Sixty years in psychiatry

Training

In 1954, after obtaining my full registration, I was obliged to do National Service. I was drafted into the RAF and found myself as a lone Unit Medical Officer on an RAF Station in the North East which I found mind-numbingly boring. An invitation to apply for a training post in neurology and psychiatry at the headquarters of the RAF Neuropsychiatric Centre based at Halton in Buckinghamshire saved my sanity and was my initiation into a psychiatric career.

Under the wise direction of my CO, Wing Commander O’Connor (later Air Vice Marshal), I learnt a great deal. Much of my time was spent assessing the suitability of other national servicemen to remain in the services. In addition, I was appointed as MO in charge of the deep insulin therapy unit. It is not clear to me as to why a youth developing schizophrenia while in the services should be treated by the RAF as it would probably have been simpler to transfer them to a civilian psychiatric hospital. Deep Insulin or Insulin Shock Therapy had been introduced in Vienna in 1927 and involved injecting schizophrenic patients with large doses of insulin on a daily basis putting them into hypoglycaemic coma, then replacing the blood sugar through a nasogastric tube, followed by a large breakfast. After a few hypoglycaemic fits, on up to 20 sessions, the patients became obese and passive but functioning as a group with a lot of nursing attention. After a few weeks, delusions and hallucinations would reassert themselves. The theoretical basis of this treatment has always remained a mystery to me, and I was appalled when one patient in my care died despite both gastric and intravenous glucose. This treatment was very popular in the 1950s, although psychiatrists became increasingly disillusioned by it, and the neuroleptic drugs such as chlorpromazine were introduced and found to be more effective in controlling the symptoms of schizophrenia. Dr William Sargant with whom I worked later at St Thomas’ Hospital was an enthusiastic user of Insulin Shock for some years and other more dramatic forms of physical treatment for psychiatric disorders.

In the 1950s and 1960s, most psychiatric treatment was carried out within the old lunatic asylums, often accommodating as many as 2000 patients. However, during my training, I was not involved in what used to be known as the catchment area hospitals. Over a 10-year period, I spent my time in the more selective general hospital units attached to London teaching hospitals. There also remained a certain dichotomy between psychoanalytic training and what might be called everyday psychiatry involving various forms of physical treatment and supportive or less elaborate psychotherapy. There was encouragement to undertake analytic training, but it was time consuming and expensive, and in my case, I feared it might uncover things about myself that I would rather not know. Psychologists with their cognitive therapies were not in evidence then and the small number that were employed within the NHS were generally engaged in doing IQ tests or personality profiles without any therapeutic involvement.

The one form of physical treatment but with a psychological content was the use of so called ‘truth drugs', either sedatives (barbiturates) or stimulants (amphetamines) and for a short-period LSD was used (sometimes precipitating a psychosis) as a shortcut way of getting the patients to unburden themselves. This had a certain dramatic appeal for young doctors, myself included. For a while, aversion therapy for alcoholics was popular (although not with many patients). It involved giving the patient a drink with encouraging words like ‘Cheers’ or ‘One for the road’ then giving them an injection of apomorphine which would then make them vomit and hopefully associate drinking alcohol with vomiting. They were of course also encouraged to attend AA Meetings which were probably much more effective in helping sufferers to maintain temperance, although some found taking a form of medication that would interact with alcohol if consumed a helpful warning to keep them away from any form of alcoholic drink.

Although penicillin was in regular use, GPI or general paralysis of the insane (neurosyphilis), famous for grandiose delusions, was still being treated with malaria-induced fever. When I was working in psycho-endocrinology in 1956, the neighbouring hospital, the Mott Clinic, even bred its own mosquitos.

Group psychotherapy – of which AA, drug addiction groups and anger management are examples – became more popular in the early 1960s even though it had been used in some units for treating ex-servicemen and women after the war and some hospitals were being run on therapeutic community lines, opening the way for personality disorder units such as the Henderson Hospital.

After spending some five years under Dr William Sargant (whose psychological sensitivity and interest in psychological treatment was minimal) at St Thomas’ Hospital, I learnt a great deal about various forms of physical treatment, many of which I rejected after I became a consultant myself. Electroplexy (ECT) was used far too frequently and in many cases, inappropriately. The more sparing use of ECT can be a life saver in severe depression and is one of the treatments that have survived the test of time. The same too may apply to psychosurgery, although this is still used sparingly and only in Wales and Scotland, mainly for patients with severe obsessional illnesses. I have seen a number of patients who have undergone personality change, and developed epileptic seizures, even with the more refined forms of psychosurgery.

