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 |
5 Difficulties and Challenges
All seemed well in 1957, for the hospital and for me. However, this situation was not to last. The year which followed was a bad one – a period of defeat and of hesitating purpose. Many things went wrong, few things went well.
I had, of course, experienced problems before – when accidents occurred within the hospital, when hostility and opposition to me had been marked, when policies had been baulked at or reversed, when patients did badly and suicides occurred – but these had passed and we were undoubtedly progressing. The general mood of the first four years had been of advance, confidence and enthusiasm. The hospital had prospered and the patients benefited. As a result, my exuberance flourished and I may have grown over-confident – instructing those who knew better, talking down those entitled to a hearing, pushing my own ideas brashly. Perhaps a reaction was inevitable.
My first hint of difficulties came in the meetings of the Hospital Management Committee. I knew that I had upset some of them and I had become accustomed to hostile criticism, particularly from Alderman Street. A retired businessman, Mr Street was often in the hospital; he came over at least once a week to go round the estate and give the Farm Manager his working orders; he was always ready to serve on any ad hoc committee. I had made several attempts to mollify him, without success. He made little secret of his view that I had too much to say for myself. On other bodies on which he served, he said, officers spoke when they were called upon. They were becoming, said Mr Street, ‘the managed committee’ not ‘the Management Committee’ and by what right had the doctor taken over the Committee Dining Room as his office? These and other of his comments were passed on to me by mischief-makers. While in Committee meetings, Mr Street was the first to make objections to any proposal I put forward.
The ‘airing courts’ and exercise yards had stood in front of the wards for a century – asphalted areas bounded by walls or high railings in which unoccupied patients were exercised. As we got everyone working, these areas stood empty and began to look derelict. One summer I led a delighted group of nurses and patients in tearing down the eight-foot iron railings that surrounded the male airing court. At the next Committee Meeting in the autumn, Mr Street stated that this was quite unjustified; these were valuable, antique railings of fine cast-iron. He had been assured they were worth hundreds of pounds. Who, he said, had given authority for this act of vandalism? When I had a shrubbery cleared by a group of patients, it was he who called attention to an ancient ruling that no tree might be felled on the hospital grounds except by resolution of the Management Committee, and he had the ancient rule reaffirmed ‘to check unwise acts by officers’.
I managed to talk my way out of most of these situations, but always felt grateful to Mrs Adrian for her support. To my dismay, in the summer of 1957, she announced her intention of resigning the Chairmanship. The favoured replacement was Alderman Holmes of St Ives, an energetic man whom Mr Street had persuaded to join the Committee a year earlier. I was most alarmed. However, the Regional Board chose an ex-Mayor of Cambridge, Alderman Howard Mallett, as the new Chairman. He joined the Committee in the spring of 1958 and, after a few meetings, took over the Chair; Mr Holmes became the Vice-Chairman.
I immediately felt things change and realised how much I had depended on the support and protection of Mrs Adrian. Mr Street became even more outspoken in his attacks on me and I began to dread Committee Fridays. Plans were turned down, deferred or mangled. The Chairman’s meetings with the Officers of the Group changed markedly. Instead of the long cosy rambling discussions that Mrs Adrian enjoyed, in which I could often carry my projects with my ready tongue, the meetings became briefer and more formal. Mr Mallett and Mr Holmes, both Aldermen and ex-Mayors with years of Town Council experience as guardians of the ratepayers’ interests, were quick to see the financial implications of any plan. They were also keen on proper procedure and believed that a Medical Superintendent was a paid official, liable to dismissal and subordinate to the Chairman of the Health Committee. They clearly felt that my view of myself as leader of the hospital, like the headmaster of a school, was inappropriate and incorrect. At Chairmen’s meetings I was chagrined to hear the financial or formal administrative viewpoint increasingly overrule the medical.
During 1957 Mr Tucker, the Chief Male Nurse, announced his intention to retire. Though I had got on quite well with him, I had been aware of how little control he had actually exercised and I felt a change might be a good thing. I looked forward to having Mr Allen, who had pushed through the work programme, take over the role and I promised I would do all within my power to get him the job. Though my promise contained the usual caveat ‘It is of course a Committee decision’, I had little doubt of my ability to have him appointed and my certainty must have conveyed itself to him. He went round the hospital talking of what he would do ‘when I am Chief Male Nurse’. However, at the Appointment Committee things began to go wrong and as the afternoon progressed I became aware that things were not going my way. Mr Allen did not show up very well at interview and came in for detailed hostile questioning. In the discussion, it became clear that several members of the Committee felt that Mr Allen was unpopular with the staff. I was puzzled as to why they thought this as I had not observed it myself. (Many months later, I discovered that a few senior nurses had been assiduously pouring poison into the ears of members of the Subcommittee.) Mr Allen was soon out of the running and an outsider was appointed. Mr Allen was bitterly humiliated. I was disappointed for him, angry that the hospital had been deprived of an excellent Chief Male Nurse, ashamed that my promise to him had not been fulfilled and dismayed that my inability to get my favoured candidate appointed had been so publicly displayed.
In the coming weeks, I began to appreciate that certain posts were not mine to allot and that I had better realise this and not make promises I could not carry out. My power was limited – I could persuade, but I could not order and I had better accept this. I also realised there were quite a few people glad to see my wings clipped. I saw Mr Allen at length to apologise for my failure and to attempt to assuage his bitterness. However, he continued to be angry and to apply for every Chief Male Nurse post that came up; I did my very best for him with references and fortunately he was appointed Chief Male Nurse to a much larger hospital, with a bigger salary than he would have got at Fulbourn.
At about this time, Fred Houston also left. Since his arrival in 1954 he had done more than anyone else to reform the hospital. He had organised the industrial programme and had implemented the open doors policy. He had run a very good clinic at Huntingdon. I loved him for his enthusiasm, industry, goodwill and good humour. For several years, he had been applying for Consultant posts up and down the country, and I had written many glowing references, for I knew he would make a very good Consultant. But the fact that he had no higher medical qualification had told against him again and again. He gave up hoping for preferment in Britain and emigrated to Canada. I was desolate at his going and angry that there could be no assured place in British psychiatry for a man of such goodwill, compassion and energy.
I was thus bereft, in 1957, of my two main lieutenants, Fred Houston and Mr Allen, and I felt sad and isolated. True, my relations with Miss Brock were now excellent, and we were working well together to get the women’s side busy and working. But I missed Houston and Allen and wondered whether I had been justified in letting them pour so much of their energies into our common task for such shabby rewards.
The doctors during the winter of 1957 were rather restless. Two Senior Registrars were in the same position as Fred – they had their DPM but no higher qualifications and kept failing to get the Consultant jobs they applied for. They were despairing of finding a place in Britain and started to think about emigrating. They began to say that success at Fulbourn was the kiss of death; that no one from Fulbourn ever won promotion. This affected the morale of the doctors and created a depressed working environment.
I then experienced a bigger blow over my favourite project, the conversion of the sports field into a better cricket pitch. During the summers of 1955 and 1956, we had made great progress on this. I had had many conferences with the architect, and the local Grasslands Adviser. The challenge was to get good turf to grow on the central cricket ‘square’; we knew that grass had never done well on our dry chalky soil, but we hoped to make a cricket pitch that could be played on. We decided to treat a portion of Fulbourn’s own natural turf with weedkillers and fertilizers until it was in really fine condition and then to move it to the carefully prepared site. We did this in the autumn of 1957, so that it would be ready to play on in the centenary summer. Alas, as the spring of 1958 opened, the turf grew rank couch grass instead of close, fine leafed fescues. The plan had been a failure and the table was unsatisfactory. Before we could discuss what should be done, Mr Street swept in. He pointed out to the Management Committee that the table was a failure and suggesting that all had been mismanaged. I had to sit helplessly listening to a tirade of allegations and half truths and see the Committee empower him to take over the whole Sports Field Project. Mr Street’s crowning phrase ‘The doctor was not the right man for the job!’ made headlines in the local paper that night. Within the next few days, the cricket table was ploughed up and the architect and the Grasslands Adviser were paid off without a word of thanks. As I thought it over, I came to the conclusion that it was mostly my own fault. In a limited sense, Mr Street was right; I was not the right man to lay out a sports field; I was a doctor, not a landscape architect, I would do better in future to stick to my own job and not attempt those of others.
During the winter of 1957–58, the men’s side went through an unsettled phase. The new Chief Male Nurse, Jack Long had arrived at Fulbourn fresh from an excellent hospital, Netherne. A tall, cheerful, lively man, his bonhomie covered a steely determination and integrity that came from wartime experiences as a Conscientious Objector and from his personal Quaker faith. However, he faced a difficult task with Fulbourn male nurses who had for years been allowed great latitude by Mr Tucker’s policy of ‘keeping everyone happy’. This policy had often meant giving way to everyone and never asking awkward questions; it was this attitude that had landed him in trouble over the missing stock. Mr Long’s attempt to bring some order and competence into the administration of the men’s wards was little liked.
The men’s wards were all open; the employment programme seemed to have reached its limit. The Charge Nurses asked me to meet them and to discuss the future. We held a series of weekly meetings in the spring of 1958 with the title ‘Where do we go from here?’ We discussed with pleasure the achievements of the last few years, the immense progress made by the patients and the improved reputation of the hospital. We cleared up a number of minor difficulties and made small improvements, but the problem remained – the patients were active and free, so what next? Rehabilitation was certainly a general aim, as was further improvement of the patients’ living conditions. Some of the Charge Nurses also mentioned the apathy of the patients as a problem – they just sat about and waited for someone to tell them what to do. The nurses looked to me for guidance, but by this time I had no major aims to lay before them. Being unable to reach any specific conclusions about our future goals, we stopped the meetings after six sessions.
By this time, in April 1958, I was beginning to feel very low. I was irritable at home, tired at the end of the day, had lost interest in work and play and my sleep was broken. It had, however, been a long hard winter, spring was very late and Easter Day was the coldest for half a century; I thought my gloom would lift with better weather. It was at this time that I met a strange but fascinating man, Richard Hauser, at a mental health conference in London. Even now, years after, I find it difficult to write about him with detachment, for he stormed through our lives like a Pied Piper. He was a middle-aged Austrian who claimed great experience in working with groups and propounded novel theories of leadership. He was charming, talented and well read, quoting the sociology classics freely; he spoke with authority and conviction, referring to the research he had done all over the world and the transformation he had wrought in several institutions. I found his ideas fascinating, his personality charming, his conversation stimulating and his new approach exciting. I talked of some of our doubts and problems at Fulbourn and asked what he was doing at present. He said he was engaged in research on many major social problems – crime, adolescence, homosexuality, addiction – but would be willing to give some time to the problems of Fulbourn; he could come down at weekends; there would be no fee.
