Kept From A Hard And Stormy World
Foreword
It is possible for anyone to have a nervous breakdown. Those who have never experienced any nervous disorder have either never been subjected to any stressful conditions in life, or they have a greater resistance to stress than most. This resistance can vary greatly according to the individual. What is a nervous breakdown?
I believe that the terms ‘nervous breakdown’ and “neurasthenia’ are the most maligned in the whole practice of medicine. They can mean anything from wild anxiety symptoms, to a complete psychotic disintegration, depending under which circumstances these terms are applied. A true nervous breakdown usually occurs in normal, sensible people as a reaction to stress they cannot bear. It manifests itself initially as a fatigue (neurasthesia) and headaches. The patient cannot concentrate. Later he develops neurotic symptoms usually taking the form of anxiety neurosis. The main symptom is muscular tension which affects the patients thinking capacity, especially in the making of decisions.
Allsorts of uncomfortable physical symptoms appear as a result of over stimulation of the sympathetic nervous system: palpitations, indigestion, over rapid speech, tremors, difficulty in breathing, diarrhoea and frequency of micturition. If the neurosis remains unattended, and if the causative influences do not improve, the symptoms grow worse and the patient has to be hospitalized. Only then is the term ‘nervous breakdown’ correct. The prognosis for such patients is good – many recover completely.
However, there are many people with some sort of mental disorder who are not treated in hospital. There are people who have phobias like not daring to cross bridges; others have petty obsessions that are a nuisance to them, but which do not radically effect their daily lives. Many vagrants who roam the country are in fact suffering from schizophrenia; many people who talk too much and are who are abnormally optimistic are mildly hypomaniac. A good example of this kind of person is Mr Wilkins McCawber from David Copperfield.
As mental illness is always among us in one form or another, I became very interested in psychology and psychiatry. This interest has developed since my grammer school days. It was then that I realized the existence of an inner force driving people to behave in a certain way. The mass media of the cinema and newspapers were responsible for my increasing awareness of people and their problems. I saw films of stressful situations that drove people to do and say things they would not normally do. The newspapers spoke of people convicted of crimes. Often a psychiatrist was called to give evidence of the accused’s background at home or other contributing factors that made his action more understandable. I found that the accused’s environment was usually unstable.
Much is done now to enlighten the general public about mental illness and psychiatric hospitals, but too often I have found that mental illness is still only whispered about in dark corners. There is still a great stigma attached if a member of your own family has to go into a psychiatric hospital. It is a topic of street gossip and the person concerned is treated with a condescending kind of sympathy that is very humiliating. Other people are often embarrassed when they come into contact with someone suffering from a mental illness. They do not know how to react. The hospitals themselves are also the object of gross misconception. Many people still imagine them as gaunt, custodial places with keys rattling in locks, where the patients are put in straight-jackets and padded cells. Another section of the public think that the patients recline on couches all day while the psychoanalyst, a demi-god who knows all the corners of the mind, probes and unearths the mysteries of the subconscious.
My education in this aspect of human nature was extended through my days as an art student. Many of the great masters suffered from a mental illness, e.g. Toulouse-Lautrec, Van Gogh, Gauguin, Blake. Through the nature of my art studies I wanted to know why certain artists should paint in a certain manner. My quest for the philosopher’s stone of human nature led me to explore many books, both on art and psychology and psychiatry. During this quest I formed my own opinions as to why people behave d in certain ways. The mass media strengthened some of my opinions and refuted others, but these media never ceased to say something, directly or indirectly, about mental illness. I could not have forgotten about it even if I had wanted to. In bygone days people used to visit the local asylum and amuse themselves by watching the inmates antics. We do not do this anymore. Instead, the mass media take over; they provide us with our peep show that way. I have seen some very commendable documentaries and newspaper articles, but I have also seen extensive damage done by the mass media in general. Some of them portray only the public’s misconceptions in order to make a box-office attraction by giving them what they want.
Mental illness is not something strange that is detached from ordinary life to be locked away in shame. It is merely an exaggeration of something that exists in us all.
Introduction
A major drawback in the recovery of psychiatric patients is institutional neurosis. It acts in the same way as a secondary infection acts on a patient in general hospital. There are many causative influences of this dangerous state of mind which I have discussed in detail. It is a very common affliction affecting all long-stay and even some short-stay patients, yet there is no book on psychiatry that even touches on this state of mind. Institutionalisation is taken for granted so much that people even forget it needs treatment in the same way as the actual mental illness. It is always with us now as septicemia was an accepted evil in the days before Dr Lister’s sterilization of surgical instruments.
What does institutionalization mean ? Even the dictionaries could not tell me exactly what I wanted to know. James Drayers Dictionary of Psychology says:-
INSTITUTION – An organization representing an established phase or aspect of social, political, or religious life, with a body of laws and principles, and subordinate rules and regulations; a custom or group of customs; or a practice; but in all cases having a degree of permanence not possessed by a fashion or convention. Popularly the name is often applied to the building housing the organization.
I was very surprised that a dictionary of psychology bore no reference to the actual institutional state of a person. Next I looked in Collins National Dictionary and found:-
INSTITUTION – An established law, custom, or public occasion; an institute; Institution (in the sociological sense) ; an organized pattern of group behaviour established and generally accepted as a fundamental part of a culture such as slavery. Institutional (adj) ; Pertaining to or of the nature of institutions.
This was not entirely satisfactory either so I looked up:- Asylum: A sanctuary; refuge for criminals, debtors and others liable to be pursued; any place of refuge; an institution for the …..insane; the protection afforded by such places.
This is the best definition I could find, but during my work at High Royds Hospital I found that many of the contributing factors to institutional neurosis could have been eliminated with a little more teamwork among the staff. Much more could have been done to help the patients overcome the institutional and more could have been done to keep alive the interest and goodwill of the young student nurses.
In this study I have examined various aspects of institutional neurosis, and have tried to provide some answers in the hope that one day the right person might read it and act upon some suggestions. It would, I feel be a breakthrough in the treatment of some psychiatric patients. My ideas on rehabilitation do not require expensive new buildings or extra staff who are unobtainable. Nor would my programme interfere with the general running of the hospital, but in order to launch projects, thought and effort are always needed.
