July 1902. 77 PROV, VPRS 3992/P, Unit 8921902/P7455, petition, 24 July 1902. 78 Monk, Attending Madness, pp. 202–5. 79 J. W. Springthorpe, ‘Our Metropolitan Asylums’, Intercolonial Medical Journal, VIII:3 (20 March 1903), 122. 80 PROV, VPRS 3992/P, Unit 892, P/7455, undated newspaper cutting. 81 Carpenter, ‘Asylum nursing before 1914’, p. 139. 82 Boschma, The Rise of Mental Health Nursing, p. 75. 83 Report of the Inspector, 1882, p. 27. 84 Boschma, The Rise of Mental Health Nursing, p. 20; compare P. Connor, ‘“Neither courage nor perseverance enough”: attendants at the asylum for the insane, Kingston, 1877–1905’, Ontario History, 88:4 (1996), 251–72 (p. 264). 85 Williamson, ‘The Training of Nurses and Attendants’, pp. 890–1. 86 C. Chatterton, ‘“Caught in the middle?” Mental nurse training in England 1919–51’, Journal of Psychiatric and Mental Health Nursing, 11 (2004), 30–5 (p. 31). 87 Chatterton, ‘Caught in the middle’, pp. 30–1, 34. 88 J. F. Sweeney, ‘The role of the Irish Division of the Royal Medico-Psychological Association in the development of intellectual disability nursing in Ireland’, CBMH/BCHM, 28:1 (2011), 95–122 (p. 99). 89 Report of the Inspector of Lunatic Asylums on the Hospitals for the Insane, 1903, VPP, Vol. II, 1904, p. 14. 90 Report of the Inspector, 1901, p. 16. 91 J. W. Springthorpe, ‘The New Lunacy Bill’, Intercolonial Medical Journal, VIII:12 (20 December 1903), 608–11 (pp. 609–10). 92 Public Service Acts, Regulations, Lunacy Department, VGG, 19 December 1906, 5120–2. 93 Hospitals for the Insane. Report of the Inspector-General of the Insane 1907, VPP, Vol. I, pp. 18, 20, 22, 25, 33. 94 P. Martyr, ‘A lesson in vigilance? Mental health nursing training in Western Australia, 1903–1958’, Issues in Mental Health Nursing, 31:11 (2010), 723–30 (p. 724). 95 R. Russell, ‘The lunacy profession and its staff in the second half of the nineteenth century, with special reference to the West Riding Lunatic Asylum’, in W. F. Bynum, R. Porter and M. Shepherd (eds), Anatomy of Madness: Vol. III: The Asylum and its Psychiatry (London: Routledge, 1988), pp. 297–315 (p. 312).

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4

‘Who are these?’ Nursing shell-shocked patients in Cardiff during the First World War Anne Borsay and Sara Knight

In his powerful poem ‘Mental Cases’, Wilfred Owen – renowned trench poet of the First World War – paints a devastating picture of men ‘whose minds the Dead have ravished’. Completed after Owen was discharged from Craiglockhart Hospital in Edinburgh where he had been treated for psychological trauma, ‘Mental Cases’ reports the reactions of a visitor on entering a ward in one of the nineteen military hospitals set up for officers and men during 1917 and 1918. The first stanza describes the physical and mental manifestations of the patients’ condition; the second explains what has happened to destroy their sanity; and the third indicts not just the enemy but the politicians who took Britain to war and the public who supported them. This message is conveyed with consummate technical skill. Ellipsis  – the grammatically incorrect omission of words – heightens the tension: ‘Surely we have perished | Sleeping, and walk hell; but who [not who are] these hellish?’ Alliteration – the repetition of consonants at the beginning of a sequence of words – underlines the grotesque: ‘-Thus their heads wear this hilarious, hideous, | Awful falseness of set-smiling corpses.’ Simile – highlighting the similarities between different experiences – and metaphor – expressing one experience in terms of another – intimate the depth of the men’s despair: ‘Sunlight seems a blood smear; night comes blood-black; | Dawn breaks open like a wound that bleeds afresh.’ And their confused disorientation is captured in the uneven form of the poem, with one pair of rhyming lines, irregularly placed, in each stanza: ‘relish’ and ‘hellish’ in the first; ‘wander’ and ‘squander’ in the second; ‘other’ and 75

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‘brother’ in the third. This technical command is compounded by an allusion to Dante’s Inferno, the first book in his Divine Comedy, which he started in 1307 while in exile from Florence. ‘Instructor! who | Are these by the black air so scourg’d?’ he asks of Virgil, on whose preChristian cosmology of the underworld he relied. By supplying this ‘Dantesque framework’, Owen extended the range of ‘Mental Cases’ beyond the First World War, identifying the tortured victims of shell shock with universal human suffering. But what about the women who nursed these ‘mental cases’ so traumatised by war? This chapter explores their experiences by examining the testimonies of those who cared for patients as they were transferred from battlefield to hospital. The Cardiff City Mental Hospital (CCMH), which was requisitioned for military purposes and became the Welsh Metropolitan War Hospital (WMWH), provides a case study to assess the interplay of medicine and gender in the implementation of treatment and educational programmes. A focus on female staff maps the restrictions placed on the professional development of mental nursing and draws attention to the controversial practice of allowing nurses on to male wards at a time when the respectability of the ‘nurse’ and the manliness of her shell-shocked patients were both under intense scrutiny.1 Testimonies of caring By the time war broke out in 1914, general nursing was a well-­ established profession with its own knowledge base and ‘a carefully trained cadre of women, subject to a severe disciplinary code’. In addition, the Territorial Force Nursing Service (TFNS) was readily available in designated hospitals, while in the empire the Queen Alexandra’s Imperial Military Nursing Service (QAIMNS), set up in 1902, consisted of small units augmented by nurses in civilian hospitals who were willing to mobilise at short notice.2 Joining these professionally qualified nurses were the Voluntary Aid Detachments (VADs), a scheme organised from 1909 by a joint committee of the British Red Cross and the Order of St John of Jerusalem as part of the preparation for a major European conflict.3 Many of these volunteers had undergone preparatory courses and most were trained from three to four months during the war. However, since payment was unusual, 76

Nursing shell-shocked patients in Cardiff

they were typically recruited from upper- and middle-class backgrounds and hence ‘posed a considerable threat to the established order of nursing, especially because the patients rarely distinguished between them and the trained nurses’ who were their supervisors.4 Whether physically or psychologically injured, soldiers were picked up by stretcher bearers and conveyed to their regimental first aid post before being transferred to a Casualty Clearing Station and from there to a base hospital – first on the French coast, and then back in Britain. Nurses became involved from the point at which patients entered the Casualty Clearing Station, assessing, treating and transporting them by road ambulance, rail and sea.5 The language for those psychologically traumatised was class-inflected. Lowerranking soldiers, typically drawn from the working classes, suffered from ‘shell shock’, a metaphor of no fixed meaning, which bridged military and civilian contexts in an effort to give respectability to a poorly understood and potentially shameful disability in a group seen as more prone to mental weakness. Conversely, the officer classes suffered from ‘neurasthenia’, this scientific label suggesting a physical cause and moral probity.6 Letters, diaries and autobiographies offer unique insight into experiences of nursing patients with neurasthenia and shell shock, though – like all other historical sources – they offer not an objective account of the past but an invaluable commentary that one person has chosen and been able to record.7 These testimonies dispel the popular myth, allegedly propagated by VADs, that trained nurses were callous. Sister Edith Appleton was thus astonished and distressed by the scale of psychological trauma: We had a convoy of 399 in yesterday, but only 70 wounded. By far the majority of the sick were suffering badly from shellshock. It is sad to see them – they dither like palsied old men, and talk all the time about their mates who were blown to bits, or their mates who were wounded and never brought in.8

The physical symptoms induced by shell shock were also handled sympathetically. Sister Mary Stollard of QAIMNS, who was based at Beckett’s Park Military Hospital in Leeds, observed: They were very pathetic, these shellshocked boys, and a lot of them were very sensitive about the fact that they were incontinent. They’d say, ‘I’m

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Mental health nursing terribly sorry about it, Sister, it’s shaken me all over and I can’t control it. Just imagine, to wet the bed at my age!’ I’d say, ‘We’ll see to that. Don’t worry about it.’ I used to give them a bedpan in the locker beside them and keep it as quiet as possible. Poor fellows, they were so embarrassed.9

Minimally trained nurse volunteers also adapted to the needs of shellshocked patients. Grace Bignold, a VAD at the No. 1 London General Hospital, who had previously worked as an orderly at a convalescent home on Streatham Hill, recalled how: One of the first things I was told was that when I was serving meals to the up-patients – and most of them got up for meals there – always to put the plate down very carefully in front of them and to let them see me do it. If you so much as put a plate down in front of them in the ordinary way, when they weren’t looking, the noise made them almost jump through the roof – just the noise of a plate being put on a table with a cloth on it!10

For some VADs, however, the horror of acute shell shock was too much to bear. Claire Elise Tisdall, a VAD ambulance nurse in London, decided not to look when ‘the hopeless mental cases’ were unloaded from the train for the asylum: ‘They’d gone right off their heads. I didn’t want to see them. There was nothing you could do and they were going to a special place. They were terrible.’11 From mental hospital to war hospital Christine Hallett has argued that even qualified nurses were untrained to cope with the ‘mental cases’ that they encountered during the First World War. What rescued them, she suggests, was their expertise as generalists, which enabled a flexible approach. Whereas doctors took a ‘mechanical’ view of patients, nurses saw them as ‘whole beings’ and used their skills to harbour a process of ‘containment’ that encouraged a restoration of ‘emotional and social integration’ as well as of ‘physical intactness’.12 This may be true for those working on the field of battle or in hospitals at home where there was no prior experience of psychiatric nursing. However, some of the institutions requisitioned for war casualties were former mental hospitals, including the CCMH which functioned as the WMWH between 9 June 1915 and 31 December 1919. In the remainder of this chapter, we tease out the implications of this transition for the nursing staff who worked there. 78

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When war broke out in 1914, there were six asylums in Wales, the most recent of which was the CCMH.13 Completed in 1908, only three years after Cardiff had won city status, the hospital was an embodiment of civic pride. Therefore, the military authorities inherited an impressive site with accommodation for 750 patients and room to expand to take 1,250. Although located several miles from the city centre in the suburb of Whitchurch, the hospital’s towers – exotic constructions that concealed water storage tanks and other engineering functions – dominated the skyline. The entire building was constructed according to the most modern medical specifications and to achieve self-sufficiency there were kitchen gardens, a farm and piggeries, and maintenance staff. It was set in approximately four-and-a-half acres of landscaped grounds and the airing courts, laid out in ‘sinuous paths of asphalt’, were ‘limited by a hairpin iron railing sunk in a deep depression of the ground’. This meant that the patients exercising were ‘well above the level of the railing, whereby the constant and ever present impression of being shut in … is largely effaced’.14 These semi-rural surroundings had been carefully planned to encourage ‘moral management’ with lunatics ‘being subtly pressed towards a cultural norm’.15 This therapeutic environment was handed over to the Army Council rent free, and the services of the existing staff were retained under the same conditions as previously. The majority of civilian patients, 218 male and 354 female, were transferred to other mental hospitals in south Wales and the English borders, but 45 male patients were kept to work on the hospital farm.16 The former medical superintendent, Dr Edwin Goodall, was commissioned by the Royal Army Medical Corps as a Lieutenant Colonel and Officer Commanding at the WMWH. Remaining in charge after the military take-over, he oversaw a refit (including an operating theatre, X-ray room, dispensary, medical, surgical and dental stores) that was reported to have cost the War Office £7,000, plus the costs of removing the civilian patients to other institutions.17 As a result of the conversion, patient accommodation was substantially increased to 900 beds. In addition to the resident medical staff and visiting physicians and surgeons, there were 110 female nurses, among whom the existing staff were included, and between 80 and 90 orderlies.18 Initially, the hospital took in general medical and surgical 79

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cases. From 1917 onwards, however, it came to specialise in orthopaedic and shell-shock patients and resisted pressure to expand the orthopaedic intake at the expense of the mentally ill on the grounds that existing facilities were best utilised in this way.19 The WMWH thus became part of a national network of shell-shock treatment centres, which had begun during 1914 and 1915 with ‘D’ Block at the Royal Victoria Military Hospital at Netley on Southampton Water and the Moss Side State Institution at Maghull near Liverpool.20 We can gain insight into the culture of treatment in Wales from an article which appeared in the British Medical Journal in April 1918, written by the Consultant in Mental Diseases to the Western Command, Ernest White. White had ‘examined and taken notes of more than 800 cases of shell shock and neurasthenia’ in ‘general, sectional, auxiliary, military, Red Cross, and V.A.D. hospitals of the Western Command’. Since many such patients at first went unnoticed, the Command had decided to remove those who subsequently displayed symptoms to Maghull, Netley, or the ‘special nerve hospitals of the command’. Dismissive of arguments in the press which condemned the ‘congregating of shell-shock patients and their association for treatment under a common roof’, White insisted that ‘skilled treatment in a special hospital … greatly assisted … recovery by contact with those … whom they see are improving daily, and who will encourage them to persevere in the treatment so as to regain their self-control and self-confidence’.21 Medicine Nursing shell shock within these centres was framed by medical knowledge and practice. Elaine Showalter famously denoted shell shock as ‘the first large-scale epidemic of male hysteria’:22 a ‘masculine-sounding substitute’ for what was regarded as an ‘effeminate’ condition. Shell shock, she declared, was ‘related to social expectations of the masculine role in war’ where ‘many combatants felt themselves rendered powerless, unmanned, by the barrage of horror to which they were subjected’.23 However, her progressive narrative – that ‘gradually most military psychologists and medical personnel came to agree that the real cause of shell-shock was the emotional disturbance produced by warfare itself, by chronic conditions of fear, 80

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tension, horror, disgust, and grief’ – has been refined by more recent historiography. Showalter acknowledged that it was common for shell shock to be viewed as a form of cowardice or other weakness of character.24 But this was not simply a hangover from less enlightened times, for as Tracey Loughran has demonstrated, shell shock was not ‘the catalyst for a psychiatric revolution’ and there was ‘no straightforward transition to a psychological understanding of the war neuroses’.25 The diversity of explanations for shell shock has long been recognised. What broke new ground was Loughran’s argument that it was always seen as a regression, whether ‘perceived as the dominance of emotion, the recrudescence of instinct, or the loss of self-control’. As she continued: the physiology of emotion, the biology of instinct, and the psychology of the unconscious were all explored in an attempt to understand … [war neuroses]. But ultimately all conceptualised the nervous and mental disorders of war in terms of a struggle between the higher and the lower in man, and as damning evidence of his animal origins.

The effect of this unifying ‘evolutionary framework’ was to ‘cut through the division between “physical” and “psychological” theories’ and to align shell shock with ‘a much older complex of fears regarding human nature, civilisation, and its future development’. The war did nothing to appease these anxieties.26 Throughout the First World War, shell shock was ‘a popularly sanctioned metaphor that crystallised the causes of mental breakdown … choreographed the symptoms and suggested the cure’.27 From 1916, however, the number of cases soared as professional soldiers were joined by more and more volunteers and conscripts. Treating physical and psychological injuries in the same way was rejected as a mistake, and ‘the policy of sending psychiatrically damaged servicemen down the line to a base hospital … [was] reversed’. Instead, a ‘new doctrine of “forward psychiatry”’ was introduced, ‘according to which soldiers were treated as near to the front line as possible, in uniform and under military discipline’. As Simon Wessely elaborates, the soldier was ‘told that breakdown had a physiological basis’ requiring ‘a couple of days rest, food, clean clothing and rest’. After that the soldier was pressurised to return to his military role and prove that he was a 81

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man.28 Furthermore, by 1917 the military authorities were banning the use of the term ‘shell shock’ outside the special hospitals.29 Within this framework, it is not easy to ascribe a particular ethos to an institution or doctor. Physical approaches were more likely to be foremost in non-specialist hospitals where few doctors had an in-depth knowledge of psychiatric medicine. Former mental hospitals had the advantage of systems designed to cope with psychiatric patients, but even their staff did not necessarily have any understanding or experience of the mental traumas caused by the war, and their preconceived ideas may have clashed with those of military psychologists.30 Furthermore, medical knowledge and practice was itself fluid and influenced by changing manpower requirements.31 The combined effect of these factors was a pragmatic, empirical methodology as doctors tried to establish which treatments worked best with which symptoms, informed by competing approaches to understanding and managing mental illness. The therapeutic optimism originally associated with moral management techniques had dissipated as late nineteenth-century public asylums struggled with unresponsive chronic cases and the routines of institutional life were gradually reworked to deliver mass rather than personalised care.32 At the same time, the influence of Sigmund Freud’s psychoanalysis was penetrating British medicine. One of the most renowned wartime centres for analytic therapy was Craiglockhart Hospital in Edinburgh, where the neurologist and anthropologist, Dr W. H. R. Rivers, adopted a modified version of Freudianism. In opposition to the ‘passive rest cures’ favoured in this period for hysterical or neurasthenic women of the upper and middle classes, Rivers and military doctors of the same persuasion prescribed ‘intense activity’ on the grounds that ‘curative work … was essential for the restoration of male self-esteem’.33 Ben Shephard is right to stress that neither the patients nor the treatments at Craiglockhart were typical, because the ‘majority of shell-shock patients were private soldiers’.34 Treatments for shell shock evolved during the course of the war in response to medical and military factors. After an early predisposition towards hereditary explanations that implied dismissing patients as unfit for military service, medical opinion began to embrace a more sophisticated biological understanding of psychological illness 82

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which led to physical treatments. As Joanna Bourke argued, ‘[i]f a breakdown was considered a “paralysis of the nerves” then massage, rest, dietary regimes and electrical treatment were prescribed – the latter often applied through small portable generators’.35 Peter Leese suggests that ‘shellshock treatment was not a time-consuming procedure with individual attention lavished on soldiers’. Rather, ‘mass treatment of psychological casualties employed low-cost treatments that required a minimum of qualified personnel’.36 Shephard also maintains that if not ‘lying neglected in a converted asylum in the depths of the country’, the ordinary soldier would face ‘periodic baths and electric shock [delivered] by a bored, unsympathetic hospital attendant’.37 It remains to be seen if this characterisation of the staff, or the care regimes they presided over, was accurate for the WMWH. The nurses Since the staff at the WMWH included female nurses originally recruited by the CCMH it is worth paying attention to their background and qualifications. In common with other contemporary asylums, the senior nurses were already qualified in both general and mental nursing, suggesting no inferiority to the general trained nurses who dominated the profession. There is certainly nothing to indicate that they were ‘bored’ or ‘unsympathetic’ in comparison to nursing colleagues; instead they shared similar training and all the virtues, and faults, which that implied. Other CCMH nurses sought and achieved Medico-Psychological Association (MPA) qualifications, with some subsequently undertaking general training.38 While some caution is needed with interpretation, these findings do not suggest that the intellectual calibre or educational background of the trained CCMH nurses was markedly different to that of those women seeking to work in local general hospitals, although it must be noted that several CCMH probationers had to leave because they were unable to pass the MPA examinations. Reforming doctors, many drawing on their experiences of the Scottish asylum system, had long argued that staff training had many benefits in terms of recruitment as well as care. Dr George M. Robertson (Royal Edinburgh Asylum) published his ideas about mental nurses, with much emphasis placed on the importance of the 83

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Handbook for Attendants on the Insane.39 The Handbook had first been published in Scotland in 1885 and after adoption by the MPA led to the certification and registration of mental nurses. MPA examinations took place in May and November each year, and candidates were usually expected to wait for at least a year between the preliminary and final exams. A new MPA syllabus including anatomy, physiology and nursing was introduced in 1893, and in 1923 the Handbook was renamed Handbook for Mental Nurses to reflect changing staff roles.40 Robertson had stated that a ‘good class of men and women [are] now engaged in asylum work’.41 If the status of the mental nurse could be further enhanced, then the asylums, being re-conceptualised as mental hospitals, could better compete with other types of hospitals for women attracted to a career in nursing and secure higher calibre recruits. Mick Carpenter explains that this was an explicit aim of the training courses for female staff introduced at the Berry Wood Asylum in Northampton.42 The CCMH also offered training as part of a package of measures to attract female probationers. Foresighted applicants may well have understood that mental training involved less competition for places and, at a later stage, opportunities for accelerated promotion. The CCMH also took younger recruits than many voluntary hospitals, allowing an earlier start to a girl’s career and paid employment, thereby filling in the traditionally difficult gap between school and nursing. Such experience could be a useful precursor to general training, with the option of returning to a senior asylum post if desired. When the CCMH was first opened, the superintendent had stated that every effort would be made ‘to maintain the Nursing Staff at a high level of efficiency by training the members by lectures, demonstrations, and tests for the various nursing examinations for which they [were] eligible’.43 Initially, forty-five nurses and attendants had passed the St John Ambulance Association (SJAA) first aid exams, and nearly all were in training for the Nursing Certificate of that body and the Certificate in Mental Nursing of the Medico-Psychological Association.44 Strangely, considering how many were receiving training, relatively few staff (eighteen male and twenty-eight female probationers) passed the MPA certificate between 1908 and 1913.45 Another thirty-three MPA passes were recorded before 1922, with 84

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more staff successfully acquiring certificates issued by the British Red Cross Society and the SJAA. Between 1917 and 1922, nine staff were also trained in general nursing. Interestingly, twenty-six female nurses left the CCMH to undertake general training between 1908 and 1922, which suggests that many excellent staff were lost to the sector.46 Information about CCMH nurses is documented in the Female Staff and Service registers.47 The Female Staff Register included details of the nurse’s name, date of joining service, age on joining service, previous occupation, certificates held, name and address of nearest relative, date of leaving service and cause of leaving and remarks. The Service Register contained dates of birth, National Insurance class, pension contribution, salary, emoluments, date of starting and reasons for leaving. Such details allow an assessment of the careers of CCMH nurses and permit a comparison with similar records pertaining to nurses at the King Edward VII Hospital (KEH), Cardiff’s leading voluntary infirmary. Oddly, despite the attention given to training at the CCHM, their records, unlike the voluntary hospital, did not include educational history or details of training completed during service. Where comparisons are possible it appears that the staff at the two institutions were remarkably similar. This may indicate a standardised approach to recruitment and shared ideas about the criteria for beginning a nursing career. It is interesting to consider the background and subsequent careers of the eighty-three new recruits who started work at the CCMH between 1911 and 1918. The majority (77 per cent) were from Wales, with the main source being the South Wales valleys, but recruits were also drawn from England, Scotland and Ireland.48 The age of the new recruits ranged from 17 to 40, although only three were over 30 and the largest number were aged 20. These CCMH probationers were slightly younger than their equivalents at the KEH,49 where probationers joined aged 19 to 39 but most were in their early twenties, the largest number being aged 22.50 The greater acceptance of teenagers at the CCMH may reflect a shortage of other applicants or a realistic assessment that the girls attracted to mental nursing could not afford the extended period of domestic training favoured by elite nursing schools seeking middle-class recruits. It is noteworthy that most of the CCHM probationers had some previous employment, whereas 85

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many of those recruited by the KEH did not.51 Interestingly, the most common prior occupation was some form of nursing,52 with CCMH probationers recording experience as mental nurses, nurses/ probationers, fever nurses, children’s nurses and VADs. While some of these ‘nurses’ were operating at the margins of the profession, their experiences reflect both the complexity of the market for nursing services and a personal determination to pursue a nursing career.53 The idea of a career in mental nursing, and confirmation of the professional status of such nurses, was endorsed by influential medical figures. In 1918 George Robertson used a letter to Nursing Mirror and Midwives’ Journal to discuss the promotion of mental nurses to asylum matrons, which was being encouraged by the Asylum Workers’ Association.54 Robertson argued that mental nurses with MPA qualifications should complete general training before returning to a senior mental hospital post as assistant matron or matron. Such nurses were believed to have both the necessary skills and experience for the work and ‘loyalty’ to the sector, and were favoured over women simply offering general training although difficulties recruiting the latter also encouraged a preference for the former.55 Robertson reported an unsuccessful history, going back to the 1880s in Scotland, of appointing general trained matrons and clearly valued the presence of dual trained nurses. Yet these nurses tended to be relatively young, and Robertson also mentioned the valuable experience of older nurses who had not had the same opportunities to progress their careers. Reforming doctors complained about the restrictive polices operated by general nurses who refused to acknowledge the skills and experience represented by a MPA certificate. Robertson used his letter to point out that in 1918 the College of Nursing was offering shortened general training to certain groups of nurses (VADs) with hospital experience but was making no concessions to those trained in the mental hospitals. It seemed that wartime experiences had divided nurses (trained and untrained, professionals and volunteers, and staff serving different types of hospitals) and encouraged discrimination against mental nurses. This had not been apparent at the WMWH where the medical superintendent valued the dual qualifications of the matron and assistant matron and accorded them unusual responsibilities during and after the war. It was the status of their subordinates, with 86

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and without MPA qualifications, that seemed less certain within and outside the institution. At the CCMH before 1918 all new staff (with possibly the odd exception) were initially appointed as probationers. This policy extended to staff with extensive experience and/or MPA qualifications who normally started as senior probationers before taking up positions as staff nurses or sisters. Such arrangements suggest a precautionary attitude towards recruiting mental nurses, and a degree of ambivalence about their status and suitability for the work. It is noteworthy that trained general nurses appointed by the KEH were immediately accorded the rank of staff nurses and sisters even if required to serve a probationary period. This ambivalence towards mental nurses was not confined to the CCHM, leading to national debates about their perceived qualities and position relative to general nurses. A 1916 article claimed that No nurse trained in a mental hospital only would assert that she was the equal of her sister from the general hospital in surgical nursing. The former knows her limitations, but the same cannot always be said of the latter with regard to mental nursing. If, as is maintained, each must stick to her own last, why is it that nurses without mental training attend mental cases, and also in some cases are ready to take high posts in mental hospitals, thereby depriving the mental nurse of the fruits of years of strenuous learning and her calling? The fact that in so far as her work is confined to technical skill … the surgical nurse is superior to the mental nurse must be admitted, but when it comes down to general ward work, management, and discipline, the positions are equalised, if not reversed.56

While superficially arguing for equality this article not only relegated mental nurses to the domestic side of nursing but also confirmed the dominance of physical illnesses and treatments over psychological ones in mental health, supporting the majority of medical opinion at the time. This had implications for all the nurses at the WMWH and the care they were able to offer patients. Some nurses remained aggrieved at the way the skills of mental nurses were undervalued by their nursing colleagues and misunderstood by the public. One disgruntled correspondent complained that ‘certificated mental nurses [are] refused positions even as staff nurses in auxiliary or military hospitals’ even though ‘[a] nurse trained in a hospital for mental diseases receives a training which befits her for medical, surgical, and phthisical, as well as mental nursing’. 87

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­ e author pointed out that the MPA certificate required knowledge Th of these subjects, and that physical wounds were not uncommon in the wards of a mental hospital, and had to be attended to. Yet, it was complained, ‘VADs of all ages [are permitted to] dress wounds, attend to the giving out of medicines, and pneumonia cases’, and ‘many hospitals for nervous complaints for our wounded … are staffed … by persons who have had no training in that respect’.57 Mental nurses arguably needed new ways of working to develop and receive appropriate credit for their skills. Female nurses on male wards One of the most contentious issues at the WMWH was the presence of female nurses on male wards. This practice had been introduced, with some success, in Scottish asylums in the late nineteenth century where reforming doctors had been keen to professionalise the workforce and create a new therapeutic atmosphere. Wartime conditions encouraged such experiments. George Robertson used a 1916 article in Hospital to publicise the perceived benefits of the ‘Scottish system of entire female nursing’. He claimed this had been introduced ‘in very large part due to the desire to make use in asylums of the high standard of skill in nursing possessed by those who had trained in … general hospitals’.58 Reflecting the modernising stance of Edwin Goodall, female leadership was very much in vogue at the WMWH. Before the war he had been a prolific researcher and author, and as superintendent of the CCMH had made a number of innovations. Even the title of the CCMH, with its emphasis on hospital rather than asylum, embodied a commitment to new and integrated approaches to the treatment of mental and physical illness. Goodall’s personal reputation was built on a series of lectures published in the Lancet in December 1914.59 In the first lecture, he argued that there was a ‘deplorable separation of psychiatry from the other branches of medicine’. While some medical superintendents lost confidence during the war, Goodall continued to innovate and used his experience of treating military as well as civilian patients to develop plans to de-stigmatise mental illness and facilitate early treatment. With like-minded colleagues he campaigned for a reform of the lunacy laws and out-patient facilities.60 88

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In 1919 Goodall opened a clinic at the KEH to provide early informal treatment for mental and allied nervous disorders.61 A few years later he was arguing that there were still no facilities for the early treatment of mental disorders and extended his concerns to address inadequate provision for the psychiatric training of medical students and probationer nurses.62 At the CCMH Goodall had consistently sought to improve the quality of the nursing staff as a prerequisite to better patient care. Long service was encouraged, and staff who stayed for a minimum of eighteen months could receive a good conduct certificate when they left. 63 In 1913 the Commissioners in Lunacy commented: ‘A Strong staff … averaging one to every 7.61 patients … more than threefourths of the staff having been in the Asylum service for more than a year.’64 The war brought disruptions, notably in the at least temporary loss of many of the male staff, but also provided a unique opportunity to develop the female nurses, which Goodall fully embraced. When the first soldiers arrived at the WMWH on 16 June 1915, Miss Florence Raynes, the matron, took over the direction of the entire nursing staff, male and female, for the duration of the war. This included over one hundred female nurses as well as male attendants and orderlies. This fact was highlighted in an article in The Nursing Mirror and Midwives’ Journal, which commented on the unusualness of the situation, which it called a ‘method of nursing soldiers suffering from mental disorders in vogue in the Welsh Metropolitan War Hospital … of interest to all our readers’.65 In the wards, the ‘sister has supreme control … and in her absence the staff nurse. The orderlies, for discipline, are under the control of a Non-Commissioned Officer (NCO), who patrols by day.’ The article goes on to explain that the wards are staffed at night by two probationers and a civilian orderly, one night sister and an NCO. The exercise gardens were under the charge of a trained nurse, with mixed male and female staff under her control. The article goes on to describe some problems thus: There was some friction at first; orderlies who held the M.P.A. certificate and had been charge attendants in asylums resented taking orders from a sister. This has died down, and the sexes appear to be working well together. While it is obvious that a due proportion of both sexes is necessary in a ward, and that successful working depends upon their loyal and harmonious co-operation, the keynote here is that of female nursing.66

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Nursing was considered to be an important part of the treatment received by patients, with interactions between nurse and mental patient meant to have therapeutic value beyond the simple performance of personal care and the administration of any treatment prescribed by doctors. However, the special nature of the relationship between nurse and patient, especially between female nurse and male patient, carried risks as well as rewards. Mick Carpenter has argued that the earliest asylum rules adopted a harsh approach to discipline precisely because of the risks inherent to patients and staff who were in continuous daily contact.67 Reforming superintendents seeking new arrangements for twentieth-century care needed to be careful to maintain close control over the nurses. It is therefore interesting to look at some of the disciplinary cases and other reasons for leaving recorded by the CCMH. Here the matron played a key role and it is interesting to review the comments she and other supervisory staff made about the personal and professional characteristics they believed made a nurse suitable or unsuitable for her position. ‘Good’ mental nurses, like their general trained counterparts, were typically reported to be neat in appearance, delicate, refined, quiet, reliable, well behaved and obedient. Conversely staff found to be untidy, uneven in temperament, indolent, dull-witted, over-excitable, neurotic and flighty were quickly deemed unsuitable. The negative comments hint at a lack of personal self-control that threatened the good discipline and order of the institution and even the well-being of patients. They also serve to confirm the power of the matron to choose and dismiss her staff. The focus on discipline is revealed by the way previously ‘good’ staff were dismissed for infringements of the CCMH rules. One woman described as ‘a good worker and a good nurse’ was given her notice after being found in a cupboard talking to a patient. In the context of nursing shell-shock victims she may have been attempting a private counselling session, but alert to the possibility of even the appearance of immorality the matron dismissed her. The precarious position of the female nurse on the male wards had to be constantly defended, in ways that no doubt challenged nurses at all levels in the hierarchy. Some female nurses clearly couldn’t cope with either the demands of mental nursing in general or the specific problems associated with caring for shell-shock cases. Several 90

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probationers were reported to have left because they ‘did not like mental work’ or ‘wanted a change’. More specific were the complaints of at least four nurses who resigned because of objections ‘to nursing men’ and ‘did not like the shell shocks’; one departing nurse reported that the ‘patients had got on her nerves’. Wartime conditions problematically disturbed existing hierarchies as well as bringing new patient groups to the institution. A sister left in 1915 because ‘[n]urse objected to working under the trained nurses, when the Hospital was taken over by the Military’. This nurse had joined the hospital in 1911, aged 23, and was a fully qualified mental nurse. The comments on her record state ‘[a]n excellent Mental Nurse, a good ward manager, good control over the nurses. [n]eat, refined and methodical’. This highly competent professional woman clearly resented the fact she was made subordinate to the general and military nurses, even though she was working in her home territory. The records give no indication that any effort was made to persuade this valuable employee to stay and give no details about where, and if, she continued her nursing career. The status of the mental nurse was, however, a concern for Goodall, who remained keen to develop and professionalise the CCMH workforce, paying particular attention to the female staff who were not only vital in covering the wartime absence of male attendants, but in the longer term could acquire general as well as mental training. While female nurses were possibly viewed as a cheap labour force,68 always a concern for the male-dominated trade unions, this was not the major issue for reforming superintendents who stressed the benefits to patient care that would follow from a feminisation of the workforce. It was, however, recognised that female nurses caring for male mental patients would have to overcome a number of practical challenges as well as ethical concerns. For these reasons, reforming superintendents such as Goodall placed great emphasis on the need for training. Training as a mental nurse was valued, indeed insisted upon, with the CCMH Female Staff Register revealing that between 1915 and 1919 four probationers were dismissed and two resigned because they either failed to take or to pass the MPA exams. But the real key to achieving parity of esteem between mental and other hospitals was having staff with qualifications recognised by other nurses. The superintendents tried to make 91

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the MPA qualification more akin to general nurse training, but with mental nurses still shunned by their general counterparts they called for more of the workforce to become dual qualified and/or seek additional specialist ­qualifications that would support the introduction of new treatments.69 The dual qualified nurses had better career prospects,70 and also offered a number of benefits to their employers. The CCMH was proud of its record in introducing female nurses on to male wards as part of a new approach to the management of mental illness and intended to continue the practice despite an apparent desire by the military authorities to limit the role of female nurses in the treatment of soldiers suffering from shell shock. The institution was only able to do so because its staff fulfilled the requirements of new regulatory arrangements. The minutes of the Special Visiting Committee explain: Resolved: That the Committee, having considered Circular Memo 29/12/17, from HQ of Western Command, which includes the Welsh Metropolitan War Hospital amongst Military Hospitals proper in an order which fixed the number of female staff allowed at various Hospitals, request the Board of Control to bring to the notice of the War Office, the latter’s communication of 20/3/15 … whereby this Committee became entirely responsible for the nursing arrangements at their Hospital. This privilege is enjoyed by the Committee because their Matron (and also Assistant Matron) is a trained Sick Nurse. Both Ladies are likewise certificated Mental Nurses. The War Office, as Board of Control is aware, having seen fit to utilise facilities afforded by Welsh Metropolitan War Hospital for care and treatment of Mental Disorders amongst Troops, this Committee ventures to believe that the propriety of the arrangements whereby the responsibility for the nursing was cast upon them is enhanced, since their Officials have special experience of requirements of Mental cases. The committee therefore desire to express through the Board of Control the wish that the arrangement whereby entire responsibility for providing and maintaining strength of Nurses and Domestic Personnel of the hospital was placed upon them and their officials, be left undisturbed.71

Conclusion As a postscript to the war years, Goodall wrote in 1921 that ‘As a result of experience gained during the military occupation, the 92

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whole of the Nursing Service, female and male, with the exception of 3 male wards, was placed under the Matron.’ The matron, deputy matron, night sister and home sister were all certificated mental and general nurses. Six out of nine male wards were under the charge of certificated female mental nurses (sisters and staff nurses), under whose supervision were a total of twenty-five female probationers. There was one male nurse on duty in every ward except the Sick Ward where there were no male patients.72 This was in stark contrast to the situation in 1910 when the matron was responsible ‘for the condition of all Female Departments of the Institution’, and as such: no Male Attendant, Servant, or Patient shall be allowed to enter the Female side, or any Female Department, nor any Female to enter the Male side or any Male Department, except in discharge of some duty and with adequate authority. Any Attendant, Nurse, or Servant transgressing this rule … shall be immediately dismissed.73

The wartime experience of the CCMH had thus redrawn the boundaries between female mental nurses and male patients in ways that exposed both to risks of stigma but also advanced a wider project to modernise mental health care. Crucial to the professional projects of reforming superintendents such as Goodall was the introduction of a feminine touch, albeit one embodied in the rather forbidding persona of the senior nurse who had survived both mental and general training and was equipped to manage both subordinate staff and patients. The highly visible presence of female nurses made the mental hospital more akin to a general hospital with aspirations to parity of esteem. Efforts to increase the status of doctors and nurses in the sector underpinned the professional ambitions of leading superintendents such as Goodall who wanted to reform institutions and remove all obstacles to early and effective treatment. Goodall used his pre-war reform agenda to shape his institution’s response to the care of shell-shock cases and used his military experiences to press for peacetime changes. Goodall placed female nurses at the centre of these projects, although his efforts to professionalise the workforce clearly created difficulties. Nurses who could not pass their exams and nurses who displeased the matron were particularly badly hit, being forced to leave the CCMH and sometimes their chosen profession. 93

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Notes   1 J. Bourke, ‘Effeminacy, ethnicity and the end of trauma: the sufferings of “shell-shocked” men in Great Britain and Ireland, 1914–39’, Journal of Contemporary History, 35:1 (2000), 57–69 (p. 59).  2 C. Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009) pp. 1–2, 7.   3 B. Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1960), pp. 85–6.   4 R. Dingwall, A. M. Rafferty and C. Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988), pp. 72–3.  5 Hallett, Containing Trauma, p. 15.   6 J. Winter, ‘Shell-shock and the cultural history of the Great War’, Journal of Contemporary History, 35:1 (2000), 7–11.  7 M. Dobson and B. Ziemann (eds), Reading Primary Sources: The Interpretation of Texts from Nineteenth- and Twentieth-Century History (London: Routledge, 2009).   8 R. Cowen (ed.), A Nurse at the Front: The First World War Diaries of Sister Edith Appleton (London: Simon and Schuster, 2012), p. 184.  9 L. Macdonald, The Roses of No Man’s Land (Harmondsworth: Penguin, 1993), p. 232. 10 Macdonald, The Roses of No Man’s Land, p. 233. 11 Macdonald, The Roses of No Man’s Land, p. 234. 12 Hallett, Containing Trauma, pp. 2–3, 157, 225–6. 13 P. Michael and D. Hirst, ‘Establishing the “Rule of Kindness”: the foundations of the North Wales Lunatic Asylum, Denbigh’, in J. Melling and B. Forsythe (eds), Institutions, Insanity and Society, 1800–1914: A Social History of Madness in Comparative Perspective (London: Routledge, 1999), p. 160. 14 S. B. Morris, A Short History of Whitchurch Hospital 1908–1959 (presented to the Chairman and Members of the Whitchurch and Ely Hospital Management Committee on the occasion of its last meeting on the 11 March 1965) (Cardiff, 1965), p. 2. This item is held in the collection of Cardiff University Library, Store LL Folio pamphlet RA988.C2.W4. See also The Times, 22 April 1908, 15. 15 E. Showalter, The Female Malady: Women, Madness and English Culture (London: Virago, 2001), p. 36. 16 H. M. Thomas, Whitchurch Hospital 1908–1983: A Brief History to Celebrate the 75th Anniversary of the Hospital (Cardiff, 1983), p. 43. This item is held in the collection of Cardiff University Library, Arts and Social Studies: Salisbury Collection, Celt RC450.W2.C2.T4. 17 Morris, A Short History of Whitchurch Hospital, p. 13; Thomas, Whitchurch Hospital, p. 43. See also Cardiff Times and South Wales Daily Echo, 12 June

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Nursing shell-shocked patients in Cardiff 1915, 7. Past copies of the Cardiff Times and South Wales Daily Echo are in the collection of the Cardiff Central Library. 18 Cardiff Times and South Wales Daily Echo, 12 June 1915, 7. 19 CCMH, Visiting (Mental Hospital) Committee Minutes, 26 April 1917. 20 P. Leese, Shell Shock, Traumatic Neurosis and the British Soldiers of the First World War (Basingstoke: Palgrave Macmillan, 2002), pp. 68–9. 21 E. W. White, ‘Observations on shell shock and neurasthenia in the hospitals in the Western Command’, British Medical Journal, I (13 April 1918), 421–2. 22 E. Showalter, ‘Rivers and Sassoon: the inscription of male gender anxieties’, in M. R. Higonnet, J. Jenson, S. Michel and W. Collins (eds), Behind the Lines: Gender and the Two World Wars (New Haven, CT: Yale University Press, 1987), p. 63. 23 Showalter, The Female Malady, pp. 171–3. 24 Showalter, ‘Rivers and Sassoon’, p. 64. 25 T. Loughran, Evolution, Regression and Shell Shock: Emotion and Instinct in Theories of the War Neuroses, c.1914–1918 (Manchester: Manchester University, Manchester papers in economic and social history, no. 58, 2007), p. 2. 26 Loughran, Evolution, Regression and Shell Shock, p. 23. See also S. Wessely, ‘The life and death of Private Harry Farr’, Journal of the Royal Society of Medicine, 99 (2006), 442. 27 E. Leed, ‘Fateful memories: industrialized war and traumatic neuroses’, Journal of Contemporary History, 35:1 (2000), 85–100 (p. 100). 28 S. Wessely, ‘Twentieth-century theories on combat motivation and breakdown’, Journal of Contemporary History, 41:2 (2006), 271–3. 29 General Routine Order No. 2384, quoted in Macdonald, The Roses of No Man’s Land, p. 237. 30 I. Whitehead, Doctors in the Great War (London: Leo Cooper, 1999), p. 169. 31 P. Leese, ‘“Why are they not cured?” British shellshock treatment during the Great War’, in M. S. Micale and P. Lerner (eds), Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1870–1930 (Cambridge: Cambridge University Press, 2001), pp. 205–21 (p. 219). 32 A. Borsay, Disability and Social Policy in Britain since 1750: A History of Exclusion (Basingstoke: Palgrave Macmillan, 2005), pp. 77–9. 33 Showalter, ‘Rivers and Sassoon’, p. 66. 34 B. Shephard, A War of Nerves: Soldiers and Psychiatrists 1914–1994 (London: Pimlico, 2002), p. 89. 35 J. Bourke, An Intimate History of Killing: Face-to-Face Killing in TwentiethCentury Warfare (London: Granta Books, 1999), pp. 257–8. 36 Leese, ‘Why are they not cured?’, p. 219. 37 Shephard, A War of Nerves, p. 89. 38 During the war, several CCMH nurses were sent to the KEH for some general training in preparation for the influx of wounded soldiers. When the CCMH

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Mental health nursing became the WMWH it received some general nurses from the Territorial Force Nursing Service (TFNS). 39 G. M. Robertson, ‘Female nurses in the male wards of mental hospitals in Scotland’, The Hospital, Vocational, LIX (26 February 1916), 481–4. 40 Dingwall, Rafferty and Webster, An Introduction to the Social History of Nursing, p. 128. 41 Robertson, ‘Female nurses in the male wards of mental hospitals in Scotland’. 42 M. Carpenter, ‘Asylum nursing before 1914: a chapter in the history of labour’, in C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980), p. 136. 43 Morris, A Short History of Whitchurch Hospital, p. 9. 44 S. Brady, ‘Nursing in Cardiff during the First World War: A Study of the Interaction Between Women, War, and Medicine in a Provincial City’, PhD dissertation, University of Wales Lampeter, 2004, p. 214 and Table 4.5. Note that Sara Brady now writes under her married name, Sara Knight. 45 Brady, ‘Nursing in Cardiff’, p. 218. 46 Brady, ‘Nursing in Cardiff’, p. 215. 47 Glamorgan Archives, Cardiff (hereafter GAC), DHWH 11/6, Cardiff City Mental Hospital Female Staff Register 1908–1928 (hereafter CCMH Female Staff Register); GAC, DHWH 11, Cardiff City Mental Hospital Service Register 1911–1922 (hereafter CCMH Service Register). The registers were completed fully for most staff although some details are missing or illegible. Records for male attendants were kept separately. 48 CCMH Female Staff Register. Analysis from Brady, ‘Nursing in Cardiff’, p. 259, Table 5.3. 49 Note that all new CCMH staff, trained and otherwise, started as probationers, but this was not the practice at the KEH so care is needed with any comparisons drawn. 50 GAC, DHC, King Edward VII Hospital Probationer Records (hereafter KEH Probationer Records); CCMH Female Staff Register. See also analysis from Brady, ‘Nursing in Cardiff’, p. 263, Table 5.5. 51 See KEH Probationer Records and CCMH Female Staff Register. 52 Other recorded occupations have been classified as office work (9), trade/ shop work (15), teaching (3), domestic service (14), munitions work (2). Analysis from Brady, ‘Nursing in Cardiff’, p. 269, Table 5.6. 53 There are continuities with the nineteenth-century situation described by David Wright. D. Wright, Mental Disability in Victorian England: The Earlswood Asylum 1847–1901 (Oxford: Clarendon Press, 2001), pp. 99–119. 54 G. M. Robertson, ‘Letter’, The Nursing Mirror and Midwives’ Journal, XXVII (13 July 1918), 228. 55 Robertson’s experiences with such staff are recounted in Asylum News (1918), cited in Carpenter, ‘Asylum nursing before 1914’, p. 136. 56 The Hospital, LXI (21 October 1916), 55.

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Nursing shell-shocked patients in Cardiff 57 The Hospital, LX (26 August 1916), 497. 58 Robertson, ‘Female nurses in the male wards of mental hospitals in Scotland’. 59 E. Goodall, ‘The Croonian lectures on modern aspects of certain problems in the pathology of mental disorders, delivered before the Royal College of Physicians of London’, reprinted from The Lancet, 5, 12, 19 and 26 December 1914. A print copy of this item is held in the historical collection of the Archie Cochrane Library, Cardiff University. 60 L. Westwood, ‘Dr Helen Boyle’s approach to mental health care’, Social History of Medicine, 14:3 (2001), 450. 61 Goodall was a co-signatory of a letter to The Times, 6 February 1920, 8, which called for the development of clinics to prevent delayed treatment. 62 Letter to The Times, 2 June 1924, 10. 63 City of Cardiff Mental Hospital, Whitchurch, Glamorgan, General Rules (London, 1909), p. 55. This item is now in the collection of the Whitchurch Hospital Historical Society at Whitchurch Hospital, Cardiff. Despite these incentives many of the probationers recruited between 1913 and 1918 left within two years. 64 Morris, A Short History of Whitchurch Hospital, p. 12. 65 The Nursing Mirror and Midwives’ Journal, XXVII (13 July 1918), 224. 66 The Nursing Mirror and Midwives’ Journal, XXVII (13 July 1918), 224. 67 Carpenter, ‘Asylum nursing before 1914’, pp. 137–9. 68 In 1914 attendant salaries commenced at £30 per annum, with emoluments valued at £39. A nurse received £19, and maids £14–18, with female staff awarded £33 of emoluments. Staff costs increased towards the end of the war as a result of inflation and shortages. See Brady, ‘Nursing in Cardiff’, p. 221, and CCMH Service Register. 69 Goodall was disappointed that none of his nurses wanted to train as masseurs, a skill sought by local voluntary hospital staff and also badly needed at the WMWH. One nurse did receive regular training at the KEH for treatments involving electrical work. See Morris, A Short History of Whitchurch Hospital, p. 11. 70 P. Nolan, ‘Mental health nursing in Great Britain’, in H. Freeman and G. E. Berrios (eds), 150 Years of British Psychiatry Vol. II: The Aftermath (London: Athlone, 1996), p. 179. 71 Special Visiting (Mental Hospital) Committee Minutes, 7 January 1918, 571. 72 Morris, A Short History of Whitchurch Hospital, p. 12. 73 City of Cardiff Mental Hospital, Whitchurch, Glamorgan, General Rules (1909), pp. 47–8.