As I travelled home from my first encounter with him, I was elated by my good fortune in meeting him. He seemed like the answer to my problems. Although I did have some vague doubts – I did not know what his training or qualifications were, who had worked with him or where, or exactly how universally applicable were his theories – but there was no question of his brilliance, charm and experience in working with groups. There could be no harm in having him down; after all, it cost nothing. I would see how others at Fulbourn reacted to him.
He came down for a weekend with his wife, Hephzibah, the sister of Yehudi Menuhin. Richard charmed the hospital and Hephzibah charmed my wife, who was musical. They made an excellent impression in the hospital, especially with Miss Brock and a number of other senior nurses. Richard was enthusiastic about the possibilities of further research at Fulbourn and said he would like to come down again. Hephzibah was devoted to Richard and told us many tales of the wonderful work he had done in Sydney, Australia and how they had transformed the old Sydney Asylum, Callan Park; Richard propounded his sociological theories of leadership. Hephzibah gave impromptu piano concerts. My wife and I were both delighted with these talented and charming visitors and filled with hope for what they could do for the hospital. After he had gone, I discussed things with those that had met him. I asked if they wanted to see him again – they certainly did! Some did because they felt he had something to teach them, others because there were questions they wanted to ask which they had failed to ask before he left. Some asked for his credentials, but I pointed out that he had apparently worked with many famous and eminent people. Everyone seemed to think we should have him back, especially as he did not ask for any money.
Then began a strange summer. Every other weekend, Richard and some of his family would come down and stay with us, talking in the hospital, talking in the house, talking till all hours. Hephzibah took my wife to great concerts and to meet Yehudi and other eminent figures in the world of music. Richard always had lots to say on any subject and welcomed a group of listeners. He was convinced of the value of his work and his theories of leadership and that lessons of vital importance for mankind would emerge from his studies. Hephzibah shared his assessment of his greatness. Whenever he talked she would sit meekly at his feet noting down all that he said; one day it would make a great book. He talked with groups of staff and patients and with visitors to the hospital; it was fascinating to watch him draw out their ideas, juggle with them, rephrase them and feed them back again; it was striking to see his charm working to stimulate the most dreary and withdrawn. Hephzibah started a patients’ choir. I felt that we had found someone who was going to uncover all the hidden talents in Fulbourn Hospital and who would lead us through to new and more valuable methods of patient care. I longed to know more about his theories and waited for him to expound them.
However, I was still finding other things difficult. My tiredness and lack of energy and insomnia did not clear up and after a full week’s work, a weekend of endless discussions with the Hausers left me little time for rest. I could not seem to get on with the centenary history which I had promised the Management Committee. They had set aside £100 to print it and it was to be a major item of the centenary celebrations. I had begun work in the summer of 1957 – collecting photographs and information, reading musty volumes of reports and minutes and spending hours in the City Library looking through ancient copies of local newspapers. During the winter I had written about half the volume, but now, in the spring of 1958, I was finding the next part very difficult. I tried writing it in the evenings – but I was too tired; I tried getting up at 6 a.m. and writing before breakfast, but that was little better. I tried setting afternoons aside – but there was too much else to do. I began to worry more and more about it and lost more sleep. Finally, in May 1958, I was forced to acknowledge that I just could not manage it in time. I told the Management Committee that I could not get the job done and felt miserably aware of this, my first failure to complete a task which I had publicly announced.
Unfortunately, a number of the other centenary celebrations had also fallen through. The cricket square had been ploughed up, so we could not open the sports field that summer. A proposal for a Grand Fete which I had floated had aroused no answering enthusiasm. We had hosted a meeting of the Royal Medico-Psychological Association at the hospital in May, but otherwise no anniversary enthusiasm seemed to be developing. This perplexed me; previously, all I had to do was to float a good idea and then other people would take it up, add their own ideas and together we would construct an exciting occasion. This did not seem to be happening with the centenary; I remarked on this lack of interest to the Management Committee and Mr Street remarked that he was not surprised; he could see little to celebrate in what had been done at Fulbourn during the last 100 years; it was much better forgotten!
Mr Street’s words stung me bitterly, as did the ripple of agreement that ran round the Committee table. At first I thought this was just another of his attacks; then I realised that in his forthright way, he had expressed what a number of other people had been feeling and what I had been too obtuse to sense, that there was a complete lack of enthusiasm within the hospital for the centenary. I now recalled a number of occasions when my references to it had fallen flat. I realised then that in future, if I floated a bright idea, I should listen for an answering echo of enthusiasm; if people came back with further ideas, I could go ahead, but if there was a dull silence and no response, I should let it drop.
Then came another blow. Alderman Holmes, who had been becoming more and more active in helping the hospital and very friendly toward me personally, suddenly died. Again I felt lost and bereft and greatly feared that Mr Street would become Vice-Chairman. I began to long for my holidays and hope that I would feel better after them. I looked forward to getting away. Richard and Hephzibah Hauser said they wanted to do more work in the hospital and asked if they could live in my house while I was away. I gladly accepted and went off to the seaside with the family. The weather was poor, and our holiday was not a great success.
On our return, Richard took my wife and me aside with deep gravity and informed us that during his survey of the hospital he had discovered what was wrong. The doctors, he had found, were deeply hostile toward me and critical of us for keeping our private life separate from that of the hospital. He gave us many details of what had been said and left us feeling very dismayed. We were deeply shocked by what he had revealed, repentant of our failings and then, gradually, incensed at the sadistic enthusiasm with which he had thrown this at us. He left next day for London to prepare his report on the hospital. I felt relieved to see him go.
When I went up to the hospital next day, I found things in a very strange state. A few people, doctors and nurses, were enthusiastic – Mr Hauser was wonderful, he had shown them what to do and they had great plans. Many had much less to say, but watched to see my attitude. I made it clear I wanted to hear what they thought and gradually comments emerged. Some were interested, but puzzled because however hard and long they listened, his talks seemed to be full of repetition and woolliness. They still wondered who he was, and what his background and training were. No one, after six months, had been able to find out. He seemed to say different things to different people. A few people were frankly hostile; they just did not like him and pointed contemptuously to his vague professional pretensions, to his name dropping, to his foreignness, to his constant yearning for an audience.
Then Richard’s report arrived. I was appalled. It was a lamentable document, badly written, clumsily put together, ill-balanced and containing nothing that we did not know already. He seemed to have assembled all the idle comment he had heard in the hospital. The recommendations were vague and grandiose – ‘the total community’ must be interested in the hospital. There was need for ‘rededification’ and so on. In October we went up to London to hear him address the Social Psychiatry Section of the Royal Medico-Psychological Association, which I had persuaded to give him a hearing. This was to be the statement of his theories for which I had been waiting. It was an embarrassing disaster – a long rambling talk, full of anecdotes and diversions, containing no theory, only the few, woolly ideas that we had heard many times before. There was no argument, no theory, no structure. Afterwards I felt obliged to speak warmly in praise of what he had shown us at Fulbourn, but could not say more and the other psychiatrists showed their dismay.
At his request, his ‘report’ was widely circulated throughout the hospital, and those who disliked Richard began to point out the faults in it that I could so clearly see myself. Other tales began to come in about outbursts of rudeness to various inoffensive but pompous people and I realised Fulbourn Hospital wished to have no more to do with Mr Hauser and his theories. I felt that I had mounted a tiger and I could not see how to get off it.
Richard, Hephzibah and family then came to spend another weekend with us to see what reactions there had been to the report. He talked with various groups and found nothing being done. Several people found it convenient to be out of the hospital that weekend. He upbraided his chief disciple for failing to make progress. When she pointed out that, according to his theory, you must wait for a spontaneous uprising of activity, he said that there was a time to order people to be active and that this was now. He left Fulbourn after the weekend and never returned. He wrote us no further letters and did not acknowledge those we sent him. When people from Fulbourn met him, he was coldly hostile to them. I heard from other sources that he blamed it all on me – I had turned the hospital against him and revealed myself as a rigid authoritarian tyrant, incapable of appreciating the wonderful message vouchsafed me.
I realise now that this man was the stuff of which both prophets and charlatans are made. He had great intuitive skill in assessing the feelings of a group, in telling them what they wanted to hear, and by a combination of charm and frankness prodding them into action. Like all prophets, he gathered a few disciples from whom he had no scruple in exacting devotion and service. If I had not been personally discouraged and seeking for help, I doubt whether I would have fallen under his spell and invited him to Fulbourn in the first place. As it turned out he disrupted the hospital thoroughly and made a bad summer far worse for me. Several of the people, patients and staff, whom he made especial proteges were deeply disturbed by his abandonment of them and the flood of dammed-up hostility that washed back over them; several had further breakdowns. However, the whole unfortunate episode did serve to benefit the hospital in one way. By laying bare a number of our concealed tensions so that we could then deal with them, both the hospital and I moved forward after he left – perhaps united by the very act of rejecting him.
Following the disastrous earlier months of 1958 I had now to pick up the pieces and put myself together again. The remaining months of 1958 were spent on the task. Hauser’s report, for all its failings, made a good basis for discussion – and friends and colleagues who read it, aware of my evident dismay and perplexity, offered comment which was often valuable. During that winter my wife and I, conscious of Hauser’s criticism of our non-involvement, made several attempts to involve ourselves more in the life of the hospital, giving parties, taking part in festivities. Gradually, however, we realised that this was not working well. It was certainly uncomfortable for us. It coincided with the time when the needs of our children were changing as they grew up, so that a home on the isolated hospital estate was no longer satisfactory. A final push came when a Ministry change of policy once again raised the rent of my tied house. We decided to move out of the hospital grounds. We found a house in Cambridge and moved during the summer of 1959.
Beresford Davies, my senior colleague, had some wise and useful comments to make on the happenings of the summer of 1958. Hauser he dismissed as clever and intuitive, but essentially destructive. He pointed to the outbursts of ferocity and the way in which he attacked those who disagreed with him. But Beresford also pointed out that I had been pushing the hospital pretty hard; the pace of change in the last few years had been tremendous and though some, like the male nurses, might beg me to provide them with new goals, perhaps it would be better to sit back a bit and let other people make some contributions. Beresford suggested that though a good push was necessary to launch a boat, it ought to be able to sail without continual pushing. Several academic friends at Cambridge University such as Meyer Fortes, Professor of Social Anthropology, and Oliver Zangwill, Professor of Psychology, also saw Hauser’s memorandum and criticised it even more than I had done myself. They pointed out that he had made use of a few catchwords borrowed from other writers, but that no one could call it an analysis. From all these discussions, I gradually emerged with one or two general conclusions and lines of development. I now felt that Hauser’s ‘theories’, especially about leadership, were not of great value, but that his observations on the hospital were factual and possibly of some use.
