A m s t e r d a m U n i v e r s i t y P r e s s The Rise of Mental Health Nursing | A History of Psychiatric Care in Dutch Asylums | 1890-1920 Geertje Boschma The Rise of Mental Health Nursing BOSCHMA 06-03-2003 12:50 Pagina 1 BOSCHMA 06-03-2003 12:50 Pagina 2 The Rise of Mental Health Nursing A History of Psychiatric Care in Dutch Asylums, 1890-1920 Geertje Boschma Amsterdam University Press BOSCHMA 06-03-2003 12:50 Pagina 3 For my parents, Yke Boschma and Jetske Jorritsma This publication was made possible by a grant from the Netherlands Organisation for Scientific Research (NWO). Cover illustration Patients on bed rest in the observation ward with two nurses. Female department at the Franeker Asylum, ca. 1900. Historical Photograph Collection, Psychiatric Hospi- tal Franeker. Cover design: Crasborn Grafisch Ontwerpers bno, Valkenburg aan de Geul Lay-out: Het Steen Typografie, Maarssen isbn 90 5356 501 9 nur 895 / 897 © Amsterdam University Press, Amsterdam, 2003 All rights reserved. Without limiting the rights under copyright reserved above, no part of this book may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the written permission of both the copyright owner and the author of this book. BOSCHMA 06-03-2003 12:50 Pagina 4 Contents Acknowledgments 11 Introduction 15 Care of the Mentally Ill 18 Asylum Attendants and Mental Nurses 19 The Historiography of Mental Health Nursing 20 Four Asylums as Case Studies 26 The Chapters in Brief 28 Chapter 1 • Asylum Reform Ideals: Personnel Matters 31 The Appeal of Institutional Care and Moral Treatment 31 A Legal Basis for Asylum Reform 33 Increased Medical Influence 35 Liberal Views, Reform Rhetoric, and the Problem of Personnel 36 Lower-Class Institutions 41 The Position of Attendants and Patients in the Asylum Hierarchy 42 Different Responses and Different Solutions: Roman Catholic Initiatives 45 Reform Ideals Frustrated: Asylum Growth and a New Law 50 A Second Law on the Insane 52 Awakening of Protestant Duty 54 Conclusion 57 BOSCHMA 06-03-2003 12:50 Pagina 5 Chapter II • The Ideal of a Mental Hospital 59 New Medical Opinions: Scientific Psychiatry 60 Medical Views in Veldwijk: A Christian Psychiatry 63 Bed Rest 65 Architectural Changes and the Increased Application of Bed Rest 67 Hydrotherapy and Bath Treatment 70 Work Remained 73 The Inspiring Example of the General Hospital: A New Demand for Skilled Nursing 75 Conclusion 78 Chapter III • Female Compassion: Mental Nurse Training Gendered Female 81 Religious Roots 81 Female Compassion, Domestic Ideology and the Women’s Movement 87 Growing Demand 90 A New Educational Structure for Nursesv 92 A Respectable Salaried Occupation 95 Female Influence 97 Hospital Hierarchyv 98 Raising the Status of Psychiatry: The Introduction of Mental Nurse Training 100 Gendered Ideals: Raising the Morality of Asylum Personnel 106 Het Wilhelminahuis (The Wilhelmina Home) 108 Conclusions 110 6 BOSCHMA 06-03-2003 12:50 Pagina 6 Chapter IV • The Burdensome Task of Nurses 113 The Invisible Role of Nurses 115 The Nurse as Object and Agent of a Disciplined Asylum Routine 118 Threat, Repression, and Abuse: The Division of Wards as a Control Mechanism 119 An Analysis of Patient Records 123 Responding to Dependency 125 Growing Old and Demented 127 Sick since Youth 129 Suffering from Mania, Acutely or Periodically 131 The Care of Paralyzed and Handicapped Syphilis Patients 132 They Wished to Be Dead: The Risk of Suicide 133 Overcome by Delusions: The Risk of Refusing Food, Self-Mutilation, Violence, and Escape 136 Nervous Afflictions and Brain Trauma: Rare Cases in the Turn-of-the-Century Asylum 138 Conclusion 140 Chapter V • Negotiating Class and Culture 141 A Gendered Structure 141 A New Discipline and Morale 147 Culture Shock 150 The Orthodox Protestant Perception of Mental Nurse Training: A Family Ideology 153 Gendered Nursing Leadership in Veldwijk 154 Implementing an Educational Structure 157 Mental Nurse Training at Veldwijk 160 Debate over The Boschhoek 162 The Boschhoek Revisited 164 Roman Catholic “Resistance” 167 Conclusion 173 7 BOSCHMA 06-03-2003 12:50 Pagina 7 Chapter VI • The Marginalization of Male Nurses 175 Nursing, a Respected Occupation – but not for Men 175 Squeezed out 176 Nurse Artisans 179 The Home of a Married Nurse: A Place of Family Care? 183 Growing Class Consciousness 186 Male Nurse Activism and the Career of P.N. Bras 186 Gendered Politics versus Expertise 192 Conclusion 196 Chapter VII • Controversy and Conflict over the Social Position of Nurses 197 An Ambiguous Social Position 197 Growing Social Awareness among Asylum Nursing Personnel 199 Activism among the VCV Nurses 204 Seeking Legal Protection from the State 206 Controversy over Training 209 Ambivalence over Morality and Class Background 210 The Threat of Private Duty 215 Tension over the NVP Exam Criteria 216 Controversy over the Somatic Approach and Biomedical Footing of Psychiatric Care 219 Conclusion 223 Conclusion • The Politics of Mental Health Nursing 225 The Disappointment of Somatic Explanations in Turn-of-the-Century Psychiatry 225 A Gendered Notion of Civilized Care 227 The