Mansions in the Orchard
Architecture, asylum and community in twentieth-century mental health care
in Communicating the history of medicine

This chapter explores the value and relevance of a combined academic and public engagement approach to the history of medicine. The authors consider a specific mental health project at the Bethlem Museum of the Mind, in the context of a longer tradition of service user involvement in mental health research and museology. It is argued that the project’s approach presented a unique opportunity for mental health education and the reduction of stigma. These elements of the project informed the historical focus, resulting in a more inclusive history than in many institutional histories of psychiatry, focusing on the importance of space, place and architecture in twentieth-century psychiatry. The chapter concludes that community engagement within a museum setting enriches the history of medicine as a discipline and vice versa.

The Mansions in the Orchard project, funded by a Wellcome Trust People Award for Public Engagement, ran from September 2013 to March 2015. On behalf of the Bethlem Museum of the Mind, the authors carried out new historical research and documentation, alongside public engagement activities. The project addressed the largely undocumented twentieth-century history of inpatient mental health care in Britain through the Bethlem Royal Hospital's current site, opened in south London in 1930. We worked with Bethlem site users (staff and patients), local residents and London-based mental health service users to expand and interpret the Bethlem Royal Hospital Archive through new photography of the site and its users, a collection of oral history interviews and donations of photographs and archive material. This informed four exhibitions, numerous talks and events and a month-long series of activities at the Dragon Café, a service user creative space in Southwark.

In this chapter we explore the value and relevance of a combined academic and public engagement approach – to the Museum of the Mind and its users as well as to the history of medicine more generally. First, we consider the value of public engagement in the history of psychiatry, through discussion of the longer tradition and benefits of service user involvement in mental health research and public engagement in a museum setting. We then move on to explore the specific outcomes of the Mansions in the Orchard project, as part of a new museum space on the site of a working hospital. The project's approach, we argue, presented a unique opportunity for mental health education and the reduction of stigma. These elements of the project informed our historical focus, resulting in a more inclusive history than in many institutional histories of psychiatry, focusing on the importance of space, place and architecture in twentieth-century psychiatry. Finally, we conclude by arguing that community engagement within a museum setting enriches the history of medicine as a discipline and vice versa. Importantly, a historical project in a mental health setting enables audiences to challenge established norms, encouraging critical thinking and combatting stigma.

Mansions in context: museums and public engagement in the history of psychiatry

In the Mansions in the Orchard project, oral histories, collected from those who worked and lived onsite, were used alongside textual research and photographic documentation of the hospital architecture to explore lived experiences of twentieth-century mental health care. By incorporating the ideas and expertise of practitioners and service users throughout, the research generated a space for collaboration between academic historians, current and former hospital staff, patients and local residents. This encouraged diverse and candid first-hand testimony, and presented a vital counterpoint to the traditional privileging of academic or medical ‘expert’ opinion within psychiatric historiography. Richard Butsch has highlighted a historical dichotomy in audience depictions in this vein; namely, the assumption of an educated and civic-minded ideal, versus the ‘ill-informed, pleasure-seeking, suggestible crowds or mass’. Such a view has traditionally negated the roles of community and culture; factors that Butsch believes are now achieving greater recognition, through ‘negotiated readings […] based upon incongruities between preferred readings and personal experience’. 1 Similarly, according to Alessandro Portelli, written and oral sources are not mutually exclusive. 2 Nicole Baur has also proposed that an emphasis on meaning can help to penetrate official or accepted accounts, facilitating exploration of the recent past and shaping the future of mental health care through a patient-centred approach. 3 Furthermore, David Russell suggests that personal testimony holds an ‘intrinsic value in giving some flavour of the basic day-to-day care in past times, through provision of historically minute detail […] The immediacy of the oral report gives an extra dimension […] is often highly graphic, and can provoke in practitioners’ minds comparisons and contrasts with present-day care’. 4 All these factors are acutely significant in research with historically and socially marginalized populations.

Service user participation in research can take many forms, on a continuum from consultation, to collaboration, to co-production. The latter approach is here employed primarily for its democratizing value, including varied and often marginalized perspectives throughout the project lifecycle, which can generate rich and representative data. Here we understand co-production as a form of research created jointly by academic researchers, artists and service users, as part of a project in which there was considerable overlap between these groups, with the intention of equal representation. This is a subtly different emphasis from Sheila Jasanoff's definition of co-production as ‘an idiom – a way of interpreting and accounting for complex phenomena so as to avoid the strategic deletions and omissions of most other approaches in the social sciences’. 5 While Jasanoff's view is supported by this project, through this research we aimed to ensure equal representation of diverse groups through overlap between roles.

Parallels and differences exist between two major models of research, Patient and Public Involvement (PPI) and Public Engagement in Science (PES). 6 The specific involvement of mental health service users in research preceded that of many other medical specialties in Britain, and foreshadowed the 1996 creation of the UK Department of Health's ‘Consumers in NHS Research’ unit (later renamed INVOLVE), which promotes patient and public involvement in research. 7 Two user-controlled research projects, ‘Strategies for Living’ and ‘User Focused Monitoring’ began in London in the 1990s, whilst the 2001 inception of the Service User Research Enterprise (SURE) at the Institute of Psychiatry, Psychology & Neuroscience, King's College London, marked the transition of user-led research into academia. This university department operates on the premise that service user researchers have the advantage of ‘insider knowledge’ about mental distress, treatments and services, in addition to conventional academic training and qualifications. 8

In this chapter, we highlight the ‘different truths’ that emerge from co-production, which represent a contrast to accepted psychiatric wisdom and hierarchies of evidence. A range of organizations and individuals have become engaged in mental health service user or survivor research on a national and international scale. 9 These have heterogeneous theoretical agendas, aims and methods, as Jasna Russo relates:

