This week I am delighted to introduce a guest post, part one of a two part series of reflections on how professionals understood and responded to bipolar (or manic depression) in the mid-20th century. This piece is © Anne Wade.
When I was training as a nurse in a county psychiatric hospital, from 1959, I was close to one manic-depressive patient who taught me much more than the official training did. (No-one was using ‘bipolar’ yet although it had recently been introduced to distinguish this mood disorder from unipolar depression.)Kate had been a private patient in and out of her county lunatic asylum since perhaps soon after the first world war. She was a member of the county set, and had been a great embarrassment to her family, not least because of her flamboyant lesbian affairs. The lesbianism was common-place because of the post-war dearth of men – her crime was indiscretion. She was very clever, and typically of her generation had been deprived of an adequate education, so she was intellectually frustrated, and far too analytic and confrontational for an Edwardian young woman. But she was not locked up unjustly. Her mood swings were classic, text-book clear, and there was no debate about diagnosis. Her father had committed her in a manic phase, and she had been kept safe and well-cared-for although there was no treatment for the disorder except chloral hydrate sedation and a padded cell in a crisis. Like many patients she described this appreciatively as giving her a break from herself when she was finding herself intolerable. Because she was a private patient under the personal care of the medical superintendent (chief doctor in overall charge of the asylum) she had her own room and was largely exempt from the petty restrictions of being bossed and herded around as most patients were. She hated the asylum but found it preferable to the trouble she had repeatedly landed herself in outside, and she subsequently re-admitted herself when necessary.
She described how she would come roaring up the drive in her red sports car each time she felt herself becoming hypomanic or suicidal: enjoyable as hypomania was, she had learned that for her it invariably led to terrifying mania. Some people can keep their balance on this side of mania and use the energy creatively, but she had found this impossible. She would hand the car keys to the superintendent, who would keep them until he agreed with her that she was fit to be discharged again. He did not give her any psychotherapy, which was deemed to be pointless with the major psychiatric conditions, but he knew her socially and although he was paternalistic, they seem to have had a kindly and reasonable relationship. She experienced the place as a genuine asylum during unbearable distress. In many ways it was a decent solution, except that it was elitist, and was not available to most of the patients, the injustice of which she appreciated. (It is also arguable that the system that allowed consultants to admit their private patients into public institutions, charging them substantially without passing over more than a token fraction, was corrupt.) We used to fantasise about the structure and funding of an NHS hospital which would be run as well as that for everyone.
I found her great fun and good company when she was stable but she could be violently psychotic and out of touch at her extremes. She nearly killed me one night, when I was arrogant enough to disobey an instruction not to unlock her door without another person present. I was still inexperienced and she took me by surprise as I gave her a drink, grabbing my collar and twisting it, throttling me. Night sister happened to do a round at that moment and rescued me. The hospital changed the uniform to eliminate collars. Kate apologised. At other times I had to ‘special’ her when she was suicidal, allowing her no privacy and literally never letting her out of arm’s reach for a moment.
At some point between the start of the NHS in 1948 and the upgrade from lunatic asylums to mental hospitals with the Mental Health Act in 1959, private patient status had been abolished. Rather than increasing equality and democracy, this was a levelling down. Her doctor retired and she was no longer special to anyone. The remaining medical staff disliked her, considering her spoiled and intractable. They cancelled her driving licence, which she found devastating. She had been quite responsible about only driving when her doctor agreed she was safe. Wondering about that now, I realise these men were probably threatened by her sexuality. Knowing her, she probably also challenged them directly, pulling class and intellect on them when they pulled medical rank on her, which would have outraged them: you still didn’t get away with being an uppity woman in the sixties, as I remember ruefully.