My own definition of institutional neurosis has arisen out of my observations on, and experiences with, my own patients. What does institutionalization mean to patients? It seems the stunting of psychological and spiritual growth, culminating in the eventual loss of identity and initiative.
Who were my patients? I came into contact with a comprehensive cross section of the hospital community, from the Day Hospital to old men in terminal stages of various kinds of dementia; from the women’s industrial therapy unit to Ward 24, a female chronic geriatric ward. On this ward I found women who I felt need not have stayed there; I found evidence of the really adverse effects that living in this environment can cause. Here was the seat of most of my indignation. It was here that I found the worst effects of institutionalization on intelligent people., and here it was that there was absolutely no understanding or communication between patients and staff. Almost everyone who came into contact with these patients was in some way to blame. Each person I mention has a case to answer, though each would protest that under the circumstances he was doing his best.
This study started with the writing of two sets of progress notes. I had been thinking of writing reports long before I was ever asked. The visiting GP merely provided the opportunity. It was not expected that anyone accept the qualified Occupational Therapists and ward sisters should write any reports. Why then did I wish to impose this upon myself?
After working here for a while I found this hospital’s attitude too complacent. The secretary kept coming round with the management committee, showing them the fresh paint, new lino, rugs, chairs, and better lighting, but nobody ever asked the patients how they felt. If they did ask, they either never waited for the answer, or did not take the answer seriously and act upon it. Obviously, one cannot take too much notice of a mentally ill person, but people who have studied this type of work should be able to distinguish between a reasonable request or otherwise. I wrote the progress notes in the hope that something could be done to make the patients feel that they count and that somebody really cares about them.
The idea of their rehabilitation was very dear to me too. It’s possibility did not seem too remote for some of them. I could see some opportunities of arranging a rehabilitation programme, which I discuss in the second part of this study. I thought that my superiors would be pleased with any suggestions I could make about the patients’ welfare, but found that not only did they not act upon what I mentioned, but they did not seem to want to discuss it with me. Perhaps they did not like the idea of a junior member of staff being so interested in the darker side of human nature. They must have also felt that I was trying to tell them how to do their job. Afterall, if somebody sets out to pinpoint matters that should be attended to, it could read like an indictment of how the hospital was run. In the hands of the wrong person this could easily be so, and the hospital must safeguard itself against such people. But when I wrote the notes, I had been there long enough for people to realize my intentions were good. I felt from the reactions of some of them that there had been a misunderstanding. As well as not being interested enough not discuss it with me, these people never tried to find out what kind of person I was. Like the patients on Ward 24, all staff were cast in the same mould.
This study is intended to decategorise all people – patients and staff.
MOIRA C’S CASE HISTORY
Moira was born by caesarean section. The mother had had a very difficult antenatal period, a prolonged pregnancy late in life. Moira was an only child, whose father died when she was young. They lived in Spalding Lincolnshire and her father had been in the gardening business. Moira was a fee paying pupil in a grammer school, and later went to college to train as a teacher, also paying fees. She had many out of college activities, including membership of Lincoln Cathedral Choir. In these early days there was no sign of mental illness.
On qualifying she took a post in a primary school in Bramley, brining her ageing mother. The mother never felt settled in Yorkshire and was always grumbling at Moira for dragging her there. Later Moira married a Horsforth man. Her mother refused to move from Bramley to Horsforth, so Moira had to look after two homes as well as teaching full-time. Later she gave birth to a son, but her husband made her return to teaching as soon as she was able. Her mother’s health began to deteriorate at this time. Moira had to watch her constantly and spend nights at her mother’s house because she refused to go into hospital. Moira herself began to show signs of anxiety neurosis and her schoolwork deteriorated. She carried on teaching in spite of contrary advice from her doctor until her mother died, then she had a complete nervous breakdown aged about 45 and was unfit to work. She was treated at home.
She developed agoraphobia (fear of open spaces) and also feared that people would burst into her house and harm her so she kept going to the back door and looking out to see if anyone was coming. Her husband had her placed in Moorpark Hospital, which was then only for fee paying patients, but contrary to expectations, her health did not improve sufficiently for discharge. Seeing this, her husband thought there was no point in continuing to pay for her. His attitude towards her changed he had her moved to High Royds and never visited her anymore. Moira was always classified as ‘informal’ but her husband tried to certify her as insane, so that he could use this classification as grounds for divorce. The motion was unsuccessful. He moved, selling their house and not letting her know his whereabouts. Her son had married, his work taking him to Glasgow. His letters to his mother remained unanswered, because his concern in her welfare was misinterpreted; she thought he just had a morbid curiosity. She was hypersensitive of being a ‘mental patient’, especially at High Royds, which was then merely called the asylum.
Moira did not settle well at the hospital. She became negligent of her personal dress and hygiene, so that the other patients did not wish to be friends with her. Her teeth grew into bad condition. She herself became a nursing problem because everything had to be done for her, from hand feeding to toileting. The diagnosis is chronic reactive depression. Treatment consisted of electro-convulsive therapy (ECT) and Largactil, a major tranquilliser, later progressing to Nardil, a major anti-depressant.
In Moira’s case, a favourable reaction to ECT was too temporary to be satisfactory so it was discontinued. The above mentioned drugs have been used ever since. She became less withdrawn, reverted to clean habits and was then able to take her place in the more active section of the hospital community. She began to attend the female occupation hut where industrial therapy was carried out. One winter whilst crossing the main path fro the hospital to this place, Moira slipped and fell with her legs under her breaking both at the neck of the femur. It was thought she would never walk again, but on complete recovery and with the right physiotherapy she was able to walk with two sticks.