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5

Discourses of dispute: narratives of asylum nurses and attendants, 1910–22 Barbara Douglas

The early twentieth century was a period of strained labour relations. Within this broader framework, attendants and nurses were evolving their own organised challenge to prevailing asylum conditions. Although there were established grievances about long hours, onerous duties and poor pay, it was the combination of strictly enforced regulations and the penalty of instant dismissal that fuelled discourses of dispute in this period. While the influence of the First World War cannot be discounted, the primacy it is given in many existing accounts of post-war labour relations tends to understate the importance of other factors in encouraging both a growing sense of agency among asylum workers and its organised expression. The establishment of the National Asylum Workers’ Union (NAWU) in July 1910, and its subsequent rapid expansion, were crucial. Other significant events included the publication of the union’s journal, the National Asylum-Workers Magazine, from 1912 and the presentation of the NAWU’s ‘National Programme of Reform on Conditions and Pay’ in 1918. Where demands for reform went unmet strikes followed; but their problematic resolution only deepened a growing sense of crisis within an asylum system that seemed beset by scandals. Ultimately a wide-ranging reform agenda helped improve conditions for staff and ushered in a period of calmer labour relations. The Exeter City Asylum, colloquially known as Digbys, provides a detailed case study of the tensions apparent at this time.1 An assessment of asylum conditions in 1918 suggests that while many actors were persuaded of the need for change, the existing infrastructure was 98

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unable to support this. The increasing militancy of asylum workers, contextualised by the rise of ‘new unionism’ as well as wartime difficulties, led not just to strikes but to discourses of dispute that arguably paralysed the system through a culture of blame and recrimination. A careful examination of the influential strike at Digbys encourages a focus on the ‘personal narratives’ of the staff as a way of understanding both the detail of events as they occurred and the human cost of the disputes. This approach is informed by the power of personal accounts, especially oral histories, to access the decisionmaking processes that take place beyond officially recorded minutes.2 It also acknowledges a contemporary concern, evident in the 1926 report of the Royal Commission on Lunacy and Mental Disorder (Macmillan Commission), to use ‘personal experiences’ to shape the reform process, which culminated with the implementation of the 1930 Mental Treatment Act.3 The promise of peace? Lets hope the band on sports day Will play God Save the King And finish with the Marseillaise And hear the nurses sing.4

The hopes that followed a return to peace after the horrors of the First World War were poetically evoked by Harry U, a long-term patient at Digbys. Harry had been admitted to the asylum in 1891, and in 1918 he expressed a longing for the resumption of familiar pre-war institutional routines including sports day, the ripening of the orchard apples and even the chimes of the hospital clock. His idealised representation of post-war asylum life did not materialise, however. The county and borough asylums, including Digbys, were in an impoverished state. Financial constraints, both before and during the war, meant the fabric of the buildings had deteriorated while food shortages contributed to a dramatically increased patient morbidity and mortality. Attendants and nurses struggled with a working week that averaged 90 hours, and even when off-duty had to sleep in rooms with or near patients.5 Staff were under increasing pressure. A 1922 article in the NAWU Magazine highlighted ‘Wages reduced: annual leave reduced: hours of day increased!’6 Another perennial complaint was the inadequacy and 99

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cost of staff meals, but it was the combination of paternalistic controls and severe disciplinary measures that provoked most resentment. At Digbys, the once respected medical superintendent, George Norton Bartlett, seemed depleted by wartime conditions and the nurses, far from singing, were expressing anger and frustration at their position. While this discontent was not entirely new, its expression was being communicated in a more direct and organised fashion through the vehicle of the NAWU and its Magazine against a backdrop of social, economic and political turmoil. Mick Carpenter suggests that within the asylums there were ‘stirrings of reform happening within a rigid system as part of a broader social reform in the post war period’.7 David Boje argues that, during periods of cultural transition, the organising narrative of a society’s institutions are no longer clearly defined or enforced.8 Challenges occur, causing attempts at redefinition of the organising structure. It was arguably this cultural transition that resulted in the post-war asylum disputes, producing a discourse of blame that swept through institutional psychiatry. Although there were signs of renewed confidence in the biological basis of psychiatric problems by the early 1920s, and the concomitant search for somatic treatments, this did little to overcome grim asylum conditions. Jacob Klasi, founder of prolonged sleep therapy, made optimistic claims about the future: Now the physician is needed again. The physician as well as the staff members now have the opportunity to present themselves as useful and necessary and gain through the treatment the patients’ gratitude and confidence.9

But during this period asylum attendants and nurses were struggling to unlock their own asylum lives. In county and borough asylums, staff morale was low and their discontent manifested itself in a series of disputes. In September 1918 the NAWU presented its ‘National Programme of Reform’ to the Asylum Officers’ Association (AOA). This was quickly followed by a series of strikes. The first of these took place in the five Lancashire asylums in September 1918,10 followed by a strike at Bodmin Asylum in Cornwall in October 1918.11 In January 1919 the AOA rejected the NAWU’s programme. The creation of a Joint Conciliation Council to arbitrate issues of pay and conditions averted a national strike but local disputes continued.12 Exeter City 100

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Asylum embarked on a lengthy dispute in April 1919 and this was followed by action at Cheadle Royal (Manchester) in December 1920, Bracebridge (Lincoln) in September 1921 and Radcliffe (Nottingham) in April 1922.13 Enthusiasm for strike action then plummeted following the disastrous outcome of the Exeter strike, with its peremptory dismissal of all strikers, and the NAWU increasingly turned towards broader social and parliamentary activities to further its cause. The growth of trade unionism The unionisation of asylum staff needs to be understood with reference to its wider social and political context. Derek Aldcroft and Michael Oliver provide a useful overview of the rise of ‘new unionism’ in the decades before 1918.14 This period was marked by the extension of the franchise, new legislation and legal judgements that governed the activities of trade unions, a significant rise in trade union membership and the organisation of semi-skilled and unskilled workers outside of the old craft unions. Although men made up the vast majority of trade unionists, women were also finding new ways to organise themselves.15 New unionism experienced both successes and setbacks before the First World War as employers, and more traditional unions, reasserted themselves. This was one of many factors behind the increasing militancy of new unionism and ‘the great unrest’ of 1911–14. Strike action peaked in these years, although Aldcroft and Oliver demonstrate that the emphasis on days lost through strikes concealed the greater number lost for other reasons, including sickness attributable to poor working conditions.16 The growth of union membership stalled during the war years, a period when the rights of both unions and employers were severely restricted by the government’s emergency powers.17 In response to wartime conditions and revolutionary movements abroad union activity changed, shop stewards became increasingly powerful and the shop floor rather than the branch or national organisation became the focus.18 It was from this background that both the NAWU and its leading figure, George Gibson, emerged. Gibson, an attendant at Winwick Asylum in Lancashire, was born and brought up on Clydeside, where shipbuilding was a focus of new unionism. In July 1910 Gibson and fourteen other attendants from the five asylums of the 101

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Lancashire Asylums Board convened a meeting at a Manchester public house resolving to form the NAWU. The union aimed to address poor working conditions and grievances over new pension arrangements.19 One year later it had achieved a membership of 4,400 across forty-four asylums.20 At its first annual conference in July 1911 it documented its aims: To obtain by legislation improvement of the status of asylum workers, reasonable hours of duty, and of freedom, fair rates of wages, abolition of vexatious restrictions and other grievances, and a better regulation of the relations between employer and employed: to assist members if wrongfully dismissed; to provide legal aid when necessary, and to promote the welfare of asylum workers generally.21

This was not the first attempt to organise asylum workers. In 1896 the Asylum Workers’ Association (AWA) had been founded, but rankand-file staff tended to see it as an arm of the authorities because senior attendants and clerks dominated its membership.22 The relationship between the AWA and NAWU was fractious and delaying tactics by the AWA frustrated an attempt by the NAWU to secure a 60-hour week for attendants as an amendment to the 1909 Pensions Act.23 This provoked a bitter article in the Magazine, where the AWA was characterised as ‘a despotic oligarchy and a showy sham, an ingenious imitation of a trade union, but a real death trap for progress’.24 The Magazine continued to portray an antagonistic relationship between the two organisations,25 and it was the NAWU that emerged as the credible champion of attendant interests. Membership, including defections from the AWA (which ceased to exist in 1921), increased rapidly to nearly 18,000 by the end of 1920.26 Discontent in the asylums had been apparent before and during the war but the major petitions, strikes, lock-ins, inquiries and legal actions took place between 1918 and 1926. This timeline is explained, in part, with reference to the growth of the NAWU. In its earliest years its main activity was promoting trade union organisation. This was aided by a radical development in communications. The Daily Herald was established in April 1912, and was the first daily paper to offer a workers’ perspective.27 The NAWU’s own national magazine was first published in February 1912. It provided essential publicity and through its own discourses fuelled and fed upon 102

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attendant grievances. Crucially, the Magazine offered a place of safety for anonymous outpourings of pent-up anger and frustration at the working conditions of members. Examples of the early sense of powerless anger can be seen throughout the cynically humorous columns, cartoons and poems published in the Magazine between 1912 and 1915. As the NAWU grew nationally, and its members became more confident within their asylum branches, the tone and content of the Magazine changed. By 1918 it portrayed a growing sense of agency, and urgency, among its members. The strikes A series of strikes by attendants and nurses took place between 1918 and 1922. The strikes had their origin in local pre-war negotiations over pay and conditions. For example, in 1911 the NAWU had sought reduced working hours at Digbys, but the Committee of Visitors (hereafter DVC) refused to acknowledge any dissatisfaction among the staff, stating: Though the existing hours are somewhat long the work is not laborious or exacting and there is no evidence that it imposes any undue strain. The attendants and nurses feel no dissatisfaction with the existing arrangements.28

This was an erroneous perception and, in 1914, thirty-seven staff once again petitioned the DVC for improved conditions.29 Although couched in deferential terms, there were new requests for the nursing staff to have one day off per week and pleas that patient entertainments should only be ‘given in recognised duty hours’. The staff presented themselves as ‘respectful’ and ‘humble’ but despite a suggestion that their conditions could be improved ‘without any extra cost to the community’, they did not receive the ‘sympathetic consideration’ they had hoped for. During the war years negotiations about pay and conditions focused on the payment of war bonuses to keep pace with rising food prices. After the war, however, attendants and nurses became determined to improve their lot in a way that strained industrial relations at Digbys and elsewhere. This point was acknowledged by Bedford Pierce, medical superintendent of the York Retreat (and later 103

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co-author of the 1922 Cobb Committee Report), in an article in the Journal of Mental Science.30 Pierce reflected that ‘[t]here is I fear, slowly developing a want of harmony with the staff and the management’. He blamed the NAWU for this problem, and chastised the union for failing to mention any concern for patient well-being in its demands. Pierce went on to claim that these showed no sign of any ‘proper nursing spirit’. Yet, continuing with this theme of blame, he addressed the asylum authorities too: We physicians have also been to blame to some extent … When we think of the daily routine in many wards, the discouraging nature of the work, and the unpleasant duties that have to be performed day after day and week after week, we admit that the conditions of service ought to be good and the remuneration liberal. Yet we, who knew all this, did not, I fear, press upon our committees, in season and out of season, the urgent necessity for their giving attention to these aspects of the question. 31

This language of blame was an important factor behind the bitter post-war disputes and was a particularly unhelpful feature of the asylum strikes of 1918–22. The protracted dispute at Digbys was noteworthy for the heavily publicised recriminations of all concerned. The strike, or at least its failure, marked a major turning point in the campaign, representing as it did a major setback for the NAWU,32 and a reversal of the apparent successes of the earlier Lancashire and Bodmin asylum strikes.33 The action at Digbys was precipitated in January 1919 when a long-serving carpenter, Phillip G, who had returned from conscription (to munitions work) the previous month, submitted a petition for improved conditions and hours to Dr Bartlett in his capacity as branch chair of the NAWU. This was part of the NAWU’s ‘National Programme’ and such petitions were presented to all member asylums in January 1919.34 Bartlett’s response was complicated by the fact that the matron had recently (December 1918) made a written complaint about Phillip G, alleging that he was inappropriately ‘gossiping’ with the nurses when his duties took him to the female wards. Bartlett chose to inform Phillip G that he would be unable to improve his conditions as his work was not up to standard.35 Phillip G reportedly replied that as he had not the knowledge on which to presume to comment on the work of Dr Bartlett, the latter was similarly not in a position to do so on 104

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his own work.36 He was immediately suspended and summarily dismissed for insolence by the Asylum Committee (DVC) the following day, despite the appeasing intervention of the NAWU, which wrote: Regretting that the member of staff should have been deemed guilty of insolence to the Medical Superintendent but having regard to his years of service respectfully submitted that the punishment was excessive. They did not defend the member in offering insolence to a superior officer and wished to know if the Medical Superintendent would be prepared to accept an apology and if so whether the Committee would re-consider the matter and if possible reinstate the member without prejudice to his previous service.37

The DVC robustly refused to reinstate Phillip G, and an atmosphere of dispute, infecting labour relations across Europe, was reflected in this local action. The unwavering response adopted by the DVC was the first of many similar ripostes to the union’s pleas for reinstatement, discussion, negotiation and mediation over the course of the next six months. One of their adversaries later characterised the committee’s attitude as like ‘granite’.38 With conciliatory letters producing no further action, the NAWU requested that a special meeting of the DVC be called to interview Phillip G in the presence of a union official.39 This took place on 29 April, but Phillip G’s dismissal was upheld, and at 6 a.m. on the morning of 30 April 1919, forty-two of Digbys attendants, nurses and artisans took strike action and picketed the asylum entrance. They were supported by the Exeter Trades and Labour Council which asked its constituent unions ‘to sanction their refusal to handle any goods for Digbys asylum or take such steps as may be necessary to bring the dispute to a satisfactory conclusion’. It further warned of the grave consequences that ‘may ensue if it is not amicably settled’.40 By contrast, the report of the Commissioner of the Board of Control, visiting on 2 May, gave no indication that anything was seriously amiss, merely stating that ‘it is satisfactory to report that the Medical Superintendent has been able to meet the difficulties so successfully as appears to be the case’.41 Elsewhere, however, the unwavering position of the DVC, which inevitably escalated the dispute, attracted considerable criticism. On 4 May a public meeting was held in Exeter calling for support for the strikers. A public petition was initiated, inviting the government to ‘appoint a Commission of Inquiry to investigate into the causes and 105

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circumstances of the dispute’.42 A week later the matter was raised in the House of Commons, and the Home Secretary stated that the Ministry of Labour had been notified and was investigating.43 The latter’s proposal for arbitration was, however, rejected by the DVC, which continued to emphasise wrongdoing on the part of the staff and claim that questions of discipline did not lend themselves to arbitration.44 Similarly, when the National Council of Institutions for the Mentally Afflicted volunteered the services of their Conciliation Committee, on 23 May, the DVC merely thanked them for their offer and said they would ‘bear it in mind should the need of such assistance be required’.45 Although the strike failed to deliver meaningful negotiations it quickly attracted wider support. At the end of May the Exeter branch of the National Union of Railwaymen publicly announced their support of the Digbys strikers. Its statement was carefully worded to indicate that drastic action would be withheld only while negotiations continued.46 The DVC remained intransigent and at public meetings, and in the media, the two sides sought to attribute blame for the crisis to named individuals in highly personal attacks. Mr Dupree (chairman of the DVC) and Mr Edmondson (president of the NAWU) featured prominently in these accounts and each was reported as disparaging the other. The Trades Council used a second public meeting to suggest that the malign influence of a few powerful members of the Asylum Committee was responsible for the impasse, a theory publicly endorsed by Edmondson.47 It is certainly true that the city council, unlike the DVC, was not unanimous in its condemnation of the strikers. Indeed, Labour members suggested that the committee had made the wrong decision. However the council was unable to intervene because the DVC refused to pass on the public petition drawn up during May, on the grounds of its ‘misrepresentations’. At this stage it seemed likely that, without recourse to arbitration, sympathetic strikes would be called locally in response to calls from the Trades Council, and nationally as the NAWU mobilised staff at other asylums. The Trades Council proposed a deputation to the city council and, if rebuffed, planned a 24-hour strike and an appeal to the Prime Minister, Bonar Law.48 The next meeting of the city council, held in public on 25 June, became the forum for discussion of the DVC’s refusal to pass the 106

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petition to the government. Mr Seaton, a Labour councillor, proposed an amendment requesting the DVC to ‘accept the suggested arbitration of the Ministry of Labour’ and thereby avoid a national strike by asylum workers.49 Dupree sought to prevent this on the grounds that the amendment had not been submitted prior to the meeting, but it was allowed by the mayor, to cheers from the visitors’ gallery. Other Labour councillors (including Mr McGaghey and Mr Gayton) spoke in favour of the amendment and blamed Dupree for needlessly prolonging the dispute. The vote for the amendment was lost by fifteen votes to thirty and the DVC obtained its support from the council, but in the process a deeply entrenched culture of blame was created that frustrated both resolution of the dispute and wider asylum reforms. Various individuals and groups were publicly denounced for their part in the dispute. Blame was attached to the DVC and its leaders, especially Dupree and Mr Stokes (deputy chairman), together with Dr Bartlett. The NAWU and individual strikers, in particular Phillip G, received disapprobation and, in a new development, women were blamed for the strike, as it was claimed that the attendants would not have acted without the nurses, some of whom were portrayed as young and ‘flighty’.50 Aspersions were also cast on the ‘Citizens of Exeter’ for misrepresentations in their petition and ‘rate-payers’ vented their anger in various ways. The workers felt betrayed by the city council and responded with a NAWU deputation to the government. There were three further heated public gatherings in Exeter, and increasingly tense local labour relations were exacerbated by October’s national rail strike. Food supplies were badly curtailed in the West Country and newspaper reporting of the asylum strike dispute widened its import from ‘The Digbys Strike’ to ‘The Exeter Strike’.51 With disputes escalating, representatives of the Ministry of Labour visited Exeter to interview both the NAWU and DVC in an attempt to achieve agreement to arbitration. The DVC again refused to agree to this. In Exeter the trade unions organised a city centre demonstration and rally. The Trades Council again called for Phillip G’s reinstatement, this time also demanding the resignation of Bartlett and the DVC. With arbitration still ruled out, attention turned to the forthcoming municipal elections in November 1919.52 These represented a particularly important measure of local opinion for several reasons. 107

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Firstly, owing to wartime conditions this was the first municipal election for five years. Secondly, electoral reform had extended the franchise to certain groups of women. This significantly changed the electoral map in Exeter, because women voters now outnumbered men in all of the seventeen contested wards. Thirdly, the Labour Party intended to increase its representation by vigorously contesting twelve of the seventeen available seats. The NAWU gave very public support and financial backing to the Exeter Labour Party ahead of the election, with the expressed, and not unrealistic, hope of changing the political balance of the council and the composition of the DVC.53 Seven of the twelve Labour Party candidates were railwaymen and Phillip G, funded by the NAWU, stood for Wonford district on the issue of the Digbys strike. Although Labour won only three seats and Phillip G himself was defeated, there was some satisfaction among NAWU members that Stokes was also defeated.54 The strike action had now gone as far as it could and, following the elections, the NAWU formally closed the strike in a bitter spirit.55 Strikers’ narratives With strike action drawing to its close, retribution was harsh. All forty-two strikers were dismissed and return of the strikers’ pension contributions was refused. Edmondson (NAWU) was granted an interview with the DVC at a special meeting at which he requested the reinstatement of the strikers. He was informed that ‘as the Committee had been obliged to fill the places of these men by appointments on the permanent staff there were no vacancies available for them’. He then requested repayment of the strikers’ superannuation contributions, but the committee decided it was unable to do so.56 This had very serious repercussions for strikers who had many years of service, although understanding of this issue was somewhat confused. Using unnecessarily emotive language, Bartlett had drawn up two lists of staff described as ‘strikers’ and ‘loyal’ staff members for the committee, which gave the occupation and length of service of each individual.57 For reasons unknown the Board of Control had characterised the strikers at Digbys as either temporary or relatively new staff.58 On the female side this was a fair assessment as the fifteen striking nurses only averaged 1.03 years of service, but overall the strikers had 108

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only marginally shorter service than non-strikers (9.5 years and 10.16 years respectively). Indeed the three striking artisans in particular, who each had twenty-three years’ service, stood to lose, and indeed did lose, everything. In public the strike remained firm to the end and the workers were defiant in support of ‘the loyal men and women who on principle have come out on strike’ – note the possibly deliberate appropriation and reversal of Bartlett’s conception of the ‘loyal’ staff.59 Once the strike failed, individual workers facing dismissal, loss of pension and in some cases homelessness were forced into humiliating personal pleas for reinstatement. The powerlessness of the strikers was revealed in a new language of deference rather than dispute. At first the committee seemed conciliatory, issuing a statement, reported in the local press, that ‘[w]hilst the committee cannot give an undertaking to reinstate all the strikers, they are prepared to sympathetically consider applications from men and women, especially those who have been some time in the service and whose pensions are in jeopardy’.60 However, it soon became clear that the strikers would receive punitive treatment, and appeals to the committee were of no avail. John P had been the cowman at Digbys for twenty-three years before the strike and throughout this period had lived in a tied cottage on the estate. His wife had accumulated eighteen years of service at Digbys.61 Both joined the strike on 30 April 1919 and were among the forty-two strikers dismissed for neglect of duty on that day. During the strike they received some financial support from the NAWU but lived under the threat of eviction from the cottage. In September the town clerk delivered an eviction notice to John P, demanding that in addition to paying the hitherto unpaid rent he vacate the house by 1 October as ‘it is required for the occupation of a person in the employ of the Visiting Committee’.62 John P pleaded with the committee and, facing legal action and homelessness, sought to break ranks with the strikers and seek reinstatement. His cringe-making letter hints at his personal desperation: Will you please make an application to the Visiting Committee to accept an apology from me for leaving their service without notice as I am very sorry for what I did as I was driven to it by others, and request them to favourably consider my return to work again considering all the circumstances under which I was.63

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Contrary to its earlier conciliatory statement, the committee took an uncompromising stance. The town clerk replied saying there was no suitable job vacancy for John P and demanding immediate vacant possession of the cottage.64 Mr and Mrs P left on 5 November but the committee continued to press them for unpaid rent.65 Other strikers were more concerned about their pensions than accommodation, and here the committee also exacted retribution. Harry R, a painter of twenty-three years’ employment at Digbys, was also dismissed after joining the strike on 30 April 1919. Encouraged by the press statement regarding reinstatement and pensions, he spoke personally to the DVC chairman who told him to put his request for reinstatement in writing to Dr Bartlett, to be laid before the committee. On 21 January 1920, Harry R wrote: You know me to be a willing, conscientious and good worker and I appeal to you sir to forget the past and give me a chance to make good. Having been informed that the Committee would carefully consider any applications I respectfully submit mine to you. I ask you Sir if you will kindly favour me with your recommendation.66

He received the same response as John P, with an additional note to the effect that the committee had reconsidered the matter and decided not to reinstate any staff who had taken part in the strike.67 Other strikers who approached the town clerk or the chairman of the DVC were also instructed to put their request in writing to the committee, only for each case to be refused. This may seem an entirely cynical exercise, but given the strength of feeling locally the elected and appointed officials concerned may have wished to hide behind the anonymity of a committee decision. Seeking at least the return of pension contributions, Harry R tried again with a deferential reply to the committee’s rebuff: I am exceedingly sorry such was the case and I respectfully ask you to rescind your decision if possible, failing that, I apply to you Sir, to place before your committee an application from me and on behalf of all the men concerned for the return of the deductions made from our wages under the Asylum Officers Superannuation Act. I have been assured that you do not act towards us in any vindictive spirit and I now ask you to be as generous toward us as you possibly can for this error of judgement which we have made.68

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But the response was again resolute, with the committee claiming it had no power to accede to his request.69 Harry R was condemned to a poverty-stricken future. Other dismissed strikers shared their desperation with the committee and drew attention to the special nature of their cases. A Mr G, married with four children, perhaps hopeful that the committee would, as stated, look favourably on the cases of long-serving staff, mentioned his war service, claiming that ‘during the whole time of the war I did practically two men’s work and without a clear Sunday and no annual leave taken’.70 However, his nineteen years of service in the asylum kitchen did nothing to sway the committee and he too received the standard response that there was no vacancy for him.71 Mrs G then wrote to Dr Bartlett begging for his assistance on behalf of their children: ‘I am appealing to you in my trouble, to ask you to reconsider my husband’s case, to reinstate him as I have four children and the times are so bad.’72 The humiliation of the individual strikers was pursued to the end. Yet while the DVC remained resolute, the city council continued to be divided on asylum matters and Labour members questioned its administration. In December 1919 Councillor Gayton criticised increased death rates, low rates of recoveries and high costs while claiming that a number of allegations of mismanagement had emerged during the recent election campaign. He demanded a public statement from Dupree, and Dr Bartlett was consulted about this.73 The superintendent’s position became increasingly untenable as wartime difficulties at Digbys were exacerbated by continuing pressure on the public finances, the impact of the strike and an apparent personal loss of support for Bartlett. As early as January 1919 several councillors had proposed that Bartlett’s requested salary increase should not be given, citing forthcoming local elections and the need to prioritise the goodwill of the ratepayers.74 In March 1920 Bartlett applied for another position and finally left Digbys in 1922 after securing a post at Derby County Mental Hospital.75 In a striking parallel with the dismissed staff, Bartlett also had to leave; possibly believing himself a victim of the culture of blame and vindictive ­personal attacks that surrounded institutional psychiatry, and Digbys in particular, at this time. His successor, Dr McKinley Reid, certainly used his first report to the DVC to discuss some of these issues.76 111

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This was arguably a pivotal moment for the asylum system. The NAWU, which had optimistically entered the Exeter strike seeking to consolidate earlier successes, found itself financially ruined and deeply humiliated. Thereafter it sought alternative ways to pursue its reform programme, with less emphasis on local disputes. These campaigns were, to an extent, assisted by alliances with other actors and organisations. The public attention given to a number of asylum scandals in the 1920s also gave impetus to calls for systemic change, although neither the NAWU nor its members escaped criticism within these debates. Ill-treatment and wrongful detention actions The sense of crisis in, and concern about, the asylum system at the end of the First World War was heightened by the presence of a large number of ex-service patients in mental hospitals, whose numbers increased from 2,506 in January 1919 to 6,435 in October 1922.77 Their detention and alleged poor treatment encouraged public outcry and debate. In a sense this created conditions favourable to direct action by nurses and attendants, although public confidence in asylum workers was simultaneously undermined by a series of allegations of patient mistreatment. These first appeared in 1920, in an article in the Quaker magazine The Friend. Subsequent inquiries at Prestwich (1921), Longrove (1922), Hull (1923) and Salop (1923) asylums were all widely publicised and so were a number of cases of alleged wrongful detention.78 It was the Prestwich inquiry which particularly caught the public’s attention, because it concerned the alleged wrongful detention and mistreatment of ex-service patients. Following a deputation to the Ministry of Pensions, led by a local Member of Parliament, the Commissioners of the Board of Control held an inquiry at the asylum.79 Although they found no substance to any of the allegations, and decided that the ‘service patients’ at Prestwich were ‘treated with kindness and consideration by the medical and nursing staff’, they nevertheless concluded that the state of the asylum system required investigation and at the end of 1921 convened a meeting of visiting committee chairmen and medical superintendents.80 In March 1922 the Board of Control collaborated with the Minister of Health, Sir Alfred Mond, to establish an inquiry into nursing in 112

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mental hospitals and make suggestions for its improvement.81 The Committee of Inquiry reported in 1924, and its recommendations reflected the view of contemporary psychiatrists that mental and physical illness should be treated in as similar a way as possible. This suggested that in the future qualifications offered by the General Nursing Council, which emphasised training in the management of physical and mental illness, would be favoured over those awarded by the Medico-Psychological Association. The report also addressed the poor working conditions of asylum nurses. It highlighted a need for social activities, separate facilities from the patients and the establishment of schools of nursing. Unfortunately very little was done in response to the report. Pressure on public expenditure dictated that conditions tended to deteriorate rather than improve and the committee, comprised of medical superintendents and members of visiting committees, did not seem to inspire the confidence of nurses or the NAWU.82 Nonetheless the pressure for reform was growing. The National Council for Lunacy Reform, whose leaders endorsed the article in The Friend, publicised demands for curative hospitals unconnected with lunacy administration for early cases and pressed for the establishment of a Royal Commission into lunacy administration.83 More significantly, Montagu Lomax published his popular but shocking book, The Experiences of an Asylum Doctor, in 1921.84 He was a retired general practitioner who had undertaken war service in two asylums, most notably Prestwich. These experiences led him to offer a damning indictment of the state of the asylums, with problems attributed less to abnormal wartime conditions than a general malaise in the system of care. After exposing specific abuses that he had witnessed, Lomax suggested that the humiliating treatment of patients was a reflection of the manner in which the system managed its staff. So long as overworked attendants were punitively disciplined for escapes and suicides they would be harsh towards patients. Lomax demanded wide-ranging reforms and improvements, and as an explicit response to his book the Ministry of Health convened the Cobb Committee, comprised of three Commissioners of the Board of Control. Its stated objectives were to investigate Lomax’s charges and make recommendations for medical or administrative changes, though it was not intended to propose amendments to the lunacy laws. This narrow remit encouraged both Lomax and 113

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the NAWU, forced into a rather uneasy alliance, to shun the Cobb Committee and call for a full Royal Commission.85 At this time a number of wrongful detention cases (Stanhope v Holdsworth (1921), Brown v Craig (1921), Everett v Griffiths (1921) and Harnett v Bond (1924)), were brought to court.86 These highly publicised cases fuelled the discourse of dispute, and the award of significant damages at one stage in the complicated Harnett case suggested that the conduct of individual doctors, the entire certification process and conditions pertaining in the asylums were all matters of legitimate concern.87 Yet the tendency of different actors to blame others for the increasingly scandalous situation was itself a major obstacle to reform. Changes were initially largely cosmetic, with for example Digbys informally renamed in 1919 as the ‘City Mental Hospital’.88 It was the appointment of the Royal Commission on Lunacy and Mental Disorder (Macmillan Commission) in 1924 that witnessed the start of a more significant reform process that sought to acknowledge changing understandings of mental illness. One of the strengths of the commission was a collectivist approach that avoided the apportionment of blame and personalised attacks that had been a feature of the post-war years. The commissioners had a broad remit and consulted with a wide range of groups and individuals. Interested parties and the general public were invited to put forward comments and questions that might serve to highlight fruitful areas of inquiry. In addition the commissioners visited twenty-five institutions, including those where witnesses had highlighted concerns.89 Digbys was not among those visited, probably because the institution had already made a fresh start after its strike and was working to remedy its problems. Notably Bartlett had left and there were new members of the DVC. The Macmillan Commission published its recommendations on 7 July 1926, and used its report to further build consensus about necessary reforms. Rather than stressing points of conflict it drew attention to shared concerns, especially about staffing problems. Many witnesses supported plans to use more and better trained medical and nursing staff.90 When explaining care failures, the commission developed the idea of a depersonalised ‘rogue’ element instead of systemic problems. A culture of blame gave way to emphasis on discussion. It argued that there would always be a number of ‘unsuitable’ 114

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attendants or nurses who might ill-treat patients, but these were isolated incidents that could be managed through improved schemes for the selection, training and supervision of staff.91 The commission took a conciliatory approach, and by offering all interested parties something it made its recommendations more palatable. This was helped by an approach of tempering criticism by means of offering a positive comment first, followed by a suggestion. For example, in recommending the provision of further opportunities for patient activities, in particular for female patients, the report stated: ‘many of the public institutions we have visited are excellently equipped for the indoor amusements of the patients … but there is room for improvement in the provision of outdoor amusements’.92 Furthermore, the report reframed specific complaints as generalised, depersonalised recommendations rather than responses to accusations of fault. Through such discursive mechanisms the commission facilitated a non-defensive examination of change that retained the dignity of the various parties to institutional psychiatry. However, there was a concomitant cost. The commission’s attempts to contain blame and dispute, while facilitating a process of change, simultaneously acted to diminish the voices of patients. The commission received 360 communications from patients (who were visited) and 194 from former patients (twelve of whom were interviewed), but attached little weight to their testimony,93 reflecting the tendency to ‘silence’ such individuals.94 The report concluded by summating the diverse and disparate accounts into a meta-narrative that sought to explain the difficulties, and therefore offer solutions. The findings, which led ultimately to the 1930 Mental Treatment Act, were grouped broadly into six categories. Firstly, treatment of mental illness should approximate as far as possible that of physical illness, thus bringing psychiatry into mainstream medicine. To facilitate this, institutions were encouraged to admit voluntary and temporary patients outside of the normal certification process.95 Secondly, it recommended that the term ‘lunatic’ should be discarded and replaced by the term ‘mental disorder’, which would subdivide into ‘persons of unsound mind’ and ‘persons suffering from mental ailment’. In addition, ‘mental hospital’ was preferred to ‘asylum’, and the term ‘rate-aided’ was meant to reduce the stigma attached to ‘pauper’ patients.96 Thirdly, the commission 115

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recommended various procedural amendments, including the provision of convalescent wards and aftercare facilities.97 The fourth recommendation addressed patient care but in a manner carefully phrased to limit blame and dispute. On basic care it acknowledged variable standards and pressed for improvement in, for example, ‘access to lavatory accommodation’.98 Encouragement was given to the involvement of new groups of staff who were recognisable as embryonic social workers and occupational therapists who played an increasingly important part in psychiatric provision during the remainder of the twentieth century.99 The report also encouraged both Medical Officers and the Board of Control to develop their engagement with therapeutic treatment and recommended the establishment of research facilities.100 Fifthly, the report considered improving regulations concerning private institutions, one of which had featured prominently in the Harnett wrongful detention case.101 Once again the emphasis of the report was on promoting discussion rather than blame, recognising the existence of excellent facilities and areas for improvement. Finally, the report recommended that, with the exception of ‘harmless senile cases’, there should be the wholesale transfer of all responsibility for psychiatric care from the Poor Law Guardians to local government. It linked this recommendation to a financial incentive by way of an improved Exchequer grant, which would in turn be linked to greater central powers of a restructured Board of Control.102 Conclusion The protracted strike action at Digbys played an influential part in shifting the focus of asylum unrest from local actions to national campaigns. In turn, the outcome of these shaped developments at Digbys. The compromise of the Royal Commission had its counterpart in conciliation at Digbys. A calmer period prevailed and staff relations gradually improved, not least because contentious figures departed from the scene.103 The institution adopted many of the commissioners’ proposals, which were broadly welcomed by Dr McKinley Reid when he discussed them with the DVC.104 New emphasis was placed on providing specialist medical services and facilities at Digbys and further developing out-patient clinics.105 Other aspects of local provision, however, did not follow the commission’s intentions. 116

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The admission of voluntary and temporary patients to the county and borough mental hospitals was considered to be best practice by the commission and the 1930 Mental Treatment Act made this possible. At Digbys there were increasing numbers of voluntary patients but these admissions were accompanied by a constant rather than declining number of certified patients.106 Admissions to the Devon County Mental Hospital reveal a similar picture.107 This suggests less a changed approach to admissions, and a commitment to early treatment of severe mental illness, than a search for new patient populations. Care of old and new patient groups at Digbys was, however, compromised by a failure to invest in the new facilities recommended by the commission, with a separate villa for newly admitted patients only completed in 1960. This perhaps reflected the parsimony of the committee and ongoing local difficulties. Here it is useful to reflect on John Hopton’s analysis. He suggests that ‘gaps between intentions and practice suggest that neither changes in mental health policy, clinical advances in psychiatry, nor official enquiries necessarily lead to substantive improvements in the quality of care experienced by service users’.108 This was, alas, the experience at Digbys, and that of the staff also undoubtedly suffered as a result. Notes 1 The Exeter City Asylum was finally established at Digby’s field in 1886 after a long campaign by the Lunacy Commission. The majority of its patients came from Exeter although London County Council was an important client. Pauper and private patients were accepted before 1914. J. Melling and B. Forsythe, The Politics of Madness: The State, Insanity and Society in England, 1845–1914 (London: Routledge, 2006), pp. 14–15, 96, 127. 2 See, for example, P. Thompson, ‘Introduction’, in J. Bornat (ed.), Oral History, Health and Welfare (London, Routledge 2000), p. 4. 3 Report of the Royal Commission on Lunacy and Mental Disorder, 1926, Cmd 2700; also, Mental Treatment Act 1930, 20 and 21 Geo V c.23. 4 This poem written by patient Harry U, patient 306, formed part of a 1986 exhibition marking the centenary of the institution. The exhibits are housed at Wonford House Hospital, Exeter. See also patient case notes in Devon Heritage Centre, Exeter (hereafter DHC), 4034A/UH/2/1, Male Case Book, pp. 45–6. 5 Working conditions for attendants and nurses are explored in M. Carpenter, Working for Health: The History of the Confederation of Health Service

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Mental health nursing Employees (London: Lawrence and Wishart, 1988), pp. 19–26; and a parliamentary debate on the subject is described in G. Gibson, A History of the Mental Hospital and Institutional Workers Union 1910–1931: From Infancy to its Twenty-First Year (Manchester: Express Co-operative Press, 1931), pp. 82–3. 6 Modern Records Centre, University of Warwick (hereafter MRC), MSS.229/6/C/NA/4/1-4, NAWU magazines 1912–15; and MRC, MSS.229/6/C/NA/4/ 5-11, NAWU magazines 1915–22. NAWU Magazine, June 1922, 8. 7 Mick Carpenter, personal communication, 27 September 2006. 8 D. Boje, ‘Using narrative and telling stories’, in D. Holman and R. Thorpe (eds), Management and Language (London: Sage, 2002), pp. 41–53. 9 J. Klasi (1922), cited in J. T. Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997), pp. 37–8. 10 Lancashire Record Office, Preston (hereafter LRO), CC/HBM4, Lancashire Asylums Board, minutes September 1913 to January 1919, pp. 449–71; LRO, HRW/36/1, press cuttings, August 1918 to June 1920; LRO, HRW acc.8209 16, staff change book. 11 Cornwall Record Office, Truro (hereafter CRO), HC1/1/3/9, Bodmin Asylum Report, 1919, pp. 22–4; CRO, HC1/1/18, minutes of the visiting  committee, 1917–19, p. 322; CRO, HC1/3/7, staff service register, 1910–34. 12 Carpenter, Working for Health, pp. 77–8. 13 For a discussion of the strike action, see Gibson, A History of the MHIWU, pp. 22–34. 14 D. Aldcroft and M. Oliver, Trade Unions and the Economy 1870–2000 (Aldershot: Ashgate, 2000), pp. 6–45. 15 M. Davis, Comrade or Brother? The History of the British Labour Movement 1789–1951 (London: Pluto Press, 1993), pp. 94, 99–100. 16 Aldcroft and Oliver, Trade Unions and the Economy, pp. 10–11. 17 Defence of the Realm Act 1915, 4&5 Geo 5 c.29; Munitions Act 1915, 5&6 Geo 5 c.54. 18 J. Hinton, The First Shop Stewards’ Movement (London: George Allen and Unwin, 1972), pp. 15–16, 23. 19 The Asylum Officers Superannuation Act (1909) left many staff financially worse off because their employers had previously operated non-­ contributory schemes. 20 Gibson, A History of the MHIWU. 21 See NAWU Magazine, August 1913. See also Carpenter, Working for Health, p. 48. 22 Carpenter, Working for Health, pp. 37–47, 50. 23 Carpenter, Working for Health, p. 52.

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Discourses of dispute 24 NAWU Magazine, May 1912, 4. 25 NAWU Magazine, March 1913, 2. 26 Carpenter, Working for Health, pp. 37, 57, 65, 75. 27 H. Richards, ‘The Daily Herald 1912–1964’, History Today, 31:12 (1981), 12–16. 28 DHC, Exeter City Archives (hereafter ECA), Town Clerk’s Papers (hereafter TCP), group D, box 4, file 19, letter to the Secretary of State, 12 June 1911, opposing the Employment, Pensions and Superannuation Bill. 29 DHC, ECA, TCP, group D, box 4, file 114, petition from staff to the DVC, October 1914. 30 DHC, ECA, TCP, group F, general, box 29, files 736–55, copy of Report of Departmental Committee on the Administration of Public Mental Hospitals (Cobb Committee) (Cmd 1730, 1922). 31 B. Pierce, ‘Some present day problems connected with the administration of asylums’, Journal of Mental Science, 65 (1919), 198–9. 32 Gibson, A History of the MHIWU, pp. 22–4. 33 Note that the apparently successful action in Bodmin still resulted in the five nurses leading the action being dismissed over succeeding months as part of a reduction in staff linked to public expenditure cuts. 34 Carpenter, Working for Health, p. 77. 35 DHC, ECA, TCP, group D, Mental Hospital (hereafter MH), Staff Training (hereafter ST), box 4, file 116. 36 DHC, ECA, TCP, group D, MH, ST, box 4, file 116, file of press cuttings about the strike kept by the town clerk (hereafter PCF). 37 DHC, 4034A/UH//1/5, p. 666, letter from Phillip G appears in minutes of the Mental Hospital Committee (hereafter MMHC), 1916–20, p. 666. 38 DHC, PCF, ‘Digbys Strike: More Protest Meetings at Exeter’, Express and Echo, 3 July 1919. 39 MMHC, special meeting of the Mental Hospital Committee, 29 April 1919, p. 677. 40 DHC, PCF, ‘Exeter Asylum Strike: Trades Council Action’, Devon and Exeter Gazette, 7 May 1919. 41 Report appears in the MMHC, 13 May 1919, p. 197. 42 Report presented to Exeter City Council meeting, 24 June 1919, MMHC, p. 199. 43 DHC, PCF, ‘Questions in the Commons’, Express and Echo, 13 May 1919. 44 MMHC, 24 June 1919, p. 199. 45 MMHC, 29 May 1919, p. 690. 46 DHC, PCF, ‘Digbys Strike: NUR Resolution, Another Mass Meeting’, Devon and Exeter Gazette, 26 May 1919. 47 ‘Digbys Strike: NUR Resolution, Another Mass Meeting’. 48 DHC, PCF, ‘Digbys Dispute; Threatened Sympathetic Strike in the City’, Express and Echo, 24 June 1919.

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Mental health nursing 49 DHC, PCF, ‘Digbys Strike: Exeter Council Refuse Arbitration: Labour’s Appeal’, Express and Echo, 25 June 1919. 50 ‘Digbys Strike: Exeter Council Refuse Arbitration: Labour’s Appeal’; ‘Digbys Dispute; Threatened Sympathetic Strike in the City’. 51 DHC, PCF, ‘The Exeter Strike, Trade Unionists Make a Demonstration, Procession and Meeting’, Express and Echo, 14 July 1919; and ‘Digbys Asylum, Exeter Demonstration, The Final Appeal’, Devon and Exeter Gazette, 14 July 1919. 52 ‘Exeter Contests: Coming Fights for City Council Seats’, Express and Echo, 24 November 1919, 5. 53 ‘Exeter City Asylum Strike’, NAWU Magazine, October 1919. 54 ‘Crocodile Tears at Exeter, The Inestimable Stokes’, NAWU Magazine, November–December 1919, 15. 55 ‘Exeter Asylum Strike Terminated’, NAWU Magazine, November– December 1919, 1. 56 MMHC, special meeting of the Mental Hospital Committee, 1 October 1919. 57 DHC, ECA, TCP, group D, MH, ST, box 4, file 116, lists of staff; DHC, ECA, TCP, group D, MH ST, box 4, file 110, written commendations for the wives of ‘loyal’ staff who assisted with the work of the asylum during the strike. 58 MMHC, report of the visit of the Board of Control on 2 May 1919, presented to Exeter City Council meeting, 13 May 1919. 59 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, pamphlet, ‘Exeter City Asylum Strike: A Word with You’, in support of the strike and against blacklegging. 60 DHC, PCF, ‘City Talk’, Express and Echo, 17 May 1919. 61 DHC, ECA, TCP, group D, MH, ST, box 4, file 116, list of strikers. 62 DHC, ECA, TCP, group D, MH, ST, Box 1, file 17, letter from the town clerk to John P, 17 September 1919. 63 DHC, ECA, TCP, group D, MH, ST, box 1, file 17, letter from John P to the town clerk, 23 September 1919. 64 DHC, ECA, TCP, group D, MH, ST, box 1, file 17, letter from the town clerk to John P, 9 October 1919. 65 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, memo written on letter from John P to the town clerk, 2 November 1919. 66 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from Harry R to the DVC, 21 January 1920. 67 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from the town clerk to Harry R, 23 January 1920. 68 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from Harry R to the DVC, 18 February 1920. 69 DHC, ECA, TCP, group D, MH, ST, box 4, fi1e 115, letter from the DVC to Harry R, 24 February 1920.

