Archive and Study Centre Publications: Series 2 Essay 1
As I thought back over 50 years of Therapeutic Community Experience I began to reflect on how we at Fulbourn had learned “to do it”: how to operate therapeutic communities; how a varied group of people from several professions – medicine, nursing, social work, O.T., and none - had learned to operate this new, exciting and rewarding way of working in an institution.
It amazes people entering psychiatry in the 21st Century to hear that 60 years ago no one had heard of therapeutic communities, or even of group psychotherapy. Now, there are many books, publications and journals; there is the Group Analytic Institute with its courses and its Membership training; there is the Association of Therapeutic Communities with its experiential workshops; there are therapeutic communities which offer hands-on experience; there are many books. Then, though pioneers were working, they were feeling their way and had not yet published. For a young doctor starting in psychiatry in 1946, as I did, all attention was centred on the one doctor/one patient relationship. That was the setting in which the “mental examination” was carried out; that was where psychotherapy and psychoanalysis were practised. No one ever suggested seeing patients together. There was not any formal discussion of the things that happened on the wards, particularly between the patients and the nurses. So my generation had to learn social psychiatry, group psychotherapy and therapeutic community practice as they unfolded, and as we fumbled our way through the difficulties and the many opinions about how to do it.
In this essay I recall some memories of how I personally learned about therapeutic communities, and some of the ways that others such as my friends and colleagues at Fulbourn went about learning to operate Therapeutic Communities. The story has been told before, but I have never before tried to set out the process of learning.
The starting point, for all of us, was dismay and disgust with the old asylum system in which we were working, and our search for something better. To those coming new to them after the War the old mental hospitals were dreadful and repugnant – barracks full of squalid, pathetic misery. They were shabby, dilapidated, and overcrowded. The older staff seemed tired, apathetic, resigned in their belief that neither the patients nor the institution could change or even become better. The choices seemed to be to get out or to accept the apathetic life. Some of us wondered if there was another option – to stay and try to change and improve the asylum way of life.
For me, the first glimmerings came as I began to suspect that there was much more going on in the wards and the hospital than I realised, and that some of these processes might be far more powerful for the patients than were my earnest discussions with them. I saw these forces at work in my first setting, an Army Psychiatric Wing in a hospital in the Middle East, and later in the closed wards of the private wing of a famous hospital. Some of the happenings were negative – the violence, the strait jackets, the padded cells, and even deliberate brutality. Others were powerfully positive, such as painting classes run by a Russian Countess, occupational therapy classes, the early meetings of Alcoholics Anonymous. I began to wonder whether the powerful positive social forces that I had seen operating in army units could be harnessed to help the life of the patients; and I also determined to find ways to make asylum life less brutal and degrading.
But it was not until I got to the Maudsley in 1950 that I became aware of the ferment of social psychiatry developing in post war Britain. I read the writings of the American social psychologists analysing the culture of asylums: Stanton and Schwartz, Dunham and Weinberg, Belknap, Goffmann. I began to see a mental hospital as a closed social system with its own bizarre rules, both spoken and unspoken, and began to wonder if it could be changed. I also began to hear about “Group Psychotherapy”, a way of treating patients together in a group. Then I had the good fortune to meet Michael Foulkes as he was starting to build up the group therapy service in the Maudsley Outpatient department; from him I learned his Group Analysis, which I found congenial and practised with enthusiasm.
By this time a few books were appearing. The Bulletin of the Menninger Clinic in 1946 contained papers from Northfield Military Hospital, the first place to call itself a “Therapeutic Community”. Foulkes published a little book with Heinemann in 1948. Maxwell Jones produced his first book in 1952. It was thus possible for someone interested, as I was, to read a little about Social Psychiatry and to visit the few places - such as Belmont and the Cassel Hospital – where existing new social experiments were going on.