FIRST SET OF PROGRESS NOTES WRITTEN 20TH JANUARY 1966
This patient was the last of the group to make any progress, but when at last she did, it was the most noticeable progress of all. For a long period she would only knit dishcloths, then complain she was fed up, but refused to do anything else. She was very depressed, one day I told her there was no knitting yarn left, brining in a simple cutting out job to do for Christmas decorations. Her attitude seemed superficially stupid, for she said she could not do it, but underneath lay a deep fear of doing anything wrong. I changed her handicrafts in the first instance at long intervals, then gradually speeding up the process until she would do anything at all. Here is a woman of great potential intelligence and ability. She is very much aware of her surroundings. It was not possible to mark her book with page numbers because she is intelligent enough to notice this and ask questions. The first page of patterns, which is where her own drawings and ideas come, is marked with a cross. The techniques of using crayons were instructed to her and she understood them perfectly first time. It was a big jump in her progress when she stopped asking me to draw her things. At first I had to be with her a considerable time until she gained more confidence, otherwise the work would have given rise to much anxiety. The patterns become more ingenious as the book goes on. Her ability equals that of Day Hospital patients. Moira does not like the idea of using a new medium, using the one she knows as a sort of protection from the unknown.
She has expressed dislike for being on Ward 24, but she has become so used to being on there, that she does not wish to move, although she is not happy. There is not enough to stimulate her intellectually. Would it be a good idea to let her go to the day hospital for one half day a week? She also hates the idea of going in a wheelchair, but I wonder if, in the long run, she might not benefit from her new surroundings.
Present State: – She peers short sightedly at her work and says she has difficulty seeing. She does not make such a fuss at bathtime and helps herself more. She is less self pitying about her leg; is much happier, less anxious and worried than she used to be though some anxiety is still there. She is very eager now to do her artwork and always asks me what there is to do. One disturbing fact, however, is that she makes no effort to communicate with her son and his family, thus cutting herself off.
8th May – 13th June 1966 Ward 24 Progress Notes
Environment lately has been very influential in governing my patients progress. Certain events in the ward and the patients responsible for those events, therefore, require a report. One patient, Lucy S dominates the whole of the gallery. The other patients are frightened of her because they do not have the means to defend themselves verbally. They are therefore on the defensive a little more than they should be when talking to her. She shouts at them and makes them feel stupid. Sometimes she would have struck the frailer patients if I had not stopped her. She refuses to do therapy, saying she has worked very hard in her life, and sits there generally causing trouble, not only among the patients, but tries to take members of staff into her confidence by gossiping about other members of staff. It is the only way she knows of buying our friendship. Because of this I believe Lucy is a very lonely and unhappy person, so I have tried to make friends with her and talk to her.
She is highly suspicious of all doctors and nurses regarding her health. Instead of telling Dr Morgan or Sister about her pains and symptoms, she tells me after making me promise not to tell anyone else. She says she has a bad pain in her abdomen when she wants to go to the toilet and must wait until it goes. Sometimes it does not go quickly enough and she cannot wait. She has a painful swollen knee. She does no work and pays another patient to dust for her.
Hilda N has bad delusions (of persecution?) and tries to punish herself for some kind of wickedness by not eating.. Sometimes she has to be hand fed. Believes someone will come to take her away to Armley Jail. Has ideas of reference from newspapers and TV, so I let her read only sections of the newspapers, taking care not to let her see anything of the nature of murders, rape, or any other disturbing subject that comes up in the news. Concentration is poor. When she comes to the end of a row of knitting she stops, looking up to see if ‘they’ are coming to fetch her and she is very frightened. I reassure her that her family is well and she is relieved. She asks after her son. She sometimes hallucinates saying she sees guns pointing at her in the toilet. She has not lost any sense of orientation. Because of all this, Sister has forbidden her to do any work on the ward. This has set off repercussions among some of the other patients that must work and I believe this has started all the trouble. There has been silliness in the kitchen, marked in a couple of the patients.
Hilda’s Present State: Tells me she dreads the electricity and can’t stand it. I believe she means ECT treatment.
The business of pensions and weekly pocket money is a very sore point with all the patients who are given no money at all. Some of them feel that absolutely everything is being taken away from them. These patients have no small possessions as far as I know, with which to identify themselves.
I have been feeling that all the patients, because they have been so unwell all at once, have been becoming too insular in their attitudes, and there has been a need to alter the therapy I used before. A group project has been introduced, that of making a desert island with all the ‘props’ – palm trees out of newspaper, old catalogues and bobbins, grass out of tissue paper, and houses out of match boxes. So far the palm trees and cardboard men have been made. Each patient had to consider the others because each did only one part of the object.
May P, has been upset because she cannot hear anything and wishes for certain possessions she says are at home; lower set of dentures, watch, and most important, hearing aid. She says if only she could hear she would find things more bearable. Feels hopelessly cut off from everyone else. This patient is of a cheerful courageous disposition, though often she feels much pain.
Doreen C, until Easter this patient has been progressing very well in occupational therapy. She has been very happy, telling me she loved painting. When she is well, she mixes her own colours to produce excellent permutations. Her drawing has been improving all the time and conversation sensible and coherent. When I started with her in September she said she was “fed up with painting” before she even began. She has been making steady progress all the time, with only one lapse when she became incoherent, upset and dirty. This was after she had been home.
At Easter her relatives came to take her home. I feel she is over excited by these trips, for she always suffers a reaction when back at the hospital. This time it has been a very bad reaction from which she has not yet recovered.
Amendment Tuesday 24th May – This patient has now recovered and works cheerfully and well. The relapse was a long one. Occasionally she kept looking out of the window and calling after her sister.
She is capable now of doing her own drawing and painting with little supervision, though she tends to fall asleep at any time. Her movements are still very unsteady, but she makes a conscious effort to control her hand when doing art.
Present State – happy and co-operative. She has been home once again since Easter but this time there has been no reaction.
Estelle R. No progress since the last report. I feel the dementia is increasing, for Estelle either sits motionlessly and stares with a fixed expression, or she is very agitated and depressed. Is totally unable to concentrate when in the latter mood and disturbs other patients by shouting and screaming. Co-ordination between brain hand and eye is non existent. She cannot make the pencil do what she wishes no matter how easy the job is and this upsets her. I have been utilizing her last relapse by breaking her away from the patterns which I felt were becoming obsessional, and she has been very good in the group craftwork. Progress was good and I felt her attitude was improving slightly until I found her as above mentioned after my holidays. Present State – looks fixedly in the direction of the corridor. Tries to run away sometimes. Is so tense she can hardly speak sensibly. There is a deep rooted fear of doing something wrong.
