The Rise of Mental Health Nursing

Front matter

The Rise of Mental Health

Nursing | A History of Psychiatric Care in Dutch Asylums | 1890-1920

Geertje Boschma

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 Chaptersin Brief 28

Chapterr e 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 anda New Law 50 A Second Lawonthe Insane 52 Awakening of Protestant Duty 54 Conclusion 57

II

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 Hutschemaeker. They provided me with the scholarly support so vital whilst far away from Philadelphia. The same is true for Eddy Houwaart, medical historian at the University of Maastricht, who generously invested time and interest. 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 Maastricht. 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 investigation of the institutional archives of the psychiatric hospitals Franeker, Veldwijk, and Reinier van Arkel, as well as of the archival collection of the psychiatric hospital in Amsterdam. I am grateful to Mr. de Vries, Martje Haitsma, 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 incredible support and love. I also thank my family and family-in-law for their unfailing 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 published in Maandblad Geestelijke Volksgezondheid 52, no. 10 (1997): 959-976 (“Psychiatrische Verpleegkunde: Een Historisch Perspectief”), and in Gesticht 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.

Introduction

Mental health nursing emerged as a new occupational field in the late nineteenth 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 nursing 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 working-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 competence and female compassion to the care of the mentally ill. The aim of establishing 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 asylum care that the new training scheme for mental nurses implied. Reform profoundly changed the work relationships of the new male and female mental 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.’

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 asylum care on the same footing as the work of their counterparts in general medicine, middle-class psychiatrists sought the assistance of middle-class women skilled in somatic care. They considered a humanitarian, refined attitude to be a characteristic not only of gender, but also of class. The process by which the hierarchical mental nurse training structure facilitated the instilling of class-based values such as discipline, punctuality, and obedience in a mental nurse workforce of largely lower middle- and working-class background 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. Moreover, Roman Catholic religious revival had a strong impact in the Netherlands at that time as well. Numerous socially respected religious and secular organizations of nursing were established in this context. Building on these religious 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 preparation for nursing as a paid professional occupation took the form of hospital-based nurse training programs and — modeled after this example — asylumbased 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-translate 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 “segmental cleavages”. In the nineteenth century, Dutch democracy took the form ofa plural society, which was divided along political and religious lines. Liberalizing 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, education, press, and association. Politically this had an emancipatory impact, particularly on religious groups such as the Roman Catholics, who had been banned from public life since the Reformation. It enabled them to re-establish 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.’ Such a political form is not unique to the Netherlands. Segmental differentiation can occur along religious, ideological, linguistic, regional, cultural, racial, or ethnic lines.° Political scientist Arend Lijphart refers to Switzerland, Belgium, Austria, 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, cooperation 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 university) to broadcasting corporations, welfare agencies, sport associations and even social research institutes.”7 This process allowed leaders within the various political and religious groups to maintain their influence over their own communities, while rationalization and transformation of traditional structures 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 movements, the laissez-faire politics of previous predominantly liberal-conservative parliamentary cabinets was replaced by the interventionism of progressive liberal and Christian politicians.’ 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 pauperism, was influenced by this process of pillarization. It also took a segmented form, which necessarily influenced the way mental health nursing developed.

Care of the Mentally II

In the Netherlands, care of the indigent mentally ill was part of the nineteenth-century poor relief system. For most of the nineteenth century the Netherlands experienced economic hardship, which stemmed from economic 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 economy 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 economy 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 combat 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 industrious, 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.'°

Within the context of the general cultural uplift and the reorganization of poor relief, reform-minded citizens and physicians began advocating for asylum 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 regulations 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 ofthe insane.

Asylum Attendants and Mental Nurses

Nineteenth-century asylum management was characterized by paternalism and hierarchical subordination. Until around 1890 asylum boards and officers, 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." 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 considered good attendants those who had a respectable and humane attitude and knew their place in society.” The expectation was that attendants would keep order and discipline among patients by maintaining moral, pedagogical predominance 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’ attending 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.

