Work and other activities in mental institutions: a historiographical approach

Abstract

Introduction  The literature on the history of occupational therapy refers to the fact that it is preceded by a knowledge built from the administration of activities, especially work, to people in asylums.

Objective  To identify how, from Latin American occupational therapy and history, the issue of work and other activities in mental institutions before the professionalization of occupational therapy has been studied.

Method  A documentary analysis is carried out at two levels: studies of occupational therapists in Latin America and studies from history in different parts of the world.

Results  The works of occupational therapists vindicate the understanding of the historical processes of shaping the professional field in Latin America. They address the issue with an exploratory scope and reveal issues that need to be deepened; they mainly employ secondary sources and some transfer analyses based on other realities. From history, seven themes are raised: the relationship between work and moral treatment; relationship between ability to work and mental illness; adaptations and appropriations of models and proposals on work in psychiatric institutions; institutional models that incorporated the work of patients; debates between economic and therapeutic benefit; meanings attributed to work in institutions; professionalization in the first half of the twentieth century.

Conclusion  This approach opens possibilities for analyzing a little-studied practice and exposes its complexity and contradictions. It also evidences gaps in the narratives about the use of work and other activities in Latin American mental institutions, its particular forms and the disputed knowledge and interests that shaped it.

Keywords:
History; Hospitals; Psychiatric; Work

Resumen

Introducción  La literatura sobre historia de la terapia ocupacional refiere que a esta le precede un saber construido a partir de la administración de actividades, especialmente el trabajo, a personas asiladas.

Objetivo  Identificar cómo, desde la terapia ocupacional latinoamericana y la historia, se ha abordado el tema del trabajo y otras actividades en instituciones mentales antes de la profesionalización de la terapia ocupacional.

Método  Se realiza un análisis documental en dos niveles: estudios de terapeutas ocupacionales en América Latina y estudios desde la disciplina histórica en diferentes lugares del mundo.

Resultados  Los trabajos de terapeutas ocupacionales reivindican la comprensión de los procesos históricos de conformación del campo profesional en Latinoamérica. Abordan el tema con un alcance exploratorio y revelan asuntos que requieren ser profundizados; emplean principalmente fuentes secundarias y algunos transfieren análisis basados en otras realidades. Desde la historia, se plantean siete temas: relación entre trabajo y tratamiento moral; relación entre capacidad para trabajar y enfermedad mental; adaptaciones y apropiaciones de modelos y propuestas sobre trabajo en instituciones psiquiátricas; modelos institucionales que incorporaron el trabajo de pacientes; debates entre beneficio económico y terapéutico; significados atribuidos al trabajo en las instituciones; profesionalización en la primera mitad del siglo XX.

Conclusión  Esta aproximación abre posibilidades para analizar una práctica poco estudiada y expone su complejidad y contradicciones. También, evidencia vacíos en los relatos acerca del uso del trabajo y otras actividades en las instituciones mentales latinoamericanas, sus formas particulares y los saberes e intereses en disputa que lo conformaron.

Palabras clave:
Historia; Hospitales Psiquiátricos; Trabajo

Resumo

Introdução  A literatura sobre história da terapia ocupacional assinala o fato de que ela foi precedida por um conhecimento construído a partir da administração de atividades, especialmente de trabalho, a pessoas em asilos.

Objetivo  Identificar como, na terapia ocupacional latino-americana e no campo da história, tem sido estudada a questão do trabalho e de outras atividades em asilos manicomiais antes da profissionalização da terapia ocupacional.

Método  Foi realizada uma análise documental em dois níveis: estudos de terapeutas ocupacionais na América Latina e estudos no âmbito da história em diferentes partes do mundo.

Resultados  Os trabalhos de terapeutas ocupacionais valorizam os processos históricos de formação do campo profissional na América Latina. Eles abordam a temática de modo exploratório e trazem à tona questões que precisam ser aprofundadas; usam principalmente fontes secundárias e algumas análises baseadas em outras realidades. Tomando-se estudos no recorte disciplinar da história são levantados sete temas: relação entre trabalho e tratamento moral; relação entre capacidade para o trabalho e doença mental; adaptações e apropriações de modelos e propostas de trabalho em instituições psiquiátricas; modelos institucionais que incorporaram o trabalho dos pacientes; debates entre benefício econômico e terapêutico; significados atribuídos ao trabalho nas instituições; profissionalização na primeira metade do século XX.

Conclusão  Este exercício abre possibilidades para a análise de uma prática pouco estudada e expõe sua complexidade e contradições. Também, mostra lacunas nos relatos sobre uso do trabalho e outras atividades nas instituições psiquiátricas latino-americanas, suas formas particulares e os conhecimentos e interesses em disputa que o moldaram.