13th June 1966: Does not speak at all, completely unfit to work.
Anna W: Still completely disorientated and unsettled. Keeps putting all the art materials away or taking her clothes off. At first she drew some very wild patterns and motifs. Images and their respective colours meant nothing and she painted all in the same colour. I have found that patients who do this have lost all touch with reality. An attempt at writing about her experiences as a nurse resulted in a rapid, undisciplined association of ideas. I changed her paints for coloured ball pens so that there would be a greater stimulus to use different colours and keep her mind more on one job. The result is some very interesting drawing. Present State: Rapidly changing moods of happiness and spasms of crying.
Sarah L: works consistently well and enjoys the work. Is very imaginative. However, sometimes she flairs up in anger very easily and picks quarrels with other patients. Says she would like to do embroidery if it was available.
Flora B: At first refused to do anything. Now will draw coloured lines but is unable to follow any instructions. Keeps referring to her father when indignant over something, constantly quoting him. Is very restless. It is a good sign however that she is now willing to put pencil to paper.
Henrietta B: Has had to stop doing therapy because of her eyes. She is more aware of her surroundings but this awareness has taken a wrong turn. Has more time on her hands to think and her thoughts are turning again in a paranoid direction.
The predominant emotion is aggression against all the agitating pressures that she feels are against her and I have been unable to make her express it on paper as she is too afraid to make a mark. The pencil flies in the air above the paper making most weird, interesting patterns, but even after all this time she cannot make marks on paper. It is maybe too conscious an effort for her rapidly flying thoughts. Once she could follow lines in colour that I drew, but she cannot do it anymore.
She misses her relatives very much. On 24th May she told me that she had two brothers, but one was murdered. She admitted her mother is dead. On 23rd May she is working better but still not well. She is quick to take the cue from any symbolism in art, eg, heart shapes that I drew for her today put her in a better frame of mind, and she drew a couple. However, when she draws something even as simple as this it takes virtually all day, the pencil tracing it’s way slowly and painfully. Often this patient’s mood undergoes a rapid change. She has once identified herself with symbolism in a flower and bird picture, without any prompting from me. Paul the bird, (her dead brother) is picking Estelle the flower with his long, sharp beak. Paul does not love her anymore. “I shall never live again” she ended.
Moira C: Since Easter this patient has suffered a relapse, during which she has had to be told every little thing about what to do in ordinary daily routines. Asked stupid questions about everything and has been in the kitchen without her sticks. Her stupid questions annoyed the other patients and there were often arguments. Moira told me that she was very frightened of doing anything wrong, so she kept asking questions. There is a very deep feeling of anxiety underlying all that she does, even her artwork. She feels her nose must be kept to the grindstone at all costs, but I have done nothing to make her feel that way. She also feels nobody likes her. Her son came to see her at Easter and she looked very happy, talking normally. Just before Easter I suggested that she should send him at least a card, but she would not. She told me that last time he came (with one of his daughters) he only came for a very short time and could not wait to go out again as quickly as possible. It is her impression he does not want her. Whenever I casually mentioned her son after Easter, she nearly cried.
She feels the hopelessness of everything very intensely, being very conscious of the fact that she has nowhere to go and is not sure of her marital state or where her husband is. Often she asked me whether she was insane and whether there was any hoipe. She often tells me that “nothing nice ever happens here”. It is just the same routine for her every single day. She badly needs some interesting stimulus but has not the emotional capacity to make use of it.
Week beginning 6th June 1966: This patient is now in the throes of another very bad relapse after a break of one week (Whitsuntide) when no therapy work was done. I feel she has been so over anxious (rather than depressed) that she has completely seized up. Her work now consists of incoherent scribbling as opposed to the very intellectual patterns she has been doing for so many months. She cannot even fill in shapes with colour.
NOTHING NICE EVER HAPPENS HERE
“ I haven’t time to discuss it now, just do it”. “These are chronic mental patients – they go queer like this, that’s why they are here”.
These two lines were constantly thrown at me by the two sister on ward 24. It was unpleasant to work under both of them for they extended their annoying petty neuroses throughout the ward, affecting staff and patients alike. A typical day would go like this:-
When I came on the ward at 9am, I greeted Sister Rush, who would often reply, “take your women out of here from under my feet, there are only two of us on today. The night staff needn’t have bothered coming for all the work they have done. And I might just as well be on by myself this morning”. She was aged about seventy and had already retired twice.
It was true that Sr Rush did her fair share of the ward work, but her standard of hygiene was appalling. She would go round the large sick room and change the nightdresses and beds of the doubly incontinent patients and wash them. As these patients were bedridden and very old they all had bedsores. Because of what I am just going to relate, these sores never healed but grew worse until they stank.
Sister wore no protecting gown or mask, but dipped her dirty fingers into the jar of Aseroine Cream, and rubbed the patients pressure areas immediately after changing the beds and handling dirty linen. It was unheard of for her ever to be seen washing her hands. She did not care under what circumstances these dressings were done – it could be while worker patients were sweeping the floor.,, bearing infection across the room in the dust. She pulled off the soggy dressings and applied Cicatrin powder. When these were replaced by fresh gauze they looked clean, but they were never sterile although there was a big sterilizer in the duty room. It stood idle except when she had a “sterilizing passion”. This would take place once a week when all the receivers, kidney dishes and other containers and instruments would be thrown in together. It needed two nurses to sort them out again. The irony of this is that these articles were rarely used on the ward. Immediately after finishing the dressings, she would serve the dinners without changing her apron, washing her hands or using the proper serving utensils. She was often seen handling food with her fingers and smoking over it. Nurses complained among themselves, but it was useless telling matron. It was very much to anyone’s disadvantage to complain, because Matron had the habit of punishing the plaintiff without investigating the matter.
Sr Rush, whizzed through the work as if her life depended on it, catching up her staff with her in a confused whirlwind. When they were doing one job, she nattered at them for not doing two; when they were trying to do two at once, she nattered at them for not doing three. The ‘worker’ patients were also shouted at, which made them bad tempered with other patients and uncooperative with staff.
