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Thursday, 16 July 2015

Survivor History Special - Bethlehem Hospital.

From Andrew Roberts
telephone: 020 8 986 5251
mobile 07505527755
home address: 177 Glenarm Road, London, E5 ONB

The next meeting of the Survivor History Group  will be on Wednesday
29.7.2015 at 1pm-4pm (ish) at Together, 12 Old Street, London,  EC1V
9BE.  Food and drink to reward those who come. Everyone is very
welcome at meetings of the Survivor History Group.

I am circulating a report on modern Bethlem based on Jennifer Walke's
presentation at the last meeting and materials provided by Jennifer.
Please note her comment on the report:

"Your draft  is largely fine as far as I can see, except that Bethlem
was never solely a private hospital, but, in its marketing etc,
increasingly targeted middle-class patients who may otherwise have
sought private care." 

The group minuted thanks to Jennifer for all the help she has given
to our history project.

Modern Bethlem includes the recently opened Museum of the Mind, which
a group of us visited and made suggestions about. We have received
this email from Victoria Northwood, Head of Archives and Museum at
Bethlem Museum of the Mind:

I am writing to thank you ... for the feedback offered by the
Survivor History Group on our new museum following their visit in
March. I have incorporated some of the comments into a summary of
visitor feedback submitted to the Heritage Lottery Fund in our most
recent quarterly report. The exhibition idea suggested by the group
was positively received by our trustees at their meeting in June, and
I am now looking into funding options. I will keep both you and Sarah
[Chaney] updated with progress. Please pass on my thanks to the other
members of the group for taking the time to visit and offer feedback,
Best wishes, Victoria


On Wednesday 27.5.2015 at the Survivors History Group, Jennifer Walke
spoke to us about the modern Bethlem.  

This is not the small house for lunatics that once stood where
Liverpool Street station now stands, nor the palace along the road
where lunatics were displayed and humiliated in the eighteenth
century. Nor is it the building that is now the Imperial War Museum
which served as a criminal lunatic asylum in the first half of the
nineteenth century and then became an asylum for middle class people
able to pay its fees. 

Modern Bethlem was opened in 1930 in Monks Orchard Road, Beckenham,
Kent. It remained an asylum for a fee-paying elite until 1948, when
it joined with the Maudsley  Hospital in the National Health Service
as a psychiatric teaching hospital. 

Until Jenny began her research in 2008, the history of modern Bethlem
had not been given the same attention as the earlier ones. Jenny's
work is enabling us to develop the timeline at 

where you will see that the hospital magazine changed its name from
"Under the Dome" to "Orchard Leaves" when it moved to Orchard Road in
1930. It had  moved from the crowded sooty splendours of the inner
city to spacious rural splendours on the unknown borders of London. 

The new hospital was built on the 'villa system', with separate
blocks for "administration, occupational therapy, refractory
patients, convalescent patients, treatment and research, along with a
nurses' home, chapel, reception hospital, mortuary, workshops and a

Bethlem was for private patients, but the villa system was also used
in the two public modern asylums: Shenley in Hertfordshire, opened in
1934, and Runwell in Essex, opened in 1934. Jenny showed us
photographs demonstrating how much better facilities were for the
middle class patients in Bethlem than they were for the public
patients in Shenley. 

A modern brand image

One of the titles for Jenny's project is "emerging medical
marketplace - how relocation and legislation influenced hospital
advertising and the profile and expectations of its patients". The
opening of modern Bethlem coincided with the passing of the 1930
Mental Treatment Act. This Act made voluntary treatment in public
hospitals possible on the same terms as it was available in private
ones like Bethlem. This meant Bethlem would be facing competition
from progressive public hospitals and needed to fight for a share of
the market. 

Jenny quoted a Bethlem Royal Hospital Prospectus of 1932 which
clearly conveys the search for what we would now call a brand image: 

     "...admission to this Monks Orchard Hospital carries with
     it the "Hall Mark" of curability, and as such, whenever
     the word "Bethlem" is used, it means "curable"'.
     Accommodation is provided for 250 patients - 141 ladies
     and 109 gentlemen - each of whom must be of a suitable
     educational status. Patients who are eligible may be
     admitted either on a Voluntary, Temporary or Certified
     footing, but in all cases treatment in the early stage of
     illness is advisable and, in fact, desirable. Patients
     are thus graded according to their varying type of
     symptoms, and the separate units, or houses, provide
     appropriate care and treatment for their individual
     needs, which is further enhanced by the provision of
     separate bedrooms, whenever deemed necessary."

