Association of Therapeutic Communities
PLANNED ENVIRONMENT THERAPY TRUST
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Therapeutic Community Open Forum
THE PLANNED ENVIRONMENT
THERAPY TRUST
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Appendix 2. Methods of Learning
Not long ago I was confined to the house for months by a cardiac disorder and found time hanging heavy on my hands. Musing about the course of my life I began to reflect on the process by which I became a psychiatrist. I began to make notes, wrote brief essays and finally put the material together as a tale for myself and perhaps for my family. To my surprise it was well received by a few friends so I have now made it into a small book. I hope it may interest some; I have certainly enjoyed the challenge of trying to tell the tale of "How I learned my Trade".
This is the story of how I became a psychiatrist, but to tell it fully it is necessary to go back before my birth to my parents for it was their values and their hopes for me which started the journey. My father Alfred Joseph Clark, born in 1885 into a Somerset Quaker manufacturers’ family had shown academic brilliance and a devotion to natural history early in childhood. This continued at school and at Cambridge University where he won many prizes. His Natural Science studies led him to the very new subject of Pharmacology – the action of drugs on the human body – to which he decided to devote his life. He qualified in medicine in 1909, and in 1914 was engulfed in World War One when he spent 3 years on the Western Front as a medical officer. In 1918 he went to South Africa to help to start a new medical school in a new University in Cape Town. There he met and married Beatrice (Trixie) Hazell a red haired school teacher with whom he found common interests in mountain climbing and passionate anti-clerical agnosticism. She too had been a star pupil who had put herself through University on Scholarships. They were both serious people with a commitment to public service and high minded ideals. Mother also had a personal spartan philosophy, believing in cold baths, hard exercise, hard work and a constant striving to excel both in studies and in sport, though she was also a merry soul, quick to laugh and enjoy life..
In 1920 Father was appointed Professor of Pharmacology at University College London. They came to England and in August 1920 I was born. At first we lived in Welwyn Garden City, just north of London, and my earliest memories are there. When I was six in 1926, Father was appointed to the Professorship of Materia Medica at Edinburgh University, the premier Chair in Britain and we moved north to the grey windy city of Edinburgh.
After inspecting Edinburgh Day Schools my father selected George Watson’s for me as it had far the best science teaching. I attended from 1928 to 1937, all my schooling. Watson’s, one of the schools of the Merchant Company of Edinburgh was a large school of 1200 pupils, devoted to providing a "Sound Scots Education" for the middle class Edinburgh boys. It concentrated on solid academic instruction to fit them for their later life roles as reliable Scots professionals – doctors, lawyers, teachers, merchants. I applied myself industriously to my school work, egged on by my mother’s deep interest and constant coaching. I did well and often won prizes, which delighted both parents.
I also developed as a naturalist. I was soon drawn to the natural world, partly because of father’s interest but also because it interested me deeply. I remember my first bird’s egg – in Welwyn Garden City, aged six - and Father showing me how to blow it. I remember books on natural history - and on dinosaurs. I recall frogspawn, collected from ponds and cherished in jam jars until the tadpoles formed. I started my "museum", a collection of natural history curiosities with an ostrich egg from South Africa and a hippopotamus tooth. By the time I was twelve I was established as a "naturalist" - in my own mind, in the minds of my schoolfriends, amongst the family. I had an aquarium and kept sticklebacks and newts and tadpoles. I kept pets in the garden – a hedgehog, a slow worm, a lizard. Friendly people brought me animals, bones, shells etc. The extended Clark family noted this with interest. "Just like his dear Father!" they said and told me many tales of my father, at home in Somerset in the 1890s or at school in York, collecting animals and studying them.
Of course I did all the other things that growing boys do – especially those with a room of their own and supportive parents. From building blocks I passed to meccano and then to making simple furniture. I played school sports, especially rugger (incompetently) and took part in school dramatic and debating societies. But natural history was always my main interest, much to Father’s pleasure and approval. As I did well at school examinations he began to say, " The boy may well make a biologist". By the time I was fifteen I knew that I was going to be a research scientist like Father but that I would study medicine first, as he had done.
