Prestwich.hospital - Daily life in a 20th century psychiatric hospital: an oral history of Prestwich Hospital

Daily life in a 20th century psychiatric hospital: an oral history of Prestwich Hospital

Dr John Hopton

Senior Lecturer

School of Nursing.Midwifery and Social Work

University of Manchester

THANK YOU FOR THE KIND PERMISSION TO USE THIS REPORT

Twenty-five loosely structured interviews were conducted with subjects who had been associated with Prestwich Hospital for varying lengths of rime between 1922 and 1975. The information which these subjects provided was significant for two reasons. Firstly, it provides an account of what life was like in one large psychiatric institution during the middle years of the twentieth century. Secondly, these accounts revealed that even within one institution there were huge variations in the standard of nursing practice. Furthermore, at the lower end of the continuum of quality of care there was little change in nursing practice until the final quarter of the twentieth century.

Introduction Prestwich Hospital is situated about four miles north of Manchester city centre adjacent to Junction 17 of the M62 motorway. Most of the hospital site has now been redeveloped as a hotel, supermarket, petrol station and restaurant, although some regional and local mental health services remain on the site and are likely to do so for the foreseeable future. However, there are several reasons why Prestwich Hospital has a special place in the history of British mental health services. Firstly, in 1910 Prestwich nurses played a significant role in forming the National Asylum Workers’ Union which later amalgamated with other unions to form the Confederation of Health Service Employees and more recently amalgamated with NUPE and NALGO to form UNISON (1). Secondly, the institution was the subject of a book (2) which led to two Royal Commissions of Inquiry into public sector mental heath services in England and Wales during the period 1922 - 1924 (2-5). Thirdly, it has the dubious distinction of having once been one of the largest institutions of its kind in Britain (6).

The author was a student nurse and staff nurse at Prestwich in the period 1975-1981, at which time there was a strong oral history tradition at the hospital with most staff knowing something about long-abandoned approaches to patient-care and staff

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discipline. In 1991, after ten years working in other health authorities, the author took up a teaching post at the then Bolton & Salford College of Midwifery and Nursing which was associated with Prestwich Hospital. However, it soon became apparent that the oral traditions had virtually disappeared and would probably die out altogether as the services on the site were rapidly being rationalised. It therefore seemed appropriate to record some oral histories to complement the archive of artifacts and documentary evidence that was being assembled and catalogued by the hospital librarian and a semi-retired charge nurse.

The significance of the oral histories that were eventually collected was twofold. Firstly, they provided a record of how the hospital evolved in response to the 1930 Mental Treatment Act and the 1959 Mental Health Act. Secondly, and perhaps more importantly, some of the experiences which people recalled represent a very different perspective to that found in conventional histories of British mental health services.

Methodology Altogether 25 interviews were conducted. In the first instance, interviews were arranged with staff still working at Prestwich Hospital. The Northern College of Nursing, and Bolton General Hospital (the site of the other mental health unit associated with the College of’ Nursing). All these interviews were with staff who had worked at Prestwich Hospital for at least part of the period spanning 1958 to 1975. This part of the sample consisted of seven male nurses and three female nurses. One person who had regularly visited a female relative on one of the wards during the 1960s and one male nurse who had worked at Prestwich during the 1970s were also contacted via this network and they were also interviewed. Further contacts were established via letters in local newspapers which yielded 13 more interviewees whose collective experience spanned the years 1922- 1975. This part of the sample comprised seven former female nursing staff, one woman who had been a patient during the 1960s, two former male nursing staff, one former male plumber, one former male clerk and one former female occupational therapist.

While this is a small group compared to the literally thousands of people who had some contact with the institution in the years between 1922 and 1975, it compares favourably with other oral accounts of similar institutions. For example, Sholom Glouberman published 12 from a total of only 60 interviews with workers in 25 different institutions spanning both sides of the Atlantic (7). Similarly, in his book on the history of British mental health nursing, Nolan used an unspecified number of oral accounts from an unspecified number of former and practising nurses to supplement documentary evidence (8).

With one exception, the interviews which form the basis of this study were recorded

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during 1993, and transcribed from tape-recordings during the period 1993-1994. In one exceptional case, the interview was conducted during 1993 and contemporaneous notes were taken.