Educational versus the Social Value of Mental Nurse Training 229 Economic Problems, Growing Costs 232 Ideals and Limitations 233 8 BOSCHMA 06-03-2003 12:50 Pagina 8 Appendix 235 Notes 241 List of Illustrations 289 List of Abbreviations 291 List of Archives 293 Bibliography 297 Index 313 9 BOSCHMA 06-03-2003 12:50 Pagina 9 BOSCHMA 06-03-2003 12:50 Pagina 10 Acknowledgments During the time I was working on this book I benefited from the scholarly support and advice of a large number of people. I am grateful for the generous comments and thoughtful critique on various papers, presentations and ear- lier drafts of this research. The study grew from an exploratory inquiry into the history of mental health nursing in the Netherlands in 1993 into a disser- tation on the nursing care of the mentally ill in Dutch asylums under the ded- icated and inspiring guidance of Joan Lynaugh at the Center for the Study of the History of Nursing, School of Nursing, at the University of Pennsylvania in 1997. I am especially grateful to the University of Calgary for a Killam Resi- dent Fellowship and Research Award in 2000, which provided me with addi- tional research time to further develop this study into a book. Additional financial research support came from Sigma Theta Tau Chi Chapter, the Catherine van Tussenbroek Foundation, Sigma Theta Tau International, the American Nurses Foundation and the University of Pennsylvania School of Nursing. I would like to thank my colleagues at the Faculty of Nursing of the University of Calgary for their support and interest in the completion of this study. I would also like to thank women’s historians Sarah Carter and Eliza- beth Jameson at the Department of History at the University of Calgary for their encouragement in the final stages of this work. Joyce Hildebrand and Nadine Kozak provided excellent editorial and research assistance. I am indebted to the faculty and fellow students at the University of Penn- sylvania, Philadelphia, both in the graduate program and the Center for the Study of the History of Nursing of the School of Nursing, and in the Depart- ment of the History and Sociology of Science. Working with this outstanding community of scholars has profoundly influenced my thinking and shaped the direction of my research. From the School of Nursing I am especially grateful to Joan Lynaugh, Ellen Baer, Karen Wilkerson, and Margaret Cotro- neo for their superb guidance, insightful comments and attentive reading of my work. I also thank Patricia D’Antonio, Julie Fairman, Barbara Brush, Bet- sy Weiss, Linda Cook, Eileen Sullivan and Terry Richmond for their com- ments and support. From the Department of the History and Sociology of Sci- ence, I am particularly indebted to Henrika Kuklick and Charles Rosenberg for their generous advice, and I thank Hans Pols for his support. 11 BOSCHMA 06-03-2003 12:50 Pagina 11 Whilst completing the research for this study in the Netherlands, I was very fortunate to be able to work with a fine group of historians of psychiatry at the Dutch Institute for Mental Health in Utrecht, now called the Trimbos Institute. In particular, the expertise and support of Joost Vijselaar has been invaluable. Without his help I could not have completed this study. I also thank Leonie de Goei, Annemarie Kerkhoven, Gemma Blok, and Giel Hut- schemaeker. They provided me with the scholarly support so vital whilst far away from Philadelphia. The same is true for Eddy Houwaart, medical histo- rian at the University of Maastricht, who generously invested time and inter- est. I wish to thank all of them for their insightful comments on parts of this work. I also thank Cecile aan de Stegge for bringing me into contact with the faculty of the Departments of Nursing and History at the University of Maas- tricht. During the preparatory work for this research, the Department of Nursing in Maastricht, directed by Huda Huijer Abu-Saad, provided me with hospitality, as did the Trimbos Institute. Many librarians and archivists have given valuable assistance throughout this research. In particular, I am indebted to Ingrid Verhoeven, librarian at the historical library of the Trimbos Institute. Many people assisted my inves- tigation of the institutional archives of the psychiatric hospitals Franeker, Veldwijk, and Reinier van Arkel, as well as of the archival collection of the psy- chiatric hospital in Amsterdam. I am grateful to Mr. de Vries, Martje Haits- ma, Tom Kappelhof, Joke Leenders, Mr. van Faassen, Mr. L. Boerman, Piet van Twuyer, and the staff of the “Rijksarchief Noord-Holland” (State Archives of North Holland). I also thank those individuals who gave helpful scholarly advice at various points, of whom I would like to mention Cora van der Kooij, Nanny Wiegman, Mart van Lieburg, Hans Binneveld, and Jaap van Belzen. Last, but not least, I would like to thank my husband Hotze for his incredi- ble support and love. I also thank my family and family-in-law for their unfail- ing support, in particular my mother Jetske, my sisters Ytje and Eppy, my mother-in-law Frouwien, and my in-laws Ton, Cora, Anna, Tineke, and Jan