The Lunatics Are Out Of The Asylum A Review Of The History Of The North Wales Hospital By Mark Alistair

Moulden

Abstract In 1842, Dr. Samuel Hitch from the Gloucester Lunatic Asylum wrote to The Times citing the plight of Welsh-speaking pauper lunatics some of whom were sent to English Asylums. A Parliamentary Report in 1844 confirmed Hitchs concerns and resulted in a new County Asylum Act in 1845 making the provision of a County Asylum compulsory. The North Wales Hospital in Denbigh resulted from a collaboration of the five counties of North Wales. Originally intended to run along the principles of moral treatment pioneered at York by Samuel Tuke, the hospital, occupying 20 acres of land, supplied refuge for the mentally ill of the region until its closure in 1995. By the turn of the century, moral therapy gave way to a more medically orientated, paternal approach and an initial capacity of 200 beds steadily grew to a peak of 1,500 beds by 1955. Boasting its own chapel, farm, sports fields and ball-room, the hospital had become a community in its own right. In 1960, the Health Minister, Enoch Powell, announced its eventual demise. By 1987, a strategy was devised to conclude its closure which was achieved in 1995. Care of the mentally ill was transferred to the community signalling the end of an era. Word Count: 6998
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Contents Title and Abstract............................................................................................................Page 1 Contents..........................................................................................................................Page 2 Introduction....................................................................................................................Page 3 The North Wales Hospital...............................................................................................Page 5 Discussion of Interview Transcripts................................................................................Page 10 Conclusion......................................................................................................................Page 21 References......................................................................................................................Page 23 Appendix........................................................................................................................Page 24 DVD of Interviews.........................................................................................................Attached

Introduction When the doors of the North Wales Hospital in Denbigh closed for the last time in August 1995, the end of an era was signalled for the mentally ill of North Wales and for the residents of the town. Since October 1848 when its doors had first opened, it had sought to serve the best interests of the mentally ill of Anglesey, Caernarfonshire, Meirionethshire, Denbighshire and Flintshire. The first part will consider the events leading up to its closure and the events which ultimately gave rise to its construction. Briefly, the report will also seek to review the significant structural and demographic changes which took place during the 147 years between construction and closure. The second part of this report seeks to evaluate the effects of its closure by conducting video interviews with five former employees. The video interviews seek to explore key areas associated with life at the hospital. It will explore the extent to which the mentally ill were stigmatised by the various communities which would now house them as opposed to the North Wales Hospital. In addition it will investigate the relative advantages and disadvantages of institutional and community care. Day to day life from the respective perspectives of the staff and the patients will also be considered. It will also attempt to reveal the main reasons for choosing to work there. Finally, the interviews will try to establish the extent to which the hospital existed for the staff and the extent to which it existed for the patients. In this, the report will reflect on the effect of the hospital surroundings on the quality of life and sense of well being of its inhabitants. To understand the factors which gave rise to construction, key legislations will be analysed. In addition, this report will seek to appreciate what life was like for the mentally ill in North Wales before an Asylum existed. Briefly, the report will also consider the relevance of the Welsh language as a precipitating factor for construction of the new hospital. The report will also attempt to identify cultural differences between North Wales and the rest of the United Kingdom with respect to care of the mentally ill. The location of Denbigh as the site of the new hospital will be explored and the report will also seek to evaluate those therapeutic models upon which the hospital was originally based.
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The evolution of the hospital from its humble origins of 200 beds to its zenith of over 1500 beds will be explored as will the variety of conditions for which patients were deemed suitable for admission. The report will seek to reflect on how some of these conditions are viewed today and the advancements which have altered our attitudes to them. Finally, the effect on employment and commerce in Denbigh will be considered both during and after the life of the hospital.