Inevitably, ascertaining the accuracy and validity of oral testimonies is an imprecise science. However, care was taken to ensure that the interviewees were actually at Prestwich at the time they said they were (9). This was not difficult because - even where the contact resulted from a letter to a newspaper - most people interviewed were either already known to the researcher or a mutual acquaintance was involved in helping to set up the interview. Where there was no mutual acquaintance and the interviewee was unknown to the researcher his/her claims to first-hand knowledge of the hospital were authenticated through indirect questioning about the geography of the hospital and the names of psychiatrists and senior nursing staff. Another factor which should he taken into consideration when recording oral histories is whether or not the interviewee is motivated by anything other than the opportunity to have the undivided attention of the interviewer (10). This is incredibly difficult to evaluate, but in most cases it was clear that the interviewees had a genuine interest in the history of the institution which arose from their sense of having once belonged to a staff community there. In the case of the two non-staff members interviewed their motivation seemed to be an opportunity to tell their story to someone who would not regard it with disbelief.

A further consideration in the collection of oral histories is the question of how the researcher can get the information s/he requires without suggesting answers to the interviewees. The approach which was adopted in these interviews was to begin the conversation by asking for details about when the interviewee first worked at the hospital and what they could remember of their first impressions of the institution. In the majority of cases few other questions were necessary as the interviewee would give a chronological account of how the institution had developed since they first worked there. In these cases, supplementary questions were geared to clarifying points the interviewee was making or asking for more information about particular aspects of hospital life. For example, several interviewees mentioned the hospital dances or hospital sports days, and in those cases the researcher may have asked them to explain more about those events in order to verify the accounts given by other interviewees and build up a broader picture of what these events were like and what residents and staff felt about them. In a few cases, interviewees needed more explicit prompts to help them focus on significant issues. In these situations, the approach used was to ask open questions about various aspects of hospital life such as, ‘What can you remember about the treatments used in the 1930s?’, or ‘What were the relationships between medical staff and nursing staff like when you first started working at the hospital?‘

Care was taken to exclude rumour, hearsay, inaccurately remembered events and researcher bias by the following process. Accounts were only considered to be authentic

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if interviewees had themselves witnessed what they were describing. Accounts were only considered to be accurate if they could be corroborated by another person. (This was usually done by comparing accounts which referred to approximately the same period of time, but sometimes involved informal conversations with people who were not formally interviewed for the research). Any information which was given before or after the tape recorder was in use was disregarded to minimise the risk that the researcher may have misheard, misinterpreted, or inaccurately remembered what had been said.

The data were analysed by reading through the transcripts of all 25 interviews, noting down recurring themes. The transcripts were then reread and passages which illustrated those themes were abstracted and grouped under appropriate headings. These abstracts were then read again and dominant or key themes were identified.

In essence, there are three key themes which emerge from the history of this particular institution. Firstly, there seem to have been few substantive changes to the regime at Prestwich Hospital between the 1920s and the 1970s. Secondly, changes at the level of policy did not necessarily have much direct impact on practice on hospital wards. Thirdly, insofar as Prestwich Hospital was more or less randomly selected for this research (the researcher just happened to be there), and had not been the focus of any official inquiry since 1923 (11, 12), the study raises important questions about mental health nursing’s claim to have been at the forefront of developing progressive and humanistic practice (13, 14).

Where time stood still Few people with knowledge of the history of mental health services would disagree that critiques of institutional care such as those of Barton and Goffman were an accurate reflection of psychiatric institutions in the 1950s (15, 16). However, many basic texts on mental health nursing give the impression that nurses responded quickly to those critiques and soon developed positive regimes (17, 18). The accounts collected in the course of this research suggest that it was a long time before dehumanising routines and unnecessary regimentation disappeared from daily life at Prestwich Hospital. For example, in the 1960s the approach to managing nocturnal incontinence on some wards for elderly male patients was to strategically place buckets around the dormitories, while on male refractory wards some patients were locked in single rooms and had to ‘s1op out’ in the mornings.

