Life in the Victorian Asylum: The World of Nineteenth Century Mental Health Care

by Mark Stevens

  Chapter 10

  Discharge

  Every new patient will be anxious about the possibility of gaining their discharge, and for some, this possibility becomes reality. The numbers vary, but each year around one in ten of our long-term patients are discharged, having recovered, and an even larger proportion of those recently admitted. As you enter this building, you have a one in three chance of leaving it again within your first year.

  Should you be discharged, then the chances of you returning to us are small. Only around one in nine of our leavers are ever readmitted, and in these cases their attacks of illness tend to be recurrent but without a clear pattern. The happy conclusion is that there is hope of recovery for all our patients, regardless of their symptoms on admission. Last month four of our patients returned home. W.G., a 55-year-old carpenter, came in with mania after he had tried to set his house on fire. He rallied quickly and left us before the year was out. F.T., a 26-year-old painter, had been hearing voices and feared that he was being followed. He confessed freely to excessive self-abuse, and once his habit was broken his health was soon restored.

  E.F., a baker’s widow, also 55, had struggled to keep up her husband’s business. When she feared that people wished to take it from her, she attempted to cut her throat with a blunt razor; having failed, she was discovered by her son standing underneath a roof beam with a rope in her hand. We stitched her neck wound and gave her sedatives; she regained her former self and was back home within four months. And finally, J.Bo., a young servant girl, who had developed puerperal mania after the birth of her illegitimate child, fretted that her food was poisoned. She was admitted after she jumped out of her bedroom window in an attempt to disarm an imaginary assassin. She too recovered after spending a few weeks in our beneficial surroundings.

  Of course, the decision to discharge any patient is not taken hastily or without regard for their future. It begins imperceptibly as the patient is gradually more trusted by the medical and nursing staff. When you first set foot on the ward, privileges are few; however, if you are able to make progress and become a cheerful, constructive presence round the place, then a greater degree of liberty will follow. Your risk of harm – to yourself or others – has diminished. A wider range of occupations and diversions are offered to you and you may move to one of the convalescent wards.

  The structure of the convalescent wards offers a system of parole. The bedrooms are unlocked at night, and the day-room doors left open to the grounds outside. Attendants need no longer accompany you everywhere and you may use the ward scullery to prepare food and drink. The quid pro quo is that you do not give in to mischief, wander, remove your asylum dress or engage in physical relations with a member of the opposite sex. This system of parole is effectively the first part of a trial, where you are encouraged to test the benefits of social intercourse in order to prepare you for a life outside our refuge. You will be asked to keep your bedroom tidy, to manage your personal appearance, to make your own way to work or mealtimes and to converse freely and rationally with other persons on the premises.

  Assuming that this period goes well, the time will come for us to consider the practicalities of your exit. For the superintendent must first judge you to be sane, and once that great step has been taken, there are various additional factors to consider. Next we must establish that you have a home to go to. Family circumstances can change during the time a patient is under our care; new lives emerge, while others come to an end and work or financial circumstances can remove people to fresh environs.

  Our task is therefore to guarantee that someone will be ready to receive you. Those who sought your admission will be contacted and an enquiry made. The Home Office likes us to provide a little extra reassurance for our former criminal patients – that the home they go to will be stable and temperate – but in all cases we do not wish to risk a repeat exposure to the triggers for your illness.

  If you are a male patient of working age, we will also need to find a job for you, ideally in the same sphere – if not necessarily with the same employer – that you worked in before your admission. Male patients will need to confirm that some third party is prepared to use their labour and to pay them for it, yet female patients do not necessarily need such an external position. Instead, they may be occupied with domestic work within the home. We are also able to offer a financial benefit in the short term. For the first month of your discharge we pay a sum to your employer or your family that is equivalent to the cost of your upkeep here. This can be a great help in either expanding a workplace or simply coping with an extra mouth to feed.

  Once we are happy with the situation offered to you, the news about your case is brought before our visitors, who will interview you. In his monthly report the superintendent lists those patients that he is recommending for discharge. Initially, you will be listed as suitable to leave ‘on trial’ only, meaning that it is possible to recall you during your first month away.

  We have touched earlier on the nature of an appearance before the visitors. We appreciate that such an occasion can be intimidating, but remember to stand and do not be concerned if anxiety causes you to stammer. The interview is largely a formality, for the visitors take great delight in seeing any patient ready to take their leave. It is unlikely that they will make excessive or difficult enquiries of you, and any questions posed in your direction will be simple prompts to let you speak. After you have been heard the superintendent will invite the committee to approve his judgement, and once it is affirmed, he has the necessary authority to sanction your departure.

  A set of clothes and shoes will be provided for you if you have none; otherwise, you are free to regain your own dress and possessions from the stores. With the prospect of employment, you can also feel proud that you will no longer be a burden on the ratepayers. A greeting with this news will be sent to the friend or relative that you wish to attend and collect you.

