PART 5 - TREATMENT AND TRAUMA

Much has been written about the treatments meted out to some of the more unfortunate who occupied the mental hospitals of the past. Usually such writing seem to come from two directions – first the angry diatribes of ex-patients who have suffered and been abused and second from the contrary point of view of psychiatry trying to justify itself. I have seen little written from the point of view of staff working in the system and even less from those who have seen the system from both sides – as staff and also as patient. Nevertheless the treatments available to people of my generation (and let’s face it, within the span of a single career so we’re not talking of a hundred years ago) were the best available or the worst available but most driven from a genuine desire to make a difference. ECT, or electro convulsive therapy has been around for over 60 years and it had a peculiar ancestry, but for those for whom it worked it was literally a life-saver. Nevertheless like many treatments it was abused and overused or used simply to control and intimidate. But that wasn’t the fault of ECT per se; it was the abuse of what is potentially an effective treatment by people who profess to know better.

Long Grove had its fair share of physical and chemical treatments and I suppose I witnessed or delivered many of them. But although sometimes horrific it is my lasting impression that most of us did the best we could with what we had.

Our materia medica or available list of drugs was very small and could possibly be counted on the fingers of your hands. There was of course the ubiquitous paraldehyde that was used liberally to sedate. Paraldehyde was so caustic that it would melt plastic syringes so most wards carried a small supply of glass syringes that were sterilised in old fashioned stainless steel sterilisers that were little more than a square boiler kept on the bench of the clinic. Other drugs included chlorpromazine and thioridazine as our major tranquilisers or anti-psychotics with the newly introduced Stelazine being also liberally used as an anti-psychotic. Antidepressants were limited to a choice of a drug called tofranil; our anxiolytic (anxiety reducing) was Librium and for night sedations we had supplies of barbiturates and chloral hydrate. There were a small number of drugs used to reduce the side effects of the primary drugs such as stemetil and phenergan but apart from that not a lot else. As many of the patients also had serious physical conditions including tuberculosis we were also treating that as best we could but with little success overall.

From time to time a new ‘experimental’ drug would arrive – this was well before ethics committees were established and the drug companies were easily able to run trials with very little in the way of informed consent. One I remember in particular was an appalling anti-psychotic called majeptyl or thioproperazine. This caused the most gross side effects including drooling, semi-catatonic states and severe rolling up into the head of the eyes. We tried to counter the side effects with injections of phenergan but to little avail. I remember one patient, Ian, who when a young fourth year medical student had developed schizophrenia. He had the misfortune to be placed on the drug and had the greater misfortune to understand exactly why he was suffering the side effects, he would stagger to the office asking in a broken voice for phenergan being barely able to say the word he was so badly affected by the drug. Mostly he seemed to be left to his own devices mainly curled up in a chair with long strings of saliva soaking his clothes. After a while the drug simply stopped being used and the enthusiastic drug reps stopped calling on the ward. I cannot recall what happened to Ian but I am sure that once off majeptyl he would have been much better off.

The use and or abuse of medication was mainly a product of the paucity of sophisticated drugs available. Nowadays there are improved anti-psychotics that have few of the side effects of the early ones and so people on them have a much better life. The early anti-psychotics certainly made a difference in terms of symptom reduction but this was offset by the side effects that were, at best, poorly controlled. People who have suffered these treatments feel rightly angry about how they were treated but their anger is often about the side effects they suffered rather than the treatment proper. I felt particularly helpless when I saw how the patients struggled with the medication but was powerless to do much about it as I was simply a dispensing tool. When I did try to remonstrate with the doctors about the effect the drugs had on the patients I was treated to a patronising address about my inexperience (true) and the wisdom of the psychiatrists (dubious) who knew what was best for the patients (definitely untrue). So I simply did the drug rounds handing out the tablets, emulsion or elixir as prescribed and feeling quite guilty at the effect I knew it would have.

One of the more obvious abuses such as dispensing paraldehyde “of the top” so that it was not diluted by the buffer solution that had settled to the bottom of the bottle, I have already referred to but there were other abuses in particular the use of PRN medication – medication dispensed as needed. Some of the older charge nurses kept old stocks of medication that belonged to people who had ceased a course or left the ward. Thus they kept in their desk their own private supply of major tranquilisers that they would dispense to anyone they thought was ‘causing trouble’ rather than bother the doctor. After all, they knew better than most of the medical staff anyway as they lived in the real world and had to manage ‘that lot’ on a daily basis!