‘Service user’ (Europe) or ‘consumer’ (Australia, New Zealand and USA), on the one hand, and ‘survivor of psychiatry’, on the other, are expressions of two different perspectives on psychiatry: the first one focuses on reforming the existing system, while the second puts the entire psychiatric system in question, including the very premise of mental illness. 10

Peter Beresford has also cautioned that ‘recent interest in service user knowledge is part of broader pressure [from funding bodies] to increase user involvement’. 11 This can be understood, on the one hand, as evidence of ‘impact’ – enabling research to reach a wider audience. On the other hand, however, it can be viewed as a tokenistic exercise, of more value as a tickbox process than for its content. In addition, it presents service users’ views as of value only where they intersect with the interests of medicine and health care, rather than of intrinsic value as research material: moreover, users in this model are presented as distinct from researchers. Thus, these ideas can be critiqued as merely another data source to inform and support a more ‘traditional’ research design, rather than as a way of enhancing democracy and empowerment. However, as a form of public engagement, mass media campaigns such as Time to Change in the UK and Mental Health Europe (MHE) have been found to support the long-term reduction of stigma and discrimination, especially in relation to prejudice and exclusion of people with mental health problems. 12 Such initiatives can also promote help-seeking behaviour, social inclusion and the gradual dismantling of conventional hierarchies and illness stereotypes. 13

In the Mansions project, a user-led research agenda benefitted from its location within a museum setting. Since at least the 1980s, non-specialist education has been considered the primary purpose of most museums in the Western world, a focus that has encouraged a visitor-centric view of museum and gallery spaces. Previously regarded as repositories for research, exhibitions came to be seen primarily as ‘visitor experiences’ and a huge body of literature has emerged on understanding audiences in museums and galleries in order to meet visitors’ needs. 14 This emphasis on the visitor rather than the researcher has encouraged a bottom-up view of exhibition design and research. In the last five years in particular, the museum has come to be viewed as a ‘shared space representing multiple perspectives’. 15 Civil or community engagement in museums has formed a central interest of funding bodies, such as the UK's Heritage Lottery Fund (HLF), which promotes community-led historical projects. 16 Both factors have led many museums to re-visit and interpret their collections and re-evaluate models of expertise within the institution, often leading to collaborative projects with under-represented groups and marginalized communities. These community groups are frequently ‘experts by experience’. 17

Such projects have not been without their challenges, similar to those encountered in user-led research. In 2009, the UK charity Paul Hamlyn Foundation commissioned engagement specialist Bernadette Lynch to undertake a study of community engagement in British museums. The resulting report – Whose Cake Is It Anyway? – indicated that engagement activities were often marginalized, were not seen as a core function of museums and were generally dependent on short-term project funding. 18 One result of this ‘empowerment-lite’ (as Lynch termed it) was that projects sometimes had the opposite effect from that intended, leaving community groups feeling disempowered and further marginalized through their perception that they were simply rubber-stamping museum projects or being ‘used’ to access funding. 19 It is vital that museum and heritage projects (and academic user-led enterprises) remain aware of this imbalance of power, and seek to redress this balance through the development of participatory practices, in which experts by education and by experience can deliver on genuine co-production, understood as supporting both parties to play an equally valued role in the research process and agenda. 20 By promoting such a model, museums can enable discussion of difficult histories by openly acknowledging the varied perspectives of contributors as well as the ways in which dominant or normative views have been created and shaped for particular social and political purposes. The curator or archivist cannot be considered a ‘neutral’ force in such a setting. 21 This approach has been taken up by heritage projects in the medical realm, such as the work of the Science Museum in London with marginalized community groups. One participant in this programme reflected pertinently that ‘the curator's voice is one version of reality. Visitors can create our own interpretation and displays. We [community groups] also have the power to do that, in our projects’. 22

In a mental health context, the value of co-production as a means of empowerment in museums has been highlighted in the recent volume, Exhibiting Madness, which brought together case studies on mental health exhibitions and collections. As the editors noted, mental health collections have played a significant role in histories of twentieth-century psychiatry. Often put together by staff in an institutional setting, certain narratives within these collections have been highlighted or side-lined in the way objects are interpreted or displayed. 23 Patients have often had little or no voice in the way collections were put together or represented over the years. Recent exhibitions have sought to redress this balance by actively seeking involvement from mental health service users past and present. These include the Willard Suitcase exhibit in New York (2004), ‘Remembering Goodna’ at the Museum of Brisbane, Australia (2007–2008) and the redisplay of both Bethlem Museum of the Mind and the Wakefield Mental Health Museum in the UK (2013–2015). 24

Figure 7.1 Photograph of Bethlem Museum of the Mind foyer during redevelopment (Max Reeves, 2014).

Mansions in the Orchard emerged from this user-led approach to exploring and understanding the history of mental health care. We argue that community engagement within a museum setting enriches the history of medicine as a discipline and vice versa. For the Bethlem Museum of the Mind, this historical project provided a ‘safe’ space, in which challenging contemporary issues (such as restraint) could be explored by mental health staff and service users, enabling the sharing of varied perspectives. Conversely, the artistic elements of the project, bringing together a number of different audiences, shed new light on historical issues by moving beyond the archive to examine the significance of the landscape and architecture of the Bethlem site, outside a traditional academic framework. Before exploring these concerns in greater depth, we will first provide a brief outline of the Mansions in the Orchard project in the context of the history of the Bethlem Royal Hospital.

