Firstly, this is a beautifully written book and for this alone is a joy to read. It is also an important book for anyone who has an interest in mental health. Barbara Taylor manages to pull off a very difficult feat, which is to write a very personal memoir but at the same time write a dispassionate historical account of the history of mental health services from the building of the large mental asylums, to today’s community care. Interwoven with this is her experience of a classic psychoanalysis which, for the main part, is agonising and embattled. Perhaps what is most extraordinary about this analysis is that she never gives up even in her darkest days. She kept a journal throughout her analysis and although she acknowledges that at times this was sporadic, the reader gets a real sense of her experience.
The last asylum, of the title, is Friern Barnet which was originally known as Colney Hatch. Its change of name reminds me how the Windscale nuclear reactor was changed to Sellafield after a leak and it became associated with poor practice. Friern Barnet was, at it’s height, the largest mental asylum in Europe. It opened in 1851 and by 1857 was home to 2000 patients. From the 1970’s onwards it began to decline and finally closed its doors in 1993. It was then turned into a luxury development called Princess Park Manor. It’s reputation is as symbolic as it is actual and features in other works of literature; most recently, I believe, in Will Self’s ‘Umbrella’.
Its most famous architectural feature was the italianate corridor which was the longest in Britain and it is reputed that it would take a visitor five hours to walk all the wards. At the time of construction it was a completely self contained world that segregated the insane from the rest of the world. There would be fetes and open days where the ‘well behaved’ patients would be exhibited to the outside world to show its ’enlightened’ treatment regime. As Taylor points out, if you were moved to the back wards there was little hope of release and patients languished there for decades.
By the time Taylor enters the hospital in the 1980’s, it is in decline and heading towards closure. It was clearly a somewhat terrifying place to be admitted but Taylor’s personal and yet objective account reveals an ambivalence towards it. She does acknowledge that she was lucky to be able to be allowed to continue with her psychoanalysis, as there seems to have been little of ‘the talking cure’ available to the majority of patients. She refers to the hospital as a ‘stone mother’ which is a wonderfully evocative phrase. She certainly witnessed casual cruelty and neglect but despite this she describes something of a community of patients who looked out for each other. Indeed for some patients it really did provide asylum. Interestingly, the 1972 film about the Philadelphia Association’s houses was also called ‘Asylum’ which recognised the need for a place of safety for those with severe mental health problems. These houses fundamental philosophy was one of community and dwelling. There is something very moving in Taylor’s book that community developed in such grim conditions and the comfort that she experienced from some other patients. She recalls sitting next to someone and not speaking but how that was both comforting and containing.
Interwoven with this are her recollections of her analysis and I can’t help wondering whether at times this was making her worse rather than better. Very few people then were undergoing a ‘full analysis’ and I expect the number is even less today. As I have written previously, today we live in a ‘quick fix’ world that five times weekly analysis would be unthinkable to most people. Taylor has done it and has come through it and what she certainly shows is how hard the process can be and this certainly gives the lie to the idea that psychoanalytic psychotherapy is a self indulgent easy ride.
What comes through in her description of her time as a psychiatric patient is that it provided the basic containment to allow her to continue with her tortuous journey through her analysis. It is at the point when there is a shift in her analysis that she gradually begins to separate herself from psychiatric services. Her analysis, however, continues for several years after this point. In between her admissions to Friern Barnet as an inpatient she attends both a day hospital and a number of day centres. She writes wryly about this experience and her ambivalent feelings towards this system. Once again she is able to write a historical account of these services combined with a personal ‘what it was like for patients’. Again this is a strength of the book because it goes beyond being a polemic for any particular view of mental health services. What is clear is that the day centres were much more patient focused and indeed the nomenclature changes to service users. Perhaps what is most striking is the move away from the medical model of biological psychiatry to one which is more about ‘being in the world’. Sadly, this was not to last and all the centres she attended are now closed.
The final section of the book could be described as, ‘So where are we now?’. This makes for grim reading. During my own time of working in the NHS I saw an erosion of the possibility of longer term connection with patients. This coincides with the growth of a business management of the NHS and the internal market. Additionally, ‘Care in the Community’ has led to conflicts between Health and Social Services in to what constitutes healthcare and what constitutes social care. This is well publicised in care of the elderly but it also occurs in mental health. Taylor points out that the obsession with ‘moving patients on’ and preventing “dependency’ often means that patients are at best ill-equipped to live without support, but at worst often still too fragile to cope. It is ironic that in an attempt to de-stigmatise mental health it is now classed as a disability. However, in terms of a physical disability, we understand that by providing ongoing support we enable the disabled to achieve as much independence as they can manage. This is not the case for most mental health patients. The few remaining day centres are either strapped for cash or have closed. Those that remain must demonstrate to funders how they are ‘moving on’ service users. As with the talking therapies this is often very time limited. When I was chair of the board of an HIV organisation which ran a day Centre, the pressure to ‘move people on’ became huge. ‘Moving on’ in this instance was to stop providing service. Perhaps the most valuable service we provided was that of community and our service users, in the main, had multiple co-morbidities. When the service was set up it was their HIV diagnosis that got them service and not any of their other problems. With the arrival of combination therapy, HIV was then deemed a ‘manageable’ disease and gradually there was an erosion of services that provided non-medical social care. Day Centres aka Drop-in Centres became seen as not providing value for money or providing measurable outcomes. The fact that these centres also provided asylum was never taken into account.
The other factor that concerns mangers of mental health services is that of ‘risk’. Now this may appear to be about reducing harm happening to patients, and of course some of it is, but what risk is mainly about is reducing ‘risk’ to the organisation. Taylor makes her concerns about this at the end of the book and I would argue that current mental health services are increasing risk to patients. Patients with florid symptomatology will undoubtedly get at least out-patient treatment but those with persistent and enduring problems are likely to be rejected by secondary care as not being severe enough and by primary care as not able to achieve ‘recovery’. These patients will be left to the care of overworked GPs to manage.
Perhaps Taylor in her title is not only talking about Friern Barnet, but she is also writing about the end of the concept of asylum. This is a great book that is thought-provoking, moving, inspiring and an elegy for institutions that had a great deal wrong with them but nevertheless their closure has left a significant number of distressed people out in the cold.