The Story of a Mental Hospital: Fulbourn, 1858-1987
by David H.Clark
| Contents | Foreword | Preface | Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Postscript | Acknowledgements | References | Index |
6 Social Therapy
My year in America had clarified my thinking about Fulbourn Hospital and helped me plan goals for the coming years. As I settled back into life in England in 1963 I began to see that there were various priorities. First, we had to reorganise the administrative structure of the hospital to meet the needs of the patients better. This would entail integrating the male and female divisions of the nursing service, bringing Consultants more closely in touch with wards, promoting new forms of occupation and providing patients with the material means for a better life – money, lockers, privacy and personal clothing. Second, there was the need to develop new social structures to allow patients more control over their lives. This meant encouraging self-government of various kinds, especially extending the practice of therapeutic communities. Third, we needed to develop more Transitional Facilities to ease the painful process of rehabilitation for long-term patients – sheltered workshops, halfway houses, group homes and so on. Fourthly there was the important task of recording, studying, analysing, and reporting what we were doing at Fulbourn so that we could manage ourselves better – as well as share what we had discovered with others.
My year abroad had also been an important turning point for me personally. For nine years I had thrown myself without reservation into the job of Superintendent. This task had entailed getting to know a despondent and demoralised institution and helping it to find new goals. I had led it through exciting changes until it had become a high-quality mental hospital, doing pioneering work and with a good reputation. During my year away, I learnt about sociology, reflected on the work I had done, wrote my book and tried out my ideas on lively and advanced thinkers. As a result I began to see the hospital, myself, and my professional future differently; perhaps there were other things I could do beyond Fulbourn.
My absence was also a turning point for Fulbourn Hospital – though they missed me, they had managed very well. They realised that it was true, as I had often told them, that their work and their advancement did not depend on one person alone; that many other people had valuable ideas and the initiative to drive them through. Oliver Hodgson had acted as Medical Superintendent – and done it very well. Bernard Zeitlyn had been Chairman of the Consultants’ Committee and managed their meetings with charm and droll humour. A locum, Norman Todd had looked after my admission ward patients, and Eddie Oram had sustained Winston House. All had done well – or at least quite as well as when I was there.
The nursing officers, Miss Brock and Mr Long were now working well together, and within a week of my return in 1963 I was invited to lunch in Miss Brock’s dining room with Mr Long and Oliver Hodgson to discuss how we should plan the operation in 1964 of Kent House, the new admission unit. These lunches soon became a permanent feature; every Thursday Oliver, Jack Long and I would eat a lunch with Miss Brock and discuss the ongoing problems of the hospital. We continued to do this over the next three years until Miss Brock retired in 1966.
One of the things I tackled soon after my return was the division of Consultant responsibility between myself, Oliver Hodgson and Leslie Buttle. We agreed that we would each have a functional unit of wards both male and female. I took on all the deeply disturbed patients, male and female, in what I called the ‘Intensive Nursing Unit’. Oliver Hodgson took on all the wards of active and recovering patients into what we called the ‘Rehabilitation Unit’, and we persuaded Leslie Buttle to accept responsibility for the two sick wards and several wards full of elderly patients as a ‘Geriatric Unit’.
My new ‘Intensive Nursing Unit’ had seven wards, three male and four female. These were the wards for the very regressed patients (formerly incontinent but now busily engaged in simple work) and the wards for long-stay, quiet people. However, the most interesting to me were the two former ‘disturbed’ wards, once Female 5 and Male 5, now Hillview and James Wards. The community meetings had continued in Hillview in my absence and things were not so stormy as they had been in early 1962. James Ward, under Joe Pattemore and later Tom Lewis, had also developed its own pattern of ward meetings; they were very formal – with a chairman and rules of debate – but had been effective in opening up the rules of the ward and involving everyone in projects and planning. I now proposed that these two wards should move into the old Admission Villas (Sunnydale and Westerlands) when the long-planned new admission unit – Kent House – opened in 1964. This was a bold move, for it meant bringing the most disturbed and disturbing people out of their wards deep in the main building and putting them in one of the most public parts of the hospital. My nurses were keen, but many other staff felt uncertain and hesitant about the move. However, in the end this worked very well and was a great and permanent success; developing the therapeutic communities of Hereward House, Westerlands and Burnet House became for me the source of my most exciting experiments.
After my return I felt I had resumed work which was following a pleasant and promising pattern. But in one area there was a major change. Soon after I had gone to California in the autumn of 1962, Alderman Mallett had to resign the Chairmanship because of increasing illness and Sir Henry Willinck, QC, Master of Magdalene College and a former Minister of Health, was appointed Chairman. In the summer of 1963, just before I got back, Mr Mitchell, the Group Secretary retired – after 43 years’ service in the hospital. His place was taken by a pleasant, able man, Mr Alan Young. The arrival of these two men caused a major shift in my relationship with the hospital administration. Although Sir Henry was always perfectly courteous to me, his many years in Whitehall had accustomed him to accepting the advice of his Civil Servants and listening to the warnings of Finance Officers. Mr Young, too, as Chief Officer, expected to take the initiative in running the hospital. There was no longer any place – or for that matter, any need – for me to take the lead in non-medical matters as I had done in my first nine years. Several times Mr Young warned me off his patch and gradually I came to see that the laying out of the cricket fields, or the management of the coal stocks, was indeed none of my business. I had slipped into leadership in such matters in my early years because of the passivity of earlier officers, especially Charles Mitchell – who learned under the old Visitors Committee in the thirties to avoid taking any initiative or responsibility whenever he could.
However, I had plenty of other things to concentrate on. The main focus of everyone’s attention at this time was the new admission unit, Kent House, soon to open. The planning, designing, building and operating of this new unit occupied a great deal of my time over several years. In the 1950s Fulbourn Hospital had been the most overcrowded mental hospital in East Anglia, so the Regional Board had proposed that an entirely new admission unit should be built. The Ministry of health granted permission in 1958 and we had started planning. I had been sent off to visit recently-built units. An enterprising young architect had been appointed and started producing working plans.
I insisted that the new building should be structured like a resort hotel, rather than a general hospital unit; that there should be wide spaces for daytime activity – a central dining room that could be made into a concert hall, billiard rooms, craft rooms, lounges. I wanted male and female patients to be able to mix by day (a revolutionary proposal in the 1960s), but agreed that there should be separate dormitories and wards at night for men and women. These would consist of an admission ward downstairs and a ‘convalescent ward’ upstairs, one for each sex. My colleagues, concerned as ever about individual (rather than social) treatments, insisted on the inclusion of a special unit for ECT that could serve both inpatients and outpatients. A range of Consultants’ offices were also provided.
The plans were of course argued about, changed and modified but we had finally settled for a 95-bed unit. Building work began in 1961. When I went off to California in September 1962 the first stage had started; colours and fabrics were being chosen and furniture ordered. When I came back in September 1963 we were almost ready to begin to use the new building. New staff for the unit and for the four wards were appointed. After the 1963 Christmas celebrations the first patients were admitted to Kent House in January 1964.
The new unit was a delight and a revelation with its wide spacious corridors and large public areas. Everyone was pleased, especially the patients and their relatives. Many people from Cambridge came to visit it, as well as official visitors from all over the country. This admission unit was a notable first for the East Anglian Regional Hospital Board and they decided to make the most of it by making a bid for a Royal Opening. Fulbourn was of course only a mental hospital, so we could not have the Queen, but they succeeded in getting the Duchess of Kent, the charming and fascinating Greek-born Princess Marina; the fact that she had been a nurse and was the patron of the National Association for Mental Health (of which Lady Adrian was Vice-Chairman), of course helped greatly. There were endless discussions and meetings to arrange the great day. Protocol officers came down from London and instructed us on the proper etiquette. Officials we had never heard of before – such as the Lord Lieutenant of the County, the High Sheriff of the County and the Ministry’s Adviser on Protocol (a Major General) came bustling along to see if we were presentable.
The Opening Day, 6 May 1964, finally arrived and was a great success. The Princess arrived in a Royal Helicopter which landed on the playing field at the front of the hospital to the amazement of the patients. Speeches were made and bouquets presented. All the great and good were there – the Lord Lieutenant in uniform and a cocked hat with plumes, the Mayors of five local towns wearing their robes and chains, the High Sheriff in breeches and garters, the Bishop in purple. Miss Brock was delighted to escort a Princess around her own new hospital; this was the peak of her professional career. The Princess herself was a charming, interested, intelligent woman, asking probing and informed questions about our work, and insisting on meeting and talking at length to long-serving members of the staff. It was a notable day for Fulbourn.
Other building was going on in the early 1960s. During the 1950s the Regional Board decided to make hospital provision in Cambridge for the local mentally handicapped (who, since 1948, had had to go to Norwich). They opted to build on the hospital land behind Fulbourn Hospital toward Fulbourn Village and they called on our Hospital Management Committee to run the new hospital. The work began in 1963, and the first patients were admitted in 1965. The unit was named ‘The Ida Darwin Hospital’ after the famous Cambridge woman philanthropist who did so much for the mentally handicapped before the First World War. They appointed as Medical Superintendent Gwyn Roberts, a talented paediatrician who became an excellent colleague and a good friend to me over the next 15 years. The HMC was kept very busy with matters concerning the new buildings, including an Official Opening by the Health Minister of the day, Sir Keith Joseph. However, the development of Ida Darwin had little impact on the lives of the Fulbourn patients.
