Reviewed by Claire Chatterton
The history of mental health care is a topic that remains ripe for further exploration and this new book, written by two experienced mental health nurses, adds to the canon. In it they, and some of their former colleagues, reflect on working in a large institution, St Augustine’s Hospital, near Canterbury in the 1970s.
The 1970s was a significant period in the history of mental health provision in Britain as it was to see a whole series of scandals and public inquiries about the standard of care in some mental health and learning disability institutions, one of which was St Augustine’s. It was also the time when the concept of ‘care in the community’ was beginning to grow and the closure of large institutions such as these was presaged by a series of government white papers, from the then Department of Health and Social Security, in the early 1970s.
The book begins with a prologue which gives the background for how the book came about, its aims and objectives and reflects on the stories chosen and the potential limitations of recall and memory. It also discusses the terminology of the time, which can seem offensive to the modern reader, and the important tenets of anonymity and confidentiality.
The next section could be described as context-setting. In this, the authors give a brief history of asylums drawing on Foucault’s concept of the ‘Great Confinement’ in which they place the founding of St Augustine’s (as the second county asylum for Kent, opening in 1875). There is a very brief section on ‘nursing as a profession’ and then some more detail about the St Augustine’s Hospital Inquiry in 1975 and its aftermath.
The next chapter (which is by far the longest) is termed ‘The Forgottens’ Tales’, which focusses on the patients, many of whom spent many years of their lives in this institution. This consists of many long quotes from oral histories of staff about their memories of patients, with some commentary and discussion interspersed.
The following chapter follows a similar format with a focus on staff memories of their time working and living in this large institution, entitled ‘The Custodian’s Tales.’ As well as their own memories, they have also incorporated those of some of their former colleagues, including other mental health nursing staff but also a social worker, a domestic employee, a pharmacy technician and a man who grew up living in the hospital grounds, as his father was a chaplain there.
Finally, the book ends with an epilogue, sub-titled ‘future conditional’ in which they discuss the closure of the asylum/hospital and the last fifty years of mental health provision (or lack of it). They ask if the legacy of the asylum era has impacted on the thinking that underpins mental health policy today and suggest that there is a considerable inheritance from the institutional times that they portray that serves to reinforce current mental health policy and mode of provision. They also reflect on some alternatives, that they argue could challenge the philosophy or ethos that ‘buttresses’ current thinking about mental health policy.
As an enthusiast for mental health nursing history, I am always pleased to see new books being published that add to this under-researched field. As a mental health nursing student in the early 1990s I straddled both worlds, training on wards in an old institution as it gradually closed down but also increasingly undertaking placements out in the community. As a lecturer in mental health nursing, I increasingly encountered students who had no experience of these large institutions, the vast majority of which have disappeared from view, either through demolition or from them being converted into luxury housing.
This book gives a vivid account of what life was like in the 1970s for some staff in one institution, and similarities can be perceived that resonate with other large psychiatric hospitals too in this period. It is therefore a valuable addition to the literature, as the reader can get many insights into the seemingly closed world of the institution at this time and the authors are to be commended for initiating and seeing through this project, which must have taken up a great deal of time. It is also good that memories of other staff members are included so it is not entirely nurse-focussed, a recognition of the nature of the multi-disciplinary team that comprised the staff at the time. There are some omissions as no medical staff were involved in the research for the book (which the authors acknowledge); porters, estates workers, and occupational therapists amongst others are also missing. However, the authors do recognise this and argue that they are presenting ‘snapshots’ or ‘glimpses’ of institutional life, rather than a comprehensive history or overview. For a modern reader, some of the accounts may seem shocking and the authors have not shied away from quoting from accounts discussing poor, negligent and cruel care, as well as from some more compassionate staff and their practices.
For me, I felt that the book would have benefited from further editing as it did feel repetitious in places and the different sections of the book were uneven in length. I have mixed feelings about the section of staff memories of patients as the patients’ voice is not heard directly and although the authors do reflect on this, it did make me uncomfortable, although arguably it does give an insight into some of the patients still remembered by staff over fifty years later, whom they quite rightly describe as ‘The Forgotten’. The authors argue that they considered and rejected grouping these memories thematically as they believe that ‘each vignette stands on its own’ but for myself I would have found this helpful.
Given that most of the contributors are former mental health nursing staff, either registered mental health nurses (RMNs) or nursing assistants/auxiliaries (or former students who did not complete their training) it would also have been good to see some more discussion about the development of mental health nursing and the inclusion of some of Peter Nolan’s excellent work in the field in the selected bibliography (in particular his seminal history with Niall McCrae, The Story of Nursing in British Mental Hospitals).
Overall though, thank you to the authors and their contributors for sharing their insights into what is now, a vanished, and sometimes forgotten or misunderstood, world and one that needs to be remembered and learnt from.