Recollections of buildings: the Mansions in the Orchard project

The Bethlem Royal Hospital is believed to be the world's oldest remaining psychiatric hospital. Founded in 1247 at Bishopsgate, just outside the City of London, Bethlem has moved three times over the centuries. In 1930, the hospital moved to its current location on the outskirts of London: the Monks Orchard estate, formerly a residential site. Bethlem's chaplain, Edward O’Donoghue, made several visits to the site in the 1920s while the new hospital was being built. In Bethlem's magazine, Under the Dome, he imagined the ‘mansions in the orchard’ that might remain in future years, when ‘a red brick palace may look down (with the recollection and wisdom of many centuries) upon the same landscape’. 25

These ‘red brick palace[s]’ still remain today, surrounded by nearly 200 acres of the quiet woodlands described 90 years ago. Unusually in British psychiatry, Bethlem was built on the villa system, an architectural style of hospital popular in continental Europe and consisting of separate, self-contained units spaced out around the grounds. The hospital landscape features heavily in the memories of those who have used Bethlem since, as staff, service users or visitors. Taking a lead from O’Donoghue's interest in the ‘recollections’ of historic buildings, the Mansions in the Orchard project sought to explore the neglected history of Bethlem's current site through its architecture. 26 The project ran during the move of the Bethlem Royal Hospital Archives and Museum from a small temporary building into a new purpose-built exhibition space in the hospital's Art Deco administration building.

Public engagement was a key element of the project. In total, our activities reached over 8,000 people. Yet this wide audience also proved to be a challenge. All three researchers on the project – two historians and an artist – worked part-time to gather data, create artwork and co-organize public engagement activities. The equal valuing of traditional research and public engagement meant that there was sometimes a lack of time to complete either in as much depth as had been hoped. The initial target for oral histories, for example, was at least 25: time and staff constraints meant we recorded only 23. Additionally, the research questions generated by the project deserved greater attention than the temporary funding permitted, although many lessons learned were incorporated into the ongoing work of the Museum of the Mind.

For the Museum of the Mind, Mansions in the Orchard offered a valuable opportunity to access existing and new audiences during the creation of the expanded museum. It helped to engage site users with plans for the museum and to encourage them to remain involved with the museum's activities. The project indicated that there was a high level of interest in mental health history across the different audiences, through a sense that the history of psychiatry can offer valuable insight and lessons for contemporary health care. This interest will be expanded on in the museum's future activities. Here, we explore the ways in which the project enabled mental health staff and service users to participate in gathering and understanding their own history, alongside opportunities for discussion and debate. This contributed to reducing the stigma of mental illness by addressing the ongoing reality of inpatient treatment in the ‘care in the community’ era. 27

Public histories of psychiatry: the academic relevance of Mansions in the Orchard

Turning to the consideration of the key historical contributions of Mansions in the Orchard at a local and wider level, we begin by looking at the new historical material gathered through the project, and the ways in which the process of the project informed the historical interpretation. Over 18 months, from autumn 2013 to spring 2015, we conducted 16 interviews and held focus groups with staff, service users and local residents. We also collated personal documents and artefacts donated by former staff members. A further five follow-up interviews with project participants were conducted in summer 2015, allowing these individuals to reflect on their involvement in the research, and their longer-term hopes for the museum. Additionally, the Bethlem blog has supported the ongoing collection of memories of the hospital following the completion of the project. 28

Today, as part of the South London and Maudsley NHS Foundation Trust (SLaM), Bethlem is globally known for its role in treating and researching mental illness. Yet the alleged disorder and neglect associated with its earlier ‘Bedlam’ alter ego has endured in both academic discourse and the public imagination. 29 Previous accounts of the hospital have drawn largely on internal records, without direct recourse to the experiences and opinions of the people at the very heart of the institution. By contrast, this project endeavoured to involve current and former service users, staff and local residents throughout all stages of conducting and disseminating the research.

The research spoke to a number of macro-level issues and debates, such as those highlighted in two recent articles in the history of psychiatry. Rob Ellis reflected on the relationship between mental hospitals and the community through a case study of Epsom Hospital, addressing the localized implementation of national policy, the (unsung) benefits of the institution to its neighbourhood and the roles of the media and/or vocal critics in perpetuating stigma and stereotypes. 30 This account resonates with stringent recent opposition to the development of a medium secure unit at Bethlem, but also with a more general ambivalence towards the hospital. It was very difficult throughout the project to engage local residents in conversation about the hospital. Thus, an attempt at conducting a focus group in a local library met with mixed success: despite widespread advertising of the event, very few people were willing to come inside to discuss their experiences of the hospital. However, over 20 people spoke to researchers outside the venue when approached directly. These included respondents whose family or friends had been treated or worked at Bethlem, as well as longstanding local residents with varied opinions, often based on hearsay, about what went on behind the hospital gates.

Moreover, although details of the project and related events were posted online, in staff publications and at key points around the hospital, the majority of interviewees were recruited through ‘snowballing’ – i.e. on the personal recommendation of previous participants. Although convenient, this increased the risk of homogeneity within our sample and responses. In addition, some participants assumed that we were only interested in amassing positive accounts of the hospital – understandable amidst a tradition of hagiographic institutional histories – whilst others exaggerated the rates of criminal admissions to Bethlem, likely reflecting adverse media coverage of mental illness and its institutions. 31 Such misgivings and misunderstandings will be further explored later in this chapter.

In another historical article, Vicky Long has underscored the necessity of studying the evolution of inpatient psychiatric care during a period more commonly associated with institutional closures and community treatment. In particular, she identified a need for the scrutiny of long-term or chronic inpatient populations, and highlighted the risk of community care reinforcing the negative attitudes and stereotypes surrounding mental illness. Long ultimately posited a need to connect the medical and social dimensions of care, and to incorporate the voices of a wider variety of auxiliary and ancillary workers. 32 This is something that we have incorporated throughout the Mansions in the Orchard project, and it is this diversity that has led to a themed history of the site and its users, broadly grouped into three overlapping categories: place and purpose, institution and identity, and community and communication.