During the two years 1965 and 1966 we made one of the most important changes in the traditional organisation of the hospital – we united the male and female nursing services. This made possible many of the most notable achievements of Social Therapy over the next 20 years. But it did not happen without a lot of discussion and quite a lot of pain for some of the staff.
In Fulbourn Hospital in 1953, as in most traditional asylums, male and female staff and patients were kept absolutely separate – and a great deal of managerial energy went into keeping them so. The Matron ran the female side; the Chief Male Nurse ran the male side; their territories were clearly defined and separate. Neither went into the other’s territory, nor did their staff. The male wards were staffed by male nurses, female wards by female nurses. This had always been so since the opening of the Asylum in 1858 and anything else was unthinkable. The only people who went freely into both sides of the hospital were the Chaplain and the Medical Superintendent. Even the Assistant Medical officers usually had their work confined to one side or the other. The patients were strictly segregated, and attempts to communicate with the other sex were severely punished.
I had always found this rigid separation rather absurd. I had worked in units and hospitals where male and female nurses worked side by side on wards. I had also visited units where male and female patients mixed in their activities. But, on my arrival at Fulbourn it was clear that there was nothing to be done about it especially since Miss Brock, the Matron, only recently in charge, and Mr Tucker, the Chief Male Nurse, in post since 1933, disliked and distrusted one another. I had to wait my time. As hospital meetings proliferated, Miss Brock and Mr Tucker were obliged to work together rather more than before; they were both at my morning meetings with the doctors and my Hospital Officers’ meetings. As we increased patient freedom and began to open wards, patients began to meet each other more frequently in the grounds and one ward even gave parties for visitors of the other sex.
The first major break, however, came when Mr Tucker retired in 1957 and Jack Long was appointed Chief Male Nurse. He had run a mixed unit at Netherne Hospital and knew that not only could male and female nurses work comfortably together, but also that men and women patients could safely be mixed. He was an open, friendly man and soon got on well with Miss Brock.
Kent House, the new admission unit, was in use from 1964. In designing it I had done all I could to break down the barriers between the sexes. Although there were two male wards and two female wards all the daytime areas were used in common, as was the dining room. Very soon most of the patients were mixing freely all through the day, and the new younger nursing staff were working cooperatively together.
The idea of men and women nurses working together gradually became more acceptable. In 1965 Miss Brock advertised a vacancy for an Assistant Matron. As there were very few suitable women applicants, Maurice Fenn, the highly regarded Charge Nurse of one of the admission wards in Kent House, applied and was appointed.
Once the Royal Opening of Kent House was over, Miss Brock began to talk of retirement. She would soon be 55; she had earned her full pension and could go; she had always said she would go at 55. But, not unnaturally, as the time approached she began to have doubts. Fulbourn Hospital was her home; she had lived in it for over 25 years, since her arrival as a bright energetic nursing tutor just before the war. She had been Miss Fossey’s deputy and succeeded her in 1952. She lived in the Matron’s flat in the centre of the hospital, served by a group of maids and long-stay patients; this was her whole life.
Finally, however, she decided to go, and I persuaded the Hospital Management Committee to appoint a Chief Nursing Officer in charge of all the nurses, male and female. There were several good candidates, but Mr Long was clearly the best and was appointed. Miss Legge, Miss Brock’s deputy and close friend, was appointed Deputy Chief Nursing Officer and the Assistant Matron and Assistant Chief Male Nurses became ‘Nursing Officers’. We gave Miss Brock a magnificent send-off party which filled the Recreation Hall and included a presentation by the Chairman of the Management Committee.
Mr Long, very wisely, proceeded slowly and made no immediate attempt to change things, although there was at first great trepidation amongst the women nurses. Then in 1966 came an opportunity. We had been working in Kent House for two years; at first it had all been novel and exciting but gradually complaints had increased. We were trying to do our admission work in several different wards. Each ward had its own Charge Nurse and team of nurses, but patients were moved as necessary, so that a Consultant seeking a particular patient might find the person on any one of five wards. ‘Ward Rounds’ became almost impossible as doctors and nurses spent most of their time trying to find patients. Equally the patients and nurses complained that they never saw the doctors. We could not go on this way. It was clearly more than just a problem of medical organisation as it involved nursing administration and the whole physical layout of the admission units.
We decided to set up a multi-disciplinary working party to look into the problem under Ross Mitchell who had just joined us. A radical solution was recommended – creating three mixed-sex self-contained admission units with their own nursing and medical teams based on Street, Friends and Adrian Wards. Each team would centre on a Charge Nurse and a Senior Registrar. Two Consultants would admit to each unit and would be able to see their own patients on their own ward. After much discussion we adopted this plan and it was a great success. Quite a lot of construction work had to be done over the next years on Adrian to upgrade its facilities but Friends and Street were able to adapt quite easily to the new pattern from the start.
These units quickly developed their own cultures and their own ways of operating. The Senior Registrars soon emerged as powerful leaders, developing new ideas of their own. The wards started holding ward meetings and in due course therapeutic community practice developed on Friends Ward in 1971 and Street Ward in 1978. For me this reorganisation made a further change. I no longer had occasion regularly to visit either Street or Adrian. Instead of vague oversight over the whole hospital I now had much stronger and closer bonds with a few specific parts – those where I was the Responsible Medical Officer for most of the patients.
In 1966 both Leslie Buttle and Christopher Scott, the psychotherapist at Addenbrooke’s, retired and we made two excellent new Consultant appointments – Ross Mitchell at Fulbourn and Malcolm Heron at Addenbrooke’s. Both men were to make major contributions to Fulbourn Hospital in the coming years. Products of postwar psychiatry, both were deeply committed to a social view of work with the mentally ill.
Ross Mitchell had learned his psychiatry in the Army, where he had become aware of the importance of social factors in contributing to mental health. A vigorous Scot of great energy and infectious enthusiasm, he threw himself into many projects. He took over Leslie Buttle’s outpatient clinics in the Fens and soon began working closely with local general practitioners and the Mental Welfare Officers to take psychiatry out into the Fen countryside and into patients’ homes. He took over the quiet, long-stay wards and began an active rehabilitation programme. One of the units he took over was a ‘workers’ hostel’ which we had developed in the former Occupational Therapy building. We had used it to house men who were going out to work in Cambridge. Ross encouraged the staff to extend its functions, first offering lunches to patients out on leave in Cambridge and then developing a formal Day Centre. He brought in the Disablement Resettlement Officers of the Ministry of Labour and began moving patients out of hospital.
Malcolm Heron was appointed as psychotherapist to the Outpatient Department of Addenbrooke’s, but he took a keen interest in what was going on at Fulbourn Hospital. Malcolm had worked in the therapeutic communities at Claybury and was fully committed to group and social therapy. He went to a number of ward meetings, and then began to attend the doctors’ meetings in my office. At first he observed and said little, but then began to comment on process. He pointed out how the setting (my office) inhibited the group, so we moved the meeting to a seminar room downstairs. Gradually the meeting became a sensitivity group for the medical staff. The discussion became less structured and more spontaneous, with Malcolm offering facilitative interpretations on the group process. We stopped bringing administrative problems to it, and Mr Long, now Chief Nursing Officer, stopped attending. When the Postgraduate Medical Centre was opened in 1970 we moved there. This ‘doctors’ meeting’ was held every Friday morning from 9.00 until 10.30 a.m. and became a key part of the programme of social therapy of Fulbourn Hospital.
By the early 1970s the notion of ‘Social Therapy’ was becoming clearer in my mind and was also beginning to be discussed in the hospital. Concepts of how the asylum should run and what should be its guiding principles had only occasionally surfaced in the first century of Fulbourn’s history. Dr Bryan, the unfortunate Dr Lawrence and Dr Bacon all had clear ideas on the management of an asylum. They had lived through the great years of medical and public debate on this subject in the first half of the nineteenth century. They knew of John Conolly’s ‘No Restraint’ System; W.A.F. Browne, the author of What Asylums Were, Are, and Ought to Be was still dominating Scots psychiatry (Browne, 1837); the notions of ‘Moral Treatment’ put forward by Tuke, Pinel and Equirol were still dominating principles. They knew that the way the asylum was run, the pattern of patients’ work and play, rewards and punishments, were the most valuable form of treatment that they had. They spoke with enthusiasm of the cures they had achieved.
During the long reign of Dr Rodgers and Mr Thorne (1883–1910) these ideas were gradually forgotten in a climate of Social Darwinism and ever-increasing legal controls. Quite different ideas were clearly stated by the irascible Dr Thompson (1910–17) who told the Visitors that the prime purpose of the asylum was to prevent lunatics breeding so as to check further spread of moral degeneracy. He did not speak of cures, but only of reduced costs.
Dr Archdale (1917–23) set out clear ideas about the treatment a hospital should provide but his was a very different and very medical view. Patients were to be isolated from the noxious influences of their homes; they were to spend at least a month in bed after admission; indeed, some spent many years in bed. There were experiments with better individual treatment for patients – outpatient clinics, social work home visits – but not much work on the general life of the asylum, especially the long-stay people. In the long inter-war regime of Dr Travers Jones and Dr Thomas (1922–53) little was said about the way the asylum was run. Everyone knew how mental hospitals should be – custodial but humane – an enclosed world where nothing changed from generation to generation, where long-stay patients and staff grew old together watching cricket, enjoying social events such as balls and dances and regarding innovations with distaste.