They did nothing for her, seeing their job merely as experimenting day-to-day with the new drugs such as largactil and tofranil (most of which she refused), according to which phase she was in. They were overdosing most of the hospital as they tried them out, turning it into zombie-town for a while, until they alarmed themselves with dangerous and sometimes irreversible side effects. Their much-vaunted chemical strait-jacket did make the hospital more manageable, but it did not cure people. All it did, as far as we could see, was prevent patients from externalising their anguish. They could no longer inflict it on others, but had to suffer it alone inside themselves. Or sometimes, as the joke went, Joe stopped his constant swearing back at the voices – instead, he started shouting incessantly, ‘Speak up, ye buggers, I canna hear ye!’
Kate’s circumstances had worsened in several other significant ways. Her family had lost much of their money, or were no longer willing to give her any. Her own trust fund was no longer worth much. She had always taken it for granted that she could go home whenever she was discharged, but suddenly she was no longer as welcome. I remember her coming back from one spell in the outside world, upset as well as depressed. The older generation had died and no-one among the younger members really knew her. She was not an easy person to live with: there had been room for her in a large country house with servants, but because she had been privileged she had never had to learn to fit in with other people, and she would have been obtrusive in a small modern home. There was no longer anyone who loved her enough to make any effort to care for her, she had exhausted the goodwill of her friends, who were also becoming elderly, and there was nowhere for her to live during remissions. Too late she realised that she should have bought an isolated country cottage and set up some sort of fund to pay for a carer, and the occasional nurse in a crisis, when there had been money available, but no-one had ever encouraged her to take responsibility for planning her own life, and now no-one else considered it was their job.
Kate seemed to flip from long periods of stability to brief episodes of being full-on manic or depressed very suddenly without warning, though I wondered whether it was more that no-one was paying her enough attention to see when it was happening. It was no-one’s responsibility to monitor her moods, and no-one saw any value in doing so. I had an impression that she might be stabilising altogether as she aged, though no-one else thought it was possible. I tried to teach her to be mindful, to notice when she was becoming unstable and nip it in the bud. No-one had ever suggested to her that she might have a degree of choice and control over her moods if she caught them early enough. She was interested in this but it was asking too much of her to do it without the support of intensive therapy and drugs. Once lithium came in it would perhaps have been feasible, if anyone had cared enough to see her every day. She also needed an environment that believed in such possibilities. There was a deterministic and negative attitude towards the prognosis for the chronic patients on the back wards. Young students and their enthusiasms were tolerated as naïve and over-optimistic irritants who would learn more sense with more experience. As a Quaker I was encouraged to defy this mind-set by the example of the Retreat at York[i], which William Tuke set up in 1796 against all the theories of the times, to provide a humane environment within which patients could be cared for and perhaps recover.
In her good spells Kate could have moved from her barren little side room on a locked ward to a pleasant room on a minimum supervision ward, but she would have had to come back if she broke down, and by then would have lost her room, so she chose to stay where she felt safe. The two permanent sisters on the locked ward liked her and gossiped easily with her. They protected her and would not let the doctors force medication or ECT on her or ‘manage’ her any more tightly. That would have been more important to her than a comfortable environment, though for a long time I did not realise how necessary it was and what a dangerous place the hospital was if a patient had no competent advocate. (Ken Kesey’s One flew over the cuckoo’s nest was not unrecognisable.) I suggested getting her decent furnishings, and they said it had been done and was pointless as she destroyed them when she got angry. Looking back, I realise she tried to avoid possessing anything that the doctors could threaten to take away. If she had accepted a move to the better ward, the doctors would then have demanded that if she were to stay there she had to take their medication, and ‘socialise’ – attend sessions of hairdressing and make-up, dish-cloth knitting in occupational therapy, slow-motion bingo and board games (oh, how I still hate board games), and the excruciating ‘largactil shuffle’ evening dances. Most of the older staff were wary of her – she was butch, ‘talked posh’ and was cuttingly sarcastic. Because they could not boss and bully her superficially, they could not see how ultimately vulnerable she was. There were some very interesting people on that ward, but Kate was snobbish, which was a pity, and there was no-one she ‘clicked’ with. Many of the other patients, the ones the doctors approved of, had allowed themselves to become drugged, docile and institutionalised, which she despised. She had stayed defiant, which I identified with, but she was lonely and had been pushed into a dead-end.