The North Wales Hospital In order to understand fully the motives for building an asylum in Denbigh, it is necessary to consider the relevant legislation prior to its construction. In 1806, Sir George O. Paul wrote to the Secretary of State referring to the existing neglect and cruelty of the insane. He wrote, Of all the lunatics, the one half are not under any kind of protection from ill treatment, or placed in a situation to be relieved of their malady (Tuke, D.H., 1882. Pauls letter was the catalyst for the passage of the 1808 County Asylums Act by Charles Watkins Williams Wyn. Thus, county magistrates could now raise a rate for building a county lunatic asylum (Michael, 2003). One such asylum was built in Gloucester and became the destination for many Welsh pauper lunatics since Wales had no asylum provision until Haverfordwest in 1824 (Davies, 1992). Writing to the Home Secretary in 1842, Dr. Samuel Hitch, the Medical Superintendent at Gloucester, wrote to The Times referring to 664 pauper lunatics in North Wales of whom 19 resided in English lunatic asylums. In citing the high levels of monoglot Welsh speakers and the absence of Welsh spoken by staff at the Gloucester asylum, he claimed that the Welshman is the most turbulent patient and that he loses the advantage of judicious conversation with properly selected persons (The Times, 1842). Of the 664 recorded lunatics, 32 were kept in Welsh Union Workhouses under Section 45 of the 1834 Poor Law Amendment Act (Hirst and Michael, 1999). By 1844, only Pwllheli, Corwen, Ruthin, St. Asaph and Holywell had built workhouses. The remainder lived within their local communities with the western counties being particularly resistant to building workhouses. In 1844, the Metropolitan Commissioners in Lunacy embarked on an expedition to North Wales and published a report which would herald the County Asylums Act of 1845. Of the many cases discovered by the Commissioners, the case of 38 year old Mary Jones in the village of Llanrhaeadr-Yng-Nghinmeirch was highlighted by Dr. Richard Lloyd Williams of Denbigh. Williams had previously been instrumental in the development of the Denbigh General Dispensary. Acting as the translator to the Commissioners, he reported Mary as
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having been in the middle of a loathsome chamber on her bed of nauseating and disgusting filth. Emaciated, her confinement had resulted in distortions to her person which now emitted a most offensive odour (Supplemental Report, 1844). Although Mary had been admitted to the Dispensary fifteen years earlier, such Dispensaries did not permit admission to the insane. Housed in a cramped room above the village smithy, her close proximity to the parish church highlighted the limitations of the existing Poor Law whereby the local parish was supposed to support pauper lunatics by amalgamating into a Poor Law Union capable of workhouse construction. As previously suggested, the people of North Wales were resistant to implementation of the Poor Law (Kidd, 1999). In his speech to Parliament in July 1844 referring to lunacy in Wales, Lord Ashley informed his reforming colleagues that If they went to the Principality, they would find that they (i.e. the insane) were too often treated as no man of feeling would treat his dog (Caernarfon and Denbigh Herald, 1844). In a speech to Parliament in 1845, Ashley cited the case of Mary Jones in promoting the new County Asylums Act. This required all counties to provide a lunatic asylum. Unlike its predecessor, this Act did not allow counties to join forces in achieving this goal. This assumed greater relevance because following the letter of Dr. Samuel Hitch, construction of an asylum in Denbigh had commenced in 1842 to serve the five counties of North Wales. Thus, an amendment to the bill was successfully brought by Sir George Grey to allow hospital construction to proceed on behalf of all five counties. Supported by Dr. Richard Lloyd Williams, Ashley denounced patient coercion in favour of kind management and moral discipline (Minute Book of Founders (1842-1848)). Yet given that the two hundred bed hospital had to potentially cater for over 600 recorded pauper lunatics in north Wales, the idea of providing moral treatment was already fanciful. Moral management of insane patients was first espoused by Phillipe Pinel in his Treatise On Insanity in 1806. Pinel urged physicians to pay attention to individual cases and their disturbances. He believed that the advent of asylums would promote moral management where patients would be cured by a new medical approach (Shorter, 1997). In 1813, Samuel
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Tuke published a Description of the Retreat. The Retreat was run by Quakers in York who objected to the ill treatment and death of one of their members at the York asylum. Because moral treatment believed mental illness to be treatable in the caring social environment of an asylum, the insane at the Retreat were treated with kindness, compassion and rational conversation. However, key to the success of moral management was the intensive involvement of staff members with relatively small groups of patients. Also, violent patients were separated from non violent patients (Loudon, 1997). It was against this ideological and legislative background that North Welsh communities took action. In October 1842, members of the nobility, clergy and gentry met in the board room of the Denbigh Infirmary. Chaired by John Heaton Esq. of Plas Heaton, six central outcomes arose. The first demanded a Welsh hospital to unite the north Wales counties and replace the existing approach of abandonment, neglect and coercion with the three principles of kind management, advancing medical science and the soothing influence of his own tongue. The second outcome was the rejection of coercion in favour of moral discipline and kind management. Unfortunately, Poor Law officials in north Wales neither shared nor understood this approach. The third outcome addressed the cost of the venture. Taking advantage of the 1828 County Asylums Act, the committee launched an appeal to raise 6,000 which was given impetus by donations of 50 each from Queen Victoria and Prince Albert and 100 guineas from the Prince of Wales. The fourth outcome was to unite the five counties. The three western counties of Anglesey, Caernarfonshire and Meirionethshire remained resistant until November 1846 by which time the 1845 County Asylum Act had been passed. An amendment prepared by Sir George Grey to allow the counties to unite was passed in June 1847 (Minute Book of Founders 1842-1848). The penultimate outcome concerned the hospital site. Twenty acres of land on the outskirts of Denbigh was anonymously donated. The donor was later revealed as Joseph Ablett of Llanbedr Hall. Its proximity to the centre of Denbigh complied with three key aspects of the 1808 County Asylum Act. Firstly, the hospital site was in good proximity to a water supply. Secondly, the