Drugs then were pretty much ubiquitously used and often in greater quantities than those prescribed. This was mainly because the nursing staff always believed the doctors prescribed too low a dose anyway and that as they had to manage the patients on a daily basis knew what was needed to keep people settled. In fairness this was possibly a reasonable response by the nurses as often the patients became quite violent and agitated and with the small numbers of staff to each ward there was a temptation to do what one could to reduce the risk to staff. No doubt the doctors in their turn were puzzled by the extent of sedation or extra-pyramidal side effects and then further reduced medication which the staff then increased the minute the doctor left the ward.

Note too that I refer to doctors, not psychiatrists. The latter were few in number and so most ward cover was by medical officers – doctors who were interested in psychiatric medicine but who had not completed, or did not intend to complete, their DPM (Diploma of Psychiatric Medicine). Mostly this group of doctors ended up covering the ‘back’ wards as the long-term wards were called, while the psychiatrists tended to cover the villas where patients were largely suffering from minor psychotic issues, mood or personality disorders. Here they could practice whatever treatment fad they were interested in so that some of the villas were notorious for being run as encounter groups or therapeutic communities, others were a hotbed of hypnosis, analysis, group therapies, individual psychotherapies, drug induced abreaction (often using LSD) and other vagaries that were in favour at the time. Certainly these villas were fun to work in as one never knew from week to week what would happen and there was considerably less risk than working on the back wards. The treatments were, to the untutored eye of us student nurses, exciting and interesting and allowed us deep insights into the human psyche as exposed by some harrowing psychotherapeutic sessions. Or at least we thought we did but then to our shame we were as caught up in the trendiness of the day as everyone else.

So if you were lucky enough to be a patent in the villas and were young, intelligent and attractive to boot, you’d have good access to psychiatry, psychology, psychiatric social workers (who acted as quasi-psychiatrists anyway and were probably the most enthusiastic adopters of the various psychotherapies) all in reasonable surroundings. On the other hand if you resided on the back wards you may be lucky to see a doctor twice a year for a physical and mental examination.

Electroconvulsive therapy was of course used regularly and an ECT clinic was held in one of the Villas three times a week, Monday, Wednesday and Friday. The patients for ECT were placed in gowns and then lay on gurneys in one area of the unit. Here they would often chat away to each other while awaiting treatment often being quite blasé and jocular about what was to happen. One by one they would be wheeled behind a screen and ECT would be administered by first anaesthetising the patient, administering a muscle relaxant, placing an airway in place and then applying electrodes to the temples for long enough to administer a brief, low voltage shock to the frontal area of the brain. If done properly the patient moved very little and the convulsion manifested itself merely by a grimace and perhaps the toes turning up for a few seconds. Following ECT we would use a resuscitator to ensure breathing occurred until the muscle relaxant wore off (only a few minutes) and then rolled the patient on their side. After this the patient would be wheeled to the recovery area where recovery would be indicated when they tried to retch out the airway. We would then sit them up and give them tea and biscuits before they went back to their ward or back home if they were out-patients. Mostly they recovered well with a small memory loss in that for a few minutes they couldn’t remember having treatment.

ECT was usually prescribed for people who were seriously depressed and who may not be responding well to antidepressants and was given in courses of six. If there was no apparent response a further course of six treatments was administered and that was usually as far as it went. There were a few people who had intractable depression who came in for a bi-weekly treatment for months on end, clocking up several hundred treatments but these were indeed very few.

ECT was sadly also used as a threat for ‘behaviour’ problems by some of the more recalcitrant patients I which case there was no clinic and ECT was usually administered ‘straight’, that is without anaesthetic or muscle relaxant. This procedure was usually when a patient had become violent and was being held down by several nurses. The ECT machine would be quickly plugged in and the patient shocked while still fully conscious. This produced a violent convulsion unmodified by muscle relaxant and we had to lie across the patient’s legs and chest to stop them having such a violent convulsion that they would break bones. Patients were rendered unconscious and woke after about twenty minutes with violent headaches and disinclined to continue their aggression whether motivated by their illness or by their anger. Usually they were placed in a PR (padded room) to recover with a nervous junior nurse watching them until they were awake when they would exit the room and slam the door on the patient for the next six hours or so, or until the next morning if late in the day.