The tricyclic and monoaminoxidase antidepressant drugs were introduced in the late 1950s and were used enthusiastically, often in disastrous combinations by those advocating physical treatments.

In 1964, I was offered the job of Associate Director of a general hospital unit in the United States working under the overall direction of Dr Nathan Kline who was one of the pioneers in the use of antidepressants. He himself was based in one of the enormous mental hospitals with 10,000 beds in New York State. At this time, American psychiatry was dominated by psychoanalysis concentrated inevitably in the private sector. For those with psychotic illnesses or dementia, there was no alternative to the enormous human warehouses where they had minimal custodial care. My job was akin to the observation wards in the UK when patients were given short bouts of treatment, mainly physical with a bit of superficial psychotherapy then, if still mentally ill, sent to one of the One Flew Over The Cuckoo’s Nest 10,000-bedded hospitals. It was a great experience working in the United States, but I was keen to return to the NHS and my native country, so about 18 months after my migration, I obtained a consultant post in London.

My mother had been brought up in North London and although I did not fully appreciate what she meant by it, she had often warned me as a child that if I behaved badly I would end up in Colney Hatch Lunatic Asylum, which is where I did indeed end up but as a consultant, and the name had been changed to Friern Hospital. I was informed by the Regional Board that appointed me that I would be responsible for some 500 beds (of the 2000) but, as if that were not enough, I would also be required to do outpatient clinics and liaison service at two other hospitals – in North London at the Royal Northern and the Whittington and also to provide liaison services to the City of London Maternity Hospital and occasional visits to Holloway women’s prison.

In 1965, I was still reasonably young and keen to establish myself as a Consultant Psychiatrist. Although on a lesser scale, than in the USA, Friern Hospital had become a home for many chronic schizophrenic patients and those suffering from dementia. There was a more refined unit with its own consultants in the grounds which was reserved for neuroses, but the main hospital had four consultants – one of whom was the Medical Superintendent. There were, of course, acute admission wards, and the hospital served a large catchment area of North London, so the consultants were also obliged to do home visits.

Shortly before I arrived at Friern Hospital, a psychotherapist, Barbara Robb, ² made some visits to the hospital and was appalled at the inadequate and inhumane treatment. She wrote a book called Sans Everything – A Case to Answer and included a description of the conditions in some of the other large mental hospitals circling London. Following this, the Medical Superintendent resigned and as a newcomer I was made Medical Director. My lack of experience of mental hospitals was considered an asset! My colleagues were very supportive as were the bosses at the Regional Board. I also received quite a lot of support from the local MP who would conscientiously have lunch with me every six months. She told me that in the House of Commons, they had always joked with her that the only reason she got elected was because she had so many lunatics in her constituency. Although we did not always see eye to eye politically, this MP, whose name was Margaret Thatcher, proved very useful in obtaining funds for increased staffing. I was also approached by the Dean of the Royal Free Hospital Medical School, Dame Frances Gardner, who wanted to expand the undergraduate psychiatry teaching, and within a few years, a professorial unit headed by Professor Gerald Russell was fully established in Friern Hospital, geared to both undergraduate and postgraduate teaching.

The 10 years from 1966 to 1976 were busy ones. Governments, both Conservative and Labour, had taken on board the need to revolutionise the mental hospitals and eventually close them. The climate of public opinion was changing and there was an awareness that incarcerating and institutionalising people with mental illness or brain damage was both inhumane and unacceptable. Even the vocabulary had changed – mental subnormality became learning disabled and people with longstanding schizophrenia or almost any other psychiatric disorder had ‘mental health problems’ which did seem to relieve some of the stigma attached to psychiatry.

Plans were going ahead for the opening of District General Hospital Units. Community Psychiatric Nursing was organised and great efforts were being made to rehabilitate patients to enable them to return either to the community or some form of sheltered accommodation. We were all inspired by the work that was being done in Colchester (Dr Russell Barton) and Cambridge (Dr David Clark) in this respect – apart from appointing more consultants and junior medical staff, the expansion of occupational therapy and industrial therapy (or IT, not to be confused with information technology which had yet to be invented!).

By the time I left in 1976 to take up my post at the new unit of the Whittington Hospital, the number of patients had been reduced to about 1000. The hospital was eventually closed in 1993, and it has since become a luxury housing development, in the same building with its mile long corridors, advertising exclusive spacious apartments. It has also acquired a new name – Princess Park Manor, with grounds described as ‘mature parkland’.

