Archive and Study Centre Publications: Series 2 Essay 4
In the Spring of 2005 the Council of Cambridge Group Work asked me to give a talk about my years of work in group and social psychiatry in Cambridge. I accepted hesitantly, since it was a long time since I had spoken in public. But gradually, I warmed to the task. I delivered the paper quite satisfactorily on 29`h June 2005.
It had started as rambling reminiscences of some 60 years of experience, and I enjoyed sharing memories with people who had taken part in many of the stirring episodes that we had seen in Cambridge. As the paper developed, however, I was led to reflect on the whole phenomenon of social psychiatry, quite unknown when I began in psychiatry in the 1940s, but by 2005 a major and irreplaceable part of psychiatric practice in diagnosis and various forms of psychotherapy. This further led me to reflect on the fluctuating fortunes of various kinds of approaches and therapy that I have seen in psychiatry during my professional lifetime - the triumphant rise of the physical therapies - insulin coma therapy, electroplexy, leucotomy, carbon dioxide therapy, etc. - and their almost total extinctions; the rise in the various pharmacological therapies, and in many cases their later discrediting - the barbiturates, the amphetamines, the phenothiazines; the tremendous rise of psycho-analysis in the immediate post war period, and its gradual decline into a minor speciality by the end of the century; and to wonder what it was that had caused these various forms of approach to mental illness and its therapy to rise and fall so strikingly. It also led me to reflect on the few forms of treatment that had persisted for more than a decade, such as electroplexy and the major anti-psychotic tranquillisers. I realised that various forms of social therapy had also seen a rise and fall, though many were still potent; and I began to associate some of these rises and falls not so much with the thinking of psychiatrists or the inventions of the chemist but the demands of the society in which we were practising our trade - which at times supported and applauded what we did, and at other times castigated us and regulated and limited what we tried to do. I have tried to put all these ruminations into reasonable shape, and offer them hesitantly as some reflections of an old man looking back a long way.
I qualified in medicine in 1943 after having been a medical student before and during the first part of World War II. After a House Surgeon's job I joined the Army and became a parachutist. I spent the earlier part of 1945 engaged in battles in Northern Europe and in the conquest of Germany - a terrifying and exhilarating experience for a young man. I had seen comrades wounded and killed, I had seen men break down in battle, I was with the troops who uncovered Belsen, and I had witnessed the devastating sight of Europe disintegrating, with armies sweeping to and fro, destruction of cities, and refugees pouring from one end of the continent to the other. I came back in May 1945 to find England rejoicing with the news that the War was over; the lights were on and the cars running freely. But when my fiance said to me "Well it's all over now!" I had to tell her that I had been warned for further service in the Far East against the Japanese, and that many dangers still lay ahead for me. We agreed that we would postpone our marriage until I had finally got free of the Army. She asked me what sort of doctoring I proposed to follow, and I told her that I had come to feel that I wanted to study psychiatry, to learn something of how people live their lives, and to understand how men did to other men some of the horrible things I had seen.
So I went off for a year and a half to the Far East and again had strange experiences, having to take charge of an internment camp of 5000 Dutch internees and finally evacuate them with the help of the Japanese Imperial Army. While in the Army I found an opportunity to begin the study of psychiatry, and as soon as I came home I started working in psychiatry in Edinburgh under Sir David Henderson.
I discovered that psychiatry seemed to be all about the disease processes that occurred within the individual, and that these were to be studied entirely in the two-person therapeutic situation, one doctor examining one patient, or one patient talking to one doctor, in what was called 'psychotherapy'. There never seemed to be any reason to involve any other person in the process, nor was there much enquiry into the circumstances that had brought this person to breakdown or what they might be going back to. I came to feel that there must be more to it than this, and wanted to explore further. All this time I was working in the traditional asylum setting: Wards full of patients, inert, trapped in insanity, standing immobile in corners gibbering and managed by hard-faced men and women nurses. I visited other asylums and saw that it was the same everywhere, hundreds of people in apathetic confinement with a few of the furious and angry in "disturbed wards", where padded cells and straightjackets were freely used: I came to realise brutal coercion was used by the staff to maintain a modicum of order. I wondered if it had to be like this.
