Mental Health History – It Matters

The history of mental health nursing has often been overshadowed by other histories. It has been overshadowed by nursing’s subservience to medical men who were quick to lay claim to the ownership of psychiatry as a science to gain respectability and a professional identity. It has been overshadowed by general nursing history which was able to celebrate heroines such as Florence Nightingale. Without such exalted heroines, mental health nursing has often been relegated as an appendage to general nursing, and its history, and given little value as part of the history of health care. It has also been overshadowed by a lack of motivation to hear its history given its association with the anxieties that society has had about mental illness and the negative mythology associated with lunatic asylums of the past. Yet, its history is rich and deserving of acknowledgement. Understanding mental health nursing history encourages a collective memory, helps to forge a professional bond and identity and a way forward out of past circumstances and old mentalities.

To seek out early mental health nursing history, we often need to search in the margins of other histories. Peter Nolan (1993), one of the first authors to acknowledge that mental health nursing is deserving of its own history, outlined early mental health care situated within religious organisations championed by saints such as St John of God and St Vincent de Paul. He also highlighted the work undertaken by the Celtic Monks, and with almost tongue in cheek, described these men as the first community mental health nurses. These monks, commonly called ‘soul friends’, supported and befriended the ‘disenchanted and melancholic’ to help them return to their family.

Undoubtedly, it was the large-scale development of lunatic asylums throughout the Western world, that provided the impetus for people to be employed as ‘attendants’ to care for people housed in asylums, while at the same time protecting the community from the perceived dangers of individuals deemed to be mentally ill. While asylums were a direct response to the remarkable advances in science, the arts, politics, and philosophy beginning in the 17^th century, the establishment of asylums continues to be perceived as one of the most controversial developments in the history of health care (Wright, 1996).

While, asylums were part of a movement embracing humanitarian ideals, the reality of asylums was very different. Underfunding, poverty, increasing numbers of elderly, chronic and incurable patients, and overcrowding quickly created a situation where asylums had little choice, than to be custodial. Humanitarian ideals were squashed. Custodial care offered a cheap and simple system for managing large institutions. It was recognised that the attendants in asylums played an important role: William Batty, a physician, called for need for care and benevolence, but also for a better class of person to become ‘attendants to the mentally disordered’ (Hunter & McAlpine, 1963, p. 252). It seemed that the early nineteenth century mental health nurse was one who was looked down upon: ‘Keepers [attendants/nurses] are the unemployed of other professions. It they possess physical strength, and a tolerable reputation for sobriety, it is enough; and the latter is frequently dispensed with’ (Browne, 1837).

Yet, there is another side to this negative stereotypical picture of the early mental health nurse. Their work was undoubtedly difficult and likely to attract those who were stronger and more able-bodied. In fact, some Asylum English histories (See Digby, 1985; Russel, 1988; Wright, 1996) indicate that these institutions offered valuable employment opportunities, wages were reasonable, and attendants were drawn from respectable professions such as soldiers, skilled artisans, agricultural labourers, and attendants from other asylums. It was not likely that the role of attendants reflected the exalted view of asylum reformers; patient numbers were high, and training was almost non-existent. However, at the same time, these attendants and nurses should not be tainted with the negative perceptions surrounding early mental health nursing history.

Similarly in Australia, while the history of general nursing is conceived of in exalted terms with its origins associated with Lucy Osborn, a nurse trained at a School of Nursing founded by Florence Nightingale, Australian mental health nursing history cannot lay claim to such illustrious beginnings. The origins of modern Australia are tainted by colonialism, convictism and the penal system, and the beginnings of mental health nursing are shrouded in this same stigma. Mental health patients were first housed in prisons before asylums were established. The first mental health nurses were often convicts, prison officers, soldiers, or domestic servants (Bradshaw, 2016; Raeburn et al., 2018). Asylums were built on a limited budget, and the first patients had a life, little different to that of a prisoner. Yet, despite such punitive conditions, there is evidence that some early attendants acted with compassion, tried to ensure that patients had adequate living skills to return to the community and engaged with families to ease the transition back to the community (Bradshaw, 2016). Little of this is apparent in the modern-day narratives which dominate mental health nursing history.

