David Abrahamson

R D Laing'

R. D. Laing and long-stay patients: discrepant accounts of the refractory ward and 'rumpus room' at Gartnavel Royal Hospital

Keywords: Gartnavel Royal, history, Kingsley Hall, long-stay patients, medication, mental illness, R. D

mental hospital experience has been considered a formative influence on his controversial views. This paper addresses a number of discrepancies in the existing accounts: important aspects of the refractory ward and 'rumpus room' were underestimated; all the 'rumpus room' patients were not discharged and readmitted as repeatedly stated; his interactions with the patients were very limited and the viewpoints of most remain unknown; and the introduction of Largactil (chlorpromazine) was not mentioned. The Kingsley Hall residential project, Laing's first book The Divided Self, and his influence on psychiatrists' attitudes are considered in the light of these findings. Pessimism about long-stay patients may have influenced the acceptance of inaccurate information.

Introduction R. D. Laing's experience of long-stay patients was almost entirely confi ned to Gartnavel Royal Mental Hospital in Glasgow, as a psychiatric registrar from November 1953 until February 1955, a time of severe overcrowding and understaffi ng. He mentioned duties across the female side of the hospital (Mezan, 1972: 168), but further described only the 65-bed female refractory ward and an associated rehabilitative unit commonly known as the rumpus room. 1 The principal account was a jointly authored paper published in The Lancet some fi fty years ago (Cameron, Laing and McGhie, 1955a), for which he subsequently claimed the main responsibility (Mezan, 1972: 168). After he became a household name, partial accounts were widely disseminated in autobiographical works [START_REF] Laing | The Facts of Life[END_REF][START_REF] Laing | Wisdom, Madness and Folly: The Making of a Psychiatrist 1927-1957[END_REF] and interviews [START_REF] Clare | the Psychiatrist's Chair[END_REF][START_REF] Mezan | After Freud and Jung, now comes R. D. Laing[END_REF][START_REF] Mullan | Mad to be Normal: Conversations with R[END_REF], as well as in three biographies [START_REF] Burston | The Wings of Madness: The Life and Work of R. D. Laing[END_REF][START_REF] Clay | A Divided Self[END_REF][START_REF] Laing | A Life[END_REF]. These all focused on his work alone, but its complex context at Gartnavel Royal was emphasized by [START_REF] Andrews | Laing in Scotland: facts and fi ctions of the 'rumpus room' and interpersonal psychiatry[END_REF].

The experience was claimed to be a formative infl uence on Laing's ideas about the psychiatrist-patient relationship and on the development of Kingsley Hall in East London as a sanctuary to promote self-cure without psychiatric interference [START_REF] Barnes | Two Accounts of a Journey through Madness[END_REF]Mullan, 1995: 172-90). It was also presented as one of the foundations for his fi rst and best known book The Divided Self [START_REF] Laing | The Divided Self: An Existential Study in Society and Madness[END_REF]Mullan, 1995: 133) which had a remarkable impact both on many young psychiatrists [START_REF] Clare | the Psychiatrist's Chair[END_REF][START_REF] Holmes | Ten books[END_REF][START_REF] Mullen | Ten books[END_REF] and on the development of 'anti-psychiatry' [START_REF] Kotowicz | Laing and the Paths of Anti-Psychiatry[END_REF][START_REF] Sedgwick | Psycho Politics[END_REF].

In his accounts subsequent to the joint 1955 paper, Laing stated that all the rumpus room patients had been discharged within ten months after he left the project and readmitted within a further year, and this statement was widely copied (Andrews, 1998: 142;Burston, 1996: 38;Clay, 1996: 56;Sedgwick, 1982: 72-3). The present study initially aimed to establish the circumstances of their discharges and why they had all been readmitted; how they had fared subsequently; and if any had been more successfully resettled when community care improved. It was possible to access six of their case notes in the Medical Records Department at Gartnavel Royal, following identifi cation via the Laing Archive in Glasgow University Library. The results were unexpected: none of them had in fact been discharged as reported and therefore, of course, none had been readmitted. Further discrepancies emerged from unpublished accounts of the refractory ward and rumpus room in the archive.

The refractory ward

The Lancet paper reported that the refractory ward housed 65 patients and was usually staffed by four nurses; sometimes only two. 2 Their energies were largely absorbed by patients who were 'exceptionally noisy and violent' so that others were habitually passed over: 'they sat round the walls or lay on the fl oor, 3 in the same place every day … if approached, several of them were liable to spit obscenities or to attack one. For this reason they were very seldom approached.' No occupational therapy was available, although 'occasionally someone tried to sew or make a rug, but another patient would interfere and nothing came of it.' In the Laing Archive, a very personal paper with handwritten amendments (Laing, 1956: 1) provides an extended account of his experiences in the ward and rumpus room. He writes:

Here I would like to take the opportunity of expressing some of the ideas that led me to start the scheme, and some of the lessons I feel I have learned from my part in it … I have to ask for a certain straining of the readers' goodwill, because part of what I have to say, may perhaps, seem somewhat odd … I have written nothing capriciously, and nothing about which I have not thought seriously. This does not mean that I am satisfi ed with what faute de mieux I have here put down.

Laing's description starts: I think the fi rst thing that happened to me when I had sat myself in a chair (in the ward) was that I got my trouser buttons ripped off, my hair ruffl ed, and my tie pulled. Several patients fought each other to hug me, or kiss me. 4 The intensity of their reactions hardly abated during the whole time I spent in this ward … My fi rst impressions therefore were mainly of my own reactions: anxiety at raw physical advances, aggressive and/ or sexual on my body, and horror at the general dilapidation of many of the patients, their obscenity and so on. Sometimes I was so physically shaken that I had to leave after half an hour, to fi nd myself trembling like a leaf. (pp. [START_REF]… maybe there'd be two nurses and a sister who were rotated to other wards quite often, so there was no possibility of establishing anything like personal relationships with the patients[END_REF][START_REF]There weren't enough chairs to go round, and you weren't allowed to be in bed during the day, so there were plenty of fi ghts over chairs[END_REF] He found the many withdrawn patients disturbing in a different way:

Occasionally I got a glimpse behind the veil of these mad creatures. And such a glimpse I still recoil from; of complete and utter hopelessness; of nothing; of non being. Each patient was a vacuum, fi lled only with hopeless terror for the beings all around who threatened by their abhorrence to obliterate her. The 'schizoid paranoid position' is truly a living death. (pp. [START_REF]There weren't enough chairs to go round, and you weren't allowed to be in bed during the day, so there were plenty of fi ghts over chairs[END_REF][4] A colleague, Dr Roy, subsequently supplied an analogy for the ward from his own experience as an observer.

