Psychoanalysis and Psychotherapy
The Story of a Mental Hospital: Fulbourn, 1858-1987
by David H.Clark.
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 Chairmans 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 Chairmens 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 womens 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 Fulbourns 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 Streets 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 195758, the mens 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 Tuckers 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 Longs attempt to bring some order and competence into the administration of the mens wards was little liked.
The mens 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 weeks 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 Streets 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 Richards 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. Hausers 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 Hausers 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 Hausers 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 Hausers 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 195859, 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 psychiatrists 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 Hausers 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 Addenbrookes.
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 firms 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 mens 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 womens 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 Chairmans 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 Advisers report came through.
Despite the necessity for this action and the Sisters 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 Womens 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 Womens 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 Womens 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 womens 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 Wheatleys 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 Wheatleys 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 everyones 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 Addenbrookes 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 womens 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 lifes 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 womens 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 womens 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 womens 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 interpreters 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 Fulbourns 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 ones 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 gardeners 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 tutors help and arranged for a weeks 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 Britains 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 Addenbrookes, 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 Addenbrookes 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 Addenbrookes and the girls, enjoying themselves greatly, took good tidings of us back to Addenbrookes. 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 Superintendents 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 Addenbrookes 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 Herberts 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. Leonards 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 policemans 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 mens 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 Ednas 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 Fenlands 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 husbands 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 Caudills 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 Batesons 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 womens 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 Edwards 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 womens 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 Marions 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 others 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 mens 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 Chairmans Rules of Debate on one side of his table and The Mental Health Act on the other. At a later period, they produced a ward magazine, which featured a letter from a recovering catatonic youth, thanking all for their understanding of his behaviour in his confused phase. This gratitude was appropriate, for when he was very psychotic he had rushed round the ward alternately kissing and hitting the other patients. They had found this very annoying, but a ward discussion had defeated a motion to ask the staff to lock him into a side room in favour of one proposing a policy of greater understanding.
Again, I was only involved marginally in this project; I was happy to see it develop, and pleased when I received petitions from the patients that I could take to the Management Committee. This irregularity would irritate some of the stuffier hospital officers, who would mutter that this matter should have been brought up through the proper channels which gave me the chance to remind them that as far as I was concerned the only purpose of the Management Committee was to serve the patients.
I personally found all these developments in patient government most interesting and longed to do some of it myself. It became clear, however, that the doctors running these projects, while gratified by my interest, only welcomed me as an occasional visitor and were not keen to have me there very often. Once again I realised that my function as Medical Superintendent was to protect their work, particularly from administrative interference, but that they had to run their own shows and that I could not directly take part. My own chance to do some work of this kind came eventually in 1960 after we had reorganised the long-stay womens wards.
During the late 1950s the patterns of consultant responsibility within the hospital changed as a result of the 1959 Mental Health Act. In 1953 I had accepted the job of Medical Superintendent on the traditional terms (based on the 1890 Lunacy Acts), that I was responsible at law for the custody and treatment of every patient in the hospital. After 1959 each patient now had a named Responsible Medical Officer, who was answerable for the treatment given to that patient. This was quite clear on the admission wards, where each Consultant admitted, treated and discharged the patients for whom he was Responsible Medical Officer. For the long-stay patients the position needed clarification as they had previously all been the responsibility of the Medical Superintendent. Now we divided the responsibility for the long-stay patients between the three full-time Consultants: Leslie Buttle, Oliver Hodgson and myself. We rearranged this several times during the 1960s; these changes gave me a chance to concentrate my personal attention on the long-stay patients, particularly the most disturbed.
At first, in 1960, I took on a group of long-stay women patients which included all those most disordered mentally and most in need of rehabilitation. Amongst my wards was the one which had been known as the Womens Disturbed Ward, F5. I was glad, at last, to be able to turn my attention to this group of patients and nurses; when I first came to Fulbourn it was this ward which had dismayed me most.