Although Watson’s was a modern school, Biology was not taught as a subject. The important subjects were Latin, English, History and Mathematics. "Science" was Physics and Chemistry (Inorganic). However there was a Field Society with supportive Masters who arranged outings. I became an enthusiastic member and contributed talks to winter sessions. I contributed one on the great apes and the descent of man, entitled "The Missing Link" and was known as "Missing Link Clark" for the rest of my school time!
My main school activity was of course my studies. These were conducted in the traditional Scots way – set books, rote learning, and frequent exams. We were rewarded for learning what we had been taught and for reproducing it in examinations. I proved to be good at this; I was always among the first few in the class and was annually awarded "Bursaries" as marks of distinction. This pleased both Mother and Father; they had both been very successful students at school and at University and had both supported themselves by bursaries through their college years. They praised my exam results and rewarded me – encyclopaedias, bicycles, overseas trips. I felt no doubt that I was intellectually special.
Among my Scots school fellows I was not particularly popular. I was a "swot" (successful at exams) and worse, an Englishman. I was not much good at team games – rugby and cricket – the main activities which gave prestige amongst boys. I clung to my English accent and was involved in many brawls about the fate of Wallace, of Bruce, and of Bonnie Prince Charlie. My best friend Denys Barnes was also English and we formed a pair of persecuted but intransigent English Nationalists. Many a battle we had. However I was larger than most of the other boys and fairly strong, so I was never bullied.
At times I found myself taking the lead in class activities – mounting a play, preparing a "newspaper" and in my senior years I found myself secretary of the Pentland Club which ran walks on the hills and occasional camps. I enjoyed arranging and managing these. This was probably the first time that I became aware that I had a capacity to "run things" – to gather a group of people for an agreed purpose and to carry them through to the common goal. In my last year I was a prefect.
In my later years at school, I spent my holidays and weekends in the Southern Scots countryside – walking the Pentlands and the Lammermuirs, cycling around the Scots Border Country, the valleys of Tweed, Ettrick and Yarrow, and fishing the lochs and burns. The Youth Hostel movement was just starting and I became an enthusiastic user of the new hostels in the Borders, Laughaugh, Broadmeadows, Shortwoodend, the Snook. I made these journeys on my own; I found I preferred it that way – but I enjoyed the comradeship of the Hostel evenings greatly. There I learned to look after myself and to handle myself amongst strangers.
Our holidays were mostly family affairs, centred on my younger brother and sisters but I was encouraged to travel. I was learning German at school and in 1935 I was sent to Hamburg for six weeks to improve my knowledge. My 1936 vacation was longer and had a much more profound effect. Partly by mistake I landed in a family of committed and devoted National Socialists in South Germany. They warmed to my idealistic attitudes and attempted to recruit me. They showed me the many achievements of the first three years of National Socialism and then arranged for me to spend two weeks in a Hitler Youth Camp. I enjoyed the camp and the fellowship but was astonished at the "history" they were taught, disgusted by their racial theories and shocked to see that they were preparing armies with which to conquer Europe and the world. I came back deeply hostile to Nazism and committed to the anti-fascist crusade which dominated my next ten years.
Although I won many prizes at school, I did not stay on to attempt distinction in the sixth form, for war was approaching and I wanted to get on with my medical studies. In 1937 at the age of seventeen, I entered the first medical year at Edinburgh University.
To begin with Medical studies were little different from school. Quite a few lads from Watson’s were with me in the first year classes. The lectures were detailed and the task was to memorise what was taught and reproduce it in the exams. The most important subject was Anatomy and the main challenge was dissection. We spent many hours in the dissecting rooms, painstakingly cutting up the pickled bodies of aged paupers, teasing out every nerve, muscle and artery. We were examined every two weeks by Dr Jamieson a formidable, elderly figure who exposed our failings ruthlessly. I found dissecting interesting and challenging and got good marks. During that first year I lived in the "University Settlement" a student residence in the middle of a new working class estate at Prestonfield where I helped with the boys’ clubs and activities. This was my first time living away from home and was arranged by my mother to "rub off the rough edges". This certainly happened. The other residents disliked my arrogant garrulity and made this clear to me. I often felt very alone.
