History of the Social Practice of Psychiatric Nursing and the Patients. Institute for the History of Medicine of the Robert Bosch Foundation, Stuttgart, 08.10.2015–10.10.2015.
Reviewed by Sylvelyn Hähner-Rombach
Published on H-Soz-u-Kult (January, 2016)
History of the Social Practice of Psychiatric Nursing and the Patients
While the conference was divided into small sessions arranged around time frames or geographical contexts of psychiatric nursing practice, it was interesting to note that as the conference progressed a number of common themes began to emerge. These themes were concerned with the changing role of the nurse as broader social and political forces impacted on thinking about mental illness; the ethical dilemmas faced by nurses in the shifting sands of psychiatric practice; and the complications of finding psychiatric nursing sources, and how to interpret what sources there are. Transformation in the social position of patients within institutions and community practice as time and circumstances changed was another common theme.
The issue of deinstutionalisation was dealt with by four papers from Fause, La Torre, Boschma and Harrisson. ASHILD FAUSE (Tromsø) presented the situation in Northern Norway in the years up to 1960, where institutions were often located long distances from where care was needed. One solution was to organise placement for people with farming families, reflecting a prevailing belief in the utility of ‘work therapy’. Host families received no formal training and were paid for providing care, but Fause’s case study analysis revealed that this type of care was often preferred by patients. Nursing was not a large part of this system until the late 1960s. The increase in trained psychiatric nursing bought new forms of knowledge and challenged traditional notions of family and community care for the mentally ill.
The interplay between community, family and formal nursing was also addressed by ANNA LA TORRE (Milan) who explored the closure of the Antonini institute in Milan. The institute had long been home to a great number of patients of various degrees of illness supervised by Catholic nuns. In the 1970s, Italy adopted a blanket policy of closing all mental hospitals, shifting services to community based teams. While this necessitated the involvement of trained nursing, and specific nursing knowledge as a result of pharmacological treatments, the move placed significant pressure on communities and families not equipped to deal with severely ill or unwanted family members. La Torre’s work raises serious questions about the reality and efficacy of deinstitutionalisation, exploring its effects not only on patients but families and local communities.
The need to find new ways of working together as a result of the move to community based services was explored by GEERTJE BOSCHMA (Vancouver), as she analyzed the changing relationships between patients, advocates, workers and nurses. These divisions became blurred during the 1970s to 1990s, as the anti-psychiatry movement combined with deinstitutionalisation created space for patients to argue for more input into the services being designed. Peer and community volunteers, as well as nurses themselves, were strong advocates for patients in this process, and in Boschma’s case study of Riverview Hospital in Canada we can see the shifting dynamics of nursing care through the formation of Pioneer House, a community based residential facility that was a new experiment in shared management by patients and nurses.
SANDRA HARRISSON (Quebec) also explored the changing role of the nurse in community based services through her analysis of the Montfore Hospital in Ottawa. As a result of Canadian policy from the 1970s, care for the mentally ill shifted to the short term acute care setting within the general hospital, followed by continuity of care in the community. Harrisson’s analysis of nursing notes demonstrates the complex role of the nurse in treatment and care. While nurses notes appear to record simple direct observations, they also reveal the nature and aim of psychiatric treatment, with the focus on moving toward discharge. A patient’s progress or activity is measured against their meeting certain requirements seen as signs of recovery and facilitating release, noted through behaviors such as mediation compliance, independence, not being ‘difficult’, self-control and personal hygiene. The notes reveal the extent of nursing power in a patient’s process from acute care to community care.
The complex relationship between psychiatrists, nurses and children was dealt with in papers by Hähner-Rombach and Vollenweider. SYLVELYN HÄHNER-ROMBACH (Stuttgart) explored the records of the Children Observation Ward in Innsbruck to analyse the ways in which children came to be admitted as psychiatric ‘patients’ during the period 1949–1966. Set against the back ground of the disruption of families after World War Two, Hahner-Rombach’s research painted a stark picture of the ease with which children who were ‘difficult to discipline’ could be admitted into psychiatric care. Nurses were active in this process as they were trained in the hospital medical psychiatric environment to facilitate the aims of the presiding psychiatrist. Nurses’ daily and weekly reports were used to develop care plans, and could dictate the therapies and disciplines to which children were subject. The paper illuminated the long term and diffuse effects of post National Socialist ideology, as well as the disruptive social effects the war had had on parents and families.