Palavras-chave:
História; Hospitais Psiquiátricos; Trabalho

Introduction

The study of the origins and recourses of occupational therapy is critical for the understanding of its foundations, principles, transformations, meanings, problems and trends. The occupational therapist Monzeli (2021) states that, in his approach to the history of the profession in Latin America, “Occupations and work as a form of social control and attention to madness” (Monzeli, 2021, p. 92) are an important achievement. In contrast, historian Ernst (2018) refers:

Historians' points of view on work and occupational therapy in psychiatric institutions do not always overlap with the perspectives of these professionals. For a historian, the historical role of the work of patients in psychiatry is subject to the vacillation between therapy and empowerment, on the one hand, and coercion and punishment, on the other. On the contrary, today's occupational therapists, as well as other professionals related to psychiatry, can consider that these last features are not characteristic of their profession. (Ernst, 2018, p. S248, own translation)

How have historians approached work and activities in mental institutions? How have we approached that in occupational therapy in Latin America?

Studies on thought and historical culture around a subject, in the disciplinary field of history, are called historiography; This, in general terms, is concerned with the analysis of texts produced from historical studies and other forms of evocation and representation of the past (Zambrano, 1994). With this article, we seek to present a historiographical approach in the way that, from Latin American occupational therapy and historical discipline, the issue of work and activities in mental institutions has been studied; to the perspectives, methods and historical sources that these views allow us to distinguish. Rather than a review with the purpose of exhaustiveness, this is an approach that can contribute to the analyzes we undertake about this precursor practice of occupational therapy.

Therefore, this approach covers the following levels: studies carried out by occupational therapists in Latin America and studies from history in different places in the world. For the first group, the texts that were analyzed were identified based on the inquiry carried out for his doctoral thesis by Monzeli (2021); other documents that circulate and are cited in historical studies of the region are included. Regarding the second, the starting point was the book Work, psychiatry and society, c. 1750–2015, edited by Ernst (2016c). Based on this work and exchanges at the Seminar on the History of Psychiatry and Mental Health, at the Historical Sources Laboratory of the National University of Colombia, headquarters in Medellín¹ , other relevant studies in Latin America will be traced.

Studies Conducted by Occupational Therapists in Latin America

In his research, Monzeli identified different texts that evoke practices of work use and other activities in mental institutions, as part of the past that precedes the arrival of occupational therapists and the beginning of training in occupational therapy in Latin American countries. These refer to Chile, Argentina, Brazil and Colombia (Monzeli et al., 2019; Monzeli, 2021).

Regarding Chile, Gómez Lillo (2012), in his account of fifty years of occupational therapy in his country, mentions the defense of moral treatment² and labor therapy³ in the texts of Chilean psychiatrists around 1930, without referring to specific practices.

Meanwhile, briefly and without details about the sources consulted, the account by Gómez Mendelberg (2007) on the occupation of “insane” people in the history of the Borda Hospital in Buenos Aires, Argentina, allows us to see three moments: first, the selection of patients to plant groves around 1800; then, the organization of work as a therapeutic resource and the installation of workshops for manual tasks from the 1870s; finally, for an indeterminate period beginning in 1892, the organization of the institution on the basis of work, with workshops that supplied it and left some economic benefit for the institutionalized people. He concludes that keeping patients carrying out activities was a constant over the years, based in each era on the current trends and concepts in force. Thus, in the second moment, he relates the practices with the “dictates of Pinel” ⁴ (Gómez Mendelberg, 2007, p. 26) and in the third with a concept of health associated with productivity, where social and labor insertion gained importance.

Also relevant to this country is Testa’s (2015) conference “Occupational therapy before occupational therapy in Argentina. Background and delimitations of a field of intervention in dispute (first half of the 20th century)”. In this work, the author points out the existence of numerous references about the use of occupational therapy from the end of the 19th century to the middle of the 20th century – not only in psychiatric institutions, but also in prisons and charitable institutions –, which show a consensus about its effectiveness in the organization of the institutional therapeutic strategy. She relates its continuity to the moral and disciplinary value of work, the economic advantages of its implementation in institutions and the transformation in the conception of the social utility of the “cripple”, from unproductive to potentially rehabilitable and susceptible to labor and social insertion.

Testa (2015), based on documents produced by doctors of the time⁵ , deals with the encounter between knowledge and practices in dispute during the first half of the 20th century in his country. From this perspective, he refers to the concurrence of the therapeutic use of activities (such as labor therapy) and occupational therapy. In such an encounter, the limits seem blurred and the terms are frequently used as synonyms, but there are also differentiations: labor therapy and the therapeutic use of activities were associated with mental patients considered chronic and with few expectations of recovery, while occupational therapy was introduced as part of a medical speech that promised the rehabilitation or recovery of the productive potential of people with motor limitations, especially those derived from polio epidemics.

The case of Brazil is particular, since there the studies have to do with the professional crisis of the 1980s in this country, triggered by questions about the role of occupational therapy in society and related to the movements of deinstitutionalization and criticism of total institutions⁶ . In this context, the need to understand the roots of this situation was recognized, that is, to analyze the historical insertion of this social practice and its transformations in the Brazilian political, economic and social context. This also highlighted the limitations of hegemonic historical accounts, as they were decontextualized, depoliticized and alien to the contradictions inherent to the social structure in which the profession was created, which have determined it and shaped it (Barros et al., 2002; Nascimento, 1991; Soares, 1991).

