History of Psychiatry Podcast Series

In this podcast, Professor Houston talks about the psychological impact on those affected by the Aberfan disaster of 1966. The podcast expands on an interview Prof Houston gave to BBC Wales as part of a series of podcasts recently produced about the disaster. It is strongly advised that you listen to podcast 7 of the BBC series prior to listening to this podcast. https://www.bbc.co.uk/sounds/brand/p09z3n7y Further reading: https://www.nhs.uk/conditions/electroencephalogram/ Iain McLean and Martin Johnes, Aberfan: government and disasters (Cardiff: Welsh Academic Press, 2000), especially chapter 5. Morgan, L., Scourfield, J., Williams, D., Jasper, A., & Lewis, G. (2003). The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry, 182(6), 532-536. doi:10.1192/bjp.182.6.532

Devolved psychiatries - Professor Rab Houston by Professor Rab Houston

Prof John Crichton - Consultant Forensic Psychiatrist and Chair of the Royal College of Psychiatrists in Scotland. What is a forensic psychiatrist? Far from the media stereotypes forensic psychiatrists are not so different to other doctors but working at the most extremes of human experience. Any one of us may have a mental health problem. Very rarely that problem may result in an inability to control ones actions and may lead to direful consequences. Forensic psychiatry is all about helping people recover their lives after such life changing events and by placing the care and treatment of patient at the centre ensuring everyone’s safety.

This is a 50 minute audio file of a talk I delivered at the National Records of Scotland on 7 August 2019, in connection with my hugely successful exhibition that they kindly hosted: ‘Prisoners or Patients? Criminal Insanity in Victorian Scotland’. It explains the records I used and the development of the criminal justice system’s attempts to deal with those who had committed serious offences, but were found to be insane and thus not responsible for their actions. The justice system faced the same problems as today and dealt with ‘prisoner-patients’ or ‘state lunatics’ (as they were known) in a remarkably humane fashion, given the constraints of limited resources, basic medicine, and different social attitudes 150 years ago. The talk explains in depth who the offenders were and what they had done, the processes for admission to, and release from the only such specialist facility in Scotland prior to the opening of The State Hospital at Carstairs in 1948, medical and scientific understandings of insanity, and the social context of Victorian Scotland.

Professor Rory O’Connor, Suicidal Behaviour Research Laboratory, University of Glasgow Suicide and self-harm are major public health concerns with complex aetiologies which encompass a multifaceted array of risk and protective factors. There is growing recognition that we need to move beyond psychiatric categories to further our understanding of the pathways to both. As an individual makes a decision to take their own life, an appreciation of the psychology of the suicidal mind is central to suicide prevention. Another key challenge is that our understanding of the factors that determine behavioural enaction (i.e., which individuals with suicidal thoughts will act on these thoughts) is limited. Although a comprehensive understanding of these determinants of suicidality requires an appreciation of biological, psychological and social perspectives, the focus in this podcast is primarily on the psychosocial determinants of self-harm and suicide. To this end, The Integrated Motivational–Volitional (IMV) Model of Suicidal Behaviour (O’Connor & Kirtley, 2018; O’Connor, 2011) is discussed; it provides a framework in which to understand suicide and self-harm. This tripartite model maps the relationship between background factors and trigger events, and the development of suicidal ideation/intent through to suicidal behaviour. In this podcast, we talk about a range of different topics including: • The epidemiological context. Suicide rates. • The myths around suicide and self-harm • The determinants of suicide and self-harm • The IMV model of suicidal behaviour • The implications for the prevention of suicide References O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour. Philosophical Transactions of the Royal Society B. 373: 20170268. Steve Platt's work on inequalities and suicidal behaviour https://onlinelibrary.wiley.com/doi/abs/10.1002/9781118903223.ch15 www.suicideresearch.info

In this podcast Professor Chris Williams, a researcher and teacher in the area of cognitive behavioural therapy (CBT) introduces CBT as a self-help form of therapy. It gives people the tools help themselves. Although correctly described as a form of psychotherapy, another way of conceptualising CBT is as a form of adult learning. That perspective can help make sense of recent advances in CBT where key CBT principles are communicated via CBT books, classes or websites. The key elements are a CBT structure that then builds on the therapeutic relationship and helps people both understand why they feel as they do, and also learn new skills to make changes. CBT provides a structure of how to make these changes in a planned and evidence-based way. However it also requires and effective and supportive therapeutic relationship to encourage people to keep on track as they plan changes in their lives. It is on this balance of structure and relationship that CBT aims to help achieve change.

