Nursing at St Audrys – an oral history of a Suffolk psychiatric hospital

 

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Images from the St Audrys project

Originally a workhouse known as the House of Industry for Looes and Wilford Incorporated Hundreds established in 1765, St Audry’s became the Suffolk County Lunatic Asylum in 1827 and went on to be renamed St Audry’s Hospital for Mental Diseases from around 1917 although the name ‘Suffolk District Asylum’ was also retained until the early nineteen thirties . Finally closing as a psychiatric hospital in 1993, the building was converted into private residencies although parts of the main structure were listed in 1985 and preserved.  St Audry’s became home for many generations of Suffolk people with mental illness and they left behind their stories, some of which are recorded although, sadly, the majority have been lost. The history of stigma and fear associated with mental health services means that patients historically have been voiceless both politically and culturally and the public remain largely ignorant about the subject too- for example, how many people today know that a person under a section of the Mental Health Act legally cannot vote? In addition, data protection and privacy laws means that a hundred years must pass from the death of the last patient before any personal details can be released into the public realm, thus (rightfully) hindering historians from accessing the archives.

In 2012, a project was set up by the Museum of East Anglian Life to explore the hidden history of St Audry’s. The Museum, alongside Felixstowe Museum and the Suffolk Record Office, were recipients of the hospital museum collection and archive when it closed.  ‘Telling it like is: the story of a psychiatric hospital in Suffolk’ collaborated with mental health service users to create work to accompany a permanent display in Abbot’s Hall, part of the Museum. The project also explored and recorded people’s emotional connections with the St Audry’s site.

We spent an afternoon visiting Abbots Hall and the very moving (and at times troubling) exhibition, telling the story of St Audrys and the people who worked and were hospitalised there. Inspired by this, I recently interviewed a Registered Mental health Nurse from Suffolk who trained at the St Audry’s School of Nursing and was subsequently employed as a staff and then charge nurse at the hospital. Trained at a time when the introduction of new Antipsychotic medication meant patients experienced far less sedating effects and fewer side effects alongside the development of Nursing as a profession meant they saw some exciting cultural changes within mental health. Add to this the closure of the old style psychiatric hospitals due to the inception of Care in the Community and the Care Programme Approach and we see how many changes staff were privy to.

Here is this nurses oral history as told to me. Parts of their account include references to self harm, suicide and methods of restraint. 

“One of the back doors to one of the hospital blocks. I think it might be have been Rendlesham Ward. (the wards were named after local villages) – the rear door, when you looked at it from the outside, you could see the outline of a white nurses uniform and hat. And it wasn’t a reflection, apparently from anything else around, and the glass had been changed. This is the myth. They’d put fresh glass in but still this white nurses effigy remained as an imprint into the glass.

“When you looked at it you could see a white apron and triangle of the hat. It was most definitely there. Spooky. And I don’t even believe in ghosts or anything like that!”

“I started there Oct 16th 1978. It was still St Audrys school of nursing and the Ipswich student cohort came out there. In my final year, they developed the school of nursing and we decanted it to Ipswich General hospital. The hospital, by and large had a very friendly, family atmosphere. Many of the patients had been there decades, many months at least and they knew each other.

“Long stay patients went to different therapies…making garden furniture, paving slabs- breeze blocks I think they made. The staff sports and social club was actually built from bricks made in the grounds. and the paving slabs certainly were. They’d got rid of the farm when I was there. No more waste food could be given to animals from domestic or other food supplies- the new Health & Safety laws. We had a big food prep area that made industrial prepared potatoes/vegetables for other institutions such as schools and hospitals and our patients worked preparing the meals. Institutions were expensive but high value, for example with St Audry’s, about 5-10 yrs prior to its close, the boiler needed replacing. Amazingly enough it was more cost effective to install a new boiler than it was to run down the old inefficient one in the last ten years of its life.

