Reviewed by Amanda Haislip (Michigan State University)
Published on H-Disability (January, 2017)
Commissioned by Iain C. Hutchison
Work, Psychiatry, and Society, c. 1750-2015 is a collection that examines how patient work in mental institutions has been conceptualized, practiced, and experienced. Patients’ work has been regarded as either therapeutic or as necessary for the continued functioning and funding of the institution, but these well-conceived chapters usefully complicate this dichotomy by placing patient work in a critical relationship with larger sociocultural, economic, and political changes across time and place. The chapters aptly investigate how ideas about, and the practice of, patient work in mental institutions have changed over time due to individual patient personalities as well as shifting social, institutional, and medical contexts. The result is a book that urges readers to consider the importance of how “work, psychiatry, and society are intrinsically bound up” (p. 10).
Waltraud Ernst, professor in the history of medicine at Oxford Brookes University, provides a well-organized and informative introduction to the collection’s seventeen chapters. As she argues, this book begins the work of filling in a gap in the history of psychiatry, constituting “the first attempt to examine patient work in a wide range of psychiatric institutions and to conceptualise the meaning of work in relation to its specific sociocultural, economic, and political contexts” (p. 1). Ernst then provides an overview of different ways in which work has been conceptualized, from ancient times, to Adam Smith’s ideas of productive and unproductive work, to Karl Marx’s theory of alienation, laying the foundation for how economic and social ideas and practices outside of institutions influenced “perceptions of patient work in institutions, and the conditions under which it was performed,” and were just as important as medical ones (p. 5).
Ernst admirably weaves the chapters together thematically and situates the book within the important debates in the history of psychiatry as well as the related fields of occupational health and industrial therapy. While the collection’s chronology begins in 1750 and ends in 2015, the majority of the material comes from about 1800 to 1970. In addition to encompassing a large chronological scope, the book covers a wide geographical one that includes the United States, Canada, Great Britain, France, Germany, Austria, Romania, India, the Caribbean, and Japan. Although this ambitious coverage makes the book a somewhat unfocused read at times, the chapters concerning colonial contexts and non-Western countries are much needed and provide valuable insight to how mental illness, work, and society intersect in a global context of capitalism and modernization in the twentieth century.
While none of the chapters have overarching thematic arguments based on class, race, ethnicity, or gender differences relating to patient work, many of the chapters engage these themes. Oonagh Walsh’s chapter, “Work and the Irish District Asylums during the Late Nineteenth Century,” persuasively incorporates a gendered perspective into an argument about patient work in an asylum setting. In one subsection, Walsh shows how ideas about appropriate female labor were more diverse than those regarding males, leading to a “higher rate of occupation for women in asylums” (p. 303). Consequently, she argues, women were much more likely to be “released ‘recovered’ and ‘cured’ than were men” because of their ability to do work within the asylum (p. 303). Walsh asserts this within the larger context of how work in Irish District Asylums drove the asylums’ functioning through patients’ freedom of movement and daily routine, while also contributing to the financial operation of the institution, providing occupational therapy, and acting as a test for sanity. Kathryn McKay’s chapter, “From Blasting Powder to Tomato Pickles: Patient Work at the Provincial Mental Hospitals in British Columbia, Canada, 1885-1920,” also touches on the relationship between gender and patient work. Within her larger argument that superintendents’ annual reports shifted from presenting patient work as fiscally motivated to a primarily therapeutic measure by 1920, McKay discusses how gender norms determined how medical superintendents presented patient work to the public and governing authorities. She argues that, although most male work actually took place on the hospital ward, superintendents’ annual reports instead reinforced larger social ideas that male work frequently took place outside and “contributed to the construction of a society” while “women stayed at home and performed domestic tasks” (p. 104).