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Discourses of dispute 70 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from Mr G to the town clerk, 19 November 1919. 71 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from the town clerk to Mr G, 25 November 1919. 72 DHC, ECA, TCP, group D, MH, ST, box 4, file 115, letter from Mrs G to Dr Bartlett, 12 December 1919. 73 DHC, ECA, TCP, group D, MH, ST, box 1, file 16, letter from the town clerk to Bartlett detailing the questions to be raised by Councillor Gayton at the next meeting of the council, 13 December 1919. 74 ‘Asylum Medical Superintendent’s Salary’, Express and Echo, 22 January 1919. 75 MMHC, DVC meeting, 25 March 1920, p. 736. 76 DHC, 4034A/UH/1/6, MMHC, Thirty-seventh Annual Report of the Medical Superintendent to the Visiting Committee of Digbys for year ended 1923, pp. 923–6. 77 ‘Ex-Soldiers in Asylums’, The Times, 9 November 1921, 8. This letter, from a Member of Parliament, quoted figures from the Board of Control and called for a Royal Commission to examine the treatment of ex-service patients. 78 See, for example, reports of the Longrove Inquiry in The Times, 20 April 1922, 12; 25 April 1922, 9; and 26 April 1922, 9. See also P. Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993), pp. 77–8. 79 ‘Treatment of Lunatics, Serious Charges Investigated, Official Findings’, The Times, 21 September 1921, 7. 80 DHC, ECA, TCP, group F, General, box 29, file 746, letter from the Board of Control, 1 December 1921. 81 ‘Appointments and Notices’, The Times, 16 March 1922, 9, published details of the appointment of the Committee of Inquiry, its membership and remit. 82 Nolan, A History of Mental Health Nursing, p. 86; NAWU Magazine, June 1922. 83 ‘Care of Mental Cases’, The Times, 2 February 1922, 6, letter signed by H.  Bentinck, G. Cecil, G. K. Chesterton and J. Kensington Parmoor (members of the National Council for Lunacy Reform). 84 M. Lomax, The Experiences of an Asylum Doctor (London: Allen and Unwin, 1921). 85 Some NAWU members were concerned about Lomax’s views on the actions of the Prestwich attendants. See, for example, ‘My Impressions of Dr Lomax’s Book’ by NAWU member in NAWU Magazine, October– November 1921, 2–3. 86 ‘Kings Bench Division, Alleged Wrongful Detention as a Lunatic, Stanhope v Holdsworth and Others’, The Times, 28 April 1921, 5; ‘High Court of Justice, King’s Bench Division, Alleged False Imprisonment in an Asylum, Brown v Craig and Another’, The Times, 13 May 1921, 4; ‘House of Lords, Alleged Wrongful Detention in a Lunatic Asylum, Everett (pauper) v

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Mental health nursing Griffiths and Another’, The Times, 11 February 1921, 4; ‘High Court of Justice, King’s Bench Division, Alleged Wrongful Detention in an Asylum, Harnett v Bond and Another’, The Times, 7 February 1924, 5. 87 For additional reporting of the Harnett case, see The Times, 26 February 1924, 5; 28 February 1924, 5; 8 April 1924, 5; 14 April 1926, 5; 16 May 1925, 5; and 20 April 1926, 5. See also ‘Mr Harnett Found Drowned, Lunacy Litigation Recalled’, The Times, 11 November 1927, 13. 88 MMHC, 24 April 1919. 89 Macmillan Commission report, p. 165. 90 Macmillan Commission report, pp. 104–5. 91 Macmillan Commission report, pp. 113–14. 92 Macmillan Commission report, p. 120. 93 Macmillan Commission report, p. 7. 94 K. Davies, ‘Silent and censured travellers: patients’ narratives and patients’ voices; perspectives on the history of mental illness since 1948’, Social History of Medicine, 14:2 (2001), 267–92. 95 Macmillan Commission report, p. 157. 96 Macmillan Commission report, p. 162. 97 Macmillan Commission report, p. 164. 98 Macmillan Commission report, p. 168. 99 Macmillan Commission report, p. 165. 100 Macmillan Commission report, pp. 169–70. 101 Macmillan Commission report, p. 170. 102 Macmillan Commission report, pp. 175–6. 103 Alderman Munroe, long-time chairman of the DVC, died in 1921 and Councillor Stokes died in 1925. Both received generous tributes from Bartlett in his annual reports. 104 DHC, 4034A/UH/1/7, MMHC, Fortieth Annual Report of the Medical Superintendent for 1926. 105 DHC, 4034A/UH/1/7, MMHC, Forty-second Annual Report of the Medical Superintendent for 1928, pp. 944–7. 106 DHC, 4034A/UH/1/56, MMHC, Forty-ninth Annual Report of the Medical Superintendent for 1935. 107 D. Pearce, ‘The Operation of the 1930 Mental Treatment Act in Local Psychiatric Hospitals: The Introduction of Voluntary Patients and New Treatment Regimes in the Devon Mental Hospital, 1931–1938’, MPhil dissertation, University of Exeter, 2002, pp. 44–6. 108 J. Hopton, ‘Prestwich Hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care’, History of Psychiatry, 10 (1999), 349–69 (p. 364).

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6

‘Surely a nice occupation for a girl?’ Stories of nursing, gender, violence and mental illness in British asylums, 1914–30 Vicky Long

The role played by gender in the history of mental health nursing has long been recognised. Early historians in this field identified how the feminised model of nursing posed difficulties for male attendants as they struggled to attain a secure occupational status, a subject developed further within this volume by Borsay and Knight (chapter 4). Equally, the extent to which gender has shaped understandings of madness has long been debated by historians. In her influential account The Female Malady, first published in 1987, Elaine Showalter argued that mental illness was reframed as a female malady in the nineteenth and twentieth centuries.1 In the eighteenth century, Showalter asserted, the insane were viewed as ‘unfeeling brutes, ferocious animals that needed to be kept in check with chains, whips, strait-waistcoats, barred windows, and locked cells’. By the early years of the nineteenth century, she claimed, the ‘symbolic gender of the insane person shifted from male to female’.2 Reconfiguring madness as a form of sickness characterised by loss of reason, reformers drew upon the more appealing image of the vulnerable madwoman, cementing associations between female irrationality and male rationality. Revisionist historians argue that it is difficult to substantiate a number of Showalter’s hypotheses when asylum records are consulted. In this vein, Jonathan Andrews and Anne Digby attacked ‘the overly ideologised and unconvincingly theorised approaches to issues of class and gender in asylum and psychiatric history’ in the introduction to their 2004 edited volume.3 Nevertheless, revisionist 123

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work rarely denies the significance of gender as a category which has shaped understandings and experiences of madness and its treatment; rather, such work points to the ways in which femininity and masculinity influenced the history of madness. In short, as Joan Busfield argues, it is to ‘the interrelationship of gender and madness, not just of women and madness in isolation’ that we should turn our attention.4 Seeking to illustrate the complex role gender played in shaping understandings of mental illness and its treatment, this chapter draws together analyses of gender and professionalisation and gender and madness. It focuses on two scandals, the first concerning the replacement of male attendants with female staff in the male wards of some asylums and the second relating to stories of abuse suffered by ex-service patients at the hands of male asylum attendants. In so doing, it explores the implications of the gender dynamic between male asylum attendants and female general nurses, but also studies how gender influenced relations between patients and nurses and within the National Asylum Workers’ Union (NAWU).5 Both scandals concerned the care and management of male asylum patients, not the vulnerable madwoman identified by Showalter. In turn, the scandals affected the status of psychiatric nurses and perceptions of mental illness and asylum patients. Analysis of these scandals illustrates how occupational struggles between different professional groups within the field of mental health care were fuelled in part by conflicting representations of mental illness, and in turn could generate stigmatising discourses which encompassed both carers and patients. Mental health care in the early twentieth century It is thus helpful to commence with a brief overview of the field of mental health in the early years of the twentieth century, so as to contextualise the strategies adopted by the NAWU within the broader constraints facing mental health care workers and the approaches adopted by other occupational groups working within this field. The most dominant group within the field, whose professional strategies impinged most directly upon the interests of asylum attendants, was psychiatry. In 1841 this group had established a professional 124

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body, the Medico-Psychological Association (MPA), to represent its interests. The MPA organised meetings for psychiatrists where they could exchange and debate ideas and published its own periodical, the Journal of Mental Science. However, the profession was far from achieving widespread acclaim as a recognised medical specialism. The Journal of Mental Science frequently bewailed the low esteem in which the profession was held by both the public and other doctors, anxieties which were not unfounded.6 Some critics writing in newspapers and popular periodicals challenged the profession’s claims to expert knowledge, arguing that medical superintendents of asylums were simply glorified hotel keepers, concerned less with providing medical treatment and more with lowering the costs of confining their inmates. Other critics pointed to the conflicting evidence given in trials by different psychiatrists to argue that psychiatric science was unproven and enabled criminals to escape just punishment by medicalising their deviant behaviour. Moreover, doubts were expressed about the ability of psychiatrists to judge who was insane and therefore should be confined within an asylum against their will. Horror stories abounded in the popular press of perfectly sane people who were imprisoned within asylums, either through the sheer incompetence of psychiatrists or because psychiatrists and relatives had colluded to confine a sane family member in order to gain access to their finances.7 At the heart of these criticisms lay a belief that insanity might not be a medical condition which required the specialised treatment of doctors at all, but rather a form of social deviancy which could be treated more appropriately outside the jurisdiction of psychiatry.8 Given the low esteem in which psychiatrists were frequently held by both the public and other doctors, it is unsurprising that the status and conditions of work for asylum attendants were poor. At the start of the twentieth century, asylum attendants could expect to work an average 90-hour week.9 The rate of pay was comparable to domestic service and attendants were under constant threat of dismissal if they infringed the array of disciplinary rules they were subject to. In the 1890s asylum medical superintendents attempted to contain the discontent of attendants by establishing the Asylum Workers’ Association (AWA). This body idealised the professionalism of asylum staff while failing to address the low wages and long working 125

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hours that were the major cause of discontent.10 The failure of the AWA to secure non-contributory pensions for attendants proved to be the final straw: in 1910 delegates from five asylums established the National Asylum Workers’ Union.11 Analysis of the NAWU’s Magazine, distributed to all members, reveals how some attendants viewed their jobs and their patients. Early representations of asylum patients within the Magazine were indiscriminate and were usually deployed by the NAWU to advance the conditions of attendants rather than those in their care. Not that an outwardly hostile attitude to the patients was taken: an article ironically entitled ‘A Patient’s Paradise’ reflected awareness of the shared fortunes of patients and attendants, describing the hard physical labour expected from patients and the poor food they received in return. This theme recurred in a further article in the same issue which described the poor food given to patients because medical superintendents preferred to spend money on the outward appearances of the asylum, inciting the editor Herbert Shaw to interpolate a sardonic aside: ‘[Why do the patients need good food? They aren’t Superintendents.– Editor]’.12 The very first editorial of the Magazine commented: we seriously maintain that if the Lord Chancellor and the Lunacy Commissioners are sincerely anxious for the welfare of the patients, the very first thing to which they should turn their attention is to see to it that the conditions of asylum service are such as to attract and retain the best types possible of men and women … they allow the public money to be wasted … in giving medical superintendents huge salaries.13

Dingwall, Rafferty and Webster note that early in the twentieth century, asylum attendants in the pauper asylums ‘shared the conditions of the patients. Both were equally subject to the same complex web of rules and to the expectation of automatic and unquestioning obedience.’14 These early critiques on behalf of the patients may indicate how the poor working conditions of attendants led them to sympathise with the patients. A more usual strategy adopted by the NAWU at this time to obtain improved conditions and pay, however, was to focus on the unpleasantness of the patients. Complaining of the visiting committees of asylums in 1912, one writer argued that ‘asylum staffs have 126

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quite enough to do to attend to the antics of deluded and degraded “­mental-deficients” and moral perverts under them’.15 Frequently, contributors to the Magazine described how attendants had to ‘manage’ or pacify these difficult patients through an astonishing array of personal qualities. ‘The staffs at asylums’, argued one correspondent in 1913, ‘have to exercise … the caution of a lion tamer, the cunning of Sherlock Holmes; they have to cajole, wheedle, threaten, persuade, fascinate, charm, captivate, pacify, soothe, calm, appease, relieve, discipline, coax and humour the patients.’16 This article represented the patient as alien, foreign, devious and different from normal people, and in need of management. The use of the metaphor of a lion tamer adds an air of animality to the description of the patient. This idea of how to handle patients could have been drawn from attendants’ training: in the main text for training attendants, the terms ‘nursing’ and ‘management’ or ‘control’ of patients appear to be interchangeable.17 Nor had things radically changed by 1929; in a description of the job of the mental nurse, the author claimed that ‘her patients may be unpleasant, abusive, filthy in habits and language, or ungrateful, suspicious, unwilling and resistive … her sympathy, kindliness and tact must be abundant to overflowing for a mental patient … is amenable to nothing else’.18 Contributors to the Magazine often advanced the argument that attendants’ calls for better wages and conditions were justified because of the violent and anti-social behaviour of the patients. An attendant’s response in the correspondence section to an earlier ‘joke’ article about the slothful life of the asylum attendant bitterly attacked his work, and the patients at the heart of his job: We have such fun, washing and dressing the patients, often belching in one’s face and worse … in some asylums … they have an endless amount of fun provided by patients wandering round the table, falling in fits, and occasionally throwing a spittoon onto the table … then … the bedding of the patients. Oh! The fun we have; it makes our sides split – undressing, bathing, pulling, struggling; it really is delightful. Then sometimes we get a black eye, a kick on the shin, or a tooth or two knocked out.19

The author of this article did not depict the patients as ill, but as violent and anti-social. Other articles explicitly responded to allegations published in the medical and general press that asylum 127

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attendants assaulted patients. Thus, in 1928, the Magazine carried a report of an incident in which an attendant had been attacked by a patient: The nurse was knocked unconscious and the patient lifted the chair to strike another, and perhaps, a fatal blow, when the patient playing cards sprang to the rescue … The nurse had to have six stitches in his head … These are the everyday ‘emoluments’ of the mental nurse which are not advertised by those critics of the service whose principal concern is to expose the alleged ‘brutality’ of the mental nurses.20

In this article, the author placed two conjectures in the account; that the next blow from the patient would perhaps have been fatal, and that such events were ‘everyday’. These phrases help shift the meaning of the story to fit the desired conclusion – that any individual undertaking such work deserved better conditions and pay, not because they were skilled professionals but because they managed dangerous, violent inmates. Violence, risk and gender As these examples illustrate, the theme of violence and risk permeated discussions of attendant–patient interactions within the NAWU Magazine. In 1920 violent and anti-social patient behaviour was emphasised and given a gendered aspect by the NAWU in a battle reflecting the composition and power structure within the organisation. Although by the end of 1920 women’s membership had increased to almost 46 per cent of the total membership,21 NAWU delegates to the annual conference and branch executives were almost entirely male. It also appears that the authorship of the Magazine was dominated by men. These tensions had their roots in wartime developments, were fuelled by conflicting models of mental disturbance, and brought simmering tensions between male and female attendants and nurses to a boil. During the First World War, a number of mental hospitals employed women on the male wards to combat the shortage of manpower.22 Some medical superintendents chose to maintain the system after the cessation of hostilities, nominally on medical grounds, although the lower wages paid to women may also have prompted this decision. This position was contested by the NAWU. 128

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Both psychiatrists and the trade unionists argued that the presence of female nurses would have a profound effect upon the male patients they cared for, although the two groups drew very different conclusions about the effects of female nursing. While the practice of female nursing was something of a new phenomenon in English asylums, born out of the exigencies of the war, Scottish asylums had been experimenting with the system since the end of the nineteenth century. Indeed, by 1916 Dr George M.  Robertson, the most prominent advocate of female nursing on male wards, felt justified in describing the practice as a ‘firmly established feature of the Scottish system of care for the insane’, adopted in the vast majority of Scottish asylums.23 Robertson argued that women showed ‘superior aptitude and skill’ for the duties of nursing, because of their mothering instinct. While he acknowledged that there could be found some male attendants ‘who have been kind and devoted nurses’,24 yet as another participant in the debate put it, ‘it is a misuse and a waste of male attributes to see a stalwart young man training as an attendant doing his year in the sick wards, feeding an advanced general paralytic, say, with sop, and carrying out other nursing duties, which, without any shadow of a doubt, are women’s work’.25 While women were believed to be ‘naturally’ gifted at nursing, men were believed to lack the qualities that made women such good nurses. Robertson reinforced his views in his paper by referring to the men who worked in asylums as ‘attendants’ and the women as ‘nurses’. Robertson also suggested that male patients would respond more favourably to a woman’s influence. Female nurses, according to Robertson and his supporters, awakened the chivalrous instinct in male patients. The presence of women on the ward thus encouraged male patients to control themselves better and to use less foul language. Moreover, Robertson argued, female nurses preferred to work with male patients who were less inclined to disregard their instructions than female patients (at no stage was the logic reversed to suggest that male nurses should attend to female patients). Speaking in support of Robertson’s paper at a quarterly meeting of the MPA, Dr Legge described how he had begun to introduce female nurses on male wards at Mickelover Asylum. The system, he argued, ‘got rid of some things one was ashamed to have’. He explained how he no longer had to be concerned with complaints from patients, 129

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because ‘it would be obviously ridiculous for a male patient to aver that a woman had struck him’.26 Regarding the proprieties of women nursing men, Robertson noted that female nurses in general hospitals nursed male patients and provided the same decencies were observed he could see no difficulties emerging. He also maintained that male patients with sexual proclivities should remain under the care of male nurses. Refashioning the asylum For Robertson, female nursing was part of a grander scheme to hospitalise the asylum, refashioning its purpose, structure and operations upon the template of the general hospital. Robertson averred that the insane were sick and required nursing. He saw male attendants as an anachronism, left over from the time when Madhouses at the end of the eighteenth and the beginning of the nineteenth centuries were not hospitals; they were prisons for the safe custody of a dangerous class. Little wonder, then, that the methods adopted in them were those of a prison, that ‘keepers’ alone were employed on the male side.27

Robertson’s arguments were not unanimously accepted by his fellow  psychiatrists. At a quarterly meeting of the MPA during which  Robertson presented a paper on the employment of female nurses in male wards, Dr Soutar objected that Robertson’s plans were flawed because he had failed to differentiate between the conditions and purposes of asylums and hospitals. While the inmates of hospitals were apparently ‘in the ordinary sense, sick physically; and … amenable to direct dietic and medicinal treatment’, asylum patients were ‘abnormal but not sick’, ‘misfits’.28 If women’s influence was so invaluable to asylum treatment, Soutar joked, then all asylum superintendents (Robertson included) should ‘at once tender their resignations, and ask that women doctors might be appointed in their stead’.29 However, the majority of psychiatrists swung behind Robertson’s ideas (at least in theory); as Dr Drapes asserted, ‘members should not give up the idea that every insane person was a sick person’.30 An editorial comment in the Journal of Mental Science, which reviewed the debate, decided that most doctors who approached the subject would ‘come to the conclusion that Doctor 130

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Robertson has proved his point’, and predicted that, sooner or later, the system would ‘be generally if not universally adopted throughout the asylum service’.31 Asylum superintendents such as George Robertson justified their decision to replace male attendants with female staff by drawing on medicalised concepts of mental disturbance as an illness which required skilled nursing, a supposedly natural female skill, in a hospital setting. Male attendants contributing to the NAWU Magazine, however, did not portray the insane as sick patients who would respond to the maternal instincts of skilled female nurses by exercising restraint and self-control. Instead they depicted male patients as violent, anti-social misfits, likely to attack female nurses or subject them to indecency. Moreover, the Magazine represented female nurses who engaged in such work not as professional and skilled hospital nurses, but instead as morally degraded by the dirty work they had undertaken. The NAWU Magazine first discussed the issue of female nurses working on male wards in January 1920 and continued to attack the practice in virtually every monthly issue throughout 1920. Arguments focused on the ‘depraved’ behaviour of male patients and the supposed vulnerability of female nurses to violent attacks from male patients. In his January article, the NAWU general secretary George Gibson incorporated a report he had sent to the annual conference of the Labour Party. Female nurses, Gibson claimed, could not manage the violent behaviour exhibited by male patients. Painting a lurid picture of the sexually depraved behaviour of male patients, he launched an attack on the reputation of female staff who undertook this work. Gibson substantiated his argument by drawing upon passages from the Handbook for Attendants Upon the Insane which related the ‘self indulgence’, ‘indecent conduct’, ‘filthy and dirty habits’ and dangerousness posed by (male) patients to (female) staff to condemn the ‘revolting’ and ‘degrading’ system of female nursing of male patients. Quoting from the Handbook, Gibson cautioned his readers that ‘many seemingly quiet patients are, at times, liable to become dangerous to themselves and others’.32 One should concede that the overall tone of the Handbook, authored by doctors and published in conjunction with the MPA, provided some ammunition to Gibson and his colleagues; as noted earlier, it was this book which conflated 131

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the terms ‘management’, ‘nursing’ and ‘control’.33 By abstracting these passages from their original context, changing the emphasis of the text through type fonts and the interpolation of sarcastic observations, and by interweaving his own views with material from the Handbook, Gibson created a stigmatising image of the male patient and the female nurse who would choose such a job. For example, Gibson quoted from page 344 of the Handbook: . 344– … Bad sexual practices are, unfortunately, common among the insane, and ought to be prevented as far as possible. The possibility of any patient indulging in bad habits should be borne in mind, and a constant watch for signs should be kept up.*34

Starring this passage, Gibson inserted his own observation: ‘*Surely a nice occupation for a girl?’35 Within the context of the Handbook, this passage was gender-neutral and would read as applying to both male and female patients. However, by placing the quotation in an article on male patients, Gibson encouraged readers to infer that the quote referred to male patients. Moreover, by choosing to emphasise the words ‘common among the insane’ Gibson tainted all male patients, while the aside, by implication, attacked the reputation of any woman who chose to undertake such work. The NAWU also linked poor recovery rates and a patient suicide to the practice of female nursing on male wards, effectively attacking the nursing standards of its female members. Instead of allowing women or ‘girls’ to voice their opinions on what he described as ‘the degrading system’ and the ‘revolting duties’ they undertook, Gibson used paternalistic language to speak for them: There is no medical superintendent, nor any male member of the Board of Control, who would permit wife or daughter to undertake such work, and having equal veneration for all women, I protest emphatically against the employment of female labour in the male lunatic wards of the asylums.36

The NAWU failed to find any female nurses to censure the system, although several wrote in attacking the Union for criticising the character of female nurses, accusing the men of ‘selfishness and jealousy’, and of branding the profession a degradation.37 One female critic perceptively commented on the harmful stigmatisation of male patients that the Union was undertaking, asserting that ‘it is an insult to a great number of patients to infer that all mental cases are depraved’.38 132

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The Nursing Times, which represented the interests of the general nursing profession, was quick to see a different side to the argument: We confess to a feeling of great distrust when we hear of complaints by male attendants in asylums of the ‘demoralising’ influence of women nurses in male wards. Why this solicitude for the women? … Not a single complaint of any kind has been made by the female nurses.39

This position was doubtless influenced by the rather strained relations between asylum attendants and general nursing. Asylums employed a roughly even split of male and female nurses, whereas nursing in general was a largely female profession – indeed, men were not admitted to the general register of nurses until 1949 and were not entitled to join the Royal College of Nursing until 1960.40 While mental nurses had chosen to fight for their interests by forming a union, nursing had eschewed this approach and had instead embraced the professional model, establishing the College of Nursing in 1916. The general nursing qualification tended to be held in higher regard than the Medico-Psychological Association certificate. Seeking to muster broader public support for its campaign, the NAWU actively encouraged its members to send copies of the articles to the local press, and suggested that branches contact local associations of discharged soldiers and sailors to ‘acquaint them with the fact that the continuance of this system of female nursing in asylum wards is depriving many ex-servicemen of the opportunity of securing employment in a public service’.41 This strategy initially met with some success. In Wakefield, the NAWU organised a joint protest with the local ex-servicemen’s branch, which stressed both the unsuitability of women for the work and the fact that their employment in male wards was depriving discharged servicemen of work. Union coverage also reached the national press: John Bull picked up on the story, attacking the practice of female nursing in male wards after reading the NAWU Magazine ‘in whose columns the revolting nature of the duties involved are emphasised with lurid force’.42 While nominally the NAWU stated that its intention was to protect women, the prime objective appears to have been to protect men’s jobs and pay levels: equally, psychiatrists advocating female nurses were doubtless motivated in part by the attractions of a cheaper labour force, although a desire to improve the low status of psychiatry within the medical 133

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profession at large by refashioning asylums on the template of general hospitals was doubtless also a factor. The NAWU had sought to mobilise the support of ex-servicemen for its campaign. Ex-service personnel would, however, play a more multifaceted role as the story unfolded in the national press. Parallel to the debate over the issue of women nursing on male wards, the Union discussed the allegations of cruelty by attendants made in the journal Truth by a former patient who had been invalided from military service after a nervous breakdown. This article belonged to the genre of tales of wrongful confinement and violent staff that had figured prominently in the Pall Mall Gazette in the 1870s.43 However, the story attracted more attention as it was written not by an ordinary discharged asylum patient but by an individual who had been treated for shell shock. As Peter Barham has argued in Forgotten Lunatics of the Great War, public concern for the well-being of working-class soldiers who experienced mental health problems as a consequence of their wartime service helped dismantle the barriers that segregated asylum inmates from the community at large.44 The article in Truth depicted the mental hospital as a place of incarceration where ‘inmates’ were ‘detained’ by ‘brutal and ignorant warders’ or ‘gaolers’.45 The writer of this article based his argument on the contention that insanity was a form of sickness that would respond to medicalised treatment in hospital settings: an objective shared by many psychiatrists and general nurses, but opposed by the maledominated NAWU. In the article, the writer depicted shell-shocked cases as patients suffering from an incipient stage of mental disease who needed to be restored to health. Violence was abundant again in this narrative, yet here the violence was ascribed not to the sick patients, but to the male attendants. The author of the piece referred to the ‘variety of forms of physical violence’ used by attendants to control patients. Those described in the article included throttling, half drowning, hitting the back of the patient’s head against the floor, and what the author referred to as ‘obscene methods of torture the nature of which I can only leave to the imagination of the reader’.46 These allegations of cruelty were restricted to male nurses. The author argued that ‘it is by no means certain that women nurses would not be quite capable of looking after many, if not the majority, of the cases, and that patients would not be better off in their hands’.47 134

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In February 1920 the NAWU responded to the allegation in its journal in an article entitled ‘Truth and Exaggeration’. The Union rejected the allegations, pointing out that nurses faced severe penalties for assaulting a patient, and arguing that patient testimony was unreliable. Despite denying the allegations, the Union writer felt it necessary to provide some excuses for poor nurse behaviour, citing ‘the confinement of nurses within asylum walls in the atmosphere of insanity for 80 to 100 hours per week’ and ‘the provocation which may be received’ that ‘maybe only those who have been engaged in attendance upon the insane can fully appreciate’.48 This response, and a NAWU publicity stunt in which George Gibson invited a journalist from the Sunday Chronicle to look round another military mental hospital and report favourably on it, failed to stem the tide of people writing to Truth with their own allegations of neglect and abuse suffered at the hands of asylum nurses. Indeed, the publicity stunt may have been counter-productive, as Truth in a subsequent article related the story of Mrs X, who alleged that her ex-soldier husband had been subjected to brutal treatment in this same institution.49 The focus of reports in Truth remained upon the discharged servicemen, contrasting ‘admirable hospitals’ in Kensington where ‘the nursing was in the hands of skilled women nurses’ with the ‘dark cells and padded room of the lunatic asylum, with brutal warders cowing the unfortunate occupants by physical force, to which the NCOs and men were condemned after their nervous systems had been wrecked by exposure to an unheard-of strain’.50 The media flurry generated by George Gibson’s condemnation of women nursing male patients illustrates how mental health workers, motivated by occupational concerns, could trigger a debate on the nature of mental illness within the general media. Treatment of the issue within the specialised medium of the NAWU’s Magazine was followed by further coverage in the local and general press. What proved to be more difficult to control was the direction and impact this might have. Diana Gittins, in her work on Severalls Hospital, has discussed popular fears of the polluting powers of the mad and madness, suggesting that those who worked with the mentally ill were perceived to be contaminated by association.51 Male nurses writing in the Magazine emphasised how the polluted identity of male patients could contaminate female nurses, enforcing the stigma of asylum 135

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patients and their carers in the public mind. Male patients, and to a lesser extent female nurses, were used as voiceless targets, victims of harmful representations, to further the occupational aims of male nurses. It is interesting that in the debate surrounding the alleged mistreatment of shell-shocked patients, some of the themes that emerged in the first debate relating to insanity, nursing and violence were deployed in an article that looked at the reverse issue of men nursing men. This may reflect the observation made by sociologist Jenny Kitzinger that the way in which a topic is covered may frame the way that future similar events are discussed and represented in the media.52 Factors arising from the First World War played a part in creating and shaping these debates. The shortage of available male staff promoted discussion among psychiatrists of the system of female nursing on male wards while the plight of shell-shocked soldiers mobilised public interest. In Truth, it was the figure of the ex-­serviceman and not the pauper lunatic who attracted sympathy and respect. Meanwhile, the NAWU argument against female nursing was based partly on an appeal that women were depriving ex-servicemen of jobs. A contested view of the nature of insanity underpinned these stories. Insanity was viewed by some psychiatrists and the journal Truth as a form of illness, requiring skilled, hospital–trained female nurses, imbued with maternal instincts, to treat the sick patients. The use of skilled female nurses, it was believed, would negate the risk of violence towards the male patient that was always present when male attendants were employed. However, for other psychiatrists and the male leaders of the NAWU, insanity was portrayed as a form of social deviance and loss of control. The introduction of female nurses on to male wards would only produce exhibitions of sexual deviance and violence that women would not be able to control. While claiming to represent the interests of their female members, the male executive of the NAWU derogatorily portrayed women who nursed male asylum patients as morally degraded by the dirty work they had undertaken, in order to gain benefit for themselves. Throughout 1920, the male writers on the Magazine waged an unremitting campaign to remove women from male wards by attacking the character of female nurses and labelling male patients as violent and sexually depraved. In so doing, they exacerbated the stigma of 136

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mental illness and smeared the nursing staff by association. The representations of male patients disseminated by the NAWU’s Magazine and by the leaders of the Union thus not only failed to represent the interests of patients; they also undermined the interests of many Union members, reflecting the imbalance of power between men and women in the NAWU in an era in which women were under-­ represented in the trade union movement throughout Britain.53 One of the main functions of the Medico-Psychological Association was to defend the interests of its members. Psychiatrists were, however, unsympathetic to the new attendants’ union, attacking the lack of interest the NAWU showed in patient welfare or in advancing the skills of its members. Although Soutar had objected to Robertson’s plans to hospitalise the asylum in 1916 on the grounds that asylum patients were not sick but abnormal, he nevertheless rejected the NAWU’s approach. In 1919 he attacked the industrial viewpoint adopted by the Union, remarking that fortunately there were still some attendants ‘who have in them the true spirit of nursing, who recognise that they are not, like factory hands, merely industrial workers. That spirit – the nursing spirit of sacrifice and readiness to serve the sick – is active in many of our asylum nurses and attendants.’54 Soutar’s critique illustrates a belief often expressed by doctors and the general nursing organisations about the incompatibility of professional ideals and efforts to improve the material conditions of workers. The NAWU’s tactics to advance the conditions of its members stood in sharp contrast to organisations that represented female nurses in general practice, such as the College of Nursing. Rather than seeking the material advancement of nurses, the college sought to promote nursing as a skilled medical profession which worked in the interests of patients. These divergent approaches, and the NAWU’s hostility towards women nurses, especially those in a position of power, no doubt antagonised the College of Nursing. Indeed, not only did the college exclude mental nurses from membership, it also dominated the General Nursing Council and contributed to the omission of mental nurses from the general nursing register. In the 1930s the NAWU shifted its strategy and sought to advance the claims of psychiatric nurses for improved status and conditions on the basis of their medical expertise, the ideal of nursing developed by female nurses in general medicine.55 These developments 137

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were facilitated by the introduction of new therapies such as ECT, insulin coma therapy and psychosurgery, which enabled nurses to equate psychiatric nursing with general nursing. In keeping with this new approach, the NAWU renamed itself the Mental Hospital and Institutional Workers’ Union in 1930. Depictions of male patients as violent and sexually perverted disappeared from view with this changed approach. This confused long-serving mental nurse C. H. Bond, writing in 1948, who was shocked that a reversal of Union policy had taken place at the previous annual conference. ‘Surely some of our old London District Council members remember the evidence produced by female mental nurses before the London County Council Mental Hospitals Committee, referring to the degradation being imposed upon females nursing male mental patients?’, he asked.56 The issue apparently died away in 1959, when a motion to bar women from nursing in male wards was overturned at the annual conference. The proposer, Mr Higgins, claimed ‘a female nurse working on male wards would be a witness to degrading scenes by chronic patients’. However, this image of the patient was seen by most of those present as embarrassingly dated and a threat to the professional image the Union was then trying to create; the resolution was dismissed by one delegate as ‘restrictionist and … as obsolete and outmoded as the padded cell or straitjacket’.57 Despite this change in direction, however, prejudice persisted towards woman within the union and particularly women in positions of authority. Attacks on the character of matrons through the pages of the NAWU Magazine were particularly prolonged and bitter. In 1913 a male correspondent to the Magazine criticised a matron who had given orders to a male attendant on duty. In his view, the matron should have been ‘kept in her place by the medical officer, and not allowed to use her opinion’.58 A motion on the Union’s 1930 conference agenda attacked the authority of matrons over male staff in mental hospitals.59 In 1942 the Magazine published a thinly veiled attack on the female nature in an article which ostensibly focused upon matrons. Disingenuously claiming to defend victimised female nurses, the author blamed the poor working conditions in many mental hospitals upon matrons, arguing that ‘the inability of most women to take positions of responsibility and behave with human tolerance to subordinates of their own sex was no small part of the 138

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problem’. Another backhanded insult was aimed at women when the writer claimed ‘it is gratifying to see our female colleagues at last realising the need of organisational action’, suggesting that women were too slow to see the advantages beforehand. Perhaps it was unsurprising that more women at that particular branch had chosen not to join the Union.60 An impression of female nurses’ attitudes towards the Union can be gleaned from a letter written in 1936 by a nurse who had been assisted in a legal case by the Union. Although she thanked the Union for the help received, she added ‘frankly, I had begun to begrudge paying my monthly subscription as I nursed a suspicion that female nurses were inadequately catered for’.61 Conclusion At this point, one might be tempted to attribute the NAWU’s attitude towards women nursing male patients, and its willingness to publicise the image of violent and depraved male patients, to gender inequalities within the Union. We could, therefore, castigate the strategies adopted by the NAWU when contrasted to the professionalisation route adopted by general nurses, and view the emergence of a medicalised professional model as evidence of progress. Arguably, however, we might arrive at a richer historical analysis if we eschew the desire to seek an easy moral conclusion and turn our attention to the broader field of mental health in which mental nurses’ occupational strategies were forged. The strategies adopted by the NAWU can thus be viewed not as an autonomous course of action but as enmeshed within this field, shaped by the aspirations and relative power of other health care workers. Psychiatrists sought to advance a medicalised model in which the asylum was reconfigured into a hospital and the attendant into a skilled (female) nurse, although this ethos was rather undercut in the Handbook for Attendants upon the Insane, written by doctors, which emphasised control rather than care. In response to the hospitalisation model promoted by psychiatrists, asylum attendants pragmatically sought to defend their interests by emphasising the occupational hazards of their work, focusing on the figure of the violent madman. However, these competing visions of the nature of mental illness and what constituted an appropriate method for caring for such individuals were 139

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not contested on an equal footing; attendants lacked the professional authority of doctors and could not exert the same influence on government policy or medical practice. And while the Union from the 1930s to the 1950s promoted the image of the professional, medically trained psychiatric nurse who cared for the sick, these trends went into reverse in the early 1960s following proposals to close hospitals and transfer care into the community, a field which at that stage psychiatric social workers laid claim to. Frustrated with a career that appeared to offer no future and stuck working in decaying buildings earmarked for closure with increasingly challenging patients as more promising cases were discharged, the Union reverted to its earlier strategy.62 Within the interconnected field of mental health, stigma was impossible to contain; it ricocheted and rebounded from the figure of the asylum patient to tar the image of the asylum and the asylum attendant. The NAWU may have succeeded in protecting the jobs of male attendants. However, its decision to represent certified patients as violent deviants requiring control, rather than as sick people requiring medical care, made it more difficult for mental nurses to establish themselves as a professional group with specialised expertise and an ethical concern for those they cared for. Indeed, the scandal generated by the NAWU about women nursing male asylum patients, and the subsequent scandal about abuses suffered by ex-service patients at the hands of male attendants, both created the impression that asylums were brutish places, perhaps perpetuating stigma in the public mind and the media about mental illness and asylum treatment. When asked by the government to promote mental nursing in 1942, for example, the BBC remained unwilling, feeling that the subject was ‘extremely difficult’;63 and while some BBC staff were keen to emphasise that mental nursing ‘is a dignified type of nursing now (with all its drawbacks on the messy side)’,64 senior staff members wanted to fit the subject discreetly into a general talk on nursing.65 The BBC correspondence on this debate revealed that perceptions of mental nursing and mental illness were linked. It was not just mental nursing that the BBC wanted to avoid; by extension mental illness continued to be perceived as ‘messy’ and ‘difficult’. When the BBC finally did cover mental health issues in its 1957 television series The Hurt Mind, connections between asylum attendants and violence 140

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resurfaced, as presenter Christopher Mayhew coerced a male nurse to admit that nurses had used violence to control patients prior to the introduction of new therapies.66 The Union’s failure to recognise just how interconnected asylum nurses and patients were in the public mind appears to have been a significant tactical error. Notes   1 E. Showalter, The Female Malady: Women, Madness and English Culture, 1830–1980 (London: Virago, 1987).  2 Showalter, The Female Malady, p. 8.  3 J. Andrews and A. Digby (eds), Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry (Amsterdam: Rodopi, 2004), p. 13.   4 J. Busfield, ‘The female malady? Men, women and madness in nineteenth century Britain’, Sociology, 28:1 (1994), 259–77 (p. 259).   5 The National Asylum Workers’ Union (NAWU) renamed itself the Mental Hospital and Institutional Workers’ Union in 1930. In 1946 it federated with the Hospitals and Welfare Services Union to form the Confederation of Health Service Employees.   6 For a helpful overview, see T. Turner, ‘“Not worth powder and shot”: the public profile of the Medico-Psychological Association, c. 1851–1914’, in G. Berrios and H. Freeman (eds), 150 Years of British Psychiatry, 1881– 1991 (London: Gaskell, 1991), pp. 3–16. Similarly, Andrew Scull, Charlotte MacKenzie and Nicholas Hervey acknowledge that while psychiatry had established the trappings of professional expertise, it remained beset by scandals and public distrust. See A. Scull, C. MacKenzie and N. Hervey, Masters of Bedlam: The Transformation of the Mad-Doctoring Trade (Princeton, NJ: Princeton University Press, 1996), pp. 3–9.   7 For examples of the concerns expressed in the press about wrongful confinement, see Lothian Health Service Archives, University of Edinburgh Main Library, LHB7/12/1, Royal Edinburgh Asylum Press Cuttings Book, Vol. 1, 1862–1881; LHB7/12/2, Vol. 2, 1882–1885; LHB7/12/7, Vol. 7, 1918–1927. Examples include ‘Mad, and Yet Not Mad’, unnamed Dundee paper, possibly the Dundee Advertiser, 7 December 1866, Press Cuttings Vol. 1, pp. 304–5; The Times, 10 April 1884, Press Cuttings Vol. 2, p. 76; ‘Strange Adventure in a Lunatic Asylum’, untitled paper, Press Cuttings Vol. 2, p. 5. For examples of concerns expressed in the twentieth century about wrongful confinement, including the confinement of shell-shock cases, see Justice Lush, cited in ‘Lost his Liberty: Sane Man Kept in Asylum for Nine Years – Doctors to Pay £25,000’, News of the World, February 1924, Press Cuttings Vol. 7, p. 231; Letter from Fiat Justitia regarding nerve-shaken soldiers, Nation, 14 October

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Mental health nursing 1916; ‘Manufacturing Madness’, John Bull, [1918], Press Cuttings Vol. 7, p. 11.   8 See M. J. Clark, ‘Law, liberty and psychiatry in Victorian Britain: an historical survey and commentary, c. 1840–1890’, in L. de Goei and J. Vijselaar (eds), Proceedings of the First European Congress on the History of Psychiatry and Mental Health Care (Rotterdam: Erasmus, 1993), pp. 187–93; and P.  McCandless, ‘Liberty and lunacy: the Victorians and wrongful confinement’, in A. Scull (ed.), Madhouses, Mad-Doctors and Madmen: The Social History of Psychiatry in the Victorian Era (Philadelphia, PA: University of Pennsylvania Press, 1981), pp. 339–61.   9 A survey conducted by the NAWU of thirty-one mental hospitals in 1912 revealed the working week of attendants to be in excess of 70 hours, in some cases more than 80 or 90. Cited in M. Carpenter, ‘Asylum nursing before 1914: a chapter in the history of labour’, in C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980), pp. 123–46. 10 M. Carpenter, Working for Health: The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988), pp. 37–41. 11 The early history of the NAWU is described in more detail by Barbara Douglas (chapter 5) in this volume. 12 NAWU Magazine, 2 (May 1913), 65–7. 13 NAWU Magazine, 1 (October 1912), 3. 14 R. Dingwall, M. Rafferty and C. Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988), p. 127. 15 NAWU Magazine, 1 (October 1912), 9. The reference to moral perverts was perhaps an allusion to the category of ‘moral imbeciles’, described in the standard mental nurses’ handbook as ‘persons who from an early age display some mental defect coupled with strong, vicious, or criminal propensities on which punishment has little or no detrimental effect’: Medico-Psychological Association, Handbook for Attendants on the Insane (London, 1908), p. 216. By adding the term ‘pervert’ to the phrase, the writer managed to convey an impression of sexual depravity, perhaps reflecting how some nurses viewed this category of patient. 16 NAWU Magazine, 2 (May 1913), 3. 17 MPA, Handbook for Attendants on the Insane, pp. 335–6. 18 NAWU Magazine, 18 (March 1929), 2. 19 NAWU Magazine, 2 (May 1913), 2. 20 NAWU Magazine, 17 (March 1928), 9. This article was satirically entitled ‘More “Emoluments”’, a reference to the earlier tradition of paying part of the attendant’s wages in goods or services. 21 Carpenter, Working for Health, p. 75. 22 In this volume Borsay and Knight (chapter 4) offer a case study of the Cardiff City Mental Hospital, which opened in 1908 and functioned as the Welsh Metropolitan War Hospital between 1915 and 1919.

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‘Surely a nice occupation for a girl?’ 23 G. M. Robertson, ‘The employment of female nurses in the male wards of mental hospitals in Scotland’, Journal of Mental Science, 62 (1916), 351–62 (p. 351). 24 Robertson, ‘The employment of female nurses’, p. 360. 25 ‘The Medico-Psychological Association of Great Britain’, Journal of Mental Science, 62 (1916), 445–55 (p. 455). 26 ‘The Medico-Psychological Association’, p. 449. 27 Robertson, ‘The employment of female nurses’, p. 352. 28 ‘The Medico-Psychological Association’, pp. 447–8. 29 ‘The Medico-Psychological Association’, p. 448. 30 ‘The Medico-Psychological Association’, p. 453. 31 ‘Female nursing of male insane’, Journal of Mental Science, 62 (1916), 416–21 (p. 421). 32 NAWU Magazine, 9 (January 1920), 8. 33 For a brief overview of the history of the Handbook, see H. R. Rollin, ‘The Red Handbook: an historic centenary’, Psychiatric Bulletin, 10 (1986), 279. 34 NAWU Magazine, 9 (January 1920), 8. Gibson took this quote from an unspecified edition of the Handbook for Attendants upon the Insane, although he italicised parts of this quotation. His italicisations have been reproduced here. 35 NAWU Magazine, 9 (January 1920), 8. Italic type in original text. Starred comment by George Gibson. 36 NAWU Magazine, 9 (January 1920), 9. Italic type in article. 37 J. Hallam, Nursing the Image: Media, Culture and Professional Identity (London: Routledge, 2000), p. 11. 38 NAWU Magazine, 9 (September 1920), 14. 39 NAWU Magazine, 9 (February 1920), 2. Reprinted from the Nursing Times, issue and page number not given. 40 Hallam, Nursing the Image, p. 100. 41 NAWU Magazine, 9 (September 1920), 8. 42 NAWU Magazine, 9 (February 1920), 9. Reprinted from John Bull, issue and page numbers not given. 43 For examples of wrongful confinement articles, see ‘Legal Difficulties in Cases of Alleged Lunacy’, Pall Mall Gazette, 8 June 1870, 10; ‘Certificates of Lunacy’, Pall Mall Gazette, 31 May 1870, 10. For examples of tales of staff cruelty, see ‘The Treatment of Lunatics: its Known and Permitted Horrors’, Pall Mall Gazette, 15 January 1870, 6; C. Reade, ‘How Lunatics’ Ribs Get Broken’, Pall Mall Gazette, 20 January 1870; ‘In a Lunatic Asylum’, Pall Mall Gazette, 9 May 1870, 6. 44 P. Barham, Forgotten Lunatics of the Great War (New Haven, CT, and London: Yale University Press, 2004). 45 Anonymous, ‘Army Mental Hospitals: A Little Light on a National Scandal’, Truth, 87 (January 1920), 95–7. The author described the mistreatment of

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Mental health nursing shell-shock patients, but argued that the same conditions applied to pauper lunatics who were cared for in the same institutions by the same staff. 46 Anonymous, ‘Army Mental Hospitals’, p. 97. 47 Anonymous, ‘Army Mental Hospitals’, p. 96. 48 ‘“Truth” and Exaggeration: Mental Hospital Treatment’, NAWU Magazine, 9 (February 1920), 6. 49 See ‘The Lord Derby War Hospital’, Truth, 87 (February 1920), 235–6. 50 ‘The Mental Hospital Scandal’, Truth, 87 (February 1920), 183–5, 183. 51 D. Gittins, Madness in its Place: Narratives of Severalls Hospital 1913–1997 (London: Routledge, 1998), pp. 21–4, 48–9. 52 J. Kitzinger, ‘A sociology of media power: key issues in audience reception research’, in G. Philo (ed.), Message Received: Glasgow Media Group Research 1993–1998 (Harlow: Longman, 1999), pp. 3–20 (p. 10). Kitzinger makes this point while discussing how coverage of the Cleveland social work scandal helped shape the representation of later sexual abuse / social work scandals, such as Orkney. 53 For a detailed account of the relationship between women workers and the trade union movement, see S. Boston, Women Workers and the Trade Union Movement (London: Davis-Poynter, 1980), especially pp. 96–184. 54 ‘The Medico-Psychological Association of Great Britain and Ireland’, Journal of Mental Science, 65 (1919), 122–30 (p. 127). 55 See V. Long, Destigmatising Mental Illness: Professional Politics and Public Education in Britain, 1870–1970 (Manchester: Manchester University Press, 2014), chapters 2 and 3. 56 Health Services Journal, 1 (January 1948), 10. 57 Health Services Journal, 12 (July–August 1959), 23. 58 NAWU Magazine, 2 (May 1913), 9. 59 NAWU Magazine, 19 (September 1939), 5. 60 Mental Health Services Journal, 31 (November–December 1942), 23. 61 MHIWU Journal, 26 (November 1936), 11. 62 See Long, Destigmatising Mental Illness, chapter 4. 63 BBC Archive Centre, Horsenden Lane South, Middlesex (hereafter BBC), BBC WAC R51/219, Talks Health: Mental Health 1941–54, internal memo from John Pringle, 1 January 1942. 64 BBC WAC R51/219, internal memo from Geoffrey Grigson to Miss Quigley, 24 June 1943. 65 BBC WAC R51/219, internal memo from Mr Ryan, 5 February 1942. 66 BBC WAC S322/117/1, Mary Adams (Assistant Controller Mental Health including the ‘Hurt Mind’), transcription of programme, ‘Put Away’, shown 1 January 1957, p. 1.