He said that at fi rst [it] sounded like an orchestra tuning up, each instrument unrelated to others, the total sound chaotic. Later, however, the actions and speech of each patient, although autistic, yet seemed to be interwoven with that of the others … [as] when the jumble of sound of a diffi cult piece of music all suddenly make sense. It did not make much sense to me but I had glimpses when I felt it could. Certainly it was sense that the patients though isolated were not exclusively self-absorbed. 5 (pp. 4-5, original emphasis)

Laing relied on 'one of the few patients with whom one did not need to speak in schizophrenese' 6

for further explanations:

For what I think I have learned about psychosis, I am indebted to a remitted manic patient, as much as to anyone. She sat by me often, and explained to me a great deal of what went on. One patient for instance, sitting in the far corner of the ward, gazing out a window, she told me was furious that I had not looked at her when I had entered the ward. Another patient, who was curled up under a table, and emerged only to collect food, which she preferred to eat in this position, she told me had been playing at being a snake for years, and so on. (p. 4)

The rumpus room Cameron et al. (1955aCameron et al. ( : 1384) ) reported that 'one of us' spent an hour or two a day sitting in the refractory ward over a six-week period, and selected eleven patients to attend a specially appointed room within the hospital. 7 The only criterion for selection was the patient's social isolation on the ward, and 'they were all schizophrenics', aged from 22 to 63 years, who had been confi ned there continuously for at least four years. They spent from 9-12 a.m. and 2-5 p.m. on weekdays in the room and returned to the ward each evening. Two nurses were regularly on duty and were given no direct instructions except to provide daily reports and to complete sociograms; 8 there were meetings with the nurses once a week to exchange information. 'One or other of the doctors' visited each day, at any time, and usually did not stay longer than thirty minutes. The room was large, bright, newly decorated and comfortably furnished, and contained magazines and material for a range of craft activities. At fi rst, it seemed little more than an extension of the ward. The patients quickly settled into their own 'jealously guarded' places and, although the nurses put a magazine on a patient's lap or offered a ball of wool, remained apparently indifferent and withdrawn. From the second morning, however, patients were waiting enthusiastically at the door to be taken across to it (Cameron et al., 1955a(Cameron et al., : 1385) ) -'one of the most moving experiences of my life' (Laing, 1985: 115).

After the settling-in period, gratifying changes were noticed as most of the patients began to sew, read or draw 'with some application' and take over small jobs such as making the tea and laying the tables. An old gas stove was available in an adjoining kitchen and when baking utensils were supplied some of those who had not previously joined in began to help:

They did more and more of the work in the room and gradually took over the scullion work in the divisional kitchen. The domestic staff responded warmly to this unexpected assistance and regularly we began to fi nd two or three patients there for most of the day. One patient began to scrub the stairs, and another polished the linoleum on all the landings. At fi rst when patients left the room they wandered erratically through the hospital but now it was obvious that they were on their way to do something -to collect stores, to clean some part of the hospital, or to go for a walk in the grounds. (Cameron et al., 1955a(Cameron et al., : 1385) ) There were regular trips into town for tea and to purchase sweets, cosmetics and materials for home permanent-waves after some money was provided by the matron. 9 Some patients began to behave towards one another in 'differentiated, individuated ways', and they helped each other with their hair, clothing or their self-appointed tasks: 'such friendliness became so common that the nurses ceased to make special note of it' (p. 1385). They were also very friendly to the doctors:

When we came in one of them at once approached us in a smiling and dignifi ed manner. With extreme formality she shook hands and invited us to sit down, at the same time expressing delight at our visit. Most of the patients greeted us in this way … Mrs. Smith said to one of us at teatime: 'Would you care for a cup of tea': he accepted and she began to pour him a cup. Nurse asked her if the doctor took sugar and milk. 'Of course he does. One spoonful of sugar. Don't you remember. He always does. ' (p. 1386) The main changes in the patients over the course of twelve months are summarized as:

They were no longer isolates. Their conduct became more social, and they undertook tasks which were of value in their small community. Their appearance and interest in themselves improved as they took a greater interest in those around them. These changes were satisfying to the staff. The patients lost many of the features of chronic psychoses: they were less violent to each other and the staff, they were less dishevelled, and their language ceased to be obscene. The nurses came to know the patients well, and spoke warmly of them. (p. 1386) No specifi c effects on symptoms such as delusions and hallucinations are described, and the comments about speech are mixed. In one instance, relatively early on, not only was the patient talking sense in sound syntax (this she had done before); but, suddenly she had abandoned the stilted intoning of words which had characterised her speech for years, which is so characteristic to [sic] psychotics and so elusive to written description … (p. 1385) But it was noted during the project's eight months that 'the patients' speech was still that of severely disturbed people' (p. 1386). Cameron et al. concentrate on one explanation for the project's success:

What matters most in the patients environment is the people in it ... the most important thing about the nurses and other people in the environment, is how they feel towards their patients. The material used or the nature of the activity was of secondary importance. Some of the patients improved while they scrubbed fl oors; others baked, made rugs, or drew pictures. (p. 1386)

Disconnecting

In his personal account, [START_REF] Laing | The Rumpus Room 1954-1955[END_REF] invokes as a role model Harry Stack Sullivan, who mainly worked through the nurses and 'spent relatively little time with the patients themselves' (p. 9). He met the rumpus room nurses at least once a week from its opening in June 1954 until he left the hospital in February 1955 (p. 5), and: they poured (out) their story about their patients … a spontaneous recital of the minutiae and trivia of daily happenings, sometimes funny, sometimes boring, sometimes interesting, sometimes disappointing. My business was to be glad to hear all this, and be sympathetic. Surely it is remarkable, that in the last month of my part in this experiment, I was never asked for any advice, or 'explanation' of any psychpathology. That had somehow become irrelevant and unnecessary. (p. 8) He also visited the patients informally in the room. At fi rst, he enjoyed his visits to this 'pleasant place' (p. 6), but he soon:

began to sense the presence some thought akin to the anxiety and hopelessness which I had felt in the refractory ward, though not so intensely. The sense of futility was not something that worried me too much, because I had come to know this as one of the most basic responses which schizophrenics can induce in me, and in others also. The anxiety however, was rather different from the anxieties I already recognised in myself until exactly the same feeling came over me at home, when my eighteen month old daughter violently pushed me away from my wife, with what struck me as undisguised anxiety … the incident with my daughter strongly suggested to me that my daughter was frightened of my taking her mother away from her and in the same way, I felt that the patients were frightened when I visited the room that I would take their nurses away from them. (pp. 6-7, original emphasis) 10 Apparently, without warning the nurses, on subsequent visits he 'hardly looked at them and didn't speak to them at all' (p. 7):

