My wife has a habit of forgetting to tell me things. When she was at university, she neglected to tell me that her parents would be moving house before she came home for the holidays and I only found out by accident. She denies that this was an attempt to dump me and says she would have told me “eventually”. Similarly, after we had been living in Herne Hill for a year, she casually mentioned that she was not going to work the next day, but instead would be starting nurse training at King’s College Hospital, just up the road. What made this particularly surprising was that she had never mentioned any interest in nursing before (I should mention that she suggests that I may not have been listening when she told me). I was a bit put out that this was going to make us a very conventional male doctor/female nurse combination, but I learned to live with it.
As we were both going to have clinical placements in various parts of South London, there was no longer any particular reason to live in Herne Hill, and we started to look for a proper flat. My school friend, Steve Hammond, and his girlfriend, Eileen, had the attic flat in a converted Victorian villa right next to Bromley South railway station. When the ground floor flat fell vacant, we took it.
Our new accommodation was not especially conveniently located for either of us. My girlfriend purchased a second hand Honda 70 motorbike and I had to commuted by train, fares paid by the Inner London Education Authority as part of my student grant. From every point of view other than location, it was a major improvement. For a start, it came with an on-site social life. The basement flat was occupied by Sam and Chrissie. Sam was an art school friend of Steve’s who was studying for a Masters in graphic design at the Royal College of Art. Chrissie was a tiny woman who wore leathers and rode an enormous motorbike. They were from Derbyshire, several years older than us and veterans of late sixties hippiedom. In the flat above us were “the Smiths”, a middle aged couple who did not get on very well with us or each other. Communication with them was limited, so that the only name that we had gathered was a surname. Above them, was Steve and Eileen.
Our living room was large, with French windows that opened onto a high veranda overlooking a neglected garden crammed with nettles and buddleia. To the right, we had an grandstand view of the platforms of Bromley South railway station. We could hear all of the platform announcements inside the flat and before long we could recite the stations of the North Kent line all the way to Folkstone. The flat was heated by a solitary gas fire in the lounge. We had problems with damp in the bedroom because it was unheated and adjacent to the kitchen. We became well-acquainted with indestructible domestic black mould, Stachybotrys chartarum, which appeared to be able to live on bleach.
On Monday 11th September 1978, I started my long psychiatry attachment, which lasted until 15th December. Initially we had a block of teaching on psychiatric history-taking and mental state examination. This was held at Clare House, which was the psychiatric outpatient clinic on the St George’s Hospital Tooting site. The teaching block was co-ordinated by a young consultant psychotherapist, Dr Andrew Powell. He had a public school accent and he smoked cigarettes in an amber cigarette holder (he has subsequently denied ever having possessed such an item. It is possible that I am mistaken. It may not have been amber). Andrew was later my psychotherapy supervisor, and in recent times we have become reacquainted, because he has been an advocate for the integration of spirituality into psychiatric practice and I have been very vocal in opposing it. I only ever saw him smoke during that first week of psychiatry, and I have never seen the amber cigarette holder again.
Our psychiatry attachment consisted of six weeks at Springfield Hospital, which was a typical Victorian County Asylum, and six weeks at the Professorial Psychiatric Unit at Atkinson Morley’s Hospital in Wimbledon, a neurological hospital that had the world’s first CT scanner in the basement (at that time known as the EMI scanner after the company that built it). We were allowed to choose which consultants we would work with. Andrew described each consultant in turn, and we made our choice. I chose Theo Schlicht, “an Australian psychiatrist with an interest in trans-sexuality” and Aggrey Burke “a young Jamaican psychiatrist who is interested in personality disorder”.
Springfield Hospital occupied an enormous site that was roughly the same size as the nearby Wandsworth Common. It had been built by Surrey County Council, and it was originally in the countryside. After it opened in 1840, London slowly engulfed it. The wards were in blocks of varying ages, and there were still a lot of workshops and buildings associated with the hospital farm. The farm had provided all of the food for the patients and staff, using patients as labourers, until World War Two, after which it closed. There was a great deal of open space, and the grounds were well-maintained. The older buildings, on the other hand, were crumbling. Medical and nursing staff were issued with hospital keys that were the Victorian originals, gothic in design and so oversized that they resembled theatrical props.
In the spirit of post-War reform at the hospital, the wards had been renamed in the 1950s. In place of letters and numbers, the men’s wards were named after trees, and the women’s wards were named after flowers: Willow, Elm, Yew, Fir, Teak, Dahlia, Aster, Bluebell, Crocus, Narcissus. The names were retained when the wards were made mixed-sex, which was seen as a progressive reform at the time. Mental health units were segregated by gender again in the 21st century, following campaigns about the extent of sexual harassment and assault that women experience on mixed wards. Like the hospital keys, the ward names seem jarringly inappropriate, and added to the sense that the mental hospital was a separate off-kilter world.