Because of this mad rush, the work was always finished early. It left the nurses tired and hungry but they were never allowed to eat any dinner on that ward under either sister. If the patients could not eat it all, it went straight into the pig bin. ( This is of course correct hospital policy but in the years 63 – 66 nurses did not get an official break and used the ward kitchen for snacks).
The nurses were not allowed to rest either, although there was nothing left to do. They were made to do unnecessary work that had already been done. To avoid this they would go around the beds in pairs, pretending to straighten the counterpanes (about which sister had another passion). This fiasco enabled the nurses to carry on a conversation. The only time when there was no need for this was when Dr Morgan, an outside visiting GP, made his daily visit to the ward. He and sister would both disappear into her office, ostensibly to discuss patients, but somehow the conversation always drifted round to his beloved Wales.
Both Sisters regarded this doctor as something higher than the normal run of mankind. He was always given most deferential treatment, coupled with a blind panic on Sr Rush’s part to find him a ‘worker’ to make him some coffee; it was served in a china cup and saucer kept in their own special corner of the crockery cupboard purely for this purpose. After these elevenses coffee with a thick slice of Wales, Dr Morgan would condescend to see the patients. He annoyed them with his habit of asking them how they were, then turning to Sister for a reply, completely ignoring them. It was true that many of them were in an advanced state of dementia, so unable to reply coherently, but there were many others who understood their position and would have dearly liked a private word with the doctor. Dr Morgan did not seem to understand this and was the unwitting cause of a sense of hoplessness and uselessness among them. “We don’t matter anymore” when of them told me sorrowfully once. It was this attitude to his patients that led him to make tactless remarks to me about them in their hearing, and later he was to make my work with them rather difficult because of this uncomprehending attitude.
Dr Morgan’s superficiality annoyed me too. He would come in with a breezy “good morning” while sister ran in circles around him. This pantomime disgusted my patients.
“It’s alright for him, being so cheerful. He can afford to be. After all, he has a home hasn’t he, probably with a loving wife waiting with hot meals. Why should he care about us ?. We don’t count, he only comes to see the sick-room patients”. These were sentiments expressed by my patients at different times. They would often tell me their trouble, not only of the big matters in their lives, but more often it was the minor points in their immediate surroundings that caused them trouble.
It is often a feature in the mentally sick who must spend their lives in an institution, that minor annoyances and troubles are the most interesting. The patients told me of these various points, usually aspects of ward life that could have been altered to their comfort without much trouble to the routine. If it was a health matter, they often would have liked a word with the doctor. I was powerless to do anything about it, and was told so a few times by both sisters in no uncertain terms. It would not have hurt Dr Morgan to listen to these patients now and then, and treat them like respectable people. This in turn would have made them respect themselves and raise them from the futile, sorrowful inertia of institutional life.
It was also hopeless trying to tell sister Rush. She never nade time to discuss the patients with me. Her attitude was that as long as I stayed on the gallery and made sure no-one wandered off, started fighting, or ate each other’s dinners and that all were sitting in the right place (about which she was obsessional), nothing else mattered. My art therapy and attempts to establish contact with the patients and to ease their sorrowful and bewildered minds were regarded as so much airy-fairy.
Sister Murphy ( who liked to be known as ‘the good mother’) was even worse. If I tried to tell her anything she was very sarcastic, asking what did I expect in mental patients?
One day, Dr Morgan would have brushed past us as usual, but something happened. I was just crossing to the radiator with some patients work to dry it, when he came in suddenly and bumped into me, upsetting some of the paintings on the floor. He had been coming in every day yet never seemed to realize there was an art therapist on the ward. He looked at the work scattered on the floor.
“Tell me, how are they progressing?” he asked. The suddenness of the question took me by surprise after being used to the prolonged indifference on all sides. There was so much I had been wanting to say, had I been given the opportunity. Now that this opportunity had so abruptly presented itself, I found that I could not think of the right things to say. I mumbled a conventional reply. However, Dr Morgan wanted to know more. He asked me loudly for details in front of all the patients, and actually expected me to tell him on the spot! All reports on patients are supposed to be strictly confidential. In any case some of them would not have been very pleased about the things I intended to tell the doctor about them. They would never have understood that it was for their own good, and trust would have been broken. As it was he had already made the situation difficult enough through his tactlessness. Contrary to common belief, my patients were not raving lunatics bereft of all logical thought. Most of them were intelligent, many of whom had led full professional lives until something went wrong and cracked a sensitive mechanism. Aware of their curious stares I asked Dr Morgan quietly if I could write a report for him as he seemed so interested, hoping that none of the patients had heard me.
“What a good idea, yes you do that !” he said to all the world. This was quite enough for the patients to put two and two together later when I presented him with the report. I was careful to smuggle the report through the gallery under my white coat to Sister’s office. I need not have bothered, on his way out Dr Morgan waved the type written sheets for all to see saying “Thanks for the report, I am sure it will be interesting”. This caused the patients to ask if the report was about them. I replied that it was just a report about ward conditions that contained points they had mentioned. It was a half truth, and they believed me, but for a long time afterwards the relationship was not quite the same. In this ward there were a large proportion of paranoid patients, and this incident gave them additional scope for their delusions. I was almost back at square one, regarded as a spy and intruder who now made disparaging remarks about them to the doctor after treacherously winning their confidence.
Soon I began to wonder if it had all been worth the effort. A fortnight passed and nothing happened, except that Sr Rush made disparaging remarks about my report to the nurses. To me she said “Don’t you think Dr Morgan is busy enough with reading your ‘stories’?” It was useless telling her that he had requested these notes. As usual she would not listen. Both she and her counterpart Sr Murphy were too obsessed with trivialities to concern themselves with patients actual feelings. Counterpanes and commodes ruled the days and filled their heads.
Sr Murphy was particularly unpleasant to work under. On meeting her the first impression would be one of a dedicated religious nurse, for she was an Irish catholic. She appeared most charming and understanding, but she worked her insidious way under everybody’s skin in time. She was nothing nut a hypocrite with an apparent hindrance policy. She would only appear to work by going round the sick room and talking to patients sitting on the commodes. She had a dingle track mind about that particular body function, the maximum intake of food being a close second subject. She engaged in long babyish conversations on the amount of excretion to the intense embarrassment of the more sensible patients. Otherwise she left the other nurses to struggle on their own while she retired to the office with “The Catholic Nursing Times”.