The fi rst comment … came from one of them, who said that the patients had previously been noisy and excited during and after his visits, but now weren't so. She put this down to the fact that now they did not have to interrupt what they had been doing together, i.e. not disrupt their relationships when I came in. 11 Thereafter, post hoc propter hoc or otherwise, I felt much less uneasy in visiting the room. Indeed far from being an alien intruder who evoked a mixture of panic and hatred, I was almost completely ignored. But not, or so I felt, in a hostile way: I was not cold-shouldered. I was simply, there, and accepted, but not as an obviously signifi cant fi gure. Again, there was a recognisable similarity between my feelings in the room, where the patients and nurses were beginning to be really fond of one another, though there was plenty of jealousy between the patients, and my feelings when watching my wife and children engrossed in each other. (pp. 7-8, original emphasis)

Discharged and readmitted?

Laing's repeated assertion that all the rumpus-room patients had been discharged within eighteen months of the project starting and all readmitted within a further year is contradicted by the case notes. The lives of three had ended in the hospital, from natural causes, well after their supposed discharges; two were transferred to nursing homes when elderly, and one patient, remarkably, remained an inpatient after fi fty years.

The only comment on the supposed readmissions in his main autobiography is the question: 'Had they found more companionship "inside" than they could fi nd "outside"'? (Laing, 1985: 117). The implication would seem to be that they had gained social networks in the rumpus room, since they had been described as the most isolated patients in the refractory ward, but there is no mention of the sociograms the nurses were required to construct.

In an earlier interview in the magazine Esquire -though still some seventeen years after the events -Laing had expressed his more familiar thesis about adverse family infl uences. He strongly criticized a team of three psychiatrists, including the other two authors of the Lancet paper, which had been running a research project on psychoanalytic techniques: So I left the three man team in charge of continuing my project and suggested that we write something up for The Lancet right away … Well, the next thing I knew, they'd published a book on their own. The results showed that after eighteen months all my patients had been released back to their families -because they seemed a lot better. And a year later they were all back again. Naturally! Nobody in these days thought in terms of the family in relation to schizophrenia. (Mezan, 1972: 171;original emphasis) Other accounts followed him in holding families responsible for the supposed readmissions:

An outcome that would nowadays be considered unsurprising by many psychiatrists, since most of the discharged patients would be returned to a family environment in which the other family members were much too involved with the patient for anybody's good. (Sedgwick, 1982: 73) Burston (1996: 38) elaborated further on purported explanations for these non-events:

After eighteen months in their new environment, all twelve subjects were so dramatically improved that they were discharged (Cameron, Laing, and McGhie, 1955). One year later, without exception, they were all back again. Most of Laing's colleagues argued that this corroborated the theory that schizophrenia is an insidious and incurable disease; improvements are only temporary. Laing argued that, if patients always returned, it was because there was something radically wrong with the social contexts 'out there.' And if they left the hospital to return their families of origin -as most did -perhaps the families were the source of the problem. Perhaps they wanted to come back or get themselves put back, because they experienced more genuine friendship from fellow inmates than from the so-called normal peo ple in the outside world.

Largactil (chlorpromazine)

An extended version of the Lancet paper, by the same three authors, includes a section dealing with the introduction of Largactil (chlorpromazine) at that time:

Before this there had been considerable strain and tension throughout the hospital … The (refractory) ward was permanently bedlam … With the commencement of Largactil comments soon began to the effect that the patients on this drug were improving remarkably. Many patients in the ward were described as completely changed. … Whatever the pharmacological effect of the drug -and this appears clinically to be considerable -the nurses were very much more confi dent in their handling of diffi cult patients once the drug had been exhibited. (Cameron, Laing and McGhie, 1955b: 20)

Discussion

Laing and his co-authors present a very restricted view of the refractory ward, and the vast majority of the 65 women remain shadowy fi gures. Their reactions to being passed over for the rumpus room are nowhere mentioned. Laing's own account focused on extreme behaviour to an extent that tends further to dehumanize the ward population, and he relied on an atypical patient to explain some aspects without attempting to check with those concerned. The 'raw physical advances' that preoccupied him may have been stimulated by an observation technique that combined intrusiveness and passivity.

Although Laing emphasized that the nurses in the rumpus room 'must not feel that there is something odd with them when they become fond of their patients, and nurses and patients actually enjoy one another's company' (Laing, 1956: 12), he did not share in this enjoyment himself. The nurses' initial attempts to mould behaviour by approval or disapproval were discouraged, and concern for patients' safety interpreted as evidence of their own anxiety (Cameron, Laing andMcGhie, 1955a: 1385). The determination with which patients sought out activities to structure their day was not fully appreciated, and the impact of the vastly improved physical environment only touched on. Lack of concern with such aspects appears to have contributed to the milieu in Kingsley Hall, on which Laing was one of the main infl uences, developing some affi nities with the refractory ward rather than the rumpus room. Deteriorated physical environments, pervasive inactivity, inadequate protection for the more vulnerable residents, and the concentration of attention on a minority are among the resemblances. Social niceties such as welcoming visitors and shaking hands, and domestic rituals, which were features of the rumpus room, were noticeably lacking and even discouraged [START_REF] Barnes | Two Accounts of a Journey through Madness[END_REF]Burston, 1996: 80-4;Mullan, 1995: 180-90).

Laing's later laconic assertion that the eleven patients had been discharged from Gartnavel Royal within eighteen months, only to be readmitted within a further year, tended to tarnish the patients' and nurses' achievements in retrospect. It is contradicted both by the six case notes and by the book to which he refers, which describes only two discharges among the six male and twelve female patients included. There is no reference to any readmissions. Also contrary to his account, families were a particular focus: mothers were seen at least fi ve times individually, as part of the research project, and subsequently in weekly groups. The two discharges were made after each patient had spent weekends and then every night at home, and 'after discharge again, close and regular contact with the relatives was maintained' (Freeman, Cameron and McGhie, 1958: 121-4).

