Asylum Years: Interview with the authors

The following post is from Jonathan Gadsby:

Asylum Years: Back to the Future? Glimpses of Institutional Life in the 1970s by Robert Hayward and Andrew Heenan is likely to be of real interest to mental health nurses engaged in thinking about our profession’s past, present and future. The book will be published in March 2025, by Free Association Books.

The following post reflects my personal engagement with this book and an interview with the authors.

The authors introduce themselves as ‘elderly men’ whose motivation for the book began in a conversation over a bottle of wine during lockdown. Towards the end of their careers, their thoughts return to the beginning: becoming student nurses in the early 1970s in a large asylum on a hill outside Canterbury. Far from being a series of dimly remembered events, the book contains precious recollections of people – patients and staff – forgotten by history. It describes institutional norms, replicated at that time throughout the country. The authors have clearly spent many years learning and reflecting on those experiences and the directions that mental health care and mental health nursing have taken since.

The book is comprised of five sections. The central three are stories and snapshots of people, places and happenings within the massive hospital, St Augustine’s, some fifty years ago. The prologue and epilogue are the authors’ shared thoughts and scholarly engagements with the themes presented.

JG: Reading this book was a wonderful and poignant experience. It is set half a century ago, while my own career in mental health nursing reaches back half-way towards that period. The authors saw the beginnings of the closure of the asylum; I lived and trained in a former asylum of 2000 beds that had mostly closed and become student flats and a nursing school affiliated with a university. I had other placements on wards at an out-of-town Victorian asylum that was almost all boarded-up, set in separate units in woodland. Many of the oddities and stories of this book, the tragedies it describes and, yes, some of the legacies of care too, were visible just under the surface of that place, a generation later. A few patients from the same era were indeed still there. While reading about St Augustine’s, I found myself recalling past patients and staff very clearly. I felt a rush of gratitude to the three staff nurses I first met, known to me now only as Welsh Nicki, Dave and Dave, for their example of thoughtfulness and care amid what they would have freely admitted was a bizarre world. And it was, in many ways, awful.

Although the focus is most certainly on people and events, Asylum Years has many important messages for mental health nurses of the present day. Robert and Andrew very kindly consented to be interviewed:

JG: Are there any myths about the past that you feel Asylum Years helps to dispel?

RH: One obvious is that these people were not less than human, part of a faceless collective or essentially ‘alien’. In the book we compare the experience of the custodians and ‘the forgotten’ which reveal many similarities and shared experience – for example, one that was picked up in the story ‘Then and Now’. We have attempted to portray people as real and in a much more human light than hitherto. The focus on the institution tends to place the blame on the buildings and the system rather than on societal attitudes and the people who were aware of the problems of the institutional system, but carried on nevertheless. Dispelling past myths is relatively easy – it’s challenging current thinking with its asylum legacy and enduring stereotypes and public perception which is more problematic.

AH: Many people have a cliched view of asylums – a cross between dark gothic halls and something out of cheap horror movies. I hope we’ve shown a more human side – a more mundane side too.

JG: Yes! The story about the food-waste bin, the decades of discarded tablets, the pigs and the illicit staff bacon breakfasts laced with tranquilizers will stay with me for a long time: somehow simultaneously hilarious and terrible! Why was it so important for you write a book that contained so many stories?

RH: The book contains a number of stories, but these only represent the tiniest fraction of the millions of stories that have never been properly told. Millions of lives have been consigned to the dustbin of history – e.g. in 1904 there were 100,000 people residing in asylums in the UK. This was only 50 years from the establishment of the first public institutions. Who knows how many people lived their lives in these bleak establishments in the 70 years before the authors fetched up in the asylum? And this is not to mention the staff who presided over these places over the past 125 years! This snapshot only provides a very limited insight into a system and institution that was perverted and insidious which rendered people’s lives as useless; an oppressive and contained world where many of society’s normal rules or entitlements could be subverted, inverted, withdrawn, denied or altered. Most stories have been forgotten, covered up or rendered inconsequential. Ours is but a modest attempt to rectify the situation before those who witnessed these things are no longer with us to challenge or contest other versions of these events.

AH: Nostalgia is not to be sneezed at. In our dotage, we enjoy revisiting those times; the bad times as well as the good. We’re also very aware of our own mortality. Getting these stories on paper will hopefully keep them alive a little longer, a way for ‘the forgotten’ to be remembered. We set out to respect those memories, as well as preserve them.

JG: One of the thoughts the book provoked for me is that there have always been nurses who are shocked when they first encounter dehumanising elements within in-patient psychiatry and who become determined to try to make it different. Others, however, seem very vulnerable to the conforming power of institutions. Do you feel your exploration of St Augustine’s the early 1970s, or your experiences since, can shed light on what factors help to decide which response student nurses will have?

AH: I think there are two main aspects to that. Part of it is what we bring with us, and the selection process should be focusing on existing attitudes in candidates for nursing. The other key point for me is the nature of the support we have around us. We were lucky, in that we had a Principal Tutor, W. Keith Newstead, who was committed to raising standards at St. Augustine’s. I started as a Nursing Assistant, and while I had some support from colleagues in the nurses’ home, it wasn’t until I was invited to the School of Nursing that I could discuss some of dreadful things I’d seen with someone who could dispassionately review my experience and advise me how best to proceed. While it’s fair to say he was recruiting, his comment that ‘while you’re a nursing assistant, I can’t help you. But once you’re a student, you will always have my support’ struck a chord and probably changed my life. Certainly, it changed my career. Becoming a student nurse gave me the confidence I hadn’t had before. I worked with many students who had been appointed ‘pre-Newstead’, and a lot of them were thoroughly institutionalised. On my first day, I saw a student holding the patient for a staff nurse to hit him. I never, ever saw such behaviour from later students, though, of course, some were better than others – and many were better than me!