On my very first visit in 1953 this ward was filled with turbulent women, shouting and screaming. Though I became inured to many things in my early months, entering ward F5 never failed to dismay me. As I unlocked the door I would be surrounded by a mob, clamouring and grabbing at my clothing and fingering my pockets. The Charge Nurse, Sister John, would soon loom up, craggy and forbidding, shouting at them to get back, which they hastily did. Making it clear that she resented my interruption of her work, she would escort me round the dreary ward, which was floored with hard terrazzo and had a dark green dado up the walls and no decorations. In the far room sat the wet and dirties; pitiful creatures forced to sit on hard wooden benches, dressed in strong clothes indestructible, shapeless, colourless garments of quilted cotton, stained by food and urine and bleached by innumerable boilings. If they got up, they were curtly ordered to sit down again. Beyond them again were the padded rooms, nearly always occupied, sometimes by a jovial and truculent manic woman, squatting naked and roaring obscenities, or else by a terrified creature who would shrink back into a corner, as if expecting to be hit again. I was disturbed, too, by the attitudes of the staff in this ward; they seemed harsh and unfeeling, shouting contemptuously at the patients and using phrases that dismayed me. Thats a bad one, doctor murder you as soon as look at you! a nurse said once, pointing at an apparently harmless woman cowering in a corner.
In 1953 I was disturbed and revolted by F5 but did not know what to do about it. A compassionate doctor bitterly recounted the tale of an attempt by one of the occupational therapists to organise knitting for these unhappy people, which had stopped after the Sister had gathered all the knitting and locked it away, saying that it made the patients too excited and difficult to handle. I knew that tales of this ward circulated round the rest of the hospital. Any woman who misbehaved might be sent there as punishment; offenders would beg with tears in their eyes Please dont send me to Fives, Doctor! When I had to go into F5, I tried to indicate my disapproval of the staff attitudes. I would stop and talk to patients who asked to speak to me, sitting down beside them on their greasy benches or squatting on the floor of the padded room to chat, trying to ignore the gathering squad of strong nurses, ready to pounce on the woman if she attempted to strike The Doctor. I knew the nurses did not like my chatting to the women like this, but felt I had to show how much I disliked the way they themselves treated the patients. My efforts, however, seemed to make little difference. I was also forced to admit the utility of the ward for the rest of the hospital; this was dramatically shown when the epileptic sister of a famous boxer was admitted in a raging temper, after she had severely damaged several policemen. No other ward could handle her, but after a few days with Sister John, she was as gentle as a dove.
Feeling that I could not yet deal adequately with F5, I made no attempt to change it in my first year. The staff there had a nasty and tough job to do controlling the violent women; I did not like the way they did it, but with the shortage of women staff, I could not see how else it could be done. Tentative explorations with Miss Brock showed that she would not tolerate any attempts to change Sister Johns ways; she was thankful that the ward at least managed to do its job and was not prepared to interfere with it.
Towards the end of 1954, when Fred Houston took over clinical control of the mens side, I took over the womens wards from Leslie Buttle. I was now responsible for what happened in F5 and even more worried about it. However, I had to start by concentrating on another ward F4, the infirmary ward and trying to raise the standard of physical nursing there. Meanwhile, Miss Brock was attempting to get better clothing and belongings for the patients in Ward Five. She managed to substitute new, floral-patterned strong dresses for the old bleached ones. As junior doctors spent more time on the ward (because they found it less unpleasant than it had been in the past), some of the consequences of inadequate medical attention for many years were remedied. Epileptic fits were better controlled, medication was increased, decayed teeth were drawn and spectacles supplied.
At the end of 1955, we rearranged the womens wards and this gave us a chance to make a major change for the disturbed women. We offered Sister John new premises for her patients upstairs in a nearby building. At first she was unwilling to go, but when she discovered that it was to be repainted (in colours of her choosing), to have rugs and curtains and entirely new furniture, she became reluctantly and then excitedly interested. She complained, however, of the lack of a padded room, and brought this up truculently at a Sisters meeting. I said I thought she could manage without one, but said that if after three months trial she still felt she needed it, I would ask the Management Committee to install one. At the end of 1956, we moved the wards and Sister John and Ward Five moved just before Christmas.
