The Second Experience
I spent the subsequent years, from 1963 to 1968, as a resident psychiatrist.
My first year of training was at the admission ward of a psychiatric hospital. All sorts of patients were mixed together there: recently admitted patients, chronic patients, patients with Alzheimer’s disease, and psychotics. Patients’ rights were hardly an issue in those days. Medical paternalism was rife, meaning that patients were at the mercy of whatever plans the psychiatrist or head nurse happened to consider suitable for them. The psychiatrist made his rounds twice a week, pointing out candidates for electroshock (ECT). On the mornings of his rounds the tension felt like it could be cut with a knife. In those days ECT was performed without anesthesia or muscle relaxants. Patients were not asked for their consent, and when necessary, were dragged to the “treatment” room by several nurses. This could do not harm, they said, as ECT cause amnesia for the events leading up to it. As agitated and chaotic patients in particular were prescribed ECT, rumor had it that ECT was not a treatment but a – terrible and dreaded -- punishment. Fear of it did not fail.
Some of the patients had been in that ward involuntarily for years, the commitment being continued by means of legally obligatory “monthly notes.” These notes amounted to: “April: patient hallucinates; May: still hallucinates; June: seems somewhat improved; July: hallucinating again,” etc. The notes were sent to the court, on grounds of which involuntary commitment was continued for another year. There could not be a bigger contrast between the simplicity of this administrative action and the consequences of it. Involuntary commitment implied that these people spent years locked up, incompetent, and deprived of their human rights, without any clear reason.
Solitary confinement was frequent. All the patients were administered psychoactive drugs, of which in those days two kinds were available: chlorpromazine for the treatment of psychosis, and imipramine for the treatment of depression. There was time for talking with patients only in exceptional cases. The psychiatrist used the framework of psychoanalytic interpretation only for determining diagnoses.
The ward was kept clean by the female patients. As a home, the ward was not wholly unpleasant, as many chronic patients were assigned chores which they performed with pleasure. For instance, there was an elderly man who kept a pheasant sanctuary; another patient fetched meals on a three-wheeler; and many ladies embroidered or knitted. Everyone participated in work therapy. Sometimes they made beautiful wooden objects or furniture, but most of the patients only assembled clothes pins or bicycle-wheel spokes. Attempts at deinstitutionalization as was the vogue in the US at that time generally failed. Precisely the chronic patients considered the ward their home and did not want to leave. At the same time they were much needed as their departure would have thoroughly disrupted the daily routine.
The head nurse who lived on the ward was instrumental in determining its atmosphere. Her impossible job was warding off the always imminent and sometimes exploding bouts of aggression while keeping the climate somewhat bearable.
I remember once hearing one of the patients saying to the psychiatrist, “It’s just like a concentration camp here,” – which was interpreted as an expression of paranoia. The other patients echoed this sentiment far too often for it to be dismissed as utterly implausible.
In summary, the psychiatric institution was paternalistic. Involuntary commitment and coercive measures were standard, and not seen as problematic. The therapeutic orientation was biological and somatic.
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