I decided to float no new ideas all during the coming winter of 1958–59, but to relax and let other people put forward their thoughts. I would also try to find outlets for my energies outside the hospital. Fortunately, there were requests at that time from Cambridgeshire County Council for a psychiatrist’s time to develop seminars for social workers. Winston House, the halfway house, was nearly ready to open and I was to be the ‘psychiatric adviser’; there was a lot to do. I felt, too, that I should not any more assume that all advancement at Fulbourn was to my individual credit, nor that all misfortunes were my fault. I would just do my best and let things turn out as they might. Immediately after Hauser’s last visit I felt a striking relief; the gloom, anxiety and insomnia that had been plaguing me for months lifted and I faced my work with a new confidence and zest. I took up some new hobbies and interests, and the family commented that I was much more cheerful at weekends.
Hauser had made several specific observations including the obvious irritation of the junior doctors towards me. I now asked them what was wrong. Many things were brought up. They resented the daily morning meetings, when I did so much talking; I cut these down to three and later two per week. They did not like having their mail handed out to them with my comments; I arranged for a secretary to sort the mail and to pass it directly to the doctors. They felt that their training programme was unsatisfactory; I asked them to propose a better one and after a good deal of frank discussion of needs, wishes and time available, they did. They expressed a number of other dissatisfactions, many quite justified, with their dining and living quarters. I had not eaten in their dining room in recent years; they invited me in and I was appalled at the overcrowding.
It became clear that while I had been busy working with the nurses, the social situation of the junior doctors had changed. In the early 1950s, there were just a few doctors at Fulbourn – several were non-resident, and there was little feeling of solidarity. We had gradually employed more doctors and had continued packing them into the same unsatisfactory accommodation and had regarded their problems as individual ones. Suddenly, under the pressure of the dissatisfactions of 1958 they had become a group with aims, aspirations and grievances in common. The main target of their dissatisfactions had, however, been me – my failings as a Superintendent, as a doctor, and as a person. I learned later that they had spent long sessions discussing my faults and the inadequacies of the hospital as a place of treatment or of training. They had criticised my dependence on the nurses, my anxiety, my garrulity, my authoritarianism, and had talked about much of this round the hospital. The senior nurses knew of it, but felt they could not tell me; it was one of the factors that had soured the atmosphere in early 1958.
Fortunately, I was able to meet some of the doctors’ needs. The Regional Board had just built some staff houses. I managed to get some of these allocated to doctors at present living in flats in the hospital. The larger flat at the top of the administration building was turned into resident doctors’ quarters and I invited the doctors who were moving into it to advise us on planning, facilities required and furniture. When the things they requested were later turned down I arranged for the doctors to meet some Committee members directly. As a result of their energetic lobbying and with my help we got nearly all they had asked for. The experience of meeting the Management Committee directly made them realise, as Miss Brock had at an earlier time, some of the difficulties I faced and, I think, made them more tolerant towards me.
Since a doctors’ group had now formed (even though it was largely an ‘anti-Superintendent’ group) I encouraged them to formalise it, with a Chairman and a Secretary with whom I corresponded. They drew up sets of rules about who might use their dining room as full members, and who might come in as guests. I was pleased that they allowed me to be a guest. When my family moved from our hospital house and I started taking lunches in the hospital, I arranged to lunch with the doctors on one day each week, but I never went in at other times without asking their permission.
In the midst of this concern with social reorganisation and psychological atmosphere, something happened which emphasised our common bond as doctors. An elderly patient developed a severe form of dysentery; the staff on her ward were dilatory about isolating her and carrying out tests, so that a number of other patients were infected and we rapidly had many ill old women on our hands. We were plunged into a turmoil of traditional medical activities; isolation dormitories had to be set up, scores of patients treated and many others screened and examined, innumerable specimens of faeces had to be sent daily to the Public Health laboratories and reports examined and assessed. For the first time in years, I had to wear a white coat to go on the wards. After great toil and effort we checked the spread of the dysentery epidemic, cured the sufferers and gradually isolated and cleared up the convalescent carriers.
Gradually things improved between me and the doctors. They had for some time been suspicious about the references I gave when doctors applied for other jobs. A secretary under notice had leaked some unfavourable references to them. I agreed to show them references before I sent them off, so that they would have an opportunity to correct anything which was unfair. In other ways, I demonstrated my willingness to listen to them and to change what could be improved. They began to put their energies back into the common task of treating and improving the condition of the patients and into their own personal tasks of learning psychiatry and passing their qualifying examination.
I began to find rewards again in my work now that I was involved in projects outside the hospital. In October 1958 the first four residents from Fulbourn Hospital were admitted to Winston House. They were all in work of some kind and were to stay for a few months until they were ready to establish themselves on their own. Over 50 people moved from Fulbourn through Winston House to independence in the first year. Its fame spread, and patients were referred from other hospitals. Over the next four years Winston house was a major and gratifying part of my work and my life. Every Tuesday evening I saw residents as outpatients, at first in the House, later in the outpatient department of Addenbrooke’s.
Talking with these Winston House residents week after week was an education for me. I saw them flower into lively people again, from the dull subservient inmates I had known on the wards. I began to see how the tremendous power that the hospital doctor has over the patient distorts any conversation there might be between patient and doctor. However relaxed and friendly a doctor might try to be, the fact that he had the power to deny discharge, to order confinement, seclusion or ECT meant that a patient must always be very careful of how much he says and how he says it. Gradually I learned other and more subtle lessons and began to respect patients’ judgement of their own needs. Some of them said they felt no need to see a psychiatrist again and I learned to accept that. Others were guardedly polite; their referring psychiatrist had spoken enthusiastically about how their psychoses had been cured and their state stabilised on Largactil; gradually, as they came to trust me, they revealed that for many months they had been putting the pills down the lavatory. I soon learned that the details of their former delusions and hallucinations were irrelevant; what mattered was whether they had the willpower to stick at a boring job until they had enough money to live on their own. Some had to learn not to talk about their hallucinations; after years of discussing them freely in hospital, they found that workmates looked at them oddly and that it was better to keep quiet and not be labelled a ‘nutter’. I began to realise what a painful journey ‘rehabilitation’ was and from these brave men and women I learned how difficult the path back to social acceptance was. They brought home to me the disadvantages of a long period of seclusion from society; even the world of Cambridge had changed in the ten or twenty years that they had been away from it. Cars and traffic had multiplied, prices had increased, well-known pubs, cinemas and shops had vanished. It was a new and difficult world to re-enter.
Although we had our disagreements, I got on well with Mr Cooper, the Warden, a former Salvation Army missionary. He was a strong-minded man with a firm conviction of divine approval for his views, but I enjoyed having a working relationship with someone who was not under my authority. At the end of the first year we reviewed the work of Winston House and prepared a paper. To our surprise and gratification it was accepted by the Lancet in 1960 and published as an account of a notable and successful experiment in Social Psychiatry. The article attracted a lot of attention, since many hospitals and local authorities were trying to set up halfway houses at that time; I had many requests for reprints and visitors started coming to see the pioneering work (Clark and Cooper, 1960).
Back at the hospital, Fulbourn Industries was making steady progress despite the departure of Fred Houston and Mr Allen. The patients worked consistently at the demanding and complex work and they used their earnings to improve their lives. They bought new dresses, made trips into Cambridge and took holidays; several of them left hospital completely. The supervisors established good relations with the suppliers and encouraged the managers to come up and see the work.
One of those who made good use of the Fulbourn Industries Workshop was big Elizabeth. Her task was to put different coloured wires together in a complex bundle (a ‘cable form’). Although she grasped what was required, she was painfully slow at first. Gradually, over the months, her speed improved until she was one of the better workers, and was working at a level comparable with paid workers outside. Then a vacancy occurred at one of the firm’s regular workshops and we recommended Elizabeth. She went into town every day and came back without incident. We asked the foreman about her and he said her work was up to standard, though the other women found her puzzling as she seemed to have little to say and so little interest in what went on around her. Elizabeth was one of the early residents in Winston House where she got on well, though making few friends. In due course she moved out of hospital to a bedsitting room. She remained bland and emotionless with always a slightly puzzled look on her plump face. However, she managed life outside without difficulty and I would see her occasionally, at the Therapeutic Social Club where she was a regular attender.
Within the hospital I was now able to take a fresh look at what was happening. I found that quite a number of interesting projects had developed of which I had not fully recognised the value. As various projects run by Charge Nurses and Sisters achieved success – such as the splitting of the men’s disturbed ward and the creating of a bowling green behind the admission ward – I began to see the staff as a source of valuable suggestions. I realised that patients who worked on these projects, particularly the ones who had specific roles, tended to do well. Their symptoms declined, their appearance smartened up and they began to plan towards going home. On talking to some of them I learned how rewarding the projects had been for them. Nearly all mentioned two things – how gratifying it was to exercise skill, responsibility and judgement, qualities which they feared they had lost altogether, and how important some sign of public approval (perhaps from a visitor, a member of the Committee or myself) had been in giving them the feeling that they were not entirely useless.
I realised that many people recovering from mental disorder were burdened by strong feelings of failure, incompetence and social uselessness which were a grave handicap to recovery. I now saw that one of our tasks must be to provide them with opportunities to dispel these feelings. I began to see that many occupational projects, though useful in getting people physically active or gainfully occupied, did not provide any scope for enterprise and responsibility. We had to provide opportunities for initiative – something far more difficult than just getting people to work. This was in fact an answer to the male nurses’ questions in the spring.
To propagate these ideas I started using slogans such as ‘Activation’, ‘Self-Government’ and ‘Social Therapy’ and these became the catchwords of the next few years. I realised that encouraging the Charge Nurses and Sisters to run their own projects was an excellent vehicle for achieving these new goals. If I allowed them freedom, responsibility and a chance to show initiative while still providing a degree of protection, there was a fair chance that they would allow the same to the patients.
Some months previously, the Sister of a women’s rehabilitation ward had asked me if I minded her getting a gas stove and doing a little baking on the ward. She was an energetic woman known throughout the hospital for her sharp tongue. I gave consent because I thought this might be an outlet for her formidable energy. She borrowed an old gas stove and persuaded the engineers to fix it up for her in the tiny ward servery. She bought flour and began to teach some of the patients to bake; she was an excellent cook. They sold the cakes to their visitors to pay for more materials. The cakes were very good and the demand expanded. Soon, they had paid off all their expenses and were making a surplus, which they began to spend on the ward. They bought plants and pictures and wall ornaments, equipment for their kitchen, a record player and a floor polisher.