In 1957, I put Arnold Orwin on to Sister Johns ward for a number of months. He was an able young doctor with a strong sympathy for the unfortunate and an active approach to suffering. He was always ready to try any remedy on another ward he was experimenting with hypnosis, which he found congenial. Although he began his time in the ward disapproving of some of Sister Johns ways and she his brashness he and the sister soon established a mutual respect which blossomed into a confident partnership. He respected her vast knowledge of the patients, with whom she had worked for nearly a quarter of a century; she liked the energy with which he took action on any problem presented to him. He reviewed all the patients, in some cases recording the first adequate assessment for years, and applied relevant treatment; for many patients, he arranged prolonged courses of ECT (1520 treatments) as proposed by Kalinowsky, the American expert; for others, trials of the tranquillisers that were then becoming available. A number of patients were given a chance to try occupational therapy or work assignments and contacts were re-established with some of their families. I, as Consultant, was of course asked to approve these treatments, but I nearly always consented, feeling that this active approach was far better for these women than the the neglect of the previous years.
The ward was now a different place to look at. It had a name, Hillview, rather than a number and was an attractive, light, airy place, painted in pastel colours, with bright rugs and curtains. When I entered it, I would see a group of neatly dressed women sitting round the fireplace doing embroidery. By this time, the general increase in numbers of women nurses had enabled Miss Brock to increase Sister Johns staff and there were more nurses to be seen about. At the far end the incontinent patients were still congregated, but they looked less repulsive; their dresses were colourful, their faces washed and their hair combed; they no longer stank of urine and paraldehyde. Occasionally, a disturbed patient would be shown to me locked in her side room with the shutters closed, but this was far better than the smelly, grey, padded cells. There seemed to be far less shouting by the nurses, and even Sister John, though still stern and forbidding, no longer talked of the patients so disparagingly. I felt I could take visitors into the ward and often did so. We were gradually opening the doors of the womens wards and in the spring of 1958, Sister John yielded to the general pressure from her fellow Sisters and nurses and from Miss Brock and myself and declared the ward door open. This was the last ward in the hospital to be opened and we could now claim that Fulbourn was an Open Door Hospital a great day for us all. However, Sister John retained the right to lock the door when she felt it necessary and exercised this right frequently.
In my early days at Fulbourn, I had hoped to get a social scientist to work at the hospital, both to inform us about the processes going on (as Schwartz had done at Chestnut Lodge) and also to record the old asylum life as it changed to something better. During 1955 and 1956, I discussed the possibility with Oliver Zangwill, put up reports to research foundations, and interviewed promising young social psychologists. It took a long time, but in 1957 Douglas Hooper, a social psychologist, started work on a three-year grant. I suggested that he study Hillview Ward. He had seen the women in the old days in Female 5 and agreed to study the changes in the social pattern as the ward door of Hillview was opened. He spent long periods on the ward observing the life of the staff and the patients and recording the type and frequency of their interactions. A charming, quiet man, he was soon accepted by the staff as unthreatening and he gained a very good picture of the way the ward operated. A year later, after the opening of the ward door, he repeated his observations.
Douglas Hoopers period in the hospital was of great value and importance to me. I found it immensely helpful to be able to talk to someone who saw the hospital as a functioning social organism and who approached things sociologically. Douglas was a discreet man and I found I could ventilate to him freely my hopes and fears about the hospital and its functioning. He was with us all through the Hauser episode and had behaved with great good sense and restraint. During my tensions with the junior doctors with whom he lunched regularly he kept their confidences and mine without losing the trust of either and probably contributed a good deal to their final resolution. He was very useful in the hospital in showing the contribution the social sciences could make to the understanding of hospital or ward happenings and in arousing in many people a better understanding of what they could contribute. He helped with a number of other social studies, particularly on Adrian Ward, but his central work was on Hillview.