In the early 1950s there was also considerable ferment in the English mental hospitals. Evacuated, bombed, overcrowded, ill maintained, they had suffered during the War and standards had fallen. But in 1948 they were drawn into the National Health Service and money was available to improve things. There was a ferment amongst young psychiatrists too, but it was mostly for the new exciting methods of “physical treatment” that had developed during the war – ECT, insulin coma therapy, narcoanalysis and prefrontal leucotomy. All produced amazing recoveries, and filled keen young doctors and nurses with enthusiasm. This therapeutic excitement enlivened the hospitals and gave doctors and nurses a feeling that they were doing something effective. Alongside these “proper” medical activities, however, some Medical Superintendents were trying to improve the life of the long-stay patients. They tried Activity, Work Therapy and Open Doors. George McDonald Bell opened all the doors of Dingleton Hospital in 1948. T.P. Rees opened those at Warlingham Park soon after, and Duncan Macmillan those of Mapperley. A general debate developed within hospital psychiatry. T.P. Rees called on us to go “Back to Moral Treatment” in his R.M.P.A. Presidential address, and this led me to the writings of the great 19th century asylum pioneers - Philippe Pinel, Samuel Tuke, W.A.F. Browne and John Conolly - and I realised that there were ways of improving asylum life that had been forgotten.
I went to Fulbourn Hospital in 1953, and in my first year I took the opportunity to visit the pioneers and was amazed at what I saw – hospitals with every door open, patients cheerfully working in gardens and workshops, visitors coming and going freely, patients well dressed and well behaved rather than crowded idly into smelly locked wards. I began to try to apply some of these ideas. Most important, I started arranging for staff to visit these pioneering units. Some charge nurses came back bursting with enthusiasm to try these ideas and to do better!
A general debate developed in the 1950s about the new ideas, especially “Open Doors”. Dingleton, Warlingham Park and Mapperley all proclaimed and demonstrated that a mental hospital could work and run safely with no locked doors. This was startling, and to many older asylum workers, doctors, and nurses, alarming and dangerous. Even a pioneering Superintendent like Joshua Carse of Graylingwell was sure it would not work. At an RMPA debate he said he was certain that there had to be at least the one locked ward to contain the dangerous patients – that we owed it to the neighbourhood. I was convinced by him and said the same in a public lecture in 1956. But I was wrong. We opened the doors at Fulbourn with safety, and by 1958 we were an open Door Hospital.
Apart from visiting, we had to read about the theory and practice of Social Psychiatry. There was a need for some people in the unit - someone in the hospital - to read the literature, the classics, the sociological studies and the current writings, and to feed them back. At Fulbourn it fell to me to do this; at Belmont to Max; at Claybury to Denis Martin and Elizabeth Shoenberg.
By the late 1950s another debate developed. The “Therapeutic Community” worked, but with selected patients – at the Cassel with psychoneurotics; at Belmont with selected psychopaths. If the patients there became too disturbed they could be certified and passed over to a nearby mental hospital. Would the method work in an ordinary mental hospital? Many psychiatrists were sure it would not. But then we began to hear of experiments – Denis Martin on an open ward at Claybury; Richard Crocket at the Ingrebourne Centre. Some of us began wonder whether it might work with us at Fulbourn.
In 1958 Eddie Oram, a Registrar in charge of a “convalescent” ward at Fulbourn, asked it he could try running it as a therapeutic community. I arranged for him to spend some time with Max at Belmont, and then encouraged him to go ahead. He gathered the patients and staff in community meetings and told them that they would be responsible for running the ward, cleaning it, serving the meals, etc. The usual results followed. The patients responded well, took charge of things, and changed from a dull mass of grumblers to a lively group facing their problems in hospital and at discharge. The standard of cleanliness slumped, however, and the Matron was dismayed. I had to intervene to divert her fury. Rumours ran round the hospital about irregular activities on the ward, etc., etc.
At the same time, in 1958, I was engaged in upgrading the lamentable “Women’s Disturbed Ward”. We moved the patients and staff to a new, redecorated ward (without padded cells), and provided new clothes for all the patients, dispensing with the “strong dresses” and “locked boots”. We increased the staffing, and sent more patients out on working parties. The ward became a pleasant place to visit, and the Matron and I were well pleased.
