Abstract
This article argues for the importance of studying life after mental illness. A significant proportion of people who experience mental illness recover, but the experience continues to affect their lives. Historical examination of the birth of mental after-care through the Mental After-Care Association (MACA) highlights the challenges faced by those who were discharged recovered from English and Welsh lunatic asylums between 1879 and 1928. This research demonstrates the relationship between ideas regarding psychiatric recovery and citizenship. Throughout the period, certification of insanity for institutional treatment stripped patients of the status and rights of citizenship. Discharge on account of recovery restored a patient's legal access to citizenship, yet suspicions about their right and ability to particate in society lingered. The MACA designed after-care to facilitate restoration to full citizenship. The MACA was a product of the active citizenship movement, according to which, one's right to identify as a citizen depended on the performance of certain duties to the community. These duties varied according to socio-economic position and sex, meaning that each individual was prescribed a gendered personal citizenship role. MACA personnel saw their endeavours as part of their own citizenship roles, and designed their treatments accordingly. The MACA used a patient's assumption of a citizenship role to indicate recovery, and believed that supporting the performance of that role had mentally healing effects for patients who had been discharged recovered. MACA workers thus imbued the psychiatric innovation of after-care with the liberal political and social values of active citizenship.
Introduction
Considering the state of having-been-mentally-disordered will generate new insights into experiences of and approaches to mental illness. By examining the birth of mental after-care via the Mental After-Care Association (MACA), which was Britain's first non-institutional psychiatric charity, this article illuminates the development of the notion that people who have experienced mental illness in the past require continued medical intervention (Voluntary Mental Health Services, 1939: 1). This development grew out of and fed into the idea that recovered psychiatric patients should be treated differently to both the presently ill and those who have never experienced mental disorder. After-care was simultaneously a medical and a political intervention because it linked patients’ mental stability with their regained right to participate fully in society, with the latter being articulated in terms of citizenship. I examine the MACA from its foundation in 1879 until 1928, when the introduction of near-universal adult suffrage signalled that being a British citizen should involve inclusion in the national franchise. This year represents a sea change in which the government relegated the identity-based components of citizenship below the rights-based emphasis upon the parliamentary vote. Only ‘idiots’, ‘lunatics’, and prisoners were excluded, with voting restrictions on the former two officially lasting until 2006 (Johnston, 2013: 45–51). Throughout the period under consideration, certification of insanity both mandated and was necessary for treatment in an institution, and officially stripped a person of their status and rights as a citizen while physically separating them from society. While recovery facilitated release and officially removed certification's legal restrictions, the label's exclusionary powers lingered. The rise of after-care formalised the idea that recovered mental patients had a legitimate claim to citizenship, but needed help to maintain their capability to perform the attendant duties. The use of organised action to prevent these patients relapsing into lunacy cemented their citizenship status as simultaneously legitimate and fragile.
Those who participated in the MACA used the language of citizenship to articulate their understanding of societal participation and belonging. Citizenship has long been used to discuss the combination of duties and rights that one must fulfil and execute to be granted membership of a political community (Leydet, 2017). In different historical contexts, various contemporaries have promoted competing interpretations of what those duties and rights should be. Indeed, there was no state-sanctioned definition of what constituted a British citizen until 1948 (Thane, 2018: 11). Between 1879 and 1928 the MACA's advocates favoured ‘active citizenship’, through which an individual gained the right to identify as a citizen – and therefore as a true participant in society – by demonstrating their capability and willingness to undertake duties appropriate to the personal financial and social circumstances in which they found themselves at any one time. That set of duties would enable the said individual to maintain self-sufficiency, whether as a single person or a member of a family unit, and then to channel surplus personal resources into the community. Fulfilling their role allowed an individual to identify as a citizen and thereby continue their life in the community, accessing employment, friendship, leisure activities, a home, and any property or voting rights attendant to their economic position and sex. The MACA's proponents thus associated the return to healthy social functioning with the fulfilment of an individualised citizenship role through which the asylum-leaver contributed to the collective.
Active citizenship was rooted in the two values of action and identity, and thus falls into the set of approaches that Joseph H. Carens has recently called ‘the psychological dimension of membership’, noting that one ‘way to belong to a political community is to feel that one belongs, to be connected to it through one’s sense of emotional attachment, identification, and loyalty’ (2000: 166). However, it was not enough to assert membership: construction of identity involves negotiation between the individual and the community to which they claim membership. After-care provided a mechanism through which individual claims to citizenship were reconciled with collective attitudes.
The MACA was founded, administered, and developed by a collaboration of professional psychiatrists and lay actors, some of whom worked in official religious capacities, for the purpose of reintegrating patients who had been released from asylums as ‘recovered’ into social life. These actors used liberal ideas of active citizenship to interpret and influence the lives of their beneficiaries, who, whether through choice or desperation, participated in the after-care project. The charity's first annual report advocated distributing patients ‘amongst their fellow citizens of robust mind’ in order to consolidate their recovery, while, during the 1920s, the Nursing Times promoted the MACA by declaring that, for those patients who had been ‘cured’ and regained their ‘liberty … the stigma remained with a fear of relapse always present’, so psychiatry needed ‘to aid the convalescent so that he may become a reasonable efficient citizen’. 1 The MACA's workers justified recovered mental patients’ right to return to full societal participation by issuing reminders of the legitimacy of recovered individuals’ claims to citizenship, but this reintegration remained threatened due to the perceived fragility of that claim.
I use published reports, publicity materials, and media coverage from the MACA to establish the charity's intentions, examine its activities, and present its rationales. Due to its charitable status, the MACA needed to justify its existence and attract supporters. The resultant publicity materials reveal why psychiatrists and lay philanthropists united to found the organisation, why the charity successfully garnered support, and how medical activity converged with philanthropic organisation. These materials also show how proponents advertised their service and indicate some of the methods used to establish after-care as a field of psychiatric intervention. Certainly, from the 1880s to the 1920s, the MACA's annual reports presented after-care as a mode of ‘treatment’ designed to consolidate recovery and prevent relapse. 2 Using materials from across five decades, I demonstrate how after-care's pioneers sought to intervene in a growing proportion of recovered patients’ lives, pushing the idea that post-mental-disorder constituted a particular state of mind requiring specific treatment.
This article proceeds in four stages. First, since I am presenting a case study to support a wider call to research the state of having-been-mentally-ill, I provide a substantial historiographical discussion. Second, I give an overarching assessment of the MACA's activities and the emergence of after-care, and how these were entwined in discourses of active citizenship. The remainder is divided into two sections that explicate the overall argument. The first of these demonstrates that philanthropists and psychiatrists who served the charity saw their involvement as part of their own citizenship roles, and integrated these ideas into their medical innovations. The second shows how charity workers’ promotion of male and female citizenship roles affected the treatments delivered by the MACA.
Historiography
I use historical examination of the MACA to demonstrate the value of studying post-mental illness in the wider mental health humanities. In a groundbreaking chapter from 1999, David Wright investigated release from asylums, but historians are yet to answer his concluding question, ‘What happened to patients after discharge?’ (1999: 108). 3 Furthermore, commentary on life after recovery is sparse across the mental health humanities. Regarding contemporary issues, Liz Sayce, the former policy director of the charity Mind, has concluded that, even if medical help can bring support or cure, ‘life chances [are] potentially jeopardised permanently by a psychiatric record’ (2000: 9). Indeed, by examining patients’ lives following the cessation of symptoms, Flanagan, Ben Zeev, and Corrigan have provided evidence of ongoing social exclusion, undermining the assumption that ‘stigma will disappear when mental illness is cured because symptoms which elicit stigma are no longer evident’ (2012: 264-78). These commentaries point to a plethora of unexplored issues. My article thus constitutes a call for new research.