As mental health nursing moved into the twentieth century, asylums generally underwent a name change and became known as hospitals. Despite these changes, the image of mental health nursing continued to be associated with the negative stereotypes of asylums. This has been described as the ‘enduring asylum’ phenomenon’ by authors such as Diana Gittins (1998). Undoubtedly, the associations with asylum care shaped the culture and identity of mental health nursing well into the twentieth century (Prebble & Bryder, 2008).

Asylum practices meant that a gendered workforce was required, with male attendants caring for male patients and female nurses caring for women. Prebble and Bryder (2008) argues that it is this characteristic of mental health nursing, the presence of a male workforce, that differentiated it from general nursing. General nursing with its female workforce was the ‘norm’ and mental health nursing, with its gendered staffing, was the ‘abnormal’. In fact, with its origins lying in attending and maleness, mental health nursing was perceived more as an occupation than a profession.

The unique nature of mental health nursing work required in large institutions, did not help dispel the conception that mental health nurses are not ‘real’ nurses. The need for these large hospitals to be self-sufficient and the belief that work is therapeutic and rehabilitative, meant that attendants and nurses engaged in work with their patients. Most mental hospitals were situated on large acreages that allowed space to farm and garden. Patients were employed in the kitchen, and females were engaged in laundry and mending. Such traditions differed little from the nineteenth century. These roles were necessarily gendered and shaped the identity of the attendant and nurse - an identity that contrasted markedly with a general nurse tending to the sick and wounded.

As we move into the twenty first century, our lack of definition, or one that is simply characterised by a difference to general nursing, led Hildegard Peplau (1994) to observe that mental health nursing was in danger of slipping back into roles focussed on little more than collecting observations for psychiatrists and handing out pills, effectively returning mental health nursing to nineteenth century approaches which amounted to little more than being the eyes and ears of medical doctors. In 2011, influential nursing theorist Phil Barker (Barker & Buchanan-Barker, 2011) argued that the field of mental health nursing remains a ‘popular modern myth’ that is difficult to define. Both Peplau and Barker drew attention, however, to the potential of history, to assist the development of mental health nursing’s professional identity. As Tosh states: ‘One of the strongest bonds uniting a large social grouping is its members’ awareness of a common history’ (Tosh, 1999, p.3).

While it is true that history has played an indispensable role in the development of an identity narrative for the profession of generalist nursing (Church, 1987), in the field of mental health nursing, a thin version of the past based on secondary and tertiary documents has often been accepted. Modern mental health nursing textbooks often lack any description of early mental health nursing (Procter et al., 2014), or skip over it, without describing the context, or care provided in early lunatic asylums (Evans et al., 2016; Raeburn et al., 2018). Such a generalised approach to history risks perpetuating myth and mistruth about the profession.

There is need for further historical research, to illuminate the complexity of the past and provide insights into the motivations behind decision-making, existing cultural and societal assumptions and the minutia of everyday life. In contemporary mental health literature, it has become all too common for authors to use historical research as illustrations of established ‘facts’, rather than data from which to develop historical reasoning. Such approaches generally fail to acknowledge the complexity of the evidence contained within historical sources, do not reflect on the purposes and motivations that source material might have served for their author and players at time of writing, and often fail to consider the understandings that readers would have brought at the time and context of writing. A lack of depth in the way history is treated in current day mental health nursing education effectively robs mental health nurses of the opportunity to use historical critique as a method to analyse contemporary issues.

In this special edition of Issues in Mental Health Nursing focussed on the topic of the history of mental health care, we are delighted to publish a broad range of theoretical/conceptual, review, and research-focussed papers addressing a range of eras and topics related to mental health nursing, services and programs, and the impact of social and cultural influences on mental health policy, treatment approaches and education. These papers showcase how mental health history has the potential to provide a window into the past which can increase contemporary nurses’ ability to interrogate differences in perspectives and biases of historical and modern-day actors on the historical stage. It also provides us with the capacity to envision a history that is not just disheartening, but one that replenishes our spirit and reinvigorates the reasons why we became mental health nurses and highlights possibilities.

Disclosure statement

There are no competing interests to declare for any author.

Funding

The author(s) reported there is no funding associated with the work featured in this article.