The ward became a different place from the dreary environment it had previously been. The patients who had been defeated and discouraged, and looked shabby and odd now seemed to have an air of purposefulness. When I went into the ward now the odour of cooking met me on the stairs, and all within was bustle and activity. The Sister, who used to be sitting fiercely in her office, was now often flushed with baking with flour in her hair. The patients were bustling about, sometimes harried but often cheerful and always busy, and I was never allowed to leave the ward without sampling several delicious cakes. I began to notice women who had been static for months or years making striking progress.
Of course, these changes did not pass unnoticed by others less favourably inclined. The Engineer commented on equipment being introduced and pointed out the dangers of overloading the ancient electrical wiring. The Supplies Officer was concerned with unauthorised purchases and ‘additions to stock’ and asked to whom the floor polisher belonged? Who would pay for its repairs and who would have to replace it? The Finance Officer was also most alarmed and asked who had allowed this Sister to collect the money? Were the takings properly listed? Where was the money stored? Were her accounts properly audited? What would happen if somebody filched some money and the HMC was sued? All these considerations were brought up at the Chairman’s meetings and at the Management Committee. In one sense, they were legitimate as the concerns of experienced officers, who had seen the trouble irregular projects caused in the past and who were issuing proper warnings. But the implied message was that irregular activities should be discouraged and, when discovered, stopped; that if anybody required anything, they should get it through ‘normal channels’ – and, of course, if it was not available, they should do without and wait. Although recognising the validity of their comments, I also knew that I must fight them if I were to create an atmosphere in which initiative could flourish. I argued all the way. I took influential and impressionable Committee members to the ward and expounded on the therapeutic value of the project. As a result, it was allowed to go on – even when the Sister and the ward began to present polishers and floor scrubbers to other wards in the hospital.
The project expanded for two years with increasing enthusiasm. They took to catering for parties and receptions, to making wedding and christening cakes. Cooking dominated the life of the ward. The final check, however, came from an unexpected quarter. The Catering Officer had never greatly cared for this activity, with the implicit criticism it contained of the food he provided, and he steered a visiting Catering Adviser to the ward. This Adviser reported back to the Regional Board, criticising the hygiene of the project. I was tipped off that this visit was impending so invited Pat Tyser, the local Medical Officer of Health and a good friend, to look over the ward unofficially. He found squalor behind the enthusiasm; there were cakes in the linen cupboard, flour in shoe boxes, margarine in the broom closet, mouse droppings in the flour bin and decaying scraps of food in corners. He told me that had he found any commercial concern like that he would have closed it at once and prosecuted! Though it might be possible to get away with such squalor in a domestic kitchen, it was inexcusable when products were being sold to the public. I saw that I had to act. I brought the Sister in and discussed the problem. She admitted that her operations had spread far beyond the space available and in contemplating the evidence of decay and infestation, agreed that she had let her enthusiasm outrun her discretion. We agreed to cut down. The surplus stock was used up and the storage places cleansed; public sale stopped, and cakes were made only for eating on the ward; the financial side was cut down. I then reported all this to the HMC before the Regional Board Catering Adviser’s report came through.
Despite the necessity for this action and the Sister’s acquiescence, there was a sharp reaction on the ward. For months afterwards patients seemed gloomy and sad and the discharge rate fell. Even more strikingly, during the next six months, two patients from the ward committed suicide while at home on leave. Although both had depressive illnesses and ample personal reasons for killing themselves and although there had been suicides from that ward in earlier years, nevertheless, there had been no suicides from the ward in the previous two years of excited cooking. I could not help thinking then that maybe there was a price to be paid for a surge of group enthusiasm – when it ebbed some people might be damaged by the trough of discouragement.
Other good things were starting at this time. For some years, Miss Brock had been giving talks to Women’s Institutes in nearby villages, telling them about the work of the hospital. She had also shown WI parties round during the summer and often the visitors had asked what they could do to help. Miss Brock had encouraged them to adopt friendless women patients and to invite them out to their WI meetings. Then, it had occurred to her that perhaps they could have a Women’s Institute within the hospital itself! After many months of discussion with the national organisation, permission was granted and they started their first meeting during the summer of 1958 – the very first time there had ever been a Women’s Institute within a mental hospital.
Although as a male I could not attend their meetings, in due course I was asked to speak to them. I was delighted to find that in the meetings there was genuine equality between staff and patients. The nurses did not wear their uniforms at meetings and they voted and took part as ordinary members. I was fascinated to find the proceedings and the atmosphere to be just like the many other WIs at which I had spoken during the days of our intensive public relations campaign. There were the same Minutes, order of procedure, writing of resolutions to be forwarded to headquarters, outings planned, competition for the best flower garden in a saucer and, of course, the singing of ‘Jerusalem’. The members of the meeting were 20 women nurses and 60 patients, all of whom I knew well. Had I not known before, I could not have told them from one another, nor could I have differentiated their plump middle-aged faces, grey heads and comfortable figures from those I had seen in so many Cambridgeshire village halls. Remembering the traditional atmosphere that had existed in Fulbourn up until a few years ago in which such a mixing of staff and patients would have been impossible, I was delighted and astonished at how far the women had come. I was also pleased to reflect that here at least no one could say that I had directed, organised or imposed the development. It had come entirely from the women themselves and especially from Miss Brock – the same woman whom foolish people had once called a block to progress.
Other smaller projects were also developing. When the new hospital kitchen was built, the old buildings were left empty. The Physical Training Instructor asked us to let him take over the biggest room. He persuaded the engineers to remove the big pipes and level the floor, a group of patients painted it and it was then used as a gymnasium, badminton court and winter exercise room for the football team. A smaller room we allotted to the Occupational Therapy class from the disturbed women’s ward and they gradually developed a little workshop, painting their own furniture and decorating the walls themselves.
Not long after I first arrived at Fulbourn, my attention had been drawn to one particular male staff nurse, Jack Wheatley. He was, I was told, an interesting man – talented but rebellious. He was a skilled craftsman and an excellent cricket player; at times, he had run small workshops. On the other hand, he had often been in trouble and had received more reprimands than any other member of the staff. In 1956 he applied for a Charge Nurse post. I suggested he be appointed and we gave him M2, a newly opened ward, to run.
This ward was a discouraging prospect as the patients had been in the hospital for many years. They were mostly middle-aged, quiet, apathetic men, often with considerable thought disorder – not good enough for the privileged workers’ ward and not bad enough for the disturbed ward. The ward was a bare dormitory with scrubbed deal floors and painted brick walls. There were no curtains and little furniture. We promised him that furniture would be provided, but we did not know when. The rest was up to him; we could not give him any other regular staff to help with the 40 men.
Jack Wheatley’s response to the challenge was outstanding. He had known many of these patients for years and believed that they had more initiative than was apparent. He gathered them together and talked to them about the purpose of the ward; he said it was to equip them for life outside. They named the ward Mitchell, after the former Chief Male Nurse. Jack divided up the housework and put groups of men in charge of each task. At first, he ran the kitchen and served the meals himself, but he soon picked and trained men to do these tasks. The furniture began to arrive, but the rooms still looked shabby. He asked if he could try improving things.
In order to plaster the painted brick walls in Fulbourn Hospital, the bricks had to be ‘chipped’ to enable the plaster to bond. This chipping was a slow, laborious, dirty job, producing much dust; normally, we would vacate a room for several months to allow for chipping, application of plaster, drying of plaster and painting. Having asked if he could do one or two side rooms, Jack donned an overall and led a team of patients who soon had the walls chipped. He then persuaded the hospital plasterers to fit this room into their schedule and finally got the hospital painters to paint the walls. We had never had rooms done so quickly and I was delighted.
He then asked if they might do the day rooms. I pointed out that this would make a mess that would last months and that there was no alternative accommodation. He put this to the men, who agreed to put up with the mess and, over a number of months, they finished all the walls. During this time, I persuaded the HMC to lay linoleum floors in the ward and install large windows. They also received new curtains and new carpets as their share of some upgrading money. As a result, within two years of his taking over, what had been a disheartening, shabby ward became one of the most attractive in the hospital – largely as a result of the patients’ own efforts. At the same time, the men had progressed greatly. A number went home, and other wards were so anxious to get people on to the ward that there was a waiting list for transfer to Mitchell!
Jack Wheatley’s men then addressed themselves to the iron bedsteads. The black paint was much chipped and rusty where it had chipped; the bedsteads looked horrible, but could not be condemned because they still held up the bed. A team of the patients set aside a room, took in one bed at a time, dismembered it, scraped it clear of rust and applied two good coats of paint, usually in a pastel colour. The painting team did all the beds in the ward and were then asked to do others; the women saw the results and begged to have theirs done. Over three years, the Mitchell team repainted all the old beds in the hospital – and the original team of workers had changed three times over as the men were discharged.
These are but a few examples of projects started independently by nurses in the hospital. Many wards also ran raffles to pay for their outings. As I thought about these excellent activities and my lack of involvement in them I felt that I had actually helped in some way and gradually I clarified my concept of the ‘Umbrella Function’. By this, I meant that my task was to protect developing projects from influences that might blight them in their early tender stages – such as Committee criticism, ill-judged publicity, the attentions of the auditors or the queries of administrators who would wish to tie things up in red tape. I began to see my role as that of facilitator – a creator of an atmosphere in which other people could try experiments. I saw that the frantic activity of my earlier years was no longer necessary.
While we were working on all these changes within the wards at Fulbourn, there came a major change in the English Mental Health Laws which had striking effects on our practice. In 1957 the Royal Commission, of which Mrs Adrian had been a member, produced their report. It was a massive document – 306 closely packed pages with 882 paragraphs – and surveyed English lunacy law since the first Lunacy Statute in the fourteenth century. The Commission now proposed that all this ancient legislation be swept away and an entirely new system established, so that entering a mental hospital (and getting out of it) should be as easy for most people as entering a general hospital. They also made many other revolutionary and exciting proposals and suggested how community treatment might be developed. Pessimists thought that the report would be pigeonholed and forgotten. To our surprise and delight, the Government produced a Bill within a year and started it through Parliament.
There followed a most active period of debate within the professions, in Parliament and in the public newspapers. After the Act was passed in July 1959 we had over a year to work out its implications before it came fully into force on l November 1960.
We found that the main effect of the Act was to make easier (and in some cases more lawful) what we were doing already. For some years, nearly all our patients had been free to come and go from their open wards; the new ‘informal status’ removed the anomaly of having certified patients going out to work, making money and owning property. The new admission procedure meant that there was much less fuss about bringing in someone who needed admission and brought to an end the previously humiliating process by which a Duly Authorised Officer, a Magistrate, ambulance and the police all descended on the family home.