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7

Reassessing staffing requirements and creating new roles for nurses during a period of rapid change at the Royal Western Counties Institution, 1927–48 Pamela Dale

The history of nursing has traditionally prioritised the experiences of female general nurses within the most prestigious hospitals. Analysis has been extended to include different groups of nurses working in other hospitals and/or community services but the focus on professionalisation, gender politics and the development of the art and science of nursing practice remains largely unchallenged.1 Such concerns tend to either exclude any consideration of asylum staff or present them as inferior practitioners, attempting but failing to meet the ideals established by elite teaching hospitals before and after state registration. While some historians have attempted to delineate the specialist skills required to care for the mentally disordered, these staff remain neglected within the history of institutional care as well as the history of nursing. This makes David Wright’s detailed survey of staffing issues particularly valuable. He extends analysis from the care of idiot children at the famous Earlswood Asylum to a wider survey of nursing and other staff serving a range of Victorian institutions across the south-east of England. He notes that ‘between 1860 and 1900 asylum attendance represented the largest sector of institutional nursing in England’.2 In a surprisingly optimistic assessment of both the quality of staff available and the careers accessible to experienced nurses and attendants, Wright does not attempt to disentangle developments in what would now be termed the learning disability 145

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sector from wider trends in the asylum system. Instead he describes a world of institutional nursing where staff gained experience in a number of roles (as domestic servants or while offering a trade, as attendants, and as nurses) while serving in a variety of institutions caring for the sick, the insane and people with learning disabilities. Rural asylums had fewer options, with scholars highlighting their reliance on new recruits fresh from local villages, a certain preference for old soldiers and a tradition of recruiting relatives engaged in ‘attending’ as a type of family trade.3 Staffing difficulties were both a cause and a consequence of problems in caring for the mentally disordered in the interwar years. Mathew Thomson notes that conditions in the mental deficiency sector were often worse, reflected in a distinctive labour force that was less qualified and enjoyed even fewer protections than in the mental hospitals.4 Recruitment and retention problems were endemic, and only likely to be resolved by a major overhaul of pay and working conditions. Yet even the existing arrangements led to significant costs that were not easily defended against charges of extravagance in an era of public expenditure constraint. Interestingly, Thomson, like Wright, surveys the whole asylum system, and wider developments in nursing, alongside the specific focus on the mental deficiency sector. This approach underlines the way contemporary actors viewed the mental deficiency institutions as a particularly backward field between the wars, needing to learn from mental as well as general hospitals. The (Royal) Western Counties Institution (RWCI) at Starcross near Exeter in Devon (colloquially known as Starcross) offers an unusual case study of an institution that provided care before and after the 1913 Mental Deficiency Act (MDA).5 It regarded itself as one of the original five English voluntary idiot asylums (EVIAs) established in the Victorian period and looked to these asylums when comparing maintenance charges and conditions for staff. Yet the RWCI had distinctive features that made it particularly difficult for the institution to respond to the changes imposed by the 1913 and 1927 MDAs. In the interwar period the RWCI faced strong competition from alternative providers, and hostile scrutiny from local and national government actors who wanted to increase their control over the facility and change its mission.6 This put incredible strain on the institution, and much of the uncertainty about what sort of 146

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care Starcross should provide was channelled into debates about the nursing staff. Acrimonious discussions between 1927 and 1948 reflect the disputed transformation of Starcross, but the failure to resolve both long-standing and newly emerging staffing difficulties also serves to illuminate wider obstacles to nursing reform within and beyond the learning disability sector. An institution in transition The RWCI had been established in the 1860s, although its permanent site was not developed until the 1870s and further extensions were added in the 1880s and 1890s. Many commentators believe that the Edwardian period marked the heyday of the institution when it came closest to fulfilling the intentions of its founders.7 At this time Starcross was recognisably an educational facility. The buildings were designed to reflect the relatively simple care/control needs of moderately disabled children, with emphasis on the provision of classrooms, dormitories and outdoor recreation facilities rather than the locked wards and secure airing courts that were a feature of contemporary asylums. There were, however, important similarities. The institutional economy at Starcross was as dependent on its farms, workshops, laundry and kitchen as any mental hospital and staff were expected to offer a trade as well as care for patients. On the male side preference was given to attendants with an interest in sport, music or military pursuits. Radford and Tipper use an article from the local press to capture a snapshot of Starcross in 1903.8 There were 179 boys and 91 girls in residence and that year saw 43 admissions, 37 discharges and 5 deaths giving an end of year total of 271 inmates (all but nine maintained by Boards of Guardians). The full complement of staff is not given but the superintendent, medical officer and matron are mentioned. It was the relationship between these three post-holders that distinguished Starcross from other contemporary asylums, and created unusual risks and opportunities for the nursing staff during the later period of rapid organisational change. Starcross had a tradition of employing lay rather than medical superintendents, with the position occupied by members of the Locke family from 1874 to 1946. The medical officer was non-resident until 1937, and the role of the doctor 147

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therefore owed more to the personality and interests of local general practitioners than any clearly defined responsibilities beyond the treatment of patients suffering from the temporary effects of illness or injury. The authority of the matron was similarly uncertain. In the early days the matron led the institution, as no male superintendent was appointed for several months. It then became practice to appoint the superintendent’s wife as matron. Over time her duties passed to his other female kin and then to unrelated women, but the matron was neither clearly at the top of a distinct hierarchy of female staff nor were her duties confined to the ‘female’ wings. Such arrangements were common in small mental deficiency homes but not in large institutions. The Board of Control expressed concern and from the early 1930s encouraged the appointment of a resident medical officer (RMO) and his promotion to medical superintendent. The Board also consistently sought improvements to the quantity and quality of the nursing staff, although no serious concerns about patient care at Starcross were reported until the 1940s. Radford and Tipper described three traditional safeguards for RWCI patients.9 The first was the ethos of the institution, which had an educational flavour and a commitment to moral therapy. This management culture was reinforced by day-to-day caring arrangements. The staff was small and relied more on experience than formal training, but was adequate for meeting the fairly modest care/control needs of the pupil-patients and since no patient was confined to a single ward there were limited opportunities for hidden abuse. A third guarantee of patient protection was the regular visits made by prominent members of Devon society who took a paternalistic interest in the governance of the institution and the welfare of its residents. The 1913 MDA initially had little impact on the RWCI, which continued to recruit patients on traditional lines from across the UK. These were mostly children whose care was funded by Boards of Guardians although youngsters sponsored by local education authorities and statutory MDA committees were also accepted after 1914. Under pressure from the Board of Control the catchment area gradually narrowed. The RWCI was thereby forced to sacrifice its independent status to develop an increasingly important partnership relationship with neighbouring local councils which controlled access to patients and funds. It became clear that the survival of Starcross 148

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was dependent on growth, with the implicit promise of change. This required public funding, and the price for this was first local authority representation on an expanded managing committee and eventually a new joint committee structure. The joint committee had a wide remit, and people whose ambitious plans for mental deficiency work across the south-west of England conflicted with previously stated RWCI priorities increasingly dominated it. Starcross traditions, personified by the leadership of Charles Mayer (son-in-law of former superintendent Locke), came under hostile scrutiny from the Board of Control and partner local authorities. They argued that the educational ethos of the institution was old-fashioned, even irrelevant in the MDA era. It was certainly true that as different groups of patients with more complex needs were admitted at the behest of local councils, several problems quickly became apparent. Older patients (including adults convicted of serious criminal offences) were not easily contained in the dormitories at night or occupied in the existing classrooms and workshops during the day. Developing accommodation and a programme of care/control for these patients strained all the resources of the RWCI. At the same time staff were tasked with meeting the needs of severely disabled patients. For the first time Starcross undertook the labour-intensive nursing involved with ‘cot and chair’ cases and accepted patients with epilepsy and other serious physical and mental health problems. These new patient groups appeared to require a regime that was both more medical and more custodial. External organisations advocated adopting such an approach, under the leadership of an RMO. As an interim measure, staff (at all levels of seniority) simply had to cope. Starcross made a commitment to long-term planned changes but from 1918 until 1948 its posture was mostly reactive. New units sprang up on and off the main site to meet the urgent needs of new categories of patients. Since the lay superintendent remained in the main building and the doctor was at first non-resident and then based in a hospital unit, these new facilities potentially encouraged a greater degree of autonomy for senior nurses. This perhaps explains why the first well-qualified nurse whose appointment appears in the m ­ anaging committee minutes was sent to run a small holiday home where selected women patients (arguably the least disabled and most healthy group of Starcross patients) took short breaks. This  nurse, Miss 149

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B. A. Allsop, was, however, always viewed as a long-term ­replacement for the RWCI matron,10 and from this time nurses with general and/ or mental hospital qualifications started to monopolise senior positions. The new preference for ‘nurses’ initially had more impact on the female side where staff turnover was higher, but when senior men were replaced in the late 1930s impressive shortlists of candidates, who were registered as mental deficiency nurses by the General Nursing Council (GNC) and/or had Royal Medico-Psychological Association (RMPA) qualifications, were assembled. Unfortunately, recruiting and retaining these individuals proved highly problematic and endemic staff shortages, which persisted until the 1970s, compromised the potential efficacy of changing recruitment strategies. Starcross staff The changes outlined above began in the 1920s, but accelerated in the 1930s when the managing committee and joint committee concentrated on staffing matters to undermine the superintendent and force change. While less is known about the employment and day-to-day routines of the staff before a new set of records started in 1935,11 there is evidence of a complicated balancing act that traditionally informed all staffing decisions. Starcross was recognised as one of the original five EVIAs, but was understood to be the least prestigious of them. The RWCI did not pretend to offer the level of care available at the other four asylums and instead competed with a variety of other institutions for publicly funded cases. Under pressure to control costs, the RWCI struggled to recruit the quantity and quality of staff it required. In 1932 the RWCI was certified for 635 patients, although average numbers were only 618 as new extensions had opened during the year. This implied a ratio of one member of staff for every 5.72 patients (or 1: 5.88 when full). The other EVIAs employed more staff and achieved better staff-to-patient ratios (table 7.1). These were all operating at full capacity, apart from the Royal Earlswood where 227 staff cared for just 524 patients (or 1: 2.3). These figures suggest that Starcross was saving money by being deliberately understaffed at a time when its patient population was changing as well as expanding. The cost per-patient-per-week (not the amount charged for actual patient care) was still less than 22 shillings at the RWCI in 1932 when 150

New roles for nurses at the RWCI Table 7.1  Staffing costs reported by the EVIAs for 1932

Certified patient  accommodation Male staff  (living-in) Female staff  (living-in) Total staff Staff-to-patient  ratio Cost of wages  and salaries (£) Net total  running cost (£) Cost per patient  per week (to nearest shilling)

RWCI

Royal Albert

Royal Midland Royal Eastern Earlswood Counties Counties

635

800

600

180

1,281

76 (27)

111 (27)

112 (50)

21 (3)

122 (59)

32 (31)

113 (81)

115 (90)

19 (16)

142 (134)

108 1:5.88

224 1:3.57

227 1:2.64

40 1:4.50

264 1:4.85

12,673

25,947

15,670

3,913

23,947

30,831

53,262

49,343

11,452

67,469

22

25

36

24

23

Source: This table includes data extracted and calculated from a comparative table of costs circulated between senior staff at the five EVIAs in 1932. Starcross archive, comparative costs of maintenance 1930–32.

equivalent costs at the other EVIAs ranged from 23 to 36 shillings (table 7.1). It is difficult to compare staffing costs, as pay scales (including adjustments for age, sex, qualifications, length of service, staff accommodation and marital status) were different for each asylum. The figures given for wages and salary costs in table 7.1 give few clues to average or individual wages for nurse-attendants/­attendants or other staff.12 The Starcross bill for wages and salaries was £12,673 in 1932 or approximately £117 for each of the 108 listed employees. Misleadingly this gives the impression that RWCI staff were comparatively well rewarded, since similar calculations for the other institutions give a figure of £116 for the Royal Albert, £98 for the Midland Counties, £91 for the Royal Eastern Counties and just £69 for Royal Earlswood. The  average Starcross figure was, however, skewed by the salaries offered to its senior officers, and median wages would have been considerably lower. It is also noteworthy that the 151

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RWCI traditionally employed long-serving married men (49 of the 108 staff were married men who lived out) whose wages were greater than those paid to single women (often young with limited service) who lived in. At Starcross only 29 per cent of the staff were resident females, whereas 36 per cent of those at the Royal Albert, 40 per cent at Earlswood, 40 per cent at the Midland Counties and 51 per cent at the Royal Eastern Counties Institution were in this category. A more detailed analysis of male wages suggests that Starcross wages were both lower than the other EVIAs and subject to contradictory inflationary and deflationary pressures in the 1920s. Higher wages had been required to attract and retain staff at a time of labour shortage between 1914 and 1920, and may have smoothed industrial relations during a period of major strikes at other Devon asylums,13 but austerity measures then led to cuts. It is interesting that most comprehensive surviving list of staff dates from this period, when Starcross was trying to assess the likely costs incurred/savings achieved from altering the wages of different grades of staff. A series of undated and untitled documents from the early 1920s, making rough comparisons of wage rates, offer unusual insight into staffing arrangements on the male side. At this time there were no recognised ‘male nurses’, but a number of single attendants lived in while married attendants lived out. They were, however, traditionally at the bottom of the institutional hierarchy and pay scales. The ‘school attendants’ had earned considerably more in 1914, though the highest pre-war wages were reserved for men with technical skills who either trained patients engaged in industrial work or were essential to the maintenance of the institution. The revised pay scale (which excluded clerical and managerial staff) introduced from 30 January 1925 gave newly recruited single male attendants a pound a week, whereas a married man with ten years of service could receive up to £128 a year. This was considerably more than the pre-war rates but less than the pay levels in 1920 and the scale in operation in 1924, although it is noticeable that the attendants’ wages showed relative improvement. A married attendant at Starcross earned 25/- a week in 1914 (the Royal Eastern then paying their equivalent staff 30/-), when an industrial trainer received 51s 6d. In 1920 this had increased to 48s 6d, with a further rise to 50/- before the new 1925 scale cut attendant pay 152

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to 45/- (exactly the same rate paid to all other male non-resident staff on the original pay scale). The male attendant’s place in the hierarchy was, however, still uncertain.14 The night fire orders superficially placed onerous duties on male staff who were expected to raise the alarm, evacuate the patients, fight the fire and treat any casualties. Yet the same orders made it clear that the schoolmaster was the person with real authority over the pupil-patients and noted that while it was desirable for attendants to oversee each group of patients, this was a task that could be left to senior patients. Until the 1970s Starcross routinely used worker-patients to perform attendant tasks, including providing personal care to younger and/or more severely handicapped patients.15 The practice ensured that the routine work of male attendants was conceived as low-skill, attracting limited status and poor pay. Staffing arrangements were scrutinised as part of plans for the expansion of Starcross in the 1930s. A site had been chosen for a new mental deficiency colony at Langdon Farm at the end of the 1920s, and although construction was subject to delays between 1932 and 1937, changing staffing requirements were acknowledged at an early stage in its preparation. Starcross staff were then still organised on traditional lines, despite accelerating institutional change affecting all sites. In response to a request for information, Mayer described his 1931 staff, then caring for 443 male and 223 female patients. On the male side there was a schoolmaster, his assistant and three school attendants; six instructors/artisans (with no attending duties); thirtythree attendants and instructor-attendants; and nine farm hands (who provided daytime supervision for working patients). The female side was even simpler, comprising a schoolmistress, three school attendants and twenty-one nurses. Mayer confirmed that the nurses performed the same duties as attendants and each offered a trade such as dressmaking.16 After 1932, a year of transition for Starcross, the male side was slower to specialise than the female one, where the appointment of general nurses encouraged differentiation between the nurse-­ attendants and a new hierarchy of seniors and specialists. Yet developments on the female side, including the admission of adult women patients, changed the whole institution. While there had always been a separation between male and female wings, there had been no need 153

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to entirely prevent contact between different staff and patient groups. It was, for example, appropriate for a female nurse to care for a sick child of either sex, but the admission of youths and men brought these arrangements into question. Just as mental hospitals were considering the benefits of using female staff on male wards, Starcross increased gender segregation.17 This policy was conceivably designed to protect the sensibilities of female staff and appease the National Asylum Workers’ Union,18 but under the MDAs a particular concern was preventing male staff from having sexual relations with female patients. At Starcross most male staff had opportunities to meet patients (and some responsibility for patient care, supervision, or training) so it is unhelpful to artificially distinguish between attendants and other workers. It is noticeable, however, that while many of the disciplinary problems involved the latter, the former also attracted much concern. Suspicion about the motivations and activities of all male staff increased as the RWCI transformed into an all-aged, mixed-sex, comprehensive mental deficiency service. There was a noticeable rise in disciplinary cases, although this is partly explained by new ways of recording incidents as the managing committee/joint committee increased scrutiny over staffing issues. While allegations of neglectful care and even abuse cannot have been unknown at Starcross, despite the safeguards outlined earlier, the criminal prosecution that arose from a lengthy affair between Mr W (misleadingly described in official reports into the incident as a temporary carpenter) and patient EMB (domestic help at the nurses’ home) was a most unwelcome first for the RWCI.19 The problem was that Starcross was not secure; indeed the relatively free movement of patients was positively encouraged by its regime, and illicit activities were difficult to police on and off the main site. Reported incidents of crime, violence and inappropriate sexual relationships became increasingly common in the 1930s and 1940s, with much criticism levelled at the staff. Some personnel were victims of serious assaults, with the matron at the central institution needing stitches to her head after an attack by a male patient in 1941.20 When the assistant matron was violently attacked by the ‘psychopathic’ husband of a newly admitted female patient, the RWCI sought a prosecution and paid all Miss P’s expenses as she recovered from several broken ribs.21 In other cases staff broke the law and/or the rules of the 154

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institution. Oddly, despite concern about the disciplinary record of male attendants, the female staff accounted for the majority of offenders. Many of the attendants were still married men with long service and a lot to lose (job, accommodation and pension) if dismissed, so they were careful when managing their relationships with patients, colleagues and senior staff. Traditional patterns of recruitment and retention, and an insistence on ‘loyalty and devotion to the institution’, still operated to protect male patients and staff. These values were personified by M.  A. Ford, the chief male attendant, who retired with fulsome tributes from the joint committee in 1939 after forty-three years of service.22 Loyalty and long service were also found and rewarded on the female side. In 1936 Miss D. Wood (then matron of the Exeter training hostel) was allowed an extended period of paid leave to visit relatives abroad. She had worked for the RWCI for thirty years and ‘apart from holidays and a period of hospital training in 1914 had only been absent from duty for a fortnight’.23 The problem was that long service could be associated with anxieties about the age, health and efficiency of the individual concerned. When the case of Matron T was considered in 1932 a genuine concern for her welfare, shown by a decision to do nothing until she returned from sick leave and then offer a suitable pension, was set against a determination to replace her with a younger and better-qualified nurse.24 The search for qualified nurses, and even nurse-attendants, altered recruitment patterns, placing greater emphasis on paper qualifications and written references. Some nurses took advantage of this situation and tried to overstate their skills, qualifications and/or experience or conceal past disciplinary problems. The potential risk to patients was clear although in the case subject to detailed investigation the dishonesty came to light as a result of attempts to defraud local tradesmen. Miss W, the senior charge nurse involved, had been appointed from 30 March 1935 and was dismissed shortly afterwards. The same fate befell Miss C, a newly appointed nurse-attendant described as ‘a friend of Miss W’ who ‘appeared to be equally unsatisfactory’.25 Both women worked at Elm Court, a special unit for mentally disturbed female patients whose operation was complicated by adherence to normal ‘duty hours’ and a lack of night staff. In the years after 1914, pupil-patients at Starcross still went to bed at 7.30 p.m. 155

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and the staff went off duty. This meant Starcross staff worked fewer hours than those at the other EVIAs. An undated comparison of hours and wages, filed with correspondence from the Royal Albert Institution from 1919 to 1922, suggests that the working week was longest at Earlswood (male and female staff worked 72 hours), followed by the Royal Eastern (females worked 67 hours and males just over 61), Midland Counties (only employed women who all worked 62 hours), and Royal Albert (all staff worked 59.75 hours). Male staff at Starcross had just had their hours reduced from 59 to 54.75 while women’s duties had been cut from 57 to 55. The gradual shift from living alongside the patients, and being constantly on-call, to accommodation in new nurses’ homes also increased leisure time for female staff. Working hours at Starcross still followed the old school model. The children needed a lot of support to complete morning and evening routines and a certain amount of care and supervision during the daytime, but once in bed no special care was needed and a single night watchman was sufficient to keep an eye on things while patients and staff slept. Such arrangements were strained by the admission of new patient groups, but Starcross staff benefited from reducing rather than increasing hours across the interwar period. This may have signified a willingness to trade reduced hours for limited pay increases, but by 1940 there were growing staff complaints about remuneration, duty hours and holiday entitlement. Miss J, assistant matron at the central institution, had already resigned after being denied a hearing before the joint committee. She had several grievances but her main complaint was inadequate remuneration.26 A new comparison, with local mental hospitals rather than the EVIAs, revealed that other institutions were more generous, especially with annual leave.27 This followed an earlier private exchange of information on hours and wages between Mayer and the Devon County Medical Officer of Health.28 The data confirmed that Starcross staff worked fewer hours, but that Devon County Council salaries were better. Mayer argued that RWCI wages did not lead to ‘difficulty in obtaining good male staff’ since the committee was prepared to make special arrangements for ‘men of ability and of special aptitude’, but on the female side ‘we can only get the probationer type of girl at the commencing rate of £35 per annum’ and a revised salary scale was being considered. 156

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Appointing, training and managing new staff at Starcross One solution to the problem of finding suitably qualified staff was to develop Starcross as a training institution. The RMPA approved its nursing school in 1927, but although more than one thousand staff were trained over the next sixty years this did little to alleviate continuing staff shortages.29 The RMPA certificate was not well regarded in nursing circles because of a perception that it was relatively easy to obtain, but evidence from Starcross suggested that locally recruited staff had problems passing it.30 Mayer discussed different models of nurse training with EVIA colleagues in the 1920s and encouraged F. D. Turner (at the Royal Eastern) to use his influence with national organisations to protect their interests against calls for change. The conservative RWCI position was supported by S. Langton (medical superintendent, Royal Earlswood) who agreed that the RMPA certificate was ‘ample’ and suggested that the GNC’s syllabus ‘is tending to become far too elaborate and beyond the nurses who join our service’.31 Faced with this evidence, an RWCI plan to offer GNC training as a registered mental nurse was shelved indefinitely, although failure to secure the necessary cooperation from local voluntary hospitals was also a factor.32 It appears that concerns about RWCI training (initially in the hands of the then elderly matron and non-resident doctor) made the Board of Control even more determined to see the appointment of outsiders to senior posts. Starcross actors resented this interference, and it was agreed that the superintendent would continue to make most junior appointments, subject to confirmation by the committee. The managing committee/joint committee sought greater powers to scrutinise senior appointments but there was still a presumption in favour of internal promotion.33 A new staff recruitment policy was initiated in July 1935 and from this date details about all appointments, except clerks, appear in the managing committee/joint committee minutes. For senior posts it was usual to record the number of applications received, the names of people interviewed and additional information about their qualifications and experience together with some justification for the appointment made. This system continued until 1948, but there are few records about temporary wartime staff. Taking the whole period from July 1935 to September 1939, eleven 157

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women and four men were appointed to posts with special titles including matron, sister and charge nurse. Two men and two women were appointed at the senior nurse/attendant level. One man and four women were appointed as night nurses but both the new day ‘nurses’ hired were female (one was temporary). Forty-five women were appointed as nurse-attendants (including one to work in the laundry and three in the kitchen) and two girls were hired as probationers. Thirty men were appointed as attendants, although eight of these jobs were only temporary and two permanent positions involved attending and another trade. One male teacher was appointed. The laundry hired two women, and four men and one woman found work in the kitchens. Five married couples were hired to provide farm labour and domestic service. Starcross also appointed four female domestics and on the male side hired two lorry drivers, two gardeners, two farm labourers, an apprentice carpenter, one mason and one stoker. The employment of David Prentice as RMO occurred in this period but was handled differently, since a number of organisations sought to influence the process. His appointment, and many others, was linked to the development of the new Langdon colony. The RWCI reported to the Board of Control that ‘on 1 April 1938 the permanent staff totalled 178 and on 31 March 1939 totalled 211, the principal increase occurred in July’. Since maximum patient numbers took time to achieve, the Board was reassured that ‘this did not imply that the staff were not fully employed throughout the year’ as much ‘preparatory work’ was required at the colony.34 The problems of managing this larger cohort of staff, including new recruits with limited experience, were compounded by evidence of increasing staff turnover across all RWCI facilities. A 1939 report described the nursing staff, concentrating on their qualifications and length of service: of the sixty-three men, fourteen had less than one year’s service but twenty-seven had more than five. The fifty-nine women were less experienced, twenty having less than a year of service and only twelve more than five.35 There was lingering uncertainty, at least until the NHS era, about how staff should be trained and which qualifications were most desirable when recruiting externally. Although the appointment process gave increasing weight to formal qualifications, Mayer was not impressed by candidates who offered theoretical knowledge rather 158

New roles for nurses at the RWCI

than practical experience. His thinking was set out in a 1933 correspondence with Devon County Council.36 The council was establishing a new home for mental defectives and sent prospective staff to the RWCI for training. Mayer was not keen on their selection, and argued that despite some knowledge of child psychology the women had no insight into the reality of providing care. He was unsurprised when both women resigned within a week of taking up their posts, and continued to place great importance on a combination of ‘experience’ and ‘enthusiasm for the work’. There was a commitment to sharing best practice by encouraging Starcross staff to visit other institutions and welcoming visiting staff to the RWCI. When qualifications were scrutinised as part of the more transparent appointment process for senior male and female staff in the 1930s, clear preference was given to the most qualified nurses, ideally with general training. Miss M. E. Goodson (appointed matron of the central institution in February 1940) was viewed as a particularly strong candidate but she was not atypical of the women applying for the most senior positions. She was general trained and had gained a midwifery qualification before undertaking further mental health training at the Maudsley. Her career had encompassed several ‘nursing and administrative posts’ at a variety of institutions, including the Wiltshire County Mental Hospital. This emphasis on mental health training/experience acknowledged that even the most senior RWCI posts would not attract sisters/matrons from voluntary hospitals. It was, however, possible to recruit their junior staff who traded career advancement for moving to less prestigious institutions. Such considerations seem to have brought some general nurses to Starcross, although a Poor Law or municipal hospital background was more common than an elite London or even provincial voluntary hospital. However, when offered a choice between extended general training (even with midwifery or sister tutor training/experience) and general training and (and sometimes or) mental hospital experience, the preference was usually for the latter. Mayer was strongly of the opinion that only practical experience with the mentally disordered prepared senior nurses for their duties at Starcross. This explains why some married women offering experience in hostel care, borstals and training homes appeared on shortlists after a definite managing committee/joint committee preference for nurses had been aired. When 159

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nurses were required, Mayer opted to recruit from the EVIAs and local mental hospitals because he could trust references supplied by medical superintendents he knew well.37 Miss DS was only twenty-six (considerably younger than most candidates for senior posts) when she successfully applied for the post of head sister at the central institution in 1938. The decision to appoint her rested on her seven years’ experience of mental deficiency work, her current post as ward sister at the Cornwall Mental Hospital and testimony that ‘the medical superintendent there could warmly recommend her but would be sorry to lose her’.38 This preference for mental nurses, especially those experienced with the new physical therapies, became even more marked after David Prentice became the RMO. Prentice introduced a number of innovations that resulted in more clinical work being carried out at Starcross. Prior to 1937 the RWCI claimed to do little more than treat uncomplicated cases of illness and injury among a patient population otherwise in good physical and mental health, although this assertion conflicts with some of the causes of death given for patients. Yet after 1937 it does appear that much more ill patients were deliberately admitted and retained. This policy presented some risks to the physical and mental well-being of staff, perhaps explaining why Prentice routinely reported on staff absences whereas Mayer had not previously done so. While much of Prentice’s work was new, an old problem is prominent in his reports. Starcross patients, and staff, had always been vulnerable to epidemic disease, and the new RMO was tasked with preventing and dealing with outbreaks. In 1938 a male ‘nurse’ in a special unit for severely disabled boys caught diphtheria from a patient and became seriously ill, necessitating an operation at a local isolation hospital.39 The same medical report mentioned that three other male staff were off-duty because of sickness while eight other men had just returned to duty after recovering from illness or injury. On the female side, one nurse (Prentice used the term nurse, not the previously favoured designation of nurse-attendant) was convalescing after an appendectomy and seven nurses were returning to duty after ‘minor illnesses’. Coping with epidemics and staff absences taxed institutional resources, but they were not the focus of research work in the hospital unit. Some experimental work was done to diagnose and treat 160

New roles for nurses at the RWCI

tuberculosis and diabetes and there was a new emphasis on discussing operative treatments and post-operative care for a variety of conditions. Prentice spent some time investigating causes of mental deficiency among the patients but his main interest was in the field of mental illness. He introduced malarial treatment and various shock therapies. This placed considerable strain on the nurses and attendants, but a more serious problem seems to have been a policy of deliberately admitting and retaining unstable patients for indeterminate periods of observation. The staff had no experience of this work, having previously sent all such cases to local mental hospitals. Mental health work was pursued with some vigour by Prentice and the temporary RMOs who covered his absence on military service from 1943 to 1945. Jan Ehrenwald had an impressive record of publications, but his short-notice arrival and even more abrupt departure (recalled by his government to serve on the medical mission to Czechoslovakia) created difficulties for senior nurses. This upheaval in the hospital unit reflected uncertainty about the Langdon colony, which had been beset by problems since it opened in 1937. The decision to transfer senior nurses from other RWCI sites to oversee the colony development destabilised the established hierarchy in the central institution and staff turnover and staff unhappiness increased markedly. This situation was complicated by ill-conceived plans to re-classify the accommodation and relocate large numbers of patients to meet the most urgent needs of the partner local authorities and belatedly acknowledge the fact that neither the old buildings nor the new site were well designed to offer the medical and custodial model of care that was being imposed on the RWCI.40 All these changes made it harder to recruit and retain staff at a time when patient numbers almost doubled in a very short space of time. While applications for attendant posts had been ‘satisfactory’, presumably in terms of quality as well as quantity, only six women applied for the range of positions available at Langdon.41 These were re-advertised but remained hard to fill. Under wartime conditions staffing difficulties became acute, and attendants seeking to leave and/or undertake local war work were reminded that ‘their first duty was to the institution’.42 Nonetheless staff turnover a­ ccelerated, with the superintendent closely questioned by the joint committee about why five staff (four male) had resigned in March 1940.43 161

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Military service provided a legitimate explanation for some departures, although the RWCI sought to restrict these with the assistance of the Board of Control.44 There was, however, lingering suspicion that contested changes at Starcross lay at the root of staffing difficulties. Disharmony between the superintendent, the doctor and senior nurses had been a feature of Prentice’s first spell at Langdon, but relations between all senior staff deteriorated during the war as roles changed and became confused. The legal and financial business of the institution was increasingly in the hands of L. W. Hedger, the secretary and accountant. Mayer’s position at Starcross was, under the hostile scrutiny of the Board of Control, paradoxically becoming less secure just as he took leadership of the EVIA group. The RMO had been identified as the superintendent designate, but until 1946 his activities centred on the hospital despite other duties as Mayer’s accepted deputy and senior officer at the Langdon site. This left the nurses nominally in charge of all the other units although subject to oversight by (and possibly competing and conflicting demands from) the still separate lay and medical hierarchies. Senior female nurses brought in from other institutions struggled to cope and had a tendency to annoy other staff by questioning procedures and perhaps trying to force change. Personality clashes were the focus of various investigations, but underlying them was a serious debate about how the institution should be managed. Having agreed to keep to their separate spheres, the lay and medical hierarchies both blamed the nursing staff for the problems that occurred just before and during the war. Some senior nurses rejected this interpretation and insisted on making their own concerns and demands public. When asked to leave they refused to go quietly. Matron N (at the holiday home) was accused of having ‘adopted an extraordinary attitude’ during a 1936 dispute with Mayer and was asked to resign.45 Further developments were expected in her case, although it does not reappear in the records. Matron S, who had various complaints that the joint committee characterised as ‘little frictions of administration’, sought independent support from the Mental Hospital and Institution Workers’ Union. Members of the joint committee were keen to assert that they were ‘masters in their own house’ and favoured her dismissal, but after taking legal advice they made the embarrassing admission that 162

New roles for nurses at the RWCI

there were no specific complaints against Miss S and agreed that she would be provided with references although there was no question of reinstatement.46 These staffing problems, exacerbated by severe staff shortages, were understood to be negatively impacting on first the administration of various units and then on patient care. This was picked up as part of the regular inspections conducted by the Board of Control. A focus on staffing issues is very noticeable in 1939 and 1940, when Commissioner George Mackay noted that a wartime increase in patient numbers had created unusual difficulties and staff shortages. He remarked that the appointment of a ‘new matron and head attendant’ should help and also credited a new and ‘active’ head attendant with ‘better organisation and delegation of duties’ on the male side, where 636 in-patients were cared for by just fifty-six day and seven night staff in 1940. His reports show that patient numbers had increased from 1,120 (962 in residence) in 1939 to 1,220 (1,049 in residence) in 1940.47 During this period the nursing staff had increased by just one (from 122 to 123) but the number with qualifications had decreased. Between the two inspections both the women with GNC certificates left and the number of staff with full and preliminary RMPA certificates declined. In 1939 forty staff (twenty-four men and sixteen women) had full RMPA qualifications and twenty-one (twelve men and nine women) had preliminary certificates. By 1940 the figures were forty-three (twenty-five men and eighteen women) and fifteen (nine men and six women), respectively. Although the Board of Control had long-standing reservations about the regime at Starcross, its first critical report dates from a visit in November 1944. An investigation into the ‘unsatisfactory state of the bedding’ and the discovery of a patient wearing outdoor clothes in bed led the joint committee to conclude that ‘while the chief male nurse and his deputy were primarily responsible, [the reported problems] at the time of the visit resulted from the indifferent work of temporary staff whose industry and supervision were lacking’.48 Staffing problems were starting to negatively impact on patient care. Compared to the other EVIAs, Starcross was understaffed, making it harder to cope with wartime vacancies. This problem was compounded by an odd distribution of permanent staff between different units and a lack of flexibility over deployments.49 In June 1945 there 163

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were vacancies for twenty-five female nurses and seventeen domestics,50 leaving just three nurses available to care for 120 patients at Langdon. In the special units for ‘cot and chair’ cases a minimum ratio of one nurse to twelve patients was barely maintained, but overworked staff struggled to deliver basic care, and bathing was left to a volunteer.51 Understaffing was equally problematic in other units where ‘unstable defectives’ could take advantage of the difficult circumstances. In one month eight female patients absconded, many returning pregnant or with symptoms of venereal disease. These problems provided the context for a highly critical Board of Control inspection in 1945, which led to senior staff and joint committee members being summoned to London to explain themselves.52 The Board insisted that the ‘deterioration in care’ witnessed at the RWCI could not simply be attributed to wartime staff shortages and began an inquiry into the unauthorised use of seclusion and restraint techniques by nurses to contain disturbed patients (and probable absconders) at the troubled Elm Court unit. New arrangements were eventually agreed for the management of Elm Court, but although the sister there was thanked by the joint committee for ‘her continuing loyalty and devotion in trying circumstances’,53 many senior nurses chose to leave and Mayer brought forward his retirement.54 Prentice became a nonresident medical superintendent with a medically qualified deputy in addition to a replacement RMO. Although a new set of post-war concerns were signified by discussion of Rushcliffe pay scales55 and the secondment of staff for general training as GNC courses replaced RMPA ones from 1947, staffing difficulties continued.56 On the eve of transfer to the NHS, Miss H (matron at Langdon) was interviewed by the joint committee after seeking clarification of her status. As a ‘highly qualified nurse’ Miss H felt that, unlike the chief male nurse, she should not have to take orders, described as ‘interference’, from the junior medical staff although she ‘accepted’ the authority of the medical superintendent. When told she was answerable to all the doctors she resigned.57

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Conclusion The RWCI was one of the original five EVIAs. Established in the 1860s, it developed as a specialist centre for the education and training of the ‘idiot children of the poor’, but struggled to cope with the new demands imposed by the MDAs. The institution grew significantly in this period as new facilities were developed for a changing patient population. As a result the institution became more medical and custodial, and this led to both a reassessment of staffing requirements and new roles for nurses. There was pressure to increase, and professionalise, the nursing staff, but recruitment and training proved problematic at Starcross, with local people struggling to meet requirements and outsiders having their own ideas about how the institution should be run. Nonetheless, Starcross was able to recruit some outstanding employees who were instrumental in developing its new institutional and community services. These nurses, male and female, tended to have general nursing as well as mental hospital experience. As a deliberate policy, and partly as a result of wider governance problems at Starcross, they remained independent of the lay and medical hierarchies that were themselves engaged in a battle for control of the institution. Senior nurses were credited with many of the institution’s successes but nurses were also vulnerable to criticism. Rank-and-file staff were blamed for an increasing number of care and control failures in the 1940s, and investigations suggested that at least some parts of the institution had fallen into a culture of neglect and abuse. In response, the Board of Control strengthened medical control over the RWCI, but this intensified clashes between the senior medical and nursing staff and exacerbated the recruitment difficulties and role confusion that plagued the Starcross nursing service from the 1930s until the 1970s. Notes   1 B. Mortimer and S. McGann (eds), New Directions in the History of Nursing: International Perspectives (London: Routledge, 2005).   2 D. Wright, Mental Disability in Victorian England: The Earlswood Asylum 1847–1901 (Oxford: Clarendon Press, 2001), pp. 99–119 (p. 99).   3 L. D. Smith, ‘Behind closed doors: lunatic asylum keepers, 1800–1860’, Social History of Medicine, 1 (1988), 301–27; J. Melling and B. Forsythe, The Politics

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Mental health nursing of Madness: The State, Insanity and Society in England, 1845–1914 (London: Routledge, 2006), p. 57; M. Carpenter, Working for Health: The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988), p. 30.   4 M. Thomson, The Problem of Mental Deficiency: Eugenics, Democracy and Social Policy in Britain c.1870–1959 (Oxford: Clarendon Press, 1998), pp. 132–9.   5 The institution periodically changed its title to reflect changing ideas about the care of people with learning difficulties.  6 G. Chester and P. Dale, ‘Institutional care for the mentally defective, 1914–1948: diversity as a response to individual needs and an indication of lack of policy coherence’, Medical History, 51:1 (2007), 59–78; P. Dale, ‘Implementing the 1913 Mental Deficiency Act: competing priorities and resource constraint evident in the south west of England before 1948’, Social History of Medicine, 16:3 (2003), 403–18.  7 J. P. Radford and A. Tipper, Starcross: Out of the Mainstream (Toronto: G. Allan Roeher Institute, 1988); D. Gladstone, ‘The changing dynamic of institutional care: the Western Counties Idiot Asylum, 1864–1914’, in D. Wright and A. Digby (eds), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Difficulties (London: Routledge, 1996), pp. 134–60.   8 Radford and Tipper, Starcross, pp. 8–18.   9 Radford and Tipper, Starcross, pp. 17–18. 10 Starcross archive (hereafter SA), Managing Committee (hereafter MC), special sub-committee, 20 August 1932, minutes 50 and 51 for details of the appointment. The MC confirmed Miss A’s promotion to matron and increased her salary from £85 to £200. MC, 24 September 1932, minute 64. She left this post on 8 April 1938, probably transferring to Langdon colony. [Note the author accessed the Starcross archive while it was temporarily housed in the University of Exeter Library. Records have moved to the Devon Heritage Centre, Exeter, and are in the process of being re-catalogued under reference 5916F.] 11 SA, an undated copy of the duties of the head female nurse is included in a file marked special reports and statistics that cover the interwar period. 12 It is not clear if the personnel listed in table 7.1 were limited to those hired as nurses/attendants. 13 See the chapter in this volume by Barbara Douglas. 14 SA, file of undated and untitled documents from the early 1920s setting out wage rates at the RWCI and other EVIAs. 15 A. B. Rowland, No Epilogue to the Saga: A Study of a Hospital and its Role in the Care of People with Learning Difficulties (Dawlish: Rowland, 1992), pp. 35–6. 16 SA, letter from S. Langton (Medical Superintendent, Royal Earlswood) to Mayer, 30 April 1931, and reply, 2 May 1931.

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New roles for nurses at the RWCI 17 See the chapter in this volume by Vicky Long. 18 SA, circular letter discussing employment of female staff on male wards from C. Fitch, Secretary of the Mental Hospitals Association, 13 March 1920. 19 SA, Joint Committee (hereafter JC), special sub-committee, 28 November 1939, minute 156; and JC, 27 February 1940, minute 190. 20 JC, 24 June 1941, minute 381. 21 JC, 26 June 1945, minute 220. 22 JC, 31 January 1939, minute 16. 23 MC, 29 January 1936, minute 477. 24 MC, 30 March 1932, minutes 2 and 3. 25 MC, 25 May 1935, minute 390. 26 JC, 31 October 1939, minute 143. 27 JC, 28 May 1940, minute 233. 28 SA, letter from L. M. Davies to Mayer enclosing salary scales, 21 January 1938, and reply, 7 February 1938. 29 Rowland, No Epilogue to the Saga, pp. 17, 36–7. 30 SA, draft copy of superintendent’s report for 1930, p. 24, noted that twentytwo out of twenty-seven candidates passed the RMPA preliminary examination. 31 SA, letter from S. Langton (Royal Earlswood) to Mayer, 7 February 1926, and reply, 13 February 1926. 32 SA, letter from Mayer to S. Langton, 24 January 1927. 33 MC, sub-committee, 17 July 1935, minute 405. 34 SA, letter from L. W. Hedger to the Secretary of the Board of Control, 6 June 1939. 35 SA, report of visit of inspection 19–21 April 1939 by Board of Control Commissioner G. W. Mackay and Inspector C. Landon. 36 SA, letter from Mayer to B. S. Miller, 12 June 1933, and reply, 17 June 1933. 37 The EVIAs had traditionally shared confidential assessments of former staff even if references were offered from more recent employers. SA, letter from Mayer to Mr Williams (Midland Counties), 16 March 1925, and reply, 18 March 1925. 38 JC, staff appointments sub-committee, 5 August 1938, minute 1221. 39 JC, 20 December 1938, minute 177. 40 JC, accommodation sub-committee, 7 September 1938, minute 138. 41 JC, 30 November 1937, minute 6. 42 JC, 27 October 1942, minute 555. 43 JC, 26 March 1940, minute 200. 44 JC, 30 March 1943, minute 619, noted the prosecution of two local mental nurses who had left their posts without permission. 45 MC, 29 September 1936, minute 69. 46 JC, 27 June 1939, minute 84; JC, sub-committee, 27 June 1939, minute 87; JC, 19 December 1939, minute 162; JC, 30 January 1940, minute 174.

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Mental health nursing 47 SA, report of visit of inspection 19–21 April 1939 by Mackay and Landon, and report of visit by MacKay, 29–30 May 1940. 48 JC, 2 January 1945, minute 139. 49 SA, document showing location of 607 patients and 52 resident staff sent to Devon County Council Valuation Department, 15 March 1933. 50 JC, 26 June 1945, minute 219. 51 JC, 29 September 1945, minute 264. 52 JC, sub-committee, 7 November 1945, minute 283. 53 JC, 16 November 1945, minute 286. 54 JC, 24 April 1945, minute 197; JC, 26 March 1946, minute 361. 55 JC, 26 February 1946, minute 343 included a report of the Mental Deficiency Committee of the Mental Hospitals Association held at Starcross, 20 February 1946. 56 JC, 28 January 1947, minute 5. 57 JC, staff appointments committee, 27 April 1948.

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8

‘The weakest link in the chain of nursing’? Recruitment and retention in mental health nursing in England, 1948–68 Claire Chatterton

After the Second World War, when the National Health Service (NHS) was being established in the United Kingdom, there was such a shortage of nurses that Aneurin Bevan, the Minister of Health, described it as approaching ‘a national disaster’.1 This was an issue for all areas of nursing at this time. Staff shortages were, however, particularly acute in mental nursing (as well as in the field then referred to as mental deficiency or subnormality) and they persisted even as the availability of general nurses improved. At the first meeting of the newly constituted National Consultative Council for the Recruitment of Nurses and Midwives in January 1958, Mr Haslam, from the Association of Hospital Management Committees, said ‘mental and mental deficiency nursing are the weakest link in the chain of nursing’.2 Contemporary commentators were only too aware of the negative impact staff shortages had on patient care and the situation was considered sufficiently serious for questions to be raised in Parliament. The mental nursing shortage remained high on the political agenda throughout the 1950s and the 1960s. Mental nursing has been described by Charles Webster, official historian of the NHS, as ‘the single, most intractable nursing problem of the early NHS’.3 This chapter will consider why mental nursing experienced such severe shortages during this period and the effectiveness of the strategies that were introduced to address this.