Consistent with this position, several master's thesis from the late 1980s and early 1990s allude to therapeutic work in institutions for the care of the insane as a precursor practice to occupational therapy. The works of Soares (1987; 1991), Galheigo (1988), Magalhães (1989) and Nascimento (1991)⁷ stand out, although only the latter focuses on the historical analysis of work and occupation as forms of intervention in psychiatric institutions.

Whether they delve deeper or less into the subject, the authors begin by locating the roots of therapeutic work in the moral treatment that was established in Europe at the end of the 18th century. According to their accounts, its first reflections in Brazil can be identified towards the middle of the 19th century, when artisan workshops began to operate in the Hospice of Pedro II, in Rio de Janeiro. This was followed by other practices for the education of people in hospices in different states, which were called labor therapy, ergotherapy or praxis therapy⁸ . Around the turn of the century there was a discontinuity in work in institutions, which was soon resumed with the creation of agricultural colonies (Galheigo, 1988; Magalhães, 1989; Nascimento, 1991; Soares, 1991).

The agricultural colonies would come to integrate a system of establishments for people with mental illnesses, in which these were used for chronic patients. In turn, the assigned activities were differentiated according to gender, class and social status (Magalhães, 1989; Nascimento, 1991). All of this would be consistent with a vision of mental illness permeated by German theories of eugenics and degeneration, in which incurability justified a protective and segregating function of the institutions, rather than a therapeutic one, and the participation of inmates in the maintenance of the establishments was desirable. In this way, their integration into the productive circuit occurred, but was limited to the world of exclusion (Nascimento, 1991).

The identification of these institutions and practices, as well as the description of their characteristics, foundations, agents, purposes or functions is based, above all, on secondary sources, among which the work of the historian Cunha (1986)⁹ stands out, focusing on the Hospice of Juquery ¹⁰ , in São Paulo, between the end of the 19th century and the 1930s.

In Soares's (1987; 1991) dialectical materialist reading, the absorption of the disabled into the labor force as a reserve army in capitalist production is regulated by the country's economy at any given time, which determines the importance attributed to services for the care of people with disabilities (among other marginalized subjects) and the role of these services and their professionals in the discipline, control, habilitation or rehabilitation of the surplus population of capital. Thus, as a hypothesis, he points out that the choice of the São Paulo psychiatrists for agricultural work in the first half of the 20th century could be understood as consistent with the economic function of the mentally ill in increasing the rural labor force or its reserve army, at a time when the agro-export hegemony in Brazil was declining.

Meanwhile, the works of Galheigo (1988), Magalhães (1989) and Nascimento (1991) critically interpret and analyse the therapeutic activity of asylum, mainly through the lens of Michel Foucault¹¹ and Robert Castel¹² works, who study the transformations in the social treatment of madness, the conditions of possibility of asylum as a form of management of individuals who threaten to break the social order in the liberal State, and psychiatric power-knowledge, all of this, primarily, from the French experience. From this perspective, as a modern and enlightened form of management of madness, moral treatment was made possible by the transformation of the status of the madman into a mentally ill person deprived of reason, who, for this reason, had to be protected and, for this reason, locked up, excluded; as a disease, this management and protection were transferred to the field of medicine. In the moral treatment, work and the regulation of daily activities would have a moral-adaptive meaning that served as support for the closed space, so that they are inherent to it and are part of the disciplinary device of normalization of behaviors, moralization and social control through which bodies and souls were tamed, and the subjectivity of the ideal worker was molded.

Although aligned with this perspective, Nascimento (1991), in her approach to the conditions under which therapeutic work emerged, highlights the importance of making a differential analysis of the Brazilian experience, warning of the risk of assuming a simple transfer from Europe to her country without adaptations. In this regard, she points out that in Brazil, 'moral treatment was not proposed in the 'positive' sense of reconstructing a new man but rather exclusively as a guarantor of the internal order of the asylum and as a provider of the material means for its living and expansion' (Nascimento, 1991, p. 94, own translation). She also identifies contextual elements, such as the long duration of slavery, which at the time influenced the social valuation of work and would have hindered its implementation as a treatment in institutions. Soares (1991), regarding these differences, refers to questions raised by other studies about whether or not moral treatment was implemented in Brazil.

In summary, the research of these and other Brazilian colleagues questioned the therapeutic nature of work and other forms of activity in asylum institutions, as they examined these practices in light of the power relations that constitute them. Their analyses, applied to the reality of professional practice at the time, questioned to what extent qualifying these practices as therapeutic legitimized segregation, institutionalization, and confinement. They also problematized work as 'the only means of social inclusion and promotion of autonomy for all individuals' (Nascimento, 1991, p. 140, own translation) and the role of the occupational therapist as a psychosocial adapter (Galheigo, 1997), a restorer of productive functioning, and a preserver of social order. Consequently, their contributions to the transformation of Brazilian occupational therapy and the care of people in psychic distress, as well as to the development of social occupational therapy, are invaluable (Galheigo, 2016; Lopes, 2010).

Finally, regarding Colombia, Trujillo Rojas (1989; 2002) developed two texts in which she offers a historical retrospective of occupational therapy in that country. She identifies four periods, the first of which she calls 'empirical disciplinary precursor: labor therapy' (Trujillo Rojas, 1989, p. 12) or 'precursor phase' (Trujillo Rojas, 2002, p. 472), this phase extends from the beginning of the 20th century until 1966, when the first occupational therapy training program was established.