The service for our patients outside hospital, both before admission and after discharge, became more appropriate, more flexible and more effective. All sorts of pointless activities which had been required by the Law now ceased. We no longer had to present to the HMC lists of people ready for discharge. The old ‘Board of Control examination’ – the bizarre ritual when a wily paranoid patient and a skilled psychiatrist fenced verbally until enough was elicited to warrant further detention – now ceased. When I had a talk with a long-stay patient, it could be a discussion to promote his welfare, speed his rehabilitation and advance his interests, rather than a series of tricks to get evidence to justify prolonging his detention.
The Act also changed our relationship with the people who sent in patients. Under the 1890 Act the Receiving Order was a legal Order from a Magistrate and we in the hospital could not disobey or even question it. There were Magistrates, doctors and DAOs who would commit a person to Fulbourn Hospital without any consultation with us – or even any warning. Sometimes the committal was quite unsuitable. There were two particularly worrying categories. Confused elderly patients in local authority institutions, the former workhouses, were sometimes sent to us when they became troublesome – before any one discovered that they were actually physically ill, with pneumonia or heart failure. People picked up by the police and found to be confused were handled summarily at the police station by an elderly local general practitioner who had been a police surgeon for many years and believed that he knew better than anyone else who was suitable for the asylum. He often lost his temper at the police station and on occasion had committed as insane someone who was merely drunk. He always resolutely refused to call psychiatrists to help him in assessments for admission.
Now, at last, we in the mental hospital could control who came in, in the same way that the staff of the general hospital could. We insisted that there should be prior consultation about all proposed admissions; where necessary we went to see the patients beforehand. We insisted that the confused elderly should be properly examined physically and treated medically before we took them. We insisted on reviewing people in the city police station. This so infuriated the elderly GP that he resigned his position as Police Surgeon – to everyone’s relief including, we discovered later, the long-suffering staff of the police station.
In 1959 Oliver Hodgson was appointed to a Consultant vacancy – for me one of the best appointments made at Fulbourn. He was a quiet, unassuming man who soon showed himself a skilled and able psychiatrist, a hard worker and a most pleasant colleague. A distant descendant of Lord Protector Cromwell and a quintessential Englishman, he recommended himself quickly to the male staff by his skill and devotion to cricket and was soon elected Captain of the Hospital team – to my relief. I found him an ideal comrade and he soon came to act as my assistant in many matters. In 1962 we persuaded Leslie Buttle to give up his nominal Deputyship and Oliver took the post. It was a great relief to me to be able to leave things in his hands.
Dr Noble, the senior psychiatrist at Addenbrooke’s retired in 1957 and we appointed Bernard Zeitlyn. I was very pleased with this appointment as I had known Bernard as a fellow Registrar at the Maudsley. He was now a fully trained psychoanalyst and strengthened our team greatly. He proved an invaluable colleague and delightful friend over the coming years: charming, talented and witty.
Although I had thought constantly about the attitudes of the nursing staff since my arrival at Fulbourn, it was not until 1958 that I attended to the question of their training. At that point we had a miscellaneous group of staff of different ages, backgrounds and cultures, of differing intelligence and education and with very different qualifications, previous training and experience. They ranged from ward orderlies who had been certified mental defectives to university graduates; they came from England, Ireland, France and further afield; some had no training, others were fully qualified psychiatric and general nurses.
Before the war during the 1930s, the staff of Fulbourn Hospital were similar to those in most English mental hospitals. Many were local youths and girls, but others came from the Welsh hills and from Tyneside – driven into a secure, if unpleasant job by the shortage of work during the Depression. The two questions that were asked of men who applied to work at Fulbourn were ‘Do you play cricket?’ and ‘Can you play a band instrument?’ Proficiency in either field won a place forthwith. Some could not stand the life and left after a short time, but those who remained settled in. They lived in cramped and spartan staff quarters, studied for their examinations and waited for promotion. Many married another hospital employee, and ultimately got a hospital house in which to live and raise their children – who often became hospital employees themselves.
In those days grading of nurses was clear. Recruits came in as student nurses. After a few years’ experience and study, if they passed the examination, they became trained nurses (‘Staff Nurses’). After many years as staff nurses they might be promoted to be in charge of a ward; they were then known as ‘Charge Nurses’ (on the women’s side ‘Ward Sisters’). For many that was the limit of their ambitions – to retire as a Charge Nurse.
All nurses were ‘full time’ – working a week of some 60 hours. If a nurse could not work full hours – as women who had children could not – they had to resign. For a minority of able and ambitious men and women there was a ladder of promotion culminating in the positions of Chief Male Nurse and Matron. On the way there were posts as Assistant Chief Male Nurse, Assistant Matron, Deputy Chief Male Nurse and Deputy Matron. Some of these ambitious people qualified themselves further by going into general hospitals for three years and taking the training as general nurses (SRN – State Registered Nurse).
The post of nursing tutor had always been an important one at Fulbourn. The holder had the task of teaching anatomy, physiology, first aid and simple psychiatry to the new nurses and helping them to pass their examinations. The tutors were qualified nurses, holding a psychiatric and often a general nursing qualification, but usually they had no training as teachers. The post was normally the first step into administrative nursing for an ambitious nurse hoping to rise towards a Matron or Chief Male Nurse position. Miss Brock, now Matron, had originally come to Fulbourn as a Nursing Tutor. In the postwar years the position was held by a succession of able men who had all moved on to administrative posts after a year or two.
During the war, as staff numbers fell, other people were recruited to Fulbourn. Married women who were trained nurses came back as ‘part-timers’. People without qualifications were taken on as ‘assistant nurses’. Other people were tried as ‘ward orderlies’, originally to assist with simple tasks about the ward – washing up, cleaning floors, clearing rubbish, and so on. Gradually, over the wartime years, some of these people proved so helpful and became so experienced that they gradually moved into positions of trust and responsibility.
After the war, the men who had been away fighting returned to their wives and homes. With them, as student nurses, came a number of other men who, during the war, had found their life’s vocation in nursing, but then discovered that male nurses were only welcome in psychiatric nursing. These were good recruits, devoted and interested, many of them of superior ability. While National Service continued, this recruitment went on; they were mostly industrious lads, who worked for their exams and passed them. The male nursing side had, therefore, maintained its numbers and standards fairly well through the 1940s and 1950s.
However the war brought a taste of economic freedom to many younger women. After the war former nurses did not return to the hospital to replace the married part-timers who had been filling in for them. For the same reason it was difficult to recruit new women staff to Fulbourn in the postwar period. The women’s side was gradually weakened. By 1953, an ageing group of women, a few full-time, but mostly part-time and many without training were struggling to serve an increasing, ageing and grossly overcrowded mass of women patients. There had been very few recruits for nearly 20 years and between 1940 and 1950 only two women nurses at Fulbourn passed the final nursing examination.
The search for people to take on the work on mental hospital back wards became more desperate. Various recruiting experiments were tried at Fulbourn, as at other English mental hospitals. At Fulbourn many immigrants, particularly refugees from Eastern Europe, were taken on – people who could often speak very little English. The challenge to integrate these staff and help them become more effective, as well as to enlist their loyalty and altruism, was enormous.
When Miss Brock became Matron in 1952 she was determined to do something about the inadequate staffing of the women’s wards. Various ideas were tried – a scheme for Nursing Cadets, employing foreigners as Nursing Assistants, improvement of the nurses’ uniforms with differential rank colouring, the use of trained nurses or student nurses from general hospitals. All these projects were endlessly discussed by a Subcommittee of the Management Committee, composed entirely of lady members. Shortly before I arrived, two Inspectors of the General Nursing Council had visited the hospital and submitted a very long report, full of criticisms of the teaching arrangements, the ward duty arrangements and the accommodation available for the nurses.
When I started as Superintendent, I listened to the various ideas for improving nursing and threw myself behind those that seemed promising, such as the recruitment of foreigners. An engaging publicity man drafted advertisements for us in the French provincial press, which brought in over 100 applications. Miss Brock and I sorted them out and sent for the girls. This involved much planning as few of them spoke English. We interviewed them all, arranged English classes for them and gradually started them in simple work on the wards. By the spring of the second year, we had about 20 French girls working in the hospital and had drawn a rebuke from the Regional Board for exceeding our budget for nursing salaries – the first time this had happened for over 20 years. This was my first clash with the budgeting accountants and it set a pattern for me. The most grievous problem of the hospital – because it did most to harm the patients – was the shortage of women staff. We had done something effective to remedy it – and the financiers’ only response was to fuss about their budget. I stormed against them in righteous indignation; Mrs Adrian and the Management Committee backed me and the Regional Board found the money.
The recruitment of the French girls was like a blood transfusion to the staff of the women’s side – though like a blood transfusion, the effect was a tonic rather than sustained. Despite the doubts that the elderly Sisters expressed, it was a great boon to have a considerable number of strong healthy girls on the wards. Even if their English was poor, they soon learned to make beds, serve meals and do all the necessary household tasks. The standards of physical cleanliness and order at last began to rise. The girls were pleasant, cheerful, reasonably educated and did well at first. It gradually became clear, however, that many had little continuing interest in nursing and most of them went home after about a year having acquired a smattering of English. Only a handful persevered, became student nurses and finally qualified as psychiatric nurses.
Employing these girls also brought its own share of problems. One started acting oddly and then took to her bed. With an interpreter’s help, I found that she was severely mentally disordered, with developing schizophrenia and I had to arrange hastily for her admission to another hospital, where she required many months’ treatment. Another girl slashed her wrists; the door of her room had to be broken down and she nearly died; it then emerged that she had been discharged directly from a French psychiatric hospital to come to work for us. Her psychiatrist thought that the change would be therapeutic for her and had written me a letter of recommendation about her, concealing her illness. Another problem was a quarrel which developed among the girls and over which they split into two factions; one group appeared to win, and about six girls resigned, including two of our best students. A few months later, two of the victorious faction were found to be pregnant. One persuaded a male student nurse to marry her; the other could not name the man and was deported back to France (standard British procedure at the time). I heard that both said their babies were conceived in the Nurses’ Home and before long lurid tales and complaints about the goings on there began to reach me.
All these matters were brought straight to me and I spent many hours during 1954 and 1955 dealing with the individual and general problems of these young women and conferring with Miss Brock about them. Gradually, I realised that some of the troubles actually arose from our method of governing the lives of student nurses. In the thirties, the Matron had policed the Nurses’ Home herself. Such an arrangement became intolerable in the postwar period when nurses everywhere revolted against petty restrictions and demanded their rights and freedom. At Fulbourn, we had abandoned fussy interference. The Matron seldom visited the Home and let them rule themselves. This worked well as long as there were very few resident staff, most of them middle-aged, long-term staff members. With a rush of newcomers, the system broke down.