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Why was it so difficult to recruit and retain mental nurses during this period? The serious and protracted problem of shortages of mental nurses attracted much attention from contemporary commentators and has also been subject to critical historical analysis. Many explanations for the crisis have been advanced, although none offer an entirely  straightforward solution to staffing difficulties. It became clear, however, that the overall shortage of staff was the result of two issues, difficulties of recruitment and problems of retention (or wastage as it was then more commonly described). These were both separate and inextricably linked. Student nurses became the main focus of concern as recruitment was faltering while wastage remained high, with up to 80 per cent of entrants failing to complete training.4 Figures from the General Nursing Council (GNC) for England and Wales show a steady decline in the numbers entering mental nurse training from 3,204 (1,412 women and 1,792 men) in 1948 to just 1,594 (604 women and 990 men) in 1954.5 At this time mental nursing was still largely practised in institutional settings, particularly the old, large-scale, long-stay ­ asylums, which were passed to the NHS in 1948 but had mostly been constructed in the Victorian and Edwardian periods. These had been re-titled as mental hospitals following the 1930 Mental Treatment Act (MTA), but changing terminology and some new arrangements for admitting and treating patients did little to overcome their ­essential limitations. The MTA had been framed by a concern to bring mental treatment closer to the treatment of physical illness, but this had done nothing to relieve the physical isolation of asylums located in remote areas and little to challenge their distinctive local cultures.6 The ‘peculiar isolation’ of the mental hospitals had been recognised as a barrier to recruitment and retention by the Athlone ­Committee in 1945.7 This isolation was, crucially, as much cultural and psychological as geographical. For some this had the positive effect of making the staff and patients part of a single ‘family’,8 but it also created conditions that could foster the mistreatment of staff as well as patient abuse. New staff often struggled to adapt to such i­nstitutional c­ onditions, and even when happy with their working lives they missed the opportunity to use off-duty time 170

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to visit family and friends or enjoy amenities found only in distant towns. There is no doubt that asylums were deliberately built in remote areas, but historians dispute the precise reason for this. An optimistic interpretation stresses the perceived benefits to patients of fresh air, country living and space to practise moral management techniques that sought to help patients rediscover their own sanity and treat even the most disturbed with compassion.9 In a different, but not incompatible, scenario, it is suggested that rural locations were favoured for economic reasons. Land was cheaper, reducing the cost of providing an institution, and the inclusion of farms and workshops allowed patient labour to subsidise the costs of maintenance and promote the goal of self-sufficiency.10 A third, and darker, explanation was a desire to completely remove deviant people from normal society as part of a care and control strategy.11 It is probable that all these considerations played their part, and staff had to deal with not just the resulting physical isolation they experienced but the problematic legacy of past mental health policy that had prioritised the need for economy and security over patient and staff welfare. Although the MTA had sought to end the stigma attached to the forced committal of the insane to pauper lunatic asylums, it was clear to those planning the NHS that ignorance and stigma surrounding mental illness were contributing to staff shortages. The Athlone Committee observed that ‘parents are reluctant to allow their daughters to enter a profession which does not appear to carry the status of the general trained nurse, and in which they may be exposed to physical violence and may have to perform duties of an unpleasant nature’.12 The supposed ignorance and prejudice of lay people was, however, just one of many difficulties that needed to be overcome. There was also concern about discrimination within the nursing profession, with leading general nurses traditionally reluctant to accept staff who had always worked in mental hospitals as fully trained, professional colleagues.13 The Nurses Registration Act of 1919 applied to mental nurses, but their inclusion on a supplementary register, rather than the main one, could be seen as indicative of their low status within the profession.14 General nurses continued to assert their superiority and even today some question the nursing credentials of colleagues working in the fields of mental health and learning 171

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disabilities.15 Other barriers to professional recognition and parity of esteem were upheld by nursing organisations. The Royal College of Nursing (RCN) explicitly excluded individuals who were not general trained female nurses until 1960.16 Evidence that the public, and even fellow nurses, held negative attitudes towards mental nursing was a significant problem, but in the working lives of such staff a more serious difficulty appeared to be their lack of power and status within the mental hospital system itself. Matrons and head male nurses were seldom included in, or consulted by, mental hospital committees.17 Within government departments mental nurses also struggled to get their voice heard. For example, there were no nurses among the Board of Control Commissioners tasked with inspecting mental hospitals and advising on nursing matters. This tendency to overlook nurses when making decisions about the management of institutions helped exacerbate the grim working conditions that commentators readily identified as a source of recruitment and retention problems. Relationships between staff, often poor and guided by an inflexible hierarchy, were singled out for frequent criticism. In 1945 the Socialist Medical Association noted with concern that ‘the idea of nurses and midwives as handmaids of the medical profession … rather than as professional colleagues giving mutual assistance’ was still prevalent.18 The lack of status accorded to mental nurses was reflected in their pay and conditions of service. National pay scales for nurses had been introduced in the 1940s, but pay for a mental nurse was often highlighted as being inadequate to attract sufficient numbers of staff.19 Low pay was seen as a particular obstacle to recruiting high-quality candidates to the profession. Emphasis was placed on the need to do more to attract recruits with a good education and the right sort of personality, itself a coded reference for a desire to recruit from a higher social class than had hitherto been the case.20 Existing staff were understandably more immediately concerned with securing a living wage. As part of a 1948 campaign by the Confederation of Health Service Employees (COHSE), the main union for mental hospital staff, student nurses were invited to submit copies of their budgets.21 These showed that many were surviving on the edge of subsistence, and as a result of the campaign a modest increase in pay followed. Wages, however, remained low, and Webster concludes 172

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that ‘The combination of inferior pay and unattractive conditions of work placed mental nursing in an extremely weak position in a market where employment opportunities were expanding.’22 Male wages in particular struggled to keep pace with those available in other sectors of the economy. In 1955 the matron at Warley Hospital reported that one male student nurse had left because he could earn more money delivering cars for Ford.23 Some hospitals were at an even greater disadvantage in competitive local labour markets. In 1952 J. Waugh (Technical Nursing Officer) visited Roundway Hospital, Wiltshire, and reported that ‘there are plenty of well paid, accessible jobs in industry etc in the Devizes area. Brewery, Bottle factory, Bacon Factory, Engineering, and a large barracks with NAAFI canteens etc’.24 Low pay was not just an issue in selecting a job; a lack of money also hindered attempts by staff who wanted a career in the sector to combine mental nursing with other life plans. Marriage presented particular difficulties for men and women, although the marriage question and its impact on recruitment, and especially retention, is usually discussed in relation to female nurses. The marriage bar had been removed from most mental hospitals by 1948, but although women were no longer required to give up their jobs on marriage many continued to do so.25 A survey at Mapperley Hospital (Nottingham) found that marriage was the single most important reason given by female students for giving up their training (33 per cent of those who left between 1950 and 1953).26 The same survey found that although men did not mention marriage as their reason for leaving, many (60 per cent of all men who left during training) cited financial difficulties. Further probing revealed that it was an existing, planned or desired marriage that brought the problem of money to the fore. In 1954 the Royal Medico-Psychological Association (RMPA) discussed wastage among male nursing recruits, suggesting that in a typical case ‘he probably marries young and finds the students’ pay is not enough for easy married life or for self-respect when the girl is earning more than he does as a nurse’.27 One way to improve pay, and status, was to seek promotion, but opportunities for this were limited in a way that created much resentment among mental nurses and led to many leaving the profession. A particular bone of contention was the fact that dual qualifications 173

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(that is, general training in addition to mental nurse training) were necessary in order to apply for senior posts in mental nursing. This devalued mental training, a point acknowledged with concern by Mr F. J. Ely (Mental Nursing Officer at the Ministry of Health) in 1954,28 especially since male staff found it almost impossible to access general training. These issues fed perceptions of unfairness and favouritism within different hospitals and within the profession as a whole.29 Male staff nurses were forced to wait ten, fifteen or even twenty years to reach the higher grades, according to COHSE.30 In the meantime most junior staff were condemned to arduous labour under strict discipline in poor conditions. Mental nursing was admitted to be hard work, both physically and mentally. It involved not simply patient care but the need to perform domestic and other tasks within antiquated asylums whose facilities were showing signs of serious dilapidation. In the 1920s there was concern that a quarter of all nurses’ time was devoted to domestic duties, and the same themes of excessive and/or inappropriate work reappeared in the 1940s and 1950s.31 In 1945 Mrs A. M. Reisner (a civil servant at the Ministry of Labour and National Service) noted that The matron agreed that the mental nurses do far too much domestic work. At Chartham they carry or wheel dirty or foul linen, pig swill, meal trolleys etc. The patients help them. There are no ward maids and no ‘corridor’ porters.32

Ten years later, J. Bickford (a consultant psychiatrist) stated that he had seen nurses working as cobblers and porters. One, he said, regularly milked the cows and others cut the grass. He even knew of one nurse who would stand in at the sewerage plant when the normal worker was away.33 As well as the heavy burden of domestic work, other aspects of mental nursing work were an issue for some new recruits. The work could be emotionally distressing as well as physically demanding. One of the most difficult problems was coping with the reality that few patients showed signs of a rapid or permanent return to mental health. Many nurses feared their efforts to alleviate suffering were unrewarded in terms of cures and the sense of professional fulfilment that accompanied them, to say nothing of the gratitude of patients and relatives normally offered to those successfully nursing 174

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the physically ill.34 This lack of job satisfaction negatively interacted with other conditions of work. The great age of the institutions was a serious obstacle to reform, but staff found themselves toiling in conditions that did seem unnecessarily grim. In 1954 H. C. Beccle (medical superintendent at Springfield Hospital, London) spoke of ‘dismal galleries, badly lighted and cold, worn furnishings and brown paint’.35 Unsurprisingly he identified this as a barrier to recruitment, but a decade later another writer described the conditions where patients were living and nurses were working as ‘dungeons’, suggesting a lack of attention to these details.36 As well as being old, the mental hospitals were also very overcrowded. Nationally, 67 out of 140 mental hospitals had more than 1,000 beds (seen as the maximum desirable) and the Leeds and Manchester Regional Hospital Boards maintained seven hospitals with more than 2,000 beds. In some areas a lack of beds was an even more serious problem than the size of the institutions. A growing number of elderly patients and a rapid increase in voluntary admissions were creating both overcrowding and long waiting lists, but some areas had created no new beds since 1948. A vicious circle was created as ‘endemic staff shortages’ were found to be ‘exacerbating the problem of overcrowding and long waiting lists’.37 The problem of too few nurses and too many patients often left large wards singlestaffed. In the worst cases there were simply no staff, with medical superintendents reporting that ‘it was necessary to move patients from one ward to another to enable nurses to go off duty’.38 By 1949 some hospitals were routinely leaving unstaffed wards ‘in the charge of a reliable patient’.39 Staff shortages were both a cause and a consequence of the difficulties nurses experienced with long hours and shift work. The Athlone Committee had found that the average working week for mental nurses varied between institutions but was typically between 48 and 60 hours a week. Mrs Reisner, following her visit to Chartham Mental Hospital in 1945, described the situation in stark terms. She wrote, ‘The “long days” worked in my opinion are iniquitous. The nurses are called at 5.45 am, on duty at 6.30 am … going off duty finally at 7.30 pm.’40 Other contemporary commentators identified shift patterns, involving long hours and also anti-social hours, as a major obstacle to recruitment and retention. In 1953 the secretary of the management 175

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committee of Whittingham Hospital (Lancashire) mentioned ‘the disadvantages of longer hours, night duty, lack of opportunity to attend dances and entertainments in the evening, and weekend duties which are not part of the conditions of service in the factories, shops and offices of the neighbouring towns’.41 The long hours of work were, however, only one off-putting feature of mental nursing. An area of increasing concern after the Second World War was the discipline demanded of nurses at a time when rules governing social conduct were being relaxed in other spheres of life, and young people were increasingly keen to seek independence rather than offer unthinking deference to established hierarchies as ‘youth culture’ took root. The Lancet Commission had highlighted restrictive discipline in all branches of nursing as a problem back in 1932, but mental nurses arguably had particular difficulties to contend with.42 This was because patient care was conducted within a comprehensive and custodial legal framework. A patient suicide, an escape or even a minor breach of discipline could and often did lead to the instant dismissal of one or more members of staff. Mick Carpenter draws attention to the importance of both strict rules and severe penalties for their infringement.43 New staff were typically issued with a long list of rules and asked to sign ‘obligation forms’. Infringement of any of them could lead to instant dismissal. Mental nurses, who usually lived as well as worked in their hospitals, found that their whole lives and not just their working hours were scrutinised and controlled. It was, for example, forbidden to marry without permission. While the all-powerful figure of the matron dominates accounts of general nursing, in the mental hospitals ultimate (and sometimes arbitrary) authority was traditionally vested in the medical superintendents.44 This could create confusion and disciplinary problems as matrons and head male nurses sought to exercise their own discretionary powers as distinct nursing hierarchies developed from the interwar period.45 The need to live in did not just create disciplinary problems and resentment about lack of freedom in off-duty hours; the accommodation itself created serious recruitment and retention difficulties because of its poor quality. The Lancet Commission had been very critical about the quality and availability of the accommodation provided for nurses in the 1930s, but improvements were slow and 176

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sporadic. In 1945 a meeting of the National Advisory Committee for the Recruitment and Distribution of Nurses and Midwives was still discussing whether or not nurses should be expected to sleep in rooms adjacent to patients (where they could be called on in the night to assist the night nurses) in the way they had been in the past.46 The Athlone Committee noted several deficiencies in the accommodation offered to nurses and made the radical proposal that nurses should be allowed to live off-site if they wished, anticipating that this would make it easier to recruit and retain staff.47 This was not the only new idea to emerge at this time. Recruitment and retention issues were so serious that training came under particular scrutiny. It was believed that many individuals favourable towards a career in nursing were lost to the profession because outmoded entry requirements unwittingly excluded them or made other options more attractive or practical. Attention focused on the gap between leaving school (with the school leaving age in England raised to 15 in 1944) and starting training (usually at the age of 17 or 18, to allow registration after training at the minimum age of 21).48 While some commentators believed that enticing younger people into nursing was the best way forward and initiated various cadet schemes, the GNC introduced new regulations in October 1952 setting a minimum age of 18 for entering training. The most committed would-be recruits found ways to use the three years between school and training to prepare themselves for nursing, but many others drifted into alternative jobs, preparation for other careers (with teaching an attractive option) or marriage plans, any or all of which ultimately deterred them from switching to nursing when this was permissible. Rafferty discusses these issues in detail. Although she notes that nursing was not the only profession (and especially female-dominated profession) to face these recruitment and retention difficulties, it did seem uniquely disadvantaged by them.49 This was certainly the opinion of the Ministry of Labour and National Service.50 The age of entry was not the only contentious issue that hindered the reform of training programmes. Competition between two opposing training bodies was also a distinct factor. The (Royal) Medico-Psychological Association (MPA or RMPA from 1925) had instituted the first national training scheme for mental nurses in 1891. The RMPA training courses and examinations continued until 177

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1951, by which time 50,000 mental nursing certificates had been issued.51 The RMPA scheme found a bitter rival in the GNC, which had anticipated that it would oversee all training and examinations for nurses after the Nurses Registration Act.52 For various reasons RMPA training proved more popular with mental hospital staff and, by 1943, 45,000 mental nurses had the RMPA certificate while only 10,600 were on the mental register of the GNC.53 It was the Athlone Committee that finally resolved the issue and determined that the GNC should become solely responsible for mental nurse training, and no new RMPA candidates were accepted after 1946. Despite some reservations about the rigour of RMPA examinations, there were reasons for anticipating problems with the GNC model of training and real questions about its appropriateness for mental nurses. The GNC offered a ‘one portal’ system of training which meant that all nurses were expected to undertake the same preliminary examination at the end of their first year (which focused on the nursing needs of the physically ill), before taking a more specialised paper for their finals at the end of three years. The appropriateness of this model of training for mental nurses remained debatable. Standards were exacting and many willing recruits, who performed good work on the wards, were unable to pass the requisite examinations and were lost to the profession.54 Yet perversely there was also concern that training was too perfunctory, with students used as cheap labour rather than being properly prepared for a career in nursing.55 Although reforms had at least established Preliminary Training Schools, once nursing students were sent to the wards they worked not so much alongside the staff but as a major part of the workforce. While it might be assumed that a desperate attempt to staff the wards would tend to relax the entry criteria for students, Kirby makes a different and very interesting argument, at least for some hospitals. She notes that since the students would almost immediately be expected to perform responsible roles it was in the interests of the institution to only accept high-calibre recruits.56 The tension between quality and quantity, in training as well as recruitment, is vividly demonstrated by evidence from the mental health sector, but the overall picture in terms of recruitment priorities is very confused. Training standards were, however, undoubtedly undermined by the requirement for students to attend lectures in their off-duty time 178

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and a shortage of qualified tutors.57A 1954 report found that there were only seventeen qualified tutors teaching in mental hospitals in England and Wales at that time.58 It was, however, easier to identify problems than remedy them. Strategies adopted at national and local level to improve recruitment and retention When considering efforts to boost recruitment and improve retention of staff, especially student nurses, four main strategies can be identified. These were dilution, educational reforms, recruitment campaigns and the search for workers from overseas. Many were far from ideal, but were useful as short-term expedients despite having long-term costs for the development of the profession of mental nursing and the enhanced patient care that was meant to follow the up-skilling of the workforce. Although central government departments, together with representatives of the mental hospitals and nursing organisations, all paid lip-service to the desirability of improving the quantity and quality of mental nurses working in the institutions, it is noticeable that one of the preferred solutions to the staffing crisis was often dilution. An infamous 1953 memo, officially known as RHB 53 (54) but more commonly referred to as the ‘dilution circular’, outlined the possibilities for expanding the employment of ‘subordinate staff’.59 This implied increasing recourse to the services of unqualified nursing assistants, although there were new plans to offer a training scheme for such staff. COHSE condemned the plan, seeing it as an excuse to use cheap labour, and bitterly fought against dilution schemes throughout the period under discussion. The early years of the NHS were marked by contentious debates about the necessary skill mix on the wards as assistant or enrolled nurses were introduced into mental health care. In 1943 the Nurses’ Act had provided a legislative framework that legitimated ‘a lower stratum of nursing labour, that would then free the student nurse to pursue an educationally orientated form of training’.60 Then, building on the recommendations of the Athlone Report (1945), experienced nursing orderlies and assistants were invited to apply for enrolment as assistant or second level nurses. After 1948 prospective enrolled nurses were expected to undergo training. This was conducted under 179

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the auspices of the GNC but was shorter than that of registered nurses. However, it is important to note that the 1943 Act only provided for a general nurses’ roll. No provision was made for staff in mental or mental deficiency institutions to be included. This situation arose because the Athlone Committee had felt that the standard of mental nursing was not high enough to be encompassed by the scheme, but it was also influenced by hostility to the new arrangements from actors in the mental health sector, including COHSE and many medical superintendents. By the 1960s the battle was lost. Enrolled nurses were introduced into mental (and mental deficiency) nursing, in 1964, over twenty years after they were established in the general field. Dilution was always contentious, and was in itself no solution to the most serious of all the wastage problems, student nurses failing to complete training. Some commentators argued that better selection techniques would improve retention rates and the use of entry requirements or an educational test (for those without the required formal qualifications) was one strategy that was energetically championed by the GNC. Rafferty has argued that ‘intelligence tests were seized upon as the panacea for nurse selection and recruitment’,61 but they created difficulties across all branches of nursing and were first adopted, then discontinued, then reintroduced in 1962. In a parallel to the debates surrounding the introduction of enrolled nurses, the mental health and learning disability sectors were initially excluded from the testing regime. Some leading mental nurses believed that this policy devalued the sector and was symptomatic of other discriminatory practices at the GNC. One wrote, ‘along comes big brother telling us any standard will do for us’.62 After a series of heated exchanges the educational test and entry requirements were finally applied to mental and mental deficiency nursing in 1966. The introduction of the tests, however, created as many problems as it solved. There remained genuine concerns about identifying the attributes essential to the good mental nurse. These included a range of experiences and personal characteristics that were not captured by tests of academic ability. A focus on educational attainment (easy to quantify) risked deliberately excluding the caring, compassionate and practical individuals whose virtues were less amenable to measurement but who were arguably the most suitable candidates for mental nursing. Mr Haworth, chief male nurse at a large mental hospital in 180

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Surrey, argued that, ‘80 per cent of people who are the backbone of the job, would have failed the educational test of today’.63 The perceived deficiencies in the basic education of many recruits to mental nursing were compounded by acknowledged weaknesses in their training. As noted earlier, the mental nurse training syllabus was often criticised for being too focused on physical health issues and therefore largely irrelevant to the needs of the new mental nursing student.64 Attempts to revise the curriculum had limited effects on recruitment and retention and instead fed disputes within the profession. One commentator described an experimental syllabus introduced in 1957 as ‘somewhat irrelevant, wrongly focussed and largely fictitious’.65 Educational reform clearly did not offer straightforward solutions to the staffing crisis. This encouraged efforts to simply publicise job/career opportunities in the sector to an ever-wider audience. Recruitment campaigns, at a local and national level, had been another strategy advocated by RHB 53 (54). A mental health exhibition opened in London in 1955 and then toured the country in an attempt to promote a positive image of mental health services.66 Major local campaigns were also organised and the Ministry of Health studied their effectiveness in some detail. Attention focused on Huddersfield and Wakefield,67 and then Durham.68 Despite the considerable efforts of those involved, all were found to have yielded little in the way of tangible results. For example, two open days at Stanley Royd Hospital (Wakefield) attracted only thirty-two visitors, although this did lead to the recruitment of two student nurses (one male and one female) and eight part-time nursing assistants. Interestingly, the exhibitions seemed to have been more successful in recruiting patients. For example, the Ministry of Health recorded that after an exhibition in Manchester, they received 150 enquiries about how to become a patient, but not one about becoming a nurse.69 At both national and local level much effort was also put into producing advertisements and recruitment brochures. These provide an interesting insight into the imagery that was used to portray mental nursing in this period. Yet there was often an uncomfortable dissonance between the images conveyed and the reality of mental nursing. This led angry nurses to picket the mental health exhibition in protest. Placards with slogans such as ‘Mental nurses wanted – to 181

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work themselves to death’ hardly helped attempts to portray mental nursing as an attractive career.70 It was not just nurses who were concerned; a medical superintendent argued that ‘much of the material that is used is misleading and unsuitable and serves to glamorise nursing’.71 Unrealistic images of mental nursing may have attracted the odd recruit, but they did not stay long if they found the reality of the work uncongenial. Indeed the gap between the image of the nurse and the reality of the job fuelled disappointment and disillusionment. Wastage tended to increase rather than decrease as a result. Since British workers were apparently not persuaded by the benefits of a career in mental nursing, recruiters increasingly looked overseas for staff. Victorian and Edwardian institutions had traditionally had significant numbers of Irish staff and this pattern of recruitment continued despite increasing objections from the Irish government. In 1946 the Irish Department of Industry and Commerce refused a request by Runwell Mental Hospital (in Essex) to visit the country to recruit nurses.72 With this recruitment pathway closed, recruiters looked first to Europe and then more distant countries. In the 1950s mental nurses were recruited from France, Italy, Germany and Spain, but there were serious concerns about language difficulties and retention rates. An investigation by the Nursing Advisory Council found that only ninety-four (51 per cent) of the overseas nurses given permits in 1948 had actually started mental hospital training, and by 1951 just four had qualified while five were still undergoing training.73 The others had quickly succumbed to homesickness or poor health, or were dealing with the consequences of illness at home, marriage, pregnancy or examination failure. In several cases it was clear that the recruits had misunderstood (or been misled about) the nature of the jobs they had been offered, with four Norwegians quitting their mental hospital once they realised it was not the children’s hospital they had anticipated. The majority of the desperately needed European recruits provided at best a temporary boon. David Clark, medical superintendent at Fulbourn Hospital (Cambridge), found that while an advertising campaign in France brought in over one hundred applicants and twenty recruits, ‘this was like a blood transfusion to the staff of the women’s side – though like a blood transfusion, the effect was a tonic rather than sustained’.74 182

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Concerns about the European recruits’ difficulties with spoken and written English as much as their retention levels called for a new approach. The annual COHSE conference held in 1965 was very critical of this, sparking considerable negative press coverage.75 Recruiters increasing looked to new territories in the West Indies and Africa with a focus on areas with colonial ties to Britain. Since mental nursing was relatively low status, its recruitment difficulties were most acute and the resulting diversity of its workforce greatest. This could be inclusive, but divisions, prejudice and also overt and covert racism and racial discrimination were common experiences despite optimistic press coverage.76 For example, in May 1964 the Daily Express featured a photograph of student nurses from thirty-four different countries, arm in arm, at Claybury Hospital (Essex). The headline was ‘Togetherness … in 34 lessons’ and the students were reported to be ‘living and working together in perfect harmony’.77 Conclusion Historians generally agree that the 1960s were a period of great change and uncertainty in the mental hospitals. Underpinning this was an apparent crisis in psychiatric legitimacy, with the emergence of the anti-psychiatry movement raising fundamental questions about the very basis on which mental health services operated.78 This spirit of critical analysis threatened to descend into a culture of blame as a number of abuse scandals were exposed in the press and made the subject of major inquiries.79 Nurses received arguably more than their fair share of criticism, even in reports that noted the difficult role they performed and the problems of providing modern standards of care in antiquated facilities. Furthermore, discussions about the nature of mental illness, and the idea that this was not necessarily sickness as previously understood, undermined the argument that mental nurses (even at their most professional) were the most appropriate people to offer care and certainly questioned their existing skill base and day-to-day activities on the wards. Patients sought new ­therapeutic relationships with staff and each other, while a more ­cooperative and collaborative atmosphere on the wards undermined old ­hierarchical structures. Some staff welcomed the changes, others found the fracturing of the old order threatening and confusing.80 Leading commentators suggest that a 183

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‘weakening of occupational boundaries’ and the ‘shift to community care’ were creating a serious crisis for mental nursing.81 This exacerbated a pre-existing staffing crisis. Since recruiters seemed unable to identify the ideal candidate for mental nursing they inevitably failed to target suitable audiences with convincing messages about the future of the profession. Similarly, training programmes were undermined by uncertainty about what nurses did and why, as debates about mental health policy and practice intensified. These issues had a devastating impact on recruitment and retention, but crucially remained unresolved. Cutcliffe and McKenna have persuasively argued that the lack of precision about what mental health nurses actually do has meant that mental health nurses ‘do not share a collective sense of self and this may be due, in part, to the ambiguous world in which they live and work’.82 Other commentators have also convincingly argued that mental health nursing has ‘no obvious purpose’83 and lacks an ideological basis.84 The low visibility of mental health nursing skills made them difficult to either demonstrate or observe, with implications for the professional status of practitioners.85 The professional credentials of mental nurses were also challenged by class and gender issues. The dissonance between the recruitment ideal (a student nurse should be a young white female from a middleclass family background) traditionally promulgated by the GNC and the Royal College of Nursing and the reality of a very diverse workforce (with a traditional bias towards working-class recruits) was even more marked in mental than in general nursing.86 Recruiters therefore needed to understand that mental nursing represented a job or occupation rather than a vocation for many of its practitioners, and the rewards they sought and gained from their employment were different from the quasi-spiritual aspirations of would-be Florence Nightingales leaving a life of relative privilege to tend to the sick. While the RCN and nursing schools in general hospitals worried about competition from the teaching profession and the expanding clerical sector, strategies to bring more well-educated, middle-class girls into mental nursing had limited utility.87 Instead more pragmatic responses, such as recruiting untrained staff and staff from overseas, proved more successful in terms of increasing available staff. Mental nurses who stayed in post were committed to their work but they were more overtly concerned with pay and other job perks (such as 184

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access to quality sports facilities) than most general nurses.88 This was especially true of male staff. These findings suggest that the reasons that people come into nursing are complex and often hidden.89 Recruitment in the field of mental nursing fell under intense government scrutiny in the years 1948–54. This was undoubtedly an issue of great national concern. A variety of initiatives were tried, but a number of investigations into their effectiveness and wider issues affecting nurse recruitment revealed that nursing shortages were attributable to a variety of complex factors not amenable to early or easy resolution. It is therefore not surprising that most of the strategies that were adopted to ameliorate this situation were unsuccessful. Recruitment campaigns, however, had an effect beyond their immediate purpose. They created an image of not only mental nursing but also mental health services in general. It is important to note that prospective patients, if not would-be nurses, were apparently attracted to the facilities on offer. There remained, however, deep uncertainty about the conceptualisation of the mental nurse in rapidly changing mental health services which, coupled with the practical problems current and prospective staff encountered with their pay and working conditions, may help explain what Rafferty has described as the ‘recruitment riddle’ in this area of nursing.90 Notes   1 ‘The Minister’s Speech to Medical Officers’, The Lancet, 29 September 1945, 412–13.  2 National Archives, Kew (hereafter NA), MH55/2196, Ministry of Health (hereafter MOH), National Consultative Council on the Recruitment of Nurses and Midwives – minutes of meetings and other papers, 1956–60; minutes of first meeting (1958) include remarks made by Mr Haslam.   3 C. Webster, The Health Services since the War. Volume One. Problems of Health Care (London: HMSO, 1988) p. 4.   4 R. White, The Effects of the National Health Service on the Nursing Profession (London: King Edward’s Hospital Fund, 1985).  5 Modern Records Centre, University of Warwick (hereafter MRC), MSS 229/6/C/3/11, papers of the Confederation of Health Service Employees, 1943–58 (hereafter COHSE papers).   6 K. Jones, Asylums and After: A Revised History of the Mental Health Services from the Early Eighteenth Century to the 1990s (London: Athlone Press, 1993).

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Mental health nursing  7 Report of Sub-Committee on Mental Nursing and the Nursing of the Mentally Defective (Athlone Report) (Ministry of Health, Ministry of Education, London: HMSO, 1945), p. 14.   8 D. Gittins, Madness in Its Place: Narratives of Severalls Hospital, 1913–1997 (London: Routledge, 1998).  9 A. Digby, Madness, Morality and Medicine: A Study of the York Retreat 1796–1914 (Cambridge: Cambridge University Press, 1985). 10 A. Rogers and D. Pilgrim, Mental Health Policy in Britain (Basingstoke: Palgrave, 2nd edn, 2001). 11 A. Scull, Museums of Madness: The Social Organization of Insanity in Nineteenth-Century England (Harmondsworth: Penguin, 1979). 12 Athlone Report, p. 15. 13 For example, see E. Bedford Fenwick, ‘Editorial – Mental Nurses II’, The Nursing Record, 452, XVII (1896), 430. 14 Mental deficiency, sick children’s, fever and male nurses were also placed on supplementary registers. See E. Bendall and E. Raybould, A History of the General Nursing Council for England and Wales 1919–1969 (London: H. K. Lewis, 1969). 15 S. Strachan-Bennett, ‘Mental health nursing deserves respect and understanding’, Nursing Times, 102:48 (2006), 10. 16 S. McGann, A. Crowther and R. Dougall, A History of the Royal College of Nursing. 1916–1990. A Voice for Nurses (Manchester: Manchester University Press, 2009). 17 O. Griffiths (sic), N. Reid and M. Scott, ‘Reconstruction scheme for mental nursing’, Nursing Mirror, 27 October 1945, 46–7. 18 Socialist Medical Association, Nursing in the Post-War World (London: Socialist Medical Association, 1945). 19 M. Carpenter, Working for Health. The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988). 20 Griffiths, Reid and Scott, ‘Reconstruction scheme for mental nursing’. 21 M. Carpenter, They Still Go Marching On. A Celebration of the History of the Confederation of Health Service Employees (London: COHSE, 1985). 22 Webster, The Health Services since the War, p. 337. 23 NA, MH55/2587, MOH, reports of visits to hospitals and hospital management committees by the Ministry’s Principal Regional Officer, based at Cambridge, 1953–55. 24 NA, LAB8/62, Ministry of Labour and National Service (hereafter MLNS), Recruitment of Nurses from Abroad – Reports to the National Advisory Council, 1952–53, report on Roundway Hospital by J. D. I. Waugh, Technical Nursing Officer. 25 J. Lewis, Women in England, 1870–1950: Sexual Divisions and Social Change (Brighton: Wheatsheaf, 1984).

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‘The weakest link in the chain of nursing’? 26 NA, LAB8/1880, survey results reported in MLNS, Wastage of Student Nurses: Analysis of the General Nursing Council Index, 1950–58. 27 NA, DT5/383, GNC, Mental Nursing Committee Minutes, 1952–54, includes a copy of this RMPA report. 28 ‘Training in mental nursing and preparation for positions of responsibility’, Nursing Times, 26 November 1954, 1320–1. 29 Liverpool Regional Health Board, The Work and Status of Mental Nurses. A Report of a Survey by the Department of Social Sciences at the University of Liverpool (1955), p. 25. The survey was conducted in 1952. 30 MRC, MSS/229/6/C/CO/3/3, COHSE papers, letter from J. T. Waite (COHSE’s general secretary), ‘Post war staffing crisis’, 1955. 31 NA, DT5/382, GNC, Mental Nursing Committee Minutes, 1946–51, include discussions of the Wood Committee findings. 32 NA, LAB8/954, MLNS, shortage of nurses in mental hospitals and mental deficiency colonies: preparation of papers for the National Advisory Council, 1944–46 (hereafter ‘shortage of nurses’). 33 J. Bickford, ‘The forgotten patient’, The Lancet, 29 October 1955, 917–19. 34 These issues were widely discussed in contemporary publications; see, for example, RCN archives (hereafter RCNA), Edinburgh, RC N/5/1/M/9, Mental Health, 1944–61. 35 ‘Training in mental nursing and preparation for positions of responsibility’, 1320. 36 M. McBrien, ‘What is wrong with psychiatric nursing?’, Nursing Mirror, 10 May 1968, 31–3. 37 Webster, The Health Services since the War, p. 337. 38 NA, LAB8/954, MLNS, shortage of nurses, comments attributed to Medical Superintendent Boyd, referring to the situation at his hospital in 1945. 39 NA, DT5/382, GNC, Mental Nursing Committee Minutes, 1946–51, comment on summary of hospitals for mental nurse training. 40 NA, LAB8/954, MLNS, shortage of nurses, memo from Mrs Reisner following a visit to Chartham Mental Hospital in January 1945. 41 NA, MH55/2098, MOH, Shortage of Nurses in Mental Hospitals and Mental Deficiency Institutions, 1951–54. 42 ‘Lancet Commission’, The Lancet Commission on Nursing (London: The Lancet, 1932). 43 Carpenter, They Still Go Marching On. 44 See Jones, Asylums and After, for an overview that is then discussed in A. M. Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996). 45 See chapter in this volume by Pamela Dale. 46 NA, LAB8/954, MLNS, shortage of nurses. 47 Athlone Report, p. 42. 48 E. Scott, ‘The Influence of the Staff of the Ministry of Health on Policies for Nursing, 1919–1968’, PhD dissertation, London School of Economics, 1994.

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Mental health nursing 49 Rafferty, The Politics of Nursing Knowledge. 50 NA, LAB8/1047, MLNS, publicity programme to increase recruitment of nurses and midwives, 1943–46. 51 54 ‘Minutes of the 111th annual meeting of the Royal Medico-Psychological Association’, Journal of Mental Science, 3 (1952), supplement. 52 C. Chatterton, ‘Caught in the middle? Mental nurse training in England 1919–1951’, Journal of Psychiatric and Mental Health Nursing, 11 (2004), 30–5. 53 Chatterton, ‘Caught in the middle?’ 54 NA, MH55/2585, MOH, Staffing of Mental Hospitals and Mental Deficiency Hospitals: Shortages, Recruitment and Training of Nurses: Policy Considerations, 1953–60. 55 McBrien, ‘What is wrong with psychiatric nursing?’ 56 S. Kirby, ‘Splendid scope for public service: leading the London County Council Nursing Service. 1929–48’, Nursing History Review, 14 (2006), 31–57. 57 NA, MH55/2098, MOH, Shortage of Nurses; NA, LAB8/954, MLNS, shortage of nurses. 58 NA, DT5/382, GNC, Mental Nursing Committee Minutes, 1946–51. 59 MOH Memorandum RHB (53) 54 HMC (53)50, August 1953. 60 R. Dingwall, A. M. Rafferty and C. Webster: An Introduction to the Social History of Nursing (London: Routledge, 1988), p. 134. 61 Rafferty, The Politics of Nursing Knowledge, p. 170. 62 RCNA, AMN/19, correspondence with the GNC regarding the minimum age of entry, 1960–68. 63 RCNA, AMN/19, correspondence with the GNC regarding the minimum age of entry, 1960–68. 64 Griffiths, Reid and Scott, ‘Reconstruction scheme for mental nursing’. 65 McBrien, ‘What is wrong with psychiatric nursing?’, 32. 66 NA, MH55/2193, MOH, Mental Illness and Mental Deficiency: Nursing Recruitment Campaign: Mental Health Exhibition, 7–12 November 1955 (hereafter mental health exhibition papers, 1954–56). For other examples of recruitment posters and publicity material see NA, MH55/943, MOH, General Nursing Campaign: Recruitment Policy and Publicity, 1951–52; and NA, MH55/2196, MOH, National Consultative Council on the Recruitment of Nurses and Midwives, minutes of meetings and other papers, 1956–60. 67 NA, MH55/945, MOH, Nursing Recruitment Campaign: Mental Hospitals and Institutions, 1953–54. 68 NA, INF12/645, Central Office of Information, Mental Nursing Recruitment (1956). 69 NA, MH55/2193, MOH, mental health exhibition papers. 70 Carpenter, Working for Health, p. 288. 71 NA, MH55/2098, MOH, Shortage of Nurses.

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‘The weakest link in the chain of nursing’? 72 NA, LAB8/1301, MLNS, Recruitment of Nurses from Eire. Eire Government’s Employment Policy in Respect of Staff for Hospitals in this Country (1946). 73 NA, LAB8/62, MLNS, Recruitment of Nurses from Abroad – Reports to the National Advisory Council, 1952–53. 74 D. Clark, The Story of a Mental Hospital. Fulbourn Hospital. 1858–1983 (London: Process Press, 1996), p. 153. 75 ‘The 18-year-old girl who couldn’t speak English … Mental Nurses’ Plea’, Aberdeen Evening Express, 22 June 1965. 76 L. Culley and S. Dyson (eds), Ethnicity and Nursing Practice (Basingstoke: Palgrave, 2001). 77 ‘Togetherness … in 34 lessons,’ Daily Express, 12 May 1964, 9. 78 For example, see R. Barton, Institutional Neurosis (Bristol: John Wright, 1959); R. D. Laing, The Divided Self (Harmondsworth: Pelican, 1961); E. Goffman, Asylums (Harmondsworth: Penguin, 1963). 79 B. Robb, Sans Everything. A Case to Answer (London: Thomas Nelson, 1969); J. P. Martin, Hospitals in Trouble (Oxford: Blackwell, 1974). 80 Carpenter, Working for Health, p. 291. 81 Dingwall, Rafferty and Webster, An Introduction to the Social History of Nursing, p. 141. 82 J. Cutcliffe and H. McKenna, ‘Generic nurses: the nemesis of psychiatric/ mental health nursing?’, Mental Health Practice, 3:9 (2000), 10–14. 83 S. P. Michael, ‘Invisible skills: how recognition and value need to be given to the invisible skills frequently used by mental health nurses, but often unrecognised by those unfamiliar with mental health nursing’, Journal of Psychiatric and Mental Health Nursing, 1 (1994), 56–7. 84 S. Owen and J. Sweeney, ‘The future role of the mental health nurse’, Nurse Education Today, 15 (1995), 17–21. 85 M. Brown and G. Fowler, Psychodynamic Nursing: A Biosocial Orientation (Philadelphia: W. B. Saunders, 1979). 86 C. Hart, Behind the Mask. Nurses, Their Unions and Social Policy (London: Baillière Tindall, 1994); M. Carpenter, ‘Asylum nursing before 1914: a chapter in the history of labour’, in C. Davies (ed.), Rewriting Nursing History (London: Croom Helm, 1980). 87 Stephanie Kirby usefully conceptualises these debates and points to other traditional and new sources of competition for female labour. See Kirby ‘Splendid scope for public service’. Mental nursing traditionally competed with domestic service for recruits, although by the interwar period both were seen as unpopular options. See P. Horn, Life Below Stairs in the Twentieth Century (Thrupp: Sutton Publishing, 2001). 88 P. Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993). 89 Hart, Behind the Mask, p. 31. 90 Rafferty, The Politics of Nursing Knowledge, p. 7.

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9

Wardens, letter writing and the welfare state, 1944–74 John Welshman

The previous chapters have concentrated on the large-scale, long-stay facilities that have been the main focus of asylum histories in the United Kingdom. These institutions still dominated the landscape of care in the third quarter of the twentieth century, although reformers were already advocating alternative forms of provision that were closer to patients’ homes and families and better integrated with other health and welfare services. This shift in the locus of care was associated with efforts to ‘normalise’ conditions for both patients and staff, and also reach out to new client groups. While the historiography has concentrated on the impact of de-institutionalisation, which gathered pace in the 1980s as the largest institutions closed, there had been increasing pluralism in terms of the provision of care since 1948. Indeed, the process of transferring the large-scale institutions to the National Health Service (NHS) drew attention to the number of statutory and voluntary sector organisations already providing care, their separate histories and different traditions, and ongoing experimentation in terms of the configuration and delivery of residential and day services. In the era of the classic welfare state, the care system developed on a tripartite basis, with the NHS, local authorities and voluntary organisations all offering care to various groups of vulnerable people in a variety of settings. Despite increasing interest in the history of care in the community, and landmark publications such as Outside the Walls of the Asylum,1 these post-war services have been relatively neglected. The smaller residential facilities provided by local authorities and voluntary groups have certainly tended to be overlooked, although the role of hostels in helping patients exit the mental 190

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deficiency institutions has recently received some attention.2 The focus of this work, however, has been patient experiences, and many aspects of service provision, not least staffing issues, remain largely unexplored. This is important because recent publications have highlighted potential tension between the needs of vulnerable serviceusers and those of staff whose own economic and social status was far from secure. In the most depressing circumstances the marginal employability of the carers encouraged a situation in which the needs of employees and service-users could be perceived to be diametrically opposed, allowing a culture of abuse to flourish. Although autobiographical accounts of people living with learning disabilities stress both positive and negative interactions with staff, there is no doubt that the quality of the relationship with individual members of staff was the major determinant of the overall experience of care.3 This conclusion can surely be extrapolated to other vulnerable service-users. We therefore need to find ways to qualitatively assess the contributions of various carers. Such an assessment must encompass, but not be limited to, developing an understanding of pay and conditions, the number and type of carers available to any given service, and their qualifications, skills and experience. It is, for example, widely recognised that throughout the study period most staff in the sectors under discussion were unqualified, although the involvement of professional doctors, nurses and social workers cannot be treated as unproblematic in terms of service delivery or service development. Among studies of post-war care services there is a pervasive conclusion that staff were powerful in relation to serviceusers but relatively powerless in their ability to access resources and influence service development.4 These constraints were, however, not always clear to contemporary actors. Many services were initiated with much optimism and then sustained by the commitment of staff who successfully managed to negotiate conflicting professional and policy agendas while maintaining a clear focus on client needs. In the early post-war period, a range of hostels and centres were established in the United Kingdom for service-users including people with learning disabilities, clients of mental health services, so-called ‘problem families’ and vulnerable young adults. In these hostels and centres, the warden was the key member of staff. Their role has been seriously neglected in the literature, even though their experiences 191

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open up wider questions about social class, gender, training, qualifications, working conditions and broader continuities between care in the community and the Poor Law.5 Even more interesting are the relationships that wardens had with the client groups who used their hostels, the experts whose research shaped the framework within which services were delivered and the policy-makers who constantly expected the impossible but who often also undervalued frontline staff. This chapter surveys studies of wardens in a range of settings and then focuses upon an archive of letters, running from the late 1940s to the early 1960s, that were exchanged between one warden and mothers who had stayed in a residential institution, the Brentwood Recuperation Centre for Mothers and Children,6 which was located near Stockport, south of Manchester.7 Some historians have argued that smaller institutions were not necessarily more caring.8 However, the themes that emerge from the letters examined here are those of friendship, advice and reassurance, information and news, material assistance and advocacy. In contrast to work that has for too long concentrated on controlling practices and notions of shared stigma, this chapter demonstrates that the regime of such residential institutions was not inevitably unpleasant or punitive, and that the warden, despite possessing only basic qualifications, could act as an important source of information, advice and reassurance. Wardens and matrons Surveys of service provision in a range of settings, published in the late 1960s and early 1970s, do offer insights into the training and expectations of wardens. Robert Apte, for instance, surveyed fifteen female and ten male wardens in his study of halfway houses for people with mental health problems (1968). He argued that many Medical Officers of Health believed that the personality of the warden and ‘his’ relationship with the resident was the most important element in achieving rehabilitation. The warden might be seen variously as a parental figure, someone who could help residents find employment, a person who could teach residents how to conform to social expectations, or someone with a psychotherapeutic role. The average age of the wardens was 47.5 years for men and 50 for women; 70 per cent of the men and 47 per cent of the women were over fifty.9 Many of the 192

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men had become wardens after completing their working life in some other form of employment; some regarded it as semi-retirement. Certainly at that time there was no recognised training for wardens working in hostels for people with mental health problems. Half of the wardens had some training in nursing, but eleven had no relevant training beyond secondary school, and only four had some experience of working in psychiatric hospitals. The fact that 80 per cent of the wardens had many years’ working experience in hospitals, and brought with them institutional values, clearly shaped the hostel environment. Recruiting wardens was not easy, and there was rapid turnover, mainly because wages were low. Apte suggested that dissatisfaction over long hours spent in residential work, the salary, the lack of privacy and too much responsibility undermined the effectiveness of the hostels. Two of the hostels that he studied did not have resident staff, but the other twenty-three did; thirteen of the wardens were married and had their wives or husbands living with them. Many local authorities deliberately employed married couples with children as wardens, believing that this recreated a ‘normal family environment’.10 However, while the idea was good in principle, any family was likely to want to protect itself from the demands and intrusions of hostel residents. In the evening, for instance, the family would withdraw into its own flat at a time when the residents would be home from work and requiring help. Apte argued that the halfway houses were socially stratified through the use of separate dining, bathing and toilet facilities, but also through the use of uniforms. Only a few hostels had more egalitarian arrangements, and most had the hierarchical characteristics of traditional institutions. In terms of rehabilitation, there was evidence of ‘stereotyped and institutional’ attitudes on the part of many of the wardens towards the residents of the hostels.11 In her study Opening the Door (1975), Kathleen Jones surveyed twenty hostels in eleven local authorities. She found that there was great variety. Some wardens organised activities such as birthday parties, games, competitions, fashion shows and day trips, but others felt that this bore the marks of institutionalism, and that residents were happier to spend their time as they pleased, watching television, chatting or going to their own rooms. Certainly much of the social organisation of the hostels, the interaction between residents and 193

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their quality of life depended on the personalities and attitudes of the wardens. Ten were female and four male, one other hostel having a married couple in charge; most were in their forties or early fifties. Most had a self-contained flat in the hostel. Seven had nursing qualifications, while the others had no qualifications. Most had institutional experience of some kind and, as Apte had found, salaries were low. The majority derived satisfaction from seeing residents in their first job, getting them to perform simple tasks such as shopping or cleaning and creating a real home. Jones felt that most of the hostels were warm, friendly places where the residents could feel at home. In only three of the hostels was the atmosphere formal and cold. In the first, the deputy warden, an ex-prison officer, wore a white coat and sat at a reception desk in the hall; in the second the warden, formerly a hospital sister, insisted on being called ‘matron’; while in the third, the problem was one of size and décor. Generally, contacts with Social Services departments were good.12 A Department of Health and Social Security (DHSS) survey of hostels for young people (1975) found that, of forty hostels visited, nineteen had a warden and matron in charge who were a married couple, full-time and resident, and eight were under the charge of a warden or matron whose spouse helped part-time. Of fifty staff in charge of hostels, 60 per cent were over fifty years old, more grandparents than parents. Again staff turnover was high, and many of the hostels and the organisations responsible for them thought that the number of posts was inadequate; only twenty-three of the fifty had qualifications.13 In terms of staff attitudes and their expectations of the job, they mainly saw themselves as engaged in helping residents to develop and lead normal lives in the community by inculcating good work habits and by enabling them to understand themselves and their backgrounds. By providing a substitute home, a secure environment and a supportive or caring atmosphere they could encourage personal development, maturity, confidence and a sense of values. However, in terms of job satisfaction, only about half the replies were positive. The biggest problems were staffing and inadequate premises. Finally, Ian Sinclair’s study of probation hostels (1975) found that they were heavily influenced by the married couples who ran them. The couples combined the roles of warden and matron with those of husband and wife, and Sinclair was particularly interested in how far 194

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the probation hostels operated like families, and how far the influence of the warden and matron was analogous to that of parents. He studied twenty-three probation hostels, each of which was run by a warden with the help of a matron who, with one exception, was also his wife. The warden and matron were in a very powerful position. The warden was the undisputed professional head of the institution; he was not faced with long-established, powerfully entrenched staff; and the warden and matron had an unusual combination of responsibilities. Differences between the nature and effectiveness of hostel regimes (such as in rules and punishments) were related to the warden’s attitude and approach. Failure rates, in terms of boys leaving the hostels because they absconded or committed a further offence, were characteristic of wardens, not of hostels. Sinclair found that, like parents, the warden and matron of a probation hostel had a very considerable influence on their charges.14 The low-failure-rate regimes showed a common pattern which could be described as paternalistic. The warden was very strict, was clearly the dominant person in a hostel where his wife agreed with him, and had a certain warmth towards his charges. In high-failurerate regimes, by contrast, discipline was ineffective, there were problems with the matrons, or there was a marked lack of warmth. Probation hostels were also prone to ‘mood swings’, often when a new warden took up a post and faltered in establishing his position. Problems within the hostel would affect not only the warden but also the rest of the staff. Moreover, the situation contained a number of vicious circles made worse by the tendency to attribute all that went on in the hostel to the warden’s personality. Overall, then, Sinclair’s research revealed the dependence of probation hostels on the warden and matron, the almost parental qualities required of these members of staff and the interdependence of staff and residents. The ‘quasifamily institution’ was very variable and its success depended on relationships. Their tensions, crises and moods placed a strain on the staff, and this was in contrast to larger, more bureaucratic, institutions. The warden’s home was ‘not a refuge but his place of work’, and the matron was the only woman in a household of men. Sinclair therefore concluded that ‘it is in its combination of family and institutional stress and in its lack of the usual institutional defences that the peculiar problems of the quasi-family institution lie’.15 195