It is true that the old mental hospitals did offer real asylum for many very vulnerable people. For instance, before I started work there, Friern had its own farm of 75 acres, a gasworks, a brewery and an aviary where canaries were bred – the patients became involved in working in the farm and laundry for small rewards which I suppose was some form of industrial therapy, and certainly many patients regarded it as ‘home’. I vividly remember one long stay patient – a middle aged woman who paid me, I suppose, a compliment by telling one of the nurses that I would come and visit her every other night for some sexual liaison. This was not a complaint although I might well have been in trouble if the matter had been raised with the General Medical Council. However, the nurse asked her what happened on the intervening nights and she replied that she reserved those for the Duke of Edinburgh!

Legislation

A series of Mental Health Acts have in many ways liberalised and humanised treatment of the mentally ill but other Acts of Parliament also had a liberalising effect. There were three landmark Acts of Parliament in the 1960s that had a particularly significant effect.

The first was the Suicide Act in 1961. Prior to the passage of this Act, it was a crime to commit suicide and anyone who attempted and failed could be prosecuted and imprisoned, while families of those who succeeded could also potentially be prosecuted.

The Abortion Act in 1967 made abortion legal in the UK up to 28 weeks’ gestation, although this was later amended to 24 weeks. Unwanted pregnancy, whether due to contraceptive failure, rape or incest was often a precursor of severe depression or suicide.

The Sexual Offences Act of 1967 acting upon the recommendations of the Wolfenden Report published 10 years earlier was responsible for relieving an enormous amount of psychological distress among men with homosexual orientation, who became depressed with feelings of alienation or involvement in clandestine activities which remained illegal. I think it was some time in 1957 that I was asked to give aversion therapy to a man who had got married, but was finding it very difficult to square this with his orientation. The consultant who had prescribed this sort of treatment was, I think, a bit naïve but he managed to obtain some photos of nude men (via I think the Home Office), and I was asked to show a picture to the patient and then give him an injection of apomorphine (as for the alcoholics) in order to associate being sick with sexual arousal. Not surprisingly, this had little effect and the patient himself said, after this treatment had been completed, that the only thing that made it bearable was looking at the pictures. Of course, in those days nobody dreamt that there would be an acceptance of both male and female homosexuality to the extent of Civil Partnerships or even same sex marriage.

Suicide, abortion and homosexuality had all been regarded as sins by the Church and the Acts of Parliament represented not just liberalisation but also secularisation.

Conclusions

Notwithstanding the myth of mental illness espoused by Thomas Szasz in 1960 and the anti-psychiatry philosophy of RD Laing, psychiatry does seem to have retained its medical base even though working closely with psychologists, self-help groups and other social agencies.

Some of the more dramatic and dangerous forms of physical treatment have been discredited and discontinued such as deep insulin therapy. ECT is still used but indications for it have been refined. Psychosurgery is now used very rarely, whereas in the early 1960s, indications for its use were much less restricted.

When I began psychiatry, padded cells were still in use and when I worked for a short time in Paris at the clinic of Professor Delay, who pioneered the use of neuroleptics, in order to observe his use of chlorpromazine, they still used the ‘camisole de force’ or straight jacket.

Before the introduction of chlorpromazine and similar drugs, patients were sedated with barbiturates and the evil smelling paraldehyde, an odour that permeated the corridors of the mental hospitals. The introduction of benzodiazepines was at first heralded as a great advance as they were thought to be non-addictive, whereas now patients sue their doctors for compensation for allowing them to become hooked on these drugs. Even the more recently introduced anti-depressant drugs, useful although they are when used appropriately, can have a downside insofar as they may give a depressed patient enough energy to attempt or commit suicide.

Aside from the expense, the uncertain outcome and length of time involved, classical psychoanalysis has little place if any in the treatment of psychiatric illness nowadays, even though the insights provided by analytic theory into the dynamics of a patient's background can be very helpful. One of the major hazards of classical psychoanalytic therapy has been an inability to conclude it, on the part of both patient and therapist. I have even seen a case in which the patient attempted to sue his analyst for failing to arrange a gradual discontinuation of therapy after 20 years, and the NHS for not providing immediate alternative care.

After a long association with the Medical Protection Society and some years as its Chairman, I have developed an interest in medical negligence. I was once asked by a fellow passenger on a plane who had heard me being addressed as ‘Doctor’, what I did. I replied ‘mainly medico-legal work’. He seemed puzzled then asked what needles I used – assuming I was involved in some sort of medical needle work! Perhaps, that would be a soothing way to spend retirement!