Given that this intervention pertains to the wider mental health humanities, my choice of nomenclature requires explanation. The fact that terminology shifted during the years examined poses further challenge. In the 1870s, lunacy was widely used, but had fallen out of favour amongst medical professionals by the final decades under consideration, while the Mental Treatment Act 1930 signalled governmental rejection of the word (Craig, 1905: iii; ‘Mental Treatment Act’, 1930: 141). Throughout the era, insanity, mental disorder, and unsoundness of mind remained common professional terms, while mental illness was sometimes used (Percy Smith, 1926: 176). I need to cater not only for differences in past and present-day nomenclature, but also for the fact that the historical period under consideration saw shifts in terminology. Therefore, when commenting on historical documents, I generally use insanity and mental disorder, but when making a wider intervention I refer to mental illness, since the phrase, although more commonplace now, was also employed during the period under historical investigation.
By focusing on life after insanity, this article provides new insight into what it meant to treat mental disorder and emphasises that many patients did not remain ill forever, but transitioned between insanity, sanity, and somewhere in between. Underscoring the often dynamic nature of mental disorder encourages us to see patients as people who underwent an experience of suffering, which may well have included recovery or improvement and perhaps the threat of relapse, as opposed to beings suspended in lunacy. It also demonstrates that stage of illness, as well as diagnosis, was used to determine what type of treatment was appropriate. Finally, focusing on life after recovery reveals new information about the relationship between states of mind and citizenship, and highlights the simultaneous importance and fragility of the post-disorder patient's claim to citizenship.
My approach emphasises the shifting dynamics of individuals’ lives and the heterogenous nature of their experiences while identifying common ways in which processes of insanity and their treatment could have lasting impacts. It thus provides fresh insights into the purposes and repercussions of psychiatric interventions. Numerous historians of Victorian asylum psychiatry have noted that one of these institutions’ purposes was to return inmates to their positions as citizens in the community (Melling, 1999; Scull, 1993: 93). Andrew Scull argues that moral treatment was deployed in late 19th-century asylums in order to ‘return the dependent to the ranks of productive citizenry’ (1991: 155). Sarah Chaney has produced more nuanced commentary than Scull's Marxist narrative, confirming his observation that asylum practitioners were interested in creating ‘useful members of society’, but looking beyond productivity (Scull, 1993: 31). She notes that the ‘term “useful” was multi-layered’ and that this was ‘not necessarily a class-specific ideal’ (Chaney, 2016: 282). By analysing community-based interventions that occurred during the height of asylums’ dominance, I reveal what happened to some of those who did reach social reintegration.
In doing so, this article illustrates the relationship between action and identity in active citizenship. Just as Chaney notes the different forms of usefulness within the asylum, I underline this concept's myriad meanings in the outside world. The MACA shows the importance of the link between usefulness and self-sufficiency rather than productivity as such, with discharged individuals being channelled into activities necessary according to their personal circumstances. Financial circumstances were, of course, extremely important in determining a patient's experience of life following confinement but, in order to highlight that personal circumstances were changeable and not solely economically determined, I relinquish the language of class. Class is a highly disputed concept, employed to discuss the experience of occupation and finances. One of this concept's limitations is its association with the sense that an individual's social and economic circumstances are static (Rubin et al., 2014: 196). By contrast, those who administrated the MACA were concerned with the changeable conditions of their patients’ lives, and generated a conceptualisation of citizenship that they believed allowed individuals whose circumstances had been transformed by insanity and confinement to reclaim and regain a place in society appropriate to the financial and social position into which they were discharged. These conditions of release often differed from those in which the patient's illness had begun. Therefore, rather than using the language of class, I write about social and economic circumstances.
Indeed, the MACA accepted former ‘pauper lunatics’ who had affluent families, alongside individuals whose professional occupation had not precluded certification or destitution upon discharge, as well as those who had lived in poverty before their illness. It also treated patients who had been employed in lower-waged sectors who had then received private asylum care, funded by a friend. For example, amongst the seven private patients that the MACA accepted from Claybury Asylum between 1916 and 1921, there was a domestic servant and a watchman. 4 Furthermore, episodes of mental illness had enduring effects upon elements of social belonging not adequately captured by the economically centred notion of class (Andrews and Digby, 2004: 40). Not only did marital status influence the experience of illness, but a record of mental treatment affected a single patient's marital prospects. While marriage was not confined to any particular social ‘class’, it was a form of social participation that contemporaries thought of in terms of citizenship. I hence show how the idea of the citizenship role was used to assess and discuss patients’ psychiatric recoveries in a way that encapsulated the social precarity projected upon and experienced by the individuals in question, illuminating ways in which patients from a multitude of economic and social backgrounds could be united by mental disorder. As Anne Digby and Jonathan Andrews argue, ‘Lunacy itself implied loss of status, in particular legal and consensual rights, which in some degree cut across class (and gender) boundaries’ (ibid.: 18).
Tying the study of post-mental-illness into historical scholarship regarding citizenship deepens our understanding of tensions within liberal debates regarding social belonging in the late 19th and early 20th centuries. Eugenio Biagini highlights that the ‘tension between concern for individual liberty and commitment to “community” was a core anxiety’ (1996: 1). This worry was especially pronounced in attitudes towards individuals who had formerly been certified due to a perceived mental incapacity to survive safely in the community, but who were now medically judged ready for social reintegration. I show that mental capacity was woven into the debates about citizenship's relationship to gender, employment and property ownership (ibid.: 1–17). As Harris demonstrates, it was common in the 1870s not to equate citizenship with the right to participate in the formal institutions of the State. Harris agrees that many saw citizenship as an identity achieved by participation in civic society through work, charity, family life, religion, leisure, and culture, and thus as a ‘sense of belonging’ not necessarily tied to the vote (1990: 67–9). Between the 1870s and 1928 the conceptualisation of citizenship as a sense of belonging to, and hence right to participate in, the community continued, but became increasingly connected to the franchise. As Mayhall shows, this shifting ideological landscape played out strongly in the women's movement (2003: 12). The changes were conducted through intense debate, but there remained agreement that access to citizenship should rest on the enactment of duties to the community. The MACA was thus able to continue promoting its conceptualisation of citizenship as an identity achieved by the execution of a citizenship role, while supporting the gendered construction of those roles and avoiding controversies over equality of male and female rights.