In accordance with my father’s plan I had been entered for his old college, King’s, Cambridge and I went there in October 1938. I was determined to follow in his footsteps, win scholarships, get First Class in the exams and prepare for my career as a research scientist. I was even going to row for the College as he had done (I had always admired the oar which hung in his study and the mugs on the mantelpiece).
These were stirring times. The shameful Munich Treaty was signed a few weeks before I started at Cambridge. Many older people were delighted that Chamberlain had obtained "Peace in Our Time" – but we youngsters, especially the left wingers amongst whom I moved, knew that it was only a breathing space and that war with Germany was inevitable. I spent much of my first year at Cambridge practising and studying in the Officer’s Training Corps and by the summer of 1939 was qualified to be an Artillery Officer. I took up rowing, and of course worked at my studies.
At first these seemed much the same – dissecting in the Anatomy Department, lectures in Physiology and Biochemistry, laboratory work in the afternoons. But I gradually found that it was different from Edinburgh. No one seemed to keep tabs on us whether we attended lectures or not. Professor Harris, the eccentric anatomist, told us that he did not mind whether we came to his lectures. It seemed to be up to us whether we worked or not. No one seemed to check our studies, though our personal lives in the College were strictly regulated with curfews, locked gates and Dean’s reports. Each week I had sessions with "Supervisors" – University teachers, many of them young – who gave me essays to write – which were often on subjects not in the lectures. They expected me to go to the library, explore the subjects for myself and to produce ideas about them. I found this perplexing and difficult. I found the exams in the summer difficult; the questions were vague and open ended and were often on subjects that had not been covered in the lectures. I did not do very well in those exams.
Then in the summer of 1939 came War. I hurried up to Cambridge expecting to join the Army as an Artillery Officer. To my surprise I was told that my duty was to carry on with my medical studies! They had plenty of junior artillery officers but expected to need many doctors later on. They refused to let medical students join the forces, and those who did were taken out and returned to their medical studies. So I returned to College determined to study harder. This I did, but the results were no better. It looked as if I might not get the desired "First" – First Class in the "Tripos" examination. Worse, as I got to know my fellow students, I realised that some of them were far brighter than I was, with lively minds that came up with surprising ideas from their reading and projects for research. I realised I was not in their class. I did not get a First, merely a Second Class; Father was deeply disappointed.
In other ways, however, my second year at Cambridge was fulfilling and exciting. I shared rooms in the 18th century Gibb’s Building of King’s with two other medical students, Bob Turner and Irvine Smith. We were the centre of a lively group of friends. The university was full of people waiting to be called up and the social life was very busy. I took full advantage of this. There was also a very active political life in which I joined with zest, learning about Marxism and anti-colonialism from the fervent student leaders, mostly devoted members of the Communist Party. There were great tussles and debates, particularly between the Communists and the Social Democrats with whom I allied myself, especially during the Soviet war against Finland in 1939. It was a strange winter as the main war seemed static and uneventful.
Suddenly in May and June 1940 while we were busy with our Tripos examinations, the war changed. Denmark, Norway, Holland, Belgium and finally France all fell to the Germans and it seemed as if England would be invaded soon. I went home and my father found me a job as "student dresser" on the surgical wards of his friend James Learmonth. I found the work on the wards fascinating. I took blood, I attended operations, I "prepared" the patients; I talked with them at length, I saw some get better and others die. I had to learn new techniques and "aseptic procedure". I worked long hours and felt very satisfied. It was decided that I should not return for a third year of research in Cambridge but get on with my medical studies at Edinburgh. I joined the third year students at Edinburgh in October 1940.