Her obsession with stuffing patients with as much food as possible led to more complaints among the nurses. These people were old and bedridden and doubly incontinent. They did not need or want all that food. It made them fat and flabby, so more prone to bedsores as well as turning them into worse nursing problems through their obesity. They became harder to lift and their bowels ceased to function properly, so every Monday they were all given old fashioned enemas and suppositories that were hated by patients and nurses alike.
This sister made favourites among the patients, with the result that some became very spoiled and demanding. It destroyed any compassion that the nurses might have felt for them because they were so very awkward and disagreeable. One such patient presided over a complete corner of the ward, her disapproving eyes would follow the nurses at their work. She had a bad habit of reporting anything untoward to the sister on duty, and both sisters had an even worse habit of listening to and acting on, her comments. The woman’s favourite pastime was playing off each shift against the other – night against morning, morning against afternoon, and so on. The concessions made to the woman were unbelievable. She lay abed everyday with her so called bad heart, which was in no worse condition than any other patients’ and was a compulsive commode demander. Every ten minutes she would ask sister for it, who would tell the nurse to fetch it, it would be seldom used. A relief sister would make her get out of bed and go to the toilet….
These are the written views of my friend Nurse Ellen Walls, who subsequently became a State Registered Nurse, and who worked with me for a long period on this ward. In her report, she goes on to describe the typical nurse’s attitude engendered by such spoiling, and how it ultimately worked to the patient’s detriment.
“….Apart from the two doting sisters, no one could stand the woman which was rather sad, for I have no doubt that if she had been treated with a little sense by the person in charge, she could have been a pleasant enough person. After all, she was mentally ill with mild depression and had no visiting relatives, and for someone so alone, one is bound to feel pity. But both sisters spoiled her intolerably and made her a nuisance and a problem to the other nursing staff, especially those of a lower hierarchy. Eventually she died of pneumonia and a certain feeling of freedom to the nurses of ward 24. Not a very commendable emotion on the part of a nurse at the passing on of a patient”.
Another very serious fault of Sr Murphy’s was not following the doctor’s directions in the administering of drugs. She was generous with vitamins, but otherwise her complete disregard for the medicine list raised hell on the ward. “….Old ladies wandered from their table making nonsensical demands, bed patients climbed up their cot sides, and the more docile ones were upset and became bewildered and tearful”.
The sister was so inefficient, that often when I came on duty at 9am, I would find breakfast pots in disarray on the tables and scraps of food on the floor. Many patients would still be unwashed and the sick room was in chaos with dirty bedding and cursing women all over the place.
In this sort of environment were placed sensible but sorrowful, ex-professional women who formed my therapeutic group. They felt utter degradation in having to live among these conditions where they were shown mo respect. They lived among the innuendos of the tale telling patients and were completely at their mercy. One of these was suffering from mania which meant that she was grossly over active for her age. She embroidered her tales with vindictiveness into the ready ears of the sisters who never thought to question what one said.
On talking to these patients I found that they had almost forgotten that they were once teachers, nurses or artisans. They were so painfully aware of being ‘nut cases in a loony bin’. Their days were dominated by the constant commands of the sisters and the general regimentation that left no wish to do anything on their own initiative. Indeed if they ever tried they would be pulled up with “what do you think you are doing?” They became so afraid of this remonstration that they gave up trying, finding it best to do nothing unless specifically told otherwise. This worked well for the nursing staff who were always short handed and for whom it was impossible to supervise all the patients comings and goings. It was ideal for the purpose of quick attention, especially at mealtimes to know that patient A always sat in chair A, but these people were kept sitting in the same place day in and day out.
Imagine the effect this would have on someone who had once sustained a major fracture of the femur, to name but one case. I had almost forgotten about the progress notes written for Dr Morgan and had shrugged them off in my mind as wasted effort, until he came in one day and told me to accompany him to sister’s office. Sister Rush was not a bit pleased by this intrusion, which struck her as most irregular. It has never been known at High Royds for a nursing assistant (for that was my official status even though I was not a nurse) to fraternize with a doctor so openly. She could only be content with a cursory “good morning” from him while being excluded from her own office and deprived of her authority and her rightful place with him. With this build up of events, I had been hoping that the outcome would have been more interesting and fulfilling, but even so with it’s slight anti-climax, it was not discouraging. I was hoping that he would discuss the notes with me, taking each patient in turn and exploring the possibilities of making their lives a little happier and more interesting. However, all he said about the actual notes was that he had no time to discuss them, but would do so at the first opportunity. His reaction to them was favourable and his manner towards me was amicable, which was a great relief to me. I had been worrying about the propriety of someone in my position having the audacity to present a doctor with case notes and telling him, no matter how subtly, how to run his work. He said he had told matron which set me wondering again, how it would be received.
I was not to wait long. In the afternoon she came with Dr MacKenzie, the superintendent or medical director, as he called himself. He visited this ward regularly once a week as they were all his patients. This fact does not sound unusual, but in many mental hospitals the geriatric wards are usually the ‘lost continents’ and are lucky if they see their consultant once every six months.
Dr MacKenzie was a man of few words, but gave one the impression of noticing everything and making mental notes of it. It took him all his time to say “good morning”, yet I never felt rebuffed by him. Unfortunately, he cut too awe inspiring a figure, so none of the patients dared speak to him, which is a pity as he proved to be a sympathetic man with a ready ear – a rare quality at High Royds. The matron usually accompanied him. This influx of the Gods always sent matron into a panic of straightening chairs and counterpanes, the anxiety radiating and generating it’s way to the patients.
Dr McKenzie was Scottish but never brought the Highlands to his work. He saw each patient with sister and they talked about nothing but the patients. Unfortunately neither sister ever told him anything of any interest. I overheard them many times. They were mostly conversations about bowel function and physical illnesses that accompany old age, but never about the patient’s state of mind. The best report on this aspect that Dr MacKenzie could hope for would be that “Patient ‘A’ is more depressed today”, or that “Patient ‘B’ has hallucinated again”. No reasons were ever given as to the causative influences of these states. Here again, all the talk was about the sick room patients, not about my patients on the gallery. The doctor did not ask them how they were, but they could never give anything but non-commital replies. Can you imagine telling your doctor your very private anxieties and troubles in front of a ward full of listening patients who might humiliate you?. Often after Dr MacKenzie had gone, the patients told me what they would have like to tell him if only they could have talked to him properly.