It is clear from the case notes that unexpected clinical improvements would have been required for the six patients to have returned home -which in some cases would have been the marital home rather than the family of origin -within ten months of his departure, although two were progressing slowly towards discharge at the time of their fi nal illnesses. If all eleven had actually been discharged and soon readmitted, questions could be expected to occur to Laing, who fi rmly regarded it as 'his project, 12 and to biographers and commentators. Obvious concerns that are not addressed in any of the accounts include: the circumstances of their discharges and their clinical states at that time; which wards they had returned to, especially if the rumpus room had by then closed; how they had been affected by the whole, presumably very distressing process, and what happened to them in the long-term.

Laing described himself at one point as a 'conservative revolutionary' (Mullan, 1995: 107), and his antagonism to medical treatments appears to have originally refl ected earlier trends at Gartnavel Royal (Andrews and Smith, 1993: 76). He wrote (Laing, 1956: 2):

Certainly some of the doctors and nurses could have strongly endorsed Maudsley's contention that chemical restraint to the brain cells was equivalent to physical restraint to the body. Rightly or wrongly (and I believe rightly) the inscription on the foundation stone of the [Gartnavel Royal] hospital that physical restraints would never be employed, was interpreted, by some at least, to extend to sedatives, and physical methods of treatment.

In a later interview Laing stated that 'tranquillisers' were introduced while he was a senior registrar in the Glasgow University Department of Psychological Medicine, after leaving Gartnavel, and referred to preparing a report about their advent (Mullan, 1995:150-1). He makes no reference to the unpublished version of the 1955 paper (Cameron et al., 1955b) which includes an account of the use of Largactil in the refractory ward and rumpus room, although he was one of its authors. Many of his well known pronouncements strikingly fail to do justice to the experience there, for example:

In the best places, where straitjackets are abolished, doors are unlocked, leucotomies largely foregone, these can be replaced by more subtle lobotomies and tranquillizers that place the bars of Bedlam and the locked doors inside the patient … (Laing, 1964: 12;original emphasis) Tranquillizers … were drugs found to help people who were interested in controlling rats, rendering them more amenable and more cooperative. Chemical agents that enable rats to be controlled more effi ciently are given to people for the same reason … (Laing, 1976: 112-13) An equation of psychosis with 'feeling', self-fulfilment, freedom and transcendence, as opposed to 'our present pervasive madness that we call normality …' (Laing, 1964: 11) appears to have been a major infl uence on Laing's later views, and could, it seems, outweigh compassion for evident suffering: 'I've often been asked by residents in hospitals to give a patient an injection when there might be some sort of life starting up in him, perhaps a crying or whimpering or yelling or screaming' (Laing, 1976: 112).

Laing's experience with long-stay patients was presented as the foundation for his fi rst and best known book The Divided Self [START_REF] Laing | The Divided Self: An Existential Study in Society and Madness[END_REF]Mullan, 1995: 133), which had a remarkable impact both on many young psychiatrists [START_REF] Clare | the Psychiatrist's Chair[END_REF][START_REF] Holmes | Ten books[END_REF][START_REF] Mullen | Ten books[END_REF] and on the development of 'anti-psychiatry' [START_REF] Boyers | Laing and Anti-Psychiatry[END_REF][START_REF] Kotowicz | Laing and the Paths of Anti-Psychiatry[END_REF][START_REF] Sedgwick | Psycho Politics[END_REF]. However, the fl esh-and-blood persons who emerge from even six case notes, with individual family circumstances and childhoods, schooling, jobs, hobbies, friendships and marriage, and hardships and bereavements, 13 are not evident in the book -still less the many others in the refractory ward. The voice of the sole rumpus room patient that features at length, who was the only one not to come from that ward, is so embedded in assumptions, theories and interpretations that it is not clear which is which (Laing, 1964: 178-205).

Conclusions

It remains a tribute to Laing's compassion and determination that he was suffi ciently concerned about the plight of long-stay patients to work towards better lives for at least a few before moving on, as was expected of ambitious psychiatrists. 14 The anomalies in his accounts do not negate evidence from the rumpus room project of long-term patients' resilience, emotional capacities and potential for better qualities of life, which are always in danger of being undermined [START_REF] Abrahamson | Long-term psychiatric patients -second class again?[END_REF]). Laing's advocacy of a fully human image of psychotic patients and more open encounters with them was the main message many took from his earlier work [START_REF] Clare | the Psychiatrist's Chair[END_REF][START_REF] Holmes | Ten books[END_REF][START_REF] Mullen | Ten books[END_REF]. This was a benefi cial infl uence at that time, even though his actual interactions at Gartnavel Royal appear to have fallen strikingly short of his ideals.

It is unfortunate that he did not remain in contact with long-stay patients suffi ciently long to appreciate their less obvious qualities, and fully to shake off the pessimism about them characteristic of that era (Abrahamson, 1993a[START_REF] Abrahamson | The transition from hospital to community care[END_REF]. Indeed, 'anti-psychiatry' tended to confi rm bleak expectations. If families were as damaging and the world outside the hospital as unwelcoming as was claimed, if the only effect of medication was control, and if sanity meant an alternative form of 'madness', then hope -probably what they and those who cared for and about them needed most -was largely undermined. Perhaps this was the context within which Laing too easily accepted that all the rumpus-room patients had returned to hospital after discharge, without revisiting them or seeking out information about their subsequent lives.

was replaced by one who asked repeatedly to go. Laing refers both to eleven patients (1985: 115) and to twelve (1976: 115) and to a 'special favourite patient' who was the only rumpus-room patient not to come from the refractory ward (Mullan, 1995: 133). There are code names for only ten in the archive. 8. It was an important innovation to take seriously long-term patients' social networks, but not recognized that families are an important component even when they are in hospital (Abrahamson, 1993b). 9. This movement out of the room was followed by the fi rst requests for weekend passesan important development that is not further mentioned. 10. Only the last sentence appears in Laing's autobiography (Laing, 1985: 116). 11. There is a puzzling variation in Laing's autobiography: 'She put this down to the fact that now they had become so used to me that they did not have to interrupt what they had been doing -say, standing still and concentrating (exhibiting the signs of catatonic mutism)' (Laing, 1985: 116). 12. To the extent of claiming that he had furnished it himself (Mezan, 1972: 168). 13. Three were married with children. Two had experienced the death of close relatives and one that of a close friend in the period leading up to their illnesses; another had experienced the break-up of an important relationship. 14. Many avoided them altogether, as long-stay patients were excluded from the major teaching centres [START_REF] Abrahamson | Long-term psychiatric patients -second class again?[END_REF]. However, there was considerable interest in chronic schizophrenic disorders at Gartnavel Royal at that time [START_REF] Andrews | Laing in Scotland: facts and fi ctions of the 'rumpus room' and interpersonal psychiatry[END_REF].