Asa result, the rhetoric about asylum personnel took on a new dimension.

The reorganization and restructuring of the class base of hospital personnel was of central importance in hospital reform. Traditionally caretakers of patients in public hospitals came from the lowest social classes. This changed profoundly as middle-class women skilled in patient care took up supervisory roles in hospitals in the context of social reform activities and a broader changing social role for middle-class women. Similarly, asylum doctors argued that they needed more refined, better trained personnel who would have the same qualities as trained hospital nurses. Psychiatrists and, following in their wake, nurses established themselves in new professional groups. Psychiatrists not only felt that a higher standard of skill and morality among personnel was necessary, they also designed a training scheme that brought the socialization of asylum personnel under medical control. Instead of attendants, they argued, they needed nurses who were properly trained in the care of the sick. The emergence of mental nursing work and training, and an analysis of its meaning, is the focus of this study. To refer to the new type of trained asylum nurses this study uses the term “mental nurse” as a translation of krankzinnigenverplegende, the common term used in Dutch psychiatry at the time.”

The Historiography of Mental Health Nursing

Historical analysis of the work of mental nurses has received little scholarly attention. The few studies on the history of mental nursing that are available in the Anglo-American historical literature developed largely in two contexts. Firstly, in the history of psychiatry the role of attendants or asylum nurses has been studied as part of the analysis of the broader social and medical meaning of the asylum. Secondly, in the context of the history of nursing, psychiatric nursing history has been examined as part of the analysis of the rise of nursing as a new occupational field. Both threads of historical analysis contributed to the understanding of psychiatric nursing’s past in different ways. Yet in neither of the two contexts has gender taken center stage. In women’s history the notion of a domestic ideology of women in the nineteenth century became central to the explanation of women’s changing role. Furthermore, in the analysis of gender differences the notion that gender is socially constructed has become increasingly more accepted.” Yet neither of these perspectives has figured importantly in the historiography of mental nurses. The emphasis on gender in this study was largely prompted by the evidence found in historical records. On studying both archival records and contemporary published literature, it became clear that gendered arguments were of central importance in the debates on the establishment of mental nurse training.

Philanthropic reform initiatives, the changing status of medical science, and the changing role of women were intertwined contexts for understanding the emergence of mental nurse training. Moreover, strong connections existed between the introduction of nurse training in hospitals and asylums. Another finding that prompted a closer look at gender differentiation was the resistance of male nurses to their exclusion from the caring domain, which was particularly evident in the records of a male nurse organization founded at the time. To the best of my knowledge, current nursing historiography has paid almost no attention to the phenomenon of men resisting exclusion from caring roles. The emphasis on women’s roles in women’s history has unintentionally rendered the gendered behavior of men invisible.” From that perspective, nursing history may make an important addition to gender history. In current women’s and nursing history, which depicts caring work as women’s work, the historical persistence of men seeking access to nursing work remains invisible and is therefore left unexplained."

The role of asylum attendants in North American and British asylums has been scrutinized by several authors, including Patricia D'Antonio, Anne Digby, Ellen Dwyer, and Nancy Tomes. They have analyzed the inner workings of the asylum as both a medical and a social institution in the era of mid-nineteenth-century moral treatment.” These studies emerged in a broader historical debate on the meaning of the rise of the nineteenth-century asylum that began as a result of the 1960s and 1970s “anti-psychiatry” and “decarceration” movements." In this debate a new generation of revisionist social scientists and historians challenged traditionalist interpretations of psychiatric history, such as those of Albert Deutch (1937) and Richard Hunter and Ida McAlpine (1963) in the United States and Britain, or Pieter van der Esch (1975) in the Netherlands. The traditionalists interpreted asylum reform and the introduction of medical treatment as clear evidence of enlightened benevolence and scientific progress, a shift from ancient darkness towards enlightened rationality characterized by the effective, humane, and scientific treatment of the insane.”