Chief Inspector Michael Brown: ‘Police, policing, and mental health in the UK’. Police services all over the world are essential as a de facto mental health service, especially around crisis care. All have struggled with untoward incidents involving the use of force, or deaths following police contact, which have framed – perhaps distorted - discussion. Reviews of these incidents have concluded that police officers are usually working in a context where the professional options available to them are not always adequate and that support after police decision-making is not always available. Reviews have also emphasized the need to improve police training and awareness of mental health, without necessarily specifying what that means and without taking account of contributory problems in healthcare provision by other agencies. Better police training and awareness of the mental health issues they face professionally is essential, but not sufficient. Many of the people the police encounter, where mental health is a factor in the incident, are known to have a history of mental health problems and have often been service users previously. The challenge is twofold – to reduce reliance upon the police service (and criminal justice system, including the prison service) to the extent we can; and to improve the quality of the police response where it is necessary for officers to become involved.

People with learning disability were understood and treated very differently in the past from the present. While attempts were always made to help them, this was against a background of pessimism about their prospects. Much progress has been made in the past half century in positive attitudes towards this group, with closures of the large institutions in which they were often housed and better integration into the community. Nonetheless, challenges remain, including a significantly shorter life expectancy compared with the general population. Dr Fionnuala Williams clarifies misconceptions and enlightens listeners on the definition, causes, and treatments relevant to this diverse population group, where communication is key.

Social workers and care in the community Social workers have a crucial part to play in improving mental health services and mental health outcomes for citizens. They bring a distinctive social and rights-based perspective to their work. Their advanced relationship-based skills, and their focus on personalisation and recovery, can support people to make positive, self-directed change. Social workers are trained to work in partnership with people using services, their families and carers, to optimise involvement and collaborative solutions. Like community psychiatric nurses, social workers also manage some of the most challenging and complex risks for individuals and society, and take decisions with and on behalf of people within complicated legal frameworks, balancing and protecting the rights of different parties. This includes, but is not limited to, their vital role as the core of the Approved Mental Health Professional (AMHP) workforce. Social workers are central to the holistic, individualised treatment available to sufferers from mental disorders, which epitomises the goals of modern healthcare provision. Dr Ruth Allen, Chief Executive, British Association of Social Workers

In the podcast I talk about my research on the biological basis of schizophrenia using brain imaging and my attempts to understand symptoms such as hallucinations in terms of brain based cognitive processes. I describe what schizophrenia is like from the point of view of clinicians and from the point of view of patients. I suggest that the experiences described by patients in history are very similar to those described today. Finally, I discuss treatments. There has been much improvement since the discovery of drug treatments in the 1950s, but we still have not identified the causes of schizophrenia and, for the majority of patients, life remains very hard. Chris Frith is Emeritus professor of Neuropsychology and the Wellcome Centre for Human Neuroimaging at UCL and Honorary Research Fellow at the Institute of Philosophy.

Autism is a neuro-developmental disorder with a prevalence of about one in 100 births. Although we assume that this disorder has always been with us, and Rab Houston and I identified a case from the 18th century, it was not given a label until the 1940s. Hans Asperger, a Viennese pediatrician, and Leo Kanner, an American child psychiatrist, both used the label ‘autistic’ to characterise the condition. It took another thirty years until it was understood that it was not rare, but there was a whole spectrum of autistic conditions, all sharing the core symptoms of impaired social communication and repetitive and restricted behaviours. To explain these symptoms I mention two proposals: the ‘Theory of mind’ account, explaining the communication impairment; the ‘Weak central coherence account’, explaining the focus on detail. Uta Frith is Emeritus Professor of Cognitive Development at UCL’s Institute of Cognitive Neuroscience.