Most asylums had set aside some wards as admission wards. The conditions there were not so sunk in chronic depression and brutality as the back wards, but were nevertheless shocking to the new patient, new doctor or new student nurse arriving for the first time. The ward was locked; the main concern of the staff was to prevent patients escaping harming themselves or harming others. There were frequently loudly disturbed patients raising clamour and disorder, and there were padded cells in which the more violent were controlled. For a first admission to a psychiatric hospital an admission ward was a shocking experience; there was little hope of discussing one's situation or finding out what chance there was of improving things.
In 1950, after three years in Edinburgh, I went to London to the Maudsley Hospital to pursue my studies further. I wished to become more skilled in psychotherapy, and so I undertook a personal psycho-analysis and attempted to practise individual psycho-analytic psychotherapy. I had the opportunity to work with Dr. S.H. Foulkes who had just come to the Maudsley and was beginning to develop his system of group-analytic psychotherapy, where psychoneurotic outpatients were seen weekly in group sessions. I practised this method under his supervision and found it not only congenial but far more effective than the individual therapy that I was attempting at the same time.
I began to hear of the work of pioneering Superintendents like T.P. Rees of Warlingham, who had changed the apathetic custodial asylums into cheerful and lively places where the patients could work and be active and live in comparative freedom. I began to read the studies of the American sociologists into the social structure of custodial mental hospitals, and to realise that the traditional way of operating made the state of long term patients even worse than it had been before they went in. I began to hear talk about "therapeutic communities", and visited Belmont Hospital where Maxwell Jones was making his experiments.
Some half-formed notions were stirring in me by this time. First, that one could not understand fully an individual's disorder unless you knew something of the world he came from and the stresses and pressures, demands and hopes that operated on him there. Second, that there might be other ways of helping people than the dyadic one-doctor/one-patient which seemed to be the only setting that my teachers could think of. Third, that the mental hospital was a much more complex social situation than we allowed ourselves to think, that the sociologists might have views on it, and in particular it didn't have to be the squalid brutal place that it had been for the last century: there might well be other ways of operating. It didn't have to be like that.
So in 1953 I came to Fulbourn Hospital as Medical Superintendent, hoping to try out some of these ideas. I found a static, custodial mental hospital rather more overcrowded and certainly more impoverished than most, with a static and discouraged feel to it. For various reasons nothing had moved for several years, but I found that a number of people in the hospital were longing to make changes and looking for some way to do it. I was very fortunate to come there at that time and find a number of able, devoted, concerned people who wanted to make things better. Just at that time the World Health Organisation published a Report setting out what a psychiatric hospital could be. They said that it should be an active place where the patients were given as much freedom as possible, where the assumption was that patients could and should be trusted as far as possible, and where there was constant attention to the spirit of the place. After visits to several of the leading hospitals where some of these ideas were being tried, it seemed to me that we might attempt them at Fulbourn.
The 1950s and 1960s were a hopeful time for institutional psychiatry in Britain. As the National Health Service developed, politicians were appalled to find that although 50% of the beds in the hospitals were in Mental Hospitals, only 20% of the funds went to them, and that the physical standards of life for psychiatric patients were appallingly low. Money was made available to improve these. This was spent in many ways: In some hospitals, in refurbishing wards; in others, in providing greater amenities for the patients. A number of hospitals developed purpose-built admission units which were a vast change from what had been before - light, airy buildings with recreational facilities, and an attempt to make the place helpful to the patient. The 1959 Mental Health Act changed the legal basis of work, and it became possible for people to enter a Mental Hospital as "informal patients" without any compulsion, and the majority of them did so. The number of people under legal detention in the hospitals declined, many of the admission wards operated as Open Door wards, and visits of family and friends were encouraged. New young staff came to work in them and began to talk and interact with the patients in an attempt to understand how their difficulties arose.