On a more light-hearted note, the annual sports days were still a prominent feature of hospital life at this time. On these occasions, all the wards would assemble on the sports field, and the staff and some of the more motivated patients would participate in various types of race. Apparently, these events went on for several hours and refreshments were

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served on the sports held. While sports days and similar recreational events such as film-shows and dances were undoubtedly intended to be entertainment for the patients, individual patients did not seem to have a lot of choice as to whether or not they attended these events. Thus, they seem to be examples of the kinds of ceremonial events which Goffman suggested served to promote a facade of community spirit to obscure the miserable blandness which characterised everyday life within institutions.

By the 1970s, the sports days were no more and unhygienic practices such as those previously described were gradually being eliminated. However, there were still plenty of other archaic practices in evidence. Perhaps the most visible of these was the weekly patients’ dance - a practice which continued until the mid-1970s. While these dances appear to have been a genuine attempt to establish a context in which meaningful social encounters could take place, detailed descriptions of these events suggest otherwise. Most of the wards at Prestwich Hospital were single-sex and were more or less kept permanently locked until the mid-l970s, and the weekly dance is an ‘asylum tradition’ which dates back to the mid nineteenth century (19). Typically patients would he escorted to a central recreation hall by nursing staff where they would be encouraged to dance with patients of the opposite sex, but there would be no contact between the sexes between the dances. Although by the mid-1970s it was not uncommon for patients to have sexual relationships with each other, this pattern of behaviour seems to have been established in earlier years when nursing staff would police the hall to ensure that there was no physical contact between male and female patients between dances.

Other practices which were still going on during this era are less easily explained. On several long-stay wards, especially male wards, patients were expected to spend most mornings walking aimlessly mound the ‘airing courts’ (enclosed courtyards adjacent to wards). It was also the practice on some of the long-stay wards to bath all the patients on the ward on the same day - a process which afforded no dignity to the patients who were obliged to undress, bath, and dress with absolutely no provision for personal privacy. The use of airing courts in this way had ceased by 1975 when the author started working at Prestwich but, even in the late 1970s, it was not uncommon for student nurses to he confronted with this approach to bathing on certain long-stay wards.

It should he stressed, however, that this was not simply a question of ‘older’ staff not having respect for those in their care, and younger more progressive stall having more enlightened views. Many of the staff who worked at the institution in the l930s and l940s had utmost respect for those in their care. However, individual wards were the undisputed territory of their individual charge nurse or sister who might have worked on that ward for decades and thereby defined its culture. If such a person became embittered or ‘burnt out’, their indifference to those in their care could be ‘infectious’:

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If the charge nurse on one ward criticised a nurse on another ward, [that charge nurse] would turn around and say you mind your own business, that’s your ward and this is mine and what goes on here is [nothing to do with you]. Male nurse 1949-1962.

They weren’t feeling nurses at all. The sister on the ward was the instigator of it all. She was the boss of the young staff and they did as she told them. Female patient circa 1963

What I didn’t like was when you saw some of the patients... on the airing court and they had no braces on, no belt on, there were no laces in their boots and they were wandering around dragging their feet, their hands in their pockets. If you asked for anything you got told: ‘Oh well, he’s not worth it’. Male nurse 1963-1967

The smell on the care of the elderly wards took a long time to get used to... If you did something about it you were frowned upon because you were making extra work for the staff... There were some patients that rather than being encouraged to walk to the toilet they were taken in chairs because it was quicker. Female nurse 1970-1978.

On [ ] ward every Thursday or Friday dinner-time the deputy charge nurse would come out and shout: “Socks off!” and they were all eating their dinner and they’d all take their socks off and throw them into the aisle and a nurse would come along with a big brush and sweep them [up] and then we’d sort them all out into pairs to send to the laundry. And someone went round with the clean cocks putting a pair onto each place at the table as he went down. The unwritten rules were the worst; the fact that you couldn‘t say anything about other people or other people’s care and treatment. Male nurse recalling the early 1970s.

On [ ] ward we were sent down to the bathroom and what seemed to be this never-ending stream of patients would turn up with a bundle of clothing and after I’d done about five of them I stopped and followed this line of people back to the dormitory. It was like a constant stream of them coming down the stairs and across the corridor: Male nurse recalling the late 1970s.