for their hospitality and generous help. My children Henk, Nico and Jenny contributed in their own special way to this book. Parts of chapters V and VI in this book have previously been published in journal articles: “High Ideal versus Harsh Reality: A Historical Analysis of Mental Health Nursing in Dutch Asylums, 1890-1920”, Nursing History Review 7(1999): 127-151, and “The Gender Specific Role of Male Nurses in Dutch Asylums, 1890-1910”, International History of Nursing Journal 4, no. 3 (1999): 13-19. I would like to acknowledge the permission from Springer Publishing Company and RCN Publishing Company respectively to include this material. Two Dutch papers, based on the same material, have been pub- 12 BOSCHMA 06-03-2003 12:50 Pagina 12 lished in Maandblad Geestelijke Volksgezondheid 52, no. 10 (1997): 959-976 (“Psychiatrische Verpleegkunde: Een Historisch Perspectief”), and in Ges- ticht in de Duinen: De geschiedenis van de provinciale psychiatrische ziekenhuizen van Noord-Holland, 1848-1994 , Joost Vijselaar (Ed.), Hilversum: Verloren, 1997 (Chapter 4, “Naar een professionele psychiatrie (1884-1918)”, pp.91- 121). I thank the Trimbos Institute and Verloren Publishing respectively for their permission to use this material. 13 BOSCHMA 06-03-2003 12:50 Pagina 13 BOSCHMA 06-03-2003 12:50 Pagina 14 Introduction Mental health nursing emerged as a new occupational field in the late nine- teenth century in the context of the rise of scientific psychiatry. Based on new understandings of mental illness and new forms of psychiatric treatment, asylum physicians legitimized and initiated the introduction of mental nurs- ing in asylums, which restructured a field of work that had hitherto been the domain of lay attendants. In light of the new significance that skilled nursing care had acquired in the context of general hospital reform, psychiatrists, themselves a rising professional group, argued that more refined and better trained personnel would greatly improve psychiatric care. Shifting social and gender relationships, particularly the changing social position of middle- class women, constructed and shaped mental nursing. The emergence of mental nursing mirrored larger social changes for lower middle- and work- ing-class men and women and their work illustrates the social complexity of the care of the mentally ill. In both nursing and psychiatric historiography, little attention has been paid to the gendered nature of the asylums’ mental health nursing politics. The introduction of mental nurse training was based on the projected image of the well-educated, middle-class female nurse who would bring compe- tence and female compassion to the care of the mentally ill. The aim of estab- lishing a nursing staff skilled in somatic care in the asylums created new opportunities for women, while at the same time restricting the role of men in nursing. This study explicitly discusses the gendered restructuring of asy- lum care that the new training scheme for mental nurses implied. Reform profoundly changed the work relationships of the new male and female men- tal nurses. The explicit attention paid to male and female nurses’ gendered experiences illustrates how concepts of femininity and masculinity were formed in relation to each other. Moreover, it paints a more nuanced picture of nursing as a gendered field of both men’s and women’s work. 1 In addition to gender, class is another important category for analysis. This study argues that the introduction of mental nurse training was an attempt to uplift the morality and class of asylum personnel. In their effort to place asy- lum care on the same footing as the work of their counterparts in general medicine, middle-class psychiatrists sought the assistance of middle-class 15 BOSCHMA 06-03-2003 12:50 Pagina 15 women skilled in somatic care. They considered a humanitarian, refined atti- tude to be a characteristic not only of gender, but also of class. The process by which the hierarchical mental nurse training structure facilitated the instill- ing of class-based values such as discipline, punctuality, and obedience in a mental nurse workforce of largely lower middle- and working-class back- ground paralleled attempts to create a disciplined, respectable workforce in industry. A third category that plays an important role in this analysis is religion. Among many social groups in the nineteenth century, religious inspiration was an important motivation for taking up philanthropic reform work, including the reform of the care of the mentally ill. As women’s historian Annemieke van Drenth and Francisca de Haan have pointed out, much like evangelicalism in North America, an influential Protestant religious revival movement of the Inner Mission in continental Europe, also called “Reveil”, had generated reform initiatives, such as the Deaconess Movement. 