Initially, I was quite perturbed to learn of his findings on Hillview, because he showed that though the place now looked different, there had been really remarkably little change in the social structure. Though the door was open, very few patients were free to go out. There had always been a group of privileged patients who did much of the housework of the ward and led a fairly good life, even in F5. Now they were more obvious, but the membership of the group had not changed. There was a group of less privileged women and then the wet and dirties, without any privileges at all. Though they were more presentable than in the old days, they were still kept sitting down, with practically nothing to do, and seldom hearing anything from the staff but curt orders. He showed, too, that though episodically disturbed patients from other wards moved in and out of Hillview, there had been very little movement amongst the main residents of the ward, some of whom had been there many years. In short, Douglas Hooper showed that though the ward had been made much more presentable there had been no change in the social structure of the ward and the long-stay patients were making no progress toward recovery.
This presented me with a challenge, which I could see no way of meeting at that time, so I decided to let things run on for a bit. During 1959 I was forced to realise I could not leave things as they were for much longer. Two deeply disturbed adolescent patients were transferred to Hillview, which proved incapable of handling them, despite locked doors and massive sedation. One of them attacked Sister John and injured her, so that she had to go off sick for a time. This shook her self-confidence; in the past she had always prided herself on her ability to tackle any woman, however tough, and to absorb bruises and violence. She was now over 60 and realised that she was not as strong as she used to be. She began to talk of retiring.
Towards the end of 1959 Sister John finally announced her intention of retiring in a few months. Here now was a chance for me to tackle the challenge of the disturbed women a problem I had been dithering about for six years. At last there was a real chance to apply social reorganisation to a difficult and challenging group and, what was more, a chance to do it myself. I wanted to see whether the Therapeutic Community approach would work with these people as it had with others in Fulbourn. I spoke to Sister Kinnear, who had done so well with Eddie Oram on Adrian Ward, and found that she also felt the challenge of these women and wanted to help them. Miss Brock revealed that she too had always been unhappy about the way that ward was run and we decided to make changes when Sister John retired in the spring.
Sister Kinnear took over in the spring of 1960 with a new group of staff. She immediately began treating the patients more tolerantly and relaxing the firm discipline. I started coming to the ward more frequently and discussing the problems with her. At this stage, the junior doctor was a bright, intense young man who also believed that a more understanding therapeutic approach was needed. All went well for a few months, and then I had to transfer to the ward a deeply disturbed, middle-aged Scots woman, Mary Bruce. A year earlier, she had been admitted to the admission ward following a determined effort to kill herself; she had persistently attempted self-damage and at times there had to be two nurses on constant duty to prevent her beating her head on the floor. This behaviour persisted despite tranquillisers, antidepressants and courses of ECT; discussion was of little value, for she remained sullen and out of contact, just reiterating that she wished to die because her husband had left her for another woman. She then started attacking the nurses and at this stage, I was asked to take her over and so transferred her to Hillview. Her disturbances were now episodic, and for periods one could hold conversations with her, though one could make little real contact.
She soon settled in Hillview, but got together with a group of other violent women. They would sit together at their table, chatting in low voices and laughing; the nurses said that they egged each other on to acts of violence. A few windows had been broken previously on the ward, but now the number rose sharply, until they were being broken every day. The nurses asked for more sedation and control; we broke up the group, putting them on separate tables, increased their sedation and provided them with other activities. I began to hold staff meetings one morning a week when we would discuss major problems on the ward. As the summer wore on, there were more difficulties. Mary Bruce began attacking members of staff, putting her hands round their throats and throttling them. She was strong, and this frightened the smaller nurses. I talked with her, but she could not explain what caused these episodes. On one occasion she did it with me, passing into a sort of trance and twining her fingers round my neck to strangle me. I found that I could disengage her fingers but could still not make contact with her. I discussed this with the staff group, sharing their anxieties. We ensured that no one was left alone with Mary, especially not young or small nurses.