During this time Douglas Hooper, a research social psychologist, was examining the changing wards. To my concern he demonstrated clearly that there was little change in the patients in the disturbed ward. Though the signs of degradation had gone, and they looked cleaner and tidier, there was no real change in their subservient behaviour. In the “Convalescent” ward on the other hand, more women were taking their discharges, readmissions had fallen, and there was a real change in their attitudes towards their own lives. What Douglas demonstrated was that, desirable though cosmetic improvements were, the only way to achieve major change was to change the social structure. This made me think. We had many discussions, and finally Eddie, Douglas and I published a paper with these findings.
I decided that I must try the Therapeutic Community method for myself, and in 1960 began holding regular community meetings in the same Women’s Disturbed Ward. These were dramatic occasions. Attacks were made – on staff and patients; scuffles broke out, windows were broken. But I began to hear why the outbursts occurred, and hear about some of the tensions in the ward. For me the most important part of the process were the staff review sessions, where long-term nurses began to speak up about what they knew and felt about the ward, and in particular the medical habit of breezing in, giving orders, and then leaving the nurses to manage the turmoil. They began to challenge and criticise some of my methods of responding to crises. I was brought to see that the interchanges between the doctor and the more attractive young women patients were a potent seed ground for subsequent turmoil, and I started to question and modify my “benign paternal” style of operating.
In 1962 I went for a year to the Behavioural Sciences Centre at Stanford University in California. I wrote my first book (Administrative Therapy 1964); had many discussions with social scientists, including Erving Goffmann; paid many visits to Therapeutic Communities throughout California; and visited Maxwell Jones in Oregon, where he was promoting change in the State Hospital.
I came back to Fulbourn in September 1963 determined to apply the Therapeutic Community approach to the hospital and see how far we could go. We started Therapeutic Communities in the Disturbed wards. More people became involved – senior long term nurses, like Ruby Mungovan and John Wise, keen young Senior Registrars, like Junichi Suzuki and Geoff Pullen, and staff of all levels and disciplines – social workers, occupational therapists, nursing assistants, student volunteers. These were exciting days, with tremendous discussions, rows and consultations, and repercussions both throughout the hospital – especially with the Administration - and the community outside. I had to spend a great deal of time and energy mediating in these matters; though by now I could call on a fair volume of goodwill and respect from what we had achieved in the first ten years. Gradually, we convinced many of the sceptics, especially when they saw patients they had known as severe troublemakers emerge as responsible community leaders.
So we began to build up a group of people who knew how to operate a Therapeutic Community – had confidence in their skill and experience, and were prepared to expound it to others. We began to be asked to pay visits, give talks on our work, and to receive visitors. I personally found myself lecturing throughout Britain, in Japan, in South America, in Europe.
The core constituency were people who had learned to operate in the old British mental hospitals – locked, apathetic, inert places, set in an authoritarian tradition of control and restraint of madness, where the main concerns of the staff were the prevention of escape, violence and suicide, and where the patients lived in a controlled atmosphere of command and order where initiative of any kind was frowned on. The hospitals had been operating in this way for a century, and no one had expected or hoped for change. Most of the staff – doctors, nurses, orderlies, patients - had come to accept the situation and had conformed to it, often by putting their energies to the hospital cricket team, or the trade union, or local politics. But there were always a few who either got out, or remained in discontented and questioning. It was amongst these – idealistic young doctors, nurses restless and dissatisfied after wartime service had challenged them, temporary staff who had not yet succumbed to asylum apathy; these were the seed corn of the Therapeutic Community movement. But the seeds took a long time to grow, and there were many doubters.
We began to explore ways of informing newcomers. Fortunately our Nursing Tutors, Reg Salisbury and Mark Bailey, were enthusiasts for the Therapeutic Community approach; they lectured on it and they brought the student nurses to attend community meetings. We organised induction courses for new nursing assistants. But we mostly relied on instruction from the senior members of staff, and of course hands-on learning – working in the ward therapeutic communities. This seemed at the time to work very well; the eager young people with their vigorous questioning enlivened the wards; they enjoyed the flattened hierarchy, and the opportunity to challenge charge nurses and consultant psychiatrists. Looking back now, however, I think we should have done more to pass on the formal knowledge of the literature and the publications about other communities.