“Supervision wise, they were supervised as workers, rather then psychiatric patients and this was an important part of developing and keeping their skills and dignity as working people. Nursing staff could be called in should a disturbance arise but we didn’t stand over them. We did have responsibility to ensure they were at work and we shared information- if a patient had an off day, supervision could be provided by OT, technical instructor (a non professionally qualified member of the Occupational Therapy team) or nursing staff. If somebody wasn’t performing at work, we had direct feedback that they might be relapsing. It helped contribute to the twenty four hour picture we built up of our patients and how they managed in the various environments they lived, socialised and worked in.

“Some of the OT staff and TI staff were hugely professional and engaged- they wanted to improve the social and economic functioning of their patients. NOT to make them ‘earn their keep’ but instead to improve the quality of their life and the value they held it in. Caring. At this time, we were in a relatively early stage in the development of the OT psychiatric knowledge base and the recent breakthroughs in drug therapy allowed therapy to become more modern. Occupational therapy took off because patients were better able to focus and engage and give feedback on how they felt they were doing and what they might like to do. Care became more proactive and nursing became less regimental.

“A lot of males went into psychiatric nursing whereas other areas of nursing  were more female dominated. Many of our original male staff were from national service/services backgrounds that had a heavily regimented and institutional control system and structure and this influenced how patients were looked after. Their background as enforcers of discipline and their physicality was relied upon when medication was very basic and primitive in its therapeutic effects. Patients often became very distressed and sometimes violent and the staff would use methods of restraint and control that nowadays (quite rightly) we have rejected. Patients usually knew where the boundaries were unless they were very unwell (and other patients would help those new to the wards) and the hospital was a microcosm of society: its social boundaries were rigid and hierarchical, it formed its own class system if you like based upon longevity of stay, type of illness, friendships and alliances.

“Even then when it was more commonplace I questioned the use of restraint and saw it as a failure of care. Only rarely could I ever find an absolute justification for it. I did what I could to discourage male C&R (Control and Restrain Teams) on female patients- just imagine what it is like to be pinned down by a man when you are so unwell you have even less capacity to understand why it is happening. As a staff member you have a split second sometimes to react and we didn’t always have enough staff or the wherewithal to use other methods, ones that involved pre-empting trouble, rows and aggression  directed at staff and other patients. I have been in a situation where a patient came at me with a stanley knife that the patient had managed to secrete about his person after spending time in the carpentry room with a technical instructor. I sensed the patient was behind me, whirled round and managed to talk them out of slashing me. Was I traumatised? I don’t know. I just got on with the rest of the night shift and reported it. Risk assessment wasn’t what it is now. Some patients were justifiably angry at being incarcerated and would take every opportunity to show that anger to us. We had to be on our best game, observation wise all the time. But it had to be subtle too.

“When I arrived, there were still charge nurses insisting on precision lined up beds- you could align the pillows all along the room, fold back of the sheets, all aligned. Not to emphasise high standards in care but simply because it was regimented. That was how you did it and all nursing in the seventies and eighties had yet to develop a professional knowledge base which expected you to account for why you were doing what you were doing and what the results of those actions might be. ‘Did it have an evidence base and was this best practice?’ was not a question nurses used to have to ask themselves. I mean, we knew then and know now that tightly tucked in sheets help reduce pressure ulcers because delicate or bony parts of the body laying on a crease or fold in the sheet fabric are more vulnerable to them, but in those days we did it because we were told to do it. The intellectual and scientific underpinning of our decisions and actions was less dominant. Wards had routines, individual matrons and charge nurses had their individual quirks, likes and dislikes that manifested as ward and care habits and practices and most of them were not rooted in objectivity.

“Minsmere House was the acute unit, very modern for its time (80’s)  and took all acute mentally unwell people, both male and female from aged sixteen to sixty four. New patients came into the services and were placed upon a regime of modern medications, O.T and pyschological therapies which encouraged independence and kept their personalities intact. Yet institutions required the enforcement of their rules which inevitably leads to the suppression of individual need to the needs of the group and organisation. Classic Talcott Parsons stuff. (Parsons described illness as ‘deviance’ with health seen as generally necessary for a functional society, thrusting the ill person into the sick role which came with its own ‘rights’ and obligations.)