The sixties were also the time when lobotomies ceased being used regularly as a means of controlling behaviour. A lobotomy was a crude operation where holes were bored into the temples and the frontal fibres of the brain cut through. The idea was to reduce agitated or obsessional behaviour but there were examples when it was used simply because a particular patient was seen as a troublemaker – much like the character of Randle Patrick McMurphy in Cuckoos Nest. More crude still was the practice of the trans-orbital leucotomy of which I probably witnessed some of the last to be done – or I hope I did. This was a leucotomy performed by the simple expedient of inducing unconsciousness by ECT, then pushing a device called a leucotome through the thin bone of the orbital socket (where the eye sits) and the wiggling it through the frontal fibres to achieve the same results as surgical lobotomy. On recovery patients sported the most terrible black eyes for weeks with their faces swollen and unrecognisable. Whether either of these procedures did any good at all is moot. Certainly patients treated this way were more tractable but then they were virtual shadows of their former selves and showed little initiative. I think lobotomy was as much a management tool as a treatment and I saw little evidence of a carefully planned, discussed and clinical approach. Rather the decision to lobotomise seemed to be made in a blasé and offhand way and was predicated as much on the perceived unpleasantness of the patient than for any obvious clinical reason.

There were a range of other treatments in fairly common practice. Prolonged drug induced narcosis (PDIN) was used frequently and patients would be subjected to large doses of major tranquilisers and left in a sedated state for sometimes months on end. In theory PDIN was not supposed to continue beyond twenty eight days but often this was stretched into much longer periods for no particular reason that I could gather. I am unsure whether this treatment made any difference and there certainly was no obvious indication as to why it should be used on one and not another. Our job was to ensure the patients were turned regularly so that they wouldn’t develop pressure sores, clean them when wet and dirty and somehow get liquid food into them which was particularly difficult in their semi-comatose state. Pressure sores were a real issue and happen for no other reason than poor nursing care in that people were not moved often enough and areas liable to pressure sores such as hips, heels and spine were not massaged regularly to make sure circulation is maintained. Pressure sores occur because the constant lying in one position excludes blood from pressure areas and they literally die. I have seen and treated people with deep sores as big as dinner plates in which bones and tissue were clearly discernable surrounded by the necrotic blackness of dead and dying flesh. We did what we could but that wasn’t much and usually included washing with a foaming solution of hydrogen peroxide, paraffin gauze dressings or sometimes honey which did seem to promote healing. So there is truth in some of the old wives’ tales after all.

Much of the above sounds brutal and horrific and in retrospect it was. My dilemma is that at the time I don’t think I saw it as such for I rapidly became as inured to the institutional excesses as anyone else who worked in that grim and grey place. Partly I switched off because it was so difficult to speak out against the system and partly it was because none of us really knew any better. What happened simply happened and the ineluctable pressure to conform and be as others became a survival mechanism and a barrier between us and madness. I think there were very few people who were deliberately brutal or violent to the patients, although there were examples of that. Mostly we simply conformed and did the best we could under the circumstances. The old school nursing staff had their own shortcuts and for some time I wondered why some of them always carried a damp tea towel in the pocket of their uniform jacket. I was to see this device used with great effect on a violent patient who would have the cloth rapidly wrapped around their neck and quickly tightened to produce almost instant unconsciousness as the carotids were compressed. Others would always have a small bottle of ‘useful’ pills in their pocket to dish out to anyone they felt needed calming down, a collection of valium, tranquilisers, or anything else they could just slip a patient they felt was getting out of hand.

The most overarching ‘treatment’ of all was of course the institution itself. Institutional life strips all sense of initiative and social skill from people who reside there in a process called institutionalisation. This is common in any closed system whether it be prison, long term hospital or rest home. What seems to happen is that people reduce to the lowest common denominator and become dependent on the organisation for their survival. Meals turn up at a certain time, they get up and go to bed in routine and everything they do is usually governed by someone else. Thus they become apathetic, listless and lack confidence. The regime plays on this by ensuring that activities are kept to a minimum (especially on the back wards) and so the residents become increasingly devoid of any social skills as they have to communicate with very few people. I was always surprised at how quiet the long term wards were and how often the only sound came from the television or the occasional mutterings of a patient talking to his or her voices. There was little spontaneous conversation and the patients did not converse freely with each other as one would expect from people who had lived together often for many years. Institutionalisation was a great weapon in the treatment armamentarium as it led to patients being quiet and easy to manage. What activities there were, were also routinised and even in the workshops and the garden crews much of the work was carried out with little interaction between patients.