2 More- over, Roman Catholic religious revival had a strong impact in the Netherlands at that time as well. 3 Numerous socially respected religious and secular organ- izations of nursing were established in this context. Building on these reli- gious and secular images of respectful care, skilled nursing could acquire social prestige as a new field of paid work for women in the late nineteenth century. At that time the demand for skilled nurses increased and the prepa- ration for nursing as a paid professional occupation took the form of hospital- based nurse training programs and – modeled after this example – asylum- based mental nurse training programs. But the legitimization of these new occupational roles – that it was the female compassion of middle-class women and their refined attitude that would make this new form of nursing a success – was in many ways a secularized version of older religious notions of disciplined devotion that had a long tradition in nursing. Furthermore, religious and political pluriformity shaped the social and political constellation of Dutch society from the late nineteenth century until about the mid-twentieth century in a particular way. A specific, hard-to-trans- late term has been coined in Dutch historical, political, and social scientific writings to refer to this phenomenon: verzuiling , often literally translated as “pillarization” (and more correctly as “compartmentalization”) and in an attempt to be more explanatory, also referred to as the emergence of “segmen- tal cleavages”. 4 In the nineteenth century, Dutch democracy took the form of a plural society, which was divided along political and religious lines. Liberaliz- ing and democratic politics of the nineteenth century prompted revisions of the constitution at several points in time, which by 1848 had resulted in the adoption of a liberal constitution that guaranteed freedom of religion, educa- 16 BOSCHMA 06-03-2003 12:50 Pagina 16 tion, press, and association. Politically this had an emancipatory impact, par- ticularly on religious groups such as the Roman Catholics, who had been banned from public life since the Reformation. It enabled them to re-estab- lish themselves and participate in a parliamentary structure and coalition government with liberal groups. The same was true for revivalist Protestant groups, who formed their own organizations, and in the latter part of the nineteenth century socialists also formed their own segment. As a result Dutch political culture was divided up into vertical groupings of Catholic, Calvinist-Protestant, socialist and liberal zuilen or pillars. 5 Such a political form is not unique to the Netherlands. Segmental differentiation can occur along religious, ideological, linguistic, regional, cultural, racial, or ethnic lines. 6 Political scientist Arend Lijphart refers to Switzerland, Belgium, Aus- tria, and Luxembourg as examples of other plural, stable democracies that are characterized by deep segmental cleavages in their societies. Since none of the sectors of Dutch society had a political majority, coopera- tion among the “pillars” had to take place at the top in the form of a coalition government. Yet in day-to-day life, people operated within their own sector with hardly any interaction with other sectors. Pillarization, therefore, was a particular way in which “Dutch society [was] organized along denominational lines.... In due course the main Pillars [denominational groups] established their own network of organizations, ranging from political parties, trade unions and educational systems (including a Catholic and a Calvinist univer- sity) to broadcasting corporations, welfare agencies, sport associations and even social research institutes.” 7 This process allowed leaders within the vari- ous political and religious groups to maintain their influence over their own communities, while rationalization and transformation of traditional struc- tures and institutions could still take place. Each sector, in its own way, responded to social changes and modernizing trends, resulting in different, yet parallel developments. This particular way in which Dutch society modernized also impacted on the organization of health care. In the second half of the nineteenth century, in response to drastic socioeconomic changes, a rising political debate on the social position of workers, and the emergence of labor and feminist move- ments, the laissez-faire politics of previous predominantly liberal-conserva- tive parliamentary cabinets was replaced by the interventionism of progres- sive liberal and Christian politicians. 8 An increased level of organization of various new professional and occupational groups emerged from the late nineteenth century, and subsequent social legislation materialized. As this study will reveal, institutional care of the mentally ill, which dramatically expanded in the context of nineteenth-century reform and the fight against 17 BOSCHMA 06-03-2003 12:50 Pagina 17 pauperism, was influenced by this process of pillarization. It also took a seg- mented form, which necessarily influenced the way mental health nursing developed. Care of the Mentally Ill In the Netherlands, care of the indigent mentally ill was part of the nine- teenth-century poor relief system. For most of the nineteenth century the Netherlands experienced economic hardship, which stemmed from