90 years ago: the Mental Treatment Act 1930 by Dr Claire Hilton

by Dr Claire Hilton, Historian in Residence at the Royal College of Psychiatrists.

Today, the jarring language of “lunatics” and “asylums” draws our attention to a bygone age. But it was just 90 years ago when the Mental Treatment Act (MTA) 1930 amended the Lunacy Act 1890, and lunatics officially became patients, and asylums, mental hospitals. The MTA was a landmark in mental health legislation, a steppingstone towards the Mental Health Act 1959, which finally repealed both the Lunacy Act and the MTA.

This blog post is about some of the changes that the MTA introduced (summarised in the table below), which affected people with mental disorders who required treatment in public institutions (different rules applied to private patients).

The MTA made obsolete some heavily stigmatising language. Until 1930, the disparaging Poor Law term “pauper”, typically applied to impoverished people and associated with the workhouse, was appended to “lunatic”, although most lunatics were not paupers in that sense. Many had caring and supportive families with reasonable financial stability.

The pauper designation was because the Poor Law Boards of Guardians were responsible for paying asylum charges for people admitted from their locality, even when the lunatic made means-tested contributions towards their own care. With the changes, an “insane pauper lunatic treated in an asylum” became “a rate-aided patient of unsound mind treated in a hospital”. The new language of “patient” and “hospital” also brought the terminology of mental illness closer to that for physical illness, a step towards “parity of esteem”, as it is known today.

Admission and discharge

Before 1930, patients had to wait to be admitted until their condition worsened sufficiently for them to be “certified” under the Lunacy Act. New categories of “voluntary” and “temporary” admission avoided the stigmatising process of certification in many cases. It also brought mental illness treatment more into line with that for physical illness, allowing admission to be negotiated between patient and doctor, and fulfilling the mantra of early treatment to prevent deterioration. The change also expressed a shift in how mental disorders were understood: it moved away from earlier assumptions that a mental disorder impaired all aspects of a person’s judgement, including about whether or not they needed help.

Regarding discharge from a mental hospital: if a voluntary patient wanted to leave, they had to give 72 hours’ notice in writing. This seems bizarre today, but in 1930 it contributed to the mental hospital fulfilling its duty of care: since most households had neither telephone nor their own transport, 72-hours gave time to contact the patient’s family by letter and to plan support for when they left the hospital.

The MTA in wider social and healthcare contexts

Other aspects of the MTA reflected changes in social expectations and in healthcare provision, beyond the specific field of mental disorders.

In the social context, women were increasingly active outside the domestic environment and their voices were being heard more. In 1928 women were granted equal voting rights with men (Representation of the People (Equal Franchise) Act) so it was fitting that the MTA insisted that women be appointed to each mental hospital’s voluntary management committee. 

Both the Lunacy Act and the MTA required medical assessments prior to admission and stated which doctors could undertake them. Reflecting on access to healthcare, the 1890 Act referred to the patient’s “usual medical attendant, if any”: most people did not have a general practitioner. In 1930, the pre-NHS National Insurance scheme meant that many people were registered with a “panel” doctor, and the words “if any” disappeared: access to primary care medicine was more widespread.

The MTA also stipulated that if the doctor assessing the patient was not their “usual medical attendant”, they had to be “approved” for the role. Precisely what approval meant, or if it required specific training, was not stated, but it was a step towards improving standards of assessments. A system of “approval” continues under today’s legislation.

Money

Under the Lunacy Act, local authorities only funded inpatient asylum treatment so outpatient clinics were rare. Occasionally they were funded by charities, as was “after-care”, to help with rehabilitation following discharge. For the first time, the MTA permitted local authorities to fund both these services. However, since they were optional, developing them was erratic: innovations perceived to cost little and to save money, such as outpatient clinics, developed more than those such as after-care, which was regarded as costly with fewer immediately tangible benefits.

Reflection

For us today, the MTA should stimulate thought on how we use language about our patients, their mental wellbeing and their treatment. It is noticeable that officially changing the language does not stop it being used colloquially, often pejoratively.

The Act should also make us consider the pros and cons of permissive and mandatory government directives concerning providing mental health services, and our responsibility, as individuals and as a College, when faced with proposals likely to benefit our patients, but which, if designated as optional, are likely to be neglected.