  You may feel a little apprehensive at the prospect of going back to the home that you left in such unhappy circumstances. It is therefore important to remember that you return relieved of your symptoms and restored to your former disposition. If the asylum is indeed a place apart from society, as some contend, then to witness the discharge of a patient is to understand that these two worlds are not destined to be forever separate.

  When a patient leaves on trial, his journey is the reverse of his admission. Goodbyes must be said in the day-room, to the staff and any friends amongst the patient group. We encourage this, for your success can serve as inspiration for your former fellows. As you travel back through the wards, past the dining room and into the great central corridor, each step takes you closer to the waiting room of your arrival. Once again, your paperwork is checked and then the senior staff will come to see you. This time, it is to offer their best wishes and to remind you that you still remain, for a short time longer, under their care.

  Those who have come to acquire you may take advantage of our carriage for a journey to the railway station. The gravel on the drive may be punctuated once more by the sound of hooves, as behind you the asylum recedes into the distance. If you wish to take a backward look then you will see once more the façade of a country house peering out from amongst the trees, unchanged from your first glimpse of it.

  It is impossible to predict how you will feel when your liberty is restored. We hope, of course, that you are grateful for the care we have provided; we hope also that you are not afraid. It is not unknown for patients to feel unable to cope when confronted by the world they left behind – a world which naturally provides many challenges. We suggest that you merely view this as a test and decide how you fare without us. If providence renders you unable to rejoin your previous life, then we will be happy to welcome you once again.

  You are not sent away alone, for the chaplain will come and visit you once a week during the trial month. He will then report back to the medical officers with an account of how your case is progressing. During that initial month you ha
ve an opportunity to repair the bonds you shared with your friends and family, and to rediscover the skills that made you useful at your home or in the workplace. It is an exciting time, and you will cast off the limitations of the asylum routine and replace it with one more suited to your own rhythms.

  After the period of trial there is the opportunity for review. Assuming that all is well, the order for your discharge will be prepared for two of the visitors to sign at their next meeting. The event of formal discharge may seem something of an anti-climax; there is no fanfare, no pomp nor ceremony. The superintendent simply makes his recommendations once again, and at the end of the committee business all his paperwork is signed. Amongst it is your discharge order. The superintendent passes the bundle of papers to the clerk, who updates his records, finding your name and inscribing in the furthest column of his registers the date of your farewell.

  You have left our care.

  Chapter 11

  Useful Information for Patients’

  Friends or Family

  This chapter is designed to help a patient’s friends or family prepare for when a patient is admitted to the asylum. Their admission marks a significant change for you too. We recognise that you do not necessarily wish to surrender responsibility for the patient’s future welfare, or to exclude them from your lives. Admission is simply a practical response to a situation that has become impossible to manage, and no one will condemn you for your role in this.

  Here, we will outline how you can communicate with a patient in our care; how you can help in their recovery; and how we deal with the eventual settlement of a case.

  Within the Asylum

  On entering the asylum, your friend or relative will be able to receive care that is appropriate to their illness. We provide sanctuary and a routine with the best opportunities for a full recovery. Our discharge rates are quite high for those recently admitted, though there is a greater chance a patient will never be restored to health.

  If your friend or relative has not returned home within the first twelve months then they may be here some time; it is worth preparing for this eventuality, particularly if you rely on the patient’s income. Our advice always is to retain hope of recovery but to plan for a permanent loss.

  You will see on your first visit that we operate within a clear framework of rules, because there is a printed set of them hanging on the wall of the visiting room. These rules are mostly administrative in nature, but we wish to draw to your attention the paramount importance placed upon asylum staff to offer gentleness and kindness to the patients. Care and compassion are the most basic targets for any hospital and we are proud to subscribe to them. You will find that this care and compassion is also extended to you.

  Although a patient is necessarily separate from non-asylum life, you may still maintain contact with them. The principal form of contact is by letter. We realise that some of our patients and their families are unable to read or write – those numbers dwindle every year – but in such cases a member of staff will help the patient, while we hope that families can find similar assistance at home.

  By law, few letters have to be communicated to patients or sent on from them. Statute insists only that we allow correspondence to pass uninspected between patients and the Commissioners in Lunacy, the Home Secretary or the committee of visitors. Outside those few individuals the matter becomes one for the medical officers’ discretion. Missives are regularly inspected before being allowed to progress to their intended recipient.

  An opportunity for censorship exists, though we do not withhold letters from patients purely on the grounds that the contents might aggravate them. Sometimes, the medical officers may choose to describe a letter’s contents to a patient instead, particularly when the news is unhappy; but even then, the written version will be forwarded later. Neither do we withhold messages written by patients purely because the contents are confused.