One day Mary, rushing towards the door, pushed Sister Kinnear down the stairs so that her ankle was broken; she was off duty for many weeks and her deputy had to take charge. At the next staff meeting, I found a shaken group. One nurse had asked for a transfer, another was off duty with a cold; that morning it had been difficult to get anyone to take Mary Bruces breakfast in to her. They were all afraid of being hurt and soon admitted it. I too felt frightened and dismayed. I wondered if Sister John had not perhaps been right, and that the only thing to do with these women was to hold them under rigid control.
I realised I must do something. I put Mary on regular ECT, which checked her over-activity; I increased sedation all round; I got some extra nurses on the ward. The nurses became more confident and the whole ward settled down. I felt, however, that what I had done was a step back, a return to authoritarian control.
One of the nursing assistants, Jean Salter, had been making an especial effort with another patient a leucotomised, schizophrenic ex-nurse called Katherine taking her with her during her duties, talking to her, attempting to understand her. Despite this, the patient constantly struck others and at times staff. We often discussed Katherine and her family at the staff meetings, but could not understand her behaviour. Then one morning I heard that Jean Salter had just gone to the Matron with her resignation. The day before she had lost her temper with Katherine and slapped her face; she felt that such behaviour showed that she was unfit to be a nurse and that she must leave. I saw her and heard her story; I realised that we had failed Jean in letting her carry all the burden of Katharine herself. I felt we must bring her back into the team and I persuaded her to tell the staff group about it at the meeting next day. She told her story with great feeling, stressing how she had given Katherine all the affection of which she was capable and how ashamed she was of her outburst of anger. This honest and painful story affected all of us and provoked a flood of response from all the staff there, trained nurses, student nurses and doctors. We began to talk of our own occasional feelings of fury toward the patients and our difficulty in accepting or controlling these. A strong feeling of fellowship emerged as we discussed how these seemingly ungrateful, hostile, bitter women upset us and how we found it difficult to go on being understanding and kind. We realised that we had all been happy to let Jean carry the burden of Katherine and we acknowledged that we should have shared it more. This deeply moving meeting was the beginning of real team work on Hillview; from it emerged a common policy for helping Jean and Katherine and sharing of our own disturbed feelings; Jean withdrew her resignation and remained a valued member of the team.
I began to realise that if I was to do a good job of making a Therapeutic Community in Hillview, I must make it a higher personal priority. I started weekly ward meetings on Hillview on Wednesday morning, followed by staff meetings. I told the porters and my secretary that I was not available at those times and that I would not answer the telephone. The ward meetings were conducted in the Belmont Therapeutic Community manner. All patients and staff sat in a circle and anyone might speak of anything they wished; the meeting went on for an hour. I was the conductor and at first all remarks were addressed to me. For the first few meetings the talk was of necessary repairs on the ward, windows, cupboards and doors, but soon we came to discuss individuals and their behaviour and the ways they reacted on one another. I tried whenever I could to bring other people in, to pass queries to other staff members and to turn the talk to enquiring the causes of disturbing behaviour, rather than discussing methods of controlling it. However, it was not easy. A number of patients were simple-minded or poorly educated, and many of my long-winded polysyllabic statements were lost on them. They tended to shout at one another, and often three women would be yelling at once. They would then become violent, and many early meetings were punctuated, or even terminated, by brawls. One patient, Jane, was a major problem; the simple-minded adolescent daughter of a professional family, she had developed a catatonic schizophrenic disorder and was constantly hallucinating. She would suddenly yell Tick-tock! Tick-tock! Deathwatching my life away! and hit her neighbour hard. Naturally, this frightened and annoyed the other patients. In the meeting we got Jane to talk of the voices that tormented her and the others became more understanding. However, they still did not like being hit and asked for her to be controlled. Though the nurses were able to manage Jane, they were still upset by Mary Bruces throttling attacks, which had now returned, and Katherines occasional outbursts of violence, as well as competitive window smashing which not only made the ward very draughty but brought a good deal of heavy humour from the maintenance man who was constantly being called in to replace the glass.
