Review of Borsay and Dale ‘Mental Health Nursing’

Anne Borsay, Pamela Dale, eds. Mental Health Nursing: The Working Lives of Paid Carers in the Nineteenth and Twentieth Centuries. Manchester: Manchester University Press, 2015. 288 pp. GBP 70.00 (cloth), ISBN 978-0-7190-9693-8.

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Reviewed by Alice Brumby (University of Huddersfield)
Published on HDisability (April, 2018)
Commissioned by Iain C. Hutchison (University of Glasgow)

Printable Version:

Professor Anne Borsay, one of the two editors of this collection, passed away in the final stages of editing this book. A pioneer for disability history, Borsay’s individual works and edited collections have substantially added to both the field of disabilitystudies and our knowledge of the history of medicine over the years.[1] This volume, co-edited with Pamela Dale, complements this tradition by highlighting a largely neglected field within the scholarship of mental health studies. This collection brings together eleven essays which focus on the role of paid carers in mental health settings over the course of two centuries from the perspectives of England, Scotland, Wales, Ireland, and Australia. As Mick Carpenter so accurately states in the foreword to the collection, the history of nursing in general, and nurses and paid carers more specifically, has previously been seen as “only marginally interesting by history” (p. ix). Within this broader context, the role and duties of the psychiatric nurse or practitioner involved in mental health nursing have been bypassed with little comment or analysis. While Roy Porter long ago recognized the need to re-insert patients back into the history of psychiatry, the individual roles of the nurses and caregivers have to some extent remained marginalized.[2]

Borsay and Dale’s substantial introduction helps to consolidate the key themes of the volume by offering a concise overview of the historiography and highlighting the gaps in the existing literature. While acknowledging the work of Peter Nolan and Mick Carpenter, among others, they highlight that this is a field which remains neglected.[3] They explain that even when “compared to other branches of nursing, the mental health sector lacks even celebratory histories of Victorian/Edwardian nursing personalities and autobiographical accounts” and this deficiency continued with the twentieth-century mental health nurse (pp. 1-2). This recognition perhaps explains why this group is largely missing from the literature; the volume’s focus on the lives of the ordinary rank-and-file staff has to some extent perhaps not being considered “interesting or worthy enough”—until now. The editors clearly highlight a number of important research questions relating to the experiences of these staff members, and how these experiences might have directly or indirectly affected others who shared the same working and living environments. The collection is organized in chronological order, allowing a contextual history to be built; however, the chapters are important in their own right and there is no illusion to a bigger Whiggish history of progress. Instead, the individual experiences of carers can be seen in their own specific frameworks. Nevertheless, collectively the volume reveals common threads throughout the different chapters, with poor remuneration, long working hours, and a claustrophobic working environment frequently identified as recurring issues encountered by staff on a daily basis.

A lack of training and the consequent perceived distinction made between the asylum nurse and the general nurse form the common themes that tie the following two chapters together. Oonagh Walsh focuses solely on female district asylum nurses in her chapter, which sheds light on nineteenth-century Irish practice. Her identification of superintendents’ views that asylum nurses needed to be constantly treated with suspicion and required “constant check and reprimand,” sits uneasily with the representation of nurses as saintly figures of nurture and care (p. 33). Walsh proposes that this image was intensified in Ireland, where the Catholic Church played a unique role in undermining the professional status of nurses. With regard to a lack of training, Walsh attests that female nurses were deprived of this by superintendents who were eager to maintain their own monopoly of knowledge. In contrast to this Irish context, in her chapter on attendant training in Victoria, Australia, Lee-Ann Monk identifies an opposing picture. Her work, which focuses upon the late nineteenth and early twentieth century, describes the trials of superintendents in their eagerness to impose training on a reluctant and resilient staff body. Monk identifies some of the key antagonisms that staff felt towards training, specifically when aspects of training were introduced (often by younger trained colleagues) into an environment where staff had considerable experience. The contextual framework of the Australian lunacy system compounded these issues. In Australia, it was the Public Service Board and not the asylum superintendent that had the authority to recruit, promote, punish, and dismiss staff. Despite superintendents strongly recommending compulsory training, tension between superintendents and the Public Service Board meant that superintendents had little power before 1903, when full control was transferred to them. This pre-1903 tension reinforces the regional and contextual variations between the experiences of paid carers in different colonies during the nineteenth century.

