QJM Advance Access originally published online on July 22, 2006
QJM 2006 99(8):563-564; doi:10.1093/qjmed/hcl083
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Coda |
The enduring asylum
‘Loonies’, they shouted from the back of the coach. ‘Loonies!’ I can't remember if we had reached the gates of the mental hospital yet, but I was excruciatingly embarrassed, and I prayed that they would stop. It didn't help me very much that I understood, to an extent, what had provoked some of the students in my year to such cruel mockery. It was 1974. Sociology had just become a compulsory subject at our medical school in London. The young sociology lecturers had arrived with a mission to radicalize the next generation of doctors, offering us the latest critiques of medicine and of psychiatry. An instructive coach trip into the countryside, to visit one of the vast Victorian ‘bins’ that still peppered Hertfordshire, Essex and Surrey, was not proving to be helpful.
In retrospect, we were all caught up a painful historical drama concerning views of madness. The sociologists were fired with a conviction that everything we were about to see was a demonstration of how society oppressed and imprisoned free spirits in the name of medical treatment. The students felt provoked by this, and were no doubt fearful as well, and they regressed into viciousness. While our tour leaders looked forward to a Utopia in which schizophrenics would all be revealed as artists and mystics, the young men on the back seat were imitating the visitors who went to gawp and jeer at the inmates of Bedlam three centuries earlier.
I remember little of the rest of the visit. It is possible that the lecturers cut it short in order to pre-empt a scandal. But I do remember a visit some time later to a rural asylum for the mentally handicapped, where dozens of adult men just sat in chairs and rocked, or wandered aimlessly around the room, in a way that seemed more like a parody of imbecility than a demonstration of it. Then, during my clinical years, I was sent for about four weeks to study at another, different ‘bin’ for the mentally ill. Politicians had already decided to shut down all the psychiatric hospitals, but at this stage most of them were still much the same as a century before.
In the place I was assigned to, the corridors were allegedly the longest in Europe. On some of the chronic wards, scores of elderly women sat quite passively, staring into the air; it was said that some of them had been admitted decades earlier for having had illegitimate children. In the acute wards, one could still encounter the ‘classic’ cases described in the text books: people with agitated depression wringing their hands all day long, patients in a state of catatonia sitting like pale statues cemented into place, and psychotic individuals babbling ‘word salad’. A hundred years after Charcot's clinical demonstrations, and more than a decade after R.D. Laing's scathing exposure of such spectacles, ward rounds still consisted of patients appearing every week or two in front of a panel of doctors and psychiatric nurses to ‘display’ their pathology.
It is now more than a generation later. These memories have been stirred up by attending a coffee morning in Denbigh, to mark the launch of a history of the North Wales Hospital.1 Like the great asylums around London, the hospital once housed 1500 mental patients and employed around 1000 staff. Since its closure in 1995, the grand buildings have stood empty, decaying quietly while developers and councils wrangle over its future. The town's identity has been stamped with its ambiguous inheritance as a centre of care and of incarceration. In some ways it is still waiting to find a new purpose as a community, while these wrangles are resolved.
At the book launch, two former psychiatric nurses from the hospital (one now a historian, and author of the book) mourn the passing of the institution, but with no illusions or regrets. They are reconciled to the harm that it did, both to its inmates and to themselves. Now in retirement, they work for voluntary organizations, visiting some of the people who were discharged from the wards into homes around the town, and making sure that their everyday needs are being met. Ironically, they explain how they now feel discounted as mere volunteers by the professionals who populate the brave new world of community mental health care. For example, psychiatric reports are written with no mention of their work with patients, or the social activities they lay on to keep these people's minds alive.
Listening to them, I am reminded of how we still remain in thrall to the asylum mentality. The asylums of brick and stone, thank God, have now been closed down; we have learned to acknowledge that the madness we observed there was largely manufactured by the institutions themselves, rather than in the minds of their inhabitants. But the virtual asylums have endured. As the two nurses have discovered, we remain in a state of mind where professionals can still ignore any involvement from lay carers. There is also the mental health ‘team’, where anonymity and bureaucracy stand in place of iron gates and locked wards. We construct another asylum out of the self-important distinctions by which a dozen different mental health professions and theoretical camps insist on identifying themselves, and bewildering everyone else. Finally, there are the tick-box inventories by which we try to pretend that mental distress can be reduced to the same kind of diagnostic categories as TB or appendicitis, and entirely divorced from any social or cultural context.
The foolish boys shouting ‘Loonies’ on the bus to Shenley could never have dreamed that the whole site would one day be converted into luxury homes for City commuters and the rural rich, as it is now. I hope that today's medical students will see a day when our own virtual asylums vanish, and are replaced in their turn by more humane care.
References
1. Wynne C. The North Wales Hospital, Denbigh 1842–1995/Ysbyty Gogledd Cymru, Dinbych 1842–1995 2006;Rhyl Gwasg Heligain.
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