In some ways this was a relief. I was back in the Scots system, attending endless lectures, memorising their contents and reproducing them at examination for good marks and applause. I was soon recognised as one of the leading students (academically) of the year and treated with respect. But in other ways it was a hard life. I lived at home, where my mother was bed-ridden and quite seriously ill with advancing tuberculosis. My father was overworked, harried and preoccupied. Food was becoming scarce. The war was going badly, with defeats everywhere. I found it difficult to fit in again with the hardworking, worthy, but dour Scots students and found my friends amongst the outsiders of the year. Soon I formed a trio with Dan Cunningham and Gus Born. (Gus as a German born Jewish refugee felt himself an outsider as did Dan who like me had left studies in the South (at Oxford) to join the Edinburgh students). The three of us became fast friends, working together and playing together.
However, the work had changed radically. Although we still spent many hours listening to lectures, for part of every day we were on the wards seeing real patients and learning about their illnesses. We had to "clerk" them, obtain their stories, carry out examinations, try to make a diagnosis – and then present our findings to the "Chief". I found the tales of their lives and the details of their sufferings and their illnesses fascinating and spent long hours working up their cases. This was "real medicine"; my studies at last began to seem relevant.
In the summer of 1941 my personal life changed dramatically. Father fell ill one weekend, was diagnosed as having intestinal obstruction, was operated on on the Monday and dead on Wednesday of "surgical shock". My mother was gravely ill (and expected to die soon). I was the eldest child and I was called on to be an Executor and Guardian to my younger brother and two sisters, all still at school. I spent many hours with lawyers and accountants. I had to shoulder a burden for which I felt little prepared. However it did teach me to take and accept responsibility. In other ways too, the summer of 1941 was hard for me. I was shortlisted for a Rockefeller scholarship to the United States but turned down by the interviewing board. I stood for the Editorship of the "Student" magazine and was not elected. No one seemed to think much of me. Yet for all these setbacks I felt more certain about myself. I was learning to be a doctor, looking after patients, and was enjoying it. I was preparing myself to be an Army Medical Officer in the fight against Fascism which was where I wanted to be. The war was going so badly in 1941, before Alamein, before Stalingrad, and before Pearl harbour, that I knew there would be plenty for me to do.
In these last three years at Edinburgh I shifted to another kind of learning. I had to master many practical procedures; I had to learn to listen to people, to assess their stories and make diagnoses – always imperfect and often wrong. I spent my vacations gaining further experience working on the wards in Edinburgh. In Easter 1942, I went to Dublin to learn and practise obstetrics at the Rotunda Hospital. That was an astonishing experience. In the slums of Dublin I saw poverty and squalor far worse than anything in even the poorest parts of Edinburgh. We medical students were sent out into the homes on our own to try and do our best for the unfortunate women in labour. We were greeted as "Doctor" and treated with gratitude and respect; although we were fully aware of our incompetence; we learned to hide our uncertainty – and the outcome was usually favourable.
As our "year" of students knitted together in all these experiences Dan, Gus and I emerged as a leading trio. We felt guilty about the fact that we were furthering our careers, while our school friends were serving and dying in the forces. We longed to get on and do our duty and in the summer of 1942 we developed a radical plan to finish our final year in six rather than twelve months. We took it to the Dean, Professor Sidney Smith, the professors accepted it and we and thirty other colleagues went forward in an accelerated course to qualify in January 1943 – six months early.
During these years we were taught about the medical specialities - surgery, medicine, obstetrics, pathology, psychiatry, dermatology, venereology etc. etc. Some subjects I found attractive, some repugnant. I knew then that my immediate task was to become an effective battlefield surgeon but I found psychiatry, as taught by Professor D. K. Henderson interesting and intriguing. It seemed to be about people, how they lived, felt, and thought about themselves and I found it more interesting than some of the more technical specialities. However my task was to become a surgeon. In the summer of 1942 James Learmonth asked me to act as a locum house surgeon for a very challenging month. The last six months of "accelerated" studies were very hard; we sat our finals at midwinter, and in January 1943 I was qualified. I well recall the delight of being addressed as "doctor" and my mother’s pride. I went straight into the Royal Infirmary, as house surgeon of the Professorial Wards 13 and 14 in the Royal Infirmary – one of the most prestigious jobs for the new graduates.
