In the second part of an interview with Niall McCrae on his recently published book, The Story of Nursing in British Mental Hospitals: Echoes From the Corridors, we discuss whether anything can be learnt from past attitudes, whether past myths take modern forms, and whether we are any further forward in treating mental ill-health.
KG: Your historical account of society’s response to mental ill-health – or to perceived mental ill-health – from the Middle Ages to the present is fascinating in itself. Has there yet been a golden age in our understanding or treatment of the mentally ill?
NM: I don’t think there was ever a golden age. People tend to see a linear trajectory of mental health care gradually improving over time, but I see a cyclical process. The asylums are often cast as oppressive, if not fantasised as a Black Hole of Calcutta, but historical accounts by doctors chart a path from ignorance to medical enlightenment. The assumption is that treating mental disorder as an illness is inherently positive. But as described earlier, patients were exposed to some drastic treatments. The drugs used today are not curative: arguably they do more for drug company profits than patients’ recovery. Use of ‘sectioning’ under the Mental Health Act and community treatment orders is increasing. Meanwhile, possibly thousands of prisoners would in previous decades have been in a mental hospital.
What would be the optimal mental health system? A balance is needed between liberty and safety. Nurses have legally prescribed powers to prevent harm to an acutely disturbed patient or to others. But generally mental health care should be a partnership between patient and carers. Although some are more susceptible than others, any of us could become mentally unwell. Mood problems, anxiety and stress are highly common, and in later life we could succumb to dementia. It’s in everybody’s interests to provide a dignified mental health service.
KG: Were there any myths about mental health care that you set out to bust, or that you uncovered in the process of your research?
NM: That’s a favourite question of mine and I’d like to focus on three commonly aired beliefs about the past. The first is that the asylums were built simply to put the mad ‘out of sight, out of mind’. To some extent this is true, but the original intent was to provide a humane, state-regulated refuge for the mentally disordered – relieving them from their distress and deprivation. The asylums grew too large, and that’s when curative ideals were discarded, and the role of the institution veered towards eugenics (preventing procreation by persons deemed to bear hereditary faults). But officially the asylums were medical rather than custodial institutions, as reflected in their renaming as mental hospitals in the early 20th century.
Second is the belief that female patients were sent to the asylum simply due to bearing an illegitimate child. Quite possibly this was a factor in some admissions, but it certainly would not have been sufficient by itself. More likely is that mentally unstable women were vulnerable to sexual liaisons and unwanted consequences. But fallen women who turned to prostitution, then got pregnant and couldn’t pay their way, were more likely to enter the workhouse. This idea can be likened to the current accusation that psychiatric wards are full of black men who have been falsely diagnosed through racism. Medical superintendents in the 19th century may have had misogynist attitudes, but with overcrowded wards they were unlikely to admit bogus patients as a patriarchal conspiracy, and the same can be said of psychiatrists and race today.
Third, that the mental hospitals were closed to cut costs. In fact, looking after a thousand patients in an institutional setting is a great economy of scale, while visiting individual patients at home is comparatively inefficient. The policy of care in the community dates back to at least 1961, when health minister Enoch Powell declared the former asylums as obsolete (the ‘water tower’ speech). By the 1970s the mental hospitals were mired in scandal, and libertarian campaigners demanded an end to a discredited and degrading system. But it took Thatcherite resolve to bring real change. Like the coal mines, if closure was so bad, why didn’t 13 years of Labour governments reverse it?
KG: You write that a linear trajectory from the unenlightened past to the progressive present is a common but naïve idea. Is this how you view the replacement of mental hospitals by the euphemistically termed ‘community care’?
NM: The real reason for care in the community is not economic but ideological. And it’s an ideology that I mostly favour, although I have come to rethink my previously uncritical stance. Some patients are dangerous some of the time, but this obvious truth is denied by mental health advocates and professional leaders, as it is argued that people with mental health problems are no less likely to be violent than anyone else. A person with paranoid schizophrenia beset by command hallucinations is not as harmless as one of the millions of people with mild depressive or anxious symptoms. Risk assessments are done for good reason. Tackling stigma has become so prioritised that the mental health establishment is failing to protect patients and the public.
I work with Julian Hendy, who founded a charity for families of victims of homicide by mentally disturbed assailants. Julian’s own father was randomly killed by a patient in 2007. As a television documentary producer, Julian has applied his investigative skill in cutting through officialdom to reveal that the number of such killings is actually increasing. An excessively liberal approach would therefore be counterproductive, leading to a public backlash.
KG: Having reviewed the entire history of mental health nursing, what direction would you most like it go in now?
NM: Nurses and society generally should be more aware of history and what it tells us. I suggest we are approaching ‘peak community care’. The number of beds has been slashed to a level where patients must be extremely ill to get admitted. Treatment on acute psychiatric wards is primarily tranquillising drugs, and patients are discharged early to free a bed for the next patient. Nurses have little time to talk to patients. I say we need to return to the original concept of asylum. Not back to 2,000-bed colonies, but small, homely settings where people can stay for an active programme including occupation and physical exercise as well as individual and group therapy. Nurses, whose therapeutic potential is unfulfilled in current hospital settings, should provide more psychosocial interventions. Some reversion to institutional care is inevitable, and policymakers should plan for this now, instead of waiting for an impending crisis. Quoting from my last line of the book: ‘The wheel does not need reinventing, but it will surely turn.’
The Story of Nursing in British Mental Hospitals: Echoes From the Corridors, can be purchased here.