I wondered what could now be done about maintaining a modicum of decency and order. We tried calling meetings to set up a committee to run the Home, but the girls did not attend and they were clearly little interested in self-government of the Home. We finally decided to appoint a Home Sister and were fortunate to find a pleasant, motherly, qualified nurse, who had excellent French and had been a governess in her time. She soon brought order into the Home, though a few of the more turbulent girls moved out into lodgings rather than conform. The Home Sister in due course set up a Home Committee, which served to ventilate some grievances and, over the years, we persuaded the Management Committee to redecorate and re-equip the Nurses’ Home.
My relations with the male nurses went quite well. Meetings with the Charge Nurses were lively and we achieved much together. I persuaded the nurses to reorganise the Staff Club (started by Mr Allen) as an independent body, open to all. This brought in the clerical workers and the engineers and made the Club generally more popular. It was largely an independent body – and rightly so – but I was always ready to help its members get the things they needed from the Management Committee.
By 1955 I had begun to realise that the nursing staff were good-hearted people, anxious to do their best for their patients and to take pride in their jobs, but that they were not very well equipped for the task. The training provided for student nurses was dully presented. Apart from them, nobody else in the hospital was receiving any instruction at all. Many male nurses and some of the women were qualified RMNs (registered mental nurses) but most of them had passed the exam many years before and their knowledge was out of date. When I studied the staff lists, I was disturbed to see that over half of the women on the nursing staff had never had any organised training at all. They had first been employed as ‘nursing assistants’. While a number of them had a great deal of experience, very few had received any formal instruction.
As a result of Fulbourn’s staffing difficulties, I began to take a view of nursing training which was radically different from that of the General Nursing Council at that time. To obtain the best possible care for the patients, it seemed to me necessary to provide all staff with good teaching at as advanced a level as they could manage or their tasks required. I came to feel that it was our responsibility to take the people we had and make the best we could of them, and that anyone who was fit to be employed to care for our patients was fit to be given training of some kind. Here, I came into conflict with the elitists at the General Nursing Council, whose solution to the problems of nursing was to raise standards of entry. The effect of this was to limit training to highly selected student nurses – and to deny it to those not selected. In a hospital like Fulbourn, this meant that many of the staff hired were given no training at all – so that the patients suffered. I also believed that the process of learning was something that never ceased. I felt qualification should be the beginning, not the end of learning and decided that my aim should be to provide learning opportunities for all grades of staff.
As I worked on this, however, I came to understand more about the process of learning. I began to see that though teaching (the process of pushing knowledge at people) was important, learning – the active process of assimilating information and applying it to one’s work – was very much more important. I saw that much formal nurse education failed because students felt that what they learned in the classroom bore little relationship to what they actually did on the wards. My ideas developed slowly and were mixed up with reflections on my own slow and painful learning of the tasks of the Medical Superintendent, and my observation of the development of our junior doctors.
I myself had been taught medicine by the Scots system of lectures and didactic instruction and had endured the postwar programme of the Maudsley, which instructed the trainee about every conceivable theoretical aspect of psychiatry, while attaching little importance to the growth of skill by practice and experience. As I watched our medical trainees, I began to feel that they gained more by being given responsibility and the chance to make mistakes (with the support of more experienced colleagues) than they did by lectures, seminars, teaching, rounds, and so on. I had had to learn the job of Superintendent by doing it and only found out how to improve myself by discussion, reading and reflection. I came to see learning as an active process, in which one was challenged by experience and thus caused to enquire, study, digest and apply. I tended to contrast two models of education – the mechanical and the horticultural, the assembly line and the garden. Many doctors seemed to think that training was like making a machine. If the teacher assembled the right cogs and wheels of knowledge and put them together correctly, then the machine, the student, would function. I preferred the model of the garden, where the teacher is seen as a gardener who can trim, prune, water, fertilise and spray; his activities are very important – but the stock and the soil set the limitations. Time, chance and the weather affect the growth and health of the plant and the final bloom is only partly a result of the gardener’s efforts.
Another problem was that the subject of psychiatry was changing so much that earlier instruction was becoming outdated. What the tasks of the psychiatrist and psychiatric nurse would be in coming years was so uncertain that training needed to produce nurses who were ready to adapt to new demands and acquire new skills when needed. I believed this could only be achieved through a training which developed active, motivated learning that would continue through life. My theories clarified slowly, under the pressure of events. In 1956 I was simply doing what seemed to be necessary to raise the standard of care of the patients. I saw that the nursing assistants who were doing the nursing had never been given any training. I felt that we must give them some and so spoke with Miss Brock, enlisted the tutor’s help and arranged for a week’s course in the spring of 1956 for a selected group of nursing assistants. There was no syllabus to guide us, so we provided what we thought they needed. They were taken on a tour of the hospital; Miss Brock and I talked to them, other senior officers talked to them; we arranged discussion periods and encouraged them to ask questions; the tutor gave a few talks on first aid, mental health, law and modern psychiatry.
I found talking to these nursing assistants excitingly different from lecturing to student nurses. Instead of a group of callow youths, sullenly listening to stuff that they did not understand or care about, I found a group of lively middle-aged men and women, experienced in the hospital and its ways, deeply interested in all the changes they saw and grateful for the opportunity to study. At the end of the week the nursing assistants expressed great satisfaction and I found that all who had talked to them had found them a stimulating group. They asked me many questions, recounted tales of how things used to be and made suggestions about how they might be in the future. We asked their advice on how to plan another course and, from then on, we ran about three courses a year. These courses had a striking effect on the nursing assistants, their morale and their work with the patients. All felt their status had been raised and some were stimulated to study further. The nursing assistants went back to their tasks with greatly increased enthusiasm and a number of them took up key positions in the developing occupation programme. At our Nurses’ Badge Days, certificates were presented to those nursing assistants who had worked for two years in the hospital, had attended one of these courses and had passed a simple examination.
Not long after the courses began, the Charge Nurses began to enquire about further training for themselves. It appeared that the nursing assistants and student nurses were starting to ask them questions that they could not answer. I responded happily to this. Feeling that straight instruction would be inappropriate to these older people with many years of qualified service behind them, we started a ‘Senior Nurses’ Meeting’ once a month. We asked local experts – the Duly Authorised Officer, our psychiatric social worker, the Disablement Resettlement Officer, the consultant psychiatrists – to give talks about recent developments, followed by a period for questions. The meetings were for qualified nurses only; most of the Sisters and Charge Nurses came to them, as well as some of the Staff Nurses. Discussion was often lively and I did all I could to encourage it. The meetings began during 1957 and continued steadily; sometimes attendance fell, but at other times this meeting was rather like a Parliament of the hospital at which some new proposal was propounded, modified and accepted. In later years, whenever I foresaw some major development in patient treatment or staff organisation, I would present it to the Senior Nurses’ Meeting as soon as I could, to get their comments, criticisms and contributions.
From 1957 to 1960 there was a period of national activity in mental nurse training, arising from the parlous staffing situation of Britain’s mental hospitals. The national situation was very similar to that of Fulbourn – a fair number of male nurses, very few trained women nurses, practically no recruits and many untrained assistants and orderlies. Many ideas were being discussed – mostly by interested parties. These included a raised standard of entry to ‘attract a better class of girl’, a lowered standard of entry ‘to make training more freely available’, the recruitment of foreigners, the banning of foreigners, the recruitment of nursing cadets, the banning of young people from disturbing work and so on and so forth. Pay and conditions of mental nurses rose strikingly over the years, as the Unions pressed successfully for more money, shorter hours and better conditions. The professional educators of the General Nursing Council worked steadily to raise the level of the formal education. They pushed the pay of Nursing Tutors up until it matched that of Nursing Administrators and they tried to eliminate unqualified tutors in favour of nurses who had received a formal training in teaching. They revised the syllabus for mental nurses deferring instruction in anatomy and physiology and emphasised instead more relevant issues such as ward and bedside teaching, discussion and seminar learning and a programme which was directly relevant to students working on the wards of psychiatric hospitals, that is one stressing human development and emotional needs.
These national currents all swept through Fulbourn. In the early 1950s, the tutors had taught in a converted cellar. The classroom was well lit and reasonably equipped with a skeleton, anatomy charts and textbooks, but its underground position was a fair measure of the standing of nursing training in the life of Fulbourn. In 1957 we appointed a trained tutor, Frank Tudgay. Miss Brock, Mr Tucker and I formed an ad hoc Committee to oversee the training programme, and to help Tudgay. This was at the time when the male nurses were active on their work programme and the influx of French girls had freed the women nurses so that they were regaining pre-war standards of care.
Probably as a result of this improvement in our standards, the Matron of Addenbrooke’s, who in the early days of the NHS had spurned the idea of cooperation with Fulbourn, now requested that some of her student nurses be allowed to work at Fulbourn. In the summer of 1956 six Addenbrooke’s students came to spend three months with us. I insisted that we should not regard them merely as extra hands to be put to work (though we sorely needed them), but should try to give them useful experience, providing special seminars and posting them to wards where they would learn. This policy paid off. The Fulbourn secondment was soon the most popular available at Addenbrooke’s and the girls, enjoying themselves greatly, took good tidings of us back to Addenbrooke’s. They in turn brought into Fulbourn a burst of youthful life and enthusiasm and their unabashed questions were often healthy for us. They became a lively part of our social life and several of them married male nurses they met at Fulbourn. Mr Tudgay started using the new GNC Experimental Syllabus, which we found a great improvement. The student nurses found that their lectures taught them useful things about their work on the wards and thus stimulated they became more interesting to teach.
At about this time, we also began to send selected nurses off on refresher courses. We began to get places on the excellent four-week courses run by the King Edward VII Hospital Fund for London at their Staff Colleges. The two Colleges, one for Ward Sisters and one for Matrons, ran occasional courses for psychiatric staff in which the emphasis was on discussion and mutual examination of their work and attitudes. Over the years, we managed to send all our administrative nursing staff and most of our Charge Nurses and Sisters on one of these courses. Invariably they came back refreshed. By talking to people working in other hospitals and through having to defend and explain the work of Fulbourn to others, they came to see new possibilities in their own work.
The attitude of our nurses towards their own hospital gradually changed. From being apologetic about working at Fulbourn they now became proud of the hospital – especially when they met nurses from other hospitals and heard how static these other institutions were. This feeling was greatly strengthened in 1957 when we were asked by the Regional Nursing Officer to host a ‘Regional Refresher Course’ for Charge Nurses and Sisters from the other East Anglian Hospitals. Miss Brock and I joined eagerly with the newly arrived Chief Male Nurse, Jack Long, and the Nursing Tutor, Frank Tudgay, to put on a two-week course in September of that year. We structured it according to the ideas of the new GNC syllabus – focussing on what nurses had to do on the wards, rather than giving them lectures on medical topics. We asked our Charge Nurses and Sisters to talk to them, to tell them what they did and to show them round their wards. This was a striking experience for these long-stay nurses from the old custodial hospitals. One of our star performers was Eric Raines who told great tales of his self-governing ward to the Charge Nurses from other hospitals, still taken up with security, counting spoons and polishing door handles.