At Fulbourn we began first with a programme of getting all the long stay patients active. We started all kinds of work, laying out a playing field, getting everyone possible out of the wards into work of one kind or another. As we increased the activity in the hospital we found there was less need for the locked doors. We began opening the doors of the quieter wards. This was greatly welcomed by both patients and staff and brought few difficulties. We also began encouraging the patients to show initiative, to undertake new projects, to explore the possibility of leaving hospital. We were able to find jobs for a number of them in Cambridge (those were the days of full employment!). We adopted slogans - "Activity, Freedom, Responsibility" - and had a very lively time. We cultivated good relationships with our surrounding community, we had Open Days, Fetes, Gymkhanas. We encouraged the local newspaper, and then the citizens of Cambridge, to come to the hospital and see how it actually was; we explained what we were doing and met any concerns that were expressed. As a result we were gradually able to open all the wards, and in 1958 Fulbourn became an Open Door hospital with no doors locked, and it remained in that state for the next 30 years - a proud achievement!
All this improved life in the hospital led us to Rehabilitation. Although a number of patients were able to leave hospital as soon as attitudes changed, others found it more difficult. After many years of institutional life they had lost social skills and found the transition from the sheltered, ordered, disciplined life of the ward to the open life of the general community more than they could manage. We opened a halfway house (Winston House) in 1958, and then developed group homes. We also developed sheltered workshops where patients could work on simple tasks and earn adequate money, so that they could begin to acquire personal property. As a result, the numbers in the long stay wards began to fall, as many long term patients learned how to live outside of hospital.
As we were developing these ideas at Fulbourn, Social Psychiatry ideas were moving generally in psychiatry. Many hospitals were opening their doors and reporting good success with it. Some hospitals were beginning to develop therapeutic communities. This system - whereby, in a small unit, the patients were encouraged to take responsibility for much of the government of the unit, and where patients and staff mingled on an egalitarian basis - had originally been developed for patients with behaviour disorders (psychopaths) at Belmont Hospital. There had been some doubt whether it would work with people suffering from major psychotic disorders, but hospitals such as Claybury, Littlemore and Dingleton began to experiment, and we did too. In the 1960s we developed a number of therapeutic communities within Fulbourn Hospital. The most notable of them was Hereward House, which was a community for all those men and women who had been regarded as the most disturbed in the hospital. It was a matter of astonishment and delight to find out how these people responded to the opportunity to run their own lives and to explore how they might get out of these difficulties and troubles. Later we developed therapeutic communities on our admission wards, notably Friends and Street wards.
In the meantime, group analysis had been slowly developing and extending in Britain. An increasing number of people came to work with Michael Foulkes to learn his method, and then began to apply it up and down the country. They formed the "Group Analytic Society" in 1952, and then the "Institute of Group Analysis" in 1971. They provided courses and experience in London, and some people from Cambridge went up to London to learn about this. Within Fulbourn many people were being asked to run groups and felt the need to get more practical experience. As a result, in 1975 Cambridge Group Work was formed, first to provide experiential groups, and then after 1980 to provide a Course in Group Analysis which continues to this day.
The idea that people could be better helped in groups than individually spread widely in Western society in the 1960s and 1970s. Many psychiatrists developed group psychotherapy in their outpatient clinics. Other forms of group therapeutic work developed. There were experiential groups, there was psychodrama and Gestalt therapy - both started by psychiatrists, but taken over by others -, and the development of common interest groups, where people with a disability or disadvantage together explored the situation and attempted to change themselves. From these arose specialist group work, such as art therapy and music therapy. Some of these group techniques were even adopted by religious and political groups, such as Rajneesh and EST. Thus, during the 1960s and 1970s the idea of using group and social methods for helping people became accepted and widespread in our society.