Ernst’s chapter focuses on patient work in South Asian colonial mental hospitals using a transnational lens of analysis. She documents how European and North American psychiatric ideas were modified to suit a local colonial context that included different cultural beliefs, social and racial prejudice, and patient and superintendents’ attitudes toward work. Ernst highlights “the shift in British India from work as a moral therapy during the nineteenth to [occupational therapy] in the early twentieth century” alongside a separation of leisure and work activities based on racial, caste, class, and gender classifications (p. 136). Akira Hashimoto’s chapter, “Work and Activity in Mental Hospitals in Modern Japan, c. 1868-2000,” explores transnational connections between the United States and Japan, with a distinct focus on the connection between patient work and occupational therapy. He underscores how patient work in mental hospitals in Japan was strongly influenced by new psychiatric ideas and the professionalization of occupational therapists in the United States. To end his discussion, Hashimoto examines how one model of occupational therapy in Japan, the kawa model, has distanced itself from Western-based theory and practice since 2000. Focused solely on Europe, Jane Freebody’s chapter, “The Role of Work in Late Eighteenth- and Early Nineteenth-Century Treatises on Moral Treatment in France, Tuscany, and Britain,” uses transnational analysis to demonstrate how doctors perceived work differently depending on region, time period, and system of medical beliefs.
Readers familiar with the history of psychiatry will appreciate how patient work relates to the creation of the asylum and its transformation to mental hospital. The linkage between patient work and movements in psychiatry such as the moral treatment popularized by William Tuke (1732-1822), the mental hygiene movement, professionalization, psychosurgery and drug therapy, and deinstitutionalization is enlightening. Also, the global political and economic impacts of World War I, the 1929 economic depression, and World War II, as well as important local events, were essential to how work was conceptualized both inside and outside the institutional setting. Particularly relevant chapters to this theme focusing on Great Britain are Sarah Chaney’s “Useful Members of Society or Motiveless Malingerers? Occupation and Malingering in British Asylum Psychiatry, 1870-1914” and John Hall’s “From Work and Occupation to Occupational Therapy: The Policies of Professionalisation in English Mental Hospitals from 1919 to 1959.” In the American context, Ben Harris’s chapter, “Therapeutic Work and Mental Illness in America, c. 1830-1970,” demonstrates that work played an important part both in the birth of the asylum and in its dismantling during deinstitutionalization.
Although many of the chapters focus on institutional records or professional publications, James Moran impressively draws on the voices of “patients, families, doctors, and court officials” from civil court trials in lunacy to show how the ability and willingness to work was perceived as an essential characteristic of good mental health and sanity in his chapter, “Travails of Madness: New Jersey, 1800-70” (p. 12). Another methodologically innovative chapter is the final chapter, “The Hollow Gardener and Other Stories: Reason and Relation in the Work Cure,” written by Jennifer Laws. Laws’s contribution is justly praised by Ernst for its “elegant and methodologically sophisticated analysis of two case scenarios” as well as its effective rounding off of the book (p. 27). Her chapter shows that understanding patient work as “rational and reasoned might be at odds with a greater view of the human as a more fundamentally ‘occupational being’” (p. 352). Furthermore, Laws’s interdisciplinary analysis is able to effectively relate Tuke’s moral therapy to present-day practice, and she persuasively argues that work, through “professional helping relationships” and not merely as rational and efficient activity, is an essential part of “human health and happiness” (p. 365).
Ultimately, this book offers a solid foundation for historians and medical professionals interested in learning more about patient work in institutional contexts and how societal conceptions of meaningful and productive work have changed over time. Ideas of patient work and willingness to work could be linked with a patient’s morality, status in society, or chance for recovery and release, and could be seen as therapeutic by providing a mental distraction from morbid thoughts. Simultaneously, institutions could use patient work to keep the institution clean and operational or to create goods or food items that would offset costs or even create revenue through sale to the larger community. This book successfully shows how patient work in institutions should not be simply viewed in terms of a dichotomy of work as therapy or work as institutional necessity. Work, Psychiatry, and Society makes a compelling case for why patient work matters and should be further explored by historians not only of psychiatry and medicine but also of labor, economic, and social history.
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Amanda Haislip. Review of Ernst, Waltraud, ed., Work, Psychiatry and Society, c. 1750-2015.
H-Disability, H-Net Reviews.
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