Whether this Refresher Course did any good to the other East Anglian Hospitals, I never heard. But the tonic effect on the Fulbourn staff was great. Recounting the tales of their achievements of the last four years, the open doors, the work programme, the self-government, the recoveries, reminded our staff of how much they had done. As they learnt how little had changed at the other hospitals, Fulbourn staff were filled with pride and pleasure in their own hospital.
In 1958, Mr Tudgay moved on and we appointed Reg Salisbury, a lively man with a zest for teaching. The school was moved from its cellar to an outside building. In 1959, when I moved my family out of the hospital grounds, the vacated Superintendent’s House was made into the nurse training school. This move into quarters that were not only comfortable, roomy and with a garden, but which had also been symbolically the seat of the hospital government, was a measure of the changed status of training in the hospital. Reg built up a good training organisation, for which we now had a fair inflow of student nurses; he instructed the seconded Addenbrooke’s student nurses and the nursing assistants; he organised the Senior Nurses’ Meetings and the Refresher Courses and took an active and lively part in all the increasing learning activity of the hospital. He also took the students onto the wards and encouraged the Charge Nurses and Sisters to teach them directly.
Recruitment had now ceased to be a matter of so much concern. As our reputation increased, students began to trickle in. They were never a flood, but there were always enough to fill our preliminary training schools and to maintain the staff numbers. We began to get general trained nurses coming for psychiatric experience. Our former students gave good reports of us and encouraged others to come. Gradually our numbers built up; we always felt short of staff, but each year found we had a few more. In 1961, after one of the national rises of pay and decrease in hours, we were able to eliminate nearly all part-time working and a count showed that about half the women staff were now trained nurses or students. By this time the general standards of care – in cleanliness, hygiene, sympathy and efficiency – had risen greatly throughout the hospital.
When we started to apply the suggestions of the WHO report in 1954, we still thought of patients as mostly passive – people to be got working and ‘activated’, people to be treated or cured. We – the nurses, doctors and planners – saw ourselves as the active ones. However, we had gradually to revise this view when it became clear that, given the chance to work, patients displayed surprising capacity and given the chance to run the affairs of a ward, they showed good sense and responsibility. Gradually, our notions about how we should organise the hospital began to change. I had hitherto accepted the prevailing medical view of patients as pathetic beings, only kept from recovery by the failure of their illnesses to respond to medical treatment or their wilful inability to do what doctors prescribed for them. It was several years before I even began to consider the possibility that patients could actually help each other – and that there might be patients who could help others better than doctors could.
Patients had shown individual initiative in the past, but the hospital had either ignored or suppressed it because such action seemed either insane or directed against the organisation. Several men in Fulbourn used to write long letters of delusional complaint to the Superintendent. One man made aeroplanes out of lead wires, which could not fly; a woman knitted crazy patterns of brilliant colours; a man made false keys out of spoons; another man fashioned bizarre guns out of scrap metal. Even projects which served some better purpose were usually stopped if discovered. Jim mended watches for staff; a recovered melancholic, Herbert, repaired bicycles and created new ones from discarded old parts taken from the parish rubbish pit behind the hospital; several men had small vegetable plots hidden in the shrubberies or amongst the engineers’ lumber. But these activities had all had to be concealed from those in power, especially the Superintendent.
As we changed our basic attitudes toward patients, we began to see that our job should be to encourage patients’ initiatives, not suppress them – especially where it led towards a recovery of independence and the possibility of returning to outside life. We therefore made Herbert’s bicycle workshop official. We gave him better facilities and allowed him to sell the bicycles that he made and to bank the money. We then got him an interview with the Ministry of Labour, who tried to find a job for him. The first job failed and Herbert came back to bicycle repairing for some months. Then his brother-in-law asked him to help in his butchery business; for some months Herbert went out to work daily from hospital, and then he moved out into lodgings.
Leonard, the maker of lead aeroplanes, was also very fond of drawing schizophrenic diagrams – highly meticulous but strange works of art; they were much sought after by medical staff as souvenirs and regularly demonstrated to visiting medical students. We talked to him and found that he was interested in working in Percy Burgess’ workshop. At first Leonard just made aeroplanes, even bigger than before, but then he became interested in the tasks going on in the room and Percy Burgess allowed him to join in. Leonard became fairly skilled at painting the finished furniture. He had been in hospital for about 15 years; now that he was rather better he started writing to his wife, whom he had not seen since coming in. This upset her and she started divorce proceedings. I looked into the matter and it seemed that in reality she meant nothing to him as a person, but was a link with the outside world. For her part she had made a complete life for herself and her daughter and was terrified at the thought of a mad stranger bursting back into her life. I gave the necessary affidavits and the divorce went through. Leonard’s brothers, who kept a small farm, then got in touch with us and asked if they could have him to stay for weekends. They found him useful and pleasant, though rather odd, and after a few visits, had him home for good.
Not all stories went so smoothly. Dick, the maker of the bizarre guns, had a ferocious reputation because he had broken a policeman’s arm when they arrested him. He responded to increased hospital freedom by growing a black beard and stalking round the grounds with a scowl on his face. He built himself a little hut at the back of the grounds which he filled with all sorts of strange inventions and contraptions – a windmill to make electricity, a bicycle with extendable handlebars and a pigeon coop filled with feral pigeons that he had snared in a trap of his own design. I was under constant pressure to limit his activities, but it was the pigeons which finally did it. A tender-hearted member of the Management Committee was led to the pigeon coop by a disapproving staff member and found the pigeons sadly neglected. I had to bow to the storm, free the pigeons and dispossess Dick. However, he gradually settled; he took off the beard and then went out to work; he moved to Winston House. While there he sardonically presented me with a large, hoarded collection of Largactil to which the ward doctor had given all the credit for his recovery. After some months at Winston House, he moved off quietly to a working men’s hostel.
These experiences underlined patients’ ability to help themselves toward recovery if given the chance. We next began to notice their capacity to help others. For years individual patients, especially in follow-up and outpatient clinics, had told me how much help they got from talking to other patients and of how the patients helped one another. I had merely regarded this as a measure of the failure of the nurses or myself to give them the psychotherapy they needed. Gradually, I began to look at this positively. What could we do actively to encourage patients to help one another? At first, the principle was only applied spasmodically. When two certified patients, John, a middle-aged, depressed rascal, and Doris, a young simple-minded woman, escaped together during 1953, in my first year, I shared the fury of the staff. The pair had been away for nearly two weeks when Edna’s sister told the police, who swooped and caught them in a caravan, living as man and wife and making a good living at fruit picking. On their return, I immediately clapped them into the disturbed wards (M5 and F5) with deprivation of all privileges. It was only as I pondered on their exploit, that I began to realise that someone clever enough to plan this should be clever enough to live outside. I saw both John and Doris and began to work on their discharges. Within a year, he was out at a job and within two she had rejoined her family. They showed no interest in one another once they were out of hospital, and sought other mates. I kept in touch with them over the years. They both remembered the other with affection for the support given at a critical time.
The traditional staff reaction to hospital friendships had been to ‘break it up’ by moving the partners to inaccessible wards. Now I persuaded the staff to let the affairs run on for a time to see how things went. Sometimes it was clear that one patient was harming or taking advantage of a vulnerable person, but on a number of occasions, one patient helped another to regain enough self-confidence to face the plunge back into the outer world. The shock of failing, of having to come into a mental hospital, the stigma and the rejection of their families had destroyed their self-esteem and often made them feel that they were of no value to anyone. That someone had actually sought out their particular company and valued it was a first step towards a more hopeful view of themselves.
Unfortunately, not all recoveries were successes. In one of our long-term wards was a woman, Mrs Elsie Thompson, grossly mentally disordered though quiet and well-behaved. I only noticed her because some members of the HMC always asked about her when they visited the ward. It emerged that she was the wife of the Town Clerk of one of Fenland’s ancient boroughs. She had broken down years ago after the birth of her third daughter and remained in the Asylum ever since. Everyone in the Town knew of the tragic situation and respected the Town Clerk and the faithful and noble way he visited her regularly every other weekend. Elsie was one of those who responded dramatically to Largactil. Her mental disorder quietened, her behaviour settled, she began to help on the ward and began to care for herself. She emerged as a quiet, self-effacing, pleasant woman in late middle age. The ward staff were delighted and told the Town Clerk when he came to visit. They suggested weekends at home and then periods of trial leave. We were all delighted and triumphant. We did not notice that not everyone shared our enthusiasm. Elsie went home.
Two months later she was readmitted, certified again – and once again manifestly mad – unkempt, shabby and talking mentally-disordered nonsense. We settled her down and reinstated Largactil. In a few weeks she was well again, no longer mentally disordered, neat and tidy. We decided that the relapse had been due to a failure to take her Largactil pills regularly. She looked forward to her husband’s visits and we suggested he try her at home again, but this time to make sure that she took her pills regularly. Once again Elsie went ‘home’.
The next thing we heard, three months later, was that her body had been found in the river. There was an inquest conducted by the Local Coroner, a friend of the Town Clerk and a fellow solicitor. A verdict of suicide while of unsound mind was recorded and everyone expressed great sympathy for the Town Clerk. It was only several months later in conversation with the Mayor of that town that I learned that the Town Clerk had recently remarried – the secretary who had been such a support to him over many troubled years. It was much later that I learned that she had in fact been his mistress for many years and a second mother to his daughters. All those years while he came to Fulbourn every other weekend to visit his ‘poor mad wife’ he spent the alternate weekends at Newmarket with his mistress. We had done Elsie no service in removing her insanity and pushing her back into a respectable home where no one wanted her, where the husband yearned for his loving mistress and the daughters resented this stranger forced into their lives. Little wonder that Elsie finally drowned herself. As a result of this tragedy we learned to do rather more preparation before rushing people ‘home to their loving families’.
As I read autobiographical accounts by former patients and reflected on their stories of medical indifference, nursing cruelty and the helpful kindness of other patients, my ideas developed. I was also reading social scientists’ accounts of hospital life, especially Caudill’s story of his time as a ‘patient’ in a neurosis unit where the other people taught him how to be a ‘good patient’, and his tales of how groups of unfortunates had helped one another (Caudill, 1958). About this time a personal friend of mine in another city made a suicide attempt and found herself in a custodial mental hospital. She later told me of her resentment of the ‘close observation’ maintained on her; the anti-suicide precautions; her contempt for the nurses and most of the doctors, and her tremendous appreciation of the help she received from other patients in learning the rituals of the hospital, in circumventing the regulations and later in working out an approach to her intolerable domestic problem. This made me ponder hard on how we could further facilitate the therapeutic potential of the patients.