RH: Much of the response by nurses, certainly the younger ones, was context-dependent. By that I mean it was the 1970s and a time when the counter-culture was at its zenith, so it was easier to not conform. This works both ways as Andrew suggests. This is explored in more detail in the Prologue in the book. Another aspect might be that, as Andrew suggests, we had support, not just from some individuals, but from being part of a larger community – which may not be the case today as nurses work in smaller groups or in smaller units and sometimes in isolation. In our experience in the early 70s not all trainees were young, unlike many of today’s intakes. Life experience does account for something in my view.

JG: The main era of the book is the early 1970s. Viewed from the present, a contemporary mental health nurse can really sense the five decades of progressive deinstitutionalisation that has taken place, and why it was so necessary. Do you think that there are improvements within modern mental health care in the UK, or elsewhere, that cannot be attributed to deinstitutionalisation?

AH: I can’t comment on current practice, as I’ve been away from mental health nursing for too long. But I do know that it hasn’t all been improvements. ‘Care in the community’ saw many long stay patients effectively abandoned with little preparation for post-institution life, and hardly a week goes past without more examples of neglect: from an outsider’s point of view, the care of young people with mental health problems is far from adequate. I’m not criticising the professionals, it’s really a matter of resources. Asylums, for all their faults, provided a safe place for vulnerable people. We’ve lost that forever.

RH: Deinstitutionalisation may have taken place but the position of today’s mental patient has changed very little. People with enduring mental illness are still regarded as ‘other’ and experience real hardship and generally poverty in today’s society. In the final section of the book we look at current practice and provide evidence that all is not well in mental health services, despite improvements. The fact that deinstitutionalisation has only a little part to play in that. Rather than developing new services, the relocation of new services will merely reproduce old services in new places.

JG: Referencing Bracken and Thomas, and Barham, you raise the suggestion that if psychiatry can be seen as a product of the institution, we should wonder about its ability to shape post-institutional care, and that what has happened is arguably that the same segregations and uses of legal force and coercion have merely been transferred to another setting. How would you respond to the further argument that the deinstitutionalisation of mental health services, rather than diminish psychiatric power, has allowed it to grow and to colonise the public with its logic and treatments?

RH: Bracken (and others) have argued that psychiatry can be seen as the product of the institution and therefore shapes post-institutional care. At one level one could agree with that statement, pointing to the medical hegemony that still dominates mental health care today. Another view might be that the institution is the product of psychiatry (and its failure to address long-term mental health problems, except by exclusion, segregation, control, legislation) which are at the basis of health care policies today, despite the rhetoric of community care, patient centred care, advances in pharmacology, etc. etc. This is further explored in the final section of the book. Psychiatric power continues to maintain its powerful influence although there is some resistance from service users, families and grassroots organisations, and alternative paradigms such as ‘mad studies’.

JG: Nurse education has changed significantly since the 1970’s. There have been periods in which efforts have been made to integrate mental health nursing with the other fields of nursing, and periods in which more separation has occurred. At present, a mental health nursing student in the UK may only have a few weeks of field-specific classes during the three-year degree. Does taking a long view shed any light on whether this is important? What priorities does that longer view suggest?

AH: There’s no doubt that a university education has given nurses a deeper understanding of mental health and the nurse’s role. But they do miss out on supervised practice, and I suspect the learning curve after qualifying is pretty steep. There’s no easy answer to how far the different branches of nursing could or should be integrated. But there’s no doubt that a knowledge of general nursing can be a huge advantage to a psychiatric nurse, particularly when working with elderly people, in whom many – if not all – of their symptoms can be due to physical health issues, from constipation to anaemia secondary to rectal carcinoma, from diabetes to malnutrition.

RH: Here I’m at slight variance to my colleague. Nurse education is uncertain in its direction. It has been subject to many changes over the past 10-20 years. The bid to academically ‘professionalise’ nursing has not been able to provide nurses with the training or knowledge to work effectively with people who use services. The fact that current training continues to espouse a medical model and is generally fragmented exposes its inherent weaknesses. Nurse education continues to follow an administrative rationalism model which purports to be ‘scientific’ or ‘evidence-based’ – but whose evidence? In my opinion it fails to prepare nurses for some essential skills, some of which can be learnt, but others, like empathy, listening skills, may be more instinctive. Medication, medication, medication! Policies continue to be ‘top-down’ whereas involvement of a greater range of actors and grass roots community development might be a better way forward. Nursing education does not really reflect this, rooted in its historical legacy.

JG: Thank you so much. So much to think about. I’m going to recommend your book to every mental health nurse I know!

Robert Hayward graduated with a B.A. in Social Psychology and Social Policy from the University of Kent in 1984. He has over 25 years of experience in community health and NGO development, working extensively in Central and Eastern Europe and beyond. Robert founded InterAction, a charity promoting mental health inclusion, and works as an independent consultant. He is the author (with Peter Barham) of Relocating Madness (Free Association Books).

Andrew Heenan qualified as an RMN at St. Augustine’s Hospital in 1975 and graduated with a BA (Hons) Sociology and Politics from the University of Kent in 1983. He had a career in nursing and journalism, including Clinical Editor of Nursing Times, TV documentary work and as a Trustee of a mental health charity.

The book will be available to purchase from the end of March at Asylum Years: Back to the Future? | Free Association Books, and can be pre-ordered at other online book-sellers.