‘Place and purpose’ looked at the historic relationship between the site and architecture of the Bethlem Royal Hospital and its therapeutic function. Specifically, we sought to examine how ideas of ‘asylum’ and ‘community care’ have shifted across the twentieth century, and how the physical and conceptual boundaries of the Bethlem site altered in relation to changes in these concepts. In light of the aforementioned shifts in models of expertise and audiences, we also considered the value of representing diverse accounts of ‘asylum’ and ‘community care’. The hospital's verdant backdrop was widely deemed conducive to mental wellbeing, and not only for its patients. As a social worker put it:

One of the things that I think is really important about the Bethlem site is that it is a place of asylum in the real positive sense of the word. People can come here and they can have tranquillity and peace and get away from the city […] I think that that's the true place for mental health to go and rest; to go and to have that space to just breakdown, so you can rebuild yourself. 33

Other staff mourned the gradual loss of land and buildings over recent decades, while ruefully observing that they ‘couldn't have expected us to remain in our own little bubble’. 34 Echoing and extending this theme, Bethlem Gallery Director Beth Elliott felt that ‘the [Mansions in the Orchard] project has really highlighted what a rich canvas the grounds are’. She stressed the importance of not losing contact with the site and its users, adding that new premises would enable the gallery to ‘really retain an open, flexible, creative space’. 35 This comment clearly connects the historical Mansions in the Orchard project with the contemporary work of the hospital and its occupational therapy department, through the unusual architecture and environment of the pastoral Bethlem landscape.

The next area of our historical approach, ‘institution and identity’, explored how a hospital can offer an identity for those within it (staff and patients), and the ways in which this has changed or remained the same across the focal period. In particular, we considered the differences and similarities between actual or fabled Bethlem and other twentieth-century institutions. The stereotype of Bethlem as more relaxed than its partner institution, the Maudsley Hospital, was entrenched in different generations of staff testimony, but was discussed with humour and irony.

We used to say ‘Oh, you are a Maudsley chap’. We would know the ones that had come from Maudsley; I think they were more forward-thinking than Bethlem. I always thought the Maudsley was ahead of us in terms of their outlook and things. I don't know if they were really. 36

Other respondents contrasted Bethlem's atmosphere and working conditions with other institutions, and with present circumstances:

We were all [aged] 18–20 and that was the beginning of our careers. We were put into a nurses' home, into a uniform, we were given food […] there was nothing to think of about fending for ourselves. So that has changed tremendously with nurses today, who do degrees, they come, they live at home, they are married, they have got families […] The one thing they don't have is the bond with the hospital that they train in, like we had. That's a big loss I feel. 37

Another staff member who contributed an oral history was interviewed again more recently, and described her personal and professional motivations for participating in the project. She and her family had lived in staff accommodation, and her first child was born there, growing up amid the scenic grounds and learning to swim in the onsite pool. She regarded the hospital as a formative influence on her nursing career, but was profoundly aware of remaining wider deficiencies in mental health care (especially community care), and a related need to help ‘normalize’ mental illness through the creation of ‘flagship’ initiatives such as the Museum of the Mind. 38 These accounts reiterate the affinity participants felt with Bethlem, but also indicate some of the challenges faced by contemporary institutions where such connections are more fragmentary and fleeting than in previous decades.

A third theme, ‘community and communication’, addressed Bethlem's impact on the local community and the longer-term value of the history of psychiatry as a tool for community engagement (particularly in relation to the new Museum of the Mind). Some current and former staff members were also local residents. Their varying personal accounts of ‘community relations’ ranged from acceptance or complacency to fear and uncertainty and even outright hostility (the latter in the context of new forensic services). One nurse found herself at the forefront of communicating these plans to local residents:

As soon as a whisper of this intention to develop a medium secure unit got outside of the hospital front gate, then there was this avalanche of objections. And it was relentless; it went on for at least three years. It was a really big campaign and it was led by I think probably quite a small group, but quite an energetic group, who really seemed to have very little else to do in their lives. 39

Recent years have seen ongoing efforts to engage the public in the life of the hospital, and dispel some of the ‘tremendous misconceptions’ still clearly held about the hospital. 40

The Mansions in the Orchard project focus on co-production and gathering of diverse perspectives served to challenge and extend existing historical narratives, shed light on beliefs surrounding mental illness and inform strategies for future engagement and educational activity. In particular, the use of oral history and creative media provided important conduits for articulating often sensitive personal experience, and supported the emergence of the three broad themes outlined above. Mansions in the Orchard also enhanced site user involvement within the new museum, a key benefit recounted by Victoria Northwood, Head of the Museum of the Mind. 41 Notably, this involvement was expanded in the design of the space, through the use of participants’ quotes in video installations, ongoing public consultation and a blog for the collection and dissemination of further memories after the formal completion of the project.

Expanding engagement: Mansions in the Orchard and the public role of museums

The Mansions in the Orchard project ran alongside the development of the new Bethlem Museum of the Mind, which opened at the close of the project in February 2015. Situated within a working psychiatric hospital, the Museum of the Mind aims to benefit the wellbeing and educational and creative needs of site users (staff and patients), as well as contribute more generally to public understanding of mental health and illness, reducing the stigma often associated with it. The museum is now housed in the same building as the Bethlem Gallery, a contemporary gallery space connected to the hospital's occupational therapy department. The gallery offers a professional platform for service user artists to display and develop their work and an ongoing series of creative workshops, such as the ground-breaking ‘Saturday Studio’, a year-long professional development programme for artists who have left the inpatient care of South London and Maudsley NHS Foundation Trust (SLaM). 42 Mansions in the Orchard contributed to the museum and gallery programmes through public engagement and involvement in historical research.