I had few preconceived notions when I came to Fulbourn in 1953, except for a deep distaste for the brutality I had seen inflicted on patients in other hospitals, a conviction that the life of the long-stay patients did not need to be so degraded, and a notion that the ideas of consultation and group discussion which Montgomery had taught us during the war might be appropriate to the running of a psychiatric hospital. I had a strong personal commitment to what was later known as open government, free communication and decision-making by consensus.
The five years 1953–58 saw Fulbourn Hospital change from a locked hospital of very low morale to an Open Door hospital of high morale and good spirits. In our campaign of changing the hospital we had developed certain themes and slogans. The first was ‘Work for All’; the next was ‘Open Doors’; and later there emerged the slogan ‘Freedom, Activity, Responsibility’. These latter three were what we aimed to provide for our patients. I had been gratified at what we had achieved but also puzzled because I knew I had not achieved it alone. As I began to ponder exactly what it was that I had contributed I developed the idea of ‘Administrative Therapy’ – that is the use of the administrative structure to produce social changes that would not only make the hospital pleasant, but actually help the patients towards recovery and departure from hospital. I studied the sociological publications that were becoming available on the life of mental hospitals and tried to apply some of their lessons.
At first I looked at the actual tasks which I was performing as Superintendent. Although I did some clinical work and even psychotherapy with individual patients, most of my effort was going into working with the staff, creating a secure environment for them by efficient, just and comprehensible administration. I attempted to refocus their idealism and altruism and create an atmosphere of change, experiment and hope. I came to see this as my most important task and called it ‘Administrative Therapy’. In the late 1950s I gave lectures with this title and changed my views as a result of various comments I received. I published articles on ‘Administrative Therapy’ in 1958 and 1959 and spent my year at the Center at Palo Alto writing a book with that title aimed primarily at psychiatrists. It aroused modest interest and sold well.
I chose the title of my book to demonstrate a paradox I discovered that in the USA young psychiatrists viewed their future as a choice between ‘administration’, a shabby job dealing with shady politicians, corrupt building contractors and venal Trade Unions, and ‘therapy’ – a highly esteemed, well-paid occupation dealing with the troubles of the affluent middle classes. Administration was shabby and low class; therapy was prestigious and well paid. In my book I tried to suggest that it might be better to devote oneself to helping the suffering poor than indulging the worried rich, but more important, that it was possible to use an administrative position to give effective therapy to the inmates of a hospital.
In 1970 I was commissioned by Penguin Books to expound these ideas again in a small paperback for nurses, social workers, occupational therapists and patients. As I worked on it I realised how much my ideas had moved on since I had first lectured on ‘administrative therapy’. I now adopted a different phrase – ‘social therapy’ – to cover all that we were doing to help patients progress. This term included activities such as carpentry workshops, plays and pantomimes, halfway houses, therapeutic communities, rehabilitation clinics and so on – everything that used social structures to help patients. It also included the ideas emerging from our therapeutic communities. These were that everyone in the hospital, but especially the patients, had valuable contributions to make, and that while communications, authority and power patterns were an essential part of the treatment process, they must be constantly reviewed, surveyed and changed. The book finally emerged in 1974 as a Pelican paperback entitled Social Therapy in Psychiatry (Clark, 1964) and was priced cheaply enough for anyone to afford it. Widely-read and translated into seven languages, this little book brought many visitors to the hospital and also a number of recruits to the staff.
I continued to reflect on these ideas, to modify them in the light of criticism and adapt them to changing circumstances, especially the development of therapeutic communities as alternative environments for patients. After the Penguin book went out of print, Churchill Livingston took the book on and published a second edition in 1982 (Clark, 1982), two years before I retired. Much of what appears in this tale is covered in those books. Many of the illustrations were taken from experiences at Fulbourn and many of the methods described were tried out there. Two major themes are relevant to this story.
First was my realisation that when people were held for years in an institution, the forces that changed them, for better or worse, were social rather than medical. It was the environment, its messages of fear, or hope, or recovery, rather than the pills they were given which determined how they recovered. From this followed the realisation that a doctor who wanted to help long-term patients would achieve little if he spent his time just talking to them and giving them pills. Rather, he must concern himself with the morale and function of the ward; he must work with the staff and their anxieties, fears and tensions. He must press for worthwhile work, freedom and responsibility for both patients and staff. Such a creative administrative action was far more valuable to the patient than clever diagnostics.
Later came the realisation that everyone in the organisation, especially the junior staff and the other patients, had to be involved in the process of helping a patient understand and change the way he had been running and ruining his life. Social analysis was one of the most valuable and important therapies a psychiatrist could deploy.
It was these insights which I continued to operate, propound and share as long as I worked at Fulbourn. Many heard them, especially the nurses and even a number of doctors. But many doctors continued to regard these ideas of mine as irrelevant and devoted their attention to abstruse diagnostics and complex pharmacotherapy.
Of the changes that occurred at Fulbourn Hospital in the sixties and seventies, the development of Therapeutic Communities was the most radical. For some people these changes were exciting, for others they were difficult and controversial.
The phrase ‘Therapeutic Community’ was coined by Main in 1946 to describe what had developed in an army psychiatric hospital, Northfield, near Birmingham in the later years of the war. A group of young Army psychiatrists led by senior psychoanalysts were working with demoralised soldiers awaiting psychiatric discharge from the Army. These psychiatrists developed a pattern of group and social treatments which transformed the hospital and helped the patients far more than the traditional pattern of individual treatment by medical officers. Several important discoveries emerged – that the soldiers learned more from each other than they did from doctors; that being allowed to take responsibility for the running of their lives within the hospital hastened recovery from their state of demoralisation, despair and helplessness (induced by their psychiatric ‘boarding’ from the Army); that taking part in a skilled group activity, such as a football team or a hospital band, was not only pleasurable but also therapeutic.
The concept of the Therapeutic Community was further developed in the 1950s by Maxwell Jones at Belmont Hospital at the Social Rehabilitation Unit (later the Henderson Hospital). This special unit took patients with long-term social relationship problems. Many were originally referred from the Ministry of Labour because of their inability to keep jobs. Most had been labelled by psychiatrists as ‘psychopaths’ – people who showed irrational, irritating, disturbing and self-defeating behaviour, but who, on psychiatric examination, showed no obvious mental disorder. Maxwell Jones tried many forms of treatment at Belmont before gradually developing a way of running this unit which was quite unlike any other psychiatric unit in the country. This new method was the ‘Therapeutic Community’ which became the model for experiments all over Britain, the USA and Europe during the 1960s and 1970s.
At Belmont there were no distinctions between people – staff and patients, doctors and nurses dressed alike in similar casual clothes and were addressed by their first names. Even the Director was simply known as ‘Max’ by everyone. The focus of the life and work of Belmont was Social Analysis – attempting to understand why a particular incident had occurred or why a person had behaved as they did. A major forum for this was the Community Meeting, held every morning and attended by everyone in the unit – patients, professional staff, domestic help and so on. At this meeting the events of the previous day were reviewed and analysed. These large gatherings of 60 to 80 people were lively and even stormy, with very free interchange and confrontation that spared the feelings of no one. At Belmont there were workshops where carpentry and metalwork were practised – but far more important than the craftwork these provided were the discussions in which the way the workers interacted was examined. Throughout the hospital there were small groups and large groups, staff groups and workshop groups. Always and everywhere people examined, questioned and analysed what they were doing and saying to one another.
It seemed that many people learned more from other patients and from low-ranking staff about how to cope with their behaviour than they did from doctors and specialists. Maxwell Jones said that ‘a therapeutic community is distinctive amongst other comparable treatment centres in the way the institution’s total resources, both staff and patients, are self-consciously pooled in furthering treatment’. Main had earlier said of the Northfield Experiment that it was ‘an attempt to use a hospital not as an organisation run by doctors in the interest of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society. Ideally it has been conceived as a therapeutic setting with a spontaneous and emotionally structured (rather than medically dictated) organisation in which all staff and patients engage.’
Like many who visited Belmont in the 1950s, I found it a fascinating, exhilarating, exciting and disturbing place. There were many visitors – psychiatrists, nurses, social workers and psychologists as well as teachers, writers, artists, lawyers and politicians. Everyone who went to Belmont was stirred and excited; some were infuriated and repelled. Emotions were very much on the surface and a visitor might be vigorously criticised for his pomposity or his assumptions. Not only were there no uniforms but many people at Belmont actually looked scruffy and the rooms were shabby, disorderly and often dirty. It was ‘nothing like a hospital’. However, the results from Belmont were impressive. People with disheartening records of job losses, prison sentences and psychiatric admissions, changed and became effective people, displaying notable talents. They testified vehemently that it was the non-judgemental, egalitarian environment that had allowed them for the first time to see and understand what they were doing to themselves and then to change.