I was told to report to Aster ward to meet Theo Schlicht on my first morning at Springfield. One Flew Over The Cuckoo’s Nest had been a recent box office success, and whilst it was fiction set in the past, it did create a certain set of expectations of what a psychiatric ward might be like. These expectations were not positive. I remember a sense of apprehension as I stepped on to the ward for the first time, followed by surprise at the ordinariness of the day room. Patients were sitting chatting with nurses or reading. No one took any notice of me. There was domestic furniture and carpets, a television and a record player. Abba’s LP Arrival was playing (this LP was a fixed feature of mental hospital wards throughout my training. The other LP that was heard in day rooms for many years was Pink Floyd’s Dark Side of The Moon).
Theo was an interesting man and an enthusiastic teacher. He had qualified as a doctor before the Second World War and he was a good physician. He was involved in the St George’s sexual dysfunction clinic and he was knowledgeable about psychotherapy. Indeed, psychotherapy was the dominant therapeutic orientation of St George’s psychiatry for the whole of seven years that I was associated with it.
In the 1970s, attempts were still being made to change people’s sexual orientation to heterosexuality through the use of various psychological techniques. I never saw any evidence of this at St George’s or Springfield. Theo’s interest in the problems of transgender people was not underpinned by a belief that they should or could somehow be “cured” of a disorder. He had a humanitarian interest in helping people who were extremely marginalised. He was empathetic in his interactions with patients and, the icing on the cake, he smoked in ward rounds and clinics. He encouraged me to sit and chat with patients in addition to practicing formal history-taking and mental state examination.
All doctors remember the patients who they saw early in their career especially clearly. I still remember the name of the first mental health patient that I ever interviewed on my own. She was a woman in her 40s who had been admitted the night before. She had had many previous admissions and had a diagnosis of manic-depression (like “trans-sexual”, the term is archaic, but they were both current and were used in the eighth edition of the International Classification of Diseases). She was pleased to talk to me. I had a check list of questions that I was supposed to ask her, but I had no opportunity to use it. She spoke rapidly, with many digressions, but she had talked to many mental health professionals in the past and she knew what I wanted to know. She gave a full but very unstructured account of her life history and her mental health problem. After about two hours, she concluded by telling me she was hypomanic. Then she gave me a piece of paper with her telephone number and home address, in case I should have any problems in the future and needed advice. From the point of view of developing my psychiatric skills, the interview did not seem terribly productive, because all I had done was sat and listened. I was fascinated, and, in retrospect, my willingness to let the patient tell her own story in her own way at such length was a good omen.
I was impressed by the therapeutic optimism on the ward, which was led by a charismatic ward sister, a Jamaican woman called Maggie. Maggie was completely in charge, but she was no Nurse Ratched-style tyrant. She was warm, humane and interested in her patients. Maggie taught me a great deal, both as a student and later when I worked with her during my psychiatric training. The nursing staff spent a lot of time talking to patients and their families. There was loads of activity, some organised by the occupational therapists, some by the nurses. A clinical psychologist was involved with the clinical team, and she saw patients on the wards. Patients were discouraged from sitting about doing nothing. The atmosphere was organised but relaxed, and there was rarely any sense of tension. If patients started to become agitated, the nurses noticed, and engaged with them. I never saw a patient restrained or forcibly medicated during my six weeks on Aster ward.
This may make it sound as if I think the bad reputation of old mental hospitals was undeserved, but there was a completely different picture away from the acute wards. There was a locked ward, with about 20 beds. It was a tense and oppressive place for patients and staff alike. Most patients only stayed there for a few days, but some showed long-term aggression and remained there for months at a time. Patients were restrained and forcibly medicated. Within the locked ward, there were seclusion rooms. These were not padded cells, but they were similar in principle.
In 1978, paraldehyde was still routinely used. This is a safe sedative and anticonvulsant, a fairly simple hydrocarbon that is not water soluble. It dissolves plastic, so it must be administered in glass vessels, including glass syringes. It has an odd, clinical-chemical odour that is unpleasant. It has no impact on psychotic symptoms and it was used solely as a sedative. If patients were injected with it, the injection site often became inflamed and sore for a few days. Similarly, sodium amytal was in use. This is a barbiturate and, like paraldehyde, it is a sedative and anticonvulsant drug, but it is much more potent and dangerous. It causes respiratory depression and death in overdose, which was unfortunate because amytal was very popular with street drug users at the time. I have not seen either drug used in adult psychiatry since the early 1980s. Each consultant looked after their own patients on the locked ward, so there was no consistent team working. The place often seemed slightly out of control, and this scariness fed disturbed behaviour in a vicious cycle. There were no proper mechanisms to monitor the management of patients in seclusion, horrible mixtures of medication were given, interactions between patients and staff were dominated by duress, and the upbeat therapeutic mood of Aster ward was absent.
