Doctor Sargant and Me

1966 was an exciting year for me but a nightmare for my elder brother Martin. The previous Christmas everyone in our family, including me, had assumed I would go to Cambridge to begin my history degree, but now I  was abruptly changing direction and heading towards becoming a doctor. As my life climbed, Martin’s appeared to be falling. Severe depression had sucked him out of Cambridge during the middle term, just as it had the year before. We all knew, without admitting it, that the brilliant future we had imagined for Martin would never happen.

My brother’s youth now seems to belong to the remote past, but one problem I was facing more than half a century ago went on dogging me all through my time as a doctor. If you have been close to someone who is very ill you may have struggled with it yourself, whatever level of medical knowledge you have. There is a tension between two almost incompatible ways of looking at mental misery. Should I think of  Martin in those days as an unhappy person, an unbalanced mind or, as his psychiatrists stoutly maintained, a disordered brain? My parents wanted to see their son as sick, and they have me the habit of looking at Martin with a diagnostic eye, making him more difficult to see as a person.    My younger brother and I were both reading RD Laing’s Sanity, Madness and the Family at the time, which made the family feel like part of Martin’s problem. hhI never wanted to blame our parents, but blame was in the air that we all breathed.

Martin’s psychiatrist was Dr William Sargant. He told my parents that Martin’s illness as a disruption of brain chemicals. If we thought of it that way there was no need to blame anybody, which was a relief to my parents.  All through my adult life I have felt indignant about the way Sargant brushed Martin’s personal perspective aside. Laing, and Freud, had persuaded me that even the craziest people had something to say. Sargant’s attitude to psychotherapy verged on contempt. This theme keeps recurring in his memoir, The Unquiet Mind, starting with his memories of practice before the advent of modern psychoactive drugs. Even then, he insists, an ounce of bromide, a sedative, was worth a hundredweight of talking. His remedy for mental distress was not psychotherapy, which was slow, costly and ineffective, but physical methods such as drugs and electroconvulsive treatment (ECT). I think he imagined he was attacking  the patient's disordered brain in the way he would have kicked a slot machine if it failed to deliver his cigarettes.  Martin was given ECT several times a week for months on end, together with various mixtures of every class of psychoactive drug then available, in enormous doses. In addition, there were sessions of sleep treatment, requiring hospital admission for weeks on end. Yet another physical treatment, frontal lobotomy, was under consideration at one satge. The merest suggestion of cutting into Martin’s brain with a knife made our blood freeze.

 It won’t surprise you that I still have intense feelings about all this. They reached a new pitch in 2025 when a book called The Sleep Room, by thriller-writer Jon Stock, came out. Its breathless prose gives us a possible picture of Sargant, who is said to have ‘a whiff of sulphur about him’, with his ‘saturnine brows’ and eyes like ‘cold pebbles’.  I did not note these sinister features on few occasions when I saw Sargant while I was a St Thomas’ medical student. Was this because saturnine, pebbly, sulphorous doctors were two a penny there?  The Sleep Room of Stock’s title was on the top floor of the Royal Waterloo Hospital, where Martin spent many weeks. Jon Stock’s eyewitnesses describe a strangely quiet, almost domestic atmosphere on that ward. I visited my brother there at least once and remember it vividly, as well as knowing one of the nurses who worked there, but at the time I never thought of Ward 5 as sinister. Stock’s claim that Sargant’s activities amounted to ‘A Very British Scandal’ shocks me. An excerpt in the Guardian has a lurid headline: ‘“He Still Features In My Nightmares”: How A Sinister Psychiatrist Put Hundreds Of Women In Deep, Drug-Induced Comas’.  One woman gives a disturbing and all-too-credible account of Sargant assaulting her in his private consulting room. In her Observer review, Rachel Clarke describes Ward 5’s goings-on as ‘monstrous’ and says they make her flesh crawl.  Sargant has always triggered difficult emotions in me, but was I now to think of my beloved brother as in the hands of a monster? With Martin in mind, what disturbs me most is evidence in The Sleep Room from ex-patients who felt coerced, as teenagers, by their parents and doctors.   Even if Martin, who died 15 years ago, never talked to anyone about those stormy years. Could his memories have been erased by ECT?