Some professionals were still sceptical and said that Belmont only worked because the patients were psychopaths – the method would not work with mentally disordered people, such as those in ordinary mental hospitals. Some people also felt that Belmont only worked because Maxwell Jones was such a charismatic personality. This he certainly was; charming, brilliant, puckish, mischievous and yet earnest, he drew around himself a talented team from all over the world. Sceptics said that the method would not work in the hands of ordinary doctors and nurses. There were dark rumours of emotional turmoil amongst the Belmont staff – breakdowns, broken marriages, orgies. However Belmont continued to flourish and evolved into Henderson Hospital after Maxwell Jones left in 1959. It continued to take in seemingly impossible people and help some of them to achieve stability.
As I began to think about the challenges and problems of Fulbourn Hospital I wondered how successfully we could use the revolutionary method of Maxwell Jones, with its abolition of rank and distinctions. Would it help our patients and could we stand it? We had taken a first step at Fulbourn in 1958 in Adrian Ward when Eddie Oram and Kay Kinnear transformed it from a sullen dispirited ‘convalescent ward’ into a lively therapeutic community. The rate of departures had risen and the number of readmissions fallen. The atmosphere had improved dramatically. The next Fulbourn attempt at a therapeutic community was my own project in 1960 on Hillview, the women’s disturbed ward. While in California I thought a good deal about therapeutic communities and on my return gave a lecture to the Mental Health Research Fund (Clark, 1964, 1965). Amongst other issues I made the point that the ‘Therapeutic Community Approach’ was fairly easily applied to any psychiatric institution, without unduly upsetting anyone’s position. but that the ‘Therapeutic Community Proper’ (as practised by Maxwell Jones) was a revolutionary change which might be too much for many doctors and nurses. In the sixties and seventies we explored whether we could actually make this revolution at Fulbourn.
Having decided to extend our attempts at using the therapeutic community method in Fulbourn, the greatest challenge and excitement of the years after my return from California was using this approach with the most deeply disturbed patients in the hospital. I had always felt that the deeply disturbed and psychotic people – the violently mad – were the most challenging. Unlike many of my contemporaries, who seemed to be repelled or frightened by the very disturbed, I had always wanted to work with them.
In my early days in psychiatry in the army and at the Royal Edinburgh Hospital, I had voluntarily spent long hours in padded cells or shuttered side rooms attempting to make contact with terrified and terrifying people gripped in severe psychosis. I had physically struggled with wild manics who attacked anyone who came near, with schizophrenics in homicidal fury and with melancholics desperate to kill themselves. I had often involved myself in restraining patients or helping the nurses to put them into strait jackets. This was partly pride in my young strength and wrestling skills, but also a genuine desire to get closer to these people in order to try and understand and help them. At the Maudsley I often spent time on ‘the Villa’ – the isolated unit at the back to which recalcitrant patients were sent before certification and removal to the county asylums.
These attempts of mine to make contact with dangerous patients were not very successful. I was told that this was because ‘their psychoses are intractable’ but I also suspected that it might be because as a doctor I was trespassing on an area which the nurses regarded as their own – particularly if they were using illicit violence. On my first psychiatric unit, in the Army, the orderlies openly boasted of their ability to ‘tame the psychopaths’ sent to them from the Army prison. I began to learn about the savage underlife of hospital psychiatry. In one hospital I was involved in uncovering the activities of an ex-Naval Petty Officer who as Deputy Charge Nurse was routinely beating up patients who caused trouble. I discovered that he believed that it was his duty to maintain discipline. He had a method of punching a man’s belly that was very painful but left no marks to be seen by a doctor. On his ward one patient died after a savage beating by the male nurses. Over the years in other hospitals ‘old hands’ instructed me about ‘towel treatment’ – garrotting a violent man with a wet towel over his nose and mouth until he became unconscious, or ‘sock therapy’ – the use of a bar of soap in a sock as a cosh.
When I first came to Fulbourn I looked for signs of such brutalities; to my relief I could not see much evidence of illicit violence by staff. The two ‘disturbed wards’, M5 and F5, each had two padded cells, which were in fairly constant use. There was tension on M5 and frantic noise on F5; there were always a few bruises to be seen on ‘difficult’ patients, but nothing worse. As Superintendent I was always closely watched and chaperoned by the staff, so that it was seldom that I could probe deeply. However, there did not seem to be clear evidence of systematic brutality – and I had so much else to do in getting the whole hospital into a better shape that I did not spend too much time probing violent incidents. As we opened the ward doors through the hospital, the general atmosphere of tension in the hospital dropped. When we opened the doors of M5 in 1957, the tension there dropped dramatically.
Having realised in California that I had put too much of myself into running the hospital (laying out sports fields, for example) and not enough into working directly with the ward staff and the patients, I came back determined to make this a higher priority. At that time (1963) nobody in England, as far as I knew, was trying the therapeutic community approach with the most deeply disturbed.
When we rearranged Consultant Responsibilities for long-stay wards in October 1963 I took on both the disturbed wards F5 (Hillview) and M5 (James) and became the Responsible Medical Officer for all the most difficult patients in the hospital. I gave more of my time to the two disturbed wards. Every Thursday morning I attended the community meeting in Hillview, followed by the staff meeting. I also began going regularly to James Ward and often attended their rather formal ward meetings.
In 1964, we moved the disturbed patients and staff from the main building into the former Admission Villas, Sunnydale (for men) and Westerlands (for women). This brought them from the back of the hospital to the front, and was, I felt, a sign of our intention to improve their lot. I got more and better staff for them – trained nurses, occupational therapists and social workers. By now the women’s disturbed ward was being led by Ruby Mungovan and had several ward meetings each week. The male disturbed ward under Norman Harwin had been operating ward meetings for some years; they were rather structured, with a chairman, rule books, and formal debates. I persuaded the staff to change to a pattern of more open, less structured community meetings. Now that these two wards were in more attractive surroundings and nearer the front of the hospital, other hospital staff became more willing to visit and work in them. Occupational therapists, social workers and psychologists began to visit and to join the ward teams – and come into the ward meetings. The two wards began to work together and joint staff conferences developed. The idea of combining their work began to be discussed.
In 1966, after the appointment of Mr Long as Chief Nursing Officer for all the nurses, and the integration of the separate male and female nursing services, the idea of combining Westerlands and Sunnydale was raised. We held joint staff meetings and then joint community meetings. Gradually enthusiasm rose and we began to look at the logistical problems – living space, dormitories, meeting rooms, and we saw that integration was possible. The debate however went on and on. Then one weekend the nurses and patients decided that there had been enough debate and reorganised the wards themselves. I came in on the Monday morning to find that it had all been done. We decided to name the new unit Hereward House, in memory of the local hero of the eleventh-century Saxon resistance to the Norman Conquest.
For the next five years, 1966–71, Hereward House was the centre of my therapeutic community work in Fulbourn Hospital. There were daily community meetings of all the patients, some 60 men and women, and all the staff. As Consultant in charge and Responsible Medical Officer for every patient, I always attended the ward meeting on Thursdays – as well as often being in the ward at other times. In the meetings the activities and the problems of these distressed, disturbed and disturbing people were discussed, probed and analysed. The staff team in Hereward House attracted some of the brightest and liveliest people working in the hospital, and many interested people from Cambridge came to visit us – research workers, students and others in those stirring turbulent times of the late 1960s. The leader of the team was Ruby Mungovan, a talented imaginative woman who had begun in psychiatric nursing in a former LCC asylum. She never forgot that grim, brutal, custodial background as we developed a new way of responding to deeply disturbed people (Mungovan, 1968). Her deputy was John Wise, another who had known the bad old ways and was keen to try new and better methods. The rest of the hospital became more willing to refer people to us and many recently admitted people were transferred to Hereward House from the admission wards. Nowhere in Britain had anyone attempted to gather in one open-door, mixed-sex therapeutic community all the most disturbed patients from an ordinary mental hospital; reporters, film makers and professional colleagues came to see what we were doing. For many of the patients, long trapped in rigidly controlled back wards, it was greatly liberating to be in charge of their own lives and to be able to participate in making decisions about the running of their wards. For many staff, too, challenging charge nurses, doctors and consultants and helping to decide policy was very exciting. A succession of bright Registrars worked with me for a year at a time as we eagerly explored new patterns of working together.
Working in this way was hard and frightening at times. Many of the patients had been violent, some seriously so. Some had been through the courts and in prison. A few had been in Broadmoor; a few had committed homicide. Violence lay near the surface; challenges and even fights were not uncommon – but these were examined at length at the next community meeting. Rumours ran round the rest of Fulbourn telling of filth, disorganisation, violence, subversion and sexual orgies going on in Hereward House. The forbearance of the nursing officers and the administrators was sorely tried. However the administrators, who had lived and worked long years in the hospital, saw patients whom they had known as crazy troublemakers change and become pleasant, cooperative and cheerful people. They could see the method was working.
The striking thing about Hereward House was how many of the very turbulent people made remarkable recoveries. One of the doctors, Kenneth Myers, after training as a Registrar and Senior Registrar, asked me if he could do a research project on Hereward House. We obtained a grant and over four years carried out a study comparing the results with men transferred into Hereward House against a control group transferred into the disturbed ward at another nearby hospital. The two groups were very similar – long-term patients who had recently become more difficult to manage – and they spent similar lengths of time on the two disturbed wards. The striking difference was that many of the Fulbourn men improved as a result of their stay in Hereward House – and even more remarkable, many were later discharged from hospital. At the other hospital they were just moved back to long-stay wards and remained in hospital. Ken and I published two articles about this study (Clark and Myers, 1970; Myers and Clark, 1972).
