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The Story of Nursing in British Mental Hospitals: Echoes From The Corridors, by TCW contributor Niall McCrae and Peter Nolan, has recently been published. Niall McCrae is a highly experienced lecturer and researcher in mental health and mental health history at King’s College London. In the first of a two-part interview, I ask Niall why mental health nursing has been shrouded in obscurity. 

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Kathy Gyngell: The very subject matter of your new book, The Story of Nursing in British Mental Hospitals, gives the reader pause for thought. Why has no one written about this before?

Niall McCrae: The historical development of mental health care is a story almost exclusively written by doctors. Nurses have made a minimal contribution, despite their crucial role in patient care and their numerical strength. This says something about professional status. The annals of psychiatry have tended to marginalise nurses, casting them as mere pawns in a compromise between progressive medical leadership and parsimonious lay authorities. Advances in care and treatment are mostly attributed to the great man in the oak-panelled office – the medical superintendent.

My co-writer Professor Peter Nolan wrote a short history of mental health nursing in 1993, but our new book is a more substantial text, featuring a wealth of anecdotal accounts. A lot has changed since Peter’s earlier book, written when the mental hospitals were still running. Now the majority of mental health nurses work in community-based services. Three decades on, we draw lessons from the policy and practice of the post-asylum period.

KG: I grew up in the shadow of Fulbourn Mental Hospital near Cambridge (from the late fifties to early seventies). In all those years I never even went into the hospital grounds. In fact there was embarrassment attached to living in a village with a 'loony bin’ as it was then disparagingly called. Was this typical?

NM: The mental hospitals were shrouded in stigma, tainting those who worked there, and people living in the vicinity. From the late 19th to the mid-20th century, the asylum was dreaded, and not without justification. Under the 1890 Lunacy Act, almost all patients were certified and a high proportion who were admitted went on to spend their whole lives within those walls.

Although hospitals such as Fulbourn had extensive grounds, one could gaze across the green acres and rarely see any patients. In the past the land was used for farming, which had the dual purpose of self-sufficiency and patient labour. By the 1960s outdoor occupation was no longer valued. Sadly, apart from events such as the summer fete, patients lingered indoors in a haze of cigarette smoke, taking little advantage of the fresh air and sylvan pastures.

KG: Have the mental hospitals of the past always been viewed through a very negative prism? I certainly (perhaps ignorantly) have associated them with what I have regarded as barbaric practices such as electric shock treatment and, worse, frontal lobotomies.

NM: Interesting that you mention ECT as a barbaric practice. In fact, it’s the only survivor of a plethora of physical treatments of the mental hospital era, as a reliable intervention for severe or suicidal depression. However, ECT has a dark past. My father was trained as a mental nurse at Denbigh Hospital in Wales, 1959 to 1962. Although anaesthesia and muscle relaxants were standard practice for ECT by that time, some doctors believed that a ‘raw’ seizure worked better. Limb fractures or spinal injuries were frequently caused by the extreme convulsions. Also widely used was insulin coma treatment, an elaborate procedure requiring constant nursing and medical supervision for the comatose patient. While an ECT course was typically about six to ten administrations, a course of insulin coma therapy sometimes stretched over several months. Each time imperilled the patient due to the risk of irreversible coma.

This treatment was finally withdrawn after the introduction of tranquillising drugs such as Largactil, which seemed to have better impact on schizophrenia without the mortal danger and labour intensity.

Insulin coma treatment failed to reverse schizophrenic illness, the symptoms tending to recur shortly after course completion. A more permanent fix was promised by psychosurgery. Frontal lobotomy, or leucotomy as it was known in Britain, entailed severing fibres in the frontal lobe of the brain with a leucotome, leaving the patient with one or two distinguishing scars. Agitation and other antisocial behaviours were ameliorated, but at the cost of irreversible blunting of the personality. Tens of thousands of patients were leucotomised, mostly without their consent, and hundreds died.

In the early 19th Century, the model for the public asylums was The Retreat in York, run by the philanthropic Tuke family. They regarded medical leadership of the institution as undesirable because it would expose patients to experimentation with potions or spinning contraptions, as used elsewhere. Considering insulin coma and leucotomy, how right they were. But it would be a simplistic anti-psychiatry position to cast all medical interventions as reckless or coercive measures. Undoubtedly the drug revolution of the 1950s contributed to a liberating atmosphere in the mental hospitals, and medication allows patients today to remain in the community.

KG: As you point out, it is the nurses who have been at the coalface of treatment and care, not the psychiatrists. In your research did you come across any nurse pioneers – unsung heroes and heroines doing what I imagine most nurses would rather not do?

NM: The difficulty in celebrating individual nurses from the past is that their role did not include writing about their work. Indeed, they could have been sacked for doing so. The medical superintendent could record his exploits in the Journal of Mental Science; there was no similar organ for nurses. The underling status of nursing began to change after the Second World War, partly due to the therapeutic community model applied by Maxwell Jones. This humanistic approach flattened the hierarchy, with democratic community meetings on the wards supposedly giving patients, doctor and nurses an equal say. In practice the therapeutic community was rarely implemented owing to resistance in the system (not least, nurses’ reluctance to relinquish control over patients). But where it did succeed, medical superintendents appreciated the support of matrons or chief male nurses. An example was Vera Darley at Claybury Hospital in Essex.

By the 1960s mental nurses were writing their own textbooks (for decades, they had been trained by a medically-led scheme). A key figure was Annie Altschul, who was inspired by American nurse Hildegard Peplau’s work on interpersonal relations. Altschul strove to change nurse training towards a psychosocial approach, and she had major influence on the curriculum. However, despite learning techniques of therapeutic engagement and social therapy, on the wards many nurses have preferred to stay in their comfort zone – the office.

Dr Niall McCrae is a lecturer in mental health in the UK. Tomorrow Niall will address the downside of mental health care in the ‘community’, whether a golden age of mental health care is yet to come, and the direction mental health nursing needs to take.

Michael Cook likes bad puns, bushwalking and black coffee. He did a BA at Harvard University in the US where it was good for networking, but moved to Sydney where it wasn’t. He also did a PhD on an obscure corner of Australian literature. He has worked as a book editor and magazine editor and has published articles in magazines and newspapers in the US, the UK and Australia. Currently he is the editor of BioEdge, a newsletter about bioethics, and MercatorNet. He also writes a bioethics column for Australasian Science and contributes occasional op-ed pieces to newspapers and websites in the US, UK and Australia.