Theory, policy and practice

Many of the things which have been described are evidence of an immense gulf between the prescriptions of theory, the intentions of policy and the realities of practice. For example, even though concerns such as dignity and privacy were not emphasised in the literature of mental health nursing until much later, the 1923 edition of The Handbook for Mental Nurses stated that ‘bathing should not be too hurried’ (20). In

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situations where up to 40 individuals were expected to bath in a matter of a few hours using only five or six baths, it was impossible to conform to the demands of this injunction:

There were all these baths in this big room…and then you used to let so many patients in to have a bath. And then you used to get them off into another room, dry them off and they were dressed and off. Then if somebody opened the door the next lot used to be in before the dirty water had drained away, before you could put new water in. You’d try to drive this horde back and there were naked bodies trying to get in the bath before the water ran out. Male nurse 1963-1967.

Bathing was not the only practice which failed to reflect the recommendations about care in contemporary nursing and psychiatric literature. Many other nursing practices were completely out of tune with the ideas about rehabilitation which were expressed in the nursing literature of the time. For example, ever since the publication of Barton’s Institutional Neurosis (21) psychiatric nursing theory had emphasised the importance of nurses organising rehabilitation programmes and recreational activities for hospital residents, but in many parts of Prestwich Hospital such things were not a priority.

There was no talking to patients. If you spoke to them or carried on a conversation you were considered lazy. Female nurse recalling the early 1960s.

I got in touch with the Octagon Theatre at Bolton and they promised to send a team once a week to do drama with the patients. The next thing was [a certain consultant] screamed [at me]: ‘Who the hell are you to organise drama with my patients? I decide what happens in this hospital.’ Female occupational therapist 1966-1973.

I remember one incident where myself and [another student] actually took two footballs into the airing court down on Fours at the Annexe and were playing football. We were more or less told: ‘You are not here to play football. You are here purely to observe.’ Male nurse recalling the early l970s.

The fact that most wards were kept locked, the expectation that patients would walk aimlessly around airing courts and the virtual meaninglessness of rituals such as sports days and weekly dances, also provides a sharp contrast to the rhetoric of mental health legislation and policy. For example, the 1930 Mental Treatment Act supposedly emphasised treatment rather than custody, but this shift in emphasis seems to have been interpreted very narrowly. Certainty ECT and the psychotropic medications discovered

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in the 1950s were widely used in Prestwich Hospital but until the mid 1970s the work of nursing staff remained predominantly custodial. Similarly, the major effect of the supposedly liberal 1959 Mental Health Act was simply to redefine the status of those patients compulsorily detained at Prestwich as informal/voluntary.

While there had been some attempts to introduce occupational therapy in the form of rug-making, woodwork, sewing, or work on the hospital farm since the 1950s (much earlier in the case of farm work) there were relatively few patients who were able to participate in these activities. Consequently, nurses who went to work at the hospital as late as the 1970s could recall some groups of patients being introduced to industrial therapy for the first time. The ‘therapy’ they described was introduced following the closure of the hospital farm and consisted of boring, repetitive, unchallenging work such as packing greetings cards or light assembly work.

Industrial therapy was supposed to provide residents with the opportunity to do light industrial work in a sheltered workshop environment, and thereby gradually get them used to the routine of a normal working day. On the face of it, this would seem to have been a reasonable policy. However, it is questionable whether the job prospects of former long-stay psychiatric patients would have been that good even before the onset of the recession. Furthermore, much of the work consisted of the sort of tasks usually undertaken by lowly paid ‘out-workers’. Consequently, it is difficult to imagine how such work might have contributed to enhancing a person’s self respect or have had any other kind of therapeutic benefit, while it would he virtually impossible for a person to have earned a living wage from such work in the outside world:

They started getting work in from other places: putting cards into envelopes and things like that. There were various things the patients would do depending on their ability: fluffing up material for putting in cushions, making cushions. Female nurse 1959-1972.

[Those] who were able to sit down were able to work, and that consisted of pressing the flip top down on fairy liquid bottles. And if patients didn’t want to be involved in that it was our job to make sure that they did. It was our job to make sure that they worked – a kind of workhouse ethic, to tell them to do it. Male nurse recalling the early 1970s.

The mythology of mental health nursing This is not intended to be a revisionist account of the history of the mental health services of England and Wales. Firstly, the grimness described in some of the above passages was not characteristic of the whole institution. Even in the 1930s it was possible to identify a genuine empathy between some staff and those in their care:

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I went to the staff dance and I had a new dress – a long one – and [this particularly disturbed patient] said: ‘Will you come in and let me see it?’ I said yes, so I went in early and I went to her room and I had to twirl round and let her see how it flared out. She was thrilled to bits with this dress. Female nurse 1937- 1976.