In 1969, after a meeting at Henderson Hospital, people from active Therapeutic Communities agreed to hold meetings – 2 or 3 a year – at different Communities, where we would talk about what we were doing and see what our host’s methods were. This was the beginning of the Association of Therapeutic Communities, though it did not take formal shape until 1981. These meetings and outings were very valuable for our learning. We saw what other people were doing. We had the ATC to Fulbourn a number of times, and presented what we were doing. This was educational for everybody, including me. But the great value for the hospital was that many people, of all staff groups, went on these outings and met their counterparts in other units. It was a stimulus and a dialogue for them and they brought many new ideas back. This was a great improvement over the Medical Superintendent going away on a visit and then telling the staff about it when he returned! They saw and experienced for themselves.
By the 1970s, in Fulbourn, the group of Therapeutic Community enthusiasts had grown and changed. The core was still those who had known the old asylum: long-term staff like myself, Oliver Hodgson and Ross Mitchell; experienced nurses like Ruby Mungovan, Jack Long, John Wise; and long-term patients, who could remember the locked doors and the repressive regime. But we had been joined by a flood of new members, who had not known the old days. We helped them to learn by practice – by working in the ward therapeutic communities, by the sensitivity groups, and by their own personal living/learning experiences. This worked very well and many of them became sensitive and effective social therapists. In 1975 Ronald Speirs and I founded Cambridge Group Work specifically to offer Cambridge people the experience of membership of group analytic group. Over the years many Fulbourn staff gained personal understanding growth in this way.
During the late 60s and early 70s people tried applying Therapeutic Community ideas through nearly all the wards of Fulbourn Hospital – ward meetings, ward projects, examination of roles. In some areas this had little impact, such as the Infirmary Wards and the Psycho-Geriatric Wards filled with demented elderly. Two areas used them effectively. The Rehabilitation Wards applied group methods vigorously and began moving people out to sheltered accommodation. The Admission Wards began trying the method. It worked very much in Friends Ward, and Geoffrey Pullen developed a notable project in Street Ward.
Then came the regression of the late 70s or early 80s, when the academic psychiatrists and the new NHS managers made their distaste for democratic ideas manifest and gradually forced the retreat of Therapeutic community work, as related in “The Story of a Mental Hospital”
So, did any principles of learning emerge from the thirty years of experiment, excitement and innovation? I think that some did, and it is perhaps worthwhile setting them out in the more staid times of the Twenty First century when “training” is well organised and the excitement of doing quite new things is unknown.
One of the first principles was go and see for yourself. I began social therapy by going to see the leading practitioners and realising how we could change Fulbourn Hospital. In late years I visited the various experimental therapeutic communities and realised how we might be able to change things at Fulbourn. It was a visit to Denis Martin at Forest Lodge at Claybury that emboldened me to back Eddie Oram in developing the first Fulbourn therapeutic community in Adrian Ward. My visits to Max at Henderson, Salem, and Dingleton always gave me new ideas to try back at Fulbourn. My many visits in the United States, and later world travels gave me ideas of what to do and sometimes what not to do in seeing other peoples’ experiments and idiosyncrasies.
I soon realised the importance of spreading the opportunity of ‘seeing for oneself’ beyond my own personal experience, and I began sending selected members of staff to look at experiments that I hoped we could copy. I sent Joe Pattimore and Tom Lewis to Warlingham, to get ideas of how they might restructure their wards for more effective social therapy. I sent Eddie Oram to Henderson, to work with Max for a week before he set up his Adrian therapeutic community. I arranged many other visits. Then, when the ATC got going, we were able to do much better. We took a team to every ATC meeting and in particular included nursing assistants, occupational therapists and social workers with the nurses so that they might see what their professional counterparts were doing in these other therapeutic communities. They came back full of ideas, enthusiasm, criticism, challenges which we fed into our work.