These were exciting, stimulating, challenging years for me. When we first started at Fulbourn I had not much more than just a general idea of trying to humanise the place and make it better than it was; but as we proceeded with social therapy, and began to open and change and activate the hospital, I began to see that we were unleashing powerful forces, and that we were able in many cases to transform the lives of people who had been considered as condemned to permanent institutional life. Then, with the development of therapeutic communities, I came very closely in contact with the life of long term patients and the long term nurses, and began to appreciate the realities and some of the harshness of what they had had to endure in the years of shortage and custodialism. I was tremendously heartened to see some of the very disturbed people make amazing recoveries and proceed to better and fulfilling lives.
During all this time Fulbourn Hospital itself changed, and it became a delightful place to work in. There was a general air of enthusiasm, challenge of new ideas, a willingness to try things and see if they worked. Sometimes they didn't, and the projects had to be closed, but many succeeded. We began by encouraging the nurses to try their ideas, but this spread down to the patients, so that if they came forward with notions for rearrangement for lives in the ward we would struggle to implement and operate these. There was also a feeling that Fulbourn was a place to learn new things and face new challenges, and a heartening number of people went through Fulbourn on to more active and exciting careers. It was said we had a "culture of personal growth". It was great fun to be part of.
It gives me pleasure to recall those days, and to tell the stories of the things we achieved; but we have to look at how things are now, and to acknowledge that some of the social therapy initiatives that we developed and ran seem to have disappeared, whereas others have continued and flourished. It is perhaps valuable to consider some of the reasons why this may be so. In attempting to do this, systems theory becomes valuable. It teaches us that you cannot understand the changes in an organisation by merely looking at the organisation itself alone. You have to see it in the context of the large society in which it operates. I find it useful to recall the differing atmosphere of the decades through which I lived.
The 1950s were a good time to practise social therapy in British psychiatry. We had come through the War and were determined to make a better world, a fairer world, a more equal. a well-planned world. We elected a Labour Government to give us a Welfare State and a National Health Service, and we were determined to make them work. There was also a desire to get rid of many of the oppressive institutions that had flourished in the 1930s; orphanages, approved schools, mental hospitals and jails were places we wanted to see changed and improved. In such a setting, the experiments that we did at Fulbourn were welcomed. The early years of the NHS had revealed how underfunded the mental hospitals had been, and in the 1950s there was a steady flow of money to fund new projects. The people of Cambridge were keen to know that their mental hospital was a good and hopeful place, and enjoyed hearing about this from the local newspaper. Full employment made it possible for us to find jobs for our people as we rehabilitated them.
The 60s and 70s were also a good time. These were the years of the youth revolt, when young people were determined to make a better world. Many of them read the writings of RD Laing. Into Fulbourn came young, idealistic people as doctors, social workers, psychiatric nurses, nursing assistants, who had read his poetic invocations of how people with psychosis would respond to kindness and understanding, and were eager to try and see if this would work. This was the time of our first therapeutic communities, and the start of Cambridge Group Work.