Most of our engagement activities combined the artistic and historical elements of the project, which were most usefully used in combination. Activities fell into four main areas: talks and tours; focus groups and discussions; artistic and creative workshops; and interviews. Each of these encouraged a different type and level of engagement. Talks and tours are a standard museum intervention whereby attendees are primarily passive listeners to an expert speaker. Our activities encouraged discussion, however, which worked particularly well during a month-long series of activities at the mental health service user led Dragon Café. The Dragon Café, a project directed by Mental Fight Club, is a safe creative space that aims to be a force of positive change for mental health in Southwark, South London. 43 The atmosphere of the cafe – a lively, non-hierarchical social space – meant that talks easily became discussion sessions, with contributions offered by a range of Dragon Café patrons. Drop-in activities and creative approaches, such as a participatory performance of historical ballads about Bethlem, offered a range of different methods of engagement. This enabled patrons to make a variety of parallels to current mental health concerns or draw attention to differences between historical and contemporary approaches. Most patrons have experience of the mental health system, and their way of thinking about history tended to be to seek answers to modern-day concerns or to use history to challenge aspects of contemporary mental health care. The historical research, engagement opportunities and contemporary social and political questions became inextricably connected. This, indeed, is a key element of Mental Fight Club's ethos: ‘We want all things to be considered, not just one version of reality, but all disciplines, all flavours of human thought’. 44 The social and political value of mental health history – both as a set of data and a tool for critical thinking – is an important consideration for academic historians, who may lose sight of the contemporary relevance of their object of study.

Throughout the project, we trialled different methods of gathering and showcasing user-generated content, including focus groups, discussion sessions, art interventions, interviews and blog posts. User-generated content is often regarded as a new and exciting development in the modern media world. 45 In museums, it has been part of standard practice for at least a decade, but is now increasingly expected by audiences and often forms centre-stage in exhibitions. 46 In this project, the user content was primarily focused on artistic practice, through the Bethlem Gallery and the employment of a service user artist, Max Reeves, who worked alongside the authors as the third member of the core project team. Reeves’ symbolic photographs were intended to depict the experience of mental illness through the landscape and buildings, and his style proved evocative to mental health service users in particular. Artist-led sessions in which participants drew, painted and wrote on the photographs were a useful means of incorporating a wide variety of personal responses from mental health service users. These were scanned and archived along with the original photographs. At a Saturday Studio session with Bethlem Gallery artists (most of whom had personal experience of mental ill-health), one artist customized a photograph of an abandoned ward to add a shadowy figure, reflecting a self-portrait she had previously painted (Figure 7.2). The photograph thus became a reminder of her experiences as a hospital inpatient but also her identity as an artist, and the method of engagement enabled her to combine the two approaches.

Figure 7.2 Photograph of interior of abandoned ward (Max Reeves, 2014), with additions by anonymous artist.

These creative engagements helped us to gather a more nuanced history of the Bethlem site. In particular, the opportunity for anonymous intervention provided a counterpoint to some of the rose-tinted nostalgia presented in interviews and focus groups. More critical comments on the hospital were received in an anonymous photo collage in the gallery than in any other medium. This included photographs where staff faces had been scrawled out in red pen and comments like: ‘As if it was that easy …’ (written next to a sign saying ‘Press Intercom to Exit’). These responses indicate the importance of offering a variety of feedback and involvement methods in a mental health museum, to avoid further marginalizing those who do not share dominant views of the hospital. In addition, it provides an alternative means of gathering historical research material to that of traditional interviews; many of those who were happy to engage in an art project did not wish to take part in formal interviews. While of great importance, this material remains difficult to incorporate into standard academic histories, suggesting a wider need to re-evaluate the ways in which historians approach user stories and the frameworks they use to interpret them.

The project was beneficial to participants in a number of important ways. There now exists a significant literature indicating the value of heritage, in particular object handling, to mental health and wellbeing. In particular, the ‘Heritage in Hospitals’ and ‘Museums on Prescription’ projects at University College London (UCL) have shown that museum objects can facilitate discussion and enable ‘emotional disclosure and communication’. 47 Objects become ‘prompts for disclosure’ as well as opportunities for working collaboratively and sharing knowledge. In the ‘Remembering Goodna’ project in Australia, reminiscence itself was ‘of powerful therapeutic value’, improving the wellbeing of participants. 48 In the Mansions in the Orchard focus groups we used collection items to open up discussions, encouraging shared reminiscence and breaking down boundaries of expertise between different types of staff and service users. When we discussed a 1950s hospital milk bottle, for example, curatorial staff ceased to be the experts, and instead reminiscences from those who had used these items in practice came to the fore. Other group members effectively interviewed their peers. This informal setting meant that the project was often valued by participants as a social activity. Those involved fed back positively on the ‘lively, friendly community involved in the project’ and rated their involvement as a beneficial social experience. 49

Objects could also provide a ‘safe space’ for exploring challenging topics, such as restraint or ECT, which proved particularly emotive. Historical ‘distance’ enabled staff and service users to participate in mutual discussion, sharing views or experiences without either group feeling excessively challenged or becoming defensive. This creative approach to objects encouraged ‘a kind of openness because we're all engaged in the object, a kind of freeness to the way people interact and talk to each other around them. It […] opens us all up to chat and to learn’. 50 Hospital staff reflected on the enthusiasm of the service user community for the project and for the history of mental health generally; some felt that awareness of this interest would help them with person-centred care. 51

This potential for interaction around emotive or painful topics also indicates the value of public history projects to empower marginalized groups. Besley and Low have suggested that museums have the potential for offering three stages needed to recover from trauma: a safe environment, a site of remembrance and an opportunity for reconnection. 52 The last of these can be associated with empowerment: an opportunity for marginalized communities to shape the way they are presented and to reconnect with other social groups as a result. The active encouragement of user-generated stories, and the opportunity to tell multiple stories of the past, is an important element of this practice. These conflicting histories came into stark relief at the Dragon Café, where several patrons questioned the use of a theme of ‘sanctuary’ in relation to Bethlem. This ‘peaceful theme’ jarred with their experiences of Bethlem and all ‘the dreary, dehumanising horrors of your average psychiatric ward in this country’. 53 By offering the opportunity to discuss and explore this topic within the safe space of the Dragon Café, as well as the creative responses outlined above, these distressing experiences could be legitimized, becoming just as much a part of the hospital's history as the positive views often recorded in oral histories.