This study contributes to explorations of the relationship between mental states and citizenship. Gauchet and Swain examine the French context, arguing that Pinel's rejection of physical constraint intersected with the democratic ramifications of the French Revolution: French lunatics came to receive humane treatment because they became regarded as citizens (1980: 25–48). These comments provide a useful contrast with 19th-century Britain. While British lunatics remained non-citizens, they were deemed to have retained the potential to become responsible citizens should they recover. Additionally, the MACA's archive prompts us to critique Gauchet and Swain's argument, even regarding France. They fail to question the universality of the National Assembly's idea of citizenship. Despite the Assembly's declaration that ‘law is an expression of the general will. Every citizen has a right to participate … in its foundation’, no French woman could vote until 1944 (Declaration of the Rights of Man and Citizen, 1789; Hause and Kenney, 1984: 251). Men and women experienced citizenship differently, rendering it illogical to assume that male and female lunatics would receive the same treatment on the basis of their citizenship. Critiquing Gauchet and Swain's generalising narrative underscores the necessity for gendered analysis in the British context (Busfield, 1996; Showalter, 1987; Ussher, 2011).
Some British studies have connected attitudes towards mental states of people outside the asylum and ideas of citizenship (Thomson, 2000; 2006: 192–4; Toms, 2020). I add to these studies by examining community-based psychiatry before deinstitutionalisation, and by focusing on the dynamic nature of many patients’ disorders. Mathew Thomson and Jonathan Toms note that the mental hygiene movement, which arose in the interwar period and continued into the 1960s, sought to maximise the mental health of the ‘normal’ person and prevent mental illness. They show that mental hygienists equated mental health with being a good citizen, usually articulated in terms of being a productive employee (Thomson, 2006: 40; Toms, 2020: 628). These studies are instructive, but raise questions about attitudes towards patients who were considered mentally incapable of performing citizenship.
An earlier work of Thomson's provides insight regarding exclusion from citizenship on the basis of mental capacity. In The Problem of Mental Deficiency Thomson demonstrates that concerns about ‘feebleminded’ people centred around their supposed threat to responsible citizenship (1998: 1–12). While Thomson's work is informative, his focus on mental deficiency, and, therefore, on a group of people who were deemed to need care rather than cure, leaves some of the elements of doubt and suspicion created by the less constant nature of mental disorder uncovered. By concentrating on insanity, with its potential for curability and relapse, I reveal a more tense and intricate connection between mental recovery and citizenship than between ‘mental efficiency’ and citizenship.
Some writers have moved away from the focus on productivity to investigate how psy-disciplines have operated as a mode of governmentality, considering how government agents have employed psy-practices in the organisation of society. Michal Shapira explores how psychoanalysis was adopted in post-war Britain to generate new approaches to selfhood and citizenship (2013: 1). She demonstrates that psychoanalysis was used to ‘make the modern democratic self’ during efforts to build a peaceful social democracy following the Second World War (ibid.: 5–6). Similarly, Nikolas Rose argues that psy-disciplines have been instrumental in the government of human subjects (1985: 1–11; 1990: ix). Rose contends that the psy-disciplines have contributed to subjective governmentality in Britain on a macro level since the late 19th century. New interventions, measurements, and the collection of statistics, he argues, have led to the construction of the normal self, and he asserts that the general populace have participated in and conformed to governmental construction of the psyche of the citizen (Rose, 1985: 1–10; 1990: 1–32). I broaden our awareness of the relationship between psychiatric practice and governmentality, deepening our understanding of the less-studied earlier period. By focusing on a specific group of individuals, rather than projecting population-wide trends, I emphasise that the social implications of psychological experiences meant that people encountered varying treatment and that experiences of citizenship have ranged dramatically.
The MACA and citizenship roles
The MACA was established to offer a stage of treatment for patients being released as recovered from asylums, providing ‘after-care’ for impoverished women who lacked friends to rely upon. Indeed, the MACA's original title was ‘The After-Care Association for Poor and Friendless Female Convalescents on Leaving Asylums for the Insane’. 5 The Association gradually expanded its mission and began to accept men in 1894. The charity adjusted its name, eventually settling on the ‘Mental After-Care Association’. I hereon use MACA for clarity. The organisation's first secretary described after-care as ‘facilitating readmission of convalescents from lunatic asylums into social life’, by providing ‘a change of scene and air’ and ‘convalescent homes’, ‘boarding out’ patients in the community, ‘giving them grants of money and clothing’, and ‘assisting them to find suitable employment’. All aspects of after-care were imbued with the practice of forming personal friendships with the patient and harnessing the healing power of individual care and ‘attention’. 6 The Association's approach displayed many continuities until Britain's welfare reforms precipitated a ‘shifting of the emphasis from convalescent to chronic patients’ in the 1950s. 7
The charity's activity was concentrated in London during its early years, and the capital's patients remained over-represented. However, the Association always planned to be a national charity. In 1904 it began to establish local branches in England. 8 In 1914 the Association founded an office in Cardiff and by the 1920s cases had been received from Edinburgh and Glasgow. 9 While the MACA developed a significant presence across England and Wales, it was never truly established in Scotland during the period because of the latter's different lunacy laws. Scottish legislation allowed uncertified patients to be treated as temporary cases and for non-violent ‘lunatics’ to be boarded out under a guardianship scheme, meaning that Scotland already had a boarding-out system (Rayner, 1897; Sturdy and Parry-Jones, 1999). The MACA's relationship with Ireland was more distant. The 1909 annual report listed Ireland amongst countries ‘abroad’ to which the MACA had sent information regarding the establishment of ‘kindred societies’. 10 The Association was hence predominantly a charity of England and Wales.
The MACA was founded in response to the difficulties that patients released from asylums on account of recovery faced due to the mechanisms of institutional treatment in England and Wales. Between 1811 and 1930 certification of insanity was imperative for treatment in a county asylum, voluntary institution, or private establishment (‘Mental Treatment Act’, 1930; Wright, 1998: 268). Certification also mandated confinement in a specialist institution and removed patients’ civil liberties, including control of property and any franchise claim, labelling a person a lunatic to be barred from society, and providing the legal mechanisms for official exclusion (McCandless, 1978: 368). A patient thus ceased to be a citizen upon admittance to an institution for the treatment of insanity.
Inmates could leave asylums via two methods. The majority of released patients were discharged because the medical superintendent deemed them recovered. As of 1853 superintendents of county asylums were obliged to report inmates’ recoveries to the Visiting Committees, which were committees of magistrates and administrators established in 1845 to manage and inspect county asylums. Inmates judged to be recovered were discharged from a county asylum when two members of the committee, alongside the superintendent, signed the appropriate order. Inmates were either officially discharged immediately upon exiting the asylum, or subject to a trial in the community, after which the documents would be signed if the patient remained well enough to cope in the outside world (Wright, 1999: 95–8). A significant minority of patients were released regardless of their mental state using a different administrative procedure on the request of friends, but these patients are not the focus of this article (ibid.: 98). ‘Recovered’ thus constituted a legal status, connected to a judgement regarding a patient's mental state. The MACA was clear in its purpose to treat only patients released on account of recovery, adopting the name ‘The After-Care Association for Persons Discharged Recovered From Asylums for the Insane’ in 1894, and using its 1921 report to reiterate that the ‘Association does not undertake for persons still suffering from mental disorder’. 11 This article examines responses to those patients who obtained the legal status of recovered, rather than all patients who had been released from asylums. By definition, a person who had achieved legal recovery following certification of insanity was an asylum-leaver, since certification mandated confinement in a specialist institution. While the MACA would treat a patient released from any institution, its dedication to impoverished individuals meant that the majority of its beneficiaries came from county or charitable institutions.