For this period, concerning mental institutions and based on accounts from other authors¹³ , Trujillo Rojas (1989; 2002) notes the presence of labor therapy, play therapy, or ergotherapy experiences in mental health facilities in Medellín, the San Camilo Institute in Bucaramanga, and the Asylum for the madmen of Bogotá¹⁴ . These experiences were intended to 'address the daily management issues' of people with mental illnesses (Trujillo Rojas, 1989, p. 12). For the author, such experiences—along with others aimed at populations we now refer to as disabled—are understood as 'early acknowledgments [...] of the value of occupation for rehabilitation, social integration, time management, and productivity' (Trujillo Rojas, 2002, p. 473-475).

On the other hand, Trujillo Rojas (2002) questions, as Soares (1991) does for Brazil, the influence of the 'moral movement prevalent in North America and European countries,' which she believes may relate to Colombia’s tendency, until the 1930s, 'to be a closed society' (Trujillo Rojas, 2002, p. 474). These authors open the door to a controversy that is generally ignored in approaches to the history of occupational therapy and make evident the need for studies on the subject.

Building on the work of Alicia Trujillo, the History of Occupational Therapies in Colombia group, led by Duarte Cuervo et al. (2016), set out to expand research on practices, institutions, and individuals to deepen understanding of the role assigned to occupation in caring for marginalized populations in Colombia, before occupational therapy arrived in the country. The review of available historical studies¹⁵ and some primary sources led the group to forms of work and vocational training dating back to the 17th century, becoming more visible in the 19th century. These formed part of the care provided to populations deemed dangerous or objects of charity or benevolence, in institutions such as hospices, orphanages, asylums, schools and workshops for impoverished children, correctional facilities, and detention houses.

Regarding mental institutions, Duarte Cuervo et al. (2016) agree with Trujillo in identifying reports of labor therapy and ergotherapy experiences in the first half of the 20th century and even into the 1960s, as well as evidence of manual activities in the Men’s Asylum of Bogotá and possible influences of moral treatment on medical thought in the late 19th century. Without delving deeply into these findings and aligned with critical perspectives, they note the continuity of practices of normalization and social control over the poorer sectors of society, which, in the context of these institutions, may have gradually been framed as therapeutic.

Finally, with an understanding of rehabilitation as a social field based on Bourdieu and an interest in the professionalization processes of occupational therapy, Amaya's recent master's thesis (2022) explores the process of social and political legitimization of 'human occupation as a disciplinary technological device' (Amaya, 2022, p. 49) in the first half of the 20th century in Colombia. To do so, she relies on secondary and primary sources¹⁶ , which she analyzes using elements of Foucault's archaeological approach.

Through this, she sketches out discourses on morality, hygiene, eugenics, racial degeneration, poverty, productivity, charity, and national modernization, which appear to have converged to establish practices and knowledge related to occupation as legitimate responses to the country’s social needs, facilitating the integration of marginalized individuals into capitalist production. Amaya (2022) refers to 'human occupation' not only in asylums but also in charitable establishments, a penitentiary, and industrial hygiene¹⁷ schools, though she does not delve deeply into these practices. In her view, institutions 'fulfilled the role of enforcing normative dispositions that allowed the State to connect with people from different social classes in the country' (Amaya, 2022, p. 48), while 'intellectuals worked as employees of the State apparatus and consistently promoted the discipline and control of the population, rationalizing their discourses among the Colombian population' (Amaya, 2022, p. 103).

In Colombia, these recent approaches, besides broadening the scope of institutions, individuals and practices, have been useful in revealing power-knowledge relationships that often remain hidden in idealized and altruistic narratives about the history of the profession. As several authors have noted (Nascimento, 1991; Laws, 2011; Ernst, 2018), such relationships are frequently overlooked by occupational therapists when reflecting on their past.

Studies from History

An approach based on the book work, Psychiatry and Society, c. 1750–2015

The work on which this section is based (Ernst, 2016c) was edited by historian Waltraud Ernst, a professor at Oxford Brookes University in England. Some of its chapters stem from the international research seminar “Therapy and Empowerment – Coercion and Punishment,” held in June 2013 at St Anne’s College, Oxford, England. Both initiatives responded to the limited attention that the histories of psychiatry and medicine had given to the work of individuals confined in psychiatric institutions in modern times, despite it being a widespread practice (Ernst, 2016a). Thus, the book represents an attempt to “examine patients’ work across a broad range of psychiatric institutions and conceptualize the meaning of work in relation to its specific sociocultural, economic, and political contexts” (Ernst, 2016a, p. 1, own translation).

Consistent with this purpose, the book includes analyses situated in France, the United Kingdom, Germany, Tuscany, Ireland, the First Republic of Austria, Württemberg, Canada, the British West Indies, Romania, the United States of America, and Japan. This geographic coverage leads to reflections on the processes of modernization/colonization through which the discourse of moral treatment of madness, the corresponding asylum model, and the work of institutionalized individuals were expanded. In this sense, it seems no coincidence that the book opens and closes with chapters centered on the principles of moral treatment, developed in Europe from the late 18th century and established as models for the organization of asylums for the mentally ill worldwide.