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site was housed in a healthy situation and thirdly, the vicinity of the town could give constant medical assistance (Jones, K. (1955), Lunacy, Law and Conscience, Routledge and Kegan Paul Ltd., London, p. 116.). The final outcome concerned its legacy. The Subscribers called for lunatics to be treated in the soothing influence of their own tongue (Minute Book of Founders (1842-1848). The North Wales Hospital, Denbigh). Nationally, however, the fervour for reform which prompted the opening of the asylums would soon give way to the resentment and fear which demanded economies and higher returns. With plans drawn up by Thomas Fulljames of Gloucester and Dr.Samuel Hitch providing advice, limestone was procured from the Graig quarry in Denbigh and building commenced in September 1844. The hospital with 200 beds was opened in October 1848 with key personnel having been identified and appointed the previous summer (Wynne, 1995). Further extensions took place in 1865, 1881 and 1908 so that by 1955 it housed 1,500 patients and boasted its own chapel and dining hall. 1851 saw the purchase of two cows which would eventually give rise to the hospital farm with the latter being sold in 1958. In 1900, a new water supply was sourced from Llyn Bran on the Denbigh moors and 1902 saw completion of the laundry, boiler house and engine room. Until the formation of the National Health Service in 1948, the hospital was managed by the Committee of Visitors with representatives from each of the five counties. Further hospital developments are detailed in the appendix. The Denbigh hospitals individual, local history of increasing size and sophistication confronted, in the twentieth century, a national impulse to reject institutionalisation for the insane. A visit by the Health Secretary Enoch Powell to Denbigh in 1960 came in the wake of the Mental Health Act of 1959. He announced the eventual demise of the hospital and the following year published the Hospital Plan for England and Wales. This proposed the amalgamation of psychiatric units with district general hospitals, but little action arose from the plan in respect of psychiatric medicine. Patients First published by the new Conservative

government in 1979 sought to place the needs of the patient first and so paved the way for the revival of Powells vision. Following the Griffiths Management Enquiry in 1983, consumer opinion was gauged to secure the best possible services for the patient (Mold, 2011). In 1987, a ten year plan was drawn up to facilitate hospital closure and in the next eight years, many patients were transferred to ordinary community housing (Wynne, 1995). The White Paper, Working for patients, which proposed the creation of an internal market within the NHS in 1989, aimed to extend patient choice and once again put the needs of patients first (Mold, 2011). Acute provision was relocated to the Ablett unit in nearby Glan Clwyd hospital and the hospital doors finally closed in August 1995 (Wynne, 1995).

Discussion of Interview Transcripts Interviews took place on the 1st and 2nd of June 2011 and the interviewees were F, a retired psychiatric social worker, B, a retired community psychiatric nurse, P, a psychiatric housing manager, K, a community psychiatric nurse and D, a retired psychiatric nurse. For the purposes of ethical compliance, all interviewees signed consent forms which can be found in the Appendix. Each interviewee was subjected to the same questions and the interviews sought to gain a picture of life at the hospital and life after the hospital. Questions aimed to ascertain the features of a typical working day, the levels of staff camaraderie, changes seen at the hospital from the perspectives of the staff and the patients, the main reasons for choosing to work at the hospital and the strength of feeling regarding its closure. Of the five interviewees, only F came to work in Denbigh from outside north Wales. He disclosed, The reason I chose to work at the hospital was that they had a link with Cardiff University where I was doing my diploma in social science and I needed a job and my first wife came from Liverpool. F began work at the hospital in 1963 and retired in 1995. D was from Meirionethshire and said, From school I worked for a firm of accountants in Blaenau Ffestiniog. I knew I wanted to do something different. Id never been to Denbigh before. I was nineteen at the time. D started as a nurse in 1966 and facilitated closure of the Pool Park hospital in Ruthin in 1991. For K from nearby Ruthin, It was proximity and it was a good opportunity for me. The job at the hospital came up which was the right sort of grade for my level of experience. K worked at the hospital from 1992 until its closure in 1995. B and P were both from Denbigh starting in 1969 and 1977 respectively. B stated that, I started as a student nurse in 1969. I qualified as a SRN and thought What shall I do? So I went back in 1974 and started as a staff nurse. P admitted that My father was determined I do something for the NHS. I was fortunate to get in in 1977. I managed to get a job as a nurse assistant. With reference to the provisions of the 1808 County Asylum Act, it is not surprising that only one of the interviewees was not native to north Wales. Equally, given the original
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requirements of the 1808 County Asylum Act, it is perhaps to be expected that three should emanate from the immediate locality. On the issue of local staff, F argued that you do need some coming in from outside to stop it from being really incestuous and too resistant to change. However, K offered a different view claiming one of the differences for me was that having originated from Ruthin, and with Ruthin and Denbigh being rival towns, I didnt necessarily feel that I quite fitted in. Perhaps the view of F reflected his own origin from outside of the area but with over thirty years service, his view clearly carries weight. Also, although K reports not feeling very accepted, this might have been partly attributable to his young age on joining and knowing many people; however, since he worked there for three years, this seems long enough to form an objective view. The interviewees offered a wide variety of views regarding the stigmatisation of mental illness. K said, I think stigmatisation fluctuates. A good proportion of the time, I would say the way things are set up are less stigmatising and people appear far more willing to acknowledge and address less enduring mental health problems. Supporting this view, D claims I think the attitude from the public has changed. I remember when I first started. There used to be a lot of stigma. The further you went away from Denbigh, the more stigma there was. I think that improved quite a lot possibly due to the development of psychiatric services within local communities. Also MIND and MENCAP being part of the community; they do make a lot of difference really with attitude. K went on to suggest I guess the issues of stigma are still around enduring mental health problems and they come sharply in to focus when there are tragedies in taking their own life, or, on occasions, disturbed or homicidal behaviour. Thats the time which makes me appreciate the degree of stigma which still exists and perhaps the lack of understanding and perhaps the lack of willingness to understand as well. By contrast, P, whose organisation is closely affiliated to MIND, stated that The sadness now is that nobody seems to have taken that sense of responsibility in the community. My organisation would say that stigma is still a big, big problem. Im not sure how much Denbigh people accepted the mentally ill at the hospital and how much of it was
