Saturday, 31.10.2020

Francois Ferrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis:
Forced Hospitalization, ECT and Sleep Therapy

Tom Craig’s comment

 

        I am most grateful to François Ferrero for letting me see his essay “Inquiry of the Geneva 1980s’ Psychiatry Crisis: Forced Hospitalization, ECT and Sleep Therapy” and the associated commentary from psychiatrists in Europe and North America.

        I feel very fortunate to have spent most of my professional life surrounded by the relative equanimity of the English character!  While a comparable revolution in psychiatric treatment and service delivery took place in the three decades between 1960 and 1990 it was a “quiet revolution” despite a lot of wider social upheaval reflecting the economic crisis and industrial unrest of the 1970s and the riots in opposition to Thatcherism of the 1980s. Despite this unrest (or perhaps because of it), psychiatry faced no mass protests and few occurrences of violence or the destruction of property. The few that I recall concerned attacks on scientists and laboratories by anti-vivisectionists where the focus was not on psychiatry per se. Changes in what was considered good practice in treatment and service delivery certainly occurred, often in response to justifiable criticism, and the more extreme manifestations of physical treatments including insulin coma, psychosurgery and narcotherapy (“sleep cure”) were already largely played out in England by the time I started training in the early 1970s.

        William Sargent, probably England’s most influential voice for the more radical physical treatments had already retired in 1973. At the pinnacle of his career he had been the president of the section of psychiatry at the Royal Society of Medicine and was awarded the Stanley medal and prize by the Royal Society of Health for his work on mental health. Calling himself a “physician in psychological medicine” he had attracted both the admiration of some colleagues and patients and in equal measure the opprobrium of others. He advocated early and intensive treatment including combinations of high dose neuroleptics, barbiturates and antidepressants, electro-convulsive treatment (ECT) and “continuous narcosis” – in which patients were kept asleep or deeply sedated for weeks at a time. This practice had come under censure in Australia where Harry Bailey, another pioneer of deep sleep treatment and in regular correspondence with Sargent, was heavily censured following the death of 26 patients at the Chelmsford Hospital in Sydney. Intensive nursing care of patients undergoing this treatment in London probably saved Sargent from a comparable disaster.

        What is surprising perhaps, is how quickly his influence waned here in England. Although his textbook, co-authored with Eliot Slater (Sargant and Slater 1972), was one recommended to new trainees like myself, many of his methods were frowned upon by my supervisors at Mapperley Hospital who had witnessed iatrogenic disasters associated with these interventions and were committed to maintaining the reputation of one of the first hospitals to operate an open door policy with no locked wards or use of physical restraint. Of Sargent’s physical treatments, only ECT remained as a regularly administered treatment albeit with a wary eye toward mounting criticism and disquiet. In 1976, partly in response to concerns about variation in how ECT was administered and partly in response to pressure from outside the profession, the Royal College of Psychiatrists issued practice guidelines, setting standards for its administration and consent (1977). Unfortunately, the guidelines were ignored by many psychiatrists in England. A survey in 1980 (Pippard and Ellam 1981) revealed huge variations in practice with fewer than half the surveyed centers meeting even minimal standards. Some appallingly poor practice was reported including the use of broken and obsolete machines, and poor practice including using unmodified ECT. This report prompted an editorial in the Lancet that referred to ECT in Britain as being “a shameful state of affairs” (1981).

        The writings of Laing (1960), Szasz (1963) and Cooper (1967) had a certain influence, most notably among non-psychiatrist members of the mental health team and the interested public, mainly concerning aspects of psychiatric diagnosis and about psychiatrists as agents of social control. But wider activists, such as the Scientologists, never really got going in England and were at best a minor irritant protesting at psychiatric meetings and conferences. Of far more long-term significance was the activity of groups such as the Mental Patients Union founded in 1972 led by “survivors” of psychiatry who, allied with other progressive patient organizations and champions for human rights had a substantial impact on mental health care, albeit very slowly and often against considerable resistance from the profession. Service user researchers also contributed to the scientific debate about ECT  (Rose, Fleichmann, Wykes and Bindman 2003) and their views were taken into account in subsequent practice guidelines (NICE 1963).

