I am very pleased to introduce the second part of this wonderful guest post reflecting on how professionals understood and responded to bipolar (or manic depression) in the mid-20th century.
I met many others who had this same label of manic-depression, and each was very different from the others.
Sally was much younger than Kate. She had a husband who adored her, two young children, parents who lived in the same village and helped as she needed, and a village community who liked her. She was admitted to the acute ward, manic but not psychotic, well aware of how inappropriately she was behaving, laughing at herself and unable to stop herself. She was given drugs (we did not yet have lithium; they were prescribing the major tranquillisers more judiciously than in their first enthusiasm) but they took a few days to kick in.
I specialled her for three nights while she could not rest, and it gave me an insight into the possibilities of really good care with ample resources and no-one interfering. And yet it was all very ordinary. I took her out of earshot of sleeping patients, gave her as much space as I could, and encouraged her to find activities that helped take the pressure off. I described to her how for instance I had found it helpful to knit frantically one time when I was too anxious to sit still while I tried to centre down and meditate; and how walking meditation could occupy the body and free the mind. We rambled in the wild parts of the grounds, away from the wards, which I probably should not have done, alone with her in the middle of the night. She scrubbed miles of already clean corridor floor (the last thing I would have thought of), laughing at how ridiculous she was being but grateful not to be stopped because the activity eased her. She sang and talked constantly at high speed and volume and I responded very simply, trying to contain her safely and non-critically while being with her soothingly and non-stimulatingly. I used what I had learned about how to centre down in Quaker meetings, to be fully with her in depth without doing anything or saying much. On the third night she baked a cake and we went to visit some of the other night staff, friends who thought as I did about how patients should be cared for, with cake and coffee, on condition she was able to keep the volume down and not wake anyone, and by then we could see she was coming out of it. She entertained us pleasantly and quite sanely for the rest of the night.
One-to-one care by someone doing no more than being kind and trying to avoid provoking you by criticising and telling you what you can’t do – it doesn’t seem too much to ask for from the NHS as short-term emergency care. But it would be harder in small units in the city, and it would be too much for family or untrained carers: the essential background was that I was not disconcerted by weird behaviour, I was young and fit and trained to restrain Sally physically but non-violently if necessary, I was also trained in general nursing and had learned how to be with people who were very ill without feeling I had to ‘do’ something, and I could sleep during the day without worrying about her because someone else took over.
Similarly, ‘specialing’ someone who is suicidal as we sometimes did with Kate, allowing her no privacy and literally never letting her out of arm’s reach for a moment, should be available on the NHS at an instant’s notice. It is something very simple and yet there is a skill to doing it well. Again, kindness is the first need, so you do not make things worse. Something that might be called a withdrawal of self, so you do not further weigh down an already intolerable situation. Becoming an empty shell to surround and hold another human being briefly while they cannot do it for themselves. The absolute rigidity of this style of nursing for suicidal patients, and the way this was prioritised regardless of the needs of the rest of the ward, was rightly seen as good quality caring and something the old county hospitals did well. It was irritating (and, as you might imagine, constipating) and so never wanted as attention-seeking. But suicide is a very real, though self-limiting, risk in bipolar, and the weight of this responsibility should be taken off both the patient and the family. Although maintaining self-care and self-mothering is a good thing most of the time, because it avoids institutionalisation and dependency, this should not be demanded during crises.
Sally was stabilised and discharged after three weeks, on medication. She was admitted twice more in the five years I worked there, and she stabilised quickly each time, getting herself under control more easily each time. She was lucky in that she had so much family and community support and everyone was there for her quickly, so she never got a chance to be indiscreet and make too big a fool of herself – which is an underestimated factor in whether there is dysphoria and how easy rehabilitation is. A large part of recovering from a manic episode is that one has probably embarrassed oneself by behaving inappropriately, and is mortified to face people.
Bipolar disorder may be enormously damaging to one’s life. Thought processes and judgment are temporarily impaired and may lead to harm. But what I took from Kate and Sally and others was how arbitrary and fortuitous the damage is, and how environmental factors may be much more significant than psychiatric ones. In itself, as far as I could see, bipolar does not cause permanent damage to brain or body. Treatment may, especially ECT, irreversible drug damage, and experimental brain surgery when patients have no advocates to prohibit them, and so may lack of care that allows self-harm, but whatever this nebulous entity of bipolar is, it is not basically toxic. Interrupting one’s career need be no worse than an unexpected pregnancy. Most of the damage is fall-out because society cannot bear to acknowledge its own issues and refuses to accommodate disorder within its neat ranks. Tidy your bedroom, don’t drop litter, keep your knickers on, don’t wake the neighbours, get your hair cut, don’t frighten the horses… nothing wrong with being considerate, but it shouldn’t be the end of your world if you break such rules.