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their bread and butter. It was business and it was their jobs so I dont see how they could very well criticise something that was going to feed them. MIND came into fruition because of stigma and people being pushed into bedsitville. Referring to a recent meeting of Denbigh residents, P disclosed that people objected to a housing project for problem youngsters claiming that As they come down Vale Street, these people are urinating in our gardens and...these people walking in the rain without an umbrella. P felt that this was ignorance because Thats people coming from the pubs. Thats our kids! He also observed that Even now, gas meters outside their bedsits (in Rhyl) get switched off by kids and teasing. Similarly, B stated that (Stigma) still comes up every week because what I do now I deal with people with stress or panic and anxiety disorder. People (who have never been near a psychiatric ward) feel the stigma of depression. Its something they cant share with their friends, colleagues or other people. They feel that if it was a psychiatric disorder they might find it more comfortable. If its a psychological disorder, they feel more ashamed because they feel some stigma perhaps the same kind of stigma. Whereas going into a unit or a hospital is traumatic in itself isnt it? The feedback on stigma was interesting because most respondents commented on stigma now. It begs the question of how much stigma was felt by the mentally ill prior to hospital closure. The latter was hinted at by P when he questioned the extent to which local employment may have masked local stigma. The evidence of P regarding the stigma experienced by patients in bedsits in Rhyl would appear to corroborate the assertion by D that stigma seems to increase as you move away from Denbigh. Certainly, the argument that Denbigh attracts less stigma is brought in to question by P when recalling some of the objections raised by local residents. It seems churlish at best to chastise someone for not having an umbrella when it is raining; however, when the north Wales hospital closed and the transition to community based care took place, Denbigh accommodated large numbers of former hospital patients in various settings within the town. Therefore, the objections offered may have been more an expression of resistance to more
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patients. This argument seems rather flimsy given that so many patients already reside in the town. Hence, the claim of P that the community is not taking responsibility would seem to support his view that stigma remains a significant problem. P is still working and covers both Denbigh and Rhyl so would seem quite well placed to provide an objective assessment. By contrast, being semi retired, D is perhaps not as well placed to make such an assessment, despite his continued involvement with MIND. The interview results intimate that during the life of the hospital, there was a local tolerance of the patients because they were safely ensconced and indirectly provided vital income to the town. This dynamic seems to have changed as the patients were relocated in to the local community. It appears that the previously masked local stigma has since come more to the fore since community based provision for mental illness has assumed a greater impact on the lives of Denbigh people. Finally, on the subject of stigma, K observed the following caveat: Although Denbigh being a town to which a former large psychiatric institution was attached, there is a disproportionate number of people living in Denbigh that have experience of working in mental health or relatives who have. Whether there would be the same degree of acceptance if we had the same number of people with enduring mental health problems in a town that didnt have the same sort of cultural background? Broadly speaking, as a society we are more accepting of a degree of mental health difficulties in peoples life spans. Things are arguably better than they were in many respects but there is still, when I listen to the people I work with, significant issues around stigma and the acceptance of broader society. Hence, K alludes to the acceptance on both local and societal levels. His point regarding the accumulation of acceptance in a town immersed in mental health provision for such a long time carries considerable weight. He puts this in to context by offering a comparative view with respect to the acceptance of wider society thus arguing the two views to be exclusive of each other. In view of Denbighs historic role as the hub of mental health provision in north Wales, the logic of this argument seems sound; however, the counter argument of P is equally compelling. After all, for over a century, most Denbigh residents were never significantly
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confronted with the mentally ill in their community. Thus, it is hard to see why their reaction to the mentally ill should be radically different from people living in other towns in the region. When questioned regarding hospital life, the respondents offered several insights. Although K served in an administrative role, he did recollect that I became comfortable with a number of patients who had been in the hospital for a long period of time to see them on the corridors sometimes behaving in ways which people would find unusual and to think very little of it. There were a couple of people who I could think of who were probably responding to hallucinations and would be quite vocal about whatever it was they were experiencing and thinking thats just part of hospital life really; they were unwell and just doing whatever they were doing. Presumably, having come straight from full time education, K would have had relatively little exposure to the mentally ill before working at the hospital and would therefore have become gradually desensitised to their respective behaviours. K also made the observation that Since qualifying as a nurse, I have wondered if some of the positives of the hospital were lost in the provision of services. I wonder for some of the very long term and very ill patients whether there is something of a community feeling and structure which might be lost in community placements. Also I wonder whether things which could be offered in a large hospital environment could be offered in a smaller community placement in the private sector. P, with his superior length of service, was perhaps even better placed to compare life for the patients during his employment at the hospital with their life since in the community. Many of his observations are highly suggestive of an inflexible regime. I can remember my first day...We had breakfast and at 9.00 she (Sister Maud) said, take the patients down to the hall for PT (physical training). This is what we had to do every Friday but not at week-ends. No choice really you know. No excuses, out of bed. Youre not staying in bed. We went back to the ward at 10.00 for a cup of tea. Theyd be smoking their cigarettes. At half past ten, Right, I want you to go down to the gardens now and get the rake and barrow and brushes and brush up the leaves. Then it