JANINE VOLLENWEIDER (Zurich) also raised the issue of children as psychiatric patients in European institutions with her analysis of the experience of children in the St Iddazell children’s home in Switzerland, in the 1960s and 70s. Vollenweider analysed patient records and presented evidence of children being taken from St Iddazell for day trips to Munsterlingen where they were given experimental doses of drugs, and the effects and behaviours then monitored by staff and nurses. Evidence suggests that there was no real regulation of dosage, that children presented with severe side effects and were regularly over-dosed, accidentally and otherwise. Nurses notes reveal no real therapeutic plans, rather an ad-hoc approach to treatment and care for tenuous psychiatric issues.
Papers by Gründler and Young also used case files and nurses notes to explore the relationship between institutions and families, analyzing the role of the nurse in broader psychiatric processes. JENS GRÜNDLER (Hamburg) analysed sources from the Woodilee Asylum in Glasgow around the turn of the century to explore the nature of nursing work and the relationship between the nursing process and patient recovery. Grundler’s research revealed that often case notes recorded disruptive or problematic patient behavior, including violence against and conflict with attendant and nursing staff. While a form of ‘moral treatment’ was the preferred method at Woodilee, there is little overt evidence in the sources of active therapeutic relationships. Positive aspects of relationships between staff and patients were simply not recorded, and negative occurrences were recorded as signs of a problem, or explanations for extended admissions. Grundler’s research raised interesting questions about the use of case files and nurses’ notes, and how to interpret what is not said. MIKE YOUNG (Huddersfield) presented research dealing with the establishment of psychiatric facilities by the British in Colonial India. Asylums were built to tend to the needs of the ‘distressed imperial mind’ and were established as fortress like sanctuaries to shield the white patient from the colonial gaze. Asylums were not readily accessible to local Indian populations as it was feared that their very presence could be taken as a sign of the fragility of Empire. Nursing staff came from the ranks of the British colonial nursing force. Young used documents from physicians and psychiatrists to ascertain what the ‘desired’ role of the nurse might be, and from this we can draw some conclusions about the nature of nursing work.
Controversial psychiatric therapies and the nurses’ role in treatment and care was addressed in papers by Foth and Nolte. THOMAS FOTH (Ottawa) examined Fever Therapy (FT) in one hospital unit in Ontario. He hypothesized that FT was used for reasons beyond its effect on neurosyphilis, in that it was more of a disciplining effort. Nurses used or applied it for disciplinary reasons - and without physician supervision. Foth examined patient records from this unit, written and kept by nurses. Foth argued that the charts seemed to suggest a lack of response to incidents of life threatening consequences as well as a lack of compliance with the prescribed protocol. FT seemed a means for discipline as much as for cure. Use of consent and whether patients had agreed to the treatment also surfaced as a theme in this research. The research also raised questions about the analysis and interpretation of the sources.
KAREN NOLTE (Wurzburg) examined shock therapies in the Wurzburg university hospital psychiatric department, such as insulin coma therapy. Shock therapy was analysed and discussed against the back-drop of the rise of national socialism and eventual systematic killing of mentally ill persons in the T4 program. Nolte argued that the shock treatments were introduced under the National Socialism dialectic of healing and extinction. Nurses had a considerable role in evaluating patients; the treatments were applied to patients considered curable, although some “incurable” patients were also contained in the clinic to help in the work. The challenge of explaining the circumstances and the nurses’ [and physicians’] roles in ECT, again raised critical questions about interpretation and how to make meaning of the events at the time when compared to current practice.
