My first job as a consultant psychiatrist was at the Towers Hospital on the edge of Leicester. At the time I believed I had been inspired by such postwar pioneers as Maxwell Jones and Tom Main, who had made asylums more egalitarian and democratic. Now I wonder if I just wanted to work in a Victorian asylum before they were all closed down. The Towers was a red-brick, three-storey structure built around a number of gloomy courtyards, its several wings steeply roofed in dark metallic slate. Under the whole complex ran a tunnel, maybe two hundred yards long, that had once joined the male and female wings of the hospital. In 1986, when I started, most of the admission wards had been moved to the district general hospital, leaving the long-stay wards for adults who suffered from chronic schizophrenia and for elderly demented patients. In the 1930s and 1940s, when asylum populations were at their peak, the Towers housed 1400 or 1500 patients, but by 1986 there were around 4oo. The decline in numbers began after the introduction of Chlorpromazine, the first antipsychotic drug, in the early 1950s.

The hospital stayed open for five or six years beyond its original closing date, but in 1994 we were absorbed into the system. The liberal mood of the public towards mental illness had shifted dramatically in the early 1990s following the publicity surrounding the Silcock and Clunis cases. (Ben Silcock climbed into the lions’ den at London Zoo; Christopher Clunis killed Jonathan Zito in a London Underground station.) The subsequent inquiry, the Ritchie Report, had a profound effect on mental health care: procedures became more formalised, tight systems of accountability were introduced, and it became difficult to act in a way which recognised patient responsibility as the most important element of care. Psychiatric patients were no longer portrayed in the popular press as victims of a harsh uncaring system but as potential killers on the loose. The first consequence of this shift has been that the number of sections – detentions under the Mental Health Act – has increased by a third. The second has been an exodus from the profession: between 10 and 20 per cent of consultant jobs are vacant. What has not changed is the small number of homicides committed each year by people with serious mental illnesses.

It was often difficult to know how the long-stay patients, who were in effect being moved out of their home, felt about the closure of the hospital. There was a definite feeling of apprehension, mitigated sometimes by a belief that the authorities would still look after them; there was a lot of ‘acting out’, supposedly unaccountable episodes of disturbed behaviour as the closure approached. The younger members of staff thought it was the right thing to do: these large hospitals tended to institutionalise the long-stay patients, making it difficult for them to adjust to normal life. (One of the wards in our hospital poured the patients’ tea from a pot that was already made up with milk and sugar; underwear was often washed in batches and not regarded as a personal item.) Many of the older staff, however, took early retirement, or viewed the changes with as much apprehension as the patients, worried that on leaving this isolated community they – like the inmates – would discover that their lives had been ignored, unrecognised, unvalued.

It was weird to be in a large Victorian institution that was closing down, ward by ward, corridor by corridor. Suddenly you couldn’t go a certain way because a wall of breeze blocks had gone up overnight. One day a loo would be handy, the next a padlock would be on the door. I used to go into the chapel sometimes; then that too was closed, its wood carvings and stained-glass windows and miniature organ just another set of lost Victoriana. As the larger spaces were emptied – the porters’ room, the kitchen, the records department – it was possible, if only for a few days, to explore them, with their wooden galleries, hammer-beam ceilings, polished brass pressure gauges, ancient forms of lifting machinery. But my best discovery was a logbook that had been kept by the first physician superintendent of the hospital from the day it opened in 1868.

The ledger recorded a patient’s name, age and physical condition, where he was admitted from, his ‘type of insanity’, and the ‘supposed cause of insanity’. There was also a column describing ‘condition on discharge’ – improved, recovered, dead. A large number of the early admissions died within a few weeks. The reason soon became clear: they had been admitted in a poor physical state from workhouses and hospitals. From its inception, a service for the mentally ill had been used to mop up problems in other parts of the system. After a few months, the asylum gradually began to admit people who seemed to be suffering from genuine mental illnesses. It would, however, be wrong to think of the asylum as a closed community to which few people were admitted and many fewer left alive. Most were discharged within a few weeks or months, and a good number, even the majority, improved or even recovered. And the supposed causes of insanity do not look too different from those found today: ‘financial ruin’, ‘ill usage by husband’, ‘neglect by family’, ‘loss of spouse’, ‘disappointment in love’. The least informative column by far was the ‘type of insanity’, which used its terms imprecisely and interchangeably. Fifteen or twenty cases of mania would be admitted in succession, followed by a dozen of melancholy and a score of demented patients. The diagnostic status of these terms was very shaky.

It has become urban mythology that some women spent their lives in mental hospitals because of illegitimate pregnancy or promiscuity. This is almost certainly true, though early records are often so sketchy that it is difficult to know for sure. Until the early part of the 20th century, it was not possible to admit yourself voluntarily to a mental hospital, any more than you might admit yourself voluntarily to prison. Before the NHS was founded, one of the main preoccupations of mental health legislation was the funding of a patient’s care. The state paid for a patient classed as ‘Pauper Lunatic’ to go to an asylum, but someone found to be poor as a result of moral failure went to the workhouse. Classification as ‘Pauper Lunatic’, ‘Lunatic so found’ (by committee) and ‘Lunatic not so found’ (by commitment to hospital) had substantial financial implications for the patient.

Until the Second World War, there were only one or two doctors in the whole institution. The physician superintendent’s role was similar to that of a modern prison governor. I found another ledger that recorded the minor medical treatment given by him and the reason for it: ‘Leg splintered after falling down a well’; ‘Superficial grazes caused chasing a pig’ (the asylum had its own farm). He lived with his family in a grand villa the size of a rectory, set in the hospital grounds, but with its own garden. The other hospital staff were also resident all year, with only seven days’ holiday. The only other escape, for male staff at least, was the opportunity to take part in the cricket leagues or brass band competitions that were arranged between different county asylums (Elgar’s first commissions were for the asylum band at the Powick in Worcestershire). When not at work, male and female staff were kept rigorously apart, and any staff member who wanted to get married lost his or her job.

Growing up in Glasgow, I knew that bad people went to Barlinnie Prison and mad ones to Gartnavel Hospital. I used to pass Gartnavel whenever I went into the city centre. It’s a grey, bleak but not unattractive building. There was a wall round it, but it wasn’t very high, certainly nothing like the wall that surrounded Barlinnie. From the train you could see people coming and going through a gate at the corner where the wall dipped into a valley. Nobody seemed to use a key and the people using the gate looked perfectly normal, in spite of what I had been told at home and at school. I wondered if the gate and the lowish wall were part of an outer rim of security, with the real barriers much further inside. I ended up working there for a time in the 1970s: before I started my formal training as a psychiatrist I wanted to see what was inside, to see if I could take it. Gartnavel was where R.D. Laing’s best work was done. He demonstrated that improvements in the attitudes of nursing staff could reduce disturbed behaviour in patients more effectively than restraint or drug treatment. In later years, he propounded the theory that mental illness was more an expression of an existential position than a medical problem. This was an extreme view, which understandably offended carers, but it led to the recognition of the importance of social factors for patients with severe mental illness.

One of the basic aims in life was to avoid ending up in either Barlinnie or Gartnavel. Yet although many people had a clear concept of moral rights and wrongs, few had a coherent idea of what constituted insanity. Most people probably thought it best not to worry too much about it: the authorities were there to pronounce on such matters. There was a story in Glasgow of a famously eccentric rich man who paid for a psychiatrist to give him a certificate of sanity.

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