Symptoms of schizophrenia develop in more than 1:200 people, in all cultures, while 2- 4% of the population may experience major depression at some time in their life. Mild and moderate depression are, of course, much more common. Sometimes illnesses run in families and show higher concordance among identical compared to non-identical twins suggesting an important genetic contribution to risk. Molecular genetics now gives us the tools to analyse genetic risk using DNA samples donated by people with schizophrenia, bipolar disorder, depression, autism, attention deficit, obsessive-compulsive disorder, anxiety, anorexia, substance use and post-traumatic stress. These disorders are the focus of ongoing international collaborations performing genome -wide association studies. Results to date are remarkable. Genes have been found that contribute to these illnesses and it is hoped this new knowledge could lead to novel drug targets and new preventative interventions. The use of advanced techniques such as gene editing and improved possibilities for accurate prenatal testing are raising important ethical questions that require informed public discussion and debate.

People in both the developed and the developing world are living longer, and in better health, than in any prior point in history. However, mental health professionals, especially psychologists, need to prepare for this upcoming increase in older persons – whom they will encounter in all areas of practice. There is an urgent need for practitioners to upskill, and students to embrace, key principles from gerontology (the science of aging) to foster greater awareness, understanding, and appreciation of later life experience. The psychological issues faced in clinical practice will evolve along with these demographic changes — for example, intergenerational issues among blended families, anxieties around retirement, and issues particularly pressing for women, such as caregiving, will present themselves more frequently. These issues are important for mental health professionals, concerned with ageing, to recognize and address with sensitivity and respect, with curiosity and a willingness to listen and learn.

Eating Disorders are understandable as a way of coping with uncomfortable feelings. A temporary sense of reward or emotional detachment can occur due to maladaptive eating. The disorders are driven by fears about being unacceptable. Beliefs about people with eating disorders being selfish or overly concerned about beauty, still seem to arise. In reality they tend to have an excessively low opinion of their appearance and are usually kind and generous to a fault. The belief that what is required to cure an eating disorder is to ‘just eat normally’, is still frequently expressed to people with these complex psychological disorders. I also believe the risk of premature death from an eating disorder is commonly exaggerated in public and professional discourse, with potentially unhelpful consequences for treatment. My hope for the future is that overly simplistic theories about and treatment of eating disorders will give way to more complex, integrated, holistic approaches to care.

Bipolar disorder is a complex psychiatric disorder of mood and behaviour that has been recognised for thousands of years. It probably affects about 1 in 50 individuals worldwide and is characterised by episodes of depression alternating with episodes of mania. In this podcast we discuss the presentation, diagnosis and treatment of bipolar disorder. We highlight the strengths and limitations of current diagnostic classifications and we consider the need for a multidisciplinary treatment approach that integrates medications (such as lithium) with psychosocial approaches (such as group psychoeducation). We also consider the intriguing link between bipolar disorder and creativity and we conclude with an optimistic discussion of latest research in the field and how this will ultimately lead to improved diagnosis and new treatments in the future.

In this podcast, Professor Rab Houston speaks to Alexander Baldacchino, Professor of Medicine, Psychiatry and Addictions, University of St Andrews and Clinical Lead and Consultant in Addiction Psychiatry with NHS Fife. This podcast will hopefully provide the right incentive for listeners to understand better the finer details pertinent to the topic of substance misuse disorder and dependence. Listeners will be taken through some of the relevant historical, clinical, epidemiological, humanistic and other cross cutting themes to allow a more positive formulation of what the problems caused or as a consequences of substance misuse can be crystallised without stigmatising the individual or population involved. The interview explores understandings and misunderstandings of substance misuse, and the possibilities for helping misusers against a background of rapid changes in society, medical provision, and the proliferation of substances.

Gerry Hastie trained between 1993-96, when nurse training programmes were changing from being delivered by the Local Health Authority to Higher Education. He has always been a mental health nurse and has worked in care home settings, long term in-patient care settings, acute admissions, addictions and the community. In this podcast he illustrates his personal journey to doing what he does, and what it takes to be a mental health nurse, focusing on values and personal qualities; skills and different remits and the many roles taken on by nurses with patients, their families and colleagues. Nurses are simultaneously therapists, advocates, teachers and researchers who within their own training and skill set but whose work is essential with other professionals. He offers a perspective on what makes nursing unique and how nurses complement the multi-disciplinary team. Finally, Gerry tries to step outside and looks into his profession as an observer and use examples from clinical experience and popular culture to imagine what the public think mental health nurses do.

