Louise Hide outlines her new project: ‘Hiding in Plain Sight. Cultures of Harm in Residential Institutions for Long-Term Adult Care, Britain 1945 to 1980s’
In 1965, the Times newspaper published a letter that prompted a deluge of responses from both the public and mental health professionals. Signed by eminent academics, care professionals and public figures, including the economist Brian Abel-Smith and the campaigner Barbara Robb, the letter was short and to the point. In just three paragraphs it drew attention to the shocking treatment to which older patients in some mental hospitals were being subjected and announced the launch of a national investigation into the abuse of geriatric patients living in institutions (Robb: 1967).
Two years later, a nursing assistant approached the News of the World to complain about the ill treatment of patients at Ely Hospital in Cardiff. His action led to the first of 18 major inquiries into the abuse of patients that were to be conducted from the late 1960s through to the early ‘80s.
The inquiry conclusions focused primarily on administrative and management failures such as a lack of resources, low staff morale, poor leadership and communication, rigid hierarchies, and professional isolation. Bolstered by growing activism around civil and patient rights, the inquiries did bring about change: nurse recruitment, training and practices improved; management structures were reorganized to facilitate greater accountability and transparency.
While many of the vast Victorian asylums containing tens of thousands of long-stay patients closed from the 1980s, smaller institutions for people who are unable to live independently continue to exist – and will do so for the foreseeable future. Yet the ‘scandals’ of Winterbourne View Hospital (2011), Stafford Hospital (2013), and the Southern NHS Foundation Trust (2015) testify that cultures of abuse persist in some institutions, often well under the radar.
Clearly, lessons still need to be learned. Historians are beginning to make important contributions that directly address these pressing social issues. This means understanding not only what happened, but how and why within specific historical contexts. What were staff thinking and feeling about people in their care? How did cultural and psychological mechanisms allow acts of harm to remain ‘unnoticed’ and normalized within the system?
For the ‘Cultures of Harm’ project, funded by the Wellcome Trust, I will return to the extensive documentation generated by abuse inquiries that took place during the 1970s. My main focus will be on those relating to the Whittingham Hospital in Lancashire and South Ockendon Hospital in East London, both of which concern people who were in need of long-term care particularly older people and those with intellectual disabilities. A close analysis of these records, including thousands of pages of interview transcripts and witness testimonies, will reveal a deeper understanding of the prevailing belief systems, attitudes and practices that gave rise to and perpetuated abusive behaviours.
Many of the attitudes leading to abuse and neglect can be traced back to the nineteenth century, or earlier. My research begins at the end of the Second World War, when living and working conditions in mental hospitals had sunk to appalling depths: buildings were run down, staff were in short supply, and most wards were locked. It was from this period, the 1940s, that ‘the hospital’ began to be reconceptualised as pathogenic in its own right. New studies into institutions by sociologists, the best known of which was Erving Goffman’s Asylums (1961), demonstrated how the processes, systems and routines – ‘the culture’ – of the mental hospital turned patients into malleable bodies that could be managed and controlled.
A history of harm in institutions of care
In his 1984 analysis of the major hospital inquiries, the sociologist John Martin suggested that many of the medical and nursing staff interviewed did not fully understand what was expected of them in terms of providing care. This project will delve deeper. Using the latest Computer Assisted Qualitative Data Analysis Software (CAQDAS) software, I will uncover the values and belief systems that people held and subsequently articulated through their actions and in-actions.
How, I will ask, did these belief systems emerge within specific contexts that revolved around the changing meanings of ‘harm’ and ‘care’, particularly during the period immediately following the Second World War? What, for example, were staff attitudes towards pain? Martin attributed some particularly cruel incidents to an assumption by staff that their ‘victims do not really understand, or feel, and therefore do not suffer’ (Martin: 1984, 101). In 1954, T. A. Couston published his article ‘Indifference to Pain in Low-Grade Mental Defectives’ where he provided case studies to demonstrate how people with ‘mental deficiencies’ showed an ‘absence of pain where pain would normally be expected’. Indeed, ideas around the degree to which certain groups of people are believed to be sentient have shifted since the eighteenth century, raising important questions about what it has meant to be human over different junctures in time.
Underlying belief systems
Cultural beliefs and practices do not exist in a vacuum. They are discursively constructed by ever-changing ideologies circulating both outside and inside the institution. In the post-war period, we cannot discount the traumatic after-effects of conflict, the re-organisation of the health system including the formation of the NHS, the prospect of deinstitutionalization and the move towards community care, the introduction of powerful new psychotropic drugs, high rates of immigration, political activism, and the move towards the privatisation of long-term care from the late 1970s. All had a bearing on the social, cultural and psychological mechanisms that created, interpreted and normalized belief systems, language and behaviours. Their influence was pervasive in the meanings that staff, patients and the public attributed to notions of ‘harm’ and ‘doing harm’ – concepts which were, in turn, articulated within shifting meanings and expectations of ‘care’, being ‘cared for’, and what it meant to be a ‘carer’ for some of society’s least valued citizens.
Transmission of beliefs
I am interested not only in the beliefs people held, but in how they gained traction in ward environments and were passed on through certain cultural vectors such as: rhetorical devices (language, jokes and silence); the organization of spatial and temporal structures; the role of material objects such as clothing; and the practice of cruel, violent and neglectful behaviours. How were these actions and behaviours understood within contemporaneous ideas of compassion and empathy? What organizational and individual mechanisms such as complicity, denial and ‘turning a blind eye’ allowed them to take place over long periods of time?