Another principle that emerged was “keep trying new things”. In those days there was no set pattern of how a therapeutic community should be, nor criteria for judging them. Many of us tried different ideas, sometimes proceeded with them, and sometimes abandoned them. Max Jones, for instance, tried psycho-drama in the early days at Belmont but abandoned it as the fuller open society of Henderson developed. As I related in “Story of a Hospital”, we tried many ideas at Fulbourn, particularly when the suggestion came from the junior staff or patients. One very successful ward cooking project expanded so much that we finally had to limit it on the grounds of food hygiene! A patients’ chess club flourished for a time, until the rehabilitation of all the more skilful chess players made it impossible to carry on.
Another area which proved more difficult to implement was studying the literature - on the sociology of mental hospitals, on experiments in social therapy, on the success and failure of therapeutic communities elsewhere. In the 1950s there was very little, by the 1960s the literature was beginning to swell, and in the 1970s a number of papers were emerging. In the 1980s the International Journal of Therapeutic Communities started. It was necessary that some people in the community should be reading these articles as they appeared, thinking about them, and - where applicable - bringing the lessons back into the community. I did this assiduously, but to my dismay I found that not many of my colleagues were interested in doing this, caught up as they were in the excitement of day to day transactions. Further attempts to introduce theoretical ideas into the community, and particularly into staff discussions, sometimes ran up against the cry that this was mere theory, and what was wanted was better practice. There was even a period when a split developed in the staff between those who “had been to College” and those who had not. The “College group” included me, the doctors, the social workers, and some of the graduate nursing assistants, while the “experienced group” included all the senior nurses, most of the junior nurses, and many of the nursing assistants, who tended to mock those who used polysyllabic phrases, and tended to praise vigorous, open and unsophisticated speech. I noted elements of this same anti-intellectualism in quite a number of other therapeutic communities, and I think it remains a challenge to this day. I certainly had to learn to speak in rather simpler language, using Saxon rather Latin words, and introducing complex ideas in simple short sentences. A useful exercise for me personally!
As we became more confident in what we were doing, and operated more successfully, we learned to our surprise and pleasure that other people wanted to learn from us! At first we were just very flattered by this, but then began to regard it seriously. Quite early on I found that being asked to explain what they were doing was very helpful to many staff because it forced them to stop and think about it. One of the most successful exercises in this area was a refresher course for charge nurses and sisters of East Anglian mental hospitals which was run in 1957, when senior nurses came from all over East Anglia and our charge nurses and sisters were required to tell them about what we were doing. Our charge nurses took pride and delight telling of their own work and were much more convincing exponents of it subsequently. When we hosted ATC conferences we encouraged the junior members of staff to present the story of what we were doing, and this again challenged and excited them, and of course they learned a great deal from the comments of their peers amongst the visitors. In the 60s I found myself being asked to lecture at mental hospitals up and down the country and in the United States, and subsequently in Japan and South America and Poland. This forced me to scrutinise my thinking and formulate more clearly what I thought we were doing, and of course in the presentations to different areas and cultures I was forced to take on board some criticisms that I had not thought of before. Quite apart from what it may or may not have done for our audiences, the experience of telling what we had done was very valuable and educational for all those of us who took part in it.
We also learned to accommodate visitors. At first we had just a few and we invited them to join our meetings; but then it became so frequent that the residents of Hereward House objected to the constant interruption of visitors, particularly when they were foreign and couldn’t understand English. We had to learn ways of introducing them and also of limiting the number of visitors in any particular week or month. One by- product of the crowd of visitors was to help the members of Hereward House, particularly the disillusioned, antagonistic patients, to realise that they were part of an exceptional and famous experiment. Though of course they scoffed, they nevertheless took pride in this, and it may have helped in developing in them that sense of responsibility and commitment which is such an important part in the rehabilitation process.
Those, then, were a few of the experiences that we went through and the ways of learning about them during the great days of the Therapeutic Communities in psychiatric hospitals in the 1950s, 1960s and 1970s. Now, psychiatric hospitals are vastly changed and there are few therapeutic communities left within the managed NHS. So it is perhaps of value to recall how we learned in those stirring times. Perhaps some of the principles are applicable even today, in 2005.
Dr. David H. Clark