Feature

Still singing the same old blues

While much has changed, many aspects of hospital psychiatric care remain depressingly familiar 30 years later. Mo Hutchison offers an insider’s view

I was a child of the Sixties. You know: anti-war demos, university sit-ins and profound, if at times incomprehensible, Bob Dylan songs. It was also the time of monolithic structures frequently recumbent on the hilltops of rural England. These were our mental hospitals and the troubled souls within them were supposed to benefit from a life of splendid isolation and quiet contemplation, tilling the land, free from the stresses and strains of everyday life. The sane, by contrast, nestled securely below, making their livings, raising their children and pursuing their hopes and aspirations unsullied by ‘the mad’. I was a patient in one such hospital.

Some 30 years on, the hospitals are finally shutting their doors and arrangements have been instigated to care for those with mental health problems within the bosom of the community, albeit a rather reluctant and suspicious community. Those who require psychiatric in-patient treatment are now more likely to receive this within the specialist wards of a general hospital. I have also been a patient on one such ward. While this was from perceived necessity rather than the urge to undertake a longitudinal, comparative study, comparisons are possible.

First, the environment. Personally, I found nothing attractive about the remoteness of the old institutions. It was slightly scary walking in the hospital grounds and my fellow patients and I did not feel inclined to admire the lushness of the view. I remember during a time of particular anguish, my psychiatrist called me to the window: ‘Do you see all those different shades of green?’ he said. ‘That’s what life is all about.’ I came very close to strangling him.

I longed to see ordinary things: shops, buses, children, normal people going about their lives — anything that reduced my sense of being abandoned and alienated. However, in my role as a user consultant many users have raised concerns about the total lack of opportunity to walk or sit somewhere relatively peaceful when psychiatric wards are sited within the grounds of district general hospitals. You need to be particularly robust to survive 24 hours on an acute psychiatric ward and most achieve this by leaving the ward from time to time (with or without official sanction). But if they are then faced with ‘concrete jungles’ they may return more stressed than when they left. It is time to strike a balance, and it would be sensible to provide green space within hospital grounds for patients to ‘stand and stare’.

One thing that really struck me as a patient on a new acute psychiatric ward was the high number of visitors compared with the old hospital. There are a number of possible explanations for this. General hospitals do tend to be more accessible. Anyone who wanted to visit without a car in the old days had to be particularly fit and determined to negotiate the foot-path as it traversed the hill. There was a hospital bus but it was rather unpredictable and timings were designed to correspond with staff shifts.

There is undeniably less stigma attached to visiting psychiatric patients in general hospitals than in the old institutions. Friends and loved ones can console themselves that those they are visiting suffer from an illness like any other treated in the hospital. The wider community is not necessarily so accepting and, at the general hospital in which I was a patient, local children quickly learned where the ‘nutters’ were. Stones are regularly thrown at the windows and names shouted at the residents. In many ways, this is a small price to pay for enabling people with acute mental health problems to retain contact with friends and family rather than be shipped off to what might as well be another planet.

What about life on acute wards — is that any different? My evaluations of user views of current acute services, wherever they are, elicit three major responses: we would like more engagement with the nursing staff; we are completely bored most of the time; and why is there such reliance on medication to the almost total exclusion of other therapies? These echo comments and my own views of 30 years ago. In those days you had to be something of a social psychologist identifying members of staff who could be relied on to communicate with you and those who could not. Nurses frequently congregated in the office, which was about as accessible as Saddam Hussain’s palaces. Whatever activity they were engaged in, nefarious or otherwise, was lost on us.

Much of this applies today but, I am often informed, this is because there are a higher number of more disturbed patients under section and therefore needing closer observation. This may be true but it is the manner of that ‘observation’ which bothers me. It seems to involve siting chairs at strategic places and watching people — no attempt is made to engage with them in any way. In my own case, I remember a student nurse rushing in and saying ‘Oh, you’re there’ and rushing out again. (Given that I had to pass her to reach the great outdoors it was difficult to understand where else I could be). I called her back and asked her what she was doing. This clearly troubled her and she reported it. Later I saw in my nursing notes: ‘objects to being observed’.

Lack of time for ordinary social intercourse is sometimes attributed by nurses to increasing paperwork. Again that may be true, but I cannot imagine what possible purpose is served by nurses writing extensive notes on each patient three times a day, usually, of course, without any contribution from their subject. Our days are not action packed. In fact, one day more or less drifts into another. Why not ask us how we feel, write that and anything else truly significant.

The rationale behind nurses not initiating communication was explained to me as being that I should take some responsibility for asking for assistance. Fine. I wonder if health professionals can appreciate how very difficult it is to approach a clutch of nurses often avidly discussing births, marriages and deaths or even, come to that, the nuances of the latest psychiatric interventions, and request a ‘word’. It feels intrusive and demeaning, more than that you feel silly, especially as the response is sometimes that you will have to wait until someone can spare the time. Presumably this is also part of the game plan.

As far as boredom is concerned, my evaluations highlighted a problem — trained nurses did not consider it to be in their remit to ‘entertain’ patients and occupational therapists, becoming ever more sophisticated and anxious to lose their ‘stuffed-toy’ image, would only do so if it was part of a patient’s treatment. But why not research what activities would be helpful on the wards, employ people to undertake those and fill some of the long hours of tedium? Thirty years ago users complained about the ‘them and us’ attitude prevalent among mental health professionals, particularly nurses, and today such complaints still abound. It seems that archaic, inappropriate buildings are relatively easy to dismantle but archaic, inappropriate attitudes are more resistant. Given that one in four people will experience mental health problems at some point in their lives one would not think that mental health professionals could afford to be so complacent.

As far as reliance on medication is concerned, it is difficult to imagine how any real changes might be made while mental health problems remain very firmly in the domain of the medics. However, lessons could be learned from the workings of therapeutic communities which do adopt a more eclectic approach and nurses could be trained in group techniques.

Further, it concerns me that medication is dispensed in such a cavalier fashion with users frequently not certain what they are taking, what it is for and what the side effects might be. This seems to me to make a nonsense of any notion of informed consent.

However, one aspect of modern in-patient care is welcome: the introduction of the care programme approach, which should encourage short and long term planning for users of mental health services. Users should have a sense of where they’re going, how they’re getting there and who’s going to help. In the old days I always felt that I was going to be in the hospital until someone got bored with seeing me there. I never saw the consultant — I didn’t even know who he was. I had regular, puzzling chats with the registrar, who chain-smoked throughout. He seemed to have no idea of what, if anything, was wrong with me and what, if anything, he could do about it apart from giving me quantities of drugs in almost biblical proportions.

The ubiquitous ward round may not be the most popular ritual but at least it should ensure that each patient is reviewed at regular intervals. The real problem here is that, although the mechanism exists for actively involving users in assessment of needs, plans for future action etc, paternalism prevails and users are routinely excluded from the decision-making process.

I had occasion to visit one of the old hospitals recently which, incidentally, had closed its doors to patients but still housed the post-graduate centre — giving a whole new meaning to the idea of lunatics taking over the asylum. It was a chilling experience which spoke of lost and forgotten folk, society’s flotsam and jetsam haunting bare and forbidding corridors. These hospitals were, in every sense, a blot on our landscape and I am very relieved that they have been consigned to history. It is incumbent on us now to provide mental health care which treats users with dignity and respect, which maximises involvement and choice and which recognises that mental health problems have as much to do with poverty and life circumstances as chemical goings-on in the brain. Otherwise, while acknowledging that the past is indeed a foreign country we might be forced to ask whether or not they really ‘do things differently there’.

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