In the first podcast of our new series, Professor Rab Houston is in conversation with Dr Miles Mack, Past chair of RCGP Scotland and a GP partner in Dingwall, Scotland. General Practice is the backbone of the British NHS and GPs provide a vital role in providing medical health care to patients registered to their practices. They provide continuity of care and a comprehensive approach, both in the first point of care and coordinating ongoing care for long term conditions. This podcast discusses their work in mental health, its relationship to physical well being and how they provide an interface with the hospital and specialist services in the wider health and care services.

I argued in the last podcast that medical theories in colonial Africa had a strong racial element to them, which buttressed colonialism. In this final podcast of my mini-series I’m going to explore how these ideas related to the actual practice of psychiatry in colonial Africa. I broaden my perspective to include not only Malawi, but also Natal and Uganda. I try to nuance some of cruder understandings of colonial psychiatry by suggesting that clinicians could adopt perspectives and treatments that focused on suffering human beings, rather than racial stereotypes. Psychiatry on the ground was different: it always is when interacting with real-life patients. I conclude by looking at the way forward for psychiatry in sub-Saharan Africa. Image: Nurse and patient, Malawi. Copyright Daniel Maissan www.danielmaissan.nl

If you have listened to my series of podcasts on the history of psychiatry in Britain and Ireland you will know that psychiatric relationships are at least partly about power and about the assumptions medical practitioners made concerning those they treated. In the old world, class and sex were important differentiators. In a colonial setting there was an added dimension. Daniel H. Tuke, a British expert on insanity and visiting medical officer at England’s York Retreat, wrote in the Journal of Mental Science for 1857 that ‘the liability to mental disease is greater (other things being equal) in a civilized and thinking people, than in nomadic tribes’. So madness was the price Europeans paid for living in civilization, but transposed to a colonial setting it was the price Africans paid for encountering civilization. Colonial psychiatrists worked to address fundamental issues of social anthropology: How did race affect mind and behaviour? Was it possible to change peoples and cultures? The answer was sadly predictable and the racist ideas I outline provided a rationale for maintaining colonial dependency because they seemed to prove that Africans were unsuited to governing themselves or interacting with the wider world. Their societies had both too many and too few restraints, making them inherently unstable. Image: Juba Central Prison, Sudan, copyright PBS (Robin Hammond, Condemned)( www.witnesschange.org )

At the end of the last podcast I explained what was special about colonial psychiatry from the 1880s to the 1960s, compared with mental medicine in the United Kingdom. 1) Continuing medical pluralism 2) Limited institutionalization of patients and professionalization of services 3) Persistently low resources 4) Attempts to introduce European-style practices of care 5) Racism Today I’m going to deal with the first three of these points. An important theme in my podcasts on the history of psychiatry in the United Kingdom is the enduring importance of different ways of dealing with the mad, including religious healing and traditional talking therapies as well as formal or learned medicine. Medical pluralism meant that there was in effect a marketplace for therapies, chosen according to availability of practitioners, the cost of treatment, the nature of the condition, the person experiencing it, and the social context in which the illness had presented itself. Biomedicine gained dominance only in the nineteenth century. I then go on to explain how the care of insane people in institutions came very late to much of colonial Africa and psychiatry as a specialisation later still. Finally, I talk about the experience of white people who went mad, because it is an important counterpoint to race and racism, which will be the subject of next week’s third of the four podcasts in this mini-series. Image: male patients, Zomba hospital courtyard, copyright Daniel Maissan, www.danielmaissan.nl

I have been asked by the Scotland Malawi Mental Health Project to prepare a short series of podcasts to act as a component of the training programme for psychiatrists at the College of Medicine in Malawi. Like much of the less developed world, Malawi has limited resources for specialist psychiatric care: the ratio of psychiatrists per head of population is less than 1% of that in Western Europe. The two series of podcasts already broadcast have been used to help train clinicians and nurses in Anglophone sub-Saharan Africa, including Malawi. The practice of psychiatry in a colonial setting is surprisingly varied. Even within British colonies around the world, those who received psychiatric care, where they were treated, and to what ends was significantly different. Other European colonies were different again. So colonial psychiatry, as practised between the 18th century and the 1940s, 1950s, and 1960s, is a rich and varied topic. I want to narrow it down. I’m going to stick to Anglophone southern and eastern Africa, between the 1880s and 1960s, because that covers the geographical and cultural area in which Malawi is located. Between 1891 and 1964, when it became independent, Malawi was the British Protectorate of Nyasaland. Up to the middle of the nineteenth century the old world shared many of the characteristics we shall encounter in African colonies between the 1880s and 1960s. I’m going to set out 8 key similarities. I then explain what changed in Britain and Ireland over the last two centuries. Finally, I’ll summarise the distinctive experience of southern Africa under colonization, which I’ll explain in detail next time. Image: Eket, Nigeria. Copyright Robin Hammond, Condemned, ( http://www.witnesschange.org )