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was back for dinner. 12.00 had dinner. She (Sister Maud) said to me after dinner, Right, I want you to take them for a walk now and I dont want to see you until tea time. I remember thinking, Where do I go for three odd hours? We went all over the fields and I can remember some of the patients moaning. Shoe polishing was on a Tuesday. There were set routines every day. They didnt have choices to some degree. In some ways they were driven but the fact is, if you didnt, they would just sit there. The latter is supported by B when he observed, If you dont give people things to do and meaningful occupations...they kind of sink in to a fantasy world and thats what happened when I started. People would be sitting in chairs rocking forward while writing meaningless stuff on paper and bizarre behaviour like walking in obsessional ways. However, since P referred to the set daily routines which he supervised as a trainee nurse in 1977, it brings in to question what patient behaviours might have been without it. His recollections are worth quoting at length because they give a sense of the multiple rigidities in the daily, weekly and annual experiences of patients. They could only smoke in the lounge twice a year; Grand National day and either Christmas Day or Boxing Day, I cant remember which. When I first started, the first thing for an acute patient was a bath. While the patient was in the bath, you could check their belongings for dangerous items. You couldnt get away with it now with human rights but it was as good as it was at the time. Largactil unfortunately it was wicked what it did on side effects; most of them had the rocking legs you know. There was no control over meals and not much control over what it was. Sunday morning was always bacon and egg. 8.30 you had to be up. On Friday it was fish and chips. Hundreds of times over the years I was asked Can I have some bread? I would reply, No, because you were rationed two rounds of bread in the morning and two at tea time and that was it. Your milk ration was half a pint of milk per patient per day. That had to be for cereal, cups of tea for breakfast, mid morning, mid afternoon and supper. Sugar was gold, honestly. If I had a ward for 24 patients and only had 18 patients, I would get supplies for 18 patients. Come Friday I may have had 6 patients admitted! Stores were strictly controlled. You couldnt get. The hospital had seclusion rooms and locked wards. I think a lot
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of the time misused to be perfectly honest. Padded cells had just gone before I started. I think a lot of the time, seclusion was used inappropriately to punish rather than using it as a form of therapy or safety. Working on a locked ward was quite stressful in itself. Its not just the patients who were locked up; staff were too. There was some staff up there I thought were really good. Good mentors. Im afraid to say there were the others. If you didnt like what you saw, there wasnt much you could do about it to be honest. You were never going to be welcomed on to another ward if you complained. You said to yourself, Thats a bit of practice I wouldnt do. In the hospital it was assumed nobody could (self medicate) so they all had medicine at the same time. The hospital was cocooned. In reality staff became family because eventually a lot of contact with family was lost. I can remember a new staff nurse and she was a new broom. She wanted to bring this new philosophy of education in. We had a bath book. Monday was that bay of four. Tuesday was that bay of four. She thought shed introduce a form where you just ticked when theyd had a bath. On the opposite shift was an old staff nurse. Old school: No way were having that, totally rebellious. The other difficulty Ive noticed is even if you work with somebody for years, if you stop supporting them, they slip back. Things started changing. The rules became more focused on individuals and why we were doing it for them and not the staff. Over time things changed towards participation, choice and rights. The good thing the hospital did, it gave them a quality of life. Clearly, routines were quite inflexible considering his descriptions of bath time, shoe shining, food, milk, sugar and smoking. It is interesting to conjecture why smoking was permitted in the lounge on Grand National day. P revealed that patients were not allowed bets on the race so it is possible that staff members had placed bets and had bargained for some freedom to watch the race in peace. On the other hand, it might just be that this race assumed greater cultural significance at that time. The attitude to change of the old staff nurse seemed to support a belief that large parts of hospital life were run by the staff primarily for the benefit of the staff; however, given the unforeseen high ratio of patients to staff in Denbigh, it
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is perhaps more understandable that this culture should predominate. Certainly, the ideal of moral treatment was giving way to the medical psychotherapy espoused by Hippolyte Benheim in 1883 ( Shorter, 1997). The description of the misuse of isolation rooms and locked wards is interesting because he also admits that working there was stressful. It could therefore be argued that the isolation rooms were used more for staff respite. Although the drugs available at that time were less effective than today, it is perhaps again indicative of the high ratio of patients that staff resorted to using the isolation facility. Perhaps his observation that some staff were better than others suggests a lack of support or training resulting in bad nursing practice. Alternatively, for large institutions, it is difficult to monitor staff behaviour for either cultural or practical reasons. Equally, his claim that staff didnt complain when they witnessed bad practice for fear of rejection by other wards strongly suggests a culture prepared to turn a blind eye when convenient to do so. Such a paternalistic and parochial culture could surely only exist in the presence of weak