These six months were the hardest medical work I have ever done. Most of the qualified staff were away on War duty. There was only myself and a part-time senior registrar to serve the Professor and his sub chief– yet the flow of patients was as great as it had ever been. I found myself working a week of 120 hours and I was so tired that I sometimes fell asleep while assisting in operations. At times I would be called three or four times in the night and would be making decisions about patients’ lives while so sleepy I could not think. I strove to meet this burden but at times knew that I had failed and that someone had died as a result of my failure. I became a fairly competent surgeon, performing my own operations and even meeting the Chief’s exacting standards, some of the time at least. In the Resident Doctors’ "Mess" there were twenty of us, a lively if overworked group. As young doctors have always done we managed to enjoy ourselves and I discovered a talent for organising parties and dances.
At the end of July 1943 I finished at the Royal and was called up forthwith into the Army. I was sent to the Army Medical College at Crookham, Hampshire. After a brief introductory month there I volunteered for parachuting and gained my "wings". I became a member of 225 Parachute Field Ambulance which was actively preparing for the invasion of Europe the following spring. I have told the tale of my war time adventures in the book "Descent Into Conflict 1945: a Doctor’s War" and so I will not repeat the tale in detail here. The book tells how I was a junior medical officer in 225 for nearly two years; how I missed D Day but was in the "Battle of the Bulge" and the conquest of Nazi Germany; how I was sent to the Far East and ended up running a camp consisting of 5000 Dutch internees and their Japanese captors and how I finally spent the last six months in Palestine and was demobbed in September 1946. What is of relevance to this story however is the medical work I did in these three years, the things that I experienced and how they shaped me, and the changing views I came to have of myself and my medical future.
The first shock was the process of being turned into an Army Officer. Although I had been in the OTC at Cambridge and had been a sergeant in the Home Guard at Edinburgh the role of army officer was quite new to me. I had to learn how to relate to the men, the other officers in the unit, and the Army hierarchy and its rules; the whole process of becoming a cog in a vast military machine ruled by traditional practices. By this time in 1943 Britain had an army of several million men mostly civilians at heart, but held in traditions of behaviour and ritual that went back three centuries. I had to learn the difference between a battalion from the Rifle Brigade and one from a County Regiment, between Royal Artillery (gunners) and Royal Engineers (sappers), between a warrant officer and a commissioned officer etc. etc.
The process was made more painful for me by the commanding officer of our unit, Colonel E.I. Bruce Harvey, an impressive six foot figure with a bristling moustache and immaculate uniform. He was of course a doctor and a parachutist - but much more. Now aged over forty he had served as a junior officer in the Navy and then as a Subaltern in the peacetime Scots Guards before studying medicine. He cherished the traditions of both those services. He was facing the task of moulding together a composite unit of regular and territorial RAMC men with years of service, a group of conscientious objectors and some new RAMC recruits. His biggest problem however was his officers – a group of young doctors like me, eager, naïve and unaccustomed to Army ways. He set about the task of making us into reliable medical officers with vigour using traditional Army methods. He soon had to call me to order using his noted "bollockings" (tongue lashings). I still remember one which ended with the comment "You’re a very junior officer, Mr Clark, with an unwarrantably high opinion of yourself!" - so vigorously delivered that at the time I entirely agreed with him!
The key medical posts in the Field Ambulance were those of Section Officers – doctors who had to lead a group of twenty men into action. I had hoped to be one of these but came too late. I was the "spare" officer, the reserve in case any of the others fell out with accident, sickness or promotion. As a result I was given all sorts of odd jobs. I was Medical Officer to the unit and also a unit of Engineers – I was first locum when any of the other doctors had to go away. When the Colonel was ordered to send one officer on some irrelevant course he usually sent me. I studied blood transfusion in Bristol, anaesthesia in York.
I gradually learned some of the strange sides of doctoring in the Army where the doctor had great power to alter peoples’ lives. Many men came to the sick parade but few were truly seeking medical treatment. Doctoring was not so much a much a matter of making diagnoses – often easy – but of working out what devious purpose this man had for presenting this disease to me at this time. Whenever a big march was due many men turned up with flat feet or blisters in the hope of being excused, while just before a period of leave, no one came for fear some diagnosis could mean their missing leave. If I saw a man with gonorrhoea (a venereal disease) I had to put him down on the sick report as "urethritis NYD (not yet diagnosed)" for if the Commanding Officer saw the exact diagnosis he would stop the man’s leave and his pay.