In the authors’ approaches to work within mental institutions, seven themes are identified: the relationship between work and moral treatment; the relationship between the ability to work and mental illness; the adaptations and appropriations of work within institutions; the psychiatric institutional models that incorporated patients' work; the debate between the economic and therapeutic benefits of work; the meanings attributed to work within institutions; and the professionalization of work-based treatment in the first half of the 20th century.

Regarding the relationship between work and moral treatment, Freebody (2016)¹⁸ studies a selection of documents produced from the late 18th century in France, England, and Tuscany, which advocate for this treatment over other methods in the management of madness. Among her findings, she notes that the earliest publications in her sample did not consider work as an integral part of moral treatment; instead, they recommended a daily regimen that, aligned with the six non-naturals ¹⁹ , included physical exercise but not in the form of work. She concludes that the emergence of work in writings on moral treatment occurred at different times, associated with three factors: the author’s preference to control patient behavior through internal methods—what we might call self-control—over external restraint; the prevailing political, socio-industrial, or economic circumstances; and the author’s attachment to classical traditions regarding recommendations on exercise and occupation.

The book also raises questions about the relationship between work and mental illness, which takes on various nuances. Professor Moran (2016) examines this topic through documentation of civil insanity trials in 19th-century New Jersey, United States. Testimonies from those involved in these trials reveal that the ability or inability to work efficiently and productively became a determining factor in assessing an individual's rationality or irrationality and, consequently, their competence to manage themselves and their property or the need to be placed under guardianship or institutionalized. Meanwhile, sociologist Hinsch (2016) studies records of people sent to forced labor institutions in the First Austrian Republic (1919–1934), finding that the boundaries between illness and immorality blurred when these concepts were built on the inability to work or to do so in a morally acceptable manner. In summary, these two studies illustrate the problematic role of work performance outside socially and culturally accepted parameters as an indicator or proof of mental illness.

A different articulation is shown by Professor Müller's (2016) research on psychiatric institutions in the context of Nazi Germany, when the National Socialist health doctrine, based on ideas of racial hygiene, determined the execution of the people institutionalized there. Their status as mentally ill people placed them in a position of racial inferiority that justified sterilization and death, so that the potential for productive exploitation of their labor force became a decisive criterion to determine who died and who continued to live.

Within the framework of the expansion of moral treatment and the isolation of people considered mentally ill, the adaptations and appropriations of work within treatment regimes in different contexts become relevant. In the book, these processes are linked, especially, to the social values ​​attributed to work and the relations of gender, race, class and social position. Thus, for example, in the institutions that were established in British colonies in the Caribbean at the end of the 19th century, work had a clear role in the exploitation of labor that reproduced the relations of domination and the functions attributed to the colonized populations; even so, this coexisted with ideas regarding its healing power (Smith, 2016). In turn, the influence of sociocultural elements was manifested in the types of activities that were recommended, imposed or from which the people institutionalized were exempted in different places and times, so that such elements ended up combining or overriding therapeutic criteria (Chaney, 2016; Ernst, 2016b; McKay, 2016; Smith, 2016; Walsh, 2016).

The chapter by psychiatrist Toma (2016) shows the variety of intervention options that were transferred and appropriated over a century in Romania, based on the study of European models and responding to intricate political, socio-economic and cultural dynamics and to criteria of cost-effectiveness and therapeutic efficiency: the asylum, where domestic labor and workshops were involved; the open-door agricultural colony²⁰ , with an emphasis on agricultural labor; the English pavilion-house system, in which those cared for participated in workshops, gardening and other activities; and the Belgian model of family care under medical supervision, which was combined with the open-door agricultural colony.

Likewise, different variations of family care for people with mental illness also emerge in the book, ranging from a distinct alternative that competes with medicalized care (Nakamura, 2016) to a complementary strategy to asylum care, which included work in a family setting as preparation for eventual discharge from the asylum (Müller, 2016). In the evolution of work in German mental institutions, family care became a provider of cheap labor for exploitation. However, when famine and personnel shortages for care arose due to the world wars, agricultural colonies and family care became alternatives to death (Müller, 2016).

Nevertheless, even in the case of Japan, the European modern reference, initially, and later the American one—especially after World War II—penetrated to such an extent that institutional care prevailed over models based on family and religion, in which work was not part of the treatment (Hashimoto, 2016; Nakamura, 2016).

An element that runs through the chapters of the book is the debate between the economic and therapeutic benefits of the work of institutionalized people, which, far from being resolved, seems to lead to three issues: the administration—essential in modern nations or those aspiring to be modern—of a social group that was growing exponentially and whose chances of reintegration into society were diminishing; the social value of work; and the legitimization of medical-psychiatric knowledge, which assumed the social problem represented by madness.