The MACA's archive illuminates two aspects of the challenges discharged patients faced. First, having been confined generated practical problems. The Association's leaders’ greatest concern was former inmates’ prospects of finding employment and, by extension, housing. Second, even when officially designated as recovered, former inmates faced consistent suspicion regarding their mental health. MACA personnel were simultaneously concerned by the consequences of this suspicion and worried by the possible fragility of their beneficiaries’ mental soundness. The charity's leaders were consistently ambivalent regarding the possibility that an experience of mental disorder could alter a person's mental state, even beyond the achievement of what they saw as recovery, worrying, for example, that patients might exhibit residual weaknesses of mind or harbour mental injuries (Savage, 1907: 15). The MACA's workers were thus adamant that their beneficiaries had recovered, but also that they needed further treatment in order to ward off relapse.
Therefore, at the same time as proclaiming beneficiaries’ rights to remain in the community on account of having returned to mental health, MACA personnel cemented the idea that those recoveries, and hence claims to community participation, were fragile. In an attempt to override the barriers to community participation, the MACA reminded the public that recovered patients had regained their claim to citizenship. In order to justify this claim, the charity's leaders needed to provide a form of after-care that actually facilitated beneficiaries’ performance of their citizenship roles. Here, the ambiguity of British citizenship provided both opportunities and challenges for the MACA and its patients.
British citizenship was contested throughout this period. Until the British Nationality Act in 1948 there was no state-sanctioned definition of citizen. At the turn of the century, ‘aliens’ could buy British nationality for three pounds; there were no immigration restrictions until 1905, and passports were not used until the First World War (Thane, 2018: 11). There were, therefore, competing claims regarding what constituted a citizen. The MACA was born of a largely liberal network of late-Victorian philanthropists, and retained a liberal character into the 20th century. Amongst liberals, it was uncontroversial that performance of one's citizenly duties facilitated one's enjoyment of the status of citizenship, but there remained debate about what these duties were and how an individual obtained or lost the identity of citizen (Freeden, 2003: 278). In order to claim their beneficiaries’ right to return to the community, the MACA's leaders turned to a definition of citizenship based on the status achieved by the performance of citizenly duties.
The MACA was part of the active citizenship movement, which was clear that performing citizenship's duties successfully was one and the same as being a citizen (Freeden, 2003: 277–8). According to active citizens, a citizen performed obligations to the community through self-help and further community service. An individual would thereby achieve two linked social responsibilities. First, one would achieve self-sufficiency. Second, one would channel surplus personal resources into community service. These two responsibilities were connected, since maintaining self-sufficiency, and thereby avoiding reliance on collective funds, reduced the burden shouldered by the community (Parker, 1998: xii). Expectations regarding civic service operated on a sliding scale: the citizenship role was adjustable according to personal economic and social circumstances. Duties were also prescribed along a sexed division of labour (Pateman, 1988: ii–3). The MACA's workers promoted an interpretation of citizenship based on male and female differences, thereby avoiding debate about whether men and women were encouraged to fulfil equal duties or afforded equal rights (Bock and James, 1992). Citizenship roles were inherently gendered, and socio-economic factors determined one's personal duties. Whether it demanded domestic labour, philanthropy outside the home, paid work, or some combination of these, each citizen had a responsibility to fulfil whatever role befell them. We can hence conceptualise active citizens’ descriptions of healthy social functioning in terms of a citizenship role (Parsons, 1951: 455–6).
By equating healthy social functioning with the citizenship role, the MACA's workers were able to use the discourse of citizenship to argue for their beneficiaries’ access to the community without lobbying for further rights for anyone or redistributing wealth. The patients served by the Association, especially in its early years, had limited opportunities to demonstrate their ability to enjoy the rights of citizenship responsibly. Women continued to constitute a large proportion of beneficiaries after 1894, and, of course, had limited property and voting rights. Furthermore, the charity's focus on poor patients meant that many of its male recipients lacked property and, until 1918, associated voting rights. By relying on citizenship roles, the MACA could sidestep the question of rights while supporting its beneficiaries in accessing the resources necessary to maintain their place in the community. In doing so, the proponents of after-care supported their patients’ claims to be allowed to participate in society on account of having regained their sanity, and also aided these individuals’ performance of a certain kind of citizenship in order to demonstrate ongoing recovery.
Claiming citizenship through founding and administering the MACA
The MACA's founders, funders, staff, and volunteers conceptualised their endeavours as part of the performance of their own citizenship roles. This network published explanations of their ethos, which informed the MACA's interpretations and treatments of mental disorder. In late-Victorian Britain a network of predominantly female philanthropists administered welfare provision through voluntary organisations, justifying their actions using a language of citizenship that centred around self-help and civic service. Here there was a reciprocity amongst professional medics and lay agents. Following the First World War, women increasingly began to serve the Association through paid employment and professionalised social work. Nonetheless, the MACA continued to attract voluntary service from women. This section illustrates how the mechanisms of charity organisation imbued after-care with the social and political values associated with active citizenship.
Professional psychiatric and lay expertise converged in the development of after-care. Reverend Henry Hawkins founded the MACA. He served as chaplain of Colney Hatch Asylum, and throughout his career combined religious calling with engagement in professional psychological medicine (‘Obituary’, 1905). Hawkins exploited his psychiatric and philanthropic networks to unite interested actors. He called upon physicians who believed that asylums were no panacea for mental disorder and had begun looking for complementary treatments, including Daniel Hack Tuke, whose great-grandfather had pioneered moral treatment a century earlier, and John Bucknill, who alongside Hack Tuke had published Britain's first textbook on insanity (Hawkins, 1892). In their textbook, Bucknill and Hack Tuke maintained that institutions were necessary for treating acute lunacy, but ‘for convalescent patients the best place for care and treatment is not the regular wards of the asylum’ (1879: 638). Having worked alongside Hawkins to establish the MACA, Hack Tuke included a chapter on after-care by the Reverend in his 1892 Dictionary of Psychological Medicine, in which Hawkins reiterated ‘the importance of after-care for the complete restoration to health’ (Hawkins, 1892: 58). These psychiatric professionals wished to establish new treatments to supplement their work in asylums and sought partnership with lay agents through Hawkins.
These alienists also believed that the social implications of asylum treatment hindered efforts to release recovered patients. Chiefly, many employers refused to hire ex-mental patients, meaning that released inmates without money or friends faced destitution. As Hawkins observed, a woman might remain ‘detained from the unwillingness of authorities to expose her to the particular hardships she would have to encounter in the outside world’. 12 Physicians believed that their asylums were collecting patients whose internment had become medically unnecessary or even detrimental, which damaged both the women's well-being and alienists’ professional standing. Indeed, Bucknill and Hack Tuke emphasised that ‘the recovery of the insane persons committed to his care’ was the ‘prime objective to which he [the psychiatrist] had devoted his life’, but delays in releasing inmates encouraged the idea that asylum alienists were failing to achieve their purpose (1879: 654). Concentrating on both the realities of and attitudes towards having been mentally unsound reveals why difficulties in discharging patients may have encouraged some custodial practices. While Wright astutely corrected historians’ tendency to overstate the prevalence of unending confinement, we now see why some asylum inmates of sound mind did have their releases delayed (1999: 94).