The major impact on participants was in attitudes. Our evaluation showed that the project highlighted the importance of making mental health less of a taboo subject and normalizing experiences of mental illness. 54 For some participants, particularly local residents, this has the potential to lead to a personal change in attitudes. As part of the project, we began to gather data in a questionnaire reviewing the stigma attached to mental health. This 20-question survey, with a mixture of tickbox and open-ended questions, was carried out with 36 participants: 20 on the local high street in West Wickham, and 16 people who came onsite to attend Mansions in the Orchard activities and events. While the small number of participants meant that it was not possible to draw any direct conclusions from this survey, questions concerning attitudes highlight areas for further research: in particular, assumptions about the relationship of mental illness to crime. The vast majority of respondents in West Wickham assumed that more than 20% of those detained in UK psychiatric hospitals have been committed through the criminal justice system; in reality, the figure is less than 4%. Onsite, a much lower figure was assumed by attendees; no one placed the real figure as more than 10%. 55 While there was potential overlap between the two groups, the mixture of staff, service users and London-wide visitors meant that those completing the survey onsite formed a much more diverse audience than those on the local high street. This potential contrast in attitudes might be usefully explored by further activities at the Museum of the Mind.

In our evaluation of the project, some participants also felt that their own insight into contemporary practice was directly enhanced by the historical approach to the Bethlem site. A historical approach provided lessons. These included avoiding the errors of the past, but also recovering valuable skills (for example, within nursing care). History, one staff member noted, ‘can provide a cautionary note about new therapies which are over-enthusiastically embraced’. 56 Even more so, the project taught ‘humility’, for ‘science doesn't – and shouldn't – have all the answers’. 57 A historical project helped to break down prejudices and expand thinking, managing fears born of stereotypes by providing awareness of the development of these stereotypes. One example that emerged from the project was the changing view of Bethlem held by some local residents as nearby county asylums began to close down; the negative associations applied to these institutions subsequently became transferred to Bethlem. 58 By raising awareness of mental health history, some participants reported that they had developed better empathy with mental health service users today, viewing patients past and present as individuals. It also offered an opportunity for people to consider their own mental health, and to improve wellbeing, as well as generating support for the Museum of the Mind from site users, with an associated understanding of the museum's purpose and value.

Conclusion

The Mansions in the Orchard project at the Bethlem Museum of the Mind emerged from a background of service user involvement and public engagement within a museum setting. Both of these approaches contributed to the success of the project. In addition, they shaped the historical method, resulting in a very different project from academic histories of medicine. This non-hierarchical history was more subtle and nuanced than standard histories of psychiatry, which have tended to focus on institutional administration, rather than people and daily life within these settings. 59 Our use of oral histories was an important element of this diversity. However, alongside this, public engagement activities resulted in additional historical material: in particular, artistic responses to the project incorporated a much wider array of responses from service user groups. This ensured that negative or critical reactions to the twentieth-century history of mental health care were incorporated throughout the project. Both the interviews and art materials have been added to the Museum of the Mind archive, forming part of the official history of Bethlem accessible to future generations.

Time and funding were, however, a major challenge throughout. While new material was added to the archive, the project funding did not cover cataloguing this or making the oral histories and transcripts accessible to a wider audience. While it is hoped that this will be carried out subsequently, none of the project coordinators were directly employed by the Museum of the Mind, which risked an uncertain legacy. In similar projects, this might be addressed by ensuring that a named member of staff acted as liaison throughout.

Despite this, the public engagement aspect of the project provided a valuable opportunity for mental health staff and service users to collaborate, recognized by core museum staff as well as workers from the wider hospital. In particular, focus groups offered a space for the exploration of difficult issues. A nuanced and critical approach to the past is a particularly important aspect of the historical method in mental health museums, to avoid further disempowering marginalized groups. In a mental health setting, creative and historical activities can promote wellbeing for participants: service users, certainly, but also staff, whose own mental health can be challenged by the stressful situations in which they find themselves. In a context of increasing financial threat to mental health services – an area of the NHS that has been particularly hit by UK government drives to austerity in recent years – both staff and patients are often left disempowered. Yet the museum and gallery could provide an alternative model, giving site users past and present a voice.

I've been encouraged by how people have embraced and supported the work that we do, and realized that it's a way of keeping this site in the picture, in profile, reminding the world at large that there's extraordinary history and expertise within the Trust. 60

Enabling these groups to write their own history offered them a space for reflection often neglected in daily work and lives, assisting with improved confidence or skills. Sessions at the Dragon Café with mental health service managers and trainee psychiatrists have indicated the immense value of such opportunities for both staff and service users. 61 This will form an important element of the Museum of the Mind's ongoing engagement programme.

The public engagement activities of the Mansions in the Orchard project emphasized three key ways in which mental health history projects contribute to the history of medicine in practice. First, involvement in a creative and historical project contributed to the wellbeing of participants. Associated with this was the ability of the project to empower staff and service users to contribute to their own histories, providing them with the critical tools to challenge and improve services today. Finally, but perhaps most importantly, a heritage project can have a significant impact in helping to reduce the stigma associated with mental illness, particularly for a public audience. Since the Museum of the Mind opened in February 2015, increasing numbers of local residents have entered the Bethlem site, often surprised by the contrast with their expectations. 62 Bringing residents together with staff and service user groups offers a social space for understanding and celebrating difference. Historical and art projects, in this context, can form a key means of reducing the stigma often associated with mental illness.