        By far the greatest and most enduring upheaval in psychiatry in my lifetime was the closure of the hospital asylum and expansion in community care. The major drivers of this policy were moral, therapeutic and fiscal. From a moral standpoint were observations of the harm caused by prolonged incarceration as shown in the work of Erving Goffman and empirical studies in England led by John Wing (a leading psychiatrist) and George Brown (a sociologist). It was also becoming apparent that the effectiveness of new treatments meant that many of the formerly institutionalized patients could now manage in the community. Enoch Powell, the minister of health in 1960 announced an intention to halve hospital beds by 1975 and shortly thereafter legislation was enacted proposing the complete abolition of the mental asylum system. Deinstitutionalization was also encouraged by the public reaction to scandals involving ill-treatment in asylums.  In 1967 a nursing assistant at Ely Hospital in Wales contacted a national newspaper with allegations that many patients were neglected and abused by staff. This triggered a national inquiry that substantiated the allegations and found that the hospital with more than 600 patients with severe learning disability had only 2.5 doctors and a medical director with no formal training in mental health care (SHI 1969). This scandal was soon followed by revelations concerning several other asylums and at least 17 inquiries took place in the subsequent decade concerning some of the largest hospital asylums in England. While perhaps the major push for closure was a moral one, there were also strong fiscal incentives with the recognition that the old institutions were no longer financially sustainable. Of interest is the fact that the chairman of the Ely inquiry was Geoffrey Howe, later Chancellor of the Exchequer and deputy prime minister to Margaret Thatcher. Nevertheless, despite all these pressures, the asylum closure program was quite a drawn-out affair, not finally completed until the mid-1990s.

        It would be nice to think that we had learned something about the need for moderation in our treatment and greater caution over potential harms consequent on how we organize and deliver mental health care. But I fear several fundamentals persist. Bubbling along more or less below the surface are continuing concerns about the nature of psychiatric diagnosis, “big pharma,” the psychiatrist as an agent of social control and apparent biases in how treatments are delivered, not least that we in England continue to detain and forcibly treat disproportionately more young black and ethnic minority men. The big institutions may be gone but have been replaced by a plethora of smaller residential “long-stay” settings including forensic units, nursing homes and specialized housing from a wide range of public and private sector providers. The quality of care in this “virtual asylum” is arguably even more difficult to ensure, so it may not be surprising that scandals continue to be uncovered.

        A final word on the status of biological approaches is warranted. We are now a quarter-century beyond the launch of the “decade of the brain”(1990-2000) but little has come from this by way of new treatments of proven efficacy beyond what was available at the start of my training. If anything, efforts to develop new pharmacotherapy is even less than it was in 1990 while it is developments in psychological therapy that have made most progress. Despite this, I imagine there are very few psychiatrists that would deny the benefits of psychotropic medication even if more now share concerns about over-use and the continuing prevalence of high-dose regimens, polypharmacy and other less well evidenced practice.  Outside the profession, opposition to pharmacotherapy persists with fairly regular media reporting of the “explosion” of psychiatric medication in the general population and particular concerns about use in children and the elderly.

        I end on a hope that Luc Ciompi is right in his optimism for a new synthesis of biological and social psychiatry.

 

References:

Cooper DG. Psychiatry and Antipsychiatry, London; Sydney: Tavistock Publications, 1967.

Editorial. ECT in Britain: a shameful state of affairs. Lancet. 1981; 2(8257):1207-8.

Guidance on the use of electroconvulsive therapy. National Institute for Health and Care Excellence (NICE). 2003. https://www.nice.org.uk/guidance/ta59.

Laing, R.D. The Divided Self: An Existential Study in Sanity and Madness. Harmondsworth: Penguin. 1960. 

Pippard J, Ellam L. Electroconvulsive Treatment in Great Britain. London, England: Gaskell, The Royal College of Psychiatrists, 1981.

Sargant W, Slater E. An introduction to physical methods of treatment in psychiatry. 5th ed. Edinburgh: Churchill Livingstone, 1972.

Szasz T. The Myth of Mental Illness. Foundations of a Theory of Personal Conduct. Harper & Row, New York, 1961.

Report of the Committee of Inquiry into Allegations of Ill – Treatment of Patients and other irregularities at the Ely Hospital, Cardiff. Socialist Health Association (SHI). 1969.

Rose D, Fleischmann, Wykes, Leese, Bindman J. Patients' perspectives on electroconvulsive therapy: systematic review. BMJ. 2003; 326(7403):1363.

The Royal College of Psychiatrists' Memorandum on the use of Electroconvulsive Therapy. Part 3 Medico-legal aspects of ECT. Br J Psychiatry. 1977;131:271-2.

 

January 16, 2020