We are now acutely aware of the effect which viewing or participating in traumatic events can have on people. This last ‘document’ (actually a set of film clips) is about such outcomes. It has no words by the mentally troubled, but it does have the other components that lay and professional alike use to identify mental state: body language, appearance, and behaviour. The symptoms of what First Wold War soldiers called ‘shell shock’ included fatigue, tremor, limb paralysis, pain, breathing problems, nausea, muteness, confusion, nightmares, and impaired sight and hearing. Paralysis and sensory impediments with no apparent biological basis or necessary connection to a specific event were central to the diagnosis. SOURCE: War Neuroses: Netley Hospital, 1917. Segment 1: film of victims of shell shock. Wellcome Library, London, b1667864 IMAGE: Wellcome Library, London, L0003888. The Nursing Sisters of the Royal Victoria Hospital, Netley. From: The Navy and Army Illustrated vol. 4, 33 (1897), p. 215. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

This extract accompanies Podcast 21 - Living With Madness 2: An Insane Murderer IMAGE: Wellcome Library, London, L0040923. John Totterdale throwing his wife down stairs. Copperplate, 18th Century. From: The new and complete Newgate calendar; or, villany displayed in all its branches ... Containing ... narratives ... of the various executions and other exemplary punishments ... in England, Wales, Scotland and Ireland, from the year 1700 to the present time, vol. 2, By: William Jackson (London: Alexander Hogg, 1795), opposite p. 275. Collection: Rare Books, EPB 30093/B. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/ Voice Credit: Sebastian Bridges

We encountered a coroner’s inquest a few weeks back, presiding over the tragic suicide of an anonymous man. An inquest could deliver a verdict on the cause of death and, if they named a third party, their verdict could serve as an indictment at an assize court. The Old Bailey was the assize for the City of London. This document illustrates how insanity was taken into account in criminal trials, even when a formal insanity defence was not pleaded. It vividly shows how the perpetrator behaved and how others interacted with him, not only family and neighbours, but also strangers he encountered in court. This extract gives a vivid sense of day-to-day interactions with sane and insane people alike, and the sorts of decisions that ordinary people had to make about assessing mental capacity in ordinary and extraordinary circumstances alike. IMAGE: Wellcome Library, London, L0040923. John Totterdale throwing his wife down stairs. Copperplate, 18th Century. From: The new and complete Newgate calendar; or, villany displayed in all its branches ... Containing ... narratives ... of the various executions and other exemplary punishments ... in England, Wales, Scotland and Ireland, from the year 1700 to the present time, vol. 2, By: William Jackson (London: Alexander Hogg, 1795), opposite p. 275. Collection: Rare Books, EPB 30093/B. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

This extract accompanies Podcast 20 - Living with madness 1: an apprentice in danger, 1738 IMAGE: ‘Fashion Before Ease, or A Good Constitution Sacrificed for a Fantastic Form', pub. by Hannah Humphrey, 1793. Credit: George Moutard Woodward / Bridgeman Art Library / Universal Images Group, Rights Managed / For Education Use Only NOTE: The young man in this extract was apprenticed to a London stay or corset maker. SOURCE: Westminster Sessions: Sessions Papers - Justices' Working Documents. London Lives, LMWJPS654130018. Find out more at http://www.londonlives.org/ Voice Credit: Sebastian Bridges