Then came the later 1970s, after the 1974 oil crisis, and the 1980s, the era of Margaret Thatcher, who roundly declared "there is no such thing as society" and made her contempt for the work of social workers and psychiatrists very clear. After the oil crisis Government funds became less available, and new developments were seldom allowed. There was much more talk about control in the NHS, and much less about encouragement and experimentation. Gradually, more negative attitudes emerged and there was a public willingness to dwell on the dangerousness of lunacy, and the media were filled with tales of the dangers from the mentally ill. There were increasing pressures on the NHS, and a tendency to deal with them by having fault-finding enquiries, and a punitive managerial culture which left staff frightened of taking any initiative as they learned that there were few rewards but constant danger of reprimand. The New Labour policy of constantly changing the goals and direction of the Health Service, and frequently reorganising the government of it, has had a negative and paralysing effect. So also has the policy of announcing "targets", which force staff into constant form-filling to produce dubious statistics that appear to indicate that the governments goals are being achieved, but have little relationship to the welfare of the patients
.So, what has happened to the various areas of social psychiatry initiative that I mentioned earlier? Some have flourished, some have withered away. We hear little these days about mental hospital reform and change. This is partly because so much work has been done. In 1950 we had tens of thousands of people held in custodial hospitals. Nearly all of them have been rehabilitated. Many of the old mental hospitals have been pulled down and cleared away. The total number of people in psychiatric care is much less and the total number in long term care is very much less. Our society has learned a better way of dealing with people suffering from long term mental disorder than locking them up in custodial, stultifying institutions. Rehabilitation has continued to be a major thrust of the psychiatric services, particularly in the community; and the provisions of sheltered workshops, sheltered housing, supported housing, half-way houses, etc. have continued to grow and develop and many of these give support to those in need. The therapeutic communities in mental hospitals have shrunk in number and there are few left now. Although they were successful in the long-term wards of the old institutions, the method proved unacceptable in most admission wards. The therapeutic community method has been widely developed in probation hostels, rehabilitation units and approved schools, so there remains a lively Association of Therapeutic Communities. In recent years this work has been developed further, by the enthusiasm of the Prison Service to apply therapeutic community methods, and they have set up new therapeutic communities throughout the prison service in England.
Group analysis has continued to grow steadily and group methods are widely used in psychotherapy and even more in growth areas outside formal psychiatry. Some of the group methods that began in psychiatry have become almost standard practice, and any managerial training, any professional learning gathering will have occasions for interest groups, focus groups, experiential groups, etc; and has now become an accepted part of our communal life.
One area where psychiatric practice has sadly slipped back has been in the admission wards. As a result of changing public attitudes they are forced to accept more and more patients, more disturbed, and many under legal detention. They are then pressured to hold them securely, so most admission wards are now locked, with the staff spending much of their time checking patients and counting them. The wards are now violent and frightening - almost as disturbing as the bad old observation wards of 50 years ago. Nursing staff numbers are fewer and they are often demoralised, so that any attempt to listen to or help the patient psychotherapeutically gets lost. The response of the managers to the recurrent crises is to hold inquiries, to find fault, and to issue more and more regulations to tighten up controls. Most doctors now confine themselves to the diagnosis of symptoms and the prescription of medication, and do not take much part in the planning or running of the ward. This situation has, in 2006, become an open scandal and it seems possible that in the years to come the principles of social therapy will once again be rediscovered, and we may move back to some of the great gains we made in the admission wards of the 1950s and 1970s. But this is a sad and demoralising time for those who work in these overcrowded and brutalised units.
So, what conclusions and reflections have I reached at the half a century of experience in psychiatry, and the applications of the principles of social psychiatry, since I learned to see an individual and his behaviour as an expression not so much of a disease inside him as of a disorder around him, in him and in others, which produce a crisis which leads him to his entering a psychiatric unit?
First, there is the great improvement in the care of the long-term mentally disordered. No longer are hundreds of thousands of citizens locked up for 20 or 30 years of their lives in the wards of impoverished institutions. Many of the old asylums have been pulled down and their sites sold off. The psychotically impaired people now live in half-way houses, in community homes, and attend sheltered workshops and other rehabilitation facilities. These services vary in different parts of the country, and often fail in the large cities, but everyone is aware of the need for them and it seems reasonable to suppose that we will not again slide into locking up tens of thousands of people for many years.
Group therapy continues to be practised in many ways, and group analysis continues to flourish modestly as one of the effective branches of psychotherapy which is now a major part of the mental health field. Although formal psychoanalysis is less practised, psychotherapy, cognitive behaviour therapy, and counselling are rendering support and help to many people outside of institutions.
The therapeutic communities, having started in psychiatric hospitals, are now no longer to be found in them, but the method continues to be explored in prisons, probation hostels, in approved schools. It is hard and difficult work, and not many people can maintain it for years, but it remains a promising form of therapy.