In the 1970s the contrast between the drudgery of the ‘back wards’ and the more progressive parts of the hospital was accentuated by the opening up of new units specialising in psychotherapy, alcohol-related problems, rehabilitation/resettlement, adolescent psychiatry and forensic psychiatry.

Secondly, there is no explicit evidence to indicate that the history of other institutions paralleled that of Prestwich Hospital. On the other hand, there is sufficient circumstantial evidence to suggest that Prestwich was not unique. Thus, the value of this study is that it reveals how the history of individual institutions may be hidden from view in ways which distort historical accounts which are based solely on documentary evidence.

For example, two of the core themes of the 1968 Review of Psychiatric (sic) Nursing were that the patient was an active participant in his/her treatment and that psychiatric nurses were highly skilled in psychotherapeutic interventions. It is difficult to reconcile these images with the awful blandness and disregard for patients’ dignity which characterised life on some of the long-stay wards of Prestwich Hospital until the mid 1970s. Furthermore, these accounts challenge the view that the hospitals which became the focus of official inquiries throughout the late 1960s and early 1970s (22) were aberrations from the norm.

If a balanced view of the history of mental health nursing is to be established, there is a need for more oral history work such as that which has been described. Only by comparing similar accounts of different institutions will it be possible to ascertain what was typical of psychiatric/mental health nursing practice. The gulf which exists between what is implied by the 1968 Review of Psychiatric Nursing and the reality of life at Prestwich Hospital demonstrates that.

Finally, work on the history of nursing is not merely of academic interest. Currently there are several competing discourses of mental distress and mental health care which seek to influence social policy in this area. One of these discourses is highly critical of the closure of the large psychiatric hospitals and argues for the provision of more hospital beds. If policy decisions are made in response to this ideology it is important that the pitfalls of institutional care are openly acknowledged and that it is not simply

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assumed that mental health professionals responded positively and constructively to the critiques of writers such as Russell Barton and Erving Goffman.

References

1. Nolan P. A History of Mental Health Nursing. London. Chapman & Hall. 1993.

2. Lomax M. The Experiences of An Asylum Doctor. London. George Allen & Unwin. 1922.

3. Jones K. After The Asylums. London. Athlone Press. 1993.

4. Butler T. Mental Health, Social Policy And The Law. Basingstoke. Macmillan. 1985.

5. Nolan P. A History of Mental Health Nursing. London. Chapman & Hall. 1993.

6. McWhirter N. et al (Eds) The Guinness Book of Records. Enfield. Guinness Superlatives. 1983.

7. Glouberman S. Keepers London. King Edward’s Hospital Fund. 1990.

8. Nolan P. A History of Mental Health Nursing. London. Chapman & Hall. 1993.

9. Thompson P. Oral History - The Voice Of The Past. Oxford. Oxford University Press. 1988.

10. Thompson P. Oral History - The Voice Of The Past. Oxford, Oxford University Press 1988.

11. Butler T. Mental Health, Social Policy And The Law. Basingstoke. Macmillan. 1985.

12. Nolan P. A History of Mental Health Nursing. London. Chapman & Hall. 1993.

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13. Ministry of Health. Psychiatric Nursing Today and Tomorrow. London. HMSO. 1968.

14. Department of Health. Working In Partnership. London. HMSO. 1994.

15. Barton R. Institutional Neurosis. Bristol. J. Wright & Sons. 1959.

16. Goffman E. Asylums. Harmondsworth. Pelican. 1968.

17. Ackner B. Handbook for Psychiatric Nurses. London. Ballière, Tindall & Cassell. 1964.

18. Burr J. Budge U.V. Nursing The Psychiatric Patient. London. Ballière Tindall. 1976.

19. Showalter E. The Female Malady. London. Virago.1987.

20. Royal Medico-Psychological Association. Handbook for Mental Nurses. London. Ballière Tindall. 1923/1939.

21. Barton R. Institutional Neurosis. Bristol. J. Wright & Sons. 1959.

22. Martin JP Hospitals In Trouble. Oxford. Basil Blackwell. 1984