Most people with mental disorders are more of a liability to themselves than to others. The same cannot be said of this podcast and the next one, where the threat or reality of physical harm at the hands of a mad person seems to have been very real. Early modern apprentices were different from modern ones because they lived as well as worked with their master in a sort of family arrangement. One unlucky apprentice petitioned London magistrates to allow him to leave the service of an employer who seems to have been erratic, controlling, threatening, and violent. The case shows how lay public opinion in the past could be just as important as professional medical certification, in identifying mental disorder. IMAGE: ‘Fashion Before Ease, or A Good Constitution Sacrificed for a Fantastic Form', pub. by Hannah Humphrey, 1793. Credit: George Moutard Woodward / Bridgeman Art Library / Universal Images Group, Rights Managed / For Education Use Only

This extract accompanies Podcast 19 - Fighting back. A ballad about William Frederick Windham, 1862. IMAGE: Broadsheet Ballad: ‘Poor Windham’. Bodleian Library, Oxford. Harding B 11(3115). SOURCE: Bodleian Library, Oxford. Harding B 11(3115). Voice Credit: Oli Savage

This series is entitled ‘the voice of the mad’, but sometimes mentally disordered people needed advocates to speak up for them. Normally that would mean a family member or someone in authority such as a local clergyman or Justice of the Peace. You might remember the young Derbyshire woman, Alice Hill, from an earlier podcast. But sometimes those alleged to be mad attracted support from a wider public, who became their voice. William Windham is an example, where crowds rallied around his cause – just as they sometimes did to frustrate what they saw as wrongful confinement. William Frederick Windham was a young man of considerable wealth and unorthodox behaviour, whose relatives tried to use the law to stop him squandering his estate on the grounds that he was mentally incapable of making his own decisions. They failed. IMAGE: Broadsheet Ballad: ‘Poor Windham’. Bodleian Library, Oxford. Harding B 11(3115).

This extract accompanies Podcast 18 - Being an asylum patient 4: Christian Watt at Aberdeen Royal Mental Asylum, 1877 SOURCE: The Christian Watt papers. Edited with an introduction by David Fraser (Edinburgh, 1983), 106-8. A newer, corrected edition is published by Birlinn. http://www.birlinn.co.uk/The-Christian-Watt-Papers-9781780270722.html Voice Credit: Oli Savage

As I showed last week, Herman Charles Merivale’s time at Ticehurst was a bit like being in a nice hotel, though he did not like the other ‘guests’. Someone who seems to have settled rather better into an institutional environment was a working class Aberdeenshire woman, who also wrote a retrospective account of her time in a public asylum. She wrote with frankness and sensitivity, about both herself and her fellow patients, making the best of her prolonged stay, which lasted 45 years. However, it is also clear that she re-wrote much of what happened, including the frightening circumstances of delusion and arson, which had caused her to be admitted in the first place.

This extract accompanies Podcast 17 - Being an asylum patient 3b: Herman Charles Merivale at Ticehurst, 1875 IMAGE: Wellcome Library, London. Ticehurst Case Records, 1875-9, pp. 15-16. Credit: Wellcome Library, London, Creative Commons Attribution NonCommercial license Voice Credit: Jem Tatar

Last week’s extract and podcast allowed us to see what others thought of the lawyer Herman Charles Merivale, when he was committed to a private asylum. The document from which it came exists in abundance for 19th century asylums. Insight into how patients saw the experience of incarceration are much rarer, though I shall give examples this week and next. Merivale is unusual because he wrote his own account of entering and living in an up-market private madhouse. Public asylums were crowded with paupers. Understaffed and with only basic facilities, they were probably difficult environments for most patients. Merivale’s experience was very different, though he does not seem to have enjoyed it. IMAGE: Herman Charles Merivale. Photograph by Elliott & Fry. From the frontispiece to H. C. Merivale, Bar, Stage & Platform (London: Chatto & Windus, 1902).