Today, we have some idea of what happened in these hospitals, even though many of the deeper ‘truths’ have died with the most important, but largely absent, group of witnesses: the patients. But we know far less about how or why ill treatment took place. How did underlying systems of belief and practices, often invisible and unspoken, gain traction in the institution? How were they normalized? What mechanisms enabled them to become the accepted and unquestioned reality on some wards?
Given that some hospitals and care homes today continue to experience poor management and communications, as well as inadequately paid and trained staff, why do cultures of abuse occur in some institutions, but not in others? What systemic deficiencies have ‘turned’ good people with good intentions into neglectful carers and clinicians who do harm? How can underlying ideologies that led to abuse tell us what it has meant to be human, or not quite human, at different junctures in history?
As social care for vulnerable people, whether inside or outside institutions, is increasingly prioritized on the political agenda, I aim to bring together a cross-disciplinary network of scholars, healthcare professionals, service users, and activists in order to find answers to these questions. Together, we will provide current inquiries, policy-makers, health workers, clinicians, and social scientists with valuable historical context that can deepen our knowledge of this pressing social issue.
Dr Louise Hide is a Wellcome Trust Fellow in Medical Humanities. If you would like to get in touch, please email: email@example.com
Short bibliography and useful references
Barham, Peter, Closing the Asylum?: The Mental Patient in Modern Society (1992)
Barton, Russell, Institutional Neurosis (1959)
Belknap, Ivan, Human Problems of a State Mental Hospital (1956)
Bingham, Adrian, Lucy Delap, Louise Jackson, and Louise Settle, ‘Historical Child Sexual Abuse in England and Wales: The Role of Historians’, History of Education, 45 (2016), 411–29
Black, N., and N. Mays, ‘Public Inquiries into Health Care in the UK: A Sound Basis for Policy- Making?’, Journal of Health Services Research & Policy, 18 (2013), 129–31
Bourke, Joanna, The Story of Pain. From Prayer to Painkillers (2014)
Butler, Ian and Mark Drakeford, Scandal, Social Policy and Social Welfare, 2nd ed. (2005)
Cohen, Stanley, States of Denial?: Knowing about Atrocities and Suffering (2001)
Gittins, Diana, Madness in Its Place?: Narratives of Severalls Hospital, 1913-1997 (1998)
Goffman, Erving, Asylums?: Essays on the Social Situation of Mental Patients and Other Inmates (1961)
Hacking, Ian, ‘The Making and Molding of Child Abuse’, Critical Inquiry, 17.2 (1991), 253-88
Hide, Louise, Gender and Class in English Asylums, 1890-1914 (2014)
Hilton, Claire, Improving Psychiatric Care for Older People: Barbara Robb’s Campaign 1965-1975 (forthcoming)
Hopton, J., ‘Prestwich Hospital in the Twentieth Century: A Case Study of Slow and Uneven Progress in the Development of Psychiatric Care’, History of Psychiatry, 10 (1999), 349–69
Jackson, Louise, Child Sexual Abuse in Victorian England (2000)
Long, Vicky, ‘“Surely a Nice Occupation for a Girl?” Stories of Nursing, Gender, Violence and Mental Illness in British Asylums, 1914-40’ in Borsay and Dale (eds), Mental Health Nursing (2015)
Malacrida, Claudia, A Special Hell?: Institutional Life in Alberta’s Eugenic Years (2015)
McCrae, N., ‘Resilience of Institutional Culture: Mental Nursing in a Decade of Radical Change’, History of Psychiatry, 25 (2014), 70–86
Martin, J. P. with Debbie Evans, Hospitals in Trouble (1984)
Reinarz, Jonathan and Rebecca Wynter (eds), Complaints, Controversies and Grievances in Medicine. Historical and Social Science Perspectives (2015)
Robb, Barbara, Sans Everything. A Case to Answer (London: Nelson, 1967)
Sheard, Sally, ‘Can we never learn? Abuse, complaints and inquiries in the NHS’, History and Policy, 2015 www.historyandpolicy.org/opinion-articles/category/sally-sheard
Smart, Carol, ‘Reconsidering the Recent History of Child Sexual Abuse, 1910–1960’, Journal of Social Policy, 29 (2000), 55–71
Smart, Carol, ‘A History of Ambivalence and Conflict in the Discursive Construction of “The Child Victim” of Sexual Abuse’, Social & Legal Studies, 8.3 (1998), 391-409
Turner, John, Rhodri Hayward, Katherine Angel, Bill Fulford, John Hall, Chris Millard et al, ‘The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research’, Medical History, 59 (2015), 599–624
Wilkinson, Iain, and Kleinman, Arthur, A Passion for Society: How We Think about Human Suffering (Oakland, CA: University of California Press, 2016)
 There are almost 14,000 registered care homes in England (CQC, June 2017).
 See Sheard (2015); Bingham, Delap, Jackson, Settle (2016) and Hilton (forthcoming).
 T. A. Couston, ‘Indifference to Pain in Low-Grade Mental Defectives’, BMJ, 15 May 1954, 1128-9.
 A 2016 US study reported that African Americans are half as likely to be given pain relief as white patients (Guardian, 10 August 2016).
 The term ‘abuse’ in relation to child sexual abuse did not come into common use until the 1980s (Bingham et al, 416).