All these problems gave us plenty to discuss at the staff meetings which were attended by the ward doctor, myself, Sister Kinnear, the student nurses, the nursing assistants and the occupational therapist. We soon developed a strong team feeling. I tried to bring about open and equal discussion, but found that the bulk of the conversation fell to me, with Sister and the ward doctor contributing a little. I was greatly pleased the day the staff actively criticised something I had done earlier at the ward meeting. Jane had been sitting beside me holding my hand and had then leapt up to cross the circle to hit Mary Bruce, who had been taunting her. I held on to her hand, and was towed across the room by the beefy girl; the nurses leapt up and had difficulty in sorting out the melee. They said afterwards that I should not have got into the fight; that was their job, not mine; mine was to conduct the meeting, which found itself without direction during the scuffle. I had to admit that they were right and furthermore that though I might know a lot about psychiatry and psychotherapy, I did not know much about how to separate fighting women a skill which the psychiatric nurses certainly had.
The nurses went on to talk about how they resented doctors who invaded the nurses areas of responsibility by taking over the feeding of catatonic patients, or by the soothing of disturbed hallucinated ones. They pointed out that this was often an implicit criticism of the nurses and they commented that the doctors, after spending half an hour doing this, would then get up and go from the ward, leaving them with the patient for the next eight hours. As I listened to all this, I remembered how I used to irritate Sister John by going into the padded cells and chatting to her patients; I began to realise what she must have faced in the wartime years when, owing to shortage of staff, she was left alone for hours with 50 women like Mary, Jane and Katherine, with no tranquillisers and no ECT, only paraldehyde and her own good sense to keep them all from chaos and homicide. I began to realise that I had been hasty in my condemnation and that the management of violently disturbed patients was far less easy than I had thought.
However, the ward meetings continued and Hillview began to change. This was now the most exciting part of my work in the hospital and I greatly enjoyed being closely involved with the patients. Gradually the violence settled down, both in the meetings and in the ward. Slowly the occupational programme became more effective and more varied until everybody was doing something most of the day. Katherine made marked progress; her homicidal attacks ceased and after severe trial visits she went home for good. We also successfully analysed Mary Bruces strangling attacks in the meeting; it emerged that she was seeking revenge on her husbands mistress and was doing it by going into dissociation (she was a Spiritualist and an amateur medium) and attacking the nearest person. As the staff and patients came to understand this their terror left them and gradually Mary was weaned from the strangling attacks. In due course, she started going out to work. Jane remained hallucinated but gradually came into much better social and emotional contact with others and was seldom violent.
Other disturbed and disturbing women were transferred to the ward and we attempted to understand and help them too. The standard of cooperation and ward work rose markedly and the patients took over many tasks, such as washing up and cleaning. The ward meeting became well-established so that Sister or the ward doctor could conduct it when I was away. It became a point of interest for visitors and Reg Salisbury, the Nursing Tutor, brought so many student nurses to experience it that we eventually had to limit the number of visitors! The Hillview nurses developed a high level of understanding of personal and social dynamics and, more importantly, an ability to feel their way into what was tormenting a particular patient at a particular time. I heard that Hillview had become a sought-after assignment with the junior nurses, instead of a place to be avoided, as Ward Five had been. It was, they said real mental nursing. The seconded student nurses from Addenbrookes had at first been kept away from the disturbed ward at their Matrons request; now they clamoured to come to Hillview and, when permitted, pressed for more time there.
Although all this was most gratifying, the real test was whether this reorganisation had truly changed either the life of the ward or the fate of the patients. Douglas Hooper repeated some of his measurements and some statistical assessments; now there was no question that a change had occurred. The staffpatient and patientpatient interactions formed an entirely different pattern from the old days, when most patients heard little but No! and Sit down! and Stop that!. Now, the responses tended to be positive; there were attempts to involve them in conversation, to explore alternatives, to engage them in positive action. The approaches often came from other patients as well as staff. The analysis also showed that several of the long-stay patients had moved from that ward to better wards and even on to their homes. Social movement and rehabilitation were occurring, where before there had been stasis.