Notes

1 R. Butsch, ‘Audiences and Publics, Media and Public Spheres’, in V. Nightingale (ed.), The Handbook of Media Audiences (Malden: Wiley-Blackwell, 2011), pp. 153, 164–165.
2 A. Portelli, ‘The Peculiarities of Oral History’, History Workshop Journal, 12:1 (1981), 96–107.
3 N. Baur, ‘Oral Testimonies in Mental Health History’, Social History of Medicine, 24:2 (2011), 484–487.
4 D. Russell, ‘An Oral History Project in Mental Health Nursing’, Journal of Advanced Nursing, 26:3 (1997), 489–495.
5 S. Jasanoff, ‘The Idiom of Co-Production’. Chapter 1 in S. Jasanoff (ed.), States of Knowledge: The Co-Production of Science and Social Order (London: Routledge, 2004), pp. 1–12.
6 C. Pinel outlined differences in the theory, objectives, methods and impacts of each model: PPI, as the newer approach, is more strongly linked to clinical research and measurable impacts; PES has roots in critical or philosophical thinking, employs more creativity in methods and is less constrained by regulatory bodies than PPI. C. Pinel, ‘The Art of Public Engagement in Science and Health Research’, Individual Presentation, Centre for Public Engagement Annual Conference 2015: Patient and Public Involvement in Research: The Art of Engagement, St George's, University of London, 16 September 2015.
7 See: http://www.invo.org.uk/ (accessed 17 September 2015).
8 D. Rose, ‘“Having a Diagnosis is a Qualification for the Job”’, BMJ, 326:7402 (2003), 1331.
9 Internationally, service-user researchers are less likely to operate collectively. However, the Hearing Voices Network (http://www.hearing-voices.org) draws on pioneering German and Dutch activity, whilst G. A. Hornstein's Agnes's Jacket also considers the wider European terrain of lived experience: G. A. Hornstein, Agnes's Jacket (New York: Rodale Press, 2009).
10 J. Russo, ‘Survivor-Controlled Research: A New Foundation for Thinking about Psychiatry and Mental Health’, Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 13:1 (2012).
11 P. Beresford and K. Boxall, ‘Where Do Service Users’ Knowledges Sit in Relation to Professional and Academic Understandings of Knowledge?’, in P. Staddon (ed.), Mental Health Service Users in Research: Critical Sociological Perspectives (Bristol: Policy Press, 2015), pp. 69–86. See also M. Cresswell and H. Spandler, ‘The Engaged Academic: Academic Intellectuals and the Psychiatric Survivor Movement’, Social Movement Studies, 12:2 (2012), 1–17.
12 C. Henderson and G. Thornicroft, ‘Evaluation of the Time to Change Programme in England 2008–2011’, The British Journal of Psychiatry, 202 (2013), s45–s48.
13 S. Evans-Lacko et al., ‘Association between Public Views of Mental Illness and Self-Stigma among Individuals with Mental Illness in 14 European Countries’, Psychological Medicine, 42 (2012), 1741–1752.
14 R. Miles, ‘Museum Audiences’, Museum Management and Curatorship, 5:1 (March 1986), 73–80. For more recent works, see D. Chittenden, G. Farmelo and B. V. Lewenstein (eds), Creating Connections: Museums and the Public Understanding of Current Research (Oxford: Rowman & Littlefield, 2004).
15 G. Black, ‘Embedding Civil Engagement in Museums’, Museum Management and Curatorship, 25:2 (21 May 2010), 129–146, p. 129.
16 From 2012–2014, for example, the HLF funded 542 community heritage projects to a total value of £4.5 million through the ‘All Our Stories’ grant scheme. For the full details and evaluation, see the HLF website: http://www.hlf.org.uk/all-our-stories-evaluation (accessed 14 September 2015).
17 R. Sandell, J. Dodd, and R. Garland-Thomson (eds), Re-Presenting Disability: Activism and Agency in the Museum (Abingdon, Oxon: Routledge, 2010); S. Iervolino, Who Am I? Hacking into the Science Museum: A Gendered Intelligence Project Co-Produced with the Science Museum within the AHRC ‘All Our Stories’ Project (London, 2014); S. Chaney, There Are as Many Different Truths as There Are People: CoolTan Arts and the Science Museum in Partnership, unpublished report (London: Science Museum, 2014).
18 B. Lynch, Whose Cake Is It Anyway? A Collaborative Investigation into Engagement and Participation in 12 Museums and Galleries in the UK (London: Paul Hamlyn Foundation, 2011), https://www.phf.org.uk/publications/whose-cake-anyway/ (accessed 25 June 2019).
19 Ibid., pp. 11–12.
20 A. Flinn and A. Sexton, ‘Research on Community Heritage: Moving from Collaborative Research to Participatory and Co-Designed Research Practice’, in CIRN Prato Community Informatics Conference 2013 (2013), pp. 1–14.
21 For a particularly pertinent challenge to the idea of archival neutrality, see T. Cook, ‘We Are What We Keep; We Keep What We Are: Archival Appraisal Past, Present and Future’, Journal of the Society of Archivists, 32:20 (2011), 173–189.
22 Chaney, There Are as Many Different Truths as There Are People, p. 12. See also S. Frampton and S. Chaney, Challenging the Normative View of Medical History: Report on ‘Whose Medical History Is It Anyway?’: A Workshop Exploring Diverse Interpretations of the Science Museum Medical Collections (London, 2014).
23 D. MacKinnon and C. Coleborne, ‘Seeing and Not Seeing Psychiatry’, in Coleborne and MacKinnon (eds), Exhibiting Madness in Museums: Remembering Psychiatry through Collections and Display (Abingdon, Oxon: Routledge, 2011), pp. 3–13.
