Claire Hilton: Caring for people who are mentally ill—lessons from a tragic past

Claire Hilton, the Royal College of Psychiatrists’s first ever historian in residence, looks at what the mental healthcare of the past can teach us about mental health services today

Two women were admitted as patients to lunatic asylums near London just over a century ago. One returned to her life in the community and lived to 93. The other never left.

The stories of these two women and their completely different experiences provide much to consider and learn from today when it comes to providing support to people with mental illness in order to live fulfilled lives.

Edith, a 42 year old school teacher, was admitted to an asylum in 1913 as a “pauper lunatic.” She was psychotic with religious delusions. While Edith was not a pauper before admission, she was given the stigmatising label to imply that she was financially dependent on the local authority while in the asylum, even if her family contributed towards asylum costs.

Edith’s behaviour and language could be provocative. In 1916, a nurse admitted that she lost her temper and pushed Edith, making her fall and bruise her face. The nurse apologised to the committee that investigated the incident and said she “did not mean to be rough,” but her apology was interpreted as an admission of guilt. She was dismissed, although after similar incidents, other nurses were merely cautioned.

Edith’s admission was long and stormy. Her psychotic symptoms persisted and she became gradually more dependent and eventually died in the asylum in 1934 after more than two decades within it.

Our second patient was Louise. Born in Turkey, after her parents died she managed the family farm and vineyard. She fled the country when her brother criticised the Turkish government. She came to England around 1905 and worked as a nurse. During the first world war, Louise was classed as an enemy alien so she had difficulty getting work and sold many of her possessions just to keep herself going.

In 1917, she paid a coal merchant for fuel to see her through the winter, but he failed to deliver. Exhausted and angry, she smashed the coal merchant’s window. Louise was arrested and sent to prison for a week. She was then released to a workhouse where she refused food—behaviour which led to her being admitted to an asylum. The “acute unsoundness of mind,” which had been linked with the coal incident, resolved. Staff observed that Louise worked well in the needlework room and on the ward. She was later discharged via a convalescent house of the Mental After Care Association (today, the charity “Together”). Louise went on to work again as a nurse and also as a dress designer. She lived until 1978 when she died in London at the age of 93.

Edith’s sad story, of someone who entered an asylum and never left, raises many questions. How much was Edith’s disturbed behaviour due to her psychosis? How much was it due to the asylum’s institutional environment with no privacy and overcrowded wards? How much was it due to insufficient and poorly trained staff who lacked the time and the right skills to support her? Was the nurse’s summary dismissal, for what appeared to be a one-off incident, a sign of a punitive asylum leadership style, which compounded the institution’s culture of harsh treatment of those with little power, including the patients?

In contrast, Louise’s asylum story was a positive one. She was rehabilitated back into the wider world, including work.

Edith and Louise’s stories, as history often does, stimulate thought about current dilemmas.

They had very different mental disturbances that are likely to account largely for their very different trajectories. However, it is striking that Louise was encouraged to develop skills and work and given the opportunity to make her way back into the world through support provided by the convalescent house on discharge. With Edith, while she was encouraged to participate in work and leisure activities within the asylum, there is no indication that attempts were made to rehabilitate her back into life outside the asylum.

Statistics from shortly before the first world war show that around four in 10 people admitted to asylums were discharged within a year. But too many historical accounts of asylums tell a story of care being inevitably custodial and that patients worked unpaidprimarily to subsidise the institutions.

Mental healthcare has come on leaps and bounds in many ways. The very fact that referring to a “lunatic asylum” seems so jarring is itself a sign of progress.

Today, the need for meaningful employment for people with severe mental illness is recognised. The recently published NHS Long Term Plan pledges to provide support for 35 000 more people with severe mental illness through the Individual Placement and Support scheme, to enter and stay in work. However, with recent estimates finding that only 8% of people with chronic schizophrenia are in employment, there is a long way to go.

Worryingly, the recent independent review of the Mental Health Act found that too often the experiences of inpatients was “awful,” partly due to “daily pressures” within our mental health services. The review also found that the strain on services means that “opportunities for early intervention are missed too often,” meaning that too many people who could have been supported to live at home reach a crisis point and need to be admitted to inpatient care. Furthermore, inappropriate out of area placements, where patients are sent away from home as there are no local beds, continue to rise despite the government’s commitment to end these by April 2021. This means that people are physically isolated by long distances from the support of their loved ones and support networks, making recovery and rehabilitation back into their local community much harder. How will historians a century from now evaluate our mental health services in 2019?

Claire Hilton is a former consultant old age psychiatrist, has a PhD in history, and is currently a research affiliate at the Queen Mary Centre for the History of Emotions and a historian in residence at the Royal College of Psychiatrists. 

Competing Interests: None declared