Witness seminar: Development of old age psychiatry in Britain 1960-1989
Witness seminars are oral histories, where those who experienced an event or historical period share their first-person accounts of it. From this, a transcript is produced which becomes an important historical reference document.
This witness seminar was produced by the following convenors and editors: Dr Claire Hilton, Professor Tom Arie, Dr Malcolm Nicolson. It is available as a PDF which includes the transcript from the event.
See our other witness seminars.
Aim
To record the development of old age psychiatry in Britain, from around 1960 until its official recognition as a specialty by the Department of Health in 1989, as seen through the eyes of some of the people who participated in creating it.
Place and people
The witness seminar took place at the University of Glasgow, Scotland. This was apt, as the model of a comprehensive, outpatient and inpatient assessment, long-stay, community and domiciliary old age psychiatry service started at Crichton Royal Hospital, Dumfries around 1958. This model was adopted widely south of the border. Glasgow was also home to leading geriatricians in the mid-20th century, the first professor of geriatrics being appointed there in 1965.
The Guthrie Trust of the Scottish Society of the History of Medicine funded the seminar which brought together 11 old age psychiatrists and one geriatrician as witnesses, and a participating audience. The witnesses were an eclectic group from diverse backgrounds, including two who were refugees from the Nazis.
Some former colleagues attending the seminar had not seen each other for over a quarter of a century. Professor David and Dr Sue Jolley wrote afterwards:
"People were coming… back together – after breaks of decades. Yet there was no sense of discontinuity.
"… appearance, dress, posture, facial expression, voice and narrative style and even content all took on as if we had been together yesterday….The strength of fellowship shared remained evident these thirty years on."
The seminar conveyed camaraderie, warmth, and a sense of fun reflecting the personalities of those attracted to breaking new ground in a Cinderella discipline where many thought little could be achieved.
A potted history of the specialty until 1989
The development of old age psychiatry commenced in 1947 when Professor Aubrey Lewis appointed Dr Felix Post as consultant psychiatrist at the Maudsley Hospital, London, to run the proposed “Geriatric Unit”.
In the 1950s and 60s, some medical superintendents of traditional, large mental hospitals, such as at Crichton Royal, and Claybury and Severalls in Essex, encouraged innovative service developments. At the same time, epidemiological studies identified a clear need for the work. Professor Martin Roth showed that not all mental illness in older people was dementia and many suffered from the same disorders as younger people. Also, in contrast with the practice of “warehousing” older people in mental hospital “back wards” without adequate assessment or treatment, Felix Post showed that they benefited from active treatment.
In 1972, the Department of Health and Social Security published Services for Mental Illness Related to Old Age, an important step in providing best quality services nationally. The Royal College of Psychiatrists Psychiatry of Old Age Special Interest Group was established in 1973 (today’s Faculty stemming from it).
A crucial challenge at this time was lack of specialty (“senior registrar”) training posts: David Jolley explained: “Had we got any? Not on your nelly! Would they give you any? Well, they might give you one, but you had to try and win every time.” This was not properly remedied until 1989, when the Department of Health officially recognized the specialty, leading to a more realistic evaluation of service needs and training requirements.
Seminar themes
To achieve their objectives, the early clinical pioneers needed inspiration, support from senior colleagues, determination, assertiveness in the face of opposition and a vision of a better future for older mentally ill people. None of the pioneers had early career plans to work specifically with older people, but some spoke of charismatic figures who demonstrated enthusiastically what could be achieved.
To almost every story of inspiration and encouragement, witnesses also had a tale of the opposite, from doctors, other disciplines and management, incredulous of the idea that the work was feasible or that anyone should want to be a dedicated old age psychiatrist. One witness recounted telling a colleague’s wife that he was a psychogeriatrician, and she replied “Oh! I am sorry!” Another had experienced people saying: “Couldn’t you get a better job?”
Incredulity was also reflected in the often inequitable allocation of resources, necessitating clinical creativity and mutual support among the new psychogeriatricians to avoid professional isolation and burn-out. There were so many challenges that Professor Tom Arie coined the phrase “trouble as a teaching tool” and Professor Brice Pitt summed up: “psychogeriatrics belongs to the family of psychiatry, is married to geriatrics and conducts an often stormy affair with social services.” To cite a report from 1978, the new old age psychiatrists had to use “occasional militancy…to gain a fair share of scant resources, to put them to best use, to make do with too little while wheeling, dealing, and fighting for more.”
Some geriatricians collaborated in setting up joint “psycho-geriatric” units (Note the hyphen, which was not used for the specialty of “psychogeriatrics”). The joint wards could work well but depended upon personal attributes and objectives, enthusiasm and mutual trust. In some places, though, it “wasn’t always so on the coal face.” Regarding collaboration with geriatricians, one remarked:
“[W]e ran an out-patient clinic, together. It was easier to get along in the out-patients than in beds. We said it was dangerous to get into beds together, you know, just for a smile.”
Humour expressed in the witness seminar reflected humour needed in the work environment.
The seminar touched on many other aspects of old age psychiatry, such as community and long-stay care which entwined with politics, especially in the 1980s. One witness commented:
“I don’t think we are covering the history of old age psychiatry if the name Thatcher hasn’t been mentioned! She wrecked the development of community care.”
Another:
“[I]f one wants to sum up the difference between the old psychiatric hospital scandals and nowadays, its sweeping it under one big carpet or hundreds of small rugs.”
There were many challenges, but the emerging specialty attracted high-achieving and enthusiastic individuals and flourished.