Revisionist social scientists such as Erving Goffman (1961) and Thomas Szasz (1974), the philosopher Michel Foucault (1965) or historian David Rothman (1971) portray mental institutes as repressive institutions and challenge the assumptions of humanitarian reform.” They present psychiatric care as either a process of normalization and disciplining or as institutionalization of social control and class domination. Initially these social scientists argued that the nineteenth-century “liberation” of the insane from their imprisonment and the introduction of moral treatment were just alternative means for the state to effectively separate and exclude those who did not meet the requirements of self-control and self-responsibility in a capitalist society. Consequently, the insane were subjected to “a gigantic moral imprisonment”. Andrew Scull, within this same context, adds to the argument of social control the postulate of moral entrepreneurship of doctors. In part to establish themselves as a scientific profession, he argues, psychiatrists successfully claimed an ever-increasing domain of eccentric behavior as their domain of expertise. As a result, the disproportionately expanding number of patients admitted to the asylums led to overcrowded institutions, which defeated the original purpose of asylum reform.”

In his analysis of nineteenth-century mental health reform in the United States, social historian Gerald Grob challenges the one-sided assumptions of the social control theorists and counteracts their almost hostile view of psychiatry with a more detailed historical analysis of public policy of the care of the mentally ill.» Grob argues that the changes in psychiatric care resulted from complex social processes rather than from deliberate control strategies. These social processes produced dilemmas that “gave rise to results that diametrically contradicted starting intentions and objectives”. The pressures of continuous underfunding, the accumulation of chronic and incurable patients, and issues of class, ethnicity, and race compromised the care of the mentally ill. Grob concludes that by the end of the nineteenth century, the ever-growing size of mental institutions constrained the initially liberating attempts of reform and moral treatment, reshaping institutional care into custodial care. Similar social processes affecting the care of the mentally ill have been observed in Western European countries, although the political context varies from country to country.”

Notwithstanding the one-sidedness of many of the revisionist criticisms, these broad analyses of large-scale social responses to the problems arising out of mental illness inspired a new group of historians in the 1980s to produce more narrowly focused and more detailed studies of the asylum, particularly in Britain and the United States®® As nurse historian D’Antonio argues, this refocusing may have been related to the fact that during the 1980s researchers had seen the devastating effects of the “deinstitutionalization” process, itself a response to the severe criticism of mental institution practices. Facing a new reality of homeless insane, the role of the mental hospital was reassessed, resulting in more nuanced portraits of psychiatric institutes and practices.27

Detailed asylum studies have produced both a reconstruction of patient experiences and an analysis of daily operations and dynamics among patients, staff, and families.” D’Antonio’s study demonstrates how the early nineteenth-century metaphor of moral treatment — that is, the institution as a family — produced its own dilemmas. The idea of an institutional family was incompatible with the day-to-day institutional reality of chaos and confusion presented by the behavior of the insane. Repressing the inevitable chaos belied the promise of compassionate family-like care. As a result the lay staff began to seek involvement of physicians and thus contributed to the medicalization of care.” The studies of Digby, Dwyer, and Tomes all devote part of their work to the role of attendants in their broader analyses ofthe inner workings of the asylum and the implications of a new, humane moral treatment regimen. They emphasize the ambiguity of the attendants’ role. Although the attendants’ impact on patient treatment was crucial, they formed the lowest ranks and were the least valued in the asylum hierarchy. This resulted in an inherent contradiction: for the day-to-day application of moral treatment the physician staff were dependent on the lay attendants, who were unprepared for the work.

The historiography of Dutch psychiatry and mental health care has been limited." During the 1970s, when the anti-psychiatric movement impacted the Netherlands, a renewed interest in psychiatric history resulted in various revisionist publications, including a historical analysis of the rise of Dutch asylums by Hans Binneveld and various publications by Joost Vijselaar on the application of moral treatment and the inner workings of the asylum. In this literature the role of the asylum attendant and nursing personnel remained underexamined.® The introduction of mental nurse training is usually addressed as a measure for improving the level of personnel in the broader context of asylum reform. Recently, more detailed asylum studies have appeared, one of which focuses in particular on the patient experience of asylum care.