However, our very success in dealing with the problems of severely disturbed behaviour in Hereward House by the use of social, therapeutic community methods brought the original experiment gradually to an end. By 1970, the three admission units of Fulbourn Hospital were moving towards becoming therapeutic communities themselves and developing greater skill in managing disturbance, so that fewer people were being transferred to Hereward House. The unit gradually got smaller and in 1971 it was divided into two units. The smaller, in Sunnydale Ward, designated for less disturbed patients ran for another three years, then closed for lack of referrals. The larger, in Westerlands Ward, led by a succession of talented charge nurses continued the work of helping the deeply disturbed all through the 1970s and 1980s. In 1971 it was warmly commended by a Hospital Advisory Service visiting team who said it was ‘psychiatric nursing at its best’. They advised staff in many other psychiatric hospitals to come and see the work. As a result we had a steady stream of visitors. In 1979 the dilapidated building was evacuated for a year and upgraded, and reopened as Burnet House. It still operated as an open door, mixed sex, therapeutic community for deeply disturbed men and women, and in 1982 was the subject of a highly regarded television film The Way Back (BBC TV, 1982).
It was during these years that our relationships with the Secure Hospitals – Broadmoor, Rampton, Moss Side – changed and clarified.
In the 1950s we had little to do with them. Broadmoor was the ultimate custodial asylum; people who committed murder and were found ‘guilty but insane’ were sent there and remained until they died. In the 1960s Broadmoor began to review their long-term quiet patients and if they felt they were harmless, to propose them for transfer to hospitals nearer their homes. Since I was responsible for the long-stay wards, the requests came to me and I began making visits to Broadmoor to assess the proposed patients.
The first Broadmoor transfers did very well with us. Vernon was a bright student at Cambridge University when he had his first schizophrenic breakdown and was admitted to Fulbourn for treatment. He responded well, went out, but then relapsed and had several readmissions. He became convinced that he had a message to give to the world and committed a series of spectacular acts of sacrilege which brought him before the courts, from which he was sent to Broadmoor. He spent several years there and his psychotic state gradually settled. He was then discharged to Fulbourn and sent to Hereward House. A gentle, charming, intelligent man with a wispy, blond beard, he became a leading citizen of Hereward House and a most useful member, helping simpler sufferers to come to terms with their plight. He developed a friendship with a woman he met in hospital and finally moved out to live with her. He took a clerical job and then a post in a government department. Eventually he went overseas to work for an international welfare organisation and did very well. He occasionally came to visit us and spoke of his time in Hereward House as the ‘time I forgot bitterness, learned compassion and learned to work within the system’.
Kasimir was a middle-aged, Eastern European businessman long resident in Britain, who killed his sister-in-law while in a state of paranoid melancholia. He was found guilty and sent to Broadmoor where his condition responded to ECT and substantial tranquilliser medication. After a number of years he was transferred to Fulbourn and to my care. We found him a quiet, pleasant, conforming man. He compared the turmoil of Hereward House unfavourably with the well-ordered life of the pre-discharge wards of Broadmoor, so we moved him to one of our quiet wards where he settled in peaceably. We sent him home to his wife for periods of leave and then discharged him home. He continued to see me as an outpatient and pressed me to cut down his medication. Finally I did so. After two months he felt much better; he was playing chess again, reading the papers, taking an interest in his grandchildren. Then after four months he had an episode of three days of terrifying hallucinations and he begged me to put him back on the tranquillisers again. I did so and he settled back to a quiet home life.
During the 1960s and 1970s pressure on Broadmoor from the courts mounted and they pushed more people for discharge. Some hospitals refused to take them, but we took about a dozen. I would go down to Broadmoor with nurses and a social worker and interview the candidate. We would go into the story and see the family. If all this was satisfactory we would accept the person. Some did very well, passing quickly on to discharge. Others found it more difficult, had relapses, or preferred to stay in hospital.
In 1974 the Hospital Advisory Service was asked to put together an inspection team to advise Broadmoor – and Ruby Mungovan and I were asked to serve on it. It was a strange and disturbing experience. For a month we lived in a hotel in Berkshire and visited Broadmoor daily. We were greeted with suspicion – they refused us keys to the hospital and were very guarded. It gradually became clear that this inspection had been forced on them and was resented. We laboured hard and advised earnestly; they took no notice of our advice and the whole month was a wasted exercise. It was, however, educative for me to experience the culture of Broadmoor at close quarters. It was a paranoid, siege culture, full of hatred, fear and contempt. Determined to resist any suggestions for change, the sturdy male staff in their heavy uniforms took pride in their membership of the Prison Officers’ Association; they despised their ‘patients’, telling with relish stories of the revolting killings some had committed. They were operating in a way reminiscent of the worst of the old asylum regime, counting patients in and out of the wards, strip-searching randomly, checking security constantly. The clash of keys in locks was constant. They took great pride in an electronic checking system which enabled them to determine in a few minutes where every inmate was. They felt themselves hated by the Berkshire people, attacked by tabloid journalists and opportunistic MPs, let down by faint-hearted liberals in the Home Office and misunderstood by society in general and the psychiatric profession in particular. They had nothing but contempt for what we were doing in what they called ‘the county hospitals’ – as one burly oaf put it ‘The Counties – I tell you they’ve gone to pot. They’re just dosshouses for layabouts and skivers these days and the staff are no better. I started in a “county” but I came to Broadmoor because I couldn’t stand their soft way of going on.’ That month in Broadmoor showed me that old asylum culture was still alive and flourishing in at least one English institution and I realised how easily it could come back again. In due course I visited the other secure hospitals. Rampton was even more oppressive – isolated in the Lincolnshire Fens, and without strong medical leadership. The staff had developed a system of ‘control’ of their mostly simple-minded patients that I could sense was brutally oppressive. I was not surprised when its malpractices were exposed on television a few years later.
We continued to go to the secure hospitals to see people whom we might be able to rescue. It was always a risk. Many of them were much less stable than the first people we had taken and I was always afraid that one day we might have an horrendous episode.
By 1970 interest in the therapeutic community method to wards management was widespread through the hospital. The three admission units – Street, Friends and Adrian – had all experimented with it. In 1970 both Street and Friends Ward began with ward meetings and restructuring the authority system on the wards. From 1971 to 1973 on Friends Ward the staff team, led by Junichi Suzuki, Senior Registrar, and Agi Lloyd, Charge Nurse, developed a system of small groups run by junior staff as the main therapeutic instruments on the ward. Patients were encouraged to talk together and to help each other. Staff discussion and confrontations were impassioned and a lively, turbulent, egalitarian culture developed. Many of us enjoyed and welcomed this, though some did not.
Although Street Ward had made some changes in 1970, it was from 1976 to 1980 under the leadership of Geoffrey Pullen, Senior Registrar, and Larry Nicholas, Charge Nurse, that the most striking developments occurred. A strong pattern of interpretation and confrontation developed linked with a very active community follow-up system. This greatly reduced patients’ length of stay in hospital, as well as improving the quality of their recoveries, so that there were always vacancies on Street Ward – unlike in the other two admission units.
In Adrian Ward, which had become a mixed-sex admission unit in 1966, they gave up uniforms, encouraged staff and patients to engage in psychotherapeutic discussions and made the weekly ward meeting the focus of the work. They did not, however, push the restructuring of the staff team as far or challenge established authority as much as in Friends and Street.
The pre-discharge ward of the rehabilitation unit, Mitchell Ward, also used therapeutic community ideas with a lively, independent-minded staff team supporting an increasing number of patients in the community. Their community meetings focussed on the problems of living in the outside community for people who still had residual symptoms of psychosis. The stigma of having been in a mental hospital for years, and the difficulty of finding jobs amidst rising unemployment were discussed, faced and circumvented.
For those of us who went through changing a traditional ward to a therapeutic community, it was one of the most liberating and exciting experiences of our whole professional lives. Although each ward worked out the therapeutic community model differently, all these units had some things in common. Most important was the egalitarian atmosphere. All in the ward were addressed by first names – from regressed patients to Consultants. The uniforms and trappings of rank were discarded; the nurses did not wear uniforms, the doctors gave up white coats. The ward meetings – usually daily – were unlike anything seen before in Fulbourn. Patients and staff sat round discussing the happenings and affairs of the ward as equals. Matters previously held secret or discussed only in selected groups were openly considered – why a certain patient was to be detained, or another discharged; why a nurse was leaving the ward; which doctor would be coming next; the hostility of ‘the Establishment’ to the experiment and the possibility of the ward being closed down. Open criticism of a person’s actions, and exposure of its unconscious roots was encouraged – by both patients and staff. I heard more truths about my failings in those meetings than I had for many years.
Patients no longer suffered the mystification and professional doubletalk to which they had been subjected for years and they began to feel that they might once more gain control of their own lives and destinies. The staff abandoned many of the professional barriers that had so long separated doctors, nurses, occupational therapists, social workers and patients. Although confrontations were sometimes fierce and even bruising, there developed a team spirit and commitment to the work of the units which most of us had never known before.