management. The recollections of B revealed a little more because he had started at the hospital as a trainee in 1969. He questioned, Was everyone on that (locked) ward detained under the Mental Health Act (1959)? But no, that was not the case, he maintained. The Mental Health Act of 1959 had tightened the procedures and safeguards relating to compulsory detention and treatment (Mind.org.uk). It therefore seems that this provision was being frequently ignored. He also pointed out that, In the modern day, you know, people would not be kept; peoples human rights and that. It was the era you know. It was very paternal. We knew what was best didnt we in those days but thats not the case now. He also revealed, People would do anything to get in as well. They knew Denbigh offered a sanctuary and if you said the right things to the right people, then you might get a few days of warmth, food and safety. However, he also stressed that Those would be in the minority and wed spot those pretty soon. This suggests that the parameters for admission were not rigidly adhered to. B considered the perspectives of both the staff and the patients when he
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said, To look back from a staff perspective, you can talk about socials and dances and cricket teams and football teams although there were equivalent things for the patients. But thats a staff perspective isnt it? I didnt experience the patients experience and Im not sure whether all the patients would look back at it as a positive experience. Again, this suggests a regime which placed the needs of the staff first. Like P, B questioned Were they asked what they wanted to eat or what they had on television or what they wanted to wear? He also disclosed, They didnt even have their own clothing until the early 1970s...because there wasnt a system in place that could keep a track and wash and return these items to an individual. It was thought too complex or maybe it was thought not worth bothering with or whatever The overtones of a prison regime are compelling here. D claimed that, There was a tendency in those days for it to run for the benefit of the staff rather than the patients. So, because of limitations with shifts and things like that, entertainments had to start at 6.00 and had to finish at 8.00. On the subject of entertainment, D went further:There was something on every evening you know. We used to have whist drives, cinema once a week, a dance every Wednesday. I was very much part of that because I played in the hospital band. This claim is fortified by a recollection of F:They always said that to become a nurse you had to be either musical or involved in sport. B corroborates the account of P when recalling the isolation rooms: Somebody might be removed to that (isolation) room until theyd calmed down, you know...because you never had the medication in them days that immediately calms somebody down. It didnt take immediate effect so people were isolated. There was a kind of attitude where you behave yourself and everythings fine but this is what can happen if you dont behave yourself. Of course, very often, peoples condition was such that they didnt know they were so far removed from reality that they didnt know what was happening. A lot of responsibility but not something that I look back on with great pleasure or proud of really. He is therefore providing a rationale for using isolation citing the limitations of medication and also the severity of some of the illness they were dealing with. However, like P, he also suggests its
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use as a deterrent. B also supports the claim of P that family contact was frequently lost so that staff became like family. B observed, Wrexham? You used to get a minibus at Ruthin to try and make it easier to come and visit at the week-ends because it would take two hours to get the bus from Wrexham. Presumably, the journey time for family members living on Anglesey or the Llyn peninsula would be even longer. Given that many patients received no visits from family, it is easy to understand how staff came to be viewed as family irrespective of the way they treated the patients. B also offered a view regarding the consultant psychiatrists: The consultants were God. They knew everything. What they said went. It was very paternal. We know whats good for you; you trust us. This adds to the picture of paternalism previously referred to. Epilepsy provides a good example of how the existing drug limitations gave rise to fear. Epileptics had been admitted to the hospital since its opening. Famously, the England cricketer Johnny Briggs suffered a violent fit on the eve of a test match in 1899 and was admitted to Cheadle asylum (Frindall, 1989). More recently, Prince John, the youngest son of King George V, was diagnosed epileptic aged four and was thereafter concealed from the public until his death at the age of thirteen in 1919. Thus fame and fortune did not insulate epileptics from institutionalisation. F asserted that, They had anti-epileptic drugs but far fewer than these days. I always felt nurses had a fear of epilepsy but I think thats because they get a distorted view and only see the people most disabled by it. When questioning the respondents about the biggest changes for patients since the introduction of community based care, most made reference to patient choice. B cited that Service users now have a choice in staff interviews. Choice is much more of a collaborative process. P added that Their lives (since the hospital) have improved immensely from those key words of value, respect and dignity. K pointed out that in the community based setting he saw an emphasis on seeing people in their home environments. However, with reference to acute cases bed availability is not always there. This view was shared by F who claimed, At the acute end of things, theres much more pressure on beds than there was. However,
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he also acknowledged the alternative outcome when he admitted, I suppose the opposite as well is that you could spend too long there (and become institutionalised). Also, F expressed a misgiving that they (patients in the community) probably did less. Like B and P though, F did believe that They preferred the life they now had. They could make choices of their own; what they did and the way they did it. There seemed to be agreement that through choice, patients were now better off. However, there were disparate views regarding the advantages of the asylum compared to the community setting. It was interesting to note that the provision of beds for acute care has become an issue since the hospital closure. This seems to have exerted extra pressure on staff working in the community. When questioned about their feelings regarding the hospital closure, there was unanimous indifference. This is understandable given that it took thirty-five years for it to close following the announcement by Enoch Powell in 1960.