Other parts of psychiatry have moved backward. There are more and more secure units locked up and holding people for many years at a time, although the number of people is still not as large as it used to be in the old days. Many psychiatric units have moved to more security and an obsession with "avoiding incidents" which leads to a repressive and stultifying regime; although, again, few are as absurd as the anti-suicidal precautions of the old asylums. The most unfortunate has been the change in admission ward practice, from an exciting and humane development in the 50s and 60s which produced admission wards where people were able to explore their difficulties in a therapeutic and supportive environment. We have slid back to conditions resembling those of the late 1940s. It is to be hoped that this may change.
Why have these changes come about? There are many reasons why the practice of psychiatry has changed. In the 1950s there were hardly any effective psychiatric drugs - now there are a wide range of powerful drugs, and young psychiatrists find it only too easy to operate entirely in the medical model, seeing themselves as doctors whose only task is to make the correct diagnosis and prescribe the right drugs. Of course there are still sensitive and concerned doctors who want to spend time listening to patients and helping them with their difficulties; but these days they are fewer than they used to be. Nursing training has changed, and the old pattern of psychiatric nursing training has largely disappeared. The new training does not prepare young student nurses very well for the tremendous challenges of working with and listening to the mentally disordered. The reorganisation of the NHS and the pressure on managers to avoid incidents has often proved repressive and regressive to the life of the psychiatric wards.
However, I feel that the basic cause for the changes that I have seen are related to those of society as a whole. In the 1950s there was a desire to build a better society in Britain, to make things freer and kinder and more humane. The Mental Health Act of 1959 embodied these attitudes, and the development of the therapeutic admission wards in the 1960s was one of the results of this. For 20 years there was substantial money available for the improvement of life in the mental hospitals and many talented and sympathetic people went into the mental health services as young psychiatrists, as nurses, as social workers, as occupational therapists. Since the 1970s we have moved into a different world, a world that feels more dangerous, more frightening, and is undoubtedly more repressive. Our society is deeply concerned about security, of prevention of violence, so that we see police armoured and armed against any kind of disturbance, and the acutely mentally disordered an easy focus for them. The media, too, express our anxiety by constantly telling stories of the dangers presented by the mentally ill, and clamouring for more security and less freedom in the hospitals.
In travelling round the world I came to the conclusion that societies get the psychiatric hospitals they deserve. A tolerant, open-minded society will develop humane psychiatric institutions; a repressive, frightened, angry society will produce locked, violent, frightening hospitals. If we have a different vision, we can only work within the limits our society will let us have; but still there is plenty of scope to modify and ameliorate the conditions, and still try to help those who come to seek our assistance in coping with their personal crisis and in making better sense of their lives.
I tell this story of the last 60 years of British Psychiatry from one point of view, that of Social Psychiatry. I am, of course, aware that the story can be told quite differently. It can be told as an account of the rise and fall of the physical treatments - electroplexy, leucotomy, etc. It can be told as the story of the rise and rise of pharmacological treatments - the tranquillisers, the anti-depressants, the "new tranquillisers" - and the domination that these new, complex, sophisticated drugs have had on the learning and attitudes of young psychiatrists. It can even be seen as a history of the great NHS experiment, particularly in the psychiatric institutions. The exciting years of the 50s and 60s, where modest funds produced a surge of refurbishing and rebuilding new admission wards, and the development of humane psychiatry, were followed by the lean years after the oil crisis, when less and less money was available, so that buildings were sold off, services contracted, and conditions allowed to deteriorate until we reach the present state of parlous admission ward psychiatry. All these are legitimate views of some of the processes that I have taken part in, and been shaped by; but for the purpose of this talk I concentrate on the insights, the practices, the successes and the failures that the social approach in psychiatry has given us.
This is a Planned Environment Therapy Trust Archive and Study Centre On-line Publication.
© David Clark 2006