Institutionalisation is insidious but can also occur very quickly. One only has to talk with people who have been hospitalised for a few months following an accident to realise that apart from physical rehabilitation they also have to make a huge step in readjusting to life back home where they have to manage their own lives. And this is people who are ‘normal’ and have good relationships and friendships to sustain them. Home quickly becomes an alien territory where it may take several days or even weeks to readjust. How much harder for people who are already damaged by mental illness and have been in hospital for long periods of time. We nurses didn’t really recognise this aspect of the hospital as we had another life, a social club, friends and relationships. The concept of institutionalisation was not taught at the school, nor was it discussed on the wards. Institutionalisation was something that was just there; patients who had been in the hospital a long time were rarely violent, were calm, quiet and bored. They were therefore easy to manage. How this state had been achieved I suppose we attributed to medication and the ‘calm’ of a long period of hospital care. In this we were perhaps partially correct but we failed to understand the subtleties and the changes that were often irrevocably wrought on our charges.

Mostly I think that in the early sixties people ‘recovered’ from mental illness as much by good luck than from the effects of treatment. Most treatments, especially those directed at psychosis provided some amelioration of psychotic symptoms but did little to relieve the disease. Drug therapies were like a sledgehammer cracking a walnut – too much, too brutal and too imprecise. Anti-psychotic medications produced significant and uncomfortable side effects that in turn required further medication to reduce. Most of the side effects involved lethargy, dry mouth or drooling, rolling upwards of the eyes, tremor, discolouration of the face, repeated movements. Long term use of antipsychotics led to what is called tardive dyskinesia, a condition characterised by repetitive involuntary movements including grimacing, tongue protrusion, lip smacking, rapid eye blinking and rapid movements of the arms and legs. There was no real cure for tardive dyskinesia and symptoms often persisted long after medication was discontinued.

Antidepressants were also in their early development and were mostly a group of what are called tricyclics that also produced significant side effects including dry mouth, constipation, loss of libido and tiredness. Again one wonders whether the cure was worth the effort or whether left to its own devices diseases such as depression would run a course. Such cynical thinking was common. Those of us who saw the debilitating effects of medication began to have sympathy with the anti-psychiatry movement in which the very process of psychiatric diagnosis was questioned. The anti-psychiatrists suggested that diagnosis was an artefact to explain our own failings and social disapprobation rather than to provide a useful treatment tool. When one has worked for four decades in the psychiatric system there is certainly a real sympathy with that idea and the general failings of the medical model.

Other physical treatments, prolonged narcosis, drug induced convulsions, lobotomy, leucotomy and such also had very dubious outcomes and looking back I can recall no instance where such treatment produced any benefit for the patient. Benefits certainly accrued for the staff in that people became easier to ‘manage’ and maybe that was the only reason such brutality continued for so long. I think most of us convinced ourselves that what we were doing was for the greater good of the patient but looking back I believe that we were more concerned with making life a bit easier on the wards. The other and perhaps most controversial treatment was ECT but here I have mixed feelings. Used appropriately ECT is a life saver and can quickly relieve otherwise intractable depression. I have received a course of ECT when in a profound and suicidal depression and have no doubt that it truly saved my life so maybe I am biased. I am sure that most criticism against ECT is about times when it was abused or simply overused. This was, and is, all too frequent but would hate to see ECT dropped from the treatment armamentarium simply because there is an emotionally charged confusion about the nature of the treatment and its abuse.

By the end of my time at Long Grove I had been privileged to work in the closing days of the asylums. And in spite of everything it was a privilege as it gave me an insight into a world that was based on the flimsiest of evidence and had little right to exist. Most of us had good intentions but then the road to hell is paved with those.

So that brings me back to the beginning and my decision to move on. It had been a formative few years and I was now qualified in nursing but the thought of a career following the footsteps of Chalky White and others filled me with disquiet. These places had to go as I was passionate in my belief that the patients deserved better and that somehow, somewhere there was a better answer.