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The history of the Brentwood Centre These studies of wardens in various settings throw up a range of questions that we can explore through a case study of a single institution. From the late 1940s in Britain, many cities problematised the behaviour of some of their families, particularly that of the mothers, labelling them ‘problem families’ and setting out to reform them through a range of strategies.16 These ranged from advice and help given by welfare workers and health visitors within the home, to segregation, albeit temporary, in residential institutions. Such practices persisted through much of the early post-war period, from the mid-1940s to the early 1970s. Nevertheless in the literature on ‘problem families’ the residential option has generally been neglected.17 The history of the Brentwood Centre needs to be understood in terms of local voluntary action and contextualised with reference to wider policy debates. Founded in 1934, the Community Council of Lancashire’s function was primarily to attempt to deal with the social effects of prolonged unemployment. Before the Second World War, ‘Brentwood’, a large house in Marple in Cheshire, south of Manchester, served as a holiday home for working-class families, and this became the most important of the responsibilities of the council. The council aimed to deal with the social effects of long-term unemployment in Lancashire by providing activities for the wives and children of unemployed men.18 In the autumn of 1940, it was proposed that Brentwood should be used for victims of the London Blitz, and for the rehabilitation of ‘bombed-out, unbilletable, and semi-problem’ families.19 The idea was that the families should spend a period at Brentwood, with the children attending a day nursery, before being passed on to billets or requisitioned houses. Thus the home’s name was changed from the Brentwood Holiday Home to the Brentwood Recuperation Centre. This ‘experimental prevention and remedial health treatment’ continued for the remainder of the war. By the mid-1940s, following the bombing of provincial cities, most of the mothers came from Liverpool and Manchester. Family members slept in the same bedroom, which they shared with one other family; the adults were required to help with housework; and the children had to go to the nursery or attend a local school.20 Learning the rules was a key element in re-education and rehabilitation.21 Activities 196

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included sewing and mending classes, cookery demonstrations, games, walks, community singing, dancing, gardening and visits to the cinema. Apart from some nursery assistants, the staff were not medically qualified, and the therapy was essentially amateur. It was recognised that the work of Brentwood had its limitations. Unless an organisation such as the Family Service Units (FSUs) had been tackling the home conditions while the mother was away, she was likely to go back to a situation as bad as when she had left. This issue was to an extent underplayed by the staff of Brentwood, who tended to focus on whether families put their training into practice on returning home. As with the tuberculosis sanatorium regime, the focus was on rest, but the concern was that the ‘patients’ could not be kept long enough to effect a complete ‘cure’. At this stage, no reference was made to the role of the husband and father, although limited provision was later made for them to visit at weekends.22 It is clear that, by the end of the Second World War, the concept of the problem family was providing a rationale for the work at Brentwood, and that as the vocabulary shifted from the tired mother to the problem family, the focus moved perceptibly from convalescence to rehabilitation. Brentwood’s establishment and subsequent development can be located within a broader context which included the earlier history of institutional care, wartime FSU experiments with social casework, a eugenic and public health emphasis on problem families and parallel developments in other countries, notably the Netherlands. The extent to which those who ran Brentwood were aware of these wider developments is unclear. Certainly the late 1940s to the early 1960s represented the zenith of the activities of Brentwood, as it was in the problem family debate in general. In the short term, the most significant change in the post-war period was the growing involvement of local authorities in the work of the centre.23 Moreover, the scope of Brentwood, originally limited to Liverpool and Manchester, had broadened beyond the north-west to encompass local authorities in most parts of England and Wales.24 While Brentwood was well publicised during this period, financial difficulties were never far away.25 Moreover, the concept of the problem family came in for greater scrutiny from the mid-1950s. Social workers influenced in part by the FSUs were anxious to discredit the biological determinism of the eugenicists. They were 197

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critical of the surveys carried out by the Eugenics Society, arguing they were based on subjective judgements and administrative definitions. Family caseworkers, too, remained uneasy about the concept of the problem family, though they continued to stress the value of practical intervention.26 By the early 1960s, and inspired largely by Barbara Wootton, there was in turn a reaction against the FSU emphasis on social casework, and a greater tendency to stress economic difficulty. By the time of the sixth edition of Penelope Hall’s guide to social services (1963), the emphasis was on integration into the community rather than separate specialised treatment, and Hall hoped that the term ‘problem family’ would fade away.27 This wider context points to changes in social work knowledge and practice, especially in relation to motherhood and the family. Brentwood attempted to modify its regime to respond to perceived social changes, for example by converting rooms and part of the nursery into flats, by allowing husbands to stay, and by attempting to find work for them.28 There was certainly much discussion in the early 1960s about the type of family that Brentwood should cater for.29 But the big question in this period was whether developments at the local authority level would affect their use of Brentwood. In this context, the issue of follow-up gained in significance, because of the need to demonstrate the effectiveness of residential training. There were many reasons for the problems that Brentwood faced by the late 1960s,30 but the net effect of these trends was that Brentwood was rapidly approaching a financial crisis. By January 1970 the anticipated deficit for the year had reached £4,890, the largest in its history, and the secretary and chairman decided that there was no alternative but for Brentwood to close.31 Brentwood was ultimately sold off to a housing association, and its eventful history came to an end. The warden and the letters What is clear is that the role of the warden was central to the work done at Brentwood, and one person occupied this post for most of this period. Doris Abraham was originally appointed as warden in May 1943; she had previously been doing similar work in a centre run by the Friends Relief Service. The Religious Society of Friends had earlier established a Friends War Victims Relief Committee as 198

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part of its broader work in missionary activity, international service and relief work. During the Second World War, many conscientious objectors were drawn to this work, which included family casework. There appear to be similarities, therefore, in the approach towards ‘problem families’ that was being pioneered at the same time by the Friends Relief Service and the FSUs. It seems highly likely that Doris Abraham was herself a Quaker, and motivated by essentially religious beliefs to become involved in this area of voluntary social welfare. At the time of her appointment, Abraham had three interviews because she felt she could not work in a place that had such a ‘dreadful’ atmosphere.32 Other comments provide insights into how she approached this work. In August 1945 she said of the mothers who stayed at Brentwood that ‘while all benefit immensely physically, and while many develop better social habits, and quite a number benefit materially, some of the cases were of such poor material that it seemed unlikely that they would secure permanent benefit’.33 Abraham was concerned about the amount of ‘good’ that could be done, and that the length of stay of mothers at the institution, typically three or four weeks, was too short.34 On other occasions she commented that there were difficulties in mixing ‘problem families’ with the other families. She divided the families into three types: ‘problem families’ who were usually in a ‘shocking’ condition and with their children in a neglected state; those families who had ‘matrimonial troubles’; and those who had problems with housing which then led to difficulties in the marriage.35 The warden wrote articles about Brentwood, which were published in medical journals and periodicals.36 But beneath the surface there were certainly tensions with other members of the committee that ran Brentwood, notably Hilda Watson, the general secretary. Abraham first offered and then withdrew her resignation over the issue of wages in May 1954. From August 1955 she had four months’ sick leave on full pay, before resuming her responsibilities. Abraham was awarded an MBE in July 1958, in recognition of the work that she had done at Brentwood. Her retirement, in October 1963, after twenty years of service posed a major problem for the organisation. Although the post was widely advertised there was little response; the salary was low and there was competition with local authorities which at that time were expanding their children’s and other departments, 199

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and which could offer higher salaries. Neither of her successors, Mary Oag (1963–66) and Mr and Mrs Davies (1966–69), stayed very long. On their departure, there was much discussion about the ideal age of the warden, and whether it should be a husband and wife team. However, Brentwood itself did not survive as an institution for very long after its long-serving warden’s retirement. It is relatively easy to reconstruct a narrative history of Brentwood, but equally interesting questions are raised by the experience of the mothers themselves. How did they view their weeks or months spent at Brentwood? Here, a collection of letters that Doris Abraham wrote to the mothers who stayed there is a potentially valuable source, especially as some (though it is not clear how many) of the mothers wrote back. In total over two hundred letters survive from the period 1948– 63. There are questions about the selection and preservation of this correspondence, with a probable bias towards positive contacts in the archive. Most of the surviving letters were associated with Abraham’s practice of distributing parcels of toys and clothing at Christmas to mothers who had been at Brentwood. These were accompanied by typed, duplicated letters, each with a personal individual paragraph. The correspondence seemed to stop with her retirement in October 1963. Historians have long worked with case notes and case histories, for example in connection with the history of the Gartnavel Royal Asylum in Glasgow.37 Jonathan Andrews’ work on these records confirms that case notes were written for the benefit of asylum administrators rather than for historians, and points to problems in their use. Yet this research has also indicated the existence of patient testimonies, unobtainable elsewhere, within the case notes. Such testimony is, of course, understood to have been selected by authority figures who used it for various purposes of their own, including promoting the institution to subscribers, donors and other supporters. There is increasing interest in writing as social practice on the part of historians, anthropologists, educators and other social scientists.38 Perhaps as a reflection of this, more recent historical work has surveyed the practice of letter writing by the families and friends of patients, including at the York Retreat Asylum, showing how relationships were formed and developed. Doctors might be seen as employees, as authoritative professionals, and as friends and confidants. Some 200

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letters have been described as ‘emotional performance’, drawing parallels with nineteenth-century begging letters designed to elicit aid.39 Other historians have considered pauper letters as a source, pointing to problems of legibility, provenance, representativeness and accuracy and truthfulness, but arguing that they can provide a unique window on to the lives, experiences and feelings of the poor.40 Gratitude and friendship The main theme that emerges from the Brentwood letters is that of gratitude for the time spent there, and of the close bonds forged with the warden in particular. Lilian H wrote in October 1948 (note that errors of spelling and grammar have been allowed to stand in this and all the subsequent letters quoted): Just a few lines to say we got home OK but very cold. Well dear with this letter I’m sending my grateful thanks to you and the staff for every think you all done for us and the happiness you gave us. As long as I live I’ll never for get Brentwood. It’s the first holiday I’ve had.41

Edith K wrote from Salford in October 1948: I am very sorry that I could not say by by to you as you where gone before I am Alan went home. I thank you very much for the nice time we had with you in Marple and I am very sorry that it was so short.42

Dorothy C, from Radford in Northamptonshire, wrote that ‘I miss not coming to see you so often. Brentwood is my second home. I shall never forget how good you where to me I hope you all well.’43 Rhoda from Eccles wrote wistfully that ‘I still look back on the time I was at Brentwood as the happiest months I have had. My family is growing up fast.’44 Indeed, such was the strength of these bonds that Marie, in July 1960, wrote that ‘I don’t mind not knowing any of the staff, as your will be there and Esla for the children’.45 Mrs B from London wrote in May 1947 that ‘I do so want to see old Brentwood & everyone again. As I said before I was never so happy as when I was at Brentwood. It was the most happiest time of my life.’46 This gratitude seemed to be shared by the children. The B family from Liverpool had hoped in January 1948 to go to Brentwood, but found it was fully booked until August. Mrs B wrote that ‘you should 201

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have seen there faces when I told them it would be August or Sep Our John started crying’.47 Emily from Burnley said that Laura is by my side watching me write this letter and she says will you tell Miss Abraham ‘Please can we come to Brentwood’ she says Auntie Else told her to come again and we haven’t been yet. I don’t think they will ever forget Brentwood, neither will I.48

On at least one occasion a child wrote directly to the warden.49 As noted earlier, at Christmas the warden sent duplicated letters to mothers who had stayed at the Centre, presumably in the course of the previous year. On 21 December 1956, for instance, she wrote that the alterations and extensions to Brentwood were almost finished, the building had been painted and there were new nurseries. She provided news of staff members, and wrote that it had been nice to see so many mothers at the sale.50 Funding provided through the Sale and Rest Breaks Funds enabled some mothers to return to Brentwood for short periods, and the warden stressed the great value of these return visits. Moreover, it was the sales of work that provided the funding for the Christmas letters and presents. The sale of work held on 12 November 1960 had a record attendance and raised £240. The minutes recorded that £160 was spent on bringing families back for Christmas, 142 parcels of toys and clothing were posted to ‘old families’ and some 300 duplicated letters were sent.51 There were other ‘Old Girls’ reunions. The letters from the mothers appear to have been partly in response to this Christmas correspondence. Helen B, from Salford, opened a letter written on Christmas Day 1953: ‘I want to say how very much I thank you for the nice letter you send me and hope all had a very nice Christmass.’52 But this was not always the case; many letters appear to have been written unprompted. Moreover, there is evidence that the friendship might be resumed after the lapse of a considerable period of time. A Mrs M, from Kirkby, wrote that ‘I hope you remember me I am one of the very old mothers. I came with Little Maureen, but now she is a grown woman now she is 22 years old now.’53 In the immediate post-war period, mothers were selected by Medical Officers of Health or children’s officers of the local authority, and their applications were supported by medical certificates. The letters reveal how these arrangements were articulated by the mothers. Joan A, from Fulham in London, for instance, wrote 202

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that ‘the welfare should never had sent me to Brentwood with a bad heart’.54 Similarly a mother from Ingleton, near Carnforth in Lancashire, wrote in September 1962 that All being well I will be bringing Timothy to Brentwood for a few weeks in the very near future – maybe a week or 10 days – the Welfare Officer called to tell me this morning that practically all the arrangements had been made.55

However, there were occasions when mothers funded themselves, perhaps for shorter visits. A Mrs B noted in May 1947 that she needed to gather together the necessary £3, and she continued: ‘Hows the garden & country side looking. You know I never valued the country until I came to Brentwood. Now I would give almost anything to see it again.’56 It seems that by the early 1960s, perhaps because Brentwood was struggling to fill its places, mothers could themselves suggest that they might come for weekend visits, or the warden could issue an invitation. In October 1963, for example, Doris Abraham wrote to Valerie P, in Milverton in Somerset: I am writing at once to ask if you have any time between coming out of hospital and returning to nursing whether you would like to come here. We should be really delighted to have you and would look after you as well as we can.57

The mothers appear not to have been frequent letter writers, and often apologise for their writing style and spelling. Lilian H, from Sunderland, for example, wrote in 1948 that ‘I’m not a one for letter writing as I’m not good at spelling’, while Helen B noted in her letter that ‘I think I should have telephoned because as I am a terrible wrighter, I do hope you can understand it.’58 Most of the letters are relatively short, and many begin with a phrase such as ‘just a few lines to say’, or ‘just a few lines hoping you are well’, or ‘just a small note hoping your cold and yourself are better’. Amy E from Grimsby wrote and said that ‘I’m afraid I’m not much good at letter writing I hope you can understand and excuse my writing I shall be able to talk to you better when I see you.’59 Material assistance There is no doubt that the majority of these mothers were extremely poor. The mother from Ingleton wrote: ‘I haven’t been very well for 203

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some time, I get so dreadfully tired, I think it is with the continual worry of having to try and make every shilling do the work of two.’60 Christmas was a time of particular anxiety, with uncertainty over whether families could afford presents for the children. Doris wrote from London that her husband was out of work and had a bad leg, while her brother had fallen off a ladder. She continued that it would be weeks before they were back at work, and despite help from the Unemployment Assistance Board she was dependent on the shillings she earned knitting and making rugs.61 Another mother wrote that she went out to work two mornings a week in addition to working a full day every other week at her sister’s ‘to get a little straighter with my debts – again’.62 Reflecting on medical bills incurred by her sister-in-law in Miami, she concluded that she was glad she lived in a welfare state. As noted earlier, the warden often sent packages containing clothes, small gifts and books. One received by a mother in Chadderton in Lancashire, for instance, contained cottons, a brooch, two vests, a cardigan and a ‘Roy Rogers’ children’s book. Mrs D wrote from Withington in Manchester in December 1959 that ‘I am writing to thank you for the nice parcel you sent to me it was quite a surprise … I want to thank you very much for thinking about me and my children.’63 Similarly, Kathleen A wrote from Bristol: Just a few lines hoping you are well as this letter leaves us at present, just a note to say thankyou for the presents you sent us for Christmas. The dress you sent for Pamela fitted her lovely just as though you fitted her for her … Thank you once again.64

Joan A wrote from Fulham to say: ‘Miss Abraham I wish to thank you for all you did for me … Miss Abraham I will send the money I owe you as soon as possible. My Husband was pleased with the little suit …’65 What was perhaps more surprising was that these mothers sometimes sent gifts to Brentwood. The warden’s letters sometimes mentioned forthcoming sales of work, and mothers sent small gifts in response. Others sent things that they felt would be useful, including for the children. Lilian H wrote in October 1948: ‘well I promised I was going to send a few toys for the nursery I will send them as soon I’m able to send them by post it will be cheaper I think’.66 Edith C 204

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wrote, saying: ‘I am sending you some pillow cussers for the baby prams I promised Valerey I would send them this is all for now so will you be so kind to rembrer me to staf and all the mothers.’67 Other mothers asked if they might return to Brentwood to buy material for clothes.68 A second mum: advice and reassurance Details in letters from some of the mothers reveal that they were receiving psychiatric treatment. In April 1948, for instance, Helena B wrote that ‘these last two weeks I have been to a Phsychiatrist and she said it is the People who have been under my roof for the last two years, who have under-mind my health’.69 Some mothers were less specific, saying they had ‘been in hospital for my nerves’ or had spent time in a ‘Nerve Hospital’. Others were writing from hospital wards, where they were convalescing following the birth of a baby. But more typical was the need for simple advice and reassurance. Peg wrote from Langley, near Slough in Buckinghamshire, to say that her two-week stay at Brentwood had been worthwhile, not least for the ‘wonderful relief I get when I am able to talk to someone whom does understand me’.70 Sometimes mothers were keen to demonstrate that they were putting into practice the lessons on looking after the home that they had learned at Brentwood. Mrs M from Colchester, in Essex, wrote that Well I know you are longing to know how im getting on I will tell you I had a visit from the council the other day & they were very pleased with the house & said it looked very nice I hope it will please you to hear im getting every thing done nice & early I get up at 6.30 every morning & get my work done downstairs & then get the boys up for breakfast then I get the beds made & do my washing.71

A mother from Manchester commented that ‘I have just finished decorating my living room. It looks rather nice considering I’ve never tackled anything like that before.’72 On some occasions mothers praised their husbands, and in some cases the temporary separation while they were away at Brentwood seemed to have had a beneficial effect on relationships. One mother 205

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from Liverpool wrote that she had been ill, but that ‘one thing I am thankful for, George has completely changed since I came home, nothing is too good for me. Three weeks on his own has cured him.’73 But in other cases there were hints that the relationship was difficult. Rita from Oldham wrote of her husband that ‘Frank is pleased to have us back home but all the same I wish we could have stayed at Brentwood longer’.74 Mrs B wrote in May 1947 that ‘I feel much better now. My cough is better to. I have a nasty cut on my leg, what my husband done. We had a fight. But we are friends again. I do wish we could get on.’75 Mrs B from Manchester wrote that ‘I have been making home made things but this last fortnight I’ve not done any thing wright … George has told me that Brentwood hasn’t done me any good but I think so.’ She went on to ask for advice on making icing sugar for the children’s birthday cakes, noting her lack of ability as a cook and saying ‘I wish every thing was alright between me and George. I often wonder what’s going to happen in the future.’76 Some mothers wrote saying that they were anticipating separating from their husbands, and seeking both advice and employment. Gwen B, for instance, from Yeadon near Leeds, noted that ‘I have no where to go … You do not have any work available do you I am a good worker when I get started … I do hope you can find a job for me.’77 Similarly a Mrs H, from Thetford in Norfolk, wrote in December 1960 that her husband was cruel to her and the children and that really she wished to leave him, but was staying because of the children; she would like to work for Miss Abraham.78 The theme of mothers expressing unhappiness over marital relationships appears to have been more prominent from the early 1960s. In at least one case a husband wrote directly to the warden. A Mr D from Bedford thanked her for letting him stay overnight at Brentwood, and for the food that she had provided when he had visited his wife a week earlier. Doris Abraham had mentioned about helping his wife to budget, and he provided details of his wages and their spending. They were heavily in debt and risked losing their house and furniture. He said that he and his wife were always arguing over money, and he had not had a suit or any decent clothes until the previous month when his wife had sent a suit and he had bought a secondhand coat and a pair of shoes. He had tried to impress on his wife the importance of working to a strict budget, and he wrote ‘she 206

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has learnt a lot from Brentwood, not just house-wifery, but about people and I suppose that in time and with help she will find out her mistakes’.79 He continued that their ‘intimate life’ was very unsatisfactory, and his wife was afraid of sex, partly due to her strict upbringing. Thus he wrote that ‘I don’t really understand what Brentwood is for, but if you can give my wife any advice on these things I have mentioned, I should be grateful.’80 News and advocacy by the warden In some of the letters, Doris Abraham simply provided news. A typical letter was that to Mary J, composed in September 1963. The warden apologised for the delay in writing because work had been so hectic, and said she was sorry that there had been no one to meet Mary at the station. One mother was now feeling better and was having the remainder of her teeth out in two weeks; another had gone home the previous week; one was going home in two weeks; and a fourth was going home on Friday, happy because she had a little cottage to go to. Abraham continued, ‘I do hope you feel better for your stay here and do try not to worry about all sorts of things.’81 She displayed an amazing knowledge of the personal circumstances of her mothers. In October 1963, for instance, she wrote to Alice S, living in Chadderton near Oldham. There was little news and she hoped Alice was well. She went on: ‘I suppose Janice has gone back to school and do hope you get good news of her. Did young Alice get married? I hope that Ricky’s job is proving satisfactory and that Eric is behaving himself.’82 Abraham often offered the advice and reassurance that mothers were looking for. She wrote to Peggy from Cromlington in September 1963, saying: ‘I am very sorry that things were so difficult when you got home. It is dreadful that your husband could not manage the money when there was only Doris and himself. How does he think you manage!’83 On occasions she also acted as a letter-writer. In October 1961, for instance, she drafted a letter on behalf of Doreen A, from Stretford in Manchester, to a Mrs L.84 Abraham wrote to Doreen enclosing the draft and noting: ‘I hope that this is what you want. You must sign your name above the typed name.’85 The warden could also act as an advocate and a broker between the mothers and professionals. In July 1960, for example, she wrote to Dr J. G. Kellett, 207

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the Director of Education for Cheshire, on behalf of the mother of Raymond K, aged nine, who was seeking his admission to a residential school. She wrote that ‘Mr and Mrs K are really trying to be good parents, and care for their children to the very utmost of their capacity but they are, as you will probably be aware, very limited people.’86 In her view, Mrs K was rapidly approaching another breakdown which, if it could not be prevented, would be tragic for the family. Whether the warden’s intervention was successful is unclear. Conclusion This chapter has drawn on a collection of letters to illuminate the relationship between the warden and the mothers who used the Brentwood Centre, which appears to have been more positive than many accounts of other similar facilities suggest. There are many things that the letters can tell us, although their value as a source is tempered by the need to be cautious in terms of interpretation. The warden was motivated principally by her being a member of the Society of Friends, and despite having limited training she was determined to reach out a hand of friendship and support to the mothers. The interactions between the warden and the mothers were structured by a number of organising points, including friendship, assistance and advocacy, which seemed acceptable to staff and clients. The voluntary sector nature of the provision determined that it would be run on a shoestring and clients were paternalistically expected to be grateful; however, its regime does not appear to have been oppressive or resented by its clientele. The personality as well as the work of the warden appears to have been crucial, suggesting that we need to know much more about the people running a variety of post-war residential services. The letters exchanged between Doris Abraham and the mothers help redress, to an extent, a recently and belatedly acknowledged concern in the social work literature that the voice of the problem mother had effectively been silenced by practitioners.87 Here at least some mothers speak, and so does a warden, thereby offering an unusual insight into an often obscure relationship between staff and clients in a relatively unknown residential setting. It is clear that the warden provided news, advice, support, reassurance, advocacy, some material help and friendship, not so much as a professional, but 208

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more as a friend and confidant. Stress was laid on the importance of the personality of the warden and her staff, and the quality of their relationship with the mothers, and the Christmas letters maintained a sense of ongoing contact. In turn, the letters written by the mothers to the warden offer a fascinating window on to the attitudes and experiences of these women. The letters offered a means for them to express their gratitude and correspond with someone who understood them, a way of talking about marital and other difficulties, and an opportunity to elicit help and advice. There were changes and also continuities in the content of the correspondence over time. Overall, these letters, with their stories of poor health, bad housing and poverty, offer a novel perspective on post-war Britain from the perspective of the working-class mother. The letters suggest that the personal relationships forged at Brentwood could be warm and perceived as beneficial, and, in that sense, they offer an important corrective to the existing literature. In contrast to work that has for too long concentrated on controlling practices and notions of shared stigma, this chapter demonstrates that the regime of such residential institutions was not necessarily unpleasant or punitive, and that the warden, despite possessing only basic qualifications, could act as an important source of information, advice and reassurance. This is particularly important now because, after a period of official disapprobation, the idea of using residential and day services in an attempt to intensively rehabilitate individuals and families exhibiting anti-social behaviour is again very much on the political agenda. Notes   1 P. Bartlett and D. Wright (eds), Outside the Walls of the Asylum: The History of Care in the Community 1750–2000 (London: Athlone, 1999).  2 J. Welshman, ‘Inside the walls of the hostel, 1940–74’, in P. Dale and J. Melling (eds), Mental Illness and Learning Disability Since 1850: Finding a Place for Mental Disorder in the United Kingdom (London: Routledge, 2006), pp. 200–23.  3 D. Mitchell and J. Welshman, ‘In the shadow of the Poor Law: workforce issues’, in J. Welshman and J. Walmsley (eds), Community Care in Perspective: Care, Control and Citizenship (Basingstoke: Palgrave Macmillan, 2006), pp. 187–200 (p. 200).

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Mental health nursing   4 Mitchell and Welshman ‘In the shadow of the Poor Law’, p. 200.   5 Welshman,‘Inside the walls of the hostel’.   6 I am grateful to Denise Partington of Community Futures for access to the Brentwood archive. Some names have been changed in order to anonymise individuals.   7 J. Welshman, ‘Recuperation, rehabilitation, and the residential option: the Brentwood Centre for Mothers and Children’, Twentieth Century British History, 19:4 (2008), 502–29.  8 S. Rolph, ‘The History of Community Care for People with Learning Difficulties in Norfolk 1930–1980: The Role of Two Hostels’, PhD dissertation, Open University, 2000; M. Spensky, ‘Producers of legitimacy: homes for unmarried mothers in the 1950s’, in C. Smart (ed.), Regulating Womanhood: Historical Essays on Marriage, Motherhood, and Sexuality (London: Routledge, 1992), pp. 100–18.   9 R. Z. Apte, Halfway Houses: A New Dilemma in Institutional Care (London: G. Bell and Sons, 1968), p. 43. 10 Apte, Halfway Houses, p. 45. 11 Apte, Halfway Houses, p. 53. 12 K. Jones, Opening the Door: A Study of New Policies for the Mentally Handicapped (London: Routledge and Kegan Paul, 1975), pp. 175–7. 13 Department of Health and Social Security, Hostels for Young People (London: DHSS, 1975), pp. 16–22. 14 I. Sinclair, ‘The influence of wardens and matrons on probation hostels: a study of a quasi-family institution’, in J. Tizard, I. Sinclair and R. V. G. Clarke (eds), Varieties of Residential Experience (London: Routledge and Kegan Paul, 1975), pp. 122–39. 15 Sinclair, ‘The influence of wardens and matrons on probation hostels’, p. 138. 16 See, for example, J. Welshman, Underclass: A History of the Excluded, 1880– 2000 (London: Continuum, 2006). 17 P. Starkey, Families and Social Workers: The Work of Family Service Units 1940–1985 (Liverpool: Liverpool University Press, 2000), pp. 86–7. 18 Lancashire Record Office, Preston (hereafter LRO), accession 9037, DDX 2302/46, records relating to the Brentwood Centre (hereafter BC), minutes of the Recuperation Centres Committee (RCC), 1 October 1953, Appendix A. 19 LRO, 2302/46, minutes of the RCC, 1 October 1953, Appendix A. 20 LRO, 2302/28, ‘Community Council of Lancashire: Recuperation Centres Scheme: Application Form for Admittance to a Recuperation Centre’, 27 July 1944. 21 LRO, 2302/30, minutes of the RCC, 4 August 1943. 22 Starkey, Families and Social Workers, p. 82. 23 LRO, 2302/46, ‘Attendance record 1953’. 24 LRO, 2302/46, minutes of the RCC, 2 April 1959.

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Wardens, letter writing and the welfare state 25 Lord Beveridge, Voluntary Action: A Report on Methods of Social Advance (London: Allen & Unwin, 1948), p. 265. 26 A. F. Philp and N. Timms, The Problem of ‘the Problem Family’: A Critical Review of the Literature Concerning the ‘Problem Family’ and its Treatment (London: Family Service Units, 1957), p. 64. 27 M. P. Hall, The Social Services of Modern England (London: Routledge and Kegan Paul, 6th edn, 1965), p. 169. 28 LRO, 2302/46, minutes of the RCC, 5 July 1962. 29 LRO, 2302/box 25, minutes of the RCC, 13 January 1966. 30 LRO, 2302/box 25, minutes of the RCC, 13 July 1967; minutes of the Brentwood sub-committee, 8 January 1970; minutes of the Brentwood subcommittee, 14 July 1970, ‘Brentwood – Future Prospects’, 9 July 1970. 31 LRO, 2302/box 25, minutes of the Brentwood sub-committee, 1 October 1970. 32 LRO, 2302/46, minutes of the RCC, 21 May 1954. 33 LRO, 2302/30, minutes of the RCC, 1 August 1945. 34 LRO, 2302/30, minutes of the RCC, 7 November 1945. 35 LRO, 2302/30, minutes of the RCC, 1 May 1946 and 1 May 1947. 36 D. Abraham, ‘Giving hope to discouraged and neglectful mothers’, Friend, August 1951, 719–20; D. Abraham, ‘Brentwood Recuperative Centre: home for problem mothers’, Medical World, 90:3 (1959), 251–4. 37 J. Andrews, ‘Case notes, case histories, and the patient’s experience of insanity at Gartnavel Royal Asylum, Glasgow, in the nineteenth century’, Social History of Medicine, 11:2 (1998), 255–81. 38 See, for example, D. Barton and N. Hall (eds), Letter Writing as Social Practice (Amsterdam/Philadelphia: John Benjamins, 2000). 39 L. Wannell, ‘Patients’ relatives and psychiatric doctors: letter writing in the York Retreat, 1875–1910’, Social History of Medicine, 20:2 (2007), 297–313. 40 S. King, ‘Pauper letters as a source’, Family and Community History, 10:2 (2007), 167–70. 41 LRO, 2302, box 26, envelope of letters, letter LH to Abraham (no date but 1948). All the correspondence between Abraham and the Brentwood mothers comes from this source. 42 Letter, EK to Abraham, 6 October 1948. 43 Letter, DC to Abraham (nd). 44 Letter, Rhoda to Abraham (nd). 45 Letter, Marie to Abraham (nd but reply was 13 July 1960). 46 Letter, SB to Abraham, 8 May 1947. 47 Letter, Mrs B to Abraham (nd but reply was 1 April 1948). 48 Letter, Emily to Abraham (nd). 49 Letter, Billy A to Abraham (nd). 50 Letter, Abraham to Annie, 21 December 1956. 51 LRO, 2302/46, minutes of the RCC, 5 January 1961.

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Mental health nursing 52 Letter, HB to Abraham, 25 December 1953. 53 Letter, FM to Abraham (nd). 54 Letter, JA to Abraham (nd). 55 Letter, to Abraham, 27 September 1962. 56 Letter, Mrs B to Abraham, 8 May 1947. 57 Letter, Abraham to VP, 17 October 1963. 58 Letter, LH to Abraham, 27 October 1948; letter HB to Abraham, 25 December 1953. 59 Letter, AE to Abraham (nd). 60 Letter, to Abraham, 27 September 1962. 61 Letter, Doris to Abraham (nd). 62 Letter, Camela to Abraham, 15 March 1960. 63 Letter, MD to Abraham, 21 December 1959. 64 Letter, KA to Abraham (nd). 65 Letter, JA to Abraham (nd). 66 Letter, LH to Abraham (nd but 1948). 67 Letter, EC to Abraham (nd). 68 Letter, MD to Abraham, 26 September 1963. 69 Letter, HB to Abraham, 11 April 1948. 70 Letter, Peg to Abraham (nd). 71 Letter, VM to Abraham (nd). 72 Letter, Jean to Abraham (nd). 73 Letter, to Abraham (nd). 74 Letter, Rita to Abraham (nd). 75 Letter, SB to Abraham, 8 May 1947. 76 Letter, SB to Abraham (nd). 77 Letter, GB to Abraham (nd). 78 Letter, Mrs H to Abraham, 26 December 1960. 79 Letter, FD to Abraham, 12 March 1957. 80 Ibid. 81 Letter, Abraham to MJ, 4 September 1963. 82 Letter, Abraham to AS, 10 October 1963. 83 Letter, Abraham to Peggy, 4 September 1963. 84 Letter, Abraham to Mrs L, 18 October 1961. 85 Letter, Abraham to DA (nd). 86 Letter, Abraham to J. G. Kellett, 4 July 1960. 87 J. E. Mayer and N. Timms, The Client Speaks: Working Class Impressions of Casework (London: Routledge and Kegan Paul, 1970).

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10

Learning disability nursing: surviving change, c.1970–90 Duncan Mitchell

Many learning disability nurses who came into the job, as I did, in the 1980s would have been told, like I was, that there was no future in the work. The main reason for this was that the institutions in which training took place were on closure programmes. At the time it was widely thought that when the institutions went, so would the nurses. This was not simply paranoia on the part of the nurses; there was a lot of evidence to support the view that the profession was finished, or at least nearly finished. This chapter explores the history of learning disability nursing and asks why the predictions of demise did not come true, and why at the time of writing training in the field of learning disability nursing is still taking place. The chapter is in several parts; the first briefly examines the development of learning disability nursing and considers its place within the wider nursing profession. It includes a discussion of the language associated with the profession. The second section highlights the challenge to the institutions in which learning disability nurses worked and charts their progress from seeming pre-eminence to closure. The third considers the ways in which learning disability nurses established new roles for themselves outside the institutions and explores how and why this process took place. In 1970 large institutions were still seen as an inevitable part of the landscape; in 1990 their closure was regarded as inevitable. A focus on these two decades not only captures this transition, but draws attention to the way decisions made at this crucial time set the course for learning disability services for the foreseeable future.

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The development of learning disability nursing Learning disability nursing was originally developed to staff the large institutions that were built throughout the country as places for people with learning disabilities to live in. To properly understand this development it is important to define some terms. People with learning disabilities have been so named in the UK since the early 1990s, when the term ‘mental handicap’ was replaced. In much of the world the preferred term is ‘intellectual disabilities’, but as concepts have changed over the years the terminology has altered. The Victorian period saw doctors, educationalists and philanthropists developing several charitable ‘asylums for idiots’.1 The terms ‘idiocy’ and ‘imbecility’ were used somewhat interchangeably in Victorian and Edwardian documents although legal and medical experts increasingly differentiated between the two, leading to further refinements of definitions and grading systems. The 1913 Mental Deficiency Act (MDA) recognised and retained the terms ‘idiot’ and ‘imbecile’ for the most disabled people,2 but also encouraged a new concern with the ‘feeble-minded group’ and a somewhat anomalous category of individuals described first as ‘moral imbeciles’ and later re-categorised as ‘moral defectives’ in 1927.3 Collectively, people subject to the provisions of the MDA were termed ‘mentally defective’, and this highly prejudicial language was retained into the era of the National Health Service (NHS). The Mental Health Act of 1959 finally replaced terms such as ‘idiot’, ‘imbecile’ and ‘feeble-minded’ with the new designation ‘mental subnormality’. Commentators are, however, careful to avoid automatically linking changing language with either new attitudes towards vulnerable people or improving care standards. Indeed, historians such as Mathew Thomson conclude that the term ‘mental subnormality’ was at least as problematic as the words it replaced.4 This may help to explain why ‘mental handicap’ was soon adopted as the preferred terminology, although it too was superseded in the UK by the language of learning disability. The terminology remains contentious, as does the definition of the group that it describes. This chapter uses the current terminology of ‘people with learning disabilities’, unless directly quoting from sources using definitions from their own period. The discussion above refers to individuals and groups who were subject to the provisions of various pieces of legislation because they 214

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were deemed to have both a low level of intelligence and difficulties in coping with the demands of society. The special vulnerability of these people had long been recognised, but from the 1890s concern about their care was linked to a new enthusiasm for controlling measures. This was because mental deficiency was increasingly linked to the social problem group and seen to menace late Victorian and Edwardian society in a variety of ways.5 Concern with care and control issues increased demand for residential accommodation and, following the 1913 MDA, there was a significant expansion of the number and size of specialist mental deficiency institutions. These facilities shaped the identity and working lives of nurses caring for such patients. Although, for the purposes of this chapter, such staff are designated as ‘learning disability nurses’ to engage with current practices and terminology, it is worth noting that in the past nurses were given the same stigmatising titles as their patients; thus mental subnormality or mental handicap nurse. In the pre-NHS era it was more common to see staff, especially on the male wards of institutions, designated as attendants rather than nurses. Although changing terminology was, in part, driven by changing working practices, the workforce undeniably remained trapped in an institutional model of care. This problem was not restricted to the UK. Most industrial societies had developed large-scale institutional provision for people with learning disabilities and in many countries this system was separate from asylums for the mental ill.6 The institutional model was dominant but flawed, with Mitchell and Welshman noting that the ‘postwar failure to properly address the issue of location of services was compounded by a failure to develop an adequate staffing policy for the service’.7 By the 1970s funding difficulties, failure to achieve parity of esteem with provision for physical or mental health problems, service fragmentation and other legacies of piecemeal historical development all impacted negatively on current provision and scope for future innovation. The 1913 MDA had placed an obligation on local authorities to make provision for those classified as being mental defectives. In the interwar period many large institutions either opened or were reconfigured. While some operated in conjunction with limited community care schemes, involving hostels and supervised work placements, it was the institutions that dominated all aspects of care.8 215

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The major facilities were absorbed into the NHS in 1948. While large hospital provision for people with learning disabilities continued to expand until the late 1960s, most had closed by the end of the twentieth century.9 An apparently decisive break with the past was signalled by the influential 2001 report Valuing People: A New Strategy for Learning Disability for the 21st Century.10 There is emotive testimony from many service-users exploring how their lives were transformed as a result of leaving large-scale, long-stay institutions, but oddly these accounts have little to say about their interactions with nursing staff.11 Where nurses are mentioned they tend to be portrayed as ­stereotypes, with cruel staff making institutional situations unnecessarily grim and the rare heroic staff member making superhuman efforts to facilitate a person’s exit from long-stay care and/or support their new life in the community.12 Such narratives can conceal as much as they reveal about the history of learning disability nursing. While leading nurses have been credited with reforming general nursing, perhaps overlooking the input of medical men,13 the development of asylum nursing owed much to medical superintendents. Reforming medical superintendents, at different times, identified skill shortages among the asylum workforce and then encouraged training as a way of disciplining and controlling their staff.14 The medical superintendents used their own professional organisation, the Royal Medico-Psychological Association (RMPA), to oversee and accredit training schemes for nurses in both mental and mental deficiency asylums. Training consisted of medical lectures and practice in the areas in which the nurse was going to work. A nationally organised examination ensured some standardisation of the curriculum and minimum standards. The RMPA’s understanding of nursing was broad and the RMPA exam developed into a scheme that allowed workers to qualify as nurses through specialising in bedside nursing, teaching of children, teaching of adults, or physical training and occupation.15 The 1919 Nurses Registration Act introduced national state registration for all nurses in the 1920s. In theory the newly established General Nursing Council was meant to integrate mental deficiency nursing into the national scheme, but in practice there were many difficulties.16 The often-problematic relationship between the wider body of nursing and its smallest member continues in the twenty-first century as contentious issues are debated without 216

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necessarily being resolved. Arguably, the crux of the matter has been nursing’s image of itself as a profession that is based on the notion of caring for the sick.17 The institutions and their closure In 1961 the Minister of Health, Enoch Powell, delivered a speech to a group of mental hospital leaders. If they expected a bland ministerial delivery of the sort that was written for ministers by civil servants, they were in for a shock. Powell was concerned by the amount of beds taken up by mental health care and had been influenced by the mental hospitals that he had visited.18 He delivered a rallying call for the closure of the mental hospitals and their replacement by care in the community for those needing services: Now look and see what are the implications of these bold words. They imply nothing less than the elimination of by far the greater part of this country’s mental hospitals as they exist today. This is a colossal undertaking, not so much in the new physical provision which it involves, as in the sheer inertia of mind and matter which it requires to be overcome. There they stand, isolated, majestic, imperious, brooded over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defences which we have to storm.19

Powell’s words have been much quoted for both their content and prophetic style of delivery, but there was a section of the speech that is much less used. In the same address he turned to the subject of institutions for those who were then described as mentally subnormal and his approach was quite different: So far I have been talking mainly of the hospitals for the mentally ill, and I have been looking at the hospital side of the equation. When we look at the future of provision for the sub-normal, the prospects for change must seem far less dramatic – certainly if we discount, as I suppose we prudently ought, the chance of some medical ‘break through’ on this front. Far from contemplating the certainty of a heavy run-down in numbers, we have here to reckon with the increase which flows automatically from the lengthened expectation of life of the sub-normal and their improved prospects of ­surviving infancy.20

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Powell’s words are important, not least because they shed light on a hitherto neglected aspect of debates about the future of the asylums. Interestingly, while there is evidence that a consensus in favour of closure developed among policy-makers concerned with mental health, there was considerable uncertainty about the future direction of care for the mentally subnormal. This divergence of opinion reflected different professional perspectives on the two different groups of service-users. While there were growing demands for mental illness to be treated in a similar way to physical illness and for general and psychiatric services to be co-located, there was still an acceptance that patients in the subnormality hospitals needed life-time care in separate and specialist facilities. This was especially true when the care of the most severely handicapped patients was discussed. The third volume of the Crossman diaries capture the period 1968–70, when Richard Crossman was trying to integrate the giant departments represented by the Ministries of Health and Social Security.21 As Secretary of State, Crossman showed both reforming zeal and a commitment to an enlightened view of mental illness and mental handicap. Yet on his own fact-finding tours he was confronted by the negative attitudes of professional staff, who were apparently convinced of the futility of their own efforts. In August 1968 Crossman recorded: I won’t describe my Lancashire tour in detail but I will just mention the long journey we made after lunch down to Greaves Hall Hospital, Southport, through most lovely countryside of woods and harvest fields. At the hospital there were some 700 or 800 patients, nearly all of them deeply subnormal aged from eight or nine to seventy or eighty. The doctor who took me round didn’t believe in research or that anything was going to be gained by undertaking it. ‘One just has to be kind to these people,’ he said. ‘There is really no hope of them getting any better.’ So there are fifty trained nurses looking after these human wrecks whose recovery has been ruled out by the medical profession.22

He went on to contrast this fatalistic approach with the determination, shown at a neighbouring facility, to transform the care of geriatric patients by challenging negative attitudes and overcoming the constraints imposed by ancient buildings, overcrowding and staff shortages.23 218

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The slow pace of reform in the subnormality sector was certainly influenced by pessimistic assessments of the abilities of, and prognosis for, such patients. Staff, even many leading professionals, seemed unable to confront their own prejudicial assumptions and differentiate between the limitations imposed by a person’s condition and the unnecessary restrictions imposed by inappropriate institutional regimes. Maureen Oswin struggled to get staff to recognise that the severely disabled children described in her book The Empty Hours were capable of so much more than their impoverished institutional lives allowed.24 Ultimately, reform of the sector appears to have owed more to scandal within the asylum system than the development of a coherent alternative model of improved care. We have already seen that Crossman had reservations about the existing model of asylum care but it was his department’s investigation into a number of hospital abuse cases, notably at Ely Hospital in Cardiff, that gave real impetus to the reform process.25 This culminated in the 1971 White Paper, Better Services for the Mentally Handicapped,26 and eventually led to the closure of the majority of institutions built to house people with learning disabilities. The 1971 White Paper aimed to improve standards in hospitals and also expand community services. These two objectives were probably contradictory, as there was insufficient money available to do both.27 Nonetheless the effect of the White Paper was profound, as throughout the 1970s there was a gradual increase in services in the community and a growing acceptance that hospitals needed to contract.28 The essential limitations of the existing service were repeatedly highlighted by a series of reports into various hospital scandals. They demonstrated that many institutions were at best places of containment, and where care did take place it did so in the face of appalling conditions.29 Yet rather than announcing a final closure programme, policy-makers in the 1970s committed themselves to ending the admission of children into long-stay hospitals, and then slowly the ending of all admissions. These measures implied that the patient population would stagnate and then slowly contract as older residents died and were not replaced. There was much less clarity about the range of services that should be offered to people who would previously have been admitted to the long-stay hospitals. It is suspected that the slow development and far from comprehensive nature of this 219

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provision did much to delay discussions about accelerating the hospital closure programme. The possibility of large-scale patient transfers from hospitals to alternative facilities only emerged in the 1980s.30 By 1988 the hospitals were well on the way to closure, but even so some policy-makers clung to the idea that some such provision would always be needed. In 1988 the Minister of Health, Edwina Currie, issued a press release that celebrated the large increase in the number of people being cared for in the community, but went on to say that ‘There will always be a place for hospitals to care for the mentally handicapped, but I am glad that families and professionals in many parts of the country have some choice about when and whether hospital is appropriate for the handicapped person.’31 It may well be that the minister was keeping her options open, or at least attempting to be seen to be keeping them open, but there were few who agreed with her at the time and it was much later that calls for specialist hospitals for people with learning disabilities would reappear. These debates were fuelled by evidence that some vulnerable people left to fend for themselves in the community suffered neglect and abuse, sometimes at the hands of family members, that was not identified or addressed because of inadequate support services. Since the 1990s there has been great anxiety about the number of homeless people with current or past mental health issues. Another concern, again more acute for people experiencing mental health crisis, is that vulnerable people living in the community may behave in ways that threaten the safety and well-being of themselves and other people. It is common to see media discussion of high-profile ‘incidents’ accompanied by calls for more secure residential facilities, although the sector remains beset by scandals.32 The nurses: old and new roles The threat to the institutions in the 1970s and 1980s led to discussions about the staff who worked in them. This chapter concentrates on nursing staff although it must be acknowledged that there were several different groups of workers within the institutions. These workers included many of the more able residents who, under varying degrees of supervision, performed a variety of essential tasks necessary to the smooth running of their hospitals.33 This overlap between patient 220

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activities and staff duties was just one of many factors undermining the status of nurses in the sector. Commentators addressing nursing issues tended towards a confused assessment of their contribution, part critical and part understanding. The 1971 White Paper is a good example of this approach. On the one hand staff were praised: The nurses, many working in overcrowded and understaffed hospital wards, are giving devoted personal service to their patients. We look to them with confidence to improve the quality of their patient’s daily life when the means of doing so are put into their hands.34

However, their work was also criticised for its limited scope: In such conditions hospital ‘treatment’ is restricted to meeting the patients’ most basic physical needs. The nurses’ time is taken up in getting patients up in the morning, dressing, washing and feeding them, dealing with incontinence during the day and putting them to bed in the evening. It is a life of minimal satisfaction for patients and staff alike.35

If the only role of the nurses was providing basic care in a custodial setting, then it is difficult to see how their function should have continued with the end of the institutions. Yet since nurses were the largest section of the workforce, there was a clear recognition that nurses could, even should, continue to be the backbone of learning disability services. This potential role for nurses was, however, dependent on the profession’s willingness to both identify its key skills and adapt to meet new service priorities. Change seemed essential, and helpfully the critical re-examination of the role of the learning disability nurse in Better Services for the Mentally Handicapped coincided with a wider re-evaluation of nurse recruitment, training and deployment. Although it was not the first major inquiry into nursing issues, Asa Briggs led a particularly comprehensive investigation after his appointment by Crossman in December 1969.36 The remit for his independent committee was ‘to review the role of the nurse and the midwife in the hospital and the community and the education and training required for that role’.37 Reporting in 1972, the Committee on Nursing made a series of recommendations about the development of the profession.38 Oddly, Asa Briggs did not feel that learning disability work had a future within nursing and suggested that a new profession should probably emerge. The government favourably received this suggestion. Here it is important to note that the 221