Solutions to the medical and social inadequacies of asylum treatment lay beyond the institution. Hawkins rallied the interest of prominent philanthropists, and generated further support by citing their names while addressing women's voluntary groups. In 1892 he appealed to the Ladies’ Diocesan Association, which recruited women from London's wealthy parishes to volunteer in poorer areas (Geddes Poole, 2014: 20–3). Hawkins evoked the names of influential philanthropists, all of whom were noted female members of the Liberal Party, listing ‘Mrs Gladstone, Lady Frederick Cavendish, Miss Emma Cons’ (Pugh, 1996). 13 Psychiatric professionals may have discussed methods to achieve full recovery, but they relied on philanthropists’ social authority to implement new treatments in the community.
The MACA emerged from a world of late-Victorian female philanthropy and active citizenship, in which participants championed voluntary causes that would enable ‘the needy’ to become self-sufficient. Many prominent philanthropists were aristocrats of extensive financial means. Lucy Cavendish was the archetypal philanthropic gentlewoman described by Julia Parker (1998: 14–19). She hailed from two eminent families, being married to the heir to the Dukedom of Devonshire and the niece of the aforementioned Mrs Gladstone, who was the Prime Minister's wife (Geddes Poole, 2014: 20–3). Without need of paid work, Cavendish fulfilled her citizenly duties through extensive philanthropy, explaining that she endeavoured to ‘care for the welfare of the people’ because it was ‘the duty of all citizens to work for the good of all’. 14 Receipt of her citizenly duties was dependent on whether individuals could hope to become self-sufficient. She did not propose ‘to support in uselessness, out of the pockets of the self-supporting, these feeble creatures’ who had no prospect of relinquishing reliance on others. Cavendish pondered what to do with ‘moral imbeciles’, concluding that only when there was a way to ‘prevent many from sinking back into the stream of moral death … injuring and contaminating others’ did women deserve to benefit from others’ community services. 15 As Parker observes, many wealthy philanthropists exercised a self-imposed duty to marshal the behaviour of wayward impoverished people (1998: xii). Cavendish operated in a network of women who saw a combination of philanthropy and self-help as the cornerstone of citizenship, and in which privileged citizens took it upon themselves to help the poor to become citizens able to fulfil these obligations to the community.
The MACA relied on the agency of philanthropists and the co-operation of its beneficiaries to function, indicating that some women across the socio-economic gradient shared ideas about citizenship roles. The Association exploited a belief that women should undertake ‘womanly charity’ no matter how modest their capacity to do so, and its archive shows that philanthropy and wage labour were not mutually exclusive. 16 While Prochaska may be correct that women used philanthropy to carve out identity beyond the home, for many women it was not their only route to a selfhood beyond domesticity. Nor was gaining recognition beyond the home the sole motivation for women's charitable activity (Prochaska, 1980: 5). Even one of the Association's most prominent philanthropists, Emma Cons, always had to earn her own living. Cons was of more moderate financial means than Cavendish, being the daughter of an artisan and later earning her own income through artisanal trades (Geddes Poole, 2014: 98). Women of diverse situations believed in flexible citizenship roles, in which self-help was available to all, and working people could make charitable contributions according to their capabilities.
Women's voluntary support for the MACA remained part of the active citizenship movement into the 1920s. In 1907 the Guild of Help was established to fundraise for and promote the Association. 17 It became an integral part of the charity's apparatus, operating until 1974. 18 In 1918 members of the Guild were expected to pay an annual subscription and give further support each year ‘either in kind or activity’. 19 A leaflet from that year featured volunteering suggestions such as ‘lending drawing rooms for meetings’ alongside activities that would have been within the capability of someone of slightly lesser means, including providing ‘a reasonable number of old garments, cleaned and mended’. 20 The Guild was part of the active citizenship movement, facilitating meetings such as that of Kensington Women's Citizens’ Association in 1923 (Breitenbach and Wright, 2014: 401–2). 21 Of course, membership was restricted to those of considerable means, but the Guild was clear that supporters would be doing ‘work congenial to themselves’ and welcomed participation on terms that suited each individual. 22
As time progressed, the MACA generated ways of eliciting support from those of modest incomes. Working women and men increasingly contributed through small financial donations. In 1903 the charity began to collect money through offertories and alms boxes and over the following decades turned this activity into a strong tradition. 23 While offertories were used to generate income, they were also adopted to allow those of modest surplus resources to exercise their citizenship by contributing something small to the community. Certainly, the MACA's 1910 report praised this method of collecting as one that ‘enables the poorest to make some small contribution’. 24 While the women who exerted influence on the direction of the MACA were of necessity of considerable means, the charity increasingly facilitated a genuine desire amongst supporters of modest resources to contribute.
During the later decades under examination, the MACA's workers increasingly encouraged beneficiaries and their families to become supporters of the charity by donating when capable of doing so. In 1916 the annual reports began to feature extracts of letters expressing thanks and enclosing money from successful patients and their families. One letter stated, ‘I am still in work, my health being built up in the beautiful little home of the After-Care Association. We send 5 s. as a small subscription to the Society, we wish we could send more.’ 25 Throughout the 1920s, the MACA's administrators advertised voluntary repayments from patients and their families for two reasons: to provide evidence for the efficacy of after-care, and to generate income from its ever-growing numbers of beneficiaries. Like many of the annual reports from this time, the 1926 report expresses gratitude for the ‘very satisfactory sums received in repayments from patients, and contributions from their friends, proving how much the work is appreciated by those who benefit and by their relations’. 26 This method of eliciting donations demonstrates how the charity's leaders saw the achievement of active citizenship as an indicator of mental recovery, and used it both as evidence of the efficacy of after-care and as a source of public support and income. Here we see a brilliant example of how after-care was progressively designed to create a virtuous cycle: beneficiaries were to heal and become supporters of the organisation, thereby allowing it to treat more recovered asylum-leavers.
The MACA's psychiatrists also served in a voluntary capacity. The vast majority of the professional medics involved until 1928 were male, but from the beginning of the 20th century Dr Helen Boyle was active in the organisation. Boyle assessed patients and liaised with the charity's non-professional volunteers by, for example, addressing the Guild of Help. 27 Professional psychiatrists served alongside lay volunteers in the Council, which decided whether and how to treat prospective patients. The Council consistently contained a mixture of psychiatrists, male and female philanthropists, and clergymen, while male psychiatrists also assumed administrative roles. 28 Indeed, Dr Savage was honorary treasurer for over 25 years (Percy Smith, 1921: 400). As I further demonstrate below, professional medics and lay actors collaborated to perform their own citizenship duties and develop the psychiatric innovation of after-care.
The MACA's approach was, however, contested. While its advocates presented their work as simply another way to support the indigent, others doubted how far helping formerly insane people was a legitimate citizenly duty during peacetime. Throughout the late 19th century, proponents suggested the MACA would struggle for support, with the chairman lamenting in 1898 that, while the organisation's cause was ‘more deserving of assistance than some other charitable work’, it ‘seemed to appeal less to sentiment’. 29 Psychiatric patients were not universally deemed as deserving as citizens suffering from physical sickness, so we cannot simply build mental illness into a narrative of citizenship and general health.