I saw the sea change and both ends of the spectrum of care quite early on in my career. I saw the beginnings of community nursing through the formation of Community Mental Health Teams (CMHT’s). I saw people going from one type of care to another, we got to know their family backgrounds and saw them in context. I went from the families of inpatients at a relative distance, to us starting to develop the beginnings of community care plans that took into account, the needs of the entire family unit. For many nurses and other professionals, this was a big change and hard to adjust to for some.

A wide range of people were admitted to St Audry’s- people coming in, young in their illness with less of the dramatic symptoms you used to see when patients weren’t treated so swiftly or with effective drugs. They’d get admitted to wards for short term treatment to medium term treatment. Or end up on long stay wards up to thirty years. Also lots of elderly people, some ex workhouse with terrible, terrible experiences documented in their files (being ‘committed’ decades earlier, because they had given birth out of wedlock for example), some newly admitted people with dementia who one year earlier had been fully productive and engaged in their lives. No prior history of mental ill-health at all so a dreadful shock for their families who had looked forward to Grandad or Grandmothers retirement and now had to adjust to a very different future.

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St Audry’s

“Patients were not often confined to the hospital and its grounds unless they were too unwell to go out. I clearly recall one patient going down regularly, weekly. He’d have his weekly wages, buy his fish and chips at the local chip shop then nip to the Horse and Groom for a pint. He was severely socially dysfunctional in that he couldn’t relate to money. He’d hold his hand out with the money and they’d take it, the bar lady or shop assistant. The pub would only let him have his allowance of beer – they just knew what he should have as we went in there and obviously could have a quiet word with the staff alongside the patient so everybody knew where they stood. Everyone knew everyone and nurses would drink with some patients in the pub on our days off. I’d see patients in Woodbridge on market day – they’d walk there or get the bus. There was a certain amount of freedom with staff taking patients out on walks which would often entail a walk to the pub!  I recall taking bored patients out on Saturday which were slower days as occupational therapy was closed (this still happens on wards now) and there was no ward round or routine medical clinics to break up the monotony of the day. I’m not trying to make it into some bucolic ideal but there was a level of acceptance in the local villages and people generally did not take advantage, or tease or ignore.

“Weekends always a great cigarette crisis you see. Everyone ran out including the staff and we’d resort to smoking dog ends out the ashtrays- we called them dog end rollies. If you had papers, you’d remake the ends. Great attacks of nicotine withdrawal all round as in those days loads of psychiatric staff also smoked. You’d find inventive ways of taking up the slack and in the seventies and eighties, shops closed at weekends, there was little public transport and less staff drove so we couldn’t necessarily get to the metropolis of Ipswich nor spare the staff. Plus it was a village. If  the pub closed, there was no sales of cigs. Everyone had spent their weekly allowance, no shops, no money. Everyone went cold turkey. So we’d invent quizzes, put music on for dancing, walks, take them gardening, anything to keep them settled and take their minds off the lack of nicotine! We’d have Christmas parties and lunch with turkey carved by the psychiatrists, ward and hospital dances where male and female patients could mix. Quite a lively social life accompanied everywhere by great clouds of cigarette smoke. We all chuffed away like Thomas the Tank Engine.

“The minibuses- elderly patients used it for trips to local villages. The staff would try to visit where patients were from to help them reminisce and get them talking to each other. We would take people to Felixstowe and book the Red Cross hut out for the day. The Red Cross would provide staff and meals and we’d take wheelchairs, carry them over the sand so the patients could paddle in the sea, buy ice creams and sit along the front, summer and winter eating them. Alcohol wasn’t banned and we had wards where patients could have a drink. Every meds trolley had alcohol. Beer wine whisky rum and brandy could be written up on the charts for night- better than many other medications as drinking a tot was socially normal and social too. Wards still have a bottle of something in the dispensary now. We wanted to offer as many ‘normal’ experiences as we could because with the best will in the world, you couldn’t totally overcome the limitations of your surroundings. I can see that group outings can be as stigmatising as any of the other practices but it was the only way we could manage to engender a social life for so many patients, with the staff and resources we had. And they had friends, people they wanted to socialise with, even intimate relationships and going to the seaside was, truly, something to look forward to- for all of us.