What was most soul-destroying was that she understood the superintendent to have told her that manic-depression was incurable, that her attacks would increase in frequency and that she would deteriorate with each attack until she was a cabbage. I did not know initially whether it was a valid prognosis. It seemed to me that if it were true that he had said this, then it was a self-fulfilling prophecy, and quite barbaric. Probably he said something more nuanced, or it had been someone else who said it. It turned out that many people in that hospital believed that was the prognosis for manic-depression. I read everything I could and found that it was not true, but that was the atmosphere she was living in – hardly a therapeutic environment.
This was the time of great debate, at least beyond the hospital, about the reality of schizophrenia, and the contribution of institutionalisation to chronic mental illness. I had been struck by how few patients were actually mad ie were so out of touch with consensual reality that we could not talk; and then it would only last a few days or weeks. I had read Barbara O’Brien’s Operators and things, her 1958 account of a psychotic episode which she had dealt with amazingly (it is out of copyright and I have it electronically). I read Ronnie Laing’s Divided self when it came out in 1960 and Erving Goffman’s Asylums the following year. I felt the same discussion needed to be had about manic-depression.
Mental illness is a reality, and Laing never denied that: there are situations of intense suffering where people simply need good care for a while.
I thought more about mindfulness and monitoring oneself. I was well aware of my own mood swings and fascinated by what stopped them before they became lethal. Getting high felt wonderful, up to a point. Then I would have a sleepless night and feel tired, or get tired of the way I was thinking, and automatically change focus somehow. This might or might not be about chemical balances and imbalances, but then what maintained or triggered them? I never went too far – why not? The swinging back of the pendulum seemed spontaneous in me, but something that did not happen automatically for Kate, something she perhaps needed to learn to trigger deliberately. Why? Depression, on the other hand, was something I found harder to control in this way, although I had learned it was useful to exercise mental discipline to stop it as soon as I was aware of it starting. (This turned out not to be enough, and I benefited from psychotherapy later.) I had always known and taken for granted a suicidal part of me that I had to keep firmly under control because a bigger part of me wanted to live, which was inadmissible then but which I later found was so common as to be almost normal. My experience seemed closer to Kate’s in this area. There seemed to be a continuum between us that was worth exploring. We could neither of us altogether trust our feelings, and it was helpful to monitor and control them intellectually. But we felt that there was also something different going on in my mind or brain from what went on in hers, and we ruminated together about what it was without getting anywhere.
One possible way that mental illness, any disorder, worked seemed to be that brain cells habituated to a bad reaction, and it happened more quickly and easily next time. But another possibility was that you could choose not to react in the way that vulnerable cells had learned – you could encourage them in a different path. The brain stays more plastic than we used to think. You could use things like yoga and meditation, even horrible Skinner-type operant conditioning, to take you out of a loop. You were a human being – you could learn and make different choices.
We were children stumbling alone in the dark. In the end I could do nothing for her, but we did know that in no way had Kate deteriorated mentally or become cabbage-like. If anything she had stabilised as the years went by, and her thinking was as competent as ever. The quality of her life was restricted, but that was not because of her disorder. It was what all parents fear for their disabled children – that when they are no longer there to fight for them, their lives will diminish because no-one cares enough to find good practical day-to-day solutions as they are needed; and no-one thinks far enough ahead to the additional problems of aging. I hate to think what happened to her when the mental hospitals closed down. It was cruelly done. I remember someone in authority saying that the first winter will take care of much of the problem – ie many of those who have ended up on the streets will not survive the cold and hunger. They are doing the same now with the financial cuts for the disabled. Those who commit suicide or die should not think they will guilt-trip the government. They are merely the anticipated collateral damage of rebalancing our priorities. The fight has to be on a different level.