We were taught that the psychoses (manic-depression, schizophrenia, puerperal psychosis caused by child birth, involutional melancholia – the psychotic depression with paranoid delusions caused by menopause – and the organic psychoses such as tumours, terminal syphylitic conditions and alcohol syndromes) were endogenous: they arose from inner causes and were largely unaffected by outer circumstances, including treatment (so they didn’t get much, apart from management). All right, no-one really believed any longer in wandering wombs as the cause of mental illness, but there was still great prejudice about women’s weaker minds.
These were opposed to the neuroses (anxiety, reactive depression, hysteria, obsessive-compulsion and phobia) which was where all the therapeutic effort went at that time. There could be no overlap. They were supposed to be caused by the environment, probably impinging on a weak personality, and were amenable to treatment.
If you were psychotic you were not to blame and there was nothing you could do about it, but you were beyond the pale, no longer quite human. Sin was out of fashion, but there was still a sense that it was a curse visited upon you by the gods.
If you were neurotic you were still within the fold of humanity. It still wasn’t your fault, but you were somehow flawed, and it was unclear whether it was a diagnosis or an insult. Older staff knew they were no longer supposed to tell people to pull themselves together, but they used to say that it was striking that no-one bothered to get neurotic during the War, when there was really something to worry about.
But I read some research which I cannot trace now. People were being forcibly moved in city slum clearance to new towns, and they were more stressed than had been anticipated. Three cohorts were set up for long term study, of patients with a history of either psychosis or neurosis, and a control group with no history of mental illness. It was postulated that statistics of schizophrenia and manic-depression were unaffected by the move, but that neurosis was spiralling and required better social engineering – ie if you are really mad, you are impervious to your surroundings, and if you are just inadequate you can be manipulated into adapting to what the authorities think is good for you. The researchers were profoundly shocked to find that the opposite was the case. Neurosis stayed constant at 30% of the population, which in itself was dismayingly high, more than had been known. Psychosis, which is statistically much lower, doubled, I think from 2% to 4% – ie schizophrenia and manic-depression became worse under stress. They could not explain this, but it undermined their current understanding of mental illness, which may be why I cannot find the research now, although it would no longer surprise anyone. (Later work ignored it, talking of New Town blues and transitional neurosis, with figures that were even higher but could be improved by giving more choice and prioritising community facilities as soon as people moved in.)
And come to think of it, older staff would say, it was funny how many more people were admitted psychotic during the War…
These were common attitudes in the 1960s, dismissive of psychotics and condescending to neurotics, with an absolute denial that there could be anything in common between staff and patients. The nurse who became schizophrenic crossed over this divide and was viewed with a fascinated horror. The Quakers who ran the NHS unit I moved to after the hospital, Bill Allchin and Lotte Rosenberg, were exceptional in the respect and empathy they demonstrated and insisted upon, and their gentle encouragement to acknowledge our own difficulties and ensure that they did not impinge on the unit. And on my days off I used to spend time in Kingsley Hall and Granville Road, the communities run by Ronnie Laing and Hugh Crawford, becoming the Philadelphia Association, which is another story, and they still didn’t have all the answers…
Yes, some of bipolar is almost certainly somehow innate, sometimes genetic, perhaps involving a biochemical imbalance. Yes, lithium and the drugs since have made a difference, though their side-effects are so complex that the simpler old knock-out drops and barbiturates might sometimes be briefly useful – and we were still using cannabis to good effect. Yes, sometimes moods can be contained by mindfulness and mental discipline if we have the right support in this and get in there quickly. And it still makes a difference if we have family or other advocates, if only to help negotiate the NHS and social services, partly because nothing is integrated but also because society is still ambivalent about whether a psychiatric disorder is really a disease, or some variation of sin or a character flaw.
Chemicals cannot invariably be substituted for caring human beings. Emergency one-to-one care should be available immediately it is needed. Patients or their carers know when they are becoming out of control and should be able to access trained support at once.
For some people, a permanent maintenance session of holistic psychotherapy makes the difference between a ‘normal’ life and disintegration. This may be largely on the phone, with a periodic top-up face-to-face, but it should be an hour weekly, not ten minutes fitted in hurriedly. It should be flexible enough to address both inner and outer issues as the patient moves to-and-fro between needing support in the practicalities of life, and being able to explore deeper aspects. Not eight weeks of CBT. Group support, especially self-help groups, can be invaluable. The idea of having therapy as permanent maintenance strikes most authorities as grossly extravagant, yet they tolerate the idea of equally expensive permanent maintenance drugs.
Meanwhile, cuts affect community psychiatric nurses, who are often highly valued, ward staff, psychiatric social workers… Above all, people need to be respected, treated as equals, and supported out of love as the need arises.
This piece is © Anne Wade.