The work of the therapeutic communities at Fulbourn Hospital aroused interest outside the hospital. Teams from other hospitals engaged in similar experiments. Littlemore Hospital, Oxford, Claybury Hospital, London and Dingleton Hospital, Melrose paid us fraternal visits – out of which, in 1969, the Association of Therapeutic Communities was born. Reporters from the local newspaper, students of sociology from the University and visitors from overseas came to see us and in some cases stayed to become members of the team as volunteers or assistant nurses.
In 1971 a government Hospital Advisory Service team was deeply impressed with the way Westerlands was handling disturbed patients. As they went round Britain afterwards, they advised other hospitals to go and see what Fulbourn was doing. For a year or two there was a stream of teams of visitors – so many that we had to space them throughout the year to avoid disrupting the therapeutic work.
In the early 1970s we at Fulbourn were able to say that out of the 23 wards at Fulbourn Hospital, four – Friends, Street, Westerlands and Mitchell – were functioning fully as therapeutic communities proper and that several others were functioning as modified therapeutic communities.
How the staff dressed had been the subject of much interest throughout the history of Fulbourn. There had been uniforms for staff from the earliest days. When young men and women were recruited as attendants in the nineteenth century they were issued with uniforms and required to wear them at all times, except when on leave – as were, in those Victorian times, Army recruits, footmen, parlourmaids and gamekeepers. These nineteenth-century uniforms can be seen in photos of the time – long skirts, aprons and bonnets for the women, like parlourmaids, short serge jackets buttoning to the neck and pill box hats for the men, like prison warders. The proper maintenance and wearing of these uniforms, which were ‘the Property of the Visitors Committee’, was used for discipline and control of the staff and much energy was spent harrying the recruits about their dress and turnout, as in any uniformed service. Staff uniforms often became a matter of pride, or even obsession, for senior staff.
In the twentieth century the Fulbourn uniform began to alter, but only after long and heated discussion. Badges of rank were introduced. The Matrons, Miss Fossey and Miss Brock, strove gradually to change the women’s uniforms to look more like those of general hospital nurses. The men had long disliked the tunic and peaked cap, and the Union finally persuaded the Visitors Committee to issue them with sturdy suits instead.
Then, in the 1960s, it was discovered that some units in some hospitals had found that patients got on better with staff who were not in uniform, trusting them more and talking more freely to them. This was the practice at Maxwell Jones’ therapeutic community at Belmont Hospital. Some daring members of staff began to suggest that we might do without uniforms at Fulbourn too. When staff took patients out from the hospital – on outings, trips, shopping trips and so on – they found these went better if they were not dressed like warders in charge of prisoners. We began to hear of other hospitals where staff had gone out of uniform (usually on experimental units) with good results. In 1968 the staff on Hereward House were allowed to try coming to work in casual clothing. This was a marked success. The patients said how much easier it was to talk to the staff, how much more relaxed and friendly the ward now was. Giving up staff uniforms was clearly a valuable part of building a therapeutic community. Other wards began to talk about doing this. The Senior Nursing Officer, Jack Long, said that any ward could go out of uniform if the majority of the nurses declared in favour of it, and if they could give considered therapeutic reasons for making the change. Several rehabilitation wards made the move and by 1972 all my wards were out of uniform.
The big debate came on the admission units in the early 1970s, where opinions were divided. Polls were taken and questionnaires administered. It emerged that some of the older patients felt ‘safer’ if nurses were in uniform and clearly identifiable, but many newly admitted and younger patients preferred the informality.
An interesting social experiment was carried out on Friends Ward in the early 1970s – at the time when it was changing over to a therapeutic community pattern of working. Several of the more vocal members of the nursing staff were keen that they should go out of uniform, but some doubts were expressed. A confidential poll of the ward staff was carried out which showed that though most of the qualified nurses on the ward, and all the doctors, social workers and psychologists were in favour of giving up uniform, the young student nurses wished to keep theirs. This apparently surprising result led us to discuss the matter with the student nurses. It soon emerged that the students were puzzled, confused and even frightened by all the changes that were going on and felt that no one was concerned about their distress. Their uniform was one of the few things that gave them security and a sense of identity; they did not want to give that up as well. This shocked us, and we wondered how to help this understandable insecurity. We decided that the senior nurses on the ward would set up a system of counselling under which each qualified nurse on the ward was named as counsellor to two or three of the students, with the task of helping them over the painful and frightening work of responding to recently admitted, acutely disturbed, mentally disordered people. These staff support groups soon became a regular part of Friends Ward activities. Six months later, the nurses as a group quietly asked for permission to go out of uniforms. This episode helped some of us to understand one function of uniforms – that they give uncertain and anxious new staff a sense of protection and security.
As the debates went on we began to appreciate even more how much significance and feeling were invested in uniforms. Some people who became hospital staff wanted and welcomed uniforms. ‘One of the reasons I became a nurse was to have a uniform like that!’ Many remembered the pride with which they donned their first uniform and the loving care they took to keep it spotless. They also recalled the pleasure in moving from grade to grade, changing to different colours. They were unwilling to give all this up without very good cause. They said ‘If we have lots of uniforms, the patients and relatives will think we are like the general hospital and as good as them.’ Some of the male staff had spent years during the war proudly wearing the uniforms of the Army, Air Force or Navy and longed for the sense of identity, of confirmed rank and of power that a neat uniform gives. These were legitimate feelings. We felt we should not demand that people abandon them unless we could show real gain for the patients. But such gains did gradually emerge and during the 1970s, ward after ward went out of uniform. There was no great pressure. If any individual insisted, she was allowed to continue in uniform. Some of the older women, particularly the Sisters, continued to wear their uniforms until the day they retired.
There were, however, some problems with the new lack of uniformity. Some informal dress became too informal, particularly as women’s skirt lengths went up and down in the eras of miniskirts and then maxiskirts. Some staff, when reprimanded for scruffiness protested that they were ‘being therapeutic’. One doctor was admonished publicly by a Coroner for coming into Court without a tie. As we debated these problems, we began to realise that the clothes we wore gave out messages to the people we met. The message might be reassuring, but could be perplexing or disturbing. People on a long-stay ward, who knew staff members personally, felt easier seeing them comfortably and informally dressed – rather than strutting around in starch and white linen. But a newly admitted patient, seeking reassurance that she was in a safe, clean and orderly place, might be understandably dismayed at the sight of sandalled feet under a ragged dress with dirty toes capped by cracked nail paint, or an unshaven face behind long dirty locks. Gradually codes of dress and turnout evolved. We realised that whilst it was good to be comfortable and friendly, our dress should not offend or startle and that professional people did well to appear to be clean and orderly in their persons and dress.
In part these changes were an outward expression of differing views of the very function of the hospital. If the task of the hospital was control (control of disordered behaviour, control of disordered thoughts) as in the old asylum days, then uniforms were an appropriate part of the system. They set staff apart and made them available for summons and direction. If, however, the task of the hospital was to assist and befriend the mentally confused, then casual clothing reduced the barrier between staff and patients and made counselling and friendship easier.
A CULTURE OF CHANGE AND LEARNING
During the years of change, learning how to be more effective in our jobs became more important and more organised at Fulbourn. Indeed for a time the way we did this at Fulbourn took on a unique flavour.
Learning about one’s job had always been important for staff at Fulbourn since the very earliest days. Young men and women came in from the Cambridgeshire villages as attendants and had to learn about lunacy. Mostly they learned from the old hands who taught them the tricks of the trade, but sometimes doctors would share knowledge with them. The Medico-Psychological Association first organised a national examination for Attendants of the Insane in 1893 and the Fulbourn Visitors agreed to extra pay for any attendant who passed the MPA Exam. A post of Nursing Tutor was established in 1937 (with Miss Brock as the first Tutor) and lectures were organised for the young nurses.
For doctors the Diploma in Psychological Medicine developed in the 1920s: any doctor who obtained it received £50 a year extra pay from the Visitors. However, there were very few junior doctors at Fulbourn before 1945 and it was left to those few to organise their studies for themselves as best they could. The idea that psychiatric nursing and doctoring were skills that needed to be learned had been accepted at Fulbourn; but this was seen as the individual’s own business. There was little idea that Fulbourn itself could be a place of learning, discovery or research. When I arrived in 1953 I found no organised training for the doctors, no library and no research. There were only a few student nurses and only dull, unimaginative instruction offered to them. I discovered that most of the nursing of long-stay patients was being done by people hired as ‘Nursing Assistants’ or ‘Ward Orderlies’ who had no qualifications and had received no formal training at all.
So we began to develop education for the staff at Fulbourn Hospital. In this there were three main tasks which sometimes ran together and sometimes at cross purposes. The first was helping people to acquire professional qualifications – helping nurses to get their RMPA Certificate and doctors to gain their Diploma in Psychological Medicine. This was apparently a straightforward task which could be tackled along traditional lines using set books. The second task was learning how to help our patients better; how to achieve this was less clear. Traditional methods – of sedation, control, and regulation – were clearly unsatisfactory. It was the wish to do better that forced us to investigate Social Therapy and led to new kinds of learning, changed practices and research – and much controversy. For these new practices there were no text books. At first we followed the practice of more advanced hospitals, but by the 1960s we found we were moving into new uncharted areas. This process too, involved all of us; ‘trained’ staff had perhaps more to learn – and unlearn – than those without qualifications. Out of all this came the third task – a quite new notion of facilitating growth. This meant producing a culture in which anyone – student, nurse, long-term senior consultant or patient – would find it safe to change and grow. For those who could allow themselves to do it, this was the most exciting. But some people found it too stressful.