 In his memoir, Sargant portrays himself as the sort of person who would favour physical action rather than reflective dialogue – not my type at all. He describes himself as curing the ‘battle neuroses’ of soldiers returning from Dunkirk with brutal-sounding techniques. In one, called abreaction, the traumatised soldier’s psychological defences were broken down by an injection of sodium amytal, with the doctor heightening the tension by describing a terrifying imaginary scene such as of a burning tank. An alternative was to give the soldier’s head some electric shocks. According to Sargant, the man of action, these methods worked wonders for neurotic or hysterical symptoms such as amnesia and limb paralysis.

 The Sleep Room adds to the negative picture of Sargant I started creating in my teenage years, but at the same time a strange ambivalence creeps over me, so that I somehow find myself tempted to identify with this very dubious character. Sargant expresses angry impatience with chronic illness, and dreams of liberating thousands of people who are languishing in asylums with schizophrenia. Shock their brains, he says, and set them free! Stock dismisses these feelings of  Sargant’s as phoney (how could someone who may well have assaulted a female patient, or who  perhaps did research funded by MI6 or the CIA have feelings?). I never have attacked a patient, but I was just as fervent an advocate as Sargant for people that health services and doctors neglect (in my case, those with progressive neurological conditions). The only doctor I have talked to who worked on Ward 5 recalls Sargant’s saying that he felt strongly about depression because he had suffered it himself.  He compared it to pain. Would you, he asked, fuss about side effects if you knew of an effective treatment  for someone in agonising pain? I would certainly have been tempted, in the way Sargant often was, by even the smallest chance that an incurable condition such as motor neurone disease might be cured by electric shocks, or insulin, or narcosis, or any half-credible drug I could get my hands on.

Stock suggests that Sargant was attracted to such treatments as ECT and lobotomy because they felt properly medical, with a curative aura that no form of psychiatry or psychotherapy could equal.  This is a feeling I had myself when I was exhausted by my efforts help patients think and talk their way through their endless difficulties. How much simpler it felt to inject a drug into a muscle or a spine!  A neurologist spends many hours trying to diagnose and relieve psychologically-based symptoms. I would sometimes catch myself fantasising about shocking the unfortunate person into wellness. Might Sargant have been right, now and then, about the futility of talking?

Sargant looks like a medical dinosaur in some ways but his dismissive attitude to all things Freudian would look thoroughly modern in contemporary psychiatry. Sargant was treating my brother at a moment in the history of British medicine when Freud quite abruptly disappeared. At this point  Sargant and I go our different ways, he with a syringe, or pair of electric terminals, or a scalpel, and me with a pair of ears, wondering how to understand what ill people want us to hear.

Second thoughts about dementia 2: HE WHO HESITATES IS LOST

I’ve written recently about some of the communication challenges of Huntington’s disease. Here is another. My encounters with a Huntington’s patient frequently went like this:

Doctor: 'How are you?’

Patient: [no response]

Doctor: 'Did you come on the bus?’

Patient: 'Not bad’

Doctor: 'Is your swallowing ok?’

Patient: 'No, my daughter brought me’

In such conversations I did not imagine that language had been in some way dammed up, as it sometimes seems to be following a stroke. One can sense the frustration of a stroke survivor who knows what she wants to say but can’t say it. In Huntington’s, by contrast, it is other people who get impatient, while the affected individual often seems unconcerned. Huntingtonian slowness is not of language, or of speech formation, but of thought. In medical terminology slowness of thinking is bradyphrenia, which adds a touch of Greek dignity to the problem (brady- , slow and phren- , mind) and at the same time acknowledges that this is a distinct impairment rather than a sign of general cognitive failure. It is entirely possible to be slow but sharp.