The next four chapters focus on a particularly neglected period of mental health research—from roughly 1910 through the interwar period to the emergence of the UK National Health Service (NHS) in 1948. The first of these chapters, jointly authored by Anne Borsay and Sarah Knight, focuses upon the role of nurses in the Welsh Metropolitan War Hospital in Cardiff during the First World War. Formerly Cardiff City Mental Hospital, the hospital was converted during the war and soon specialized in caring for shell-shocked patients. As with the earlier chapters, part of the narrative centers on the tensions between asylum nurses and general nurses and specifically identifies the precarious position that female staff found themselves in while looking after male shell-shocked patients. Nevertheless, they describe how the war brought greater opportunity to try to professionalize the workforce and bring mental health nursing more in line with physical nursing during these years. However, despite clearly making a difference in some areas of mental health care, it has been argued by some historians that the unique circumstances of the First World War have been overstated as a factor in postwar shaping of industrial relations. Using Exeter City Asylum, colloquially known as “Digby’s,” as a case study, Barbara Douglas highlights the discontent that staff felt about their working and living conditions. Personal testimonies of the staff are used to highlight the severe tensions between asylum staff and the officials of the visiting committee. Douglas uses the magazine of the newly established National Asylum Workers’ Union (NAWU) to identify staff complaints and to explain strikes during these years. Continuing the theme of poor working conditions, Vicky Long employs gender analysis in her study of nursing and violence in the interwar years. Long goes further than Douglas, however, and criticizes the NAWU for a “significant tactical error” that succeeded in holding back the image of the asylum as a curative general hospital specializing in treating sick minds (p. 141). While, in theory, the union sought professionalism, on the subject of female nurses working on male wards, the union was content to disparage patients and the nursing profession itself, by characterizing male patients as dirty, aggressive, sexually perverted, and socially deviant, as opposed to sick. Although this narrative was designed to protect male jobs from the lower wages of female nurses, Long argues that such representation belittled the work of professionals of both genders. It reinforced the image of mental health nursing as primarily consisting of the role of a custodian and keeper, thereby reinforcing stigma on both staff and patients alike.

While these chapters focus specifically on the role of nursing and working conditions in mental hospitals, Pamela Dale’s chapter offers an interesting comparative account in her analysis of the conditions in an institution set up to cater principally for children with learning disabilities. Following the Mental Deficiency Act of 1913, treatment and care of the “mentally deficient” was intended to be separated from mental health care. The staff at the Royal Western Counties Institution found themselves adapting to changing legislation as the custodial role increased and the educational role decreased in priority. The distinctive role of caring for learning disability created subtle differences for the staff who worked there. Nonetheless, there remained many familiar challenges, including poor pay and working conditions, which ensured the same epidemic of staff shortages that was apparent at mental hospitals across the country. Concluding this section on large institutional settings, Claire Chatterton identifies how familiar themes of chronic staff shortages hounded the mental health profession into the postwar NHS world. Looking at the period from 1948 to 1968, Chatterton shows how little change there was in terms of staff incentives, suggesting that the all too familiar cocktail of poor pay, long hours, and a negative representation continued throughout the closing years of era of institutional confinement.