Experiences of war, however, encouraged civilians to see supporting psychiatric patients as a core citizenly duty during conflict. In 1914 even the MACA's volunteers doubted how far to prioritise their psychiatric endeavours, when those from the Birmingham branch ‘decided not to hold any meetings for a time and thus liberate members for other work’. 30 However, the charity continued to operate, and workers soon identified the amplified call for their services. In 1915 the branch observed that ‘there has been much distress … since the commencement of the war, and our patients have had far less difficulty in obtaining employment, as so many ammunitions workers are wanted’. 31 Volunteers noticed that their pragmatic response constituted two functions of war service. First, the MACA was performing treatment, helping servicemen and civilians to recover from mental distress induced by military service, air raids, and the fear and reality of loved ones dying. Second, the organisation was providing a source of labour to undertake other citizenly service for the war-stricken nation. By the end of the conflict, the MACA's workers articulated their wartime role, with the 1917 report noting that ‘it has been said that this is not a War Work, which is only true inasmuch as the Charity was founded long before 1914 … Shell shock and air raid sufferers are being received, and many of the other patients helped can trace their mental breakdown to the war’. 32 By 1918 volunteers, staff, and observers agreed mental after-care was a priority for active citizens during wartime.
The Great War did not entirely cement the MACA's activities as accepted core citizenly duties. Interwar communications suggest that advocates felt the return of some reservations in the community. Press coverage complained that ‘mental disease was the Cinderella of medicine’, 33 while the 1926 report explained an ‘excess of expenditure over income’ by stating that finances were ‘necessarily limited … by the amount of support given to it by local bodies undoubtedly benefited by its work, and by the charitable public’. 34 Yet the experiences of the First World War had a lasting impact. Both state and society again viewed supporting mental recovery as a vital duty when the Second World War began, with promotional literature declaring at its outbreak that the Association was ‘carrying out work of National Importance in a Reserved Occupation’. 35 The MACA's prompt response to the new conflict is testament to the Great War's lasting impact upon attitudes towards psychiatric philanthropy during conflict.
The charity continued to provide opportunities for supporters to fulfil their citizenship roles in the interwar years, but there were shifts in the ways in which women performed their duties, with growing numbers undertaking paid work and professionalisation of some roles beginning to occur in the 1920s. The charity's first secretary was Mr Thornhill Roxby. Upon his retirement in 1915, Ethel Vickers, who was initially appointed as an assistant to the Council in 1904, became secretary. 36 Vickers had always been employed as a paid member of staff, and increasingly performed a leadership role in shaping after-care. She began to push for professionalisation amongst the women who worked directly with beneficiaries, arguing in 1926 that patients’ casework required such personal knowledge that it could not ‘be undertaken by temporary workers without experience’. 37 By 1932 ‘all vacancies now arising on the staff are [were] filled after consultation with the London School of Economics and the Institute of Hospital Almoners’, with the former providing the Mental Health Certificate for social workers. 38 While some women were beginning to exchange volunteering for professional careers, MACA personnel continued to see both types of labour as acts of citizenly service. 39 Furthermore, this nascent process of professionalisation highlights growing formal recognition of women's work rather than a simple increase in opportunities to contribute.
Those who founded and worked for the MACA conceived of their own services as acts of citizenship. The charity was born of a late-Victorian movement in which women in particular enacted and promoted the concept of a flexible citizenship role. According to this movement, in order to claim identity as a citizen, one needed to strive for self-sufficiency and to channel surplus personal resources into serving the wider population. This network, which combined professional and lay expertise and authority, enabled some of its members to take ‘after-care’ to the community. The MACA hence constituted a channel of psychiatric treatment and a recruitment exercise for active citizens. While the general ethos remained intact throughout the period, some changes began to take root in the 1920s. Women increasingly assisted the charity through paid employment, but volunteering remained prominent. Additionally, the Great War had cemented the MACA's activities as core citizenly duties during times of conflict. As the following section demonstrates, uncovering how lay and professional actors performed their citizenship roles through the MACA illuminates how ideas of citizenship were entwined in a new medical intervention.
Making citizens through the MACA
After-care was conceived of as final stage of ‘treatment’ for recovered patients, with Reverend Hawkins promoting ‘after-care treatment for mental convalescents’ in the Journal of Mental Science (1898: 303). After-care's practitioners continued to see their work as a form of psychiatric treatment, referring to recipients as ‘patients’ 40 and using the 1928 annual report to publicise the Royal Commission on Lunacy and Mental Disorder's endorsement of ‘after-care’, presenting this official praise as ‘evidence that such services are an imperative need in the effective carrying through of the treatment and convalescence’ of those affected by mental disorder. 41 This section thus demonstrates how a form of what contemporaries explicitly conceived of as mental ‘treatment’ was imbued with social and political values of citizenship. Those who wished to ensure that the indigent fulfilled their citizenship roles designed charitable mental health services accordingly. Recovered psychiatric patients provided a particular opportunity for such an endeavour because Britain's lunatics were not deemed citizens. Insane people had lost their capacity to perform their citizenship roles, but were seen to have retained the potential to return to citizenship. The MACA's workers attempted to mould newly recovered patients into what they saw as model citizens for three reasons. Firstly, performance of an appropriate citizenship role was used to mark a return to mental health. Secondly, active citizens wished to shape patients into model citizens in their own image, thereby recruiting members to their movement. Thirdly, psychiatric practitioners and lay philanthropists agreed that enacting citizenship duties was of healing value for recovered patients. In demonstrating how these three principles interconnected, and exploring intellectual and practical changes and continuities over the period, this section uses the MACA to highlight the relationship between citizenship roles, the return to mental health and life after recovery.
While the MACA has attracted some attention from historians, examination of ‘after-care’ as a psychiatric intervention has been limited. 42 Stephen Soanes has focused on one element of after-care – the boarding-out cottage – to explore mental convalescence. He illustrates ‘how these homes influenced patients’ experience of discharge, identity and belonging through residential psychiatric after-care’ (Soanes, 2013: 109). Soanes agrees that cultivating a sense of social belonging was a vital tenet of after-care within the remit of the boarding-out cottage, but I look belong the residential home to examine the intervention as a whole. I also challenge Soanes’ assertion that these cottage homes became ‘a type of lay-managed institution for the temporary convalescent’ (ibid.: 109). In 1920 each cottage home received no more than four convalescents at a time, which is in stark contrast to the large asylums from which patients were predominantly drawn. 43 Moreover, treatment from the MACA was voluntary, meaning that potential recipients had the right to refuse. While after-care was certainly a continuation of psychiatric treatment and monitoring, these cottage homes cannot be characterised as a form of institution comparable to the asylum.
MACA personnel used the popular media to present after-care as the provision of a therapeutic route from recovering lunatic to citizen. The 1887–8 report featured an AGM attendee's pronouncement that ‘it was preferable to distribute’ convalescent psychiatric patients ‘among their fellow citizens of robust minds’ to finalise recovery. 44 At the turn of the century, newspapers publicised the charity's efforts to help recovered lunatics to ‘take their place amongst their fellow creatures on equal terms’. 45 Media coverage continued to promote the MACA's interventions as returning asylum-leavers to ‘useful and active citizenship’ during the 1920s. 46 The MACA's champions consistently stressed that asylum-leavers were recovered because they were capable of returning to the performance of useful citizenship, and that the charity's treatments cemented mental recovery by supporting this return.