The matron was quite hopeless at even beginning to understand how people felt in any given situation. She was disliked by the patients and even more by the staff because of this lack of understanding. This unpleasant quality reverberated through the hospital with sometimes disastrous effects, especially to young student nurses. She treated and spoke to my patients as if they were babies. It humiliated them and they hated it; needless to say, matron was completely unapproachable. She ran the hospital on the lines of vindictiveness and innuendo in the same way as the two sisters ran the ward, depending on favourite nursing assistants for her information as the sisters depended on favourite patients. This meant that the nurses had to be very careful not to offend the “trusties” as matron acted on their tales without investigation.
She came in now with Dr MacKenzie and gushed about my ‘very clever’ progress notes in front of the patients. Dr MacKenzie listened in surprise. Nobody had told him about the notes. He asked to see them. Matron hedged, then said she had forgotten where they were. Immediately I chimed in and said cheerfully “ don’t worry Dr MacKenzie, I have a carbon copy at home”. Matron was amazed that a mere nursing assistant should even think about writing out case notes. The fact that carbon copies were made, amazed her even more. She suddenly remembered where the original case notes were, and Dr MacKenzie insisted on seeing them. This pantomime was enacted on the ward gallery, larger than life in front of patients and a too interested staff. The tale of my case notes spread through the hospital very quickly. It is interesting to note various reactions.
The older nursing assistants thought I was mad and could not understand why I should not only wish to write them, but to give my time to them freely without thought of financial reward. Some of them thought I was trying to soft soap the consultant. My student nurse friend thought it was something that needed doing badly and agreed with it in principle, but she added sadly that nothing would come of it. She said that Dr MacKenzie would not have the courage to fight over it with the rest of the staff, for instance, matron and the old fashioned sisters. She was right. Dr MacKenzie was pleased with the notes and said he would like another report later, but nothing was done. Too many people would have been upset, therefore it was better to leave things alone.
No scandal has ever been caused by jogging along in the same old rut. Nobody suffered physically; most patients were reasonable comfortable and as well as could be expected.. However, any radical change in the routine was bound to cause unrest; it is essential that a hospital should work in harmony. Yet the very fact that I felt the need to write those notes was a sign that all was not well, and the lack of teamwork was evident in every monotonous day.
I wrote the second set of notes because I knew now that Dr MacKenzie was interested, and I was hoping that if I wrote them penetratingly enough, he might be sufficiently impressed to act upon them. He was certainly pleased and came on the ward specially to tell me so, but some people started acting very strangely. I had made two carbon copies, one for Dr Morgan and one for Matron. Dr Morgan kept his copy without ever mentioning it to me, but he or someone else must have pulled sister up. Sr Rush was very cross about me mentioning the patients’ financial matters, and said I should have spoken to her first. She discussed certain matters with me but she was so stupid that she completely missed the point of what I had been trying to say. I would have been glad to speak to her if only she had been a bit more approachable and amenable to new ideas. There was a suggestion box in the ward but it was never opened. No other members of staff ever put anything in. It’s contents were buttons, pins and pieces of paper on which were written requests for millions of pounds to be paid from Fort Knox to “Prince Albert”, one of the female patients on the ward who cleaned the toilets!
Matron completely ignored me for a long time after sending her copy of the notes back to me immediately without comment. My student friend said this attitude was typical of the attitude at High Royds. You enter the hospital, keen to help people only to find that nobody thanks you for your efforts. Sooner or later, she said, you give up because of the pointlessness of it all and become as the rest of them, lethargic, and growing to hate the boredom of your job. They were in the habit of treating staff as if they had no intelligence, and like the patients, the staff responded accordingly. Many could not stand it and either left the profession altogether, or went to another hospital. The student failure rate was appallingly high. Very few actually finished their training. They seldom stayed long as staff nurses. There are various causative influences governing this rapid turnover:-
1. The matron was not a suitable person to be in the position, being the unsympathetic and vindictive woman she was. Many young girls suffered at her hands.
2. She did not interview people well. Girls told me they were asked nothing about themselves and references were waived, yet they were accepted for a three year training.
3. There was no one to whom these girls could turn for help if they had any problems. Many of them were miles away from home for the first time ; others who were near home had problems there usually with unsympathetic parents.
4. The tutors at the training school were out of touch with the hospital, so that nurses found difficulty in applying what they had learnt.
5. The tutors did not ensure that the students received adequate practical training in all spheres of psychiatric nursing. In more than one case, student nurses complained bitterly because they were either left on one ward for a long period, or they were changed from one ward to the other very often. Matron often did this to people she disliked.
Here was the breeding ground of discontent, which together with ward conditions, did not make for a happy atmosphere. In the end it was the patients who suffered. A nurse who is unhappy in her job does not make a good therapist. Her discontent can be felt by the patients.
I have just read a book by Barbara Robb called ‘Sans Everything’. It is a survey of the treatment of old people in mental institutions, pinpointing all the malpractices. One consultant psychiatrist to whom I have spoken about it said the book was written by a trouble maker who went round looking for all the bad points in these places, then editing them to form a book that makes frightening reading. At High Royds, nobody ever hit or hurt patients. The wards were not unpleasant as they had once been; they had been painted and new lights were put in, and plants were on the window sills. Television and newspapers were in every ward. There was no evidence of real cruelty but bathtime was most distressing:-
1. Patients were made to strip in full view of each other, causing unnecessary embarrassment in some cases.
2. Naked women sat waiting on a form in the bathroom, jostling each other. There were more quarrels in the bathroom than anywhere else.
3. Bowls of water were thrown over patients’ heads without them being given anything to cover their eyes with.
4. All sizes of clothes were piled together in the cupboard, making it impossible to sort out the right size. As a result patients were often in uncomfortable, ill fitting clothes that also undermined their self respect.
