In 1899, 35-year-old Alexander was admitted to the Bethlem Royal Hospital. Recorded as having no occupation, Alexander told his doctors that what he required was “a little discipline,” and he wanted to be “helped to work” (“Male Patient Casebook for 1899,” Bethlem Museum of the Mind, CB/160-16). Occupation, within and outside the hospital, was an important part of nineteenth- and early twentieth-century asylum life and approaches to mental health. However, as Freebody's monograph explains, the meaning of work within the institution changed over time. By comparing several different hospitals in France and England, Freebody explores how national contexts, as well as medical theories and individuals, impacted diverging views of work and mental health.

In both France and Britain, interest in occupation emerged from moral therapy. This was proposed by its founders as a therapeutic regime, tailored to each patient's individual needs in order to facilitate cure. It is arguable how well this claim translated into practice. However, from the second half of the nineteenth century, as institutions grew in size and became increasingly bureaucratic, work certainly became less tailored. For the late nineteenth-century hospital superintendent, patient work was more about cutting asylum costs and keeping patients busy than about therapeutics. In France, this approach to work continued well into the twentieth century. In England, however, a new focus on occupational therapy emerged in the interwar period. Inspired by the US Mental Hygiene Movement, occupational therapy focused on arts and crafts, emphasizing cure rather than usefulness.

Freebody associates the differences between the two countries under study to a number of factors. This includes the different structures of institutions (in France administrative and medical organization was separated, whereas in Britain both were managed by the medical superintendent). In France, she says, there was a far greater emphasis on neurology and physiological factors in mental illness, as well as greater economic challenges that meant patient work was essential to support stretched asylum budgets. However, in France, unlike England, patients were paid for their work, which provided a useful cushion on leaving the institution. Institutional work also appeared to better prepare these patients for work and life outside the asylum than did arts and crafts.

Freebody's aim is to contribute to comparative histories of psychiatry, and the book's strengths certainly lie in this area, reminding the reader that national (and local, such as between Parisian and regional institutions) contexts are important to understand the way institutions functioned and concepts of mental health and illness. At times, however, the claims appear a little too broad, given the small number of institutions studied. While Freebody is clear that, for example, Bethlem, Maudsley, and the Littlemore are not representative of English institutions, her comparative approach means she is apt to generalize about a psychosocial approach in England that was not necessarily true of other, much larger or less specialized, institutions. Indeed, even at the Maudsley others have found a much more physiological approach than that claimed by Freebody (for example, Edgar Jones and Shahina Rahman, “Framing Mental Illness, 1923–1939: The Maudsley Hospital and its Patients,” Social History of Medicine 21, no. 1 [2008]: 107–125).

Freebody's choice of sources also limits the scope of some of the later chapters. By relying on annual reports, psychiatric journals and reports of asylum inspectors, she can only scratch the surface when investigating the role of support staff and patient experience. Using a broader range of sources could have fleshed out these chapters further, offering some useful case studies to bring the material to life. The National Asylum Workers Union magazine, hospital magazines and patient casebooks and letters would all include relevant material to shed more light on patient and staff attitudes to work and occupation. This would help to expand on important points made, such as greater insight into the specific skills (and time) needed by nursing staff to deliver occupational therapy, rather than a more general history of mental health nursing that is covered in other literature.

The most interesting and novel areas of the book are the chapters dealing with occupation after the First World War. The beginnings of the US approach, and its adoption by David Henderson, offers insight into its popularity in England, given that Henderson and Gillespie's textbook was a standard in British psychiatry for so many decades. Yet, as Chapter 5 indicates, this is simply one factor: the economic context of asylum work explains a range of other elements in the development (or not) of occupational therapy. Indeed, this careful analysis indicates that a simplistic emphasis on the effects of the First World War on psychiatric theories would be mistaken.

Freebody's overall thesis is that “the nature of occupation prescribed to patients tells us so much more than simply how patients were occupied” (46). Although there are areas that could be better fleshed out (and others that might be reduced to focus in on the theme), her book nonetheless outlines the importance of understanding a wide range of factors on occupation and mental health. This ranges from national political and economic contexts to medical theories and individual superintendents, as well as the structure and functioning of institutions in shaping attitudes to work and occupation. From this perspective, Work and Occupation in French and English Mental Hospitals offers a valuable addition to the history of psychiatry.