24 J. Besley and M. Finnane, ‘Remembering Goodna: Stories from a Queensland Mental Hospital’, in Coleborne and MacKinnon, Exhibiting Madness in Museums, pp. 116–136; ‘The Willard Suitcase Exhibit Online’, http://www.suitcaseexhibit.org/ (accessed 14 September 2015); S. Clarke, A. Elliott and F. Costain, Bethlem Royal Hospital Archives and Museum: Museum of the Mind Consultation Report (London, 2011); R. Ellis, “‘Without Decontextualisation”: The Stanley Royd Museum and the Progressive History of Mental Health Care’, History of Psychiatry, 26:3 (2015), 332–347.
25 E. O’Donoghue, ‘Scraps from the Larder’, Under the Dome, 53:9 (1926), 55.
26 The main exception to the general lack of interest in twentieth-century Bethlem is the multi-authored ‘History of Bethlem’: however, the twentieth-century section focuses largely on administrative changes, and not users’ experiences of the hospital and site. J. Andrews et al., The History of Bethlem (London: Routledge, 1997).
27 For more on the project, see the final evaluation report. S. Chaney, Evaluation Report: Mansions in the Orchard (London: Bethlem Museum of the Mind, 2015).
28 See: http://museumofthemind.org.uk/blog (accessed 26 September 2015).
29 For example, Roy Porter's assertion that, by the late eighteenth century, Bethlem had become ‘a byword for man's inhumanity to man’. R. Porter, Mind-Forg'd Manacles: A History of Madness in England from the Restoration to the Regency (London: Penguin, 1987), p. 129.
30 R. Ellis, ‘“A Constant Irritation to the Townspeople”? Local, Regional and National Politics and London's County Asylums at Epsom’, Social History of Medicine, 26 (2013), 653–671.
31 S. Chaney and J. Walke, ‘Life and Luxury in Monks Orchard: From Bethlem Hotel to Community Care, 1930–2000’, The Lancet Psychiatry, 2:3 (3 March 2015), 209–211.
32 V. Long, ‘Rethinking Post-War Mental Health Care: Industrial Therapy and the Chronic Mental Patient in Britain’, Social History of Medicine, 26 (2013), 738–758.
33 Wendy Whitaker, Interview with Jennifer Walke, 13 December 2013.
34 Peter Lambert, Interview with Jennifer Walke, 3 October 2013.
35 Beth Elliott, Interview with Jennifer Walke, 28 August 2015.
36 Mary Butler, Interview with Jennifer Walke, 29 September 2013.
37 Irene Heywood Jones, Staff Focus Group, Bethlem Royal Hospital, 18 November 2013.
38 Mary Chambers, Interview with Jennifer Walke, 28 August 2015.
39 Mary Yates, Interview with Jennifer Walke, 3 October 2013.
40 Brian Woollatt, Interview with Jennifer Walke, 13 December 2013.
41 Victoria Northwood, Interview with Sarah Chaney, 29 June 2015.
42 Bethlem Gallery, ‘Artists Survival Manual’ (2012): http://bethlemgallery.com/resources/Bethlem_Gallery-Artists survival_manual.pdf (accessed 26 September 2015).
43 See: http://dragoncafe.co.uk/ (accessed 26 September 2015).
44 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015.
45 N. Carpentier, ‘New Configurations of the Audience? The Challenges of User-Generated Content for Audience Theory and Media Participation’, in V. Nightingale (ed.), The Handbook of Media Audiences (Malden: Blackwell, 2011), pp. 190–212.
46 See B. Adair, B. Filene and L. Koloski (eds), Letting Go?: Sharing Historical Authority in a User-Generated World (Philadelphia: Pew Center for Arts & Heritage, 2011).
47 R. Solway et al., ‘Museum Object Handling Groups in Older Adult Mental Health Inpatient Care’, International Journal of Mental Health Promotion, 17:4 (2015), 2. See also R. Lelchuk Staricoff, ‘Arts in Health: The Value of Evaluation’, The Journal of the Royal Society for the Promotion of Health, 126:3 (1 May 2006), 116–120; A. Lanceley et al., ‘Investigating the Therapeutic Potential of a Heritage-Object Focused Intervention: A Qualitative Study’, Journal of Health Psychology, 17:6 (21 November 2011), 809–820.
48 J. Besley and C. Low, ‘Hurting and Healing: Reflections on Representing Experiences of Mental Illness in Museums’, in Sandell et al. (eds), Re-Presenting Disability, p. 132.
49 Chaney, Evaluation Report, p. 10.
50 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015.
51 Other museum projects have looked at the value of creative and museum settings in breaking down stigma in the medical profession. J. L. Cutler et al., ‘Reducing Medical Students’ Stigmatization of People with Chronic Mental Illness: A Field Intervention at the “Living Museum” State Hospital Art Studio’, Academic Psychiatry, 36:3 (1 May 2012), 191–196.
52 Besley and Low, ‘Hurting and Healing’, p. 136.
53 Sarah and Thomas Tobias (Sarah Wheeler), Interview with Sarah Chaney, 2 August 2015.
54 Chaney, Evaluation Report, p. 10.
55 Chaney and Walke, ‘Life and Luxury in Monks Orchard’, p. 210.
56 Chaney, Evaluation Report, p. 7.
57 Ibid.
58 Chaney and Walke, ‘Life and Luxury in Monks Orchard’, p. 211.
59 As was the case with much of the material in Andrews et al., The History of Bethlem. For a lengthy critique of this approach, see A. Scull, ‘Bethlem Demystified?’, Medical History, 43 (1999), 248–255.
60 Beth Elliott, Interview with Jennifer Walke, 28 August 2015.
61 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015.
62 Victoria Northwood, Interview with Sarah Chaney, 29 June 2015.

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Communicating the history of medicine

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