Some of our doctors attempted group therapy within the hospital, but it did not seem to go down very well. They assembled a group of selected patients from different wards and told them they would be meeting regularly and could discuss all matters freely. This was a method I had used successfully with outpatients. However, something seemed to go wrong with this scheme. At first, I heard a good deal from the doctors about how interesting it was and then nothing. Enquiry revealed that the meetings had stopped; the time was not convenient, the Sisters failed to send the patients down, the doctor had too much other work to do; there was always some reason. Another attempt at group therapy ended but more strikingly. Two doctors and a psychologist had been reading about Bateson’s ‘double-bind’ hypothesis, which suggested that schizophrenia was due to the patient getting equivocal messages from his parents during early childhood, so that his later communication with the world became permanently disordered. The two doctors proposed to set up a group for young schizophrenics in which the doctors would act as group leaders, taking the roles of mother and father and giving interpretations of the patients’ responses based on the theory. It sounded a bit far-fetched to me, but, in accordance with my principles of encouraging experimentation, I let them go ahead. They had about ten meetings. Several of the patients attending became very disturbed and were withdrawn from the group by the ward doctors. Several parents complained of the strange things their children were saying when they came home at weekends from the hospital; they did not enjoy being called ‘schizophrenogenic mothers’. Charge Nurses and Sisters began to complain that the doctors were undoing the work of months. Then the prime mover announced that he was going to London for further (and, he implied, better) training and the groups stopped. None of the patients suffered any obvious harm – there were no suicides – though several were very disturbed for months and it took a long time to win the confidence of some of the parents again. Group therapy inside hospital seemed different from outpatient groups.
In 1958 one of our Registrars, Eddie Oram, took over Adrian Ward, the women’s convalescent ward. He came and asked me if he might try to run it as a ‘Therapeutic Community’. I remembered my visit to Belmont in 1953 and what Maxwell Jones had told me about therapeutic communities during our four weeks at the King Edward’s Fund course in 1957. I had begun to wonder whether the Therapeutic Community approach might not be a good way to involve the nurses more and, in particular, to make the patients partners in the treatment process. I agreed to let him try. However, having heard tales of the upsets that these therapeutic communities caused, I was quite anxious about what might happen. Still, Eddie Oram was a level-headed man who had worked in many parts of the hospital and who was trusted by the Consultants, respected by the senior nurses and well liked by his fellow doctors. If he could not carry it through, no one could. I put the idea to Miss Brock, who was enthusiastic. The elderly sister of Adrian Ward was due to retire and we picked a younger woman to run the ward, Kay Kinnear, whom we thought might cooperate in these new ideas. We sent Dr Oram down to Belmont for a few days to see the work of Maxwell Jones and he read the books about other similar projects.
Since its opening two years earlier Adrian Ward had been used for the overflow from the women’s Admission Villa. As the pressure of new admissions mounted, patients who were improving but were not yet well enough to leave were sent to Adrian Ward. The ward held up to 40 women, some about to leave, going out regularly on weekends, others still upset and confused or having the last of their ECT treatments; others moderately well and receiving psychotherapy, but not yet thinking of leaving. The ward doctor on Adrian had spent his time seeing patients, assessing progress, adjusting medication and providing supportive individual psychotherapy; the elderly sister had organised the nurses to run the ward and the patients tended to sit about knitting and talking sadly about their symptoms, their illnesses and their difficulties at home. In its brand new building, it was the most handsome ward in the hospital with the most comfortable accommodation and we had expected that patients would wish to go there, especially to escape the Admission Villa, which was often clamorous with the noise of new arrivals. However, they would often refuse, and even go home before time, saying that Adrian was unfriendly, ‘snooty’, dreary and unpleasant. It was not clear to us why this should be so.
Eddie Oram proceeded with caution and good sense. He drafted his plan and discussed it with the Consultants, with Miss Brock and with the nurses. He then called the patients together and told them that the ward was going to change and that they were going to run it. They would be responsible for all housekeeping; there would be a series of group meetings, of which the most important was the weekly ward meeting, where everyone – doctor, sister, nurses and patients – would be present and where all important decisions would be taken; he said further that he would rarely see them individually and then only by appointment. After the protests had subsided, he explained that all this was to prepare them for the responsibilities they would shortly be facing outside.
I heard all this at second hand. Eddie would tell the doctors’ morning meeting of his latest moves. I encouraged him to come and talk to me of what he was doing, but he seldom did so – partly I think from a desire to work things out for himself, partly for fear of the repercussions that would arise if people knew he was telling things to the Superintendent. I gradually came to see my task as tempering the complaints and other complications that arose and particularly in reassuring Miss Brock who was upset when the standard of cleanliness fell after self-government began. After a period of disorganisation when beds were left unmade, when women stayed in bed all day and when the first comers to meals ate the best of the food, the women began to organise themselves, set up work rotas, and lay down general rules for their group life. The nurses were at first upset at having ‘nothing to do’, but soon found plenty of work in counselling and discussions with the patients. After some weeks of exploration, the meetings became very active and the women began to talk openly of their fears of leaving hospital, of the stigma they would face, of the problems from which they had taken asylum and which they must now face again – the unsympathetic husband, the complaining mother-in-law, the demanding children. A number of ward feuds, which had been covert for months, came into the open, and the tyranny of one well-established, dominant woman, Marion, was challenged. Marion was an artistic, attractive women of histrionic and dominating personality who had been in the ward a long time. She had received a great deal of personal psychotherapy from junior doctors and had for long claimed the best of everything; this right was now challenged by the other women in a series of stormy meetings.
All this time, Eddie Oram was maintaining the usual service, assessing drug dosages, arranging leaves, and writing discharge letters. The Consultants were satisfied. The junior doctors had rather more night calls to the ward, but they were mollified by his explanations. The other nurses in the hospital were, however, very critical. Some of them disapproved of all the freedom and of the long sessions of discussion between the doctor and the nurses. They expressed these feelings so forcibly in jibes and veiled remarks that Sister Kinnear stopped going to the staff dining room for a time, saying that she preferred to take sandwiches on the ward.
One morning, at 6 a.m., before any staff had arrived, a fire broke out in the sitting room of the ward; the patients called the duty staff and the fire brigade and started putting the fire out. By the time that I and the fire brigade arrived the blaze was under control, and very soon cups of tea appeared for everybody. This incident was a turning point. The patients of Adrian Ward had coped with an emergency without panicking; the rest of the hospital had to admit that these patients could look after themselves quite well. Within the ward, too, they felt more confident. We never found the exact cause of the fire; it had started in a wastepaper basket that had then ignited the curtains; Eddie and I suspected that it was a deliberate act of spite by Marion against the new regime, but we could not prove it.
The Adrian Ward meetings continued actively. They arranged a number of outings, set up a welcoming committee to help patients just transferred from the Admission Villa and made several trips to the Admission Villa to improve relations. In an attempt to overcome their fears of the ‘main building’, some Adrian patients arranged to have a tour of the long-stay wards; several reacted to what they saw by trying to help – some gave singing and piano sessions on long-stay wards and Marion ran painting classes for a group of regressed women on a long-term ward. This class was a turning point for her, as it made her feel that there were people she could help; some months later she got a job in Cambridge to which she cycled daily. The change in Marion’s behaviour demonstrated clearly how the changed atmosphere operated. Previously, she had been very skilled at being a patient; she attended her psychotherapy sessions, she painted ‘schizophrenic paintings’ for the doctors she liked, she dominated the sitting room but dared not think of leaving. After the change, she found herself in an atmosphere of rehabilitation where her domination was challenged by other patients; she was provided with chances to help others, then to work, and finally to re-establish herself in the outside world. I heard of many of these things in a roundabout way, or months afterwards, but I could see for myself how different Adrian Ward was. It was less tidy, but more homelike. The women did much more. Patients from the Admission Villas seemed to pass through more effectively and rapidly and often seemed to make more stable recoveries.
There were, however, problems. Just before the annual Open Day Miss Brock, going round, had found the ward untidy and ordered Sister Kinnear to get it clean – an instruction which annoyed the ward meeting but which was obeyed. Some experiments failed altogether. Dr Oram proposed to the nurses that the staff should use each other’s Christian name and that they should call him ‘Eddie’ not ‘Dr Oram’. They complied, though awkwardly. After a week, the patients came to him in a deputation asking for things to revert to the way they had been.
The Adrian therapeutic community ran for 18 months under Eddie Oram and Kay Kinnear, from 1958 to 1960. After she left another Sister was appointed, but was so disturbed by the patients’ freedom to comment on what they did and did not like that after six weeks she asked Miss Brock for a change. Another Sister took it on and settled in well. In due course, Eddie Oram handed over to another Registrar. By that time however the pattern of self-government was well settled and the weekly meetings went on regularly, some doctors contributing more than others. Under the leadership of one extrovert doctor, the patients adopted a group of crippled children and gave a series of lively parties; under another quieter doctor they held more discussions. I was very pleased that the project had worked so well and survived its various crises, and wondered where we could next apply the notion. The general principle of self-government was by now accepted in the hospital as a desirable aim, but there were doubts as to how far it might go. Eddie Oram and I, with Douglas Hooper, our research social psychologist, wrote and published an article about the Adrian experiment (Clark, Hooper and Oram, 1962).
The men’s disturbed ward had also begun to develop their own pattern of patient government. The first Charge Nurse, Joe Pattemore, who had opened the ward door, had always consulted the patients about any major development or excursion and had shared his plans very openly with the other nurses on the ward. When he moved to other work, Tom Lewis took over as Charge Nurse and decided to explore self-government. The main problems of the ward at the time were certain schizophrenic men who repeatedly misbehaved; one ran away frequently, another shouted obscene abuse at passers-by from the ward windows, a third absconded and broke into churches. Lewis called a patients’ meeting to discuss ward problems, in particular the behaviour of these particular offenders. This proved to be a very lively meeting and became a regular feature of ward life. The Chairman and Secretary were patients, selected by staff and patients and holding office for a few weeks; they conducted the business and kept the minutes. The Charge Nurse and the ward doctor attended but held no office. All proceedings were kept fairly strictly to order, but many ward subjects were discussed. At times the meeting wrote to the Management Committee; at one period, when they had an accumulation of problems, they invited me to attend and put their difficulties to me, courteously and firmly. One of their Chairmen, a former Naval Officer, sat with ‘Chairman’s Rules of Debate’ on one side of his table and ‘The Mental Health Act’ on the other. At a later period, they