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Conclusion The five respondents yielded a wide variety of opinion in response to the questions posed. However, there was unanimity in their response to the hospital closure. They all accepted that the time had come to move away from such a large asylum. There appears to be general agreement that stigma continues to be an issue for the mentally ill. However, the scale of stigma before the hospital closed is rather more difficult to measure. This is because during its existence, the hospital existed largely as an enclosed community. The patients were therefore seldom introduced to the local community and the residents of Denbigh had little contact with them. The argument that stigma is greater further away from Denbigh is both supported and questioned by the testimony of P; however, the argument of K that stigma had been masked in Denbigh residents when the hospital was open is hard to ignore. Evidence for paternalism within the hospital was offered by all the respondents. Given the high patient numbers, it is likely that paternalism evolved as a coping mechanism for the staff; however, for comparison, it would be valuable to gain the measure of paternalism in non-psychiatric hospitals during the same period. Perhaps the worst examples arose where patients were detained without employing the Mental Health Act and where staff checked patient belongings while patients were in the bath. One thing is certain: the misuse of the isolation room seems far removed from the philosophy of moral treatment espoused by Samuel Tuke and the hospital founders. The admission of 142 patients in the first year and the extension to house another 200 beds in 1866 is testament to the demand for the hospital and the inevitable demise true moral treatment. By 1875, the hospital was once more operating at full capacity (Michael, 2003). If it is accepted that acute mental illness needs specialist hospital care, it is surprising to see that acute bed space has become a concern in the wake of hospital closure. B reported that there are now just four beds for each sex in Denbighshire. It seems that the hospital had reached a peak of 1500 patients because of the variety of conditions being treated. Many
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patients were geriatric and those classed as chronic had become institutionalised through being at the hospital for many years. In addition, epileptics were sent there. Neither of these were acute conditions so it begs what patient care might have been had the hospital only been faced with acute admissions. It seems that the pendulum of acute care provision has lurched from one extreme to the other. The respondents agree that the biggest transformation in the lives of the patients since the hospitals closure has been in their extended life choices. However, the sheer patient numbers and size of the building at the hospital would have rendered patient choice impractical in some instances but this does not and did not obviate the fact the patients deserved to have a greater voice in such matters as their diet, clothing and daily routines. In many ways, staff were restricted in the choice they could offer the patients in their care, by both institutional constraints and by the effectiveness of drugs at their disposal. Taking the views of all the respondents in to account, it seems as though community care for the mentally ill has benefitted most patients; however, for a minority of acute cases, there still seem to be sound arguments for institutional care but on a much smaller scale.

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References Books Frindall, B. (1989) England Test Cricketers: Collins pp 61-62 ISBN 0002183390. Hirst, D. and Michael, P. (1999) Family, community and the lunatic in mid-nineteenthcentury north Wales, London: Athlone pp 66-85. Jones, K. (1993) Asylums and After: A Revised History of the Mental Health Services from the 18th Century to the 1990s, London: Athlone. Kidd, A. (1999) State, Society and the Poor in Nineteenth Century England, Basingstoke: Macmillan. Loudon, I. (1997) Western Medicine: An Illustrated History, Oxford pp 236-237 ISBN 0199248133 Michael, P. (2003) Care and Treatment of the Mentally Ill in North Wales, University of Wales Press ISBN 0708317405. Parliamentary Papers (Lords), 1844, xvi, Supplemental Report of the Metropolitan Commissioners in Lunacy Relative to the General Condition of the Insane in Wales, 25 August 1844, London, Bradbury & Evans, 24. Tuke, D.H. (1882), Chapters in the History of the Insane in the British Isles, Kegan Paul, and Trench & Co., Nabu Press ISBN 9781144822581. Minute Book of Founders (1842-1848), The North Wales Hospital Denbigh. Shorter, E. A History Of Psychiatry (1997) Wiley pp 19-21 ISBN 0471245313. Wynne, C. The North Wales Hospital Denbigh 1842-1995 (1995) Gee and Son Denbigh Ltd ISBN 0707402719. Journals Davies, T.G. (1992-3) Of All The Maladies, Journal of the Pembrokeshire Historical Society, 5, pp 75-90. Mold, A. (2011) Making The Patient-Consumer In Margaret Thatchers Britain, Historical Journal, 54(2), pp 509-528. Newspapers Caernarfon and Denbigh Herald, 20th July 1844. The Times, Saturday 1st October 1842.

