Geertje
Boschma’s account of the origins of mental health nursing in the Netherlands
offers an insightful and scholarly analysis of a period of social history that
is otherwise not especially well researched. Boschma’s research draws on the
archival records of four Netherlands asylums. The rise of mental health nursing
situates late nineteenth century psychiatry within the complex and structure
unique structure of Dutch society, and provides a careful documentation of the
many influences of that period that shaped both psychiatry and the emerging
discipline of nursing. The result is a satisfying and rich description.

The
turn of the nineteenth century is an especially interesting period in the
history of psychiatry. The asylums that had expanded throughout the western
world in the previous 100 years had lost much of their legitimacy as places of
medical care, and had become, using Scull’s phrase ‘warehouses of despondency
and gloom’. The many histories of psychiatry that have been written about that
period concentrate mainly on psychiatry or the social history of patients.
Nursing has seldom been studied with the depth that Boschma brings to this
task.

The
book begins by with a description of the plural nature of Dutch society; the
phenomenon of verzuiling, translated as ‘pillarization’ or ‘compartmentalization’.
Political reform enabled religious groups such as Roman Catholics and
Protestants to develop their own organizations, something denied under the
national government with followed the end, in 1815, of French occupation.
Understanding this social context, and the increasing industrialization of the Netherlands in
the latter half of the nineteenth century is crucial to an appreciation of the
development of asylum care and psychiatry. The categories of gender, class,
religion and scientific psychiatry reflect the plural nature of the Netherlands at
this time. Boschma shows how these related categories were played out in the
secularization of the asylums and in the contradictory interests served by the
feminization of asylum care and the development of mental nurse training.

Boschma
describes the different processes by which moral treatment regimes, to
different degrees committed to religious models of insanity, became
secularized, and committed to what was regarded as scientific psychiatry. Care
of inmates became the business of the emergent discipline of nursing, initially
based on the nursing practices of general hospitals, but later incorporating
elements of pedagogy. By the early twentieth century something we would recognize
today as a therapeutic relationship formed part of the mental health nursing
curriculum. The process of change was uneven and contested. Professional groups
of psychiatrists and, later, nurses, labor and clerical interests, and womens’
groups with differing agendas for change, all played a part in the development
of mental health nursing. At times their interests converged, for example when
psychiatrists’ and nurses’ organizations lobbied for the introduction of
training. But even this convergence of interests contained contradiction. Psychiatrists’
interests in creating a compliant workforce subject to psychiatric rather than
religious authority did not extend to supporting nurses’ release from domestic
duties such as cleaning and housekeeping.

The
idea of asylum care as a civilizing enterprise requiring cultured individuals
of good moral character and social standing is a prominent theme. The
perception that women were more morally suited to the task coincided with the
rising expectations of women for participation in the labor market. For many
women asylum care offered an opportunity for employment that was otherwise
denied. However the reality of asylum work was such that the expectations of
women as employees were not met. The long hours, restrictive living conditions
and arduous tasks of asylum work led to high attrition rates. To some extent
this was exacerbated by the introduction of training programs, as graduates
left the asylum for more congenial employment in providing private care,
especially to individuals with ‘nervous conditions’ who, it can be imagined,
presented less onerous problems to their nurses.

The
everyday work of mental health nurses comes to life in this book. Supervising ‘bath
treatment’ in which patients were restrained, sometimes for days on end, in
baths of water and in which they ate, drank, defecated and slept, sleeping in
dormitories with the patients whose care they provided, facing fines and
disciplinary action in any case of perceived dereliction of duty, especially if
it resulted in adverse publicity for the asylum administrators, combining care
of patients with domestic tasks were all part of the lot of the mental health
nurse at this time. Low rates of staff retention were explained in terms of the
nurses’ lack of ‘civilization’.

One
of the intriguing aspects of this book is its analysis of the marginalization
of male nurses. As the new gendered model of asylum care developed, male nurses
were seen to lack the necessary civilizing moral character necessary for asylum
work, to be unreliable as employees, and less easy to discipline by
psychiatrists. But Boschma never opts for a one-dimensional analysis. Labor
market conditions meant that men has less reason than women to see asylum work
as a career opportunity, as there were other employment opportunities available
to them that were denied to women. Thus although the gendered stereotype of
females as possessing natural caring qualities contributed to the decline of
males in mental health nursing over this period, that alone is not a sufficient
explanation for their relative exclusion.

Boschma’s
skill in showing the relationships between the various forces at work in
shaping the history of mental health nursing, evident throughout the book, is
one of the factors that makes her work rewarding and informative.
While there are certainly themes that could be developed further, Boschma’s
achievement in bringing together an analysis of Dutch society with themes of
gender, class and religion is impressive. The work is extensively referenced to
other research and published material, and the explanatory footnotes provide a
rich source of detail for those interested in the minutiae of historical
research. Any student or teacher of the history of psychiatry or mental health
nursing will find this book has something to offer in extending their
understanding of that history, and of the Dutch context in particular.

© 2004 Tony O’Brien

Tony O’Brien M Phil., Lecturer,
Mental Health Nursing, University of Auckland

Categories: General, MentalHealth