The broader social and political context of psychiatry, and its impact on nursing knowledge, was raised in papers by Smith and Grant. KYLIE SMITH (Atlanta) examined American mental health nursing in the post WWII and Cold War era and studied how the work and writings of psychiatric nurse leaders Hildegard Peplau and Dorothy Mereness reflect larger societal trends and the uptake of contemporary psychiatric ideas in nursing. Smith looked at the evolution of American psychiatric nursing practice in the context of Cold War concerns with anxiety, trauma and mental health for social stability. Nursing was also affected by professional rivalry among the psychiatric and psychological professions, as ideas about prevention, public health and expanding community mental health unsettled traditional approaches to practice and challenged nurses to develop new roles.
SUSAN GRANT (Liverpool) examined psychiatric care in the Soviet Union from 1930–1950, particularly psychiatric nursing in the Odessa psychiatric hospital. She focused in particular on the role of middle and junior nursing personnel, based on textbooks and medical handbooks. The books seem to reflect wider 1930s debate about the level of nurses and the need to be caring (as opposed to custodial traditions). The research revealed how the training of the nursing personnel changed. An interesting source in the research is the use of photographs and how to interpret what appears from them.
The need for nurses to negotiate other complex social issues such as psychiatric attitudes towards homosexuality and addiction were addressed in papers by Braunschweig and Dickinson. SABINE BRAUNSCHWEIG (Basel) examined the social context of professional regulation of licensing and diploma issuing of psychiatric nurses by the Swiss Office for Practical Psychiatry, who held the regulatory authority over psychiatric nursing between 1934 and 1965. She examined 25 cases in which diplomas were cancelled and hence license to practice withdrawn during this time period. Her analysis centred both on demographic description as well as on social norms, cultural values, gender and power dynamics shaping alleged misconduct, dismissal and sanctions. Analysis of alleged misconduct using evidence from these case reports provide an intriguing window into the realities of practice and normative context of professional behaviour as well as on the hierarchical structure that shaped nurses’ work.
TOMMY DICKINSON (Manchester) examined the ‘hidden history of homosexual life in British psychiatric hospitals during the mid-twentieth century’ by means of a study of the challenges men experienced who were institutionalised to receive so-called aversion therapy, either electrical or chemistry, between 1935 and 1974. Dickinson drew from oral history with psychiatric nurses and former patients. As such the paper casts light on the way homosexuality was understood and treated at the time, as well as on the lives of gay nurses working in the hospitals. How to interpret the nature of the treatment and the role of the nurses generated discussion about the risk of presentism; How to look at treatments we now perceive as cruel and inhumane raises important questions about historical interpretation as well as about the nature of power differentials and how they operate, both at the time and in the context of interpretation. Such nuancing also applies to interpretation of the nurses’ role and how nurses might have justified their work at the time.
The reform of German psychiatric nurse education during the 1960s and 1970s and the relationship to social psychiatry, especially in Germany, was presented by Rotzoll and Beyer. MAIKE ROTZOLL (Heidelberg) investigated the introduction of advanced training for nurses at the Psychiatric University Clinic Heidelberg as part of the psychiatric reform in West-Germany during the 1960s and 1970s. The introduction and advancement of social psychiatry provided a context to promote community psychiatry and to introduce an advanced psychiatric training program. The new therapeutic role envisioned for nurses seemed an exceptionally independent one. Multidisciplinary relationships and power dynamics and hierarchies between social work, psychology, nursing, and psychiatry shaped the way nurses role. The influence of psychiatrists taking the lead in shaping the advanced nurses’ role seemed to perpetuate traditional hierarchies and it seemed the new social psychiatry programs were implemented in university clinics and were harder to implement in asylums.