Despite mental disorder rendering a patient unable to perform their citizenship role, failure to undertake one's social obligations was not necessarily seen to indicate insanity. A physician considered a patient insane only if he could trace the lack of service to psychopathology. From the outset, MACA literature differentiated between people rendered unable to undertake their duties by insanity and people who neglected their citizenship roles for other reasons. The 1921 annual report reiterated this position with the reminder that the ‘Association does not undertake to care for persons still suffering from mental disorder … or habitual want of control in regard to moral conduct’. 47 Non-performance of one's citizenship role was not a diagnostic indicator of psychiatric disorder but was rather deemed a result of mental illness. This distinction shows that post-insane life differed from life before certification: while non-performance of one's duties did not alone precipitate a diagnosis of mental disorder, former asylum patients faced pressure to perform their citizenship roles to ward off suspicion regarding their recovery.
We thus identify MACA personnel's first reason for ensuring their patients performed appropriate citizenship roles. A patient's ability to perform their duties confirmed that he or she had sufficiently regained their mental capabilities. Promotional literature used patients’ return to social duties as a shorthand to demonstrate successful treatment. The first annual report depicted a case in which a woman, ‘after being placed in a Home, obtained work as a dress maker and is doing very fairly well’. 48 Here there was considerable continuity in the MACA's attitudes and communications. A typical case study from 1924 described a woman who was ‘placed in service, where she is much liked and has been for five and a half years in the same situation’. 49 The charity's literature presented these people's ability to sustain self-sufficiency as evidence of their ongoing mental health.
The MACA's leaders often equated the maintenance of self-sufficiency with earning one's own living because this was the only way for individuals who lacked money or friendly support to avoid the workhouse. As its capacity increased, the Association accepted a wider range of patients, helping some return to usefulness within self-supporting social units. Married women were helped into various roles according to their husbands’ income. In 1916 one woman's recovery was celebrated because she had ‘been able to go to work to augment her husband's small earnings’, while a ‘soldier's wife’ ostensibly did not find employment but ‘settled in a cottage’ and was deemed a successful case because ‘help was given with the furnishing of the new home, where the three little children are now with their mother’. 50 Practitioners focused on returning patients to useful, rather than necessarily economically productive, roles, and the prescribed duties varied according to the means of the social unit.
The work deemed suitable for patients varied according to their income and social circumstances, but the MACA did not just send beneficiaries deemed working-class into domestic service. Many patients from county asylums might traditionally be described as working-class, but insanity also turned highly educated people into paupers and left them destitute upon discharge. While income and occupation experiences did influence patients’ treatments and the conditions into which they were released, so did factors such as migration and familial relationships. Thornhill Roxby described the MACA's purpose as helping women who had performed traditionally working-class jobs such as ‘shop women, domestic servants’, but also mentioned ‘(almost more to be pitied than these) governesses, highly educated ladies, quite destitute, for whom the workhouse surroundings are quite unsuitable’. 51 The MACA's founders saw all discharged patients, whether they had endured poverty before their illness or not, as united by the unfortunate experience of insanity.
I focus on social and economic experiences rather than ‘class’ for two reasons. First, while some highly educated patients were returned to roles traditionally seen as middle-class, others’ post-disorder situations differed from life before certification. For example, in 1904, for ‘a superior middle aged woman, formerly in very comfortable circumstances, a post was found as housekeeper’. She later expressed surprise at how comfortable she found this new situation. 52 The MACA in part existed because certification of insanity could induce a drastic change of circumstances even if recovery and discharge were attained. After-care practitioners equated the citizenship role with mental health in an attempt to create a virtuous – rather than a vicious – cycle for asylum-leavers. After-care was deliberately designed to ‘combat the fear of the recurrence of the malady in the patient's mind, and to give assurance to the employer that the cure was permanent’. 53 Once a patient had obtained employment or, for example, returned to their household duties, the Association used and promoted the maintenance of that role as evidence that the beneficiary was sustaining recovery. That role did not necessarily match the patient's pre-illness life. What is more, when describing patients’ life circumstances and consequent citizenly expectations, the MACA's advocates spoke not of ‘class’ but of self-sufficiency, destitution, respectability, and self-respect.
Second, imposing class as a category of analysis before consulting the evidence encourages the assumption that pauper patients were necessarily ‘working-class’, and that private patients were themselves always affluent, obscuring realities and the importance of temporalities. Matching the records of Claybury Asylum with the MACA's files reveals pauper patients discharged to affluent families and individuals previously in blue-collar and domestic employment who had received private institutional care. Certainly, upon B. C.'s release from Claybury, where she had been confined as a pauper inmate, both the asylum's visiting committee and the MACA's worker identified her family as ‘well-off’ and in no need of a grant, but believed that visiting and advice on finding employment would be beneficial to her health. Claybury's records describe B. C. as a ‘munitions worker’, but documents from the MACA show that she lived comfortably with her mother and sisters. Nonetheless, the MACA's visitor encouraged her to seek employment, not out of a need to earn her own living, but out of a need to fulfil her citizenly duties by contributing to society. She would, ostensibly, experience attendant psychological benefits. 54 We see that citizenship roles did not simply correlate with working-, middle-, and upper-class expectations. B. C. was a woman of comfortable private means, but also a former ‘pauper lunatic’ who was expected to contribute to wider society by pursuing paid employment, possibly as part of the war effort.
We arrive at the second reason for encouraging patients to perform appropriate citizenship roles. The Association provided the MACA's workers access to a group of people in need of support, but ready to be moulded into citizens in their own image. Just as the MACA encouraged the general populace to observe self-help and community service, they encouraged patients to do the same. Here, the charity's primary aim was to make patients self-supporting either as a single person or within the context of their social unit. The MACA's secondary aim was to encourage beneficiaries who did achieve stable self-sufficiency to donate surplus income to the charity, thereby helping the wider community by allowing the organisation to treat other recovering patients. As demonstrated above, the MACA not only recruited beneficiaries to the general active citizenship movement, but specifically to its own ranks of supporters, eliciting voluntary ‘thank-offerings’ from those who sustained recovery and self-sufficiency well enough. Importantly, the Association trusted the recipients of its services as responsible citizens, able to make their own judgements about how large a donation was feasible and never prescribed whether a full repayment or a token of gratitude was expected.
Just as the wider discourse of active citizenship allowed for a sexed division of duties and rights, the MACA promoted citizenship roles that adhered to a sexed division of labour, which varied also according to the circumstances of the social unit. Female patients were predominantly sent into domestic service, while male patients were directed into a wider range of occupations, with some being provided with tools of their trade. 55 While men were always directed into paid work, some women were deemed recovered if they returned to unpaid household duties.
Personnel did not merely follow the conventional division of labour, but actively believed different occupations were beneficial for patients of different sexes. Many people linked to the MACA connected domestic service with women's well-being, with Cavendish seeing its relative, but not impeccable, virtues in regulating ‘moral imbeciles’, noting that ‘there is no domestic service in the outside world in which a girl can be kept absolutely shielded from temptation’. 56 The MACA's literature also emphasised the importance of a man's wage-earning capacity and his status as the breadwinner, even if his wife earned enough to support the family. In 1908, MACA personnel viewed earning less than one's wife a legitimate cause of distress, describing ‘a married man whose wife was, to a great extent, the breadwinner, but who was much distressed by his own inability to contribute’. 57 After-care was designed to prevent mental relapse by directing men and women into occupational positions deemed naturally beneficial to their sex's mental well-being.