  We will usually decline only to send on letters if we think that the text may upset you, or if you have asked us to stem the flow of items you receive. Also, we do not censor any bulletins that contain accusations against the treatment here, and all allegations of this nature, however regular, are always investigated. It is usually a simple matter to reassure you that these charges are entirely groundless.

  We realise that friends and family would generally prefer some communication from a patient than none at all, as this contact offers an update on their case, whatever the evidence of mental improvement. We hope that you will choose to write too. If so, please include details of your relationship to the patient in any correspondence and a stamped addressed envelope if you wish to receive a reply.

  Visits are also encouraged. These are scheduled on the first and third Thursday of each month, between 10am and 12.30pm, and then from 2.30pm to 4.30pm, though we ask that new admissions are left to settle for a month before any trips are made. Visits take place in a designated room at the front of the asylum. Friends or relatives of any patient considered to be dangerously ill are permitted to visit the infirmary every day between 8am and 8pm.

  There is no formal requirement to announce your intentions in advance, though if you are not known to us, but rather someone who has taken an interest in a case – such as the local rector, or the wife of the patient’s employer – then please write first stating your desire to visit.

  We recognise that visiting is not always an easy commitment, and that a day spent here will always involve some monetary sacrifice, at the very least, to cover transport to and from the asylum in addition to your loss of earnings. If you are unable to call often, or at all, then do not feel that your loved one will lack a comfort that is available to other patients. You would not be alone in finding it impossible to make regular visits.

  Occasionally, we find it necessary to restrict personal contact with patients, usually in cases where a significant detriment is likely to be caused to them or when the asylum rules are in danger of being broken. You must not give a patient false hope of discharge, for example, as you risk retarding their recovery. We must also strictly control the provision of gifts, as items that contravene the required uniform or that might be used as a weapon cannot be received into the asylum. Neither are we able to store large quantities of foodstuffs, particularly perishable items. If you persist in trying to bring in forbidden goods then future meetings will be struck out.

  Discharges and Escapes

  If you visit a patient, then one of the topics they are likely to discuss is the possibility of their discharge. This is perfectly normal, and it does not necessarily mean that a patient is being recommended for it; no proposal will be made without you being informed. The type of discharge that we wish to see is one effected through recovery. The poor law then ceases to have an interest in the case and the state ceases to have a financial obligation towards it. If a patient is discharged to your care, then you become responsible for them and certain obligations are subsequently placed upon you.

  Our first exhortation is that a recovered lunatic should not be allowed to wander, as unsupervised travel is a great risk. We would always recommend that the patient stays in the house to which they are discharged for a certain period of time. You also have a duty to be mindful of persons with whom they may come into contact. No new friend should be the cause of an unhealthy influence and neither should anyone be put at risk. This is especially true in the context of marriage; if a patient is single, then it is best they remain so. The perilous nature of a marital union should not be burdened further by the prospect of disease, and condemning future generations to similar suffering should be regarded with horror. We remain strict advocates of celibacy for the insane.

  In exceptional circumstances a patient may be discharged even if they are not yet entirely well, for instance if, during the course of a patient’s stay, your domestic life changes in a way that allows you to provide for their care. In this case, the patient is discharged ‘relieved’ rather than ‘recovered’.

  But discharge
does not necessarily involve relief or recovery; sometimes it is not possible to bring about that conclusion. If a case turns chronic there is only a slim chance that it will ever be resolved; this is part of the reason for the recent growth in asylum accommodation. However, that very growth also means that we must sometimes consider other options for disposal of patients in our care. We are obliged to constantly review the cases here and judge whether ours is still the most appropriate place for them. If that ceases to be so, we must consider transfer or removal.

  Such cases occur only occasionally. At admission, we will always check that a patient is local to us, as there have been incidences of wandering persons brought here whose proper place of residence is distant. In such cases, it is entirely proper for relatives to petition this institution for transfer to another, more local asylum. More significantly, there are times when our own institution approaches its capacity and it is necessary to board patients out in other houses. Usually the quieter and easier to manage chronic patients are selected for such temporary arrangements, particularly those who have no recent history of visits from friends or relatives.

  As the question of removal arises, it is advisable to address the matter of unauthorised discharges too, by which we mean an attempt made by the patient to escape. There is a very strict definition as to what constitutes an escape: a patient must make their way outside the asylum grounds and in so doing, fall out of the sight of staff. Any such event is noted, yet it is a comparatively rare occurrence – we suffer between two and three attempts every year, and patients are almost always retaken quickly. Nevertheless, it is best avoided: many patients are unable to make their way safely, and are at risk of harm from the road, the railway or the river. An escape is fraught with danger even if – as in our most recent case – the patient is later apprehended sitting peacefully in the family home.