1943-4 was a lonely and perplexing year for me as I struggled to fit myself into what the Army seemed to want of me. I gradually grasped some of the underlying responsibilities of an officer, especially a medical officer, as taught by Bruce Harvey. My first responsibility was to my patients – especially those wounded in action; my duty was to care for them, stay with them, if necessary die with them. My next responsibility was towards my men – my Section when I had one – I had to lead them and care for them, putting their comfort before my own – I should see all my men fed before I ate – my men bedded down before I slept. Only then should I care for myself. Nothing aroused Bruce Harvey’s ire more than evidence that one of his Medical Officers had placed his comfort and welfare before that of his patients or of his men.
One of the few things that relieved that winter was that on leave in London I met and fell in love with Mary Rose Harris, a nurse at University College Hospital, who shared my commitment to idealistic socialism. Whenever I had leave I sought her out in her various hospital postings around London. In the autumn of 1944 we became engaged.
The summer of 1944 finally came – and D day, 6th June. 225 (Para) Field Ambulance took part in the parachute operation and the subsequent Normandy Campaign. As the reserve officer however I was left behind; which was just as well for I developed hepatitis and spent a month in an army hospital as a patient listening to the reports of the battles.
In October the unit came together again and I was at last given a Section; I settled down to train them and weld them together. Our prime task in action was to set up and run Field Dressing Stations, receiving the wounded from the battalions in the front line, patching them up and sending them back by ambulance to the Main Dressing Station with the Surgical unit. In December 1944 we went into action in the "Battle of the Bulge" – checking the German Ardennes offensive. After a few battles I found myself and my unit in a devastated Belgian village whose doctor had been killed. The village nurse asked our help and for a week I did doctor’s rounds, my first experience of trying to do medicine through an interpreter. It was there I had a painful lesson in war time priorities. A child of about ten was quite obviously ill and I suspected tubercular meningitis. I used an army ambulance to take him to a civilian hospital where a lumbar puncture confirmed the diagnoses. When I asked for his admission, the doctor just said "No! He’s going to die". He had few beds and wanted them for those he could really help. We had to take the child back to die with his devastated parents.
We went back to England in February 1945 to prepare for the last great parachute operation, the crossing of the Rhine. We parachuted down over the German guns and took heavy casualties. I started the day with a staff sergeant, a corporal, two lance corporals and fifteen men. By the evening the corporal and two men were dead, the staff sergeant and the two lance corporals were wounded and unable to carry on. I had to manage with the remnant. Then followed two hectic months chasing across North Germany. We set up dressing station after dressing station and bandaged many wounded, our own soldiers and German last-ditch defenders. We saw shattered towns, concentration camps, devastated people. In the end we met the Russians on the shore of the Baltic at Wismar. During this time I had many strange tasks. As I was the only German-speaking officer I was called on to deal with the perplexed and defeated Germans. Towards the end we were dealing with thousands of refugees. For a time I was medical officer to a transit camp, full of internees – English, escaped American fliers, released civilian workers, Germans all going joyfully West and many Easterners – Russians, Poles, Yugoslavs, prisoners of war, forced labourers and others – going apprehensively East, fearing what might befall them. They told me of their pains in many languages most of which I could not understand. I had as my interpreter a Latvian lawyer very anxious to be helpful (probably fearing his fate if sent to his "home"). There were the thousands of Germans fleeing west – disintegrating Army units eager to surrender, walking wounded, terrified civilians fleeing the Russians. I was asked to see women who had been repeatedly raped by Russian soldiers (which they accepted as the usual fate of the conquered) but merely wished to know if they were also infected with venereal disease. By this time we had little sympathy for the Germans because we had been shown the films of the abominations of Belsen and had seen many small Belsens on our way across Germany. Looting was widespread and I found myself joining in. At one stage I had a wounded Russian sergeant in my care who would each morning plead "Tovaritch Doctor, schiesse mich, schiesse