econom- ic malaise in the late eighteenth century and a period of French occupation at the beginning of the nineteenth century. This hardship resulted in a growing number of poor people. The Dutch population grew from about three million in 1850 to five million by the end of the century. The social structure of the Netherlands was characterized by a relatively large urban population in an extensive network of relatively small towns and cities. However, particularly in the rural areas, the Netherlands retained the characteristics of an agrarian society for most of the nineteenth century, during which time the Dutch econ- omy was based on trade and on wealth gained from the colonies. It was not until the 1870s that the impact of industrialization began to be felt. In part driven by the economic recession in agriculture during the 1870s, the mechanization of farming began with the introduction of new machines and techniques. An increasing number of former farm workers moved to cities where new industries such as ship and machine building emerged. Increased international trade, new means of transportation, improvement of the infrastructure, and an emerging service industry characterized the appearance of an industrial society. By the late nineteenth century, the econo- my had begun to flourish, leading to an increase in the average income as of 1890. 9 Under the influence of the Enlightenment, a cultural uplift began at the beginning of the nineteenth century. The rising middle class sought to com- bat pauperism, which they perceived as predominantly a problem of poor morality and improper habits. In particular, the threat of several epidemics of contagious diseases during the earlier part of the nineteenth century, which hit hardest among the poor, prompted social reform initiatives. With various philanthropic, often religiously inspired reform efforts, progressive middle- class citizens sought to educate and transform the lower class into industri- ous, productive, and loyal citizens. The national government, established after the end of French occupation in 1815, gradually attempted to reorganize poor relief and to bring it under national regulations. Public education became available to the lower social classes and special projects to provide work for the poor emerged. 10 18 BOSCHMA 06-03-2003 12:50 Pagina 18 Within the context of the general cultural uplift and the reorganization of poor relief, reform-minded citizens and physicians began advocating for asy- lum reform at the beginning of the nineteenth century. The hope for a cure for the mentally ill also prompted reform. As early as 1841, when legal regula- tions on insanity care passed in parliament, the management of the indigent mentally ill began to change. The reformed asylum initially resembled a large, disciplined middle-class household, albeit with gradual expansion of medical responsibility and influence on the care of the insane. Asylum Attendants and Mental Nurses Nineteenth-century asylum management was characterized by paternalism and hierarchical subordination. Until around 1890 asylum boards and offi- cers, including the asylum doctors, referred to the day-to-day caretakers most commonly as “servants” ( bedienden ) or “keepers or attendants” ( oppassers ) responsible for overseeing patients. 11 Day-to-day caretakers in the asylums left little evidence behind about themselves or their experience. They were largely anonymous. Attendants were just one level up from the lowest group in the asylum hierarchy, the patients. Asylum boards and physicians consid- ered good attendants those who had a respectable and humane attitude and knew their place in society. 12 The expectation was that attendants would keep order and discipline among patients by maintaining moral, pedagogical pre- dominance over them. Such ideals reflected the aspirations and class values of the rising middle class. But from the outset of asylum reform physicians regularly complained about the supposed poor quality of the asylums’ attend- ing personnel. They felt that the behavior and work morality of attendants were ill-fitted for the medical ideas of kind and humane treatment that emerged in the first half of the nineteenth century. However, as the late nineteenth-century progressed, medical ideas on treatment for the mentally ill again changed as a result of social and medical transformations. During the 1870s and 1880s psychiatrists began to orient themselves towards the values and findings of the natural sciences and emphasized organic origins of mental illness. They conceptualized mental illness as a brain disease. In principle, they argued, mental patients should receive the same care and treatment as physically ill patients in the general hospital. Hospital medicine gained momentum during the late nineteenth century, and psychiatrists attempted to model the traditional asylum after the example of the general hospital. In this context they initiated new treatments, the most important being bed rest. As a result, the rhetoric about asylum personnel took on a new dimension. 19 BOSCHMA 06-03-2003 12:50 Pagina 19