A new approach towards historical analysis within the historiography of nursing evolved in the 1980s. Beginning with works such as Celia Davies’ Rewriting Nursing History and Ellen Condliffe Lagemann’s Nursing History: New Perspectives, New Possibilities, a new generation of historians, most often nurse historians, broke away from a traditionalist, celebratory style of writing nursing history. Traditionalist history merely highlighted nursing’s past as undeniable progression from dark times to enlightened professional discipline and scientifically based authority, usually marking the role of Florence Nightingale as a definite turning point. The new generation of (nurse) historians seeks to develop social historical analyses of nursing’s past that puts it in the broader context of social, women’s, and labor history. In other words, this new scholarship contextualizes nursing in the complex social and political dynamics of work and gender relationships. In this way it seeks to be critical and more realistic in understanding nurses’ individual and collective experiences in the context of broader social trends and cultural transformations.”

However, most nursing history studies, written from a revisionist view on nursing history, focus on general rather than psychiatric nursing.” Only a few mental nurse historians, interested in the history of their own discipline, have analyzed the development of mental nursing within the broader context of nursing and social history. At the same time they have attempted to provide psychiatric nurses with an empowering historical identity. The best well-known studies in this area are those of Olga Church on the emergence of mental health nursing in the United States and of Peter Nolan on the history of psychiatric nursing in Britain.»

Church’s work can probably best be characterized as a transitional style of writing nursing history. She outlines how the establishment of the first training program in the asylums was established as part ofa medical reform effort by doctor Edward Cowles — and headed by nurse Linda Richards — at the McLean Asylum near Boston in 1882. She views mental nursing in particular in its struggle for professional autonomy. Church’s study contrasts the efforts of professional nursing organizations and their nursing leadership, who claimed psychiatric nursing as a separate but shared sector of the professional nursing community, with the initiatives of organized psychiatrists to control the work of asylum nursing through apprenticeship training. Church interprets psychiatric nursing history as a process of professionalization in which asylum nursing eventually escaped from medical domination and grew “out of a state of apprenticeship toward an autonomous and self-reliant discipline,”*° particularly in the shift towards community mental health in the mid-twentieth century. The study’s emphasis on professionalizing strategies prevents an analysis of the construction of nursing’s work or nurse-patient dynamics.

Peter Nolan highlights the nurses’ point of view in psychiatric nursing work and training from the late nineteenth century to the present. He builds on recent revisionist historiography in psychiatry, which, he argues, often overlooked the role of nursing in mental health care but at the same time empowered nurses to question such marginalization. Using a social historical perspective, Nolan strives to elucidate the identity of mental nursing and to give it a rightful place in psychiatric history. He gives a vivid description of the mental nurse experience, particularly after 1920, using oral history. He places the traditional scheme of mental nurse training, established in the 1890s and largely maintained until the 1980s, in its historical context. Despite the discrepancy between medical aspirations and the lived experience of nursing, he argues, and despite medical domination, mental nurses developed their own identity and sought their own organizations in response to their social circumstances and work conditions. He emphasizes the gap between the work culture of the asylum workforce and the general nursing leadership’s understanding of nursing work, a gap that underlay a separation between the two groups and led to the separate organization of asylum nurses. Nolan perceives the recent shift from institutional to community care as an opportunity for nurses to acquire a more central place in mental health care.

Furthermore, several articles provide the beginnings of the documentation and analysis of the work conditions and class background of attendants or asylum nurses and their role in asylum discipline in the nineteenth and early twentieth centuries.“ These articles speak explicitly of the day-to-day experience of nineteenth-century institutional caretaking of the mentally ill and the often harsh working conditions in the ever growing mental institutions. The articles emphasize how attendants were usually young and were recruited from the local working class. Both pay and appreciation of caretaking were low, and asylum life very much restricted the attendants’ social life. Strict discipline and bureaucratic control regulated the attendants’ work.#