Acknowledgements

The author is very grateful for assistance from Alistair Tough, Greater Glasgow NHS Board Archivist; David Weston, Keeper of Special Collections at Glasgow University Library; and Eileen McCaffery, Sector Medical Records Offi cer, and Iain Smith, Consultant Psychiatrist, at Gartnavel Royal Hospital.


Claire Hilton
email: claire.hilton@nhs.net

Changes between the 1959 and 1983 Mental Health Acts (England & Wales), with particular reference to consent to treatment for electroconvulsive therapy

Keywords: consent to treatment, ECT, electroconvulsive therapy, England, Mental Health Act, MIND, Royal College of Psychiatrists, Wales

Consent to treatment was not mentioned in the Mental Health Act 1959, assuming that a detained patient could be treated against his/her will. However, consent was a crucial new feature in the 1983 Act. This paper traces and evaluates the issues, debates, people and organizations in England and Wales who advocated and enabled this important change to come about, using examples from the clinical practice of electroconvulsive therapy.

Introduction

Developing mental health legislation is a slow process. The Government is currently introducing new mental health legislation: a draft Mental Health Bill was published in September 2004 (Department of Health, 2004a: 2), and this remains under review [START_REF] Dyer | Mental Health Bill for England and Wales may be postponed[END_REF]. The revision of the Mental Health Act 1983 has so far taken 8 years, mirroring the prolonged process of revision in the 1970s between the 1959 and 1983 Acts.

By the early 1970s various aspects of the Mental Health Act 1959 were being questioned. There were several possible triggers to this. Care and treatment of people detained in mental illness and mental handicap hospitals had been highlighted by several reports of abuse, such as at Ely Hospital (1969), Farleigh Hospital (1971) and Whitingham Hospital (1972) (Fennell, 1996: 172), and also by Barbara Robb in Sans Everything (1967). The focus was moving away from the legal principles of detention towards how people were cared for within the hospital. In addition, treatment was already in a period of transition, towards 'community care' with the development of more effective pharmacotherapy, and also controversial physical treatments such as psychosurgery. 1 Both the civil rights movement involvement with the care of detained patients in the USA (Fennell, 1996: 170;[START_REF] Krouner | Shock therapy and psychiatric malpractice[END_REF][START_REF] Salzman | ECT and ethical practice[END_REF] and concerns over abuses of psychiatry in the former Soviet Union (Jones, 1993: 198) were of public interest. In England, with the writings of Ronald D. Laing among others [START_REF] Sedgewick | Psychopolitics[END_REF] and the new civil rights and legalistic focus of the National Association for Mental Health (MIND), 2 there was further impetus to review the care of the severely mentally ill. With the 1983 Act under review, in the not to distant future its origins are likely to be of more interest to historians and the individual patients whose lives it infl uenced rather than to mental health care professionals. Perhaps it is now time to look at how that Act emerged, in particular on the issue of consent to treatment, prominent in the 1983 Act but unmentioned in the 1959 Act.

Consent to treatment and electroconvulsive therapy

The concept of consent is closely linked to concepts of rights and autonomy. The rights of the individual within society emerged in the Enlightenment, and the philosopher Immanuel Kant (1724-1804) developed the ideas that people have rights and duties which ought to be respected [START_REF] Lepping | Consent in psychiatry -an ethical review[END_REF]. Other landmarks in the development of autonomy of the individual include: the French Revolution; the Universal Declaration of Human Rights (1948), which includes the right to liberty, and to be free from cruel, degrading or inhuman treatment; the Nuremberg Code (1949); and the Human Rights Act (1998) [START_REF] Lepping | Consent in psychiatry -an ethical review[END_REF]. Such developments form the bedrock upon which consent to treatment legislation has developed. In terms of mental illness, although the notion of informed consent was recognized as early as 1700, it was not until the advent of the voluntary boarder status in the Lunacy Act 1890 and the voluntary patient in the Mental Treatment Act 1930 that the issue of capacity and consent for psychiatric treatments was fi rst raised in non-detained patients [START_REF] Raymont | Not in perfect mind' -the complexity of clinical capacity assessment[END_REF]. In detained patients this issue was not raised until the 1970s with the review of the Mental Health Act 1959.

The importance of consent was well established in medical practice by the early 1970s (Medical Defence Union, 1971). However, a method for medical practitioners to ensure valid consent, i.e., that the patient could actually understand the nature and purpose and likely effect of treatment, was not outlined. Even by the time of the Mental Health Act 1983, this was not included in the text (Bluglass, 1983: 84). The process of ensuring that the person has capacity to consent -that they are able to understand information about the proposed treatment, are able to remember the information long enough to weigh up the benefi ts and risks in order to make a decision, and to communicate that decision -evolved later. It has been recognized for decades that, although consent to treatment criteria apply to all medical and surgical interventions, in the context of mental illness there may be specifi c diffi culties when the patient is unable to fulfi l the criteria to make such decisions because of the very mental illness which requires treatment (Medical Defence Union, 1971: 7-8).

Although there are numerous different treatments for mental illness, examples in this essay are drawn from the practice of electroconvulsive therapy (ECT), the passage of a small current of electricity through the brain to induce a convulsion. ECT, despite recognized clinical effectiveness, has remained a controversial although widely used treatment since its introduction in 1938 by Ugo Cerletti and Luigi Bini in Rome. Since the 1950s, it has been standard practice to give a general anaesthetic plus a muscle relaxant before the induction of the convulsion, and thus the patient is unconscious before the convulsion is induced. An epileptic convulsion modifi ed by the effects of the muscle relaxant occurs. The convulsion lasts about 30 seconds, the whole procedure a few minutes. For half a century, ECT has been recognized to give therapeutic benefi t in the treatment of severe depressive illness.

In clinical practice, however, emotive debates persist around consent issues, particularly in relation to ECT. Postal surveys of psychiatrists about the legal framework they use for deciding whether to use ECT in 1980 and[START_REF] Dyer | Mental Health Bill for England and Wales may be postponed[END_REF] bear remarkable similarities, suggesting the issues and concerns remain unresolved (Anon., 1981; 3 Law-Min and Stephens, 2006).