The problem was that the Victorian nightingale wards were open, and you only got a curtain if you were lucky and a locker. So little privacy. The locker was lockable although only the staff member would have a key though. Several long stay patients saved up to buy their own beds, bought their own side tables and decorated their side rooms. Or family would bring in an armchair. Not often but it would be taken on board. No issues about fire retardancy and smoking on wards in those days and we did have ward fires. Although more fires started after they banned smoking in public and inside areas because patients, staff and visitors now hide away when they have a cigarette and then toss it in a place where it smoulders and sets things alight. The amount of small fires always went up when a trust banned smoking!

“There was a token economy of sex going on. Some patients would find ways of having a ‘finger’ for a fag- yes I know this sounds a crude way of putting it but that’s the truth of it and what many of them referred to it as. Sexual feelings don’t stop because you have a mental illness and nor does the need for human closeness, intimacy, comfort and pleasure. Some of the women got their cigs this way. The staff would encourage discretion because sometimes masturbation became addictive behaviour or a form of acting out and obviously sometimes the sexual activity might not be consensual or it was exploitative or the patient was especially vulnerable. We encouraged the use of private space for private activities. I don’t recall patients getting pregnant. Only staff and not only by their husbands! There was a fair amount of relationship problems and break ups among staff because the job could be stressful, there was a lot of staff and…well…live hard, play hard. Upsetting events at work can throw people together. They cling together like puppies in a basket and see their colleagues as understanding in a way that their partner does not. It could be an illusion or it could be the real deal.We had second generation staff- those born to coupled up nurses or nurses/doctors who came back here to work when they grew up!

“Sexual relations were not encouraged but they did go on, however a lot of medication related sexual dysfunction also happened, stopped some of the sexual behaviours and this is still a problem today. Sadly one of the biggest barriers to people remaining on medication that is otherwise beneficial to them in terms of preventing relapse and keeping them well and happy is the fact that it destroys their sex life. I did and do believe that patients have a right to open and honest discussion about sexual side effects and we don’t talk about it enough. We need to be trained to discuss alternative ways of maintaining sexual intimacy in relationships and we need to prepare patients before they start the meds, NOT wait until their orgasm is retarded or simply doesn’t happen.( This is a common side effect of SSRI’s, for example) We need to be able to refer service users for sexual therapy if they require it.

“I do recall that one male patient was with another lady in the cricket pavilion and he rushed back in a distressed state. She had collapsed and he mistook a seizure for sexual ecstasy. That curtailed their sex life! It kind of put him off.

“We had staff cricket matches- our social club had team and home matches which were quite well supported and we played matches and games in the grounds which were extensive. Some patients would wander over, others would be taken to watch. The kitchens would celebrate patients special events and birthdays with beautiful home baked birthday cake and other celebrations. They’d make match teas too. Staff related to their patients over a period of time and tried to make value of their lives, tried to make it constructive with events that would stand out in their mind, create memories that were happy and good. There were horrible staff, but not hugely. The kitchen staff tended to get on very well with the patients because they got hugely positive feedback for the food they cooked- it was a highlight of the day, sadly, and so patients would feel very warmly towards the chefs and cooks. They’d try to get in the kitchens and snaffle food too (and staff would be bringing up the rear!).