The so-called “back-wards” were just as troubling. These were long-stay facilities away from public gaze. Each consultant had responsibility for one or two of these wards. They were in the oldest buildings, and they were mostly in poor repair and sparsely furnished. Most long-stay patients had been admitted decades earlier, and had never recovered. They had not shown a good response to the new drug treatments of the 1950s and 60s, and they had been judged too ill or too impaired to be moved out into community facilities in successive waves of deinstitutionalisation. Many of them showed the combined effects of chronic psychosis and institutionalisation. Their case notes were not bulky, as their lack of improvement provoked few entries. There were old-fashioned admission records in the back of the case notes, written in archaic copper-plate handwriting, usually accompanied by an admission photograph. These mug shots were of dishevelled and evidently distressed young people. You could find details of a previous life, which had passed out of reach once the patient had entered the twilight world of the back-ward. These forgotten people were called “old long-stay”. There was a younger cohort, “new long-stay”, who had been admitted more recently and who still received visitors. Some had diagnoses of personality disorder associated with severe and intractable self-harm. Some had chronic psychosis and showed continuous or intermittent disturbed behaviour. Patients from these ‘rehabilitation’ wards filed across the grounds daily to the ‘Industrial Therapy Unit’ where they put screws in plastic bags or packed cutlery for airline meals. It was not clear what the therapeutic component was, because the work looked more like exploitation than rehabilitation to me.
The other group living on the back-wards were elderly people with dementia. The number of people with dementia had been increasing rapidly with improvements in life expectancy, but no one had decide how they should be cared for. The “psychogeriatric” wards were Nightingale-style dormitories, full of people with severe cognitive impairment. Some were agitated, some were serene. Some continually pleaded to be helped, unable to say what troubled them. Although they lived in close proximity with each other, they rarely interacted. Hygiene was difficult in this environment, and there were recurrent outbreaks of gastroenteritis, which sometimes caused fatalities. Everyone agreed that this was not an appropriate form of end of life care, but old age psychiatry had only just started to develop and there was a gap in Government policy. A lot of UK long-stay provision at the time was the workhouse rebranded.
During a visit to a long stay ward, I got talking to a senior registrar, Tom Burns. He was dressed in a dark blue corduroy suit, he had a stylish leather shoulder bag, and he talked with an angry passion about how scandalous it was that patients were being kept in such conditions. He had an impressive certainty that there was a better way. He talked about the potential of community psychiatry to offer more effective and humane care. Tom has no recollection of this encounter with an anonymous medical student, which is hardly surprising. A few years later we became good friends and we still are. He is Professor Emeritus of Social Psychiatry at Oxford University, one of the world’s best mental health service researchers, and a very fine writer and speaker. He still is unhappy with the quality of mental health care in this country, and so am I.
Springfield Hospital had a very civilised doctors mess. There was a small library upstairs, and on the ground floor there was a sitting room. A range of daily papers were available and there was tea and coffee provided three times a day. At lunchtime and coffee breaks, the medical staff came together and discussed patients, scientific papers they had read and politics. I thought that the conversation was of a much higher standard than in other placements. With another student, I had been talking to a man with a diagnosis of schizophrenia who had marked formal thought disorder. This means that his thinking was difficult to follow, combining themes in a way that was hard to understand, including non-sequiturs (known as “knight’s move thinking”) and frequent use of neologisms. Over coffee, I wondered about the effect of thought disorder on his perception of what other people said. For example, would he be able to distinguish the logical from the illogical in what we said to him? We came up with the idea of asking him a thought-disordered question and seeing how he reacted. It is not very easy to spontaneously imitate thought-disordered speech, because you cannot help but think in more coherent ways. Together we wrote a thought-disordered question and I memorised it. Then I went and had another chat with him. I put the question to him. “Sorry” he said “I don’t understand. You’re not making any sense. You’re wasting my time” and with that, he got up and left. We discussed the experiment with the psychiatrists in the coffee room, and it generated a lot of interesting discussion. It made me think about what is preserved during severe mental illness, which is a theme that I have returned to repeatedly and I have published about.
By the time I had been at Springfield for two weeks, I knew that I was going to be a psychiatrist. I was completely engrossed by the subject. The daily journey from Bromley and back took about an hour each way, and I voraciously read psychiatric textbooks and photocopied journal articles on the train. Nothing had ever gripped me so strongly before, except possibly music. I could imagine being this kind of doctor. I was troubled by many of the things that I had seen, but it was clear to me that there were people within psychiatry who wanted change. I had found my natural habitat.