5. The same hairbrush was used on everyone.
6. On the male side it has been known for nurses to leave soap in the patients hair causing irritation and infection.
The resulting physical and psychological ward conditions had adverse effects on the longstay patients:-
1. Negligence in hygiene brought about frequent outbreaks of gastroenteritis and even one of scabies.
2. Institutional clothing and identical hairstyles undermined patients’ self respect.
3. Soft diet food was served in an unattractive way which some patients noticed.
4. Case histories were freely discussed in patients hearing. Most of them could not understand what was being said, but they knew they were always being talked about, never talked with.
I did not have to think very hard to mention these facts, although the hospital itself is no longer visually unpleasant. And is certainly not notorious for cruelty to patients. Overcrowdings, shortage of nursing staff and outdated buildings are the standard excuses for the inability not to do the job properly. These are understandable reasons, but a fourth, wrong priorities, need not have happened. Theirs was more the sin of omission. The vices were thoughtlessness, tactlessness and the failure to realize that people exist in their own right, even if they are unfortunate enough to be mentally ill. The hospital was full of those that had ears, yet heard not.
THE PROBLEMS OF INSTITUTIONAL NEUROSIS AFFECTING DIFFERENT TYPES OF MENTAL PATIENT
“Monastery, prison, hospital, nursery, it sheltered us from the hard, stormy world; it kept us from the foggy, foggy dew”
This is the apt summing up of life in a mental hospital by William Seabrook in his autobiography. ‘Asylum’ recounts his experiences in such an institution, and the effect it had on him as a person. The words that I have underlined are the essence of the state of mind in institution-conditioned psychiatric patients who are intelligent and aware of their surroundings. It is a highly dangerous attitude, symbolizing a wish to return to the womb (Freud). The patient is afraid to face up to his problems in the outside world. If allowed to do so, he sinks further and further in the shelter. Rehabilitation becomes increasingly difficult.
Mr Seabrook was treated in the days preceding electro-convulsive therapy and the drugs used in psychiatry today. It is interesting to examine his treatment briefly, because it induced his institutional state of mind. However, the hospital took care not to let this state of mind grow.
In the days of Seabrook’s admission all wards in psychiatric hospitals were locked. The wards containing wild and dangerous patients lay in the heart of the hospital; they were nicknamed the ‘back halls’ in spite of the staff’s efforts at emancipation.
Although Seabrook was never in one of those, his ward had barred windows, even when he was moved to the convalescent wing.
Seabrook was subjected to a form of regimentation as soon as he was admitted. He had to join queues for various items and reasons and was marched from one place to another down long dark corridors, alive with echoing footsteps. Because of this, one patient actually developed an obsession with marching up and down one particular corridor all day; he was afraid of being late for the various queues.
Seabrook’s first few days were spent in helping to fill various forms about personal belongings, and in being taken to see his doctor, dentist, barber; butcher, baker and candlestick maker. He felt swallowed up in the labyrinthine institution with it’s ordered life and precise timing of every day. He had his own bedroom but the fact that the door had to be kept open with a blue nightlight shining on him was the cause of much annoyance. The locked doors and barred windows added their own note of finality. Seabrook mentions that the risk of escape almost caused more worry to the doctors and administrative officials than the risk of suicide.
His initial treatment consisted of body temperature baths that completely submerged the whole body except the head. These were supposed to be relaxing. They did not help him but gave him a sense of being cocooned in foetal fluid within the great protective institution walls. Straight jackets were a dirty word in this then progressive hospital; instead the nurses used ‘the pack’ to pacify forcible disturbed and restless patients. This involved a special technique of rolling the patient in sheets and bands on the bed. When the process was finished the patient was left to writhe alone on the bed, completely helpless until he was exhausted, sweating profusely. This treatment was given to Seabrook when he grew restless with the diminishing alcoholic fog and he suddenly realized his new position and status more clearly. After a couple of sessions it was discontinued. It was found that he was deriving some kind of pleasure from being bound up tight and completely helpless in another sort of cocoon. Soon after this, the doctor declared him fit enough to be taken out of the special observation room and put in the main ward with the other patients. He resisted this move although he knew it would mean no more disturbed nights with blue nightlights and open doors. This active resistance is a clear symptom of institutional neurosis. On release, long stay prisoners have been known to resist rehabilitation very strongly. They have lived so long in prison that , however unpleasant it might have been, they have come to accept it and become completely dependant upon it.
His removal to the main ward was timely, but this was offset by the ward atmosphere being reminiscent of a nursery. Nothing was left to patients’ initiative. They were told exactly how and when to dress, wash, eat; the times of each event were fixed everyday alike. They were all taken for walks together always with a nurse to escort them at the same time each day. In between walks, meals, treatments, handicraft and gymnastic classes, the patients were left to recline on soft chairs and read or play games.
And all the time in the background the attendants hovered like motherly hens watching over their brood. The very fact that these days were so comforting, protecting and predictable led to an institutional state of mind. This place was so unlike the relatively unpredictable outside world, where people must take the initiative and make decisions.
The convalescent ward to which Seabrook was later moved had a completely different atmosphere from the one to which he was used. He resisted that move more energetically than the first, to the extent of him making a nuisance of himself. There were neither soft chairs, nor vigilant nurses. Here the patients were supposed to think for themselves. These were not the only reasons for Seabrook’s intense dislike of the move. He was placed among new patients, none of whom he knew. He was removed from the old familiar, comforting fraternity, and was determined to do all in his power to be placed back amongst them. A timely remonstration from his doctor made him realize the gravity of such a move. It would have meant his becoming more and more dependant on the institutional way of life to such an extent that his chances of recovery and rehabilitation would have grown less and less. It was only the doctor’s foresight that saved his life.
“INSTITUTIONALISATION LEAVES AN UNMISTAKABLE STAMP ON MEN – SHABBINESS, WEAKNESS, AND LACK OF SELF RESPECT”
Nurse Walker
There were hundreds of patients at High Royds answering to this characteristic description – patients who had been there for up to forty years. On them, the mark of institutionalization was indeed unmistakable, but there is a more subtle kind that goes unnoticed. It is deceptive in it’s manifestation, for all appears to be well.