In relation to the above, fluctuations are identified in doctors' confidence regarding the therapeutic power of work, particularly connected to changes in theories about mental illness. However, this did not lead to the discontinuation of work; rather, it led to its reinterpretation and justification in each context, mixing arguments of different kinds regarding its usefulness and appropriateness, among those, that it was a necessary or desirable element for the economic support of institutions, especially those funded by public resources and intended for the poorest; a quality indicator and income generator for the institution, and occasionally also for the individuals themselves; a facilitator of administration and maintenance of order; a way to counter boredom and combat idleness; a measure for structuring daily routines; a means to instill habits; a socialization element; a way to facilitate reintegration into community work; a form of physical exercise; a provider of well-being for the brain; a means to improve sleep and rest, achieve self-control of behavior, curb morbid introspection, restore rational faculties and emotional energy, or bring thoughts back to the material world (Ankele, 2016; Ernst, 2016b; Harris, 2016; Laws, 2016; McKay, 2016; Müller, 2016; Smith, 2016).

These conceptions about the work of institutionalized individuals were primarily those of doctors and directors of the establishments; the scientific, administrative, and financial documents they produced are the main sources used to investigate them. Nevertheless, the chapter by historian Ankele (2016) approaches the perspective of those who received treatment by studying the clinical records of two institutions during the period of German history known as the Weimar Republic²¹ . In general, these individuals, including those considered chronic, perceived their work more as preparation for re-entering the labor market in the outside world than as a permanent measure. Therefore, at times, they questioned whether the tasks assigned to them were useful for developing skills and requested to attend workshops that would provide better tools. There were also those who expressed a preference to remain in the institutions because they were aware of the unemployment and difficult conditions outside. Ankele (2016) recounts that, during crises, some establishments became refuges, and the teams had to provide their patients with gradual exit plans while they achieved labor integration.

Regarding this complex and contradictory nature that becomes evident when analyzing the use and significance of work in institutions, Professor Laws (2016) elaborates, as a closing reflection for the book, on the rationalization of the attributes of therapy through work and on the lenses of reason and rationality with which the “therapeutic encounters with work” have been attempted to be understood (Laws, 2016, p. 352, own translation).

A final theme that the book addresses is that of scientific administration and the professionalization of work-based treatment in the first half of the twentieth century. This process, while referring specifically to occupational therapy, also refers to other specialties. According to the narratives, the appearance of occupational therapy, industrial therapies (in England) and scientific occupational therapy (in Germany) within the establishments accompanied different tensions and transformations tied to particular local and institutional dynamics and to broader legitimation processes. Among these, the way in which activities were administered was questioned and, in some contexts, it even helped to reaffirm the therapeutic nature of work; there were disputes between the new professionals and the personnel who had been carrying out supervisory or support functions, borders were drawn, generally blurred, and disputes emerged about what was or was not therapeutic, rehabilitative, preventive, productive, while the practices continued to coexist (Ernst, 2016b; Hall, 2016; Harris, 2016; Toma, 2016).

Some Latin American approaches

The study of work in mental institutions does not seem to have occupied a prominent space in Latin American historiography either. However, there are researches located in Argentina and Mexico, in which some historians have addressed the subject with a depth that allows tracing meanings, transformations, theoretical transfers, institutions and concrete practices. The book reviewed above and another previously co-edited by the same author (Ernst & Mueller, 2010) reference the work of Yolanda Eraso, who for more than a decade addressed the Argentine case. On the other hand, in Mexico, Cristina Sacristán has also dedicated part of her research to this issue.

Eraso, interested in medical discourse in Argentina, has investigated the meanings of work since the end of the 19th century, but particularly in the first half of the 20th century, identifying the ideas and proposals of some psychiatrists who shaped two models of care (Agüeros & Eraso, 1999; Eraso, 2002a; 2002b; 2010). First, the asylum itself, in which objectives of exclusion, regeneration and adaptation were combined, and work was understood as part of the strategies to achieve them. For this historian, in Argentine asylums there was a belief in moralization through work and in the possibility of re-educating and transforming the mentally ill. Later, the colony model was implemented on the ideas of incurability and chronicity, in a scheme that would correspond more to social assistance than to medical-psychiatric care, responding to the growing problem of overcrowding in asylums and the challenges of their economic sustainability. The Oliva Mixed Regional Asylum for the Insane is its main exponent.

Also interesting in Eraso's analysis (2002b) is the allusion to the discourse on agricultural colonies in Argentina as a generic model of assistance in which regeneration would be imposed, through work activity, on all those people who were removed from work, whether they were considered lazy, delinquent or crazy.

The author is also concerned with the transfer of theories and proposals from Europe. She highlights the strong ties of exchange with Germany in the context of the prelude and development of the Second World War and the rise of eugenic theories of Nazi racial hygiene. In this scenario, the “active therapy” of the German Hermann Simon²² arrived in Argentina –and other countries in the region– and, in its implementation, was crossed by debates around the economic cost of social assistance and philanthropy, the ideas of social Darwinism that circulated among psychiatrists and the questioning of the role of institutions in the production of unproductive beings, so that transfers occurred, but also deviations (Eraso, 2010).

