By the beginning of the 20th century it had become all too evident that the 1890 Lunacy Act rendered recovery for many patients unlikely owing to impediments concerning early diagnosis and treatment. The lack of provision for early treatment was discussed widely in Parliament during the 1920s: ‘contrary to the accepted canons of preventive medicine, the mental patient is not admissible to most of the institutions provided for his treatment until his disease has progressed so far that he has become a certifiable lunatic. Then, and then only, is he eligible for treatment’ (Historic Hansard, 17 February 1930). In 1922 the Royal Commission on Lunacy and Mental Disorders was set up to review the existing legislation. In its 1926 report it concluded that ‘the keynote of the past has been detention. The keynote of the future should be prevention and treatment’. Recognising that treatment is at its most effective when it is consensual, the Commission suggested that ‘certification should be the last resort in treatment, not the pre-requisite of treatment’. Advances in medical sciences and more enlightened views began to have a positive impact on how mental disturbances were regarded, i.e. diseases similar to bodily diseases: ‘there is no clear line of demarcation between mental and physical illness’ (Royal Commission, 1926). Consequently, the first decades of the 20th century saw major attempts to de-stigmatise mental illness and align its treatment with that for physical illnesses.

The 1930 Mental Treatment Act was founded on these principles and can be viewed as a first step towards the empowerment of patients, nowadays a key concept in medical treatment. One of its major reforms concerned patient status. For the first time in British mental health history the two-class system of private and pauper patients, i.e. the dependency of treatment options on people’s wealth, was replaced by a three-class system based on a patient’s ability to consent to treatment. Although patients were not yet able to act as full consumers, they were no longer mere passive recipients of treatments over whose nature other people had decided. Regardless of their financial status patients could now enter mental hospitals on their own volition, providing they were capable of signing the admission form. As many other patients in 1933, patient 254 was admitted on certificate, but later regraded to ‘voluntary class’, which gave her greater options including the refusal of treatment and self-discharge. Regrading was a process many DCMH patients underwent in the early 1930s, as voluntary admissions were slow to start. One factor impeding voluntary admissions was the opposition of some doctors who felt out of control and did not appreciate the need of negotiating with their patients about treatment and prolonging their stay in the hospital. A prerequisite of the new admission system was that the patient had to recognise and admit to their illness by actively seeking treatment. Surviving documents of the DCMH illustrate however that relatives and other third parties could still exercise considerable control over this step. Methods employed ranged from gentle persuasion by embellishing the conditions in the hospital or downplaying the duration of hospitalisation to the involvement of authorities to the threat of certification should the patient fail to comply.

Patients whose illness prevented them temporarily from consenting to admission could be hospitalised against their will for six months after which an extension for another six months could be issued. After a maximum of one year the patient had to be either certified, agree to remain in hospital voluntarily or released. In Devon, this form of admission was not frequently used, as the regular reassessment of patient put additional strain on overworked medical staff.

Certification was supposed to be reserved for people in need of treatment who would or could not consent. One large group amongst them were the elderly demented patients who increasingly ended up in the DCMH for want of other care facilities. Another group consisted of people entering the DCMH through the Public Assistance Institutions (PAIs). Destitute and often homeless without relatives available or willing to care for them they also were not necessarily in need of psychiatric care. The tendency of the Unions to rid themselves of such people dates back to the 19th century, as Medical Superintendent Eager reminded the Board of Control in 1936: ‘since 1845 my predecessors have repeatedly called the attention of the members of this committee to the tendency of PAIs to transfer patients to this hospital for their last offices or when they give the slightest trouble and I can only say before relinquishing my present office that his has by no means yet been abolished and I can only wholeheartedly support my predecessors in office in condemning it’ (Medical Superintendent’s Monthly Reports, May 1936). Such admissions further aggravated the overcrowding of the DCMH to the effect that voluntary admissions had to be suspended on occasions. Existing research shows that there remained social class differences in the patients who were certified with labourers more likely to be certified, whereas clerks and similarly salaried employees entered as voluntary patients (Pearce, 2006). Whether a patient was certified also depended on their status in society (Henderson & Gillespie, 1936). The new legislation therefore provided the possibility of admission without a magistrate which lessened the stigma attached to psychiatric hospitalisation. It further emphasised the alignment of mental and physical illness by adopting a less labelling terminology under which, amongst other changes, ‘lunatic asylums’ were renamed ‘mental hospitals’, hence the change from DCLA to DCMH. While this, in theory, empowered patients to decide about their need of treatment, it did little to reduce the pressure families could exercise on them to enter the mental hospital.