The hospital was and remains small (250 beds) by asylum standards.
Providing for patients in separate villas in open parkland meant that
the actual units in which they lived were even smaller. The word
hotel is often used in describing modern Bethlem of the 1930s and
later. (See "Life and luxury in Monks Orchard: from Bethlem Hotel to
community care, 1930-2000" by Sarah Chaney and Jennifer Walke The
Lancet Psychiatry Volume 2, No. 3, p209-211, March 2015, available at
http://www.thelancet.com/journals/lanpsy/article/PIIS2215- 0366%2815%2900068-1/fulltext)
Before and after nationalisation - statistics tell a story

The history of modern Bethlem divides into two clear periods: before
and after 1948 when in the new National Health Service Bethlem became
a public hospital and combined with the Maudsley Hospital as the
country's teaching hospital for mental disorders. The statistics
Jenny showed us reflected this division in that she contrasted
statistics for 1931 to 1948 with statistics for 1950 to 1983. 

Jenny's patient database

Jenny gave a presentation on the social history of patients admitted
and new treatments introduced in 20th century. Her research used
written archive and oral histories. For her archival work she used
admission and discharge registers, patient casenotes, committee
minutes and in-house publications. Her oral histories were interviews
with nurses, psychiatrists and administrators. 

By transferring existing records from paper to digital database, she
was able to make cross references - to identify trends in the
population and treatments administered. The admission registers were
the key to creating a patient database. This digital database takes
information from both admission and discharge registers and patient

For much of the time from 1930, the hospital registers were vast,
leather-bound volumes, providing detailed (if sometimes
indecipherable) records of patients on admission and discharge. They
noted age, sex, marital status, mode of admission (voluntary,
temporary or certified), occupation, previous attacks/admissions,
diagnosis, cause of illness, length of stay, and outcome. Official
classification schemes were used for occupation, specific disorder
and the presumed cause. 

What actually happened to the patient once admitted is found in
patient casebooks and Jenny's database combined this with the
information from the registers. Her anonymised computer patient
records are a searchable resource for her own research which can also
be used by future researchers. 

A hospital-assigned reference number allowed patients or subgroups
(for example, patients of a certain age or diagnosis) to be followed
up at casenote level, to learn more about their experiences. A total
of 2669 admission entries were recorded, but changing register
formats and incomplete, duplicate or unclear entries meant detailed
records were not available for each individual case. 


From 1907 to 1947 asylum records in England and Wales classified
people according to codes set out in two schedules produced by the
Lunacy Commission (which became the Board of Control in 1912). These
were based on a classification scheme devised by a statistical sub-
committee of the Medico- Psychological  Association between 1902 and
1905. The Medico- Psychological  Association is now the Royal College
of Psychiatrists. 

One set of codes covered the forms of insanity, the other causes and
associated factors. This meant that a form and a cause were linked in
classifying people. An actual example is a man who died in 1939 who
suffered from Congenital/Infantile Mental Deficiency caused by Cardio-
Vascular Degeneration. That is, he had a learning disability from
birth which was associated with some kind of (presumably congenital)
heart defect, thought to be the cause of the learning disability. 

Apart from mental deficiency, forms included General Paralysis of the
Insane, insanity with brain damage, acute delirium, stupor, mania,
melancholia, alternating insanity, delusional insanity, volitional
insanity (including impulse, obsession, and doubt), moral insanity
and dementia. 

There were a wide range of causes or contributory factors. At the top
of the list was heredity. Others included mental instability,
puberty, the menopause, age, child bearing, stress, malnutrition,
over-exertion, masturbation, sexual excess, alcohol, drugs, poisons,
tuberculosis, syphilis, injuries, operations, sunstroke, brain
damage, epilepsy, nervous damage linked to hysteria, neurasthenia,
asthma and chorea, infant convulsions and night-terrors. 

Full details of forms and causes will be found if you follow the
links from http://studymore.org.uk/mhhtim.htm#1907Codes
Jenny said that the principal cause was based on medical opinion, 
but contributory or associated factors could reflect the views of
other people who knew the patient. 