“With regard to the upsetting side of the profession and life in St Audrys- I recall one elderly patient got to their mid sixties and had been depressed for decades. They’d been in for MECT (modified electro convulsive therapy- what we used to call ECT), lived life for thirty years with depression. Existed really. Decided in their sixth decade that this was it so took themself into the bathroom with a bread knife, was found but took three days to die- They just couldn’t recover. This patient got the knife from the kitchen as the elderly ward was not secure. Even when the kitchen was out of bounds, if you looked at what patients made themselves implement wise- my god that was a cabinet of horrors. We’d be as careful as we could, counting tools and implements in and out, checking everything was secure but sometimes things happened. That death had profound effects upon me and others. The sense that all we’d done was postponed this person’s death for decades and decades because they had been so depressed for so long. The staff were very shaken by that and the patients too. This can trigger spate suicide attempts among them so we promoted a time of high awareness and modified our awareness of risk factors. Grief is not always shown in way you expect by people whether they are deemed mentally well or ill. In fact Freud stated that the times when man (and woman) are unreachable to both therapy and reason is during times of bereavement or when they are falling in love. Freud spoke some sense here.

“We question ourselves also. What could we do better? What was the point of our jobs? Yes- we ask that too when we work so hard to try to keep somebody alive when they themselves do not thank you for it nor wish you to do it. In other branches of medicine patients and relatives say “Thank you for saving him, Doctor and Nurse” and “Thank you for saving me, Doctor or Nurse”. We cannot be assured of that response. Of course now we have all manner of risk assessments and critical incident evaluation and clinical and peer supervision to help us manage ourselves and others when things like this happen. Not then. We went home or to the pub or staff social club. Or we just buried it in our minds and carried on. We developed a dark humour, still have that dark humour and it is psyche saving, it really is but of course we needed to be careful who overheard because not everybody understands that it is not something that truly reflected how we felt about our patients. Our peers and indeed many of the patients themselves got it. I remember the patients with the most immensely acute and sharp sense of humour and sense of the ridiculous. They knew everything that was going on and nothing got past them.

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“Patients lived for decades there and died there too. The hospital had its own morgue and graveyard and we buried patients in it if their families had no other plans for them. Or sometimes families chose our graveyard because after all, the hospital may have been their loved ones only or main home and of course their fellow patients grieved for them and had a grave to visit. Sadly now, the graveyard has not been maintained. I find this very insulting to the patients memories, in fact I get really angry whenever I think of it and I used to go and lay flowers there every time I visited the area. I planted loads of Spring bulbs too. I wonder what happened to them. The patients used to love the snowdrops and aconites.

“Staff had to deal with patients’ relatives dying too – breaking the news to them and of course there were marital break ups that we had to support patients through. Their parents start dying and when you’ve had schizophrenia since you were seventeen and you are now fifty, you are very likely to have no friends off the wards and those parents are the only relatives that visit you. Remember that stigma of mental illness was much much worse and families often did not mention their sick relative in the local psychiatric hospital. The patient with schizophrenia now is in NO way comparable to what they were like twenty, thirty, forty years ago. The modern meds arrest the break up of the personality that we used to see with the older drugs such as Chlorpromazine which wasn’t nicknamed ‘Liquid Cosh’ for the hell of it. On these old drugs they became ciphers, empty vessels. A very harrowing thing to see and difficult to work with as we all need that feedback from those we communicate with. Getting little response every day, little emotion showing. Very hard and very sad. And that is just our perspective- imagine what it must have been like for them. Our difficulties pale into comparison. When we saw a spark of the old personality struggle through the haze of drugs, well, it was painful to see. I still feel ashamed of the effects of those drugs- the extrapyramidal side effects as they are known such as the dystonias (abnormal muscle tone resulting in muscular spasm and abnormal posture), dyskinesias (impairment of muscle movement) and akathesias (compulsion to move, inability to be still). Once these had set in, they never went away, becoming entrenched and incredibly disabling. There are some even worse ones too and some, rarely, caused death through something called Neuroleptic Malignant Syndrome (NMS). Ironically, I didn’t experience my first patient death to because of NMS until late in the 90’s when a patient had a totally unexpected and devastating reaction to a small stat dose of a antipsychotic medication, a decade and a half after we stopped using Chlorpromazine so freely.