Following the lines drawn by Eraso, a work by Vanadia & Rodríguez (2019)²³ was interested not only in the medical discourse, but in the concrete practices revealed by the analysis of clinical records of The Oliva Mixed Regional Asylum for the Insane. The authors reconstruct and analyze a particular case to stress and expand readings about the institution as a mere device of power at the service of the State. In this perspective, efforts to theorize about labor therapy are recognized, as well as the coexistence of scientific and economic criteria in its administration, as well as the complexity of lives crossed by psychic suffering.

Regarding Mexico, the historian Sacristán (2003, 2005) has been interested in analyzing the confluence between the proposals for treatment by work of the mentally ill and the ideas and political projects of the Mexican governments that led to the deployment of agricultural farms between 1945 and 1968.

The texts by Sacristán (2003; 2005) differentiate two moments and institutional models that align with the Argentine pattern, although in Mexico the colony model—here, an agricultural farm—was implemented a little later. Unlike Eraso, for Sacristán (2005), in the La Castañeda Asylum, work was not based on therapeutic ideas; instead, it was the way in which those who could not pay compensated for the care they received. However, in light of the crisis of legitimacy surrounding asylum treatment around 1930, psychiatrists promoted the idea that therapeutic work could reveal the productive potential of the mentally ill, a proposal that resonated with the post-revolutionary governments, as it aligned with public assistance's goals of integrating individuals into productive life.

The first farm, San Pedro del Monte, was considered a successful model that inspired the eleven that followed in Mexican territory. In addition to agricultural tasks, it incorporated manufacturing workshops, recreational, sports, and playful activities, and even jobs outside the institution, organizing itself as a relatively self-sufficient, autarkic community with limited contact with the outside (Sacristán, 2005). Again coinciding with Eraso, Sacristán (2003, 2005) argues that the social aspect of treatment was prioritized in the farms.

As a Summary and Synthesis

Overall, the studies presented here highlight the importance of situating, problematizing, and understanding the complex and contradictory historical processes that shape the fields of knowledge, power, and practices of occupational therapy in our territories. This understanding is a central element in the ongoing ethical-political reflection that should accompany everyday professional practice.

In general, the studies conducted by occupational therapists have an exploratory scope, aligning with the context and objectives of the research in which they are embedded. Consistent with this, and with few exceptions, they primarily rely on secondary sources and use analyses of practices produced from other realities. This approach provides fundamental elements while raising questions and revealing gaps in the narratives about work and other activities in the daily functioning of mental institutions in our region's countries, as well as the particular forms and transformations, and the contested knowledge and interests that shaped them in each context. Filling these gaps is necessary to broaden knowledge about the configuration of occupational therapeutic knowledge and practices in Latin America, as well as to enhance understanding, reflection, and debate regarding the role of occupational therapy in society.

Moreover, this analysis reveals the vast universe that opens up when attention is focused on a practice that seems to have attracted so little interest in historical studies, despite its persistence over time and its forceful exposure of the enormous contradictions faced by societies and professions in attempting to answer the question of the place of individuals who do not conform to accepted patterns of behavior and social functioning.

Based on these studies, it is possible to outline a synthesis of the interplay of ideas, meanings, and perspectives concerning madness, the madman, and their work in confinement. According to the reviewed texts, these aspects configured the practice of using work and other activities in mental institutions throughout the 19th century and the first half of the 20th century (Figure 1).

Figure 1
Set of elements that shaped work and other activities in mental institutions. Source: own elaboration.

Moral treatment appears as the basis that supported work and other activities within the closed space regime, which, supported by a medical-psychiatric knowledge in the process of legitimation, is transformed, adapted and appropriated in particular economic, political and sociocultural contexts; the social valuation of work and class, race and gender relations especially permeate life in institutions.

Meanwhile, the conceptions regarding the curable or incurable nature of madness, linked to theoretical perspectives on mental illness, give the activity of the institutionalized persons a therapeutic or utilitarian character, attributing to it the potential of self-control or balance, of re-education or normalization/discipline, of (re)integration into society or rehabilitation. In this context, the asylum and the agricultural colony are projected as extreme institutional models, in a diversity of proposals that move between medical assistance and social assistance.

These elements in play form a useful reference for analyzing and trying to understand, from a historical perspective, work and other activities in mental institutions. Above all, to recognize nuances, deviations, transpositions and other particularities of specific contexts. As can be seen, advancing in the analysis of this practice involves understanding these institutions as tools of social control, but also as spaces in which life took place and resisted, where knowledge and values ​​circulated, were appropriated, constructed and disputed. It also involves understanding them in the social, political, economic and cultural context in which they occurred. Finally, it implies digging into the sources with a focus on the daily life in institutions, from the provisions that aimed to regulate it to the stories and records that document it. The ongoing research, from which this article is derived, aims to contribute from this perspective, addressing a significant institution in the Colombian context.