Timing is crucial to human connection. The slightest lapse between lip movements and speech, for example, makes a video difficult to watch. Our motor skills each have their characteristic time signatures, as every tennis player knows. The image above shows that handwriting becomes strangely distorted when you try to produce it bit by bit, slowly. The same constraints apply to gestures and also to speech acts. If you plan to dig someone playfully in the ribs, for example, you must act rapidly or not at all. The spontaneity of human dialogue is soon lost if it is slowed down, as sometimes happens across a mobile phone network, or during a broadcast relay. The conversational thread gets more and more tangled with each pause, and jokes fall flat because a punchline will not be funny if it is held back for even a moment. Everyone feels frustrated when responses seem hesitant, and there is a strong urge to disconnect. The instinct to disengage is often provoked, in my experience, by the silences and mistimed responses of someone with Huntington’s. We long to give up, and we excuse ourselves with the idea that it must be impossible to talk meaningfully with a person who 'has’ dementia.

If we are aware of the effects of conversational slowing we are more likely to attend to the other person’s pace. Two people must always adapt to each other in dialogue, of course, but there are situations where we need to take a brain as well as a person into account. An inspired American nurse called Jim Pollard [i], who has been a close observer of Huntington’s for many years, gives some useful tips in his booklet, 'Hurry Up and Wait’ [ii]. At times, the brain masks the person. Your half-speed signature seems deceptively child-like, as does the slowed-down speech- production of cerebral palsy and multiple sclerosis.

The most fundamental requirement in a relationship is curiosity, which is all too easily extinguished by a label such as Huntington’s. During the 1920s epidemic of encephalitis lethargica, patients stood or sat for hours in statuesque silence (see my paper 'On Doing Nothing’ [iii]) and bradyphrenia was said to be one reason for this. At the time, the flamboyant neurologist and psychoanalyst Smith Ely Jelliffe quoted the pre-socratic philosopher Protagoras, who wrote that 'it is only when we do not act at all that we are able to live our own private life apart, and to differ utterly from all others’ [iv]. However difficult it might have been to penetrate the inscrutable silence of a person with a Huntington’s, I was always intrigued by a sense that something was there for me to understand.

References

[i] See https://vimeo.com/270056128

[ii] Hurry Up and Wait: http://www.lulu.com/gb/en/shop/james-pollard/hurry-up-and-wait/paperback/product-3610588.html

[iii] Ward CD. On doing nothing: descriptions of sleep, fatigue, and motivation in encephalitis lethargica. Movement Disorders, 2011; 26: 599-604.

[iv] Dialogues of Protagoras. See F. C. W. Schiller, Studies in Humanism, Macmillan 1907 p 319

Second thoughts about dementia 1: THE BODY SPEAKS

The Body Speaks

Chris Ward - February 7, 2020

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One of my challenges as a specialist physician was Huntington’s disease. To give you a picture, imagine 'Diane' [i] slumped in a wheelchair, stirred into speaking by something her husband has said about their 7 year old son, Will. Diane’s strong feelings are obvious but what she wants to say is not, because her speech is unclear and her body’s jerking movements make the wheelchair shudder. Huntington’s is a genetic condition and there is a one-in-two chance that Will will eventually develop problems like his mum’s. She could expect disorders of cognition and mood as well as involuntary movements, the best known of which is the irregular jerking called chorea [ii].

One of my challenges as a specialist physician was Huntington’s disease. To give you a picture, imagine 'Diane' [i] slumped in a wheelchair, stirred into speaking by something her husband has said about their 7 year old son, Will. Diane’s strong feelings are obvious but what she wants to say is not, because her speech is unclear and her body’s jerking movements make the wheelchair shudder. Huntington’s is a genetic condition and there is a one-in-two chance that Will will eventually develop problems like his mum’s. He could expect disorders of cognition and mood as well as involuntary movements, the best known of which is the irregular jerking called chorea [ii].