The Mental Health Act 1959 and consent to treatment

The 1959 Act was based almost entirely on the recommendations of the Royal Commission on the law relating to mental illness and mental defi ciency chaired by Lord Percy ('The Percy Commission') which gave its report in 1957 (Royal Commission, 1957). Sweeping away much of the legalistic framework of the old Acts of 1890 and 1930, the 1959 Act was guided by the philosophy that, whenever possible, care should be provided without the use of compulsion (Gostin, 1983: ix). However, in terms of treatment, it was assumed that detained patients admitted for treatment could be treated against their will. Although unwritten, it was considered good practice to discuss treatment in these circumstances with the patients' relatives, or to seek a second opinion from a colleague. It is unclear from the literature precisely when these good practice recommendations were put into effect, and quite how controversial or widely implemented they were. They were certainly still being debated in 1977, and some psychiatrists contributing to the debate described considerable paternalistic practice (Guirgis, 1977;[START_REF] Sedman | [END_REF][START_REF] Spencer | [END_REF]. However, mental illness has always been constructed or framed by society at the time in which it was experienced. In the 1960s and 70s, debates on the nature of mental illness itself were confronting the medical profession. The social aetiologies proposed by Laing, for example, contrasted with the biological basis of mental illness derived from neuroscience research (Shorter, 1997: 270-7). The 1960s were also more generally associated with anti-authoritarian attitudes. Clearly, the view of the medical profession, despite a practical expertise on treating mental illness acquired over a century or more, largely from asylum-based work, was not going to be exclusive; the expectations of the patient, their family, society and the law were inevitably involved.

In 1973, Sir Keith Joseph, Secretary of State at the Department of Health and Social Security (DHSS), was asked in Parliament about consent. He stated that he had been advised that, for detained patients, consent to treatment was not necessary, but it was normal practice to obtain the patient's agreement if he or she was capable of understanding the proposed treatment (Hansard, 1973;Medical Defence Union, 1971: 7-8). In the same year, the Davis Committee on Hospital Complaints was convened in response to a series of enquiries into mental hospitals. This Committee considered the issue of voluntary patients refusing treatment and then being detained under the Mental Health Act in order to enforce treatment. It stated that detained patients could not legally refuse treatment (Gostin, 1975: 120), but proposed that a second medical opinion should be obtained before treatment could be imposed (Fennell, 1996: 172). It recognized that the 1959 law was coercive in terms of treatment and needed reform.

The National Association for Mental Health

The National Association for Mental Health (MIND) was undoubtedly a key player in the changes in mental health legislation in the 1970s. Founded in 1946, it initially sought to provide education on mental illness, and to provide care facilities for people with a wide range of psychiatric disorders. It was a traditional voluntary organization based on a partnership between professionals, relatives and volunteers, aiming to improve services and public understanding within current structures. With a limited budget mainly from central government, its work was based on local associations, and discrete pressure behind the scenes was preferred to public campaigns. 4 All this changed in 1974 with the appointment of Tony Smythe as Director. He brought in experience in the fi eld of human rights, having been Director of the National Council for Civil Liberties; he had also worked in the fi eld of civil liberties in the USA (Jones, 1993: 200). His appointment, and a greater emphasis on the development of an advisory service dealing with welfare and legal rights, led to the establishment of the legal and welfare rights service in 1975 (MIND, 2005). Larry Gostin, an American lawyer who had recently been a Fulbright Fellow at Balliol College, Oxford, and had worked at the Social Research Unit, University of London, was appointed fi rst legal offi cer. He subsequently received the Rosemary Delbridge Memorial Award from the National Consumer Council for the person 'who has most infl uenced Parliament and government to act for the welfare of society'. Later he became internationally recognized for his work in law and public health, and is currently professor of law at Georgetown University, USA. 5 With both Gostin and Smythe having worked in civil liberties the USA, where the rights of detained mentally ill people was already an issue, their previous experience appeared likely to infl uence their work in Britain. For example, concepts such as the US principles of 'least restrictive alternative' and 'due process' (a legal principle which ensures that the government cannot deprive an individual of life, liberty or property without respecting all of the individual's legal rights) became incorporated into arguments on mental health legislation in Britain (Jones, 1993: 200). A psychiatrist and observer of the events unfolding from within both MIND and the Royal College of Psychiatrists commented: Smythe and Gostin turned [things] upside down; they also recruited into the staff a number of aggressive anti-psychiatrists who had political connections with the Far Left. The traditional co-operative methods were replaced by confrontation. Before Gostin, MIND had never had a legal rights offi cer, but he established a dominant position within the organisation. Smythe, who was a weak character, took a back seat. Gostin was brilliant at manipulating the media so that whenever a mental health issue came up, their fi rst call was always to him. 6 While legal director for MIND (1975-82), 7 Gostin wrote A Human Condition, MIND's proposals for reforming the Mental Health Act 1959[START_REF] Gostin | A Human Condition. The Mental Health Act from 1959 to 1975: Observations, Analysis and Proposals for Reform[END_REF]. Volume 1 dealt with admission and discharge procedures, review tribunals and in-patient rights including consent to treatment. Volume 2 related to mentally abnormal offenders and the Butler Committee Report (1975). Gostin challenged the assumption that compulsory detention also allowed for compulsory treatment, based on the Percy Commission's statement that 'there should be no distinction of "status" based on whether a patient is admitted informally or through the use of compulsory powers' (Gostin, 1975, Vol. 1: 122). He proposed that all treatment to be given to a hospital 'resident' who cannot or does not give consent should be reviewed by an independent body, the Committee on the Rights and Responsibilities of Staff and Residents of Psychiatric Hospitals (CORR) (p. 116). CORR would consider concerns of advocates, residents, staff, parents and guardians concerning 'suspect' treatments, and its decisions would be based on the principles of the resident's individual treatment plan, on protecting the dignity of the individual and being the least restrictive to them (p. 117). In particular, 'Treatment which involves surgery, electro-convulsive therapy or the use of experimental drugs or procedures shall not be given without approval by CORR'. In addition, for a patient who could not consent, 'express and informed written consent of his legal guardian must be obtained ' (p. 152).