• 1
  Carried out in the second half of 2022 and during the year 2023.
• 2
  Although subject to variations, Mattos' definition (Mattos, 1929) is a guide: "all measures taken to bring a patient to work, with the execution of which we hope to achieve a beneficial influence on his condition; it is a treatment aimed at obtaining improvements and even cure" (p. 19, own translation). In their etymology, the words labor therapy and ergotherapy refer to treatment through work.
• 3
  The relationship between moral treatment and occupational therapy is interpreted and described in different ways in historical analyses of the profession, although a close link is identified. It is considered a precursor to occupational therapy and even a single practice with different names (Peloquin, 1989).
• 4
  It would refer to the ideas of the French doctor Phillipe Pinel on the moral treatment of madness..
• 5
  Another source is the undergraduate thesis of occupational therapist Sara Daneri: “Background of Occupational Therapy at the José T. Borda Hospital, from the assumption of Dr. Domingo Cabred as director of the institution (1892) to the effective presence of the first group of occupational therapists (1960).”
• 6
  Sociologist Goffman (1961) proposed the concept of a total institution to designate a “place of residence or work, where a large number of individuals in the same situation, isolated from society for an appreciable period of time, share in their confinement a daily routine, formally administered” (p. 13).
• 7
  His master's dissertation was defended in 1987 and then published as a book in 1991.
• 8
  Although the term most frequently referred to in the studies analyzed is labor therapy, ergotherapy and praxis therapy are also used. The latter is also used in studies from Argentina. According to Soares (1991), work-based treatment, with an emphasis on rural activities and under the name of praxis therapy, was introduced at the Juquery Hospital during the administration of the doctor Antonio Carlos Pacheco e Silva (1923-1950) (Tarelow, 2011), which coincides temporally with the use of the term in Argentine agricultural colonies for the mentally ill (Vanadia, 2021).
• 9
  The text Psychiatric Occupational Therapy (Arruda, 1962) is also a common source in dissertations.
• 10
  Opened in 1898 as an agricultural colony for the insane in the city of Franco da Rocha, near the capital of the state of São Paulo, it operated until 2021. Its history is marked by abuses and violations of human rights of the institutionalized people (Franklin, 2023).
• 11
  Commonly cited are History of madness in the Classic Age (Foucault, 1978), The birth of the Clinic (Foucault, 1979), Microphysics of power (Foucault, 1984a) and Discipline and punish (Foucault, 1984b).
• 12
  Especially, The Psychiatric Order (Castel, 1978).
• 13
  Mainly, the works on the history of psychiatry in Colombia by the psychiatrist Roselli (1968, 1987), in addition to the text “Homes for the Mentally Ill in Medellín”, by the doctor Uribe Cálad (1958), director of the State Asylum of Antioquia (1920-1946).
• 14
  Trujillo Rojas (2002) places the beginning of the labor therapy service in this establishment under the direction of Edmundo Rico (1942-1950). According to Ospina Martínez (2006), by this time, the institution had changed its name, at least formally, to the Women's Phenocomium.
• 15
  Among others, studies of social history of medicine, psychiatry and education.
• 16
  Mainly legal documents and images.
• 17
  Institutions aimed at training doctors in industrial hygiene, a knowledge related to the control of risks associated with unhealthiness in the workplace (Amaya, 2022).
• 18
  This researcher has a special interest in the study of moral therapy and the notions of well-being and occupational therapy. In 2023 she published the book Work and occupation in French and English mental hospitals, C. 1918-1939 (Freebody, 2023).
• 19
  “The six non-naturals comprised air, food and drink, exercise and rest, sleep and wakefulness, retention and evacuation, and passions and emotions. These had to be carefully regulated to maintain a balance between the four bodily moods. In this way, health would be maintained in a healthy person and restored in a sick person [...]. Their influence is reflected in early texts on moral treatment, which stress the importance of routine, diet, and the patient's environment, as well as exercise and diversion. Exercise is a recurring, and often unexplained, aspect of texts on moral treatment (Freebody, 2016, p. 34).
• 20
  Of German origin and known in Latin America by its English name: open door.
• 21
  Or Deutsches Reich (1918 – 1933). The author states: “The end of the First World War marked the end of the German Kaiserreich (1871–1918), and the 1918 revolution led to the proclamation of the Republic and a new democratic constitution in 1919. The Weimar period was marked by civil war-like conditions in the early years of the Republic and by hyperinflation, followed by poverty and high unemployment, and by a short period of economic expansion and political stability (the so-called “golden age”) whose conditions began to deteriorate during the Great Depression of 1929 and led to the transition to the Nazi era in 1933. In German history, the Weimar period still represents (failed) democratization, the implementation and development of the welfare system, social reforms, and the strengthening of organized labor (Ankele, 2016, p. 238, own translation).
• 22
  Particularly, the Spanish version of his book Occupational Treatment of Mental Patients (Simon, 1937).
• 23
  Psychologist and historian, respectively.
• How to cite:
  Duarte Cuervo, C., & Lopes, R. E. (2024). Work and other activities in mental institutions: a historiographical approach. Cadernos Brasileiros de Terapia Ocupacional, 32, e3905. https://doi.org/10.1590/2526-8910.ctoAO400939052
• Funding Source
  Work carried out with the support of the Coordination of Superior Level Staff Improvement (CAPES) – Brazil – Financing Code 001.

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Edited by

• Section editor
  Prof. Dra. Mónica Díaz-Leiva

Publication Dates

• Publication in this collection
  20 Dec 2024
• Date of issue
  2024

History

• Received
  19 July 2024
• Reviewed
  07 Aug 2024
• Accepted
  07 Oct 2024