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Web Sites
www.MIND.org.uk

www.northwaleshospital.btck.co.uk/home

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Appendix Chronological History Of The North Wales Hospital 1842 (September) Dr Samuel Hitch, Medical Superintendent of Gloucester Lunatic Asylum wrote a letter to the Times about the poor treatment of Welsh Pauper Lunatics in English Asylums. 1842 (October) The first meeting of interested local people was held in the Denbigh Infirmary. 1844 (September) Building started. 1847 (June) First staff appointed. 1848 (October) Hospital completed and opened 1850 Ablett Fund set up to assist discharged patients to re-establish themselves in the community. 1851 First cows bought. 1852 December First Annual Ball for patients held. 1853 Gas works installed to replace candle and oil lighting. 1862 Chapel built for 200 people. 1865 Extension to main building for 150 patients. 1867 First hospital band formed. 1868 Bakery and Brewery built. 1870 First hospital choir formed 1871 Turkish baths installed. 1881 Extention to main building for 160 patients plus dining hall for 400 patients and Chapel extended to hold 440 patients. 1890 New Lunacy Act 1897 Work commenced on major extension. 1900 New water supply from Llyn Llymbran (Brn) in use. 1902 Laundry, Boiler House and Engine room and Isolation Hospital completed. 1903 Female epileptic and chronic wards (Female 7 and 8) for 243 patients completed.
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1904 Male attendants accommodation, Kitchens and Dining/Recreation Hall completed. 1905 Female attendants accommodation and administrative block completed. 1908 Extension for 78 male patients (Male 8&9) and 74 female patients (Female 6&9) completed. 1913 Old workroom converted into a ward (Female 5). 1915 First formal training in mental illness for nursing staff. 1923 X Ray Equipment installed. 1926 Gwynfryn house bought to accommodate 25 - 30 'useful female patients'. 1927 Trefeirian used to accommodate 20 male convalescent patients. 1930 Mental Treatment Act allowed voluntary admissions for first time. 1933 Bryn Golau and Convalescent Villa (Tal y Fan) built. 1934 Extension to Gwynfryn for Reception wards completed and Nurse Home for Female staff opened. 1935 First Out patient clinics in Bangor, Wrexham and Dolgellau. 1937 Pool Park near Ruthin bought and opened for 80 patients. 1937 First qualified Occupational Therapist appointed. 1920's/30's Many physical treatments developed including Malarial treatment, Insulin Shock treatment, Sulphur based drugs, Cardiazol. 1941 Electro-Convulsive Treatment (ECT) first used. 1942 Pre-frontal leucotomy operations carried out in hospital theatre. 1942 First qualified Dispenser appointed. 1944 First Psychologist appointed 1945 First Psychiatric Social Worker appointed. 1946 Holistic approach to treatment introduced including physical, medical, psychological and rehabilitation treatments. 1948 With the introduction of the National Health Service Act the hospital was transferred to the National Health Service. The management committee was given responsibility for Coed Du, Broughton, Llwyn View, Fronfraith, Garth Angharad and Oakwood Park.
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1953 Largactil and Stelazine introduced as effective treatments for Schizophrenia. 1956 Brynhyfryd Villa opened. 1958 Hospital Farm sold. 1958 Sports and recreation Officer appointed. 1959 Mental Health Act gave improved rights to patients. 1959 Many Hospital and ward doors were permanently unlocked. 1960 Enoch Powell visited the hospital and announced its eventual demise with the Hospital plan for England and Wales which proposed Psychiatric units attached to General Hospitals and more community care. 1967 New Kitchen and Staff Cafeteria opened. 1968 First Community Psychiatric Nurse appointed. 1969 New Nurse Training School opened. 1987 10 year strategy for closure devised. 1991 Pool Park hospital closed. 1995 Main Hospital closed. 2002 Gwynfryn closed.

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Acknowledgements I would like to express my sincere gratitude to Clwyd Wynne for helping to identify the subjects for interview. Also, I would like to extend my thanks to Dr. Phillip Morgan for his advice in conjunction with preparation for the oral interviews and my tutor, Dr. Alannah Tomkins for her patience and encouragement. Finally, I would like thank each of the interviewees for their time. Without them, this report would have been impossible.

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