Beyond large institutional settings, John Welshman analyzes a selection of letters at Brentwood Centre for “problem families” in order to identify the importance of staff to the lived experiences of hostel clientele. Welshman highlights how life in Brentwood Centre was often perceived to be an important and much-needed break for families struggling to maintain “respectability.” This chapter highlights the need to examine a variety of postwar services where reformers were advocating alternative forms of residential provision that were more homely than traditional, and enduring, Victorian asylums. The final two chapters study learning disability and mental health care services throughout the years 1970-90. Duncan Mitchell offers an interesting insight to the plight of learning disability nurses and their attempts to gain recognition of their role and professional identity in a changing landscape in which large institutions were closing their doors in favor of community practices. Mitchell argues that the adaptability of these nurses saved their profession from near extinction. By the end of the period, he contends, these nurses became “an essential part of reconfigured services” (p. 228). Offering an analysis of the same chronological period, Val Harrington’s work is an interesting comparative study, which identifies the complexity of mental health provision between 1971 and 1991. Harrington argues that the historiography of these years focuses predominantly on the transition from mental hospitals to community care, with Mitchell’s earlier chapter providing a case-in-point. However, Harrington argues that this linear structure conceals the interesting intermediary spaces of provision between hospital and community care, such as the district general hospital. Using oral history testimonies of the nurses who worked in Withington Psychiatric Unit in South Manchester, Harrington concludes that the nurses who worked there forged a professional identity far removed from that of traditional asylum nurses. Despite this positivity surrounding this new role, however, it is clear from the nurses’ testimonies that general nursing and mental health nursing remained as far apart as ever, and mental health continued to be an unequal partner in the battle for proving professional standards and providing care. Despite the attempts at professionalization and advancing medical and social understanding, mental health nurses continued to be the “poor relation” in the nursing family, burdened with the stereotyping and stigma which, as this volume all too clearly shows, has besieged their profession.

Overall, while other narratives and edited collections have tended to focus on the patients and their experiences of mental health treatments, this volume focuses on the experiences and roles played by ordinary staff. Michel Foucault’s thesis identified an oppressor/victim power hierarchy between nurses and patients, thereby suggesting that nurses were part of the institutional system of oppression.[4] This volume seeks to overcome that somewhat simplistic dichotomy by identifying some of the clear complexities of mental health nursing. By focusing predominantly upon poor working conditions, long hours, and poor pay, the collection suggests that paid carers in mental health settings, to some extent, were as constrained and victimized within the system as were the patients. Furthermore, the contributors have made clear the important duties that some of these workers carried out, notably in becoming friends and confidants to patients. As ever with these volumes, it would have been nice to see a broader selection of countries represented. Lee-Ann Monk’s chapter exploring the colonial perspective in Australia appears a little tokenistic in a volume offering geographical coverage predominantly of the British Isles. Furthermore, given the strong similarities between the chapters, it would have made for a more cohesive volume for the contributors to acknowledge each other’s work on points of difference and similarity. Nevertheless, this scholarship provides a selection of interesting new research questions and opens the door for further research which might explore the experiences of professional paid caregivers in different countries and contextual frameworks. This is an important book, and a timely reminder that, in spite of setting or of policy, those who work on the front line of patient care are the ones who often have the biggest impact on patient experience. Within the caring relationship, the patient and the nursing staff are inextricably bound, and this volume allows us to further understand the intricacies involved in this important, complex relationship.


[1]. Anne Borsay, Disability and Social Policy in Britain since 1750: A History of Exclusion (Basingstoke: Palgrave, 2005).

[2]. Roy Porter, “The Patient’s View: Doing Medical History from Below,” Theory and Society 14, no. 2 (1985): 175-98.

[3]. Peter Nolan, A History of Mental Health Nursing (London: Chapman and Hall, 1993), “Mental Health Nursing in Great Britain,” in 150 Years of British Psychiatry, ed. Hugh Freeman and G. E. Berrios, vol. 2 (London: Athlone, 1996), 171-92; and Mick Carpenter, Working for Health: The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988).

[4]. Michel Foucault, Madness and Civilization (New York: Pantheon, 1965).

Citation: Alice Brumby. Review of Borsay, Anne; Dale, Pamela, eds., Mental Health Nursing: The Working Lives of Paid Carers in the Nineteenth and Twentieth CenturiesHDisabilityH-Net Reviews. April, 2018.