I want to reflect here on the patients I worked with in the hope of capturing something of their experience. What I am after is experience, not experiences: not a 'then-I-did-this’ narrative, but the mental and bodily qualities, in other words the phenomenology, of Huntington’s. Medical language has little to do with experience, as I’ve argued in a recent book [iii]. What, then, can a doctor say about his or her patient’s consciousness? Not much, but not nothing. Our bodies constrain what and how we feel, and the particular constraints of Huntington’s disease are worth thinking about. The one I will consider first is disordered movement. In subsequent pieces I reflect on two others, slowness of thinking and obsessive traits, before coming finally to the larger question of what it might be like, subjectively, to have these difficulties.

My specialist nursing colleagues and I met people like Diane in their houses, and in nursing homes, and in our clinics. The 'patient’ would often be restlessly silent, as though preoccupied with something other than our conversation, so that we often found ourselves talking around, rather than directly to, the person. I wondered then, and I still wonder, what lay behind our patients’ apparent inscrutability and what made it difficult to establish some kind of presence within their mental worlds.

I think we can be sure that people with Huntington’s have the same desire to communicate as any of us. Above is a sample from a journal (I feel able to publish them here because the person is not identifiable, 30 years have elapsed, and there was nothing secret about them at the time). The lower is several months after the upper page. Over this period, the person’s efforts to communicate seem to be outstripping the capacity to write. The journal shows the effect of abnormal movements on handwriting, which might give us a picture of a faulty TV in which 'noise’ (jerkiness) interferes with a 'signal’ (thoughts).

This simple model has been rejected by theorists of human communication and says little about the conversational efforts of someone affected by Huntington’s, where noise frequently evolves into a signal. The ghost of some meaningful expression often flits across the person’s face, sometimes fading but at other times becomes unmistakeably expressive, and a movement of the head or of the arm may either subside or else turn into a recognisable gesture, all of which makes it difficult to separate the means of communication from the message. Facial grimaces, head-nodding, shoulder shrugs and movements of the spine can be part of anyone’s communicative repertoire. In Huntington’s, similar movements are hallmarks of brain dysfunction. Should we, for that reason, dismiss them as meaningless?

The body speaks to me, and also through me. A cough is a symptom but also an utterance. It tells everyone I have a cold, it suggests that I am someone to avoid (chorea has the same effect, socially), and it can also be a conversational gambit, transmitting private messages such as 'Stop talking about that!’. In communicating with each other we use pathologies such as coughing together with facial expressions, bodily postures and limb movements, and we also resort to whatever images or objects the environment happens to contain (the floor, say; or a spoon; or a part of the body). Together, these are among the affordances of communication. I learned to use the word affordance in this way from James Gibson, a psychologist who studied perception and action [iv]. We can only expect to understand someone with Huntington’s if we attend carefully to the person’s affordances. It is difficult to notice what someone is trying to say when the body’s involuntary movements and awkward postures are interpreted purely as signs of disease, or when a lack of verbal fluency is interpreted simply as dementia. Effective communication requires imagination, patience and, above all, curiosity about that person’s experiences, ideas and feelings.

Dementia, if we want to call it that, can expose affordances that were not available to the person before the onset of symptoms. Some of the modes of expression that people with Huntington’s resort to have a tragi-comic dimension. One angry man used a mower to write c*** on the lawn. He had his reasons.

Notes

[i] 'Diane' and other characters I mention here are not identifiable individuals, but nothing in their stories is invented.

[ii] For some of the physical challenges of Huntington’s, and more, see: https://www.youtube.com/watch?v=U4BSZ4FlGRg&feature=youtu.be.

[iii] See Between Sickness and Health. The Landscape pf Illness and Wellness. Routledge, 2020. .

[iv] Gibson, JJ. The Ecological Approach to Visual Perception. Houghton Mifflin, 1979.