We reach the third reason the MACA's workers directed patients towards certain citizenship roles. After-care used citizenship roles as treatment. Beliefs about optimum ways to function as citizens converged with ideas of mental healing. Practitioners suggested that different acts were beneficial for the separate sexes, and so offered gendered interventions. However, we must not assume that men simply imposed gendered treatments upon women. Professional medical and lay expertise converged in the MACA and, while the vast majority of the psychiatrists were male, women contributed to the intellectual underpinnings of after-care while undertaking responsibilities as philanthropists, administrators, working associates, and cottage matrons. As demonstrated above, the 1920s saw the beginning of the professionalisation of some of these women's positions, but throughout the time, lay women, and some lay men, engaged in discourses of psychology and influenced the charity's psychiatric practices.
After-care, like many contemporaneous psychiatric interventions, centred work as therapeutic (Ernst, 2016). The MACA's founders subscribed to what Jennifer Laws describes as an ‘occupational view of humanity’, in which the healthy individual is marked by a capacity and desire to undertake useful work, and in which mental healing can be induced by facilitating the return to this state (2016: 352). Cavendish certainly saw work as a method of contending with mental suffering. An obituary expressed ambivalence about her use of work to cope with her husband's assassination, commenting that ‘she was far too sane for self-pity and an attitude of woe’ and that the ‘energy with which she entered into every sort of charitable and religious activity after her husband's death was undoubtedly an effort to work herself numb’. 58 Cavendish seems to have integrated her personal responses to mental suffering with psychological practices. Her private visitors’ book indicates that the French popular psychologist, Emile Coué, visited Cavendish in 1922 ‘for auto-suggestion’. 59 Coué's psychology of self-improvement, which he accompanied with the mantra ‘Every day, in every way, I am getting better and better’, aligns with Cavendish's involvement in a citizenship movement in which women engaged in self-improvement by supporting poorer women to do the same, and with her conviction that such practices could be employed for mental healing purposes (Thomson, 2006: 38–40).
The women who served the MACA were complicit in using psychiatric practice to promote gendered citizenship roles. At an early AGM, Florence Davenport-Hill, a member of the Council, suggested that a patient must be retaught to be ‘a member of the family with all the duties such a position necessarily entails’ to regain health. Therefore, ‘a cottage baby will be beneficial to a convalescent’. 60 Given that she spoke before the charity accepted men, Davenport-Hill was suggesting that women's natural maternal roles had curative benefits. Maternal obligations were, of course, central to female citizenship roles, with many women expressing their identities as citizens by evoking the duties they carried out as mothers (Pateman, 1992: 19). We here see how women who had experienced mental disorder found themselves in situations in which their adherence to feminine social expectations was marshalled more strongly than it might have been had they never experienced insanity. Davenport-Hill suggested that looking after babies would optimise the health of convalescent women, but made no insinuation that remaining childless would actively make women ill or indicate sickness.
The MACA's practitioners moulded male beneficiaries into citizens too, using masculine duties to treat men. For example, the patient whose distress arose from earning less than his wife was treated with ‘a grant … to enable him to stock and start a sweet stall’ and hence be less overshadowed by his wife's breadwinning activities. 61 Similarly, the Association advertised its support for a young man ‘who had had a second breakdown; chiefly caused in the opinion of his friends; by the difficulty of finding work during the war, although totally exempt’. The organisation responded by finding for him ‘an excellent situation’ in which he could be useful. 62 Such treatments were used consistently and advertised heavily, indicating that their underlying ethos held sway in the community.
During its earliest years, the Association focused on ensuring that patients maintained employment to avoid the workhouse. This activity was motivated not simply by a desire to prevent asylum-leavers becoming reliant on the rates, but also by the belief that patients could obtain health benefits by being surrounded by fellow citizens and avoid the workhouse's accompanying ‘indignity’ and ‘feeling of degradation’, which Dr Rayner, who was prominent in the MACA from its foundation until 1926, judged to be ‘not conducive to their mental health, indeed it has even produced relapses’ (Percy Smith, 1926; Rayner, 1891: 537). Furthermore, Rayner believed that the ‘association with their [workhouse's] inmates does not tend to the improvement of the self-respect or self-control of the convalescent’ that was vital for consolidating recovery (1891: 537). Helping recovered patients to remain in the community spared them the mentally damaging indignities and interpersonal associations of indoor relief.
As time progressed and the workhouse, although still a presence, receded as the symbolic antithesis of citizenship, the discourse of self-respect and self-confidence through citizenship became dominant within the MACA's promotional materials. The MACA's particular and lasting interpretation of citizenship as an identity of belonging was utilised as a healing agent in after-care. Boarding out was a central component in supplying ‘the personal and practical link between discharge from hospitals and the assumption of the regular work and duties of citizenship’. 63 Immediately after release from the asylum and before placement in employment a patient often stayed in a cottage home in which he or she became ‘part of a sympathetic and understanding family, and by that means gradually regain[ed] self-confidence and re-adapt[ed] himself to non-institutional conditions and contact with his fellow man’. 64 As noted above, Harris reminds us that citizenship as an identity of belonging was constructed through leisure and social participation alongside work (1990: 67–9). The MACA consistently promoted the psychiatric benefits of the performance of the citizenship role, but, towards the end of the period, increasingly articulated this belonging in terms of a sense of self, which would lay the foundations for the post-war trends examined by Shapira (2013: 1–23).
Examining how the MACA used after-care to ensure that asylum-leavers transitioned into their citizenship roles shows how lay and professional medical actors generated a new ‘treatment’ for people who had recovered from insanity. The MACA's practitioners made the citizenship role central to after-care for three reasons. First, they used patients’ performance of citizenship roles as evidence of recovery. Second, they wished to shape citizens in their own image, thereby recruiting new active citizens to the general movement and as supporters of the MACA. Third, they saw the performance of citizenship roles, through work and sociability, as of healing value, combatting residual weaknesses and preventing relapse.
Conclusion
The MACA's case demonstrates the importance of studying post-mental-illness. A significant proportion of people who encounter mental illness recover, and yet the experience continues to influence their lives. Historical examination of the MACA shows that individuals discharged from asylums faced difficulties reintegrating into society due to suspicions that, despite the cessation of symptoms, they harboured worrying mental scars. Perhaps as a consequence of these attitudes, many asylum-leavers had trouble securing employment and housing, and these issues were compounded by personal circumstances like friendlessness. Life after recovery could, therefore, differ significancy from life before treatment. The MACA's archive reveals both the difficulties of post-discharge life and the consequential development of after-care.
Unveiling the relationship between the MACA's work and contemporaneous debates about British citizenship shows how approaches to psychiatric healing and the maintenance of regained mental health were imbued with social and political values regarding community participation. After-care emerged from and was embedded in the active citizenship movement until 1928. This movement defined citizenship as an identity that a person could claim if they fulfilled a role in which they maintained self-sufficiency and donated some surplus resources to the community. Those who led and supported the MACA construed their endeavours as part of their own citizenship roles, and influenced the charity's practices with their social ethos. After-care was thus designed to transform asylum-leavers into active citizens and thereby cement and maintain their regained mental health.
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was edited during a PhD studentship funded by the ESRC.