This extract accompanies Podcast 16 - Being an asylum patient 3a: Herman Charles Merivale admitted to Ticehurst, 1875 IMAGE: Wellcome Library, London. Ticehurst Case Records, 1875-9, pp. 15-16. Credit: Wellcome Library, London, Creative Commons Attribution NonCommercial license SPOKEN VERSION: Jem Tatar

The most abundant sources for understanding the history of psychiatry are medical case notes, kept by asylum staff. In addition, petitions for admission gave accounts of behaviour that precipitated the committal of a person to an institution. In this case he was a well-off London lawyer and the asylum was an up-market private one in the Home Counties of England. In drawing up the certification necessary for compulsory committal, the medical men relied much more on accounts given by servants and family, than they did on the rather uncommunicative object of their consultation. IMAGE: Wellcome Library, London. Ticehurst Case Records, 1875-9, pp. 15-16. Credit: Wellcome Library, London, Creative Commons Attribution NonCommercial license

This extract accompanies Podcast 15 Being an asylum patient 2: Letters from the Royal Edinburgh Hospital, late 19th century. IMAGE: Lothian Health Board Archive, University of Edinburgh, LHB7/51/54, p. 314. James P. to Dr Thomas Clouston 28 April, 1891. Credit: Courtesy of Lothian Health Services Archive, Edinburgh University Library.

Last week I looked at some regulations from Cardiff District Asylum at the start of the twentieth century. One of their main functions was to restrict communication between patients and the outside world, but it is often difficult to see how patients experienced their lives within institutions. The most abundant records are of what doctors and their staff did to patients. Yet patient letters to the staff or ones they tried to get to outsiders give unique insights into the spectrum of heartfelt attitudes from gratitude to anger and dislike, shown by patients. The uses and abuses of power in the narrow compass of a mental hospital come through very clearly. IMAGE: Wellcome Library, London V0012576. Edinburgh Lunatic Asylum, Scotland. Line engraving by R. Scott after R. Reid. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

This extract accompanies Podcast 14 Being an asylum patient 1: Cardiff Asylum regulations, 1919 Voice credit: Rosie Beech IMAGE: Psychiatric patient, 19th century. Credit: KING'S COLLEGE LONDON/SCIENCE PHOTO LIBRARY / UIG, Rights Managed / For Educational Use Only

In this podcast and the next four, I’m going to look at what patients made of entering and being in what we call mental hospitals and what were known until 1930 as lunatic asylums. The podcasts are about life in the institutions which dominated care of the insane and mentally impaired from the mid-nineteenth to the late twentieth century. The first extract shows why we seldom hear the voice of those who were institutionalised: asylums were highly regulated and authoritarian, not only for patients, but also for staff. The regulations show how closed many public asylums were. This was the day-to-day existence of about 100,000 asylum inmates in a British population of 36 million; by 1900 there were over 100 asylums whose average size was nearly 1,000. The average length of stay ran to several years because asylums increasingly filled up with chronic cases. IMAGE: Psychiatric patient, 19th century. Credit: KING'S COLLEGE LONDON/SCIENCE PHOTO LIBRARY / UIG, Rights Managed / For Educational Use Only

Eighteenth and nineteenth century English coroners’ inquests investigated roughly one death in every twenty. Their main task was to discover if someone else might have been involved or if a crime might have been committed. Suicide was one of those cases because it was a crime until 1961. The truly poignant part of this verdict is that nobody knew the name of the man who had hanged himself. Juries were always comprised of men from the locality where the body was found. That means the suicide must have been an outsider, perhaps a vagrant or even a suspected criminal as he seems to have been locked in a room or cage with iron bars. Still, the jury was prepared to give him the benefit of the doubt and say that he was insane when he killed himself. Increasingly common during the 18th century, this verdict may indicate the emergence of an attitude which automatically linked self-murder with mental illness.

This extract accompanies Podcast 13 - Suicide 2. A London coroner's inquest verdict. Voice Credit: Rosie Beech

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

This voice extract accompanies Podcast 12 - Suicide 1. Letters, diaries, and notes in the National Archives of Scotland Read by: Sebastian Bridges, Caroline McWilliams, Hannah Raymond Cox

These nine examples of letters, diaries, and notes build up to what I think is a compelling picture of the despair and powerlessness felt by suicides. Some were left by those who had killed themselves, but most were written by survivors. We can sum up suicide quite simply as a search by those who felt trapped, for an end to unbearable mental anguish. Desperation, darkness, and depth of suffering depressed their minds as they struggled with feelings of being worthless, alone, and pointless. But the extracts also show the range of emotions felt by survivors, from bewilderment and awful comprehension to blame and stigma. IMAGE: French Artist – Bibliotheque des Arts Decoratifs, Paris, France, engraving. Credit: Bridgeman Art Library / Universal Images Group, Rights Managed / For Education Use Only