Learning to pass exams was the first challenge we tackled. In the fifties there were few student nurses and educating nurses was not recognised as a separate skill. It was not until 1956 that our first qualified Nursing Tutor was appointed and not until 1958 when Reg Salisbury joined us that nurse education was properly addressed at Fulbourn Hospital. We trained young men and women for the State RMN Examination. We began to hold ‘Training Weeks’ for ‘Nursing Assistants’ so that they could gain a better understanding of what they were doing. Later the Ministry of Health established the new category of State Enrolled Nurse and we began to provide formal training for it. Many people who were good and sympathetic nurses but not very academic found this syllabus more manageable. It was a useful starting point, too, for nurses for whom English was their second language. Some of them, after qualifying as State Enrolled Nurses, then went on to train and qualify as Registered Mental Nurses.
Doctors starting in the old asylum service had had to learn their psychiatry by themselves, studying in their spare time. We, the Consultants, had taught ourselves that way when we were junior doctors in the thirties and the forties. We studied the books and in due course passed the examination for the Diploma in Psychological Medicine. At Fulbourn in the 1950s the Consultants decided to try to do better and help our junior doctors with their learning. We assembled a medical library; we arranged clinical meetings; we arranged for money to pay doctors to go on courses. For a number of years I acted informally as ‘Clinical Tutor’; in 1965 the Regional Board made this appointment official and in 1968 Ross Mitchell took over the post. An old dormitory was reorganised as a Postgraduate Training Centre with lecture room, seminar room and library. By now there were a dozen doctors at Fulbourn designated as trainees and most of them passed their DPM while working with us. That examination, however, was not too difficult. More important was to arrange the medical posts so that each doctor gained a wide range of experience of different disorders and different ways of working – in outpatient clinics, admission wards, long-stay wards, and so on. Our plan was to allow each doctor to learn what he felt he needed to know; doctors passed from one unit to another in the hospital when they were ready for it. This allowed them time to mature and to grow into jobs that interested them, such as in Hereward House, Child Psychiatry or Psychotherapy.
In the early 1970s the national training of psychiatrists was formalised and became more academic. In 1971, the Royal Medico-Psychological Association transformed itself into the Royal College of Psychiatrists and started a Membership examination. They also began inspecting and upgrading psychiatric training programmes. Gradually through the 1970s the examinations became increasingly academic. The first Royal College Approval team to visit Fulbourn in 1971 was very favourably impressed with our rather unusual training for doctors. But later Approval Visitors were more critical. In particular they insisted that doctors in training should ‘rotate’ in order to have varied experience. Admirable though this was in intention, it meant that young doctors had little chance to become committed members of ward or unit teams, or to follow patients through for any length of time.
The application of Social Therapy in the 1950s was fairly easy. We were applying the measures which had been known as good asylum practice (though often not achieved) for a century and a half. We were following the current leaders of practice, such as T.P. Rees of Warlingham and Duncan MacMillan of Mapperley. We got the patients active; we got them out into the open air. We started workshops and let the patients earn, handle and accumulate money; we reviewed their incentives and made them more meaningful. We extended parole and freedom and challenged restrictive practices; we reviewed patterns of seclusion and sedation, removed the padded rooms and eliminated excessive dosing with paraldehyde. We gave the whole hospital an air of purpose, cheerfulness and hope. It was hard work but it did not challenge any established ideas.
Our Open Doors policy was more controversial; this led to many discussions and arguments within the hospital and with our neighbours in the villages of Cherryhinton and Fulbourn. But again, pioneering hospitals such as Dingleton, Mapperley and Warlingham had led the way and we were following their lead. Like them, we found immediate gain; the patients were more cheerful and less violent. Many improved markedly. The nurses found the Open Wards more relaxed and enjoyed becoming the patients’ friends rather than their gaolers.
It was during the 1960s, as we began to explore therapeutic communities and mixed-sex wards, that we entered areas where there were no guidelines. We knew we wanted to change the hospital and improve life for the patients and staff, but we were not sure what would work and what would fail. Some experiments – such as the Adrian Therapeutic Community and Hereward House – went well. Others failed. Some doctors ran groups which made people more rather than less disturbed and which had to be terminated. These incidents taught us that discussion groups could unleash powerful forces, that they should be assembled with care and that the ward staff must also be involved in them.
One of the most important lessons I learned about how group methods could – and could not – be applied in a mental hospital, was that all experiments depended on the long-stay staff. If they were not involved the experiment failed; if they were committed to the experiment, it was often successful. I had also long wondered what part formal psychotherapy could play in the mental hospital. In the early 1950s psychoanalysts were very confident of their ability to right many social ills. They asserted that psychoanalytic understanding and therapy could not only cure all neuroses and psychoses but could also solve the problems of industrial management, prevent strikes, and, by curing the neuroses of statesmen, prevent wars. I had benefited greatly from my personal psychoanalysis and had practised psychotherapy, individual and group, for years. I had no doubt of its effectiveness for emotional disorders in the outpatient setting. As soon as I began working at the Psychiatric Outpatient Department of Addenbrooke’s Hospital in 1953 I started to do individual and group psychotherapy. Several other colleagues, Beresford Davies, Russell Davis and Christopher Scott, the Consultant Psychotherapist, also had patients in individual outpatient psychotherapy, often long term. We encouraged the trainee doctors, registrars and senior registrars to try to develop psychotherapeutic skills. But did this mean that psychotherapy could be imported into the mental hospital? Would it benefit long-term inpatients? This was an issue constantly debated at that time. Psychoanalytic enthusiasts spoke of a time when all patients, however psychotic or long term, would receive and benefit from psychoanalysis and quoted the work of John Rosen, Frieda Fromm-Reichmann and others doing ‘Direct Analysis’ with deeply disordered people.
Many of the Fulbourn inpatients, especially on the admission wards, received informal psychotherapeutic support from the doctors as they told of their domestic difficulties and their problems at work. But some of the registrars attempted to conduct more structured psychotherapy, arranging to see selected patients for regular intensive sessions on the wards. However, I noticed that somehow this seldom seemed to work. Sometimes the patient discharged herself, sometimes the doctor would move to another ward. Often there would be ‘administrative difficulties’; the room selected would not be available; the time was not convenient. Sometimes the Sister would complain that ‘these treatments’ were making the patient worse, and ask the Consultant to tell the doctor to stop them. I was puzzled by this. I did however notice that the patients selected from the ward as ‘suitable for psychotherapy’ were nearly always attractive and well-spoken young women.
It was Eddie Oram’s work on Adrian Ward in the late fifties that finally helped me understand why individual psychotherapy of patients specially selected by the ward doctor did little good to the woman selected and often quite a lot of harm – to her, to the ward and to the doctor’s morale. Eddie had selected patients for psychotherapy when he first went to Adrian Ward. However, when he changed over to a therapeutic community style he stopped seeing selected people. Soon the other patients and the nurses began to reveal how much envy and jealousy the former selection had caused; how the favoured woman had used her ‘special relationship’ with the doctor to attempt to exercise tyranny and had brought hatred and contempt down on herself. We came to realise that to give anyone in the ward privileged access to a major power holder was to put them into a painful and damaging position. From then on, if we were convinced that an inpatient should have individual regular psychotherapy, we arranged for her to go down to the outpatient department for it – and not to receive it from the doctor of the ward, whose time was better shared with the whole community of the ward.
In the later 1960s world-wide student revolts occurred and at Cambridge University, as elsewhere, there were riots and sit-ins. Some of this excitement washed out as far as Fulbourn. Many more students came to the hospital, as volunteers, to help with the patients’ recreation, and some worked on the wards as Nursing Assistants during vacations. The writings of R.D. Laing, the revolutionary psychiatrist poet, attracted some of the brightest to the plight of the schizophrenics, though they found the reality very different from his idealistic pictures.
Another challenging theme was patient self-government. This started with the experiments of Eric Raines in 1956 in inviting the patients to draw up rules for his ‘Male Open Ward’ and in Adrian Ward in 1958 when Eddie Oram and Kay Kinnear made the patients responsible for cleaning the ward. But it was within Hereward House in the mid-1960s that patient government developed furthest. I well remember how difficult I found it when the patients voted that I should reduce one man’s sedation – a great trespass on the prerogatives of the doctor. It turned out that they were right; I did reduce the dosage and his disorder did improve. These experiments challenged the roles of all on the ward, but especially the authority of the doctor and the Charge Nurse. Junior nurses revelled in the freedom to criticise their elders. Many staff nurses and some doctors felt very insecure when challenged. If, and when, things went wrong there was of course an immediate cry to return to the old ways. The staff at Fulbourn began to write, talk and think about what we were doing. Nurses and doctors published articles about our work. We presented papers at other hospitals and conferences and listened to the criticisms. We invited speakers from other hospitals and arranged informal visits. Gradually we clarified and organised our experience and I put much of it into my book Social Therapy in Psychiatry, in 1974.