The term 'resident' (Latin sedeo = sit) is interesting. Using this unbiased term rather than the more medical 'patient' (Latin patiens = suffering) tended to negate the illness part of the person's condition, almost implying that the individual's condition was a social phenomenon. Indeed, this would have been compatible with MIND's preferred term of 'mental distress' rather than 'mental disorder'. 8 Gostin, however, maintained that this less stigmatizing terminology 'was intended as a mark of respect … We wanted to convey the idea that they were people fi rst, with rights, and not patients who were subservient to the medical profession'. 9 Gostin was not just an academic lawyer: he took cases to the European Court of Human Rights, 10 which may also have spurred change.

The Royal College of Psychiatrists, Mental Health Act reform and consent to treatment

While MIND claimed to be the representative voice of the mentally ill and their advocates, the Royal College of Psychiatrists was the voice of the psychiatric establishment. The College, however, was not the only professional group involved in the debates on reform of the legislation. Nursing, psychology and social work professional bodies were also participants, as well as the Royal Society for Mentally Handicapped Adults and Children (MENCAP), but they were more active during the later stages of debate (Bluglass, 1983: 6;Jones, 1993: 204).

Unfortunately, there is a dearth of archives for many of the College's subcommittees. However, references made to these committees in College Council minutes do survive, and they give glimpses of major concerns and debates expressed by practising psychiatrists in the 1970s. Tensions between MIND and the College are apparent. 11 Although Gostin emphasized that it was not the psychiatrists' decision to give ECT which was under question but the detained patients' competency to make a decision, in essence it appeared that his increasingly infl uential ideas would remove decisions for giving treatment from the medical profession to an independent multi-disciplinary committee. 12 Gostin's views were interpreted as a challenge to the professional integrity of psychiatrists [START_REF] Anon | ECT, forty years on[END_REF]. Debates on treatment were common in the USA at that time [START_REF] Morrissey | Developing an empirical base for psycho-legal policy analyses of ECT: a New York State survey[END_REF]; for example, an Alabama state judge had ruled that ECT could not be given even to consenting patients without the agreements of four psychiatrists and one neurologist with at least two attorneys monitoring the proceedings [START_REF] Anon | ECT, forty years on[END_REF]. However, in Britain, during the previous one-and-a-half centuries mental illness had become both more medicalized and subject to treatment by physicians claiming special expertise in this subject, and more legalized.

As far back as 1828, the Madhouse Act placed requirements on the frequency of doctors' attendances on patients in madhouses (Scull, 1993: 231). Practice in the care of the mentally ill had been infl uenced by legal requirements at least since 1819, with the establishment of a lay Board of Inspection for madhouses (Scull, 1993: 202-3). Since the Mental Treatment Act 1930, there had been a consistent move towards treating psychiatric patients, as far as possible, in the same way as those who were physically ill (Bluglass, 1983: 6;Jones, 1991: 97). Even with challenges by the anti-psychiatry movement since the 1960s, autonomy in medical treatment decision-making by psychiatrists had largely been retained. Now psychiatrists' decisions were being further challenged, and they did not appear prepared for it. Medicine had prided itself on its status as an autonomous, self-regulating profession for centuries.

Concerns over the adequacy of the 1959 Act were being explored by a Royal College of Psychiatrists Working Party by 1972, 13 preceding the Parliamentary questions to the Secretary of State, the Davis Committee and the publication of Gostin's work. The trigger for the establishment of this Working Party is not clear. Unfortunately their minutes no longer exist in the College archives. However, their draft report was circulated to College Council in July 1974. 14 It was also documented that 'MIND is shortly to publish its review of MHA … College's review is to be published without delay'. 15 Clearly, the desire to appear responsive and innovative in considering legal and ethical matters was of major importance to the College. The College's 'Review of the Mental Health Act 1959' was published in October and November 1974. A large part of this was about consent to treatment. Concerns were raised and some solutions proposed.

The Working Party are fi rmly of the view that compulsory powers should include power to treat patients compulsorily for any sort of mental disorder, but has doubts as to how certain types of treatment should be applied on sole authority of the Responsible Medical Offi cer 16 against the patient's will or when he is incapable of giving consent. Some further suggestions were made such as consulting the next of kin. 17 In addition, the College advocated that if a second medical opinion was obtained, it should be advisory rather than binding, the patient's own consultant psychiatrist -the responsible medical offi cer -taking the fi nal decision about treatment (Royal College of Psychiatrists, 1974). The provision of the 1959 Act was clearly regarded as adequate in these circumstances. As will be seen, the development of the 1983 Act manifested a major departure from this standpoint.

Specifi c concern over ECT followed the 1976 report on St Augustine's Hospital, Canterbury, which highlighted misuses of the treatment. It was alleged, for example, that ECT was given as a punishment, under force, was used excessively, and was inappropriately used as a tool (supposedly) to differentiate depression and dementia (South East Thames Regional Health Authority, 1976: 63-71, 162, 163). The Committee of Enquiry at St Augustine's specifi cally requested the College to 'give urgent consideration to these problems and offer clear guidance' (p. 71). The issues raised were of a suffi ciently sensitive medico-legal nature that the College sought advice from the Medical Defence Union and Medical Protection Society on how to proceed. 18 Guidelines for the use of ECT were published by the [START_REF] College | Memorandum on the use of electroconvulsive therapy[END_REF][START_REF] College | Memorandum on the use of electroconvulsive therapy[END_REF], although the section on medico-legal aspects is somewhat vague. For example, in keeping with other documents of the time, it does not clearly specify criteria, or refer to other sources, for capacity to consent.

The College was clearly aware of considerable public interest in ECT which may have been triggered by the release of the highly acclaimed fi lm One Flew over the Cuckoo's Nest in 1975 which dramatically portrayed psychiatric treatment being given without consent to detained psychiatric patients in the USA. But ECT was also in the British press. For example, in 1979 there were disconcerting reports that ECT was being given 'unmodifi ed' (i.e., without anaesthetic or muscle relaxant) at Broadmoor Hospital [START_REF] Roper | Royal College of Psychiatrists (1974) Review of the Mental Health Act 1959. In 'News and Notes[END_REF], 19 despite previous College recommendations (Royal [START_REF] College | Memorandum on the use of electroconvulsive therapy[END_REF], and reiteration in the College Minutes that this should only happen if medically indicated or it may 'not be clinically advisable to wait for an anaesthetist (… a contingency unlikely to arise in the United Kingdom)'. 20 Tensions with MIND are hinted at, reference being made, for example, to a letter in The Times by Tony Smythe which may have 'made misleading statements about the College and ECT' 21 [START_REF] Revill | Treatment in mental hospitals[END_REF]. When the medical advisor to MIND, Dr Anthony Clare, was asked to state his views at College Council, they were far less radical than had been anticipated. 22 But the College still proceeded with caution: their new paper on 'Medico-legal aspects of ECT' was not to be issued without consulting their lawyers. 23 In summary, the College's fi rst publication reviewing the Mental Health Act 1959was published in 1974(Royal College of Psychiatrists, 1974), MIND's report in 1975[START_REF] Gostin | A Human Condition. The Mental Health Act from 1959 to 1975: Observations, Analysis and Proposals for Reform[END_REF], and the DHSS produced a consultative document on the same subject in 1976 (Jones, 1993: 203). The fi eld of consent to treatment and ECT remained an emotionally charged medico-legal debate.