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Wilson governments took a keen interest in learning disability issues, especially in the 1970s. The Secretary of State for Health and Social Services, Barbara Castle, set up a committee chaired by Peggy Jay to examine the role of the nurse.39 Its report, published in 1979, appeared to sound the death knell for learning disability nursing as part of the nursing profession. The Nursing Times acknowledged, and sought to counter, these threats to the sector in an editorial discussing the nursing legislation introduced at the end of the 1970s: With the Briggs Bill about to become law, the nursing profession is all set to start talking seriously about a new pattern of education, using the Briggs report as its starting point. Where does mental handicap nursing fit in? There is no home for it within the new style training except as a bubble on the side of psychiatric nursing – and no-one wants that. Change there must be.40

The nature of the necessary change remained contentious, however. In some quarters there was outright opposition to any change, certainly along the lines proposed by Mrs Jay. The Nursing Mirror, for example, suggested that the Jay Committee was about to plunge nurses into ‘a dark abyss’, and started a campaign entitled ‘No Way, Mrs Jay’.41 Other critiques were more nuanced, with some nursing groups supportive of the principles embodied in the Jay Report but critical of certain recommendations, for example the training proposals.42 The problem for many contemporary commentators was that the Jay Committee had gone well beyond its brief, which was to examine nursing in the light of the Briggs proposals, and had proposed a radical redesign of learning disability services that envisaged the replacement of the old hospitals with community-based provision designed to replicate as far as possible the ordinary lives of most of the population. Many leading reformers welcomed such a radical vision, but in the event little came of the Jay proposals. The committee had been set up under a Labour government, but in an unfortunate accident of timing reported just as a new Conservative government with very different priorities was elected.43 Peggy Jay, in an interview with the author two decades after the report’s publication, reflected that the proposals were not political in themselves, but the plan to give a central role to councils was unlikely to be accepted by a government that was in conflict with local authorities through much of its term 222

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of office. Likewise, the major new investment that was proposed was problematic at a time of public spending cuts. Since the Jay Report was ultimately shelved it is difficult to fully evaluate the effect of the proposals on nursing itself. A bitter debate played out in the pages of major nursing periodicals, with the Nursing Mirror being opposed to Jay and the Nursing Times offering qualified support. It is likely that the proposals helped to encourage first reflection and then action from many nurses who were determined to have some place in the services of the future. At the time, and certainly for many of us who started their careers in learning disability nursing in the early 1980s, the future seemed to be either very bleak or at best unclear. The evidence seemed to point towards an uncertain future and I recall discussions within my own group of student nurses about whether we ought to at least add an additional qualification to our threatened learning disability nurse registration. Despite this corrosive uncertainty, the profession of mental handicap nursing has remained a force within different services and at the time of writing is still a separate part of the nursing register in the UK. The key to survival was arguably developing new roles for learning disability nurses. It appears that many of the early initiatives in community learning disability nursing came from the institutions. They were apparently introduced on the understanding that change was on its way but that nobody could predict likely service configurations or nursing roles with certainty. Instead experimentation became the order of the day. Evidence for innovative new models of care can be found in contemporary reports published in nursing periodicals. The following example, published in the Nursing Times, outlines the experience of nurses working in a community setting. Tom Yates and Elaine Loch are two nurses who are convinced that the Jay report is right. They work in the community, running a home for children whose handicaps include multiple and severe. They find that residential, rather than nursing, skills predominate. And they have greater autonomy as the people in charge of the unit who are in a truly caring relationship with the mentally handicapped.44

It is noteworthy that the writer deliberately contrasts nursing and residential skills in a way that many nurses at the time would have rejected. 223

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While the two nurses featured above worked in an existing social care facility, other learning disability nurses helped create and staff new environments that were managed by the NHS. One example of these NHS community-based facilities was also celebrated in the Nursing Times. In an article written by a psychiatrist, he made it clear that in his view such care arrangements would not work without ‘a highly skilled nursing workforce’.45 Other examples of nurses working in new ways outside the institutions can also be found in oral history projects. A study conducted in the north-west of England examined the ways in which nurses adapted to the change from working in a hospital to a community setting.46 In this project nurses talked about the changes in their working practices and in some cases explained how difficult it was to move from a large institution working with lots of people to a small environment with just two or three residents. Some of the nurses also talked of the mixed feelings about the changes evident within their institution. Interestingly, staff seemed divided on generational lines, with students initially far more enthusiastic about the prospect of working outside the institution than long-serving staff who identified more closely with its routines. Interviewees drew attention to the special difficulties faced by the older staff, and also suggested that staff confidence in the process of managed change was often undermined by weak planning, a failure to secure necessary resources and a lack of any credible alternatives or fallback position if things went wrong. In the words of one respondent: It was definitely seen as a positive thing at (the institution), especially from students, couldn’t wait for people to get out of that environment generally speaking, it was the older staff who were more difficult to, and it wasn’t that they were saying, this isn’t right, what they were saying was, we can’t see how this is going to be done. And doubting that there’d be enough resources to support people in the community, and more worried about the consequences if it went wrong. So it wasn’t, you know, it wasn’t that people were being obstructive, it was that people were genuinely worried, because the planning was utterly haphazard.47

Despite the anxieties revealed above, the slow process of relocating care services from large institutions to smaller facilities was not immediately accompanied by any real change in the nature of care offered by learning disability nurses. Residential work, focusing on personal care and supervised daily activities for patients, was broadly 224

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similar in small homely settings to the old ward routines in ways that were at once both reassuring (for patients and staff) and the enemy of innovation. The gradual shift of nurses from large to small care facilities was certainly not seen to require a major reorientation of their work or reassessment of core skills. Yet the new focus on community work did open up completely new, and stimulating, roles for some learning disability nurses. Work with families, and on assessments, became increasingly important, and outside the institutions nurses began, for the first time, to work with individuals and families who needed to access services but did not require round-the-clock care. The potential to develop these services, and roles for nurses within them, was, however, constrained by a variety of factors that operated at local as well as national levels. Confronted by piecemeal service development and inconsistent professional leadership and managerial support, opportunities for the new role of community learning disability nurse developed in a haphazard and muddled way.48 An early research project exploring the functions of community learning disability nurses concluded: It had been clear, both to us and to the nurses, that many of the problems they faced in carrying out their work derived from the absence of any formal organizational goals or management directives. Left almost entirely to their own devices in devising appropriate forms of intervention, they had evolved a system of ‘muddling through’ which satisfied neither themselves nor those to whom they were officially accountable.49

It is easy to be critical of such confusion, but many of the early community learning disability nurses struggled to identify clear roles for themselves. Many such nurses found themselves actively looking for work among people who had had little previous contact from services. Caseloads were built up, but it was not entirely clear what distinctive contribution community learning disability nurses could make to these new, or indeed former, patient groups and their families. A review of embryonic services in 1980 captured some of the ­difficulties encountered: differences in the structure, functions and client groups of community mental handicap and psychiatric services have to be seen in relation to the problems faced by both services in establishing a legitimate professional identity. The problems which arise from a confused understanding of their

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In retrospect, the remarkable aspect of this change was that a group of workers who had been perceived to be among the most conservative supporters of a discredited system were able to transform themselves into new roles away from the institutions. This type of flexibility was increasingly demanded of all nurses, as the NHS confronted the demands of new medical technologies, an ageing population, rising costs and the pressure to shorten all hospital stays while needing to demonstrate improved responsiveness to market forces, patient choice and consumer preferences. Their professional colleagues therefore appreciated the adaptability and resourcefulness shown by the learning disability nurses. The general secretary of the Royal College of Nursing warmly congratulated learning disability nurses on the way that they both adapted to, and led, a process of change that ‘appeared at first to threaten their very existence’.51 Efforts to improve the flexibility of learning disability nursing were supported by research funded by the Department of Health and carried out by the University of York.52 The main findings of this research were that existing nursing skills could be transferred to the community and that nursing reflected the current philosophies of care. The credibility of the nurses was based on their direct involvement with people with learning disabilities. The research found that some managers did not appreciate the potential contribution of the learning disability nurses, as they were influenced by their institutional image. This was one of the reasons why nurses felt themselves to be in an insecure position despite the positive evidence to the contrary. Significantly, in 1985 the Chief Nursing Officer (CNO) for England published an open letter to regional nursing officers in which she confirmed that there was an ongoing commitment to maintaining and developing the role of learning disability nurses. The CNO was sufficiently convinced about the secure position of the learning disability nurse that she seemed surprised that other people were uncertain about the nature or future of the role: The development of the Mental Handicap Nursing Service in the community is already demonstrating the contribution which nurses can make to the support of people in their own homes or in a range of residential and

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Learning disability nursing other settings in the community. Training and sound educational support and advice to families, friends and other professionals is also an integral part of the nursing service.53

This seemed a remarkable change of fortunes. In the 1970s there were explicit proposals to phase out learning disability nursing as the large hospitals closed. By the 1980s, however, learning disability nurses were identified as a core component of new community services and were being invited to further develop their role, with an emphasis on nurse education and research; a process that continues to date. In 2014 there are still signs of professional uncertainty, but nonetheless student nurses are still being prepared to be learning disability nurses and posts are still being advertised and filled. This apparently significant improvement in the position of learning disability nurses between 1970 and 1990 poses two important questions; what accounted for the change, and why didn’t frontline staff feel more secure as a result? The changing position of the learning disability nurse owed much, at a local level, to individuals (and small groups of staff) reinventing themselves and pioneering new services that helped long-stay residents of the old institutions make new lives in the community, and/ or reached out to potential service-users who had not previously been in contact with the monolithic hospital-based service. With many such schemes being almost entirely dependent on the enthusiasm and resources mobilised by the nurses themselves, sometimes in the teeth of strong managerial opposition and restrictive budgetary controls, it is small wonder that even their successful operation gave little sense of security to other staff unable or unwilling to transform their working lives through similar personal efforts. These nurses usually remained in post, but their future was dictated by the changing priorities, even whims, of central government and local NHS managers. As we have seen, neither was totally (and certainly not consistently) committed to a nurse-led (or even a nurse-staffed) future for learning disability services, but for a variety of reasons continued to accept that nurses had a role at least in the medium term. Nurses often felt insecure and unsupported but there were still jobs, and job vacancies, for them. There were positive and negative reasons for this. Some nurses were innovating and making 227

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themselves an essential part of reconfigured services, while other nurses benefited from the fact that they, as the largest component of the workforce, were not easy to remove. With public opinion generally favourable to nurses any attack on them was politically dangerous, and nursing staff also enjoyed employment rights that their unions and professional bodies were prepared to defend. The political and economic costs of forced redundancies were likely to be prohibitive, a point acknowledged by those pressing for the reconfiguration of services. This encouraged an explicit concern with staff welfare,54 and arrangements to either help existing nurses transfer to new services when their hospitals closed or offer early retirement to long-serving staff reluctant to break out of the institutional mould. The closure of the old large-scale, long-stay institutions was an enormous undertaking, requiring detailed negotiations between various stakeholders (including organisations not used to close collaboration with one another) and careful work to prepare residents, and their families, for the move. To facilitate the relocation of patients, and help them settle into new provision, some nurse leaders and managers became convinced that familiar staff were in the best position to support the process. In some institutions wards were reconfigured to allow small groups of staff and patients to be brought together before moving as a unit to a new community facility. Even where such elaborate arrangements were impossible, resettlement teams were able to positively utilise one of the features of the large hospitals. Institutional life dictated that people got to know each other extremely well and having familiar people around eased the transition for many. There was also a shared memory of the institutions that, while not welcome to everyone, meant a lot to some of the people who were resettled.55 The willingness and ability of staff to both relocate themselves and work in new ways outside their institutions were just some of many unknowns when the closure programme started. The Jay Report had argued that many of the nurses would be prepared to work within the new model that was to replace the hospitals. This assumption appears to have been correct, because in many cases nurses were successfully transferred from closing institutions to newly created successor services. The Jay Report was, however, incorrect in asserting the view that many such nurses would be prepared to lose their identity as nurses in the process.56 228

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Without a doubt the survival of learning disability nursing owed something to both the costs of removing the nurses and the practical benefits of retaining experienced staff. In many ways it made sense for staff and patients to move together, as large rural hospitals (with a soon-to-be-redundant workforce) were replaced by new facilities built in urban areas (under-resourced in terms of alternative care staff) to allow proximity to patients’ families and access to a spectrum of community facilities. But a commitment to an ongoing role for learning disability nurses went far beyond administrative neatness and practical problem-solving. The retention of professional nurses offered many additional benefits, some of which were outlined in the Griffiths Report: It is important that the skills of staff formerly employed in long stay hospitals are not lost, as patients are discharged and responsibility for their care passes to another authority. Such staff are likely to have direct personal knowledge of individual former patients and their needs, as well as a wide range of skills which are equally valuable in a community care setting.57

Staffing of both hospital and community services remained an issue throughout the period covered by this chapter. The hospitals still needed to be staffed even as they moved through their closure programmes. In many institutions care became more difficult as the most able residents left first, on-site recreation facilities were scaled back and buildings became increasingly dilapidated without routine maintenance and new investment. Yet the commitment to improve all learning disability services was associated with a drive to provide enhanced staff–patient ratios within the old hospitals.58 Staff numbers were prevented from declining in proportion to patient numbers and some new staff, with specialist skills and/or relevant experience, were hired to assist the closure programmes. There was certainly an effort to make quite detailed personal assessments of patients’ needs ahead of transfers, and these voluminous forms contrast with the paucity of earlier paperwork. The new and existing nursing staff generally received enhanced terms and conditions during the closure phase.59 It is clear that the nature of change from institutions to community was so profound that it was crucial to keep as many people as possible as part of the service. In other words, it was politic not to upset any group of workers, including the nurses. 229

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Conclusion This chapter has been concerned with the period from 1970 until the 1990s. Contrary to gloomy predictions, the profession (or subgroup of the nursing profession) survived the closure of the institutions and continued, even flourished, in new community settings. As the 1970s terminology of mental handicap nurse gave way to the new language of learning disability nursing, the profession seemed more secure and its anxieties less acute. Yet the changes these nurses had both witnessed and gone though (personally and collectively) were profound. At the start of the study period it seemed inconceivable to many people that the subnormality hospitals would close, but close they did. It also seemed impossible that there would be a place for nursing outside the walls of the institution, but a place there was. With hindsight, the closure of the institutions seems inevitable. They were so big, so expensive to run and so out of step with the antiinstitutional ethos of the time that closure was imperative, not least on economic grounds. The old hospitals were also, although it was not well recognised at the time, an offence against the human rights of the many people who were obliged to live in them. Many stories have subsequently been told that show that in contradiction to the intentions of their founders, despite the good work of most of the staff and regardless of the poverty of the alternatives available for many residents, the institutions were a bad place to be. On a personal note I remain unclear about the reasons for the continuation of an insecure profession that has provided me with a livelihood throughout my career. I suspect that, as with many things, there have been a variety of reasons and I have tried to explore them in this chapter. Mental handicap nursing attracted some very good people who became leaders in the field. Some of them helped to close the institutions that they had worked in all their lives, others helped to build community services for people who left the institutions. There were great risk-takers as well as people who went along with the flow of change. The new services needed staff and mental handicap nurses were the experienced people who could staff and manage services. There were also practical considerations. The NHS, anxious to avoid a large redundancy bill, had an interest in providing jobs for nurses outside the institutions and it was politically important to maintain 230

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professional structures to manage the changing system. Yet under continuing pressure to save money and reconfigure services, learning disability nursing remains, to many of its members, insecure despite its survival well into the twenty-first century. Notes   1 D. Wright, Mental Disability in Victorian England: The Earlswood Asylum 1847–1901 (Oxford: Clarendon Press, 2001), pp. 23–45.   2 Mental Deficiency Act, 1913 (3 & 4 Geo. V, c.28).   3 Mental Deficiency (Amendment) Act, 1927 (17 & 18 Geo. V, c.33).   4 M. Thomson, The Problem of Mental Deficiency: Eugenics, Democracy and Social Policy in Britain c. 1870–1959 (Oxford: Clarendon Press, 1998), p. 294.  5 Thomson, The Problem of Mental Deficiency, pp. 10–35.  6 K. Johnson and R. Traustadottir, Deinstitutionalization and People with Intellectual Disabilities: In and Out of Institutions (London: Jessica Kingsley, 2005).  7 D. Mitchell and J. Welshman, ‘In the shadow of the Poor Law: workforce issues’, in J. Welshman and J. Walmsley (eds), Community Care in Perspective: Care, Control and Citizenship (Basingstoke: Palgrave Macmillan, 2006), pp. 187–200 (p. 188).   8 G. Chester and P. Dale, ‘Institutional care for the mentally defective, 1914– 1948: diversity as a response to individual needs and an indication of a lack of policy coherence’, Medical History, 51:1 (2007), 59–78.   9 J. Walmsley and J. Welshman, ‘Introduction’, in Welshman and Walmsley (eds), Community Care in Perspective, pp. 1–13 (p. 1). 10 Department of Health (DOH), Valuing People: A New Strategy for Learning Disability for the 21st Century (Cm 5086, 2001). 11 The Camden Society, I Want What You Have: Five Decades of Making it Happen: The History of the Camden Society (London: The Camden Society, 2010). 12 D. Mitchell, R. Traustadottir, R. Chapman, L. Townson, N. Ingham and S. Ledger (eds), Exploring Experiences of Advocacy by People with Learning Disabilities: Testimonies of Resistance (London: Jessica Kingsley, 2006). 13 C. Helmstadter, ‘Early nursing reform in nineteenth-century London: a doctor driven phenomenon’, Medical History, 46:3 (2002), 325–50. 14 P. Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993). 15 RMPA, Manual for Mental Deficiency Nurses (London: Bailliere, Tindall and Cox, 1931). 16 These debates parallel those in the mental health sector. See the chapter in this volume by Claire Chatterton.

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Mental health nursing 17 D. Mitchell, ‘A contribution to the history of learning disability nursing’, Nursing Times Research, 7:3 (2002), 201–10. 18 S. Heffer, Like the Roman: The Life of Enoch Powell (London: Weidenfeld and Nicolson, 1998), pp. 282–3. 19 Enoch Powell, ministerial address to the Annual Conference of the National Association for Mental Health, 21 August 1961. See www.studymore.org.uk/ xpowell.htm [last accessed 22 August 2014]. 20 Ibid. 21 Richard Crossman, The Diaries of a Cabinet Minister, Volume Three (London: Hamish Hamilton, 1977). 22 Crossman, Diaries of a Cabinet Minister, p. 177. 23 Crossman, Diaries of a Cabinet Minister, pp. 177–8. 24 S. Rolph and D. Atkinson, ‘Maureen Oswin and the “forgotten children” of the long-stay wards’, in Mitchell et al. (eds), Exploring Experiences of Advocacy, pp. 153–71; M. Oswin, The Empty Hours: A Study of the Weekend Life of Handicapped Children in Institutions (Harmondsworth: Penguin, 1971). 25 Crossman, Diaries of a Cabinet Minister, pp. 408–13, 418–20, 425–30, 685. 26 Department of Health and Social Security (DHSS), Better Services for the Mentally Handicapped (Cmnd 4683, 1971). 27 At a local level, estimates of the money required to bring the hospitals up to standard gave new impetus to community schemes now seen as a definite alternative rather than an adjunct to large-scale facilities. See D. King, Moving on from Mental Hospitals to Community Care: A Case Study of Change in Exeter (London: Nuffield Provincial Hospitals Trust, 1991). 28 J. Welshman, ‘Ideology, ideas and care in the community, 1948–71’, in Welshman and Walmsley (eds), Community Care in Perspective, pp. 17–37. 29 J. P. Martin, Hospitals in Trouble (Oxford: Basil Blackwell, 1984). 30 Community Care with Special Reference to Adult Mentally Ill and Mentally Handicapped Persons (Second Report of the Social Services Committee) (London: HMSO, 1985). 31 DOH, Press Release 88/291, ‘Shift towards care in the community for mentally handicapped people in England’, 7 September 1988. 32 There has been something of a reassessment of provision following the exposure of problems at the privately run Winterborne View Hospital, Bristol by the BBC Panorama programme ‘Undercover care: the abuse exposed’, first broadcast 31 May 2011. 33 See P. Morris, Put Away: A Sociological Study of Institutions for the Mentally Retarded (New York: Atherton Press, 1969) for a full account of these issues when institutions were at their largest. 34 DHSS, Better Services for the Mentally Handicapped, p. 1. 35 DHSS, Better Services for the Mentally Handicapped, p. 22. 36 Crossman, Diaries of a Cabinet Minister, p. 759.

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Learning disability nursing 37 Crossman, Diaries of a Cabinet Minister, p. 840n. 38 Report of the Committee on Nursing (Briggs Report) (Cmnd 5115, 1972). 39 Report of the Committee of Enquiry into Mental Handicap Nursing and Care (Jay Report) (Cmnd 7468, 1979). 40 ‘The right to care’, Nursing Times, 75:10 (1979), 383. 41 ‘No Way, Mrs Jay’, Nursing Mirror, 146:26 (1978), 1. 42 Leavesden Group, ‘A comment on the Jay Report by members of the “Leavesden Group”’ (October 1979). The Leavesden Group was one of a number of groups of senior nurses discussing, and seeking to influence, DOH policy in the late 1970s. A copy of this unpublished report is retained by Duncan Mitchell. 43 A similar fate of mistiming leading to inaction befell the Black Report exploring health inequalities. A useful political commentary on its presentation and reception is provided by P. Jenkin, ‘Dispelling the myths of the Black Report: a memoir’, in V. Berridge and S. Blume (eds), Poor Health: Social Inequality Before and After the Black Report (London: Frank Cass, 2003), pp. 123–7. 44 ‘According to Jay’, Nursing Times, 3 January 1980, 8. 45 ‘The Gloucestershire Project’, Nursing Times, 24 May 1979, 887–90. 46 D. Mitchell and M. Chapman, ‘And people said they will never do it!’ Staff Stories of Resettlement from Institutions for People with Learning Disabilities in the North West of England (Accrington: North West Training and Development Team, 2008). 47 Mitchell and Chapman, ‘And people said they will never do it!’, p. 25. 48 M. Jukes and S. Jones, ‘Community learning disability nursing’, in M. Jukes (ed.), Learning Disability Nursing Practice: Origins, Perspectives and Practice (London: Quay Books, 2009). 49 V. Hall, Case Load Management: Monitoring the Progress of New Referrals to a Community Mental Handicap Nursing Service, Department of Mental Health, Mental Handicap Studies Research Report, 11 (University of Bristol, 1980), p. 1. 50 Hall, Case Load Management, p. 12. 51 C. Hancock, speech to community nurses, reported in the Newsletter of the Society of Mental Handicap Nursing, July 1990. 52 M. Clifton, I. Shaw and J. Brown, The Transferability of Mental Handicap Nursing Skills from Hospital to Community, Final Report, Volume One (York: University of York, 1992). 53 DHSS, (85) 5, letter from A. A. B. Poole, Chief Nursing Officer, to Regional and District Nursing Officers, Directors of Nursing Services and Directors of Nurse Education, ‘The Role of the Nurse in Caring for People with Mental Handicap’, 18 December 1985. 54 Community Care with Special Reference to Adult Mentally Ill and Mentally Handicapped Persons, paragraph 178.

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Mental health nursing 55 This collective memory of institutional life did, however, include, for some, a lively resistance against staff. See S. Ledger and L. Shufflebotham, ‘Songs of resistance’, in Mitchell et al. (eds), Exploring Experiences of Advocacy, pp. 68–90. 56 D. Mitchell, ‘A chapter in the history of nurse education: learning disability nursing and the Jay Report’, Nurse Education Today, 23 (2003), 350–6. 57 Community Care: Agenda for Action (Griffiths Report) (London: HMSO, 1988). 58 DHSS, Mental Handicap: Progress, Problems and Priorities (London: HMSO, 1980). 59 DHSS, Mental Handicap: Progress, Problems and Priorities.

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Between asylum and community: DGH psychiatric nurses at Withington General Hospital, 1971–91 Val Harrington

It was an exciting place to work. It was a general hospital, which was something very new […] and the whole, well the whole emphasis was completely different. You know, it was exciting. Most of the staff had two or three qualifications, everybody was very enthusiastic, they’d come from like the Maudsley, the Royal Edinburgh, all over […] The whole building was new […] It was a fantastic place to actually work. In fact I think over the years it’s … I’d probably put it down as being more progressive than most places now.1

The post-war history of mental health services is dominated by the transition from mental hospitals to community care, with a corresponding shift from asylum nurse to community psychiatric nurse (CPN).2 Within this broad history, however, the role of the district general hospital (DGH) psychiatric unit is often overlooked. Sited in local hospitals, these units were arguably an important intermediary between the old institutional system and community care as it is currently conceived. Indeed, in the 1970s and 1980s, policy-makers and practitioners viewed such units as a central component of any modern, comprehensive community psychiatric service.3 This chapter focuses on the role and experiences of nurses in the Withington Psychiatric Unit in south Manchester, which opened in 1971. Part of the Withington hospital complex, a former workhouse that had evolved into a modern 1,264-bed DGH by the early 1970s, the unit was purpose built, with 170 beds spread across ten wards. Facilities included an 80-place day hospital, a busy outpatients’ department running twelve clinics per week, EEG facilities 235

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(electro-encephalography used to detect abnormal electrical activity in the brain), an industrial therapy workshop (ITW), an occupational therapy unit and an impressive gymnasium. Its staff included five medical ‘firms’, over 120 nurses, seven psychiatric social workers, four occupational therapists, an ITW manager and, by 1974, six clinical psychologists. This pristine new building, with its state-of-the-art facilities, embodied a new vision of psychiatric care. Patients would no longer be incarcerated in isolated asylums but would have their illnesses treated at their local hospital. Neil Kessel, Withington’s first professor of psychiatry, claimed this would bring mental patients and their services into line with the treatment of other illnesses: When you are ill you go to your local hospital … For ordinary illness, of all systems, the district general hospital should serve. I believe in the rightness of that principle. I know that it can work. Its practice is humane and efficient. It is good for patients and relatives and it is good for staff […] The district general hospital is where the action is.4

This chapter briefly examines the origins and development of DGH units, and the concept of DGH psychiatry espoused by Kessel. It explores how the units in general, and Withington in particular, are situated within the broader history of post-war mental health care. Given their importance in policy terms, it is surprising that so little has been written about them. To date, the historiography has been particularly silent about their nurses. This chapter recognises that nurses were central to the running of the Withington unit, and seeks to evaluate its development from their perspective. Nurses were not only the largest staff group, but the nature of both their work and their working hours meant that they were omnipresent. They thus occupy a dual function in the narrative, as both actors and witnesses. The chapter explores how nurses both contributed and adapted to the DGH environment. This process helped forge a new ­professional identity, far removed from that of the traditional asylum nurse and also quite distinct from that of the CPN. Since it is the figure of the CPN who dominates both contemporary and historical  accounts of late twentieth-century psychiatric nursing and mental health care this alternative pathway merits further investigation. 236

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The DGH phase was, however, not without difficulties. This chapter draws on oral testimony from former nurses, doctors and social workers together with documentary evidence and a postgraduate thesis describing the origins and early development of the unit5 to examine some of the tensions and frustrations faced by the nurses, particularly during the later period, which was dominated by staff shortages, deteriorating environmental conditions and falling standards of care. Within these sources there is a noteworthy divergence of opinion between the nurses and colleagues from other disciplines. This means that, although nurse informants explicitly endorsed the dominant narrative that the innovation, commitment and high standards of care which characterised Withington’s early years were increasingly curtailed by funding cuts and political interference, they simultaneously, and at times perhaps unintentionally, provide other narratives and perspectives. The nurses offer a particularly distinctive account of relationships, both within the unit and between the unit, the rest of the hospital and the outside world. The existence of alternative narratives was far more noticeable among the nurses than the other professionals. As Helen Spandler so eloquently points out in the context of Paddington Day Hospital, single, linear narrative accounts can be very compelling. They offer a version of events that is logical, coherent and thus easily understood and processed, but they often fail to capture the totality and complexity of a situation.6 There is no doubt, from the nursing sources, that the initial success and later failings at Withington cannot be explained just by reference to external factors. At least some of Withington’s problems lay within both its internal relationships and structures, and in its pattern of interactions with other services. While some of these issues were peculiar to Withington, they point to some of the tensions and contradictions inherent in the DGH model of psychiatry itself, and ultimately in the mental health system as a whole. Post-war mental health services and DGH units That wasn’t a new idea, that was quite an old idea at the time. During my  training I remember hearing the first presentations of Manchester ­psychiatrists. Blackburn had a unit … Jan Leyberg had a unit … they’d

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Mental health nursing written them up and described them […] It wasn’t new, the idea of the DGH unit.7

The historiography exploring mental health care in the United Kingdom in the second half of the twentieth century concentrates on the demise of the asylum and its replacement by the new ‘community care’.8 The 1950s, for example, are characterised by the erosion of the mental hospital as a custodial institution, the ‘triumph’ of the medical model and the growth of extramural services. Such developments culminated in the 1959 Mental Health Act. This provided the legal framework for a new, predominantly informal, voluntary system of treatment and a clear ‘shift in emphasis from hospital to community’.9 By the 1960s the asylum system was under threat from changing government policies,10 intellectual critiques of institutional life11 and media interest in hospital scandals that all served to fuel public hostility to mental hospitals.12 Yet despite this new interest and concern, and evidence of a declining mental hospital population, the 1970s were marked by frustration and disappointment. Some innovative work was being done but, overall, the pace of change was unacceptably slow. A major constraint was the lack of community care facilities. This point was openly acknowledged by Barbara Castle, Secretary of State for Social Services, in her much quoted foreword to the 1975 White Paper, Better Services for the Mentally Ill13 but it was not until 1984, when the government instructed regional health authorities to produce plans for the run-down and closure of their large mental hospitals, that service providers were forced to seriously address the issue. By the end of the century most of the old institutions had shut but concerns about inadequate community care arrangements persisted to the extent that in 1998 Frank Dobson, Secretary of State for Health, asserted that ‘community care has failed’.14 Analysis of community care policies tends to focus on the changing economic and political context within which they were developed. For example, the asylum closures of the 1980s and 1990s and the new models of community care that replaced them were arguably driven as much by economic and ideological factors as by therapeutic ones. Under the neo-liberal policies of the Thatcher government, people experiencing mental illness were increasingly drawn into a new ‘mixed economy of welfare’, characterised, according to Rogers 238

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and Pilgrim, by the triple themes of ‘privatisation, marketisation and managerialism’.15 These impacted on the organisation and configuration of services, and also led to the erosion and transformation of traditional professional power relationships in the context of general management and the multidisciplinary community mental health team. Within accounts either celebrating or deploring such changes, the DGH units receive little attention. Thus, the Minister of Health Enoch Powell’s 1961 address to the Annual Conference of the National Association for Mental Health is better remembered for its attack on traditional asylums than its endorsement of a new policy of treating psychiatric in-patients ‘for the most part … in wards and wings of general hospitals’.16 Similarly, little has been written about the professional debates which accompanied the announcement of the policy, or the way in which, in subsequent White Papers, it was developed and integrated into a much broader concept of district psychiatry, in which the DGH unit was located at the centre of a ‘comprehensive integrated hospital and community service’.17 One explanation for this lies in the way in which community care has been defined and understood. In 1957 the Percy Report positioned local authority community care very much in opposition to hospital services.18 Thirty years later, official definitions had broadened to encompass ‘care delivered by a range of professionals and funded from a range of sources … treatment from a general practitioner and the primary health care team … more specialist psychiatric community services … sometimes in a hospital setting’.19 However, the opposition between hospital and community has remained. It has continued to permeate many historical narratives, with the result that the role of the DGH unit within early models of community care has often been overlooked. Similarly, the units themselves were operating within a system that was deeply divided. Despite their attempts to distance themselves from the old asylums, the hospital units remained administratively and ideologically separate from other community services and so were unable to fulfil their original mission to be accepted as an integral part of the communities they served. Before 1948 the only alternative to the traditional asylum was an observation ward in a municipal hospital. With the NHS came the opportunity to experiment with new forms of general hospital inpatient care for mentally ill patients. At Withington, for example, 239

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twelve short-stay beds were made available on two medical wards.20 Such arrangements were replicated in a number of other hospitals,21 and in 1956 the first report of a fully equipped general hospital psychiatric unit appeared in the medical press. This was located in Newcastle General, a medium-sized teaching hospital. The 54-bed unit was promoted as a symbol of ‘the radical change during recent years in our concept of psychiatric services’, combining ‘the application of scientific method’ with a ‘warm home-like setting … a compromise between the need for privacy and the need for social activity’.22 In the same year, the conversion of the observation ward of West Hill Hospital, Dartford, into an acute, short-stay psychiatric unit was completed.23 Although symptomatic of changing attitudes to psychiatric care, the examples above were rather isolated developments. They were meant to complement traditional mental hospital provision, not replace it. In contrast, a very different type of experiment was underway in Lancashire, although this arguably owed more to political expediency than psychiatric vision. John Pickstone has described the fascinating interplay of geography and politics which led to the Manchester Regional Hospital Board (MRHB) ignoring the advice of its psychiatric technical advisory panel, which had argued for the centralisation of mental health services around the existing large mental hospitals. They opted instead for an experimental programme of more locally based facilities, linked to the mental hospitals but based in the observation wards of its DGHs. These were to be upgraded and developed by a new generation of consultant psychiatrists who, under a joint appointments scheme, would serve as a link between the new units and the mental hospitals.24 The first unit opened in Oldham in 1950, and by 1961 there were twelve.25 They varied in scope and size but all provided in- and out-patient facilities, and many offered day care and rehabilitation services. Their supporters highlighted the uniqueness of these arrangements, and claimed staff and patients benefited from strong links with both general hospital and local authority services. Unlike the projects in Newcastle and Dartford, the MRHB offered what Smith termed an ‘integrated scheme’ rather than separate, small-scale innovations.26 Crucially, despite being built around an acute, episodic model of mental illness, they saw the full range of patients and the full 240

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spectrum of disorders. Thus, although the MRHB units were originally intended to complement and extend the services of large mental hospitals, they quickly became virtually self-sufficient, claiming that they were able to provide a comprehensive services for all patients in their catchment area. As a consequence, consultants severed their links with the ‘parent’ mental hospitals and the DGH units quickly became ‘more or less independent units, expected (and indeed able) to deal with every type of case … an alternative to the more conventional mental hospital based service and … a radically new development’.27 In the early days of the DGH units, they operated on bed ratios well below the national average of 3.4 per 1,000 population. This was initially seen as an indicator of efficiency, but in later years Neil Kessel argued that estimates of need had been distorted by the ‘sturdy resignation among Lancastrians: a usedness to suffering; an acceptance of it …They are prepared to suffer and put up with it.’28 The unique features, and apparent benefits, of the MRHB units meant that they quickly came to the attention of the Ministry of Health. George Godber, Deputy Chief Medical Officer, makes it clear, in contemporary documents and his later recollections, that they had a major influence on government policy.29 Indeed, by 1958, three years before Enoch Powell’s speech, there were clear signals that what had started out as a small regional experiment was now being seen as ‘the probable development of the future’.30 Within four years the notion of DGH units had been formally incorporated into the 1962 Hospital Plan for England and Wales,31 and they became the cornerstone of the comprehensive integrated hospital and community service outlined in the 1971 White Paper.32 Progress was slow, however, with only seventeen new units opened between 1964 and 1970, giving a total of ninety-four.33 By the mid1970s only 6 per cent (5,400) of in-patient beds and 23 per cent of admissions were within the general hospital system.34 This was not unexpected. It took time to plan and build facilities,35 and funding was tight despite significant extra resources committed to the Hospital Plan. The delay also reflected divisions among the psychiatric community. Views aired in the medical press ranged from unconditional support36 to marked hostility,37 though caution and scepticism were more common than either extreme. In many quarters there was genuine doubt that existing evidence supported such a wholesale shift 241

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in policy.38 There was also concern about the willingness and ability of DGHs to adapt to the very different approaches and practices of psychiatry, and anxiety about meeting the needs of patients with chronic mental health difficulties in acute care psychiatric units.39 Quite apart from these difficulties, there were administrative problems associated with such a major transformation of mental health services. While a process of gradual change would facilitate consultation and planning,40 there was concern that creating a two-tier system, even during a transitional period, risked the mental hospitals becoming ‘dumping grounds … poorly staffed, apathetic institutions with conditions worse than they had been for the past 100 years’.41 It is in this context that Withington needs to be understood. It benefited from the MRHB’s established commitment to DGH psychiatry, and the timing of the original proposal (May 1960) was fortuitous, with the deliberations of the board coinciding with the publication of the Hospital Plan. By the summer of 1962 the unit had received official government backing, and crucially the promise of funding, as part of the region’s ten-year plan. This meant that, in contrast to the Lancashire units, Withington had the luxury of new, purposebuilt premises and also benefited from more generous staffing levels. Interviews with former staff suggest that the unit also exuded a level of confidence, even arrogance, which was not evident in 1950s Lancashire. In part this was a sign of the greater acceptance such units had by the 1970s, but it also reflected Withington’s unusual status as a teaching unit.42 This, more than anything else, helped create a highly stimulating but also strongly hierarchical and competitive working environment. Published accounts of the DGH units discuss their impact on psychiatrists’ roles, relationships and work practices. Within these accounts the presence of nurses is usually assumed rather than documented. There is silence about, as well as silence from, the nurses, and even basic details about their recruitment, retention and day-to-day routines tends to be missing. It is, for example, unclear whether the nurses came from the rest of the hospital or were trained registered mental nurses (RMNs). This leads to further uncertainty about the nursing staff. Were they permanently attached to the psychiatric wards or did they rotate through the whole hospital? Did student nurses ever work on the units? The journal articles offer only a few 242

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hints. For example, a call in the Lancet for all nurses-in-charge to be dual trained implies that in 1962 this was not standard practice for senior staff, let alone the rest of the workforce.43 Indeed, in contrast to those working in mental hospitals, only a minority of the nursing staff at St James’s Psychiatric Unit in Leeds had any qualifications whatsoever and there was concern that this ‘deficiency in numbers and in quality’ of nurses was ‘a universal difficulty in general hospital psychiatric units’.44 There was some interest in developing training programmes for state registered nurse (SRN) and/or RMN students but such issues were rarely discussed in the medical press. Nursing at Withington: the early years You can’t compare, ’cos I went from one to the other and so did my friend. We know what Rainhill [an old mental hospital] … where they went round with a saucer and gave people a tablet ‘oh, you’ll have a white one today’ ‘Oh, you’re not so good, have a yellow’… I mean the ward rounds at Rainhill, as a postgrad when I qualified, you just went from one ward to another just organising these doctor’s rounds and you never discussed people’s symptoms or … I mean I didn’t understand what schizophrenia was until I went to Withington because to me everybody was institutionalised and they were all diagnosed as schizophrenic […] It was at Withington you started seeing people as individuals and looking at signs and symptoms and treatments and social activities.45

While there are only limited details about the recruitment and training of nurses for the DGH psychiatric units, even less is known about their working lives, roles and responsibilities, and their everyday encounters with staff and patients. For example, did the nurses, like their medical colleagues, see themselves as pioneers? No published account seems to address this point, although nurses’ experiences within mental and mental subnormality hospitals during this period have recently received attention.46 Here oral testimony can add to our understanding, especially where informants draw a clear distinction between the DGH unit and their previous working environments. Many of the old asylums were crumbling Victorian structures which practised ‘dehumanising routines and unnecessary regimentation’, alongside minimal levels of care and limited treatment options.47 When informant A left Rainhill, a large mental hospital in Merseyside, to take up a staff nurse’s post at Withington, 243

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she could have been moving to another planet. Withington had new buildings and extensive facilities. Its ten modern wards boasted day areas and four-bed and single rooms. This contrasted sharply with the crowded 40-bed dormitories at Rainhill. This sense of newness was not confined to the buildings; like the majority of my informants from the early period, her recollections are underpinned by a sense of excitement and energy. This feeling was reinforced by the staff demographics. In contrast to the large mental hospitals, where the staff were stereotypically as institutionalised as the patients,48 Withington selected its nurses carefully. The unit advertised widely before opening, and by deliberately targeting areas where there were known to be progressive mental hospitals it attracted applicants from the Royal Edinburgh Hospital in Scotland and the Maudsley in London. The newly appointed chief psychiatric nurse planned not merely to combat the local shortage of qualified RMNs but also to recruit staff who were ‘enthusiastic, flexible and prepared to bring and accept innovatory ideas on nursing care’.49 Initially, competition for posts and training places was high. One nurse recalls that when he started training (in 1974), ‘there were literally hundreds of people applying. Not everyone got in and we were seen as a centre of excellence.’50 New recruits thus found an exciting mix of nurses and an atmosphere that encouraged them to share their ideas and experiences. A delayed opening, which brought nurses to the unit ahead of the patients, encouraged staff discussions about unit philosophy as well as policy,51 a luxury not often experienced within the mental health service. Interestingly, in view of the concerns discussed in the medical journals, the early generations of Withington nurses were almost all dual trained. This highly unusual situation was reinforced by the introduction, in 1973, of eighteen-month post-registration training for qualified SRNs. This was the first course of its kind in the country, and its graduates were arguably different from their mental hospital counterparts. They were academically stronger (entrance requirements for SRNs were higher than for RMNs) and their only exposure to traditional mental nursing was a short placement at nearby Springfield, described by one informant as ‘like going into the dark ages’.52 The course also required them to unlearn many of the assumptions and attitudes they had acquired as general nurses. 244

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This new type of training was explicitly designed to ‘place psychiatric nursing firmly within the medical context’ and, by ‘bringing SRNs into the specialty’ to ‘raise the general standards of the nursing care of psychiatric patients and enhance the status of this branch of nursing’.53 Such thinking reflected concerns about the quality of the existing RMN workforce, and an attempt to raise the status of psychiatric nursing within the profession without sacrificing its distinctive identity. Like their qualified counterparts, the trainees worked across the whole unit, taking part not only in clinical work but engaging in a variety of social and therapeutic activities. The occupational therapy department offered a range of art and craft options, as well as car maintenance, clerical work and domestic skills training in its therapeutic kitchen; while the social and recreational team, generously staffed with a charge nurse, three or four staff nurses and a couple of nursing assistants, helped organise social and leisure activities on and off the site. We used to take people out. That was the first time I was ever in a bookies, I remember. In fact probably the first and only time. And we’d go shopping and out for walks and stuff […] there was the gym … that was genuinely a nice thing to go and do, particularly with younger patients, you know, go and have a game of badminton. That was fun and good for everybody.54

What was particularly striking was the extent to which nurses were involved in these activities. Occupational therapists were regular visitors to the ward; nurses would stay with their patients when they went to the OT department. ‘I know as a student OT was part of what happened, and everybody went to OT […] we were expected to go.’55 On some of the wards, nurses were encouraged to take part in therapeutic groups, an activity which, perhaps more than any other, challenged conventional notions of the nurse–patient relationship: We always used to have, this is on the wards … community meetings. There was a very strong emphasis on patients running things as much a possible for themselves and giving patients a lot of free rein […] the patients would discuss the problems they were having with each other and also how to run the ward, things like running the tea … issues of noise, issues of managing the toilets, how things should be done, and behaviour … what were the rules for them. So it was a patients’ meeting … we’d get a patient to chair it … intervene where necessary, sometimes therapeutically, if a patient was

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Mental health nursing being got at, you’d have to … make sure the patients’ power wasn’t being abused […] There was quite a lot of skill involved, and the skill of holding back, trying to get nurses not to take over the meeting and start running it themselves because some nurses would sit there and run a court instead of trying to get patients to actually do things.56

While it would be misleading to suggest that Withington fundamentally challenged or disturbed the traditional, even oppressive,57 power relations around which psychiatric care was structured, such activities and approaches undoubtedly contributed to a more informal, permissive and humane atmosphere. This enabled and encouraged nurses on the unit to develop a whole new set of roles and skills that were well beyond the remit of both their mental and general hospital counterparts. Key to this was team-working. Professional relationships at Withington were structured around the multi-disciplinary clinical team (MDCT). Led by the consultant, it consisted of junior doctors, nurses, a social worker, an occupational therapist and a clinical psychologist who, by all accounts, worked very closely together. The crucial ward rounds were, in terms of both size and duration, grand affairs: The ward rounds were very large and formal and they were teaching ward rounds, with medical students, doctors in training, OTs in training, social workers in training, nurses training. I mean Goldberg [Professor of Psychiatry] would take over a four-bedded ward for his ward round and have vast numbers of people … [patients would come in one by one] into this huge room to be interviewed by Goldberg … amazing interviews that you’d never forget … It was part of the culture of the hospital.58 Ward rounds were very long, they took a lot of the time … Two days weekly [for the two different consultants ] … you’d have two separate days and a ward round might last from one ’til sometimes five or six in the evening.59

For nurses like informant A, coming from a background of hospitalwide rounds organised more like factory assembly lines, these represented a unique learning experience and a forum within which, unusually, the contribution of the nurse was both encouraged and valued. This helped reinforce the sense that 1970s Withington was an exciting and stimulating place to work. Nurses were proud of their contributions and sensed that they were part of something genuinely innovative and of real value and significance. 246

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External threats and internal tensions I remember at the time feeling I was leaving a sinking ship. I was just worn out, fed up of a successful day being when nothing awful had happened rather than making a positive contribution.60

By 1991, when the Health Advisory Service (HAS) inspected the unit, this sense of purpose had dissipated. Its report presents a vivid picture of staff worn down by their daily ‘struggle … to provide a safe, imaginative and therapeutic environment’ and of a ‘resigned acceptance’ of the sub-standard conditions they and their patients were forced to endure. It was particularly critical of what had become dangerously low staffing levels, commenting that ‘the biggest single problem for the profession is the lack of finance to employ sufficient permanent nursing staff’.61 The lack of nurses, which was an increasing problem from the early 1980s onwards, affected the whole ethos of the wards as it became increasingly difficult to provide the therapeutic environment that had been the hallmark of the 1970s. Staff were increasingly engaged in policing rather than interacting with their patients; their general ward commitments left no time to organise therapeutic groups; and the disbanding of the social and recreational team in the mid-1980s meant that there were very few activities on offer for the patients and even fewer opportunities to leave the ward. Bored and restricted, patients were more likely to ‘act out’. This put even more pressure on the nursing staff and created a vicious circle in which therapeutic approaches were increasingly replaced by custodial practices. I can remember being on shifts with just a student or just a nursing assistant. There was a six month period when it was really bad and I actually had meetings with the consultants to make sure they were aware of what was going on […] I was worried because I had some very disturbed patients and all I was doing was gate-watching. I was worried what might happen.62

The situation undermined the morale of nurses who, unable to do the job they had been appointed to do, protected themselves by disengaging either psychologically, in terms of the way they approached their work and the patients, or literally, by leaving. The physical environment did nothing to counter these threats to staff morale and patient well-being. The 1960s facilities were not built to last, and internally as well as externally the buildings were soon in a serious 247