CHRISTOPH BEYER (Hanover) analysed the conceptualisation and practice of nurses as “sociagogues”, or socio-therapists, another innovation in the incorporation of nurses in therapeutic roles in social psychiatry, which had triggered new emphasis on the importance of social relations and rehabilitation in treatment of mental illness. Beyer examined the social psychiatric training of nurses at the Hanover Medical School, which also was part of the psychiatric reform in federal Germany in the 1960s and 1970s. It seems a generational influence might have been at play in that a new generation of (young) psychiatrists challenged the established role of an older generation of psychiatrists, whereas a broader social critique and rights movements also shaped anti-psychiatric critique. The idea of generational difference might also may apply to nurses, in that a younger generation perhaps was more receptive to change, whereas an older generation may have been entrenched in institutional culture. The impact of culture change within mental hospitals came in part from newly university trained, social workers and psychologists, often also hippies, who unsettled the established institutional culture.
While the locations, cases and time frames addressed throughout the conference varied widely, the papers addressed a number of similar themes, and raised issues pertinent to contemporary psychiatric nursing. These include issues of sources and methodology; how to read and analyse documents such as nursing notes; the recurring issue of unethical practice in psychiatry and why mental health patients sometimes seem as less worthy of safe care; the central role of the nurse in developing distinctive therapeutic interventions; and the impact that broader social and political contexts have on ideas about mental health. For the more recent time period transformation of patient voice was another pertinent theme. The conference was an excellent opportunity to explore these issues in depth, and revealed new and innovative work being done in this field in a range of international contexts.
Session 1: Hospitalisation and Dehospitalisation
Åshild Fause (University of Tromsø): The impact of knowledge from different psychiatric facilities in psychiatric nursing in Norway
Anna LaTorre (Universty of Milan): The closure of Antonini’s Madhouse. A walk through an Italian psychiatric nursing revolution in Milan
Geertje Boschma (University of Vancouver): New Contexts of care and work relationships among nurses, patients and community volunteers in community-based psychiatry in western Canada, 1970-1990
Sandra Harrisson (Université du Quebec): Psychiatric nurses: An invisible role in the process of transition between General Hospital and the community
Session 2: Children as Psychiatric Patients
Sylvelyn Hähner-Rombach (Institut für Geschichte der Medizin der Robert Bosch Stiftung, Stuttgart): Postwar children and adolescents patients of children observation wards on the example of Innsbruck
Janine Vollenweider (Universität Zürich): Generation “Münsterlingen-Seaside”: medically treated children in the care of the St. Iddazell children’s home in the 1960s and 70s
Session 3: Nurses, Patients and Their Families
Jens Gründler (Hamburg): Configurations of dispute – everyday lives of nurses and patients in an asylum at the turn of the century in Glasgow
Mike Young (University of Hudderfield): A hidden agenda: attempts to determine the contribution of nurses to the care of distressed British Imperial minds in Colonial India, 1914-1947
Session 4: “Heroic Therapies” and Nursing
Thomas Foth (University of Ottawa): „Heroic treatments“ and the suffering of patients diagnosed with „neuro-syphilis“. Nurses at the fever therapy unit, Ontario Hospital, Toronto
Karen Nolte (Universität Würzburg): “Shock therapies“ and nursing in the psychiatric clinic of the University of Würzburg in the 1930s and 1940s
Session 5: Nursing and “Cold War”
Kylie M. Smith (Emory University Atlanta): “The number one social problem of our time”: Psychiatry, nursing and the Cold War in America
Susan Grant (John Moores University Liverpool)): Psychiatric care in the Soviet Union, 1930-1950
Session 6: Diversity, Deviance and Psychiatric Nursing
Sabine Braunschweig (Basel): Theft, homosexuality, addiction to morphine: Cancellation of diplomas between 1934 and 1965 in Switzerland
Tommy Dickinson (University of Manchester): Living and working on the fringe: The hidden history of homosexual life in British psychiatric hospitals during the mid-Twentieth Century
Session 7: Reform and Training of Psychiatric Nurses
Maike Rotzoll (Universität Heidelberg): „Fundamentally changed duties“. The introduction of advanced training for nurses at the Psychiatric University Clinic Heidelberg as part of the psychiatric reform in West Germany
Christoph Beyer (Medizinische Hochschule Hannover): From nurse to ‘sociagogue’? Ambitions, realisation and practise of social psychiatric training at Hanover Medical School against the background of the German psychiatric reform
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