“There were great minds trapped by psychotic conditions such as Schizophrenia. One person who was forty or close to it, had an ageless trapped face. His psyche was trapped. He used to move chess pieces around the board, take half of them off and it all looked random until you looked more closely and spoke to family. He was a chess champion, with a phenomenal brain, plotting seven or eight moves ahead. I worked in dementia too- these people have experiences they cannot always tell us but they are all great experiences. Remember their personhood. I used to ensure their rooms were plastered with photos, drawings, things that reminded us and them of their lives, their families and I brought in changes that were based upon some research I (and then some other staff) conducted into the effects of colour and other markers to improve mood and orientation. Remember that then, the research base for nursing was meagre and there was no real support in the UK such as grants and continuing professional development (CPD) in a formalised manner. We instigated those changes and they worked well. Twenty years after this Kitwood started his own exploration of dementia care and a lot of the principles he developed were ones that, all those years ago, I explored, although the trust then wasn’t that interested in supporting what we (and I) were doing.

“I recall this one patient, who’d been quite psychotic some 8-10 years. Had this belief that one day men would take a rocket ship into space, fly around, then land that same rocket back on earth. This patient was completely fixated on men flying into space- it absorbed so much of their thinking. Then in the year of the first space shuttle I was on the ward with them and the shuttle was making a final approach to land, all televised. I tried to engage them in discussion about this, tried to explain what was happening. They would NOT engage in the reality of it and then went back into their patter of ‘one day’ .”No mate, it HAS happened!” The actual reality of it was not the point for this patient. Their delusional framework was completely constructed around the future event and not it as reality and there was little success in challenging this. The patient wanted to retain that dream of a great and magical feat of science.

“There was often a lot of tenderness between patient and nurse- they would want to help us, offer to carry sports equipment and  would insist, fighting for the right to carry stuff back and we’d try to discourage this and guard against appearing to have ‘favourites.’. Anything they could do for you, they would want to try. Patients would know about your life. They would care. They knew the ages of our children, they would closely watch our faces and know instantly if we weren’t right, if we’d had a row with our partner before work. They would ask about it and we would have to manage boundaries without being seen to offend their genuine concern although I do think some staff get hung up about ‘boundaries’ and don’t have the skills to understand when, actually, it is appropriate to share, to let patients into your life a little more. When you work in a place for twenty or more years with patients who have been there for maybe double that time….well… There’s not much they don’t know about you, the hospital, the local area. You ended up all talking about the same thing- not because we didn’t see them as people who’d respond, but because we did interact with them. Patients would chip in and add to conversations and the ones appearing least engaged, would often surprise you. Patients would care about others too, taking you aside “keep an eye on….”They might not tell you why, but you knew it was to be taken very seriously. In fact ignore their observations at your peril.

Yes the old style hospitals have had their day and they were terribly institutionalising- patients often had communal clothing and the stories you hear of them sharing dentures in older times were true. That was untenable. BUT we have also lost a lot. No use talking about caring in a community that doesn’t actually care because it absorbs messages about the mentally unwell from the government and society as a whole- that they don’t matter, that they are not worth spending public funds on and should accept the dregs. That they should be housed in prisons and homeless hostels, in substandard housing or left to manage until they deteriorate to critical levels as opposed to being treated proactively so they maintain their lives in between any relapses in a way that is meaningful to them and to us all. People with mental health problems are so often valued according to the Marxist ideas of a person as economic currency which places untenable pressure upon them to manage within a work and social system that is not predicated upon the intrinsic value of people per se. It is the way we work economically that is broken, not the person with a mental health problem.

Our mental health system is broken and at least the old style hospitals gave the mentally unwell a bed, warm clean clothing, three meals and a sense of community. Now they are left to depend upon relatives with sharp elbows, trying to get the best care they can for their loved ones while government ministers pretend that cuts = better care.

“They must think we are all stupid”

To find out more about NSFTCrisis- the campaign for better mental health care in Norfolk and Suffolk visit them here. 

Telling it like it is- St Audry’s, the story of an asylum’.

 

 

 

 

 

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