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state of disrepair, contributing to the overall sense of neglect. And, although the HAS report praised the commitment of the staff and their attempts to provide good-quality care, by the early 1990s this was clearly an institution pushed to its limits. The above description implies that Withington’s deterioration was essentially a story of diminishing resources. Adequate funding is fundamental to the health of any institution and all the evidence suggests that, in the context of the year-on-year ‘saving efficiencies’ imposed on health and social services by the 1980s Thatcher government, Withington was starved of the staff and resources needed to provide a modern, high-quality mental health service. The effects of the cuts were further amplified by local health authority politics and regional mental health policies. There were battles between powerful teaching specialties, in which psychiatry consistently lost out.63 By the mid-1980s the regional health authority had a mental health strategy dominated not by the DGH units but by the twin problems of closing the large mental hospitals and developing new forms of community provision.64 Yet this was not the whole picture. Withington was a complex organisation and although some of its problems were resource driven, other tensions were the product of its own distinctive dynamics. Nurses were at the centre of these. From the time the first DGH units opened, one of their main claims was that by bringing together physical and mental health services they would reduce the stigma of mental illness.65 This was one of the guiding principles behind the Withington service, and interviews with the medical staff certainly suggest that the unit enjoyed close relations with the ‘general side’. The nurses, however, offer a very different picture. Despite many of them having dual training, they were reportedly treated as a separate race by their general nurse colleagues. The half-mile corridor connecting the two parts of the hospital served more as a barrier than a link: general nurses rarely went down it and patients and nurses from the unit who trespassed on to the general side were treated with suspicion and apprehension. Whatever the experience of the doctors, the segregation of the mentally ill and their professional carers was still a reality: Whilst it was at the end of a corridor it was like a different world. Nobody went past that […] You’d go to the canteen and then go further, but nobody

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Between asylum and community ever went past the canteen unless they were going to work there […] So you were set apart and considered to be different.66 If you had to go over to the general side it was like another world and if you had to take somebody for an X-ray or whatever they usually dealt with you quickly because you were, you know, the mental side. A number of times I was called to special67 someone on the general side. They treated us like we were unclean or whatever. I was once looking after somebody on the burns unit. The staff wouldn’t give eye contact, they wouldn’t speak to me, they wouldn’t speak to the patient. I even had to ask for a cup of tea.68

Ironically, despite this distancing there was a definite pull at senior nurse manager level to keep the psychiatric unit in line with the rest of the hospital. One informant, for example, recalls: There was a lot of friction between the department and the general hospital, a lot of things that the general hospital didn’t like, like the fact that we didn’t wear uniforms. I don’t think they really liked the fact that we were there at all. They didn’t like the social models being used. The [nurse training] school itself didn’t like what was being taught […] and they tried to rein it in.69

In her dissertation on the origins and development of the unit, Carol Percival provides an example of this ‘reining in’ when she describes how attempts by the psychiatric nurse tutor to set up a multidisciplinary steering group to discuss and develop nurse training were obstructed on the grounds that ‘provision for establishing such a body was not catered for within the nursing hierarchy of the general hospital’.70 The incident was symptomatic of the deep tensions that existed between the unit and the general nurse hierarchy. At one level it was simply about the uneasy relationship between two very different paradigms. At another, however, it was about a battle for control, a battle that, arguably, the general side ultimately won. When the Withington unit first opened, it was under the supervision of the chief psychiatric nurse who was directly accountable to the hospital matron. With the implementation of the 1966 Salmon Report,71 the whole structure changed and the hospital was reorganised. The unit became part of a larger, non-psychiatrically oriented division and its senior nursing officer answerable to a principal nursing officer whose background was in general, not psychiatric nursing. Although this move was 249

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largely in response to new DHSS guidelines, it is noteworthy that the change was warmly welcomed by the managers on the general side who, as Percival discovered during the course of her research, had been uncomfortable with the level of independence enjoyed by the unit in the pre-Salmon days: It has been suggested by senior nurses on the general side that the close working relationship between medical and nursing staff in the Unit encouraged the latter to neglect their own channels of authority. This situation was perceived to result in psychiatric nurses exercising too much autonomy – a tendency which was seen to militate against efforts to develop a strong nursing management.72

From the perspective of many informants, however, this ‘strong nursing management’ provided only weak support and leadership to its psychiatric nurses, especially as working conditions became more challenging. The nursing hierarchy was apparently more concerned with keeping them ‘in line’ with the rest of the hospital than in exploring what the hospital could do to accommodate and foster their values and practices. For example, staff from the unit found it difficult to attend courses or develop their skills in a systematic way despite its reputation as a centre of academic excellence,73 a factor that undoubtedly contributed to the exodus of staff from the late 1970s onwards. These nursing tensions reflect more general and deeply rooted problems in the relationships between physical and mental health professionals. The separate development of both psychiatry and psychiatric nursing has undoubtedly hindered attempts to integrate services. While there have been attempts, since the interwar period, to bring provision for mental and physical illness closer together, these have always been met with a degree of ambivalence and suspicion, particularly in nursing circles.74 With one notable exception,75 the Lancashire DGH pioneers downplayed these tensions and claimed that the new model enhanced interdisciplinary understanding and cooperation. Others were less convinced, and in 1962 two psychiatrists from the West Middlesex Hospital wrote about the difficulties of accommodating two very different ‘regimes’ within the same institution, arguing that, in order for it to work, ‘the psychiatric unit should have the maximum possible autonomy within the general hospital’.76 250

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They qualified this in a subsequent letter, explaining that they had been referring to the ‘coming phase in which such departments will be a novelty in most hospitals’ and agreeing that ‘once established on the right lines … mutual understanding and integration will surely follow’.77 Their final point, however, that psychiatric matters should be ‘settled by psychiatrists and not by the weight of general-hospital tradition’ reminds us that, as was clearly the case at Withington, relationships between the two were never free of power struggles, struggles in which mental health has, throughout its history, been the unequal partner. Conclusion The position of Withington’s psychiatric nurses within the hospital highlights a central paradox of the DGH unit. How, in a setting geared to the physically unwell, is it possible to accommodate the very particular and specialised needs of people with mental health problems without isolating them and setting them apart from the rest of the institution? Within the highly regulated environment of Withington General Hospital, and in the face of unequal power struggles and stigmatising attitudes, it was a tension there seemed little hope of resolving. Nurses seem to have felt this tension more acutely than any of their professional colleagues. This helps explain the greater pessimism shown by nurses and the alternative explanations they offered for the unit’s increasingly obvious limitations and failings. The earlier account, and the dominant narrative, implies that workforce difficulties were a direct consequence of the funding cuts, and that the problem lay in establishment levels which, through the 1980s, were steadily eroded. However, careful analysis of the nurses’ testimonies suggests a more complex picture, in which economic factors were compounded by broader issues pertaining to recruitment and retention, role-conflict and role-confusion, and professional development and support. While concerns about the quality and supply of mental health nurses stretch back to the earliest days of the asylum, it is important to recognise that debates about these issues are in fact time-specific and owe much to consideration of wider contextual issues.78 In the mental health sector inadequate funding and poor working conditions have 251

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invariably contributed to the problem, but most commentators agree that its roots also lie in the stigma, prejudice and inequalities that have defined and shaped social responses to mental disorder through the centuries. The early optimism of the Withington’s pioneers was insufficient to overcome these insidious attacks on staff morale and patient well-being. As unit staff became frustrated and/or disillusioned they disengaged, a process that encouraged a vicious spiral of decline fuelled by growing staff shortages. These structural problems were, however, compounded by other sources of workforce-related tension that were more specific to Withington. Here friction between senior nurses at the unit and the general hospital hierarchy was a significant factor. As key unit staff quit, their junior colleagues felt simultaneously oppressed and undersupported by the wider nursing hierarchy and hospital managers, and often turned to their multidisciplinary colleagues for support. Consultant-led and strongly hierarchical, the MDCTs generated their own tensions, however, particularly for the nursing staff. One informant, for example, felt that nurses were often treated as hostesses rather than equal partners,79 while another expressed concern that he was expected to prioritise attendance at the multidisciplinary ward round over his primary responsibilities for patient care.80 This ambivalence is reflected in the way in which, in contrast to the social work informants, who recalled that their allegiance to the MDCT overrode their commitments to their own social work departments, the nurses emphasised how they prioritised loyalty to their ward team not the MDCT. Frustratingly for radical nurses, the work of DGH units, despite their apparent innovations, thus tended to reaffirm the existing professional power relationships around which traditional institutional care was structured. This meant that nurses were ultimately powerless to challenge the medical model of care that was practised within the units. In contrast, their increasingly autonomous CPN colleagues were embracing and developing new community models.81 These would increasingly replace rather than complement the original DGH vision, which was no longer viewed as the solution to problems of stigmatisation and segregation. The DGH units continued to offer services, but their role and status changed. Many were significantly scaled back, with a consequent diminution of influence and loss of 252

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mission. Withington closed in 2001, its 180 beds replaced by two wards housing acutely disturbed patients, all compulsorily detained. The DGH experiment, at Withington and elsewhere, was ultimately unsustainable, but it is wrong to overlook what happened or underestimate its wider importance for understanding the history of mental health services and the gradual transition from asylum nurse to modern CPN. The DGHs were arguably an important stage in the movement towards de-institutionalisation, despite an assumption that the process was driven by the closure of large mental hospitals. Support for the model meant that institutional care remained centrestage longer than might be imagined, and yet its inherent contradictions also encouraged the search for community-based alternatives to any hospital. Nurses arguably made a distinctive contribution to the optimism associated with the early work of the DGH units, but more than any other staff group they were acutely aware of their limitations. Thus nurses were also a key part of the decline of the model and the search for alternatives. The DGH units provided an opportunity to simultaneously develop new ways of working and raise the status and visibility of psychiatric nurses within both general nursing and other mental health professions. Yet arguably it was the failure of the DGH system to fully recognise and foster the professional skills and autonomy of its nurses that ultimately undermined their support for the experiment they helped create. Notes  1 Informant A (nurse at Withington, 1971–77). All the informants whose remarks and opinions appear in this chapter were personally interviewed by the author between February 2005 and July 2008 as part of a larger case study of Withington Psychiatric Unit. More information about the informants and interview process appears in V. Harrington, ‘Voices Beyond the Asylum: A Post-War History of Mental Health Services in Manchester and Salford’, PhD dissertation, University of Manchester, 2008 (available online at www. zizek.demon.co.uk/Val/PhD.html).   2 This chapter draws on the findings of a Wellcome-funded research study into the post-war history of mental health services in Manchester and Salford.  3 H. Freeman, ‘District psychiatric services: psychiatry for defined populations’, in P. Bean (ed.), Mental Illness: Changes and Trends (New York: John Wiley, 1983), pp. 351–78 (p. 366).

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Mental health nursing   4 N. Kessel, ‘The district general hospital is where the action is’, in R. Cawley and G. McLachlan (eds), Policy for Action: A Symposium on the Planning of a Comprehensive District Psychiatric Service (London: Oxford University Press for the Nuffield Provincial Hospitals Trust, 1973), pp. 53–64 (pp. 53, 64).   5 C. Percival, ‘The Origins and Development of a Department of Psychiatry in a Recently Established University Hospital’, MSc dissertation, University of Manchester, 1974.  6 H. Spandler, Asylum to Action: Paddington Day Hospital, Therapeutic Communities and Beyond (London: Jessica Kingsley, 2006), pp. 98–100.   7 Informant B (consultant psychiatrist at Withington, 1969–93).   8 The most comprehensive post-war histories are K. Jones, Asylums and After: A Revised History of the Mental Health Services: From the Early Eighteenth Century to the 1990s (London: Athlone Press, 1993), pp. 141–255; and J.  Busfield, Managing Madness: Changing Ideas and Practice (London: Unwin Hyman, 1986), pp. 326–71. See also S. Goodwin, Comparative Mental Health Policy: From Institutional to Community Care (London: Sage, 1997); H. Freeman, ‘Psychiatry and the state in Britain’, in M. GijswijtHofstra, H. Oosterhuis and J. Vijselaar (eds), Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century (Amsterdam: Amsterdam University Press, 2005), pp. 116–40; and A. Rogers and D. Pilgrim, Mental Health Policy in Britain (Basingstoke: Palgrave Macmillan, 2nd edn, 2001), pp. 61–84.  9 Report of the Royal Commission on the Law Relating to Mental Illness and Deficiency 1954–1957 (Cmnd 169, 1957), p. 207. 10 Enoch Powell, Minister of Health, used his 1961 ‘Water Tower Speech’ to call for the ‘elimination of by far the greater part of this country’s mental hospitals as they exist today’. Text available at http://studymore.org.uk/xpowell. htm [accessed 30 January 2012]. 11 Kathleen Jones refers to ‘the ideologies of destruction’ underpinning classic texts by Goffman, Barton, Laing, Szasz and Foucault. Jones, Asylums and After, pp. 164–79. 12 J. P. Martin, Hospitals in Trouble (Oxford: Basil Blackwell, 1984). 13 DHSS, Better Services for the Mentally Ill (Cmnd 6233, 1975), p. ii. 14 ‘Third way for mental health’, BBC News report, 29 July 1998, http://news. bbc.co.uk/1/hi/health/141538.stm [accessed 27 January 2012]. 15 Rogers and Pilgrim, Mental Health Policy in Britain, p. 84. 16 Powell, ‘Water Tower Speech’. 17 DHSS, Hospital Services for the Mentally Ill (London: HMSO, 1971); DHSS, Better Services for the Mentally Ill. 18 Report of Royal Commission on the Law Relating to Mental Illness and Deficiency 1954-1957, p. 207. 19 S. Payne, ‘Outside the walls of the asylum? Psychiatric treatment in the 1980s and 1990s’, in P. Bartlett and D. Wright (eds), Outside the Walls of

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Between asylum and community the Asylum: History of Care in the Community 1750–2000 (London: Athlone Press, 1999), pp. 244–65 (pp. 250–1). 20 Percival, ‘The Origins and Development’, p. 8. For an account of the scheme’s first year of operation, see J. Carson and E. H. Kitching, ‘Psychiatric beds in a general ward’, Lancet, 253 (1949), 833–5. 21 See, for example, H. Freeman, ‘Mental health services in an English county borough before 1974’, Medical History, 28 (1984), 112–28 (p. 113) [Hope Hospital in Salford]; and C. P. Brook and D. Stafford-Clark, ‘Psychiatric treatment in general wards’, Lancet, 277 (1961), 1159–62 [New Cross Hospital, London]. 22 Special article, ‘Psychological medicine at a general hospital’, Lancet, 268 (1956), 1150–1. 23 H. S. Capoore and J. W. G. Nixon, ‘Short-stay psychiatric unit in a general hospital’, Lancet, 278 (1961), 1351–2. 24 J. Pickstone, ‘Psychiatry in district general hospitals: history, contingency and local innovation in the early years of the National Health Service’, in J. Pickstone (ed.), Medical Innovations in Historical Perspective (Basingstoke: Macmillan, 1992), pp. 185–99. 25 S. Smith, ‘Psychiatry in general hospitals: Manchester’s integrated scheme’, Lancet, 277 (1961), 1158–9. For contemporary descriptions of some of the individual units, see H. Freeman, ‘Oldham and district psychiatric services’, Lancet, 275 (1960), 218–21; J. T. Leyberg, ‘A district psychiatric service: the Bolton pattern’, Lancet, 274 (1959), 282–4; R. S. Ferguson, ‘Side-effects of community care’, Lancet, 277 (1961), 931–2 [Blackpool]; E. T. Downham, ‘The Burnley psychiatric service’, in H. Freeman and J. W. S. Farndale (eds), New Aspects of the Mental Health Services (Oxford: Pergamon Press, 1967), pp. 636–51; and M. Silverman, ‘A comprehensive department of psychological medicine: the problem of the in-patient case-load: a 12-months review’, British Medical Journal, 5253 (1961), 698–701 [Blackburn]. Burnley and Blackpool were also the subject of a research study, conducted in 1962 and later published as J. Hoenig and M. Hamilton, The Desegregation of the Mentally Ill (London: Routledge and Kegan Paul, 1969). 26 Smith, ‘Psychiatry in general hospitals’, 1158. 27 Hoenig and Hamilton, Desegregation of the Mentally Ill, p. 9. 28 Kessel, ‘The district general hospital is where the action is’, p. 55. 29 G. E. Godber, ‘Health services, past, present and future’, Lancet, 272 (1958), 1–6 (p. 6); H. Freeman, ‘In conversation with George Godber’, Psychiatric Bulletin, 12 (1988), 513–20 (pp. 514–15). 30 Godber, ‘Health services, past, present and future’, p. 6. 31 Ministry of Health, A Hospital Plan for England and Wales (Cmnd 1604, 1962), p. 8. 32 DHSS, Hospital Services for the Mentally Ill.

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Mental health nursing 33 J. Brothwood, ‘The development of national policy’, in Cawley and McLachlan (eds), Policy for Action, pp. 11–31 (p. 15). 34 F. M. Martin, Between the Acts: Community Mental Health Services 1959– 1983 (London: Nuffield Provincial Hospitals Trust, 1984), p. 43; Freeman, ‘District psychiatric services’, p. 367. 35 For example, although plans for the Withington unit received MRHB approval in 1962, the building was not completed until 1972. 36 H. Jacobs, ‘Letters to the editor: psychiatry in general hospitals’, Lancet, 283 (1964), 176. 37 Lancet annotations, ‘A look at mental hospitals’, Lancet, 279 (1962), 900. See C. P. B. Brook, ‘Psychiatric units in general hospitals’, Lancet, 284 (1964), 684–6, for a discussion of the main arguments for and against the units. 38 Leading article, ‘Psychiatry in general hospitals’, Lancet, 282 (1963), 1149. 39 N. A. Cohen and F. P. Haldane, ‘In-patient psychiatry in general hospitals’, Lancet, 279 (1962), 1113–14; Lancet annotations, ‘A look at mental hospitals’. 40 R. Cawley, ‘Postscript’, in Cawley and McLachlan (eds), Policy for Action, pp. 179–87 (p. 180). 41 J. A. Whitehead, ‘Letters: towards general-hospital psychiatry’, Lancet, 298 (1971), 1037; P. Williams, ‘The district general hospital psychiatric unit and the mental hospital – some comparisons’, British Journal of Preventive and Social Medicine, 28 (1974), 140–5 (pp. 144–5). 42 This was reflected in its facilities, which included clinical demonstration rooms, a lecture theatre and a TV/video studio; its ward structure, which included a professorial unit, staffed by doctors holding academic posts with the University of Manchester; and its strong commitment to teaching and research. 43 Cohen and Haldane, ‘In-patient psychiatry in general hospitals’, p. 1114. 44 J. C. Little, ‘Development of a psychiatric unit in a large general hospital’, Lancet, 281 (1963), 376–7. 45 Informant A. 46 J. Hopton, ‘Prestwich hospital in the twentieth century: a case study of slow and uneven progress in the development of psychiatric care’, History of Psychiatry, 10 (1999), 349–69; D. Mitchell and A. M. Rafferty, ‘I don’t think they ever really wanted to know anything about us: oral history interviews with learning disability nurses’, Oral History, 33 (2005), 77–87. 47 J. Hopton, ‘Daily life in a 20th century psychiatric hospital: an oral history of Prestwich Hospital’, International History of Nursing Journal, 3 (1997), 27–39 (p. 31). 48 The institutionalisation of mental hospital staff is a recurrent theme both in accounts of mental hospital life and in my interviews. Staff often spent their whole working lives in one institution, and, even in the 1960s and 1970s, a significant proportion lived in and/or mainly socialised in the hospital social club.

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Between asylum and community 49 Percival, ‘The Origins and Development’, p. 43. 50 Informant C (nurse at Withington, 1974–86). 51 Informant A. 52 Informant D (nurse at Withington, 1974–85, did the eighteen-month ­training in 1974–75). 53 Percival, ‘The Origins and Development’, p. 49. 54 Informant E (nurse at Withington, 1979–85). 55 Informant C. 56 Informant F (nurse at Withington, 1974–86). 57 I. Vassilev and D. Pilgrim, ‘Risk, trust and the myth of mental health ­services’, Journal of Mental Health, 16 (2007), 347–57. 58 Informant G (psychiatric social worker at Withington, 1977–78 and 1984–88). 59 Informant C. 60 Informant E. 61 NHS Health Advisory Service, Report on Services for Mentally Ill People and Elderly People in the South Manchester Health District: HAS/SSI(91)MI E51: November 1991 (London: HAS, 1991) (hereafter HAS report), pp. 14, 28, 60. 62 Informant H (nurse at Withington, 1979–83). 63 The HAS report described how, between 1988 and 1991, the proportion of total expenditure allocated to mental illness services fell, concluding that ‘it appears that the Health Authority has decided to place its priorities elsewhere’. HAS report, p. 5. These conclusions were confirmed by Informant I who was present at many health authority meetings in her capacity as chair of South Manchester Community Health Council, 1987–91. 64 North Western Regional Health Authority, Mental Illness Services: A Consultative Document: Short Term Strategy for Run-Down of Large Hospitals (Manchester: NWRHA, 1985). 65 Leyberg, ‘A district psychiatric service’, p. 283. 66 Informant C. 67 ‘Specialling’ is the term given to the one-to-one supervision of patients deemed to be at risk of seriously harming themselves or others. 68 Informant H. 69 Informant F. 70 Percival, ‘The Origins and Development’, pp. 50–1. 71 Ministry of Health, Report of the Committee on Senior Nursing Staff Structure (Chair B. Salmon) (London: HMSO, 1966). The Salmon Report heralded a new management structure for nurses. It abolished the old matron/ward sister system, in which lines of accountability were often confused and blurred, and replaced it by three levels of nursing management: first line management at ward level; middle management, consisting of nursing officers and senior nursing officers; and, at the top level, principal nursing officers, who each headed a division and were responsible to the chief nursing officer.

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Mental health nursing 72 Percival, ‘The Origins and Development’, pp. 45–6. 73 Informant E; Informant J (nurse at Withington, 1978–99). 74 P. Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993); Central Health Services Council, Psychiatric Nursing: Today and Tomorrow: Report of the Joint Sub-committee of the Standing Mental Health and the Standing Nursing Advisory Committees (London: HMSO, 1968). 75 Ferguson, ‘Side-effects of community care’. 76 Cohen and Haldane, ‘In-patient psychiatry in general hospitals’, p. 1114. 77 F. P. Haldane, ‘Letters to the editor: inpatient psychiatry in general hospitals’, Lancet, 279 (1962), 1350. 78 See the introduction to this volume. For nursing shortages in the twentieth century, see C. Chatterton, ‘The Weakest Link in the Chain of Nursing? Recruitment and Retention in Mental Health Nursing 1948–1968’, PhD dissertation, University of Manchester, 2007. 79 Informant E. 80 Informant C. 81 Withington did employ CPNs. However, they followed the traditional DGH model, working under the supervision of consultants and taking referrals only from hospital doctors, unlike the growing proportion of CPNs who were based in community settings and had the freedom to define and develop their own caseloads and services.

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Index

Abel-Smith, Brian 3 Abraham, Doris 198–200, 203, 206–8 Africa 183 Age 64 Aldcroft, Derek 101 alienists 54, 57, 69 Andrews, Jonathan 123, 200 anti-psychiatry movement 183 AOA see Asylum Officers’ Association Apte, Robert 192–4 Ararat Asylum, Victoria, Australia 55, 57, 59, 61, 63 Army Council 79 Association of Hospital Management Committees 169 Asylum Officers’ Association 100 asylums for idiots 214 see also EVIAs Asylum Workers’ Association 86, 102, 125–6 Athlone Committee 170–1, 175, 177–8, 180 and Report 14, 179 attendants x–xi, 4–6, 9–10, 32, 38, 40–1, 54–70, 98–103, 105, 107, 112–13, 115, 123–31, 133–4, 136–40, 146–7, 152–5, 161, 215 and training 54–61, 64–6, 68–9, 127 Audit Commission 17 Austen, Jane 49 Australia 2, 9, 54–74 AWA see Asylum Workers’ Association

Ballinasloe see Connaught District Lunatic Asylum Barham, Peter 134 Bartlett, George Norton 100, 104, 107–11, 114 BBC see British Broadcasting Corporation Beckett’s Park Military Hospital, Leeds 77 Beechworth Asylum, Victoria, Australia 55 Belfast 43 Berry Wood Asylum, Northampton 84 Better Services for the Mentally Handicapped 219, 221 Better Services for the Mentally Ill 238, 241 Bevan, Aneurin 169 BNA see British Nursing Association Board of Control 92, 105, 108, 112–13, 116, 148–9, 157–8, 162–5, 172 Board of Guardians 39, 147–8 Bodmin Asylum 100, 104, 160 Boje, David 100 Boschma, Geertje 68 Bourke, Joanna 83 Bracebridge Asylum, Lincoln 101 Brentwood Recuperation Centre for Mothers and Children 2, 192, 196–209 Briggs, Asa 221

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Index Briggs Committee 221–2 and Report 221–2 Britain 2, 30, 32, 54, 66, 75, 77, 137, 183, 209 British Broadcasting Corporation 140 British Medical Association 57 and Australasian Branches 57 and Psychological Section 57–8 British Medical Journal 80 British Nursing Association 29 British Red Cross 76, 80, 85 Browne, W. A. F. 7 Busfield, Joan 12, 124 Canada 9 Cardiff 79, 85 Cardiff City Mental Hospital 76, 78–9, 83–93 care assistants 16 Carpenter Mick 1, 5, 60, 67, 84, 90, 100, 176 Castle, Barbara 222, 238 Castlebar Asylum, Co. Mayo 46 Casualty Clearing Station 77 Catholic Church 36, 41–3 CCMH see Cardiff City Mental Hospital CDLA see Connaught District Lunatic Asylum Chartham Mental Hospital 174–5 Cheadle Royal Asylum, Manchester 101 Cherry, Steven 7, 16 Chief Nursing Officer for England 226 child psychology 159 Cinderella services xii, 14 citizenship 10 class 2,10, 28–9, 33, 36, 41–2, 77, 82, 85, 123, 184, 192, 196, 209 Claybury Hospital, Essex 183 Cobb Committee 104, 113–14 COHSE see Confederation of Health Service Employees Commissioners in Lunacy 89 community care x, 6, 11–12, 15–17, 140, 145, 165, 184, 190, 192,

219–20, 224–5, 227–9, 235, 238–9, 248, 252 community learning disability nurse 225 community mental health team 239 Community Psychiatric Nurse 16, 19, 235–6, 252–3 Confederation of Health Service Employees 172, 174, 179–80, 183 Connaught 28, 32, 46 Connaught District Lunatic Asylum 28–53 Conolly, John 7 Cornwall Mental Hospital see Bodmin Asylum CPN see Community Psychiatric Nurse Craiglockhart Hospital, Edinburgh 75, 82 Crompton, Frank 11 Crossman, Richard 218–19, 221 Currie, Edwina 220 Cutcliffe, John 184 Czechoslovakia 161 Daily Express 183 Daily Herald 102 Daughters of Charity 43 Davies, Celia 3 de-institutionalisation 16–18, 190, 253 Department of Health 226 Department of Health and Social Security 194, 218, 250 Derby County Mental Hospital 111 Devon 15–17, 146, 148, 152 Devon County Council 156, 159 Devon County Medical Officer of Health 156 Devon County Mental Hospital, Exminster 117 DGH see District General Hospital DHSS see Department of Health and Social Security Dick, Thomas 55–6, 58–60 Digby, Anne 123 Digbys Asylum 98–101, 103–6, 109–11, 114, 116–17

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Index Dingwall, Robert 3–4, 126 District General Hospital 18, 235–7, 239–43, 248, 251–3 and psychiatry 236–7, 250 Dobson, Frank 238 DOH see Department of Health domestic servants 6, 8, 30, 32, 36, 38, 44, 49, 125, 146, 158 Dublin 31, 36–7, 43 Durham 181 Earlswood see Royal Earlswood Asylum ECT see electroconvulsive therapy Edinburgh 75 EEG see electro-encephalography Ehrenwald, Jan 161 electroconvulsive therapy 11, 138 electro-encephalography 235–6 Ellis, William 30 Ely Hospital, Cardiff 219 Empty Hours, The 219 England 69, 85, 145, 149, 170, 179, 197, 224, 226 English asylums 129 English Voluntary Idiot Asylums 146, 150, 152, 156–7, 160, 162–3, 165 enrolled nurses 180 epilepsy 11, 149 escapes 113, 176 ethnicity x eugenicists 197 eugenics 197 Eugenics Society 198 Europe 18, 105, 182–3 EVIAs see English Voluntary Idiot Asylums Exeter 10, 16, 105–8, 112, 146, 155 Exeter City Asylum see Digbys Asylum Exeter Strike 10, 101, 107, 112 Exeter Trades and Labour Council 105–7 Experiences of an Asylum Doctor, The 113

Family Service Unit 197–9 Female Malady, The 81, 123 feminist history ix Fenwick, Ethel Bedford 29 Finnane, Mark 64 First World War xi, 10, 75–6, 78, 81, 98–9, 101, 112, 128, 136 Forgotten Lunatics of the Great War 134 Foucault, Michael ix, 44–5, 48 France 182 Francis Report xii Freud, Sigmund 82 Friend, The 112–13 Friends Relief Service 198–9 Friends War Victims Relief Committee 198 FSU see Family Service Unit Fulbourn Hospital, Cambridge 182 Galway 46–7 Gamp, Sairey 31 Gartnavel Royal Asylum, Glasgow 200 gender x, 2, 9–10, 12–13, 28–9, 37, 39, 44, 76, 123–4, 128, 132, 139, 145, 154, 184, 192 and madness 124 and professionalisation 124 general nurses ix, 3–5, 10, 12, 14, 28, 36, 83, 87, 90, 134, 137, 139, 145, 150, 159, 169, 171, 180, 248–9, 252 and training 84, 86, 91–2, 243–4, 248 general nursing 3, 8, 12, 29, 37, 41–2, 76, 83, 133, 137–8, 165, 176, 184 General Nursing Council 113, 137, 150, 157, 163–4, 170, 177–8, 180, 184, 216 Germany 182 Gibson, George 101, 131–2, 135 Gittins, Diana 135 Gladesville Hospital for the Insane, Sydney 57–8 Glasgow 200 GNC see General Nursing Council Godber, George 241

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Index Goddard Report 14 Godden, Judith 9 Goodall, Edwin 79, 88–9, 91–3 Griffiths Report 229 Hall, Penelope 198 Hallett, Christine 78 Handbook for Attendants on the Insane 40 Handbook for Mental Nurses 84 Handbook for the Instruction of Attendants on the Insane 40, 58–60, 64, 84, 131–2, 139 Hanwell Asylum, Middlesex 7, 30 HAS see Health Advisory Service Health Advisory Service 247–8 health visitors 18, 196 Helmstadter, Carol 9 history of asylums 5–7, 10, 20, 123, 171, 190, 238 history of care in the community 190 history of institutional care 145, 192 history of madness 124 history of mental health nursing xi–xii, 6–7, 13, 20, 123 history of mental health services ix, 253 history of nursing ix, xi, 1, 3–4, 9–10, 20, 41, 145 history of psychiatry ix, 5, 123 Holland see Netherlands Hopton, John 117 Horder Report 14 Hospital 88 Hospital for the Insane, Parramatta, Australia 57 Hospital Plan for England and Wales 241–2 Hospital Services for the Mentally Ill 241 hostels 159, 190–1, 193–5 hours of work x, 38, 98–9, 102–4, 125–6, 135, 155–6, 175–6, 193 House of Commons 106 and Social Services Committee 17 Houston, R. A. 7 Huddersfield 181

Hull Asylum 112 Hurt Mind, The, BBC television series 140 industrial therapy 236 Inspector-General of the Insane in New South Wales 57 insulin coma therapy 11, 138 intellectual disabilities see learning disability Intercolonial Medical Congress 57, 68 Ireland 2, 28–53, 85, 182 Irish Department of Industry and Commerce 182 Irish Sisters of Mercy 42 Irwin, Rob 18 Italy 182 Jay, Peggy 222 Jay Committee 222 and Report 223, 228 job satisfaction 194 John Bull 133 Jones, Edgar 11 Jones, Kathleen 193–4 Jones, W. Ernest 69 Journal of Mental Science 104, 125, 130 keepers 6–7, 28, 37, 39, 44–5, 55, 130 KEH see King Edward VII Hospital, Cardiff Kelly, Anne 7 Kessel, Neil 236, 241 Kew Asylum, Melbourne 55, 60, 62, 64 King, David 15 King Edward VII Hospital, Cardiff 85–6, 89 Kirby, Stephanie 178 Kitzinger, Jenny 136 Klasi, Jacob 100 labour history ix Labour Party, the 108, 131 Lancashire 196, 203–4, 240, 242, 250 and Asylums Board 102 and Community Council of 196

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Index Lancashire asylums 100, 104 and strikes 100, 104 Lancet 88, 243 Lancet Commission 176 and Report 14 Langton, S. 157 Law, Andrew Bonar 106 learning disability 2, 20, 43, 147, 171 and autobiographies 191 and services 145, 191, 213, 222, 227, 229 and terminology 214 learning disability nurses 4, 213, 215, 223–5, 227 see also community learning disability nurse; RNMH learning disability nursing 146–7, 213–14, 223, 229–31 Lectures on the Care and Treatment of the Insane 57, 64 Leeds Regional Hospital Board 175 Leese, Peter 83 Leitrim 46 Liverpool 196–7, 201, 206 Lomax, Montagu 113 London 4, 8, 78, 159, 164, 181, 196, 201–2, 204 London County Council Mental Hospitals Committee 138 London General Hospital No. 1 78 Longrove Asylum 112 Loughran, Tracey 81 lunacy laws 88, 113 McCreery, J. V. 54, 56–61, 65, 68–9 MacKay, George 163 McKenna, Hugh 184 Macmillan Commission 99, 114–16 mad doctors x– xi madhouse 6, 130 Maggs, Christopher 3 Manchester 102, 181, 192, 196–7, 204–7, 235, 237 Manchester Regional Hospital Board 175, 240–2 Manning, Frederick Norton 57

Mapperley Hospital, Nottingham 173 Marks, Shula 8 marriage 32, 48, 173, 176, 193–4 marriage bar 32, 48, 173 Maudsley Hospital 11, 18, 159, 244 Mayer, Charles 149, 153, 156, 158–60, 162, 164 Mayhew, Christopher 141 Mayo 46 MDA see Mental Deficiency Act MDCT see multi-disciplinary clinical team medical education 11, 39 medical model xi, 238, 252 Medical Officers of Health 156, 192, 202 medical staff 31–3 medical superintendents 6, 40–1, 54–6, 60, 86, 90–1, 105, 112, 125, 128, 132, 139, 160, 164, 175–6, 180, 182, 216 Medico-Psychological Association see RMPA mental deficiency 146, 169, 190–1, 215 Mental Deficiency Act 140, 146, 148–9, 154, 165, 214–15 mental handicap see learning disability terminology mental health 1, 13, 139–40, 171, 174, 218 and care 124, 179, 217, 236, 238 and crisis 19, 220 and exhibition 181 and issues 1, 220 and policy 184 and problems 134, 193, 251 and projects 3 and sector 2, 10, 12, 14, 16–17, 178, 180 and services 1, 181, 183, 185, 191, 235, 237, 242, 244, 248, 253 and workers 135 Mental Health Act (1959) 214, 238 mental health nurses see mental nurses mental health users movement xi

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Index mental hospital ix, xi, 11–13, 15, 67, 78, 82, 84, 88, 91, 112–13, 115, 128, 134, 138, 154, 156, 160, 170–3, 176, 178–9, 182–3, 217, 235, 238, 240–4 Mental Hospital and Institutional Workers’ Union 138, 162 see also NAWU mental hygiene 18 mental illness xi, 1, 2, 10, 40, 88, 114, 123–4, 135, 137, 139–40, 161, 171, 183, 218, 238, 240, 248, 250 and representations 124 mental nurses ix, 1, 5, 19, 83–4, 86–8, 91–3, 127, 140, 157, 171–4, 176–85 mental nursing 20, 85–6, 90, 140 169–70, 172–4, 176, 179 –85, 244 mental subnormality see learning disability terminology Mental Treatment Act 10, 12, 99, 115, 117, 170–1 mental well-being 1, 160 MHIWU see Mental Hospital and Institutional Workers’ Union Mickelover Asylum 129 Midland Counties Institution 151–2, 156 midwives 18 Ministry of Health 113, 174, 181, 218, 241 Ministry of Labour 106–7, 174, 177 Ministry of Pensions 112 Mitchell, Duncan 5, 215 Monaghan Asylum Soviet 49 monasteries 6, 17 Mond, Alfred 112 Monitor xii monks 6 moral management 79, 82, 171 moral therapy 29–30, 148 Moss Side State Institution 80 MPA see Medico-Psychological Association MTA see Mental Treatment Act multi-disciplinary clinical team 246, 252

National Advisory Council for the Recruitment and Distribution of Nurses and Midwives 177 National Association for Mental Health 239 National Asylum Workers’ Union 98, 100–8, 112–13, 124, 126, 128, 131–40, 154 and Magazine 98–100, 102–3, 126–8, 131, 133, 135–8 see also MHIWU National Consultative Council for the Recruitment of Nurses and Midwives 169 National Council for Lunacy Reform 113 National Council of Institutions for the Mentally Afflicted 106 National Health Service xii, 11–15, 17, 19, 158, 164, 169–71, 179, 190, 214–16, 224, 226–7, 230, 239 nationality x NAWU see National Asylum Workers’ Union Nelson, S. 48 Netherlands 41, 197 neurasthenia 77 Newcastle General Hospital 240 NHS see National Health Service Nightingale, Florence ix, 7, 9, 29, 42, 184 and ‘Lady with the Lamp’ 28 Nightingale model 5 Nolan, Peter 1, 6–7 Northern Ireland 19 North Wales Lunatic Asylum 30 nuns 6, 36–7, 41–3 nurse and dual qualifications 83, 86, 92, 173–4, 243–4, 248 and education 15, 180–1, 222, 227 and examination 66 and recruitment 2, 12–14, 16, 20, 30, 146, 150, 155, 157–8, 161, 165, 170, 177–9, 185, 221, 242–3, 251 and registration 10, 84, 223

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Index and retention 12–14, 20, 30, 146, 150, 155, 161, 170, 177, 179, 242, 251 and training 3, 16, 18, 20, 29, 36, 39, 48, 64, 91, 113, 115, 177–81, 184, 193, 221, 243–6, 249 and wastage 173, 182 Nurse Ratched 28 Nurse Rooke 49 Nurses’ Act (1943) 179–80 Nurses Registration Act (1919) 171, 178, 216 Nursing Advisory Council 182 nursing and knowledge 3, 12, 16, 76 and organisations 3, 9, 20, 137, 172, 179 and practice 3, 18–19, 145 and schools 113, 157, 178, 184, 249 Nursing Mirror 86, 89, 222–3 Nursing Times 133, 222–4 occupational therapists x, 116, 236, 245–6 occupational therapy 236, 245 Oldham 240 Oliver, Michael 101 One Flew Over the Cuckoo’s Nest 28 Opening the Door 193 oral history 224 Order of St John of Jerusalem 76 Oswin, Maureen 219 out-patient services 18, 88, 235 Outside the Walls of the Asylum 190 Owen, Wilfred 75–6 Paddington Day Hospital 237 Pall Mall Gazette 134 Parahoo, Kader 19 patient and allegations abuse/mistreatment 31, 45, 112–13, 115, 124, 135, 154, 165, 170, 191 and care 163, 169, 174, 176, 179 and experiences 2, 8, 19–20, 99, 191 and ex-servicemen 112, 124, 134–5 and rights x

and voices 115 and welfare 45, 126, 137, 171 and well-being 104, 247, 252 pauper lunatic 136 pay see wages pay scales 55, 152, 164, 172 and Rushcliffe 164 pensions 17, 35, 85, 102, 108–10, 126, 155 Percival, Carol 249–50 Percy Report 239 physical therapies/treatments 11, 16, 83, 160–1 Pickstone, John 240 Pierce, Bedford 103–4 Pilgrim, David 239 Platt Report 14 Poor Law 5, 7, 116, 159, 192 Porter, Sam 45 post-natal depression 18 Powell, Enoch 217–18, 239, 241 power 8, 32, 45–6, 48, 56, 67, 109, 128, 137, 139,172, 176, 191, 195, 239, 246, 251–2 Preliminary Training Schools see nursing schools Prentice, David 158, 160–2, 164 Prestwich Asylum 112–13 privatisation 12, 239 problem families 191, 196–9 promotion 55–6, 59–62, 67, 69, 84, 86, 157, 173–4 psychiatric nurse 4, 16, 28, 124, 137, 139–40, 249–51, 253 see also CPN; mental nurses; RMN psychiatric nursing 78, 138, 245, 249–50 psychiatric social worker 140, 236 psychiatric treatment 205 psychiatric unit 235, 240, 242–3, 250 psychiatrist ix–xi, 113, 125, 129–30, 133–4, 136–7, 139, 174, 224, 240, 242, 251 psychiatry ix, 18, 40–1, 44, 88, 100, 111, 115, 117, 124–5, 133, 236–7, 242, 248, 250 psychologist x, 80, 82, 236, 246

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Index psychosurgery 138 public health 1, 197 and nurses 18 QAIMNS see Queen Alexandra’s Imperial Military Nursing Service Quakers see Religious Society of Friends Queen Alexandra’s Imperial Military Nursing Service 76–7 racism 183 Radcliffe Asylum, Nottingham 101 Radford, J. P. 147–8 Rafferty, Anne Marie 3–4, 126, 177, 180, 185 Rahman, Shahina 11 Rainhill Mental Hospital, Merseyside 243–4 Rayner, Claire 13 RCN see Royal College of Nursing Red Cross see British Red Cross Registered Mental Nurse 4, 19, 242–5 see also mental nurses; psychiatric nurse Registered Nurse Mental Handicap 4 see also learning disability nurses rehabilitation 192, 196–7, 209 relatives x, 7–8, 19, 40, 125, 174 Religious Society of Friends (Quakers) 198–9, 208 resettlement 228 retired nurses 49 Richmond Asylum, Dublin 31 Rivers, W. H. R. 82 RMN see Registered Mental Nurse RMPA see Royal MedicoPsychological Association RNMH see Registered Nurse Mental Handicap Robertson, George M. 83–4, 86, 88, 129–31, 137 Rogers, Anne 238–9 Roscommon 46 Roundway Hospital, Wiltshire 173 Royal Albert Asylum 151–2, 156

Royal Army Medical Corps 79 Royal College of Nursing 10, 86, 133, 137, 172, 184, 226 Royal Commission on Lunacy and Mental Disorder see Macmillan Commission Royal Earlswood Asylum 7, 145, 150–2, 156–7 Royal Eastern Counties Asylum 151–2, 156–7 Royal Edinburgh Asylum 7, 83, 244 Royal Hospital Kilmainham, Dublin 37–8 Royal Medico-Psychological Association 125, 129–30, 137, 173, 216 and nursing certificates 38, 84, 88 and nursing examinations 91, 177–8, 216 and nursing qualifications 4, 38–9, 83–4, 86–7, 89, 92, 113, 133, 150, 157, 163 and publications 40, 58–60, 64, 84, 131–2, 139 and training for nurses 68, 164, 177–8, 216 Royal Victoria Military Hospital, Netley 80 Royal Western Counties Institution, Starcross 17, 146–65 Runwell Mental Hospital, Essex 182 Russell, Richard 69 RWCI see Royal Western Counties Institution St James Psychiatric Unit, Leeds 243 St John Ambulance Association 84–5 St Patrick’s Asylum, Dublin 31 Salmon Report 249–50 Salop Asylum 112 scandals xi, 14, 19, 98, 112, 114, 124, 140, 183, 219–20, 238 Scotland 84–6 Scottish asylums 88, 129 Scottish asylum system 83, 88 Scull, Andrew 54

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Index Seacole, Mary ix Second World War 12–14, 169, 176, 196–7, 199 Severalls Hospital 135 Shaw, Herbert 126 shell shock 76–7, 80–2, 90–1, 134–6 Shepherd, Ben 82–3 Showalter, Elaine 80–1, 123–4 Sinclair, Ian 194–5 Sir Patrick Dun’s Hospital, Dublin 38 Sisters of Charity in Ireland 36 SJAA see St John Ambulance Association Sligo 46 Smith, W. Beattie 57, 61, 63 social deviancy 125 Socialist Medical Association 172 social worker 16, 116, 191, 197, 226, 237, 246, 252 see also psychiatric social worker social work knowledge and practice 198 Somerset 17 South Africa 8 Spain 182 Spandler, Helen 237 Springfield Hospital, London 175 Springthorpe, J. W. 64 SRN see State Registered Nurse Stanley Royd Hospital, Wakefield 181 Starcross see RWCI Starns, Penny 12, 14 State Registered Nurse 243–5 see also general nurses status 12–13, 17, 29, 31–2, 36–7, 41, 43–4, 84, 86–7, 91, 102, 124–5, 133, 137, 153, 164, 171–4, 183, 191, 221, 252–3 stigma x, 9, 13, 43, 88, 115, 124, 132, 135–6, 140, 171, 192, 209, 215, 248, 251–2 stress 13 strikes 10, 98–112, 114, 116 suicide 13, 19, 46, 113, 132, 176 Sunbury Asylum, Victoria, Australia 55, 59–60

Sunday Chronicle 135 Symonds, Anthea 7 Territorial Force Nursing Service 76 TFNS see Territorial Force Nursing Service Thatcher, Margaret and government 238, 248 therapeutic communities 18 Thomson, Mathew 146, 214 Thornton, Frederick 33 Tipper, Alison 147–8 Truth 134–6 Turner, Frank Douglas 157 Unemployment Assistance Board 204 United Kingdom 3, 6–7, 9–10, 18, 20, 169, 190–1, 214–15, 223, 238 United States of America 13, 18 University of York 226 VAD see Voluntary Aid Detachment Valuing People 216 Victoria, Australia 54–70 and Chief Secretary 55–6, 60, 64, 67 and Department of the Chief Secretary 55 and Hospitals for the Insane Department 55 and Inspector-General of the Insane 69 and Inspector of Asylums, 54–5, 60 and Lunacy Act (1903) 69 and Official Visitors to the Metropolitan Asylums 64, 66–7 and Public Service Act 56 and Public Service Board 56, 61, 63, 67–9 and Public Service Commissioner 67, 69 and Royal Commission on Asylums for the Insane and Inebriate 55, 62, 66 violence 9, 43, 45, 127–8, 131, 134, 136, 139–41, 154, 171

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Index vocation 8, 184 Voluntary Aid Detachment 10, 76–8, 80, 86, 88 wages x, 17, 36–8, 42, 55, 69, 98–100, 102–3 125–8, 146, 151–3, 156, 172–3, 184–5, 191, 193–4, 199–200 see also pay scales Wakefield 133, 181 Wales 79–80, 85, 170, 179, 197 wardens 3, 191–6 Warley Hospital 173 Webster, Charles 3–4, 126, 169, 172–3 Welsh Metropolitan War Hospital 76, 78–80, 83, 86–9 Welshman, John 5, 215 Wessely, Simon 81 West Hill Hospital, Dartford 240 West Indies 183 West Middlesex Hospital 250 White, Ernest 80 Whittingham Hospital, Lancashire 176 Williams, Chris 17

Williamson, W. C. 57–8, 64, 68 Wilson, Harold and government 222 Wiltshire County Mental Hospital 159 Winslow, L. S. Forbes 40 Winwick Asylum, Lancashire 101 Withington General Hospital 235, 251 Withington Psychiatric Unit 235–7, 239, 242–4, 246, 248–9, 251–3 WMWH see Welsh Metropolitan War Hospital Wood Report 14 Wootton, Barbara 198 workers’ rights xi workhouse 29, 42–3 Working for Health 1 Wright, David 8, 145–6 wrongful confinement x, 134 wrongful detention 112, 114, 116 Yarra Bend Asylum 54–5, 62–3 York Retreat 103, 200

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