One way of monitoring the new ideas we were trying out was to examine the results scientifically and to publish them. Through the fifties, sixties and seventies a series of research workers probed and studied our new ideas and published articles. In 1955 Fred Houston did a double blind trial of a new drug alleged to ‘activate apathetic schizophrenics’ (Houston, 1956). He taught Tom Lewis and the staff on Ward M6 (the male incontinent ward) to give out pills not knowing which were potent and which were dummies, to rate the patients’ activity daily and to chart their findings. Everyone was fascinated; never before had a senior doctor spent so much time on such a back ward. Many of the patients improved greatly, but when the code was broken it was found that the people on dummy tablets had improved as much as the people on the drug. This proved that the drug was ineffective. But it also showed that increased staff attention and enthusiasm was highly effective in improving the behaviour of apathetic patients.
In 1957–60 Douglas Hooper spent months as a participant observer on Ward F5, the women’s disturbed ward, while it was moved from its old squalid quarters to a newly decorated airy ward, Hillview, without any padded cells. He had shown that despite the Open Door, the old system of social control and repression was as effective as ever in keeping most of the patients cowed and inactive. He contrasted this with what happened in Eddie Oram’s experiment on Adrian Ward about the same time, where giving responsibility for the running of the ward to the ‘convalescent ladies’ had not only changed the ward from a dull, resentful, static ward to a lively, active, therapeutic community, but had also cut down lengths of stay without any increase of readmissions. These studies taught us that merely tidying things up and making them pleasanter – though a legitimate aim in itself – was not enough to help patients trapped in long-term resentful apathy. We had to change the social structure of a ward if we were to change its effect on the patients and help them recover. Douglas, Eddie and I published a paper on Adrian’s therapeutic community (Clark, Hooper and Oram, 1962) and Douglas completed a PhD on his work on Hillview (Hooper, 1960).
In 1960–63 Eddie Oram obtained a research grant to study the problem of long-term patients leaving the hospital. He followed up everyone who had left Fulbourn after staying two years or more. To our surprise he traced quite a number and found them well settled in their villages. This did much to dispel the myth that long-stay patients never left hospital permanently and that if they did they did not do well. This work laid the basis for our later rehabilitation work.
In 1966–68 Kenneth Myers’ controlled study of the work of Hereward House showed that far more of the men sent to Hereward House left hospital later than did those from the ward in the other hospital. He considered that this was due to the atmosphere of hope, excitement and involvement in the therapeutic community and the fact that it attracted exceptional staff, such as creative therapists and social workers – who were never seen on the traditional control ward (Myers and Clark, 1972).
All these studies established a tradition at Fulbourn of action research. When we were faced by a problem we asked first ‘What is the problem?’ and then ‘What are the facts?’ before we looked for solutions. Often we found the facts different from what we had at first believed; sometimes the problem changed as we examined it. After we implemented our solutions we measured and followed up to see whether or how they had worked. This approach was formalised in 1972 in the Hospital Innovation Project. The project was funded by the Department of Health and Social Security working through the Tavistock Institute of Human Relations. A project officer was appointed who was available to help any group of staff who wanted to change the way they were operating. The results of this experiment were written up in Innovation in Patient Care (1979), a collection of essays by Fulbourn staff edited by David Towell and Clive Harries, successive project officers (Towell and Harries, 1979). These showed how action research had proved effective in many parts of the hospital, including geriatric wards and even the stores department. As well as these research reports, many members of staff published descriptive articles about the work at Fulbourn, particularly the Social Therapy and the adventures in rehabilitation.
All this experimenting and writing was very different from what the Royal Colleges of Nursing and Psychiatry called ‘Learning’ which to them was a process of studying text books, memorising the teachings of others and reproducing them at examinations. Instead, we were changing our practice and then studying what we had achieved, analysing it, comparing it with the work of others, writing it up and publishing it as articles and books. During the late 1960s and early 1970s a subtle change occurred in the atmosphere of Fulbourn Hospital which can best be described as the development of a ‘culture of growth’. This was not recognised by many people at the time, even those most affected by it, and did not affect everyone. But it was this, I believe, that made Fulbourn so exceptional during the 1970s.
In the first 90 years of its existence the Fulbourn Asylum was a social institution devoted to containing madness, to quietening furore, to maintaining the fabric of society and to discouraging change. Patients were sent there to be quietened down. Staff joined the hospital because it offered steady pay and a good pension. During the 1960s and 1970s the ethos of Fulbourn was quite different. Staff came to Fulbourn because it was reputed to be different, to be challenging, to be ‘progressive’. When they arrived they were stimulated, questioned, offered opportunities, invited to take risks and were often upset. Some left, finding it all too unsettling. Others attempted projects which failed and also left, discouraged and disappointed. But many responded – and in doing so found themselves changed. People came to Fulbourn as staff members, especially as student nurses, and having worked and trained there left for other more challenging life roles. Amongst our student nurses of the sixties two became doctors, three social workers, two teachers and one a monk.
One of the more unusual learning developments of the ‘Culture of Change’ at Fulbourn was the ‘Doctors’ Friday Meeting’ mentioned earlier; this was a unique experiment in egalitarian sharing between doctors of all grades. This started from the meetings in the Medical Superintendent’s office which I had begun shortly after I arrived. Through the fifties I met every morning with all the hospital doctors and the Nursing Officers. We focussed on day-to-day affairs, sorting out the mail, arranging patient transfers, and so on, and getting to know and trust one another. The style of the meeting was open and saw a good deal of plain speaking. By the mid-sixties we were meeting three times a week and spending more time on major differences, policies and medical staff training. Then came a number of changes in the hospital. Oliver Hodgson was appointed Consultant in 1959 and in 1962 took over as Deputy Medical Superintendent; in 1966 Ross Mitchell was appointed Consultant. Both attended the meetings regularly and worked with me and challenged me as issues arose. The meetings began to concern themselves more with relationships between the doctors, especially doctors of different grades. In 1966 Malcolm Heron as Consultant Psychotherapist began to attend the doctors’ meetings at Fulbourn and to move the group towards examining its own structure and function. The meeting moved out of the Medical Superintendent’s office and settled on meeting once a week, every Friday morning for an hour and a half.
This continued for about ten years and is remembered by many doctors who worked in those years as one of the most interesting parts of their psychiatric training. The meeting had no agenda and no Chairman. The discussion was free-floating and spontaneous with an emphasis on open expression. The focus was on our medical work within the hospital, in particular the stresses and problems we could not talk about elsewhere – the struggles and rivalries between doctors, the pressures on us from other hospital staff and people outside (general practitioners, social workers and general hospital consultants), the drives which brought us into psychiatry in the first place and the pains of becoming a psychiatrist. We often became very personal and talked of our own private problems. Although it was not compulsory, nearly all the medical staff working in the hospital attended regularly. The Fulbourn Hospital Consultants, Oliver Hodgson, Ross Mitchell and I, attended every week, the Addenbrooke’s Hospital Consultants less often. Malcolm Heron came consistently and was the chief facilitator until his untimely death from cancer in 1974. The meetings varied greatly – sometimes being passionate confrontations or bitter personal rows, at other times quiet relaxed discussions of current medical political happenings. Sometimes they were flat, boring and repetitive, but not often – for the stresses of psychiatric hospital life meant that there was always some doctor distressed or enraged by recent challenges from his work. Doctors starting in psychiatry were often able to share their distresses with those of us who had lived through similar turmoils, and could begin to come to terms with our stressful specialty.
People used the meetings differently at different times. I found it helpful to share with them the pressures that came on me, as Superintendent (and later as Chairman of the Division of Psychiatry) from Management Committee, police and Magistrates. I also valued being challenged over my mistakes and ineptitudes in my way of working. Both Oliver Hodgson and Ross Mitchell used the meeting as a sounding board during their periods as Chairmen of the Division of Psychiatry. Sometimes the meetings were painful but often very warm and supportive. Few of us will forget how Malcolm shared with us the knowledge that he was soon going to die, and allowed us to express some of our despair, grief and anger at this news.
Oliver, Ross, Malcolm and I saw these meetings as an essential part of the psychiatric trainees’ introduction to their chosen speciality and spent a lot of time attending to the reactions of newcomers. Some young doctors welcomed this atmosphere and took to it with glee, revelling in the chance to challenge Senior Registrars and Consultants openly and to learn more about themselves. Others found the departure from traditional medical relationships disturbing and distasteful. It was particularly stressful to more senior doctors, Senior Registrars and Consultants who had come from other hospitals and more traditional ways of working and who could not tolerate being challenged or confronted by their juniors. The Friday meeting continued through the early 1970s, but ran into difficulties in the mid-1970s, after several new Consultants joined the staff. Some of them found the meetings intolerable; one even cried out in fury ‘It’s a Communist attempt to brainwash me!’ as he left the meeting for ever.
The arrival of the university academics in 1977 brought a major change. They made it clear that they disliked this meeting and thought it of no value. They believed that psychiatric training should consist of instruction given by the skilled and experienced to the unskilled and inexperienced, and that egalitarian discussions were of little value. After a few visits to the Friday meeting they stayed away and advised other doctors to do so too. As the academic model became dominant in Cambridge psychiatry during the late 1970s, the Fulbourn doctors’ meeting withered. The numbers at the Friday meetings dwindled; the discussions became flatter and the meetings finally stopped in 1979.