In 1931 the schedules referred to forms of mental illness rather than
insanity. The name changed, but not the content, except in one
significant addition: the introduction of a new label,
'psychoneurosis' which was just for use with voluntary admissions
under the 1930 Mental Treatment Act. Jenny commented that this built
both class and gender biases into a supposedly clinical diagnosis.
Shortly before 1944 the (now Royal) Medico- Psychological 
Association produced a revised classification scheme with a section
for neuroses and psychoneuroses. This fed into work on a new
international system. 

An international system

In 1948 the World Health Organisation published the Sixth Revision of
the International Classification of Diseases. For the first time this
included sections on mental disorders. The national classification
used in the English and Welsh schedules was now replaced by an
internationally recognised classification. 

Bethlem and Maudsley, like all hospitals, replaced the schedules with
the international system, but Jenny notes that postwar casenotes
showed the continuation of older terminology, suggesting [some?]
doctors were unaware of, or resistant to, the new scheme. 

The international system introduced diagnostic categories similar to
those  we are now familiar with. The psychoses began with
"schizophrenic disorders (dementia praecox)", and included "manic-
depressive reaction", and "paranoia and paranoid states".  Psycho
neurotic disorders included "anxiety reaction", "hysterical
reaction",  "phobic reaction", "obsessive-compulsive reaction" and
"neurotic-depressive reaction". 

Overall features

Jenny showed us three graphs which highlighted the general trends
before and after Bethlem became part of the National Health Service
in 1948. I have put these online at 

Two show in-patient age distribution, one for 1931 to 1947 and the
other for 1952 to 1983. The third shows the distribution of key
diagnoses at different points between 1952 and 1983 

Before the National Health Service the outstanding feature is the
large number of women, especially between the ages of 20 to 40 years,
which Jenny commented is childbearing age. She has written on a blog
that "a rising tide of voluntary admissions from the 1930s coincided
with the emergence of 'psycho-neuroses', a category in which women
were over-represented".  (See
http://museumofthemind.org.uk/blog/post/gender-and- madness-in-post- war-bethlem-a-meeting-of-minds)

Post war patients were much more evenly distributed between men and
women. The main reason for this was probably that the hospital was no
longer selecting fee-paying patients. The distribution of key
diagnoses 1952-1983 shows that, in the National Health Service,
Bethlem increasing provided for patients of both sexes with a
psychotic diagnosis. 

Under the National Health Service Bethlem ceased being a private
asylum seeking voluntary patients from middle class people,
especially women, willing to pay a fee for hotel like conditions. The
change was, however, gradual, and it was not a change to being a
standard public asylum. Facilities were developed for the new types
of elite needed for a comprehensive teaching hospital, and new brand
images were developed. 

After 1948 the hospital developed "specialisms" which allowed it to
develop novel approaches. The first adolescent inpatient wards in
England were opened for boys (17 beds) and girls (18 beds) in 1949
amidst fears that the young people would roam the park disrupting the
peace of the established patients. 

Equally, or possibly more, radical was that Bethlem took seriously
the development of treatment for patients over sixty. Felix Post, a
young ambitious psychiatrist, was reluctantly persuaded to do this
and within a few years "reluctance to work with older people had been
transformed into a therapeutic optimism and a zeal for the
specialism. His in-patient ward, out-patient clinics, research,
teaching, and the Gresham Club (a pioneering after-care club for
former in-patients) all flourished". [For a time, at least]. 

Jenny paid particular attention to the work of Robert Hobson between
1954 and 1974. Hobson developed psychotherapy on a therapeutic
community model. Jackie Hopson, a patient, has written about this on
the Museum of the Mind blog: 

     "Winning a place in the Charles Hood Unit at Bethlem
     Hospital in 1974 was harder than getting into university
     and felt to me like a greater achievement.  There were
     two long and demanding interviews, each time with a
     roomful of doctors, nurses and social workers.  After the
     first interview, they sent me away with what seemed an
     insuperable task: to finish university, get a job and
     survive for a few months.  I sat down on the platform at
     King's Cross Station and cried.  Some months and the
     second interview later, I was given a place."

The most controversial specialist facility was the secure unit. Its
opening  in 1980 "was preceded by discussions with local residents to
allay fears. Jimmy Savile OBE, television presenter, was invited to
open the unit, an event that, despite the bad weather, was regarded
as 'a most successful exercise in public relations'. (Andrews and
others The History of Bethlem 1997). 

In retrospect the Jimmy Savile episode was not considered such a
successful exercise in public relations, but it worked at the time. 


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