The Mental Health (Amendment) Bill Consent to treatment was undoubtedly the most controversial legislative issue in the proposed Bill. The College took the stance of protecting professional standards and medical autonomy, but questioned if 'better' patients' rights were synonymous with better, more effective treatment [START_REF] Hamilton | Observations on the Mental Health Act 1983[END_REF]. MIND was anti-medical profession and libertarian, based on a very strong belief in law as the safeguard of liberties and the legal profession as the guardians of the law (Jones, 1993: 204). MIND, the DHSS and the Royal College of Psychiatrists held a series of meetings to 'thrash out a compromise' on consent issues, and 'the Government made a sincere and highly professional attempt to reconcile the disparate views of MIND and the College' [START_REF] Bingley | A Practical Guide to Mental Health Law: The Mental Health Act 1983 and Related Legislation[END_REF]. The DHSS committee took the view that the public would not be satisfi ed with the College's advisory second opinion proposal, but were concerned about diffi culties in obtaining independent second opinions (Fennell, 1996: 176). Gostin's proposition of a multidisciplinary review body was also discussed, but if individual independent second opinions were going to be diffi cult to obtain, an independent multidisciplinary team would be unworkable. Finally, a compromise was accepted of a second opinion with a multidisciplinary component, and the second opinion would be binding. In summary, for detained patients unable to consent, an independent medical second opinion would be obtained through the newly created Mental Health Act Commission, the independent psychiatrist consulting with nonmedical health care professionals who knew the patient. The precise details of this process would vary between different forms of treatment, depending, for example, upon the duration of treatment for pharmacotherapy or the perceived degree of irreversibility of other treatments. 24 ECT, for instance, was permitted to be given to detained patients either with their consent or following the second opinion procedure. Thus the assumption in the 1959 Act that the compulsory detention of a psychiatric patient also provided authority for treatment was overturned.

The Bill was published by the Government in 1981 (Mental Health (Amendment) Bill 1981) and enacted on 28 October 1982. According to Beedie and Bluglass 25 (1982) in the British Medical Journal, psychiatrists viewed the change as cumbersome and unworkable. Jumping on this bandwagon, a subsequent letter in the BMJ from Gostin and Davis at MIND joined with their psychiatry colleagues to criticize the Bill. They claimed:

The Bill as currently drafted is a triumph of the Lunacy Laws … it does not satisfy mental health professionals because of its heavy legalistic quality … it will not provide patients with any meaningful safeguard … because professional self-regulation will not be seen to be open, rigorous and dispassionate … if enacted, these provisions will fail to maintain the confi dence of the public. [START_REF] Gostin | Consent to psychiatric treatment[END_REF] None of the major contenders in the debate appeared to approve of the outcome. What is truly remarkable, however, is that so much of the development of the 1983 Act was achieved by the inspiration of an American lawyer with remarkable skills of political and public persuasion.

The Mental Health Act 1983 and subsequent developments

The 1959 and 1982 Acts were consolidated in the Mental Health Act 1983. MIND congratulated itself on this new Act: 'two-thirds of the new provisions of the 1983 Act are based on proposals originally made in A Human Condition' but in respect to consent to treatment 'MIND still has some reservations about this particular part of the new Act' [START_REF] Bingley | A Practical Guide to Mental Health Law: The Mental Health Act 1983 and Related Legislation[END_REF].

The process of change had taken a decade from the establishment in 1972 of the Royal College of Psychiatrists Working Party on the 1959 Act. Consent to treatment had been the most controversial issue -a battle between mental health care professionals, represented largely by the Royal College of Psychiatrists, and MIND defending civil liberties and as an advocate for the mentally ill. Of course others were involved including nursing and social work professional bodies, concerned individuals reporting malpractice, such as at St Augustine's, and the DHSS. Whether public confi dence in psychiatric treatment was undermined by the 1983 Act, as predicted by Gostin, would be another study in its own right.

However, almost as important as the legislation itself, was the fact that the relationship between the psychiatric profession and MIND was seriously damaged. For many years, MIND has been viewed by psychiatrists as being anti-psychiatry, rather than negotiating mental health care in the patients' best interests. In Gostin's opinion, the Royal College of Psychiatrists, rather than MIND, has changed to a stance of being 'more on the patients' rights side'. 26 It would be diffi cult to validate this statement, but taking into account the considerable paternalistic style practised in the 1970s, as already mentioned, (Guirgis, 1977;[START_REF] Sedman | [END_REF][START_REF] Spencer | [END_REF], 27 psychiatric practice itself appears to have changed in the context of a changing social milieu.

In 2006, with further changes in the new Mental Health Bill on the horizon, issues of capacity and consent remain a priority. In particular, a multidisciplinary panel to authorize treatment similar to [START_REF] Gostin | A Human Condition. The Mental Health Act from 1959 to 1975: Observations, Analysis and Proposals for Reform[END_REF] previously rejected radical proposal, remains under consideration. The current Bill provides for a multidisciplinary Mental Health Tribunal to approve written care plans for all compulsory treatment for detained patients (Department of Health, 2004a: 3) and 'to authorise ECT where a patient lacks capacity' (Department of Health, 2004b: 47). Perhaps Larry Gostin was ahead of his time: in 1975 he really thought that his proposals relating to consent to treatment would work; 28 30 years later a similar prototype for multidisciplinary consent is still under debate and could even become law.

Acknowledgements

Thanks to Dr Michael Neve, Wellcome Trust Centre for the History of Medicine at UCL, for his discussions on this paper, and to the anonymous reviewer of the paper whom I understand is both a historian and was practising psychiatry in England at the time of the events described. Professor Lawrence Gostin also kindly read the manuscript and offered comments.