This proved at last that though the old method of impersonal control had been effective in checking violence among a group of deeply disturbed women, and was economical of staff, it did tend, like all custodial methods, to produce dependence and social regression. It had also dehumanised the patients. The Therapeutic Community, on the other hand, tended to promote social recovery and gave the patients human dignity. It was more satisfying to intelligent and sensitive staff and was more humane and dignified. However, it did require more staff and it was perplexing and exhausting work. To open oneself fully to the tortured feelings of the deeply mentally ill is very disturbing. It was clear that the full and informed support of a good staff team was necessary for people undertaking this kind of work.
In 1959 the Hospital Management Committee asked me to visit the other East Anglian Mental Hospitals to see what they were doing and to see if they had any useful new ideas. During December 1959 and January 1960 I visited each one with the professed aim of seeing their work and gathering comparative statistics. I produced a report in which I noted that I entered 65 wards in two months. For the benefit of the HMC I gave accounts of how the hospitals looked and what they were doing as well as many comparative figures on staffing, overcrowding, facilities and suchlike.
I saw much that I envied; Hellesdon Hospital at Norwich had new spacious buildings and a delightful admission unit built in the 1930s. St Audreys Hospital at Woodbridge had excellent workshops for their male patients. St Clements Hospital was a cosy little hospital in the centre of Ipswich. However, I found the visits depressing overall because many of the practices in these hospitals were still backward and oppressive. I saw padded cells in regular use and occupied (we had removed ours two years earlier). I saw locked wards full of tensions and violence we had been an Open Door hospital for two years. I saw hordes of idle patients milling around vast, overcrowded wards. Although there were some good traditional workshops, the level of patient activity was low. None of the hospitals had an Industrial Workshop, as we had. None of them had patients going out of hospital to work, nor did they think it possible, while we had about 30 people going out to work in Cambridge every day. None of them had a halfway house. The vists in this respect served as an important tonic for me especially after the uncertainty and self-doubts of 1958.
In October 1957 I had addressed the Social Psychiatry Section of the Royal Medico-Psychological Association about how I thought a mental hospital should be run. I called the talk Administrative Therapy; it was published in the Lancet in 1958 (Clark, 1958) and in a revised version in the American Journal of Psychiatry in 1960 (Clark, 1960). As a result, I was invited to go on a lecture tour of American psychiatric hospitals; in October 1961 I spent six weeks there, going from coast to coast.
I was very excited at the prospect of my trip. Like every restless young man in postwar Britain, I had yearned to go to America. The United States in those days was the land of dreams of unlimited wealth, opportunities and riches, the country which had conquered the world, the land of the films we had all seen, of mountains and prairies, of Cadillacs and film stars. Some of my friends had gone there for postgraduate study; a number had emigrated and prospered. Now at last I was going to visit it, and see what it was actually like.
The tour was delightful. I experienced the heartwarming generous hospitality of Americans so much more open than anything in Europe. I saw something of the breathtaking beauty of the great continent. I tasted the heady intoxication of American lecture audiences so courteous, so appreciative, so flattering with none of the carping, penetrating, deflating comments I knew so well from Cambridge and the Maudsley. I talked everywhere of what we were doing in Fulbourn and other British mental hospitals, of open doors, of activity, freedom and responsibility for the patients, of Industrial Workshops, of halfway houses and of Administrative Therapy. My talks were well, even enthusiastically, received. I went to ten cities, including Boston, New York, Washington, St Louis, Omaha and San Francisco, visited 25 hospitals and gave 18 lectures, all in six weeks. However, I drove myself so hard that I collapsed with acute lumbago and had to be flown home in a corset.
This trip was personally fulfilling for me but was also an important event for the hospital. Never before had anyone from Fulbourn been asked to lecture internationally, never before had any East Anglian Superintendent been asked to cross oceans to tell of the work of an East Anglian mental hospital. It was an external validation of what we were doing which confounded some of my critics, both in the hospital and within the region. There was of course envy, jealousy and backbiting, and I had to endure a good deal of humorous comments about superintending from a distance of 5,000 miles. Nonetheless, the fact that the Americans wanted to hear about the work of Fulbourn Hospital, and in particular admired and wanted to copy our Open Door policy, was noted in the local newspaper and elsewhere.
I also brought back a number of useful ideas with me from the States. I saw volunteers being used very widely in some American hospitals. We had a few volunteers working at Fulbourn, but somehow they seldom stayed long. I noted that the American hospitals with successful volunteer schemes took good care to support and organise them well. I suggested to the HMC that we should have a Voluntary Services Organiser. Over the next two years funds were obtained (from the Nuffield Provincial Hospitals Trust) and an Organiser was appointed in 1963 another first for Fulbourn.
I also saw that some American hospitals had a wide range of specialist technicians helping their occupational therapy departments and that some of these were very valuable for selected patients. I visited several halfway houses, but was particularly impressed by Fountain House, New York a fascinating and stimulating self-governing day centre for discharged patients from mental hospitals. Another place I visited was Stanford University near San Francisco in California, where Dr David Hamburg was starting a pioneering department of psychiatry. Nearby was a postgraduate institute, the Center for Advanced Study in Behavior Sciences; some of my Cambridge academic friends, notably Meyer Fortes, the Professor of Social Anthropology, had told me about the Center. They apparently invited scholars of the Social Sciences from all over the world to spend a year there. Scholars were flown in with their families from wherever they lived, given a house, a salary, a study, a secretary and unlimited leisure for a year; all their expenses were paid, and there were no obligations on them to lecture, teach or treat patients merely the hope that they would use the time to forward their academic work. It sounded like an academics heaven.
Some months after my return I was amazed to be offered a place at the Center for 196263. My wife and family were delighted by the idea and so I asked the Regional Board for a years leave without pay; they could hardly refuse, since it would cost them nothing. A locum was hired to do my clinical work while I was away and Oliver Hodgson agreed to act as Medical Superintendent for the year.
Gradually, I ran things down and hectically tried to tidy everything up; finally at the end of August 1962 I emplaned for San Francisco with my family.
There followed an amazing and delightful year for all of us. California and the USA were then at the height of their confidence; John Kennedy was President, the world was full of hope. The American Government had declared war on poverty and, more important for us, war on mental illness. Federal funds were flowing freely into many mental health projects, particularly Community Mental Health Centers. While we were there Kennedy faced down Khrushchev in the Cuban missile crisis and world peace seemed assured. California had had 20 years of boom and there was ample money available to use for any good cause. I bustled about visiting mental health centres and mental hospitals, lecturing about British Open Door psychiatry and hearing about American ideas. I went up to Oregon where Maxwell Jones was revolutionising the State Hospital at Salem.
My main effort during my year at the Center went into trying to write a book about what I had learned and demonstrated during my first nine years at Fulbourn. I found the task dauntingly difficult, writing draft after draft and discussing it with some of the very talented people available; at the Center, Carl Rogers and Erik Erikson; at Stanford, David Hamburg and Irvin Yalom; at Berkeley, Erving Goffman, the author of Asylums; in Palo Alto, Ken Kesey, the author of One Flew Over the Cuckoos Nest. I revised my ideas again and again under the comments of so many brilliant, disturbing and provocative men. Gradually the book came together. I entitled it Administrative Therapy. By the time I got home in September 1963 it was ready for the publisher and it came out in 1964 (Clark, 1964).
I returned to Fulbourn Hospital on 1 September 1963 ten years and one month exactly since I had started work there on 1 August 1953. What a contrast there was this time with my initial furtive entry into a locked and gloomy asylum. The staff were delighted to see me back; they even hung a banner across the front of the main building proclaiming Welcome Home, Doctor Clark! The HMC welcomed me, and Oliver Hodgson was happy to hand back the Superintendency. I resumed my responsibilities and spent much of the early months telling tales of my travels. I even constructed an illustrated lecture based on my many slides, and presented it to Womens Institutes and evening classes round the town. I then prepared a report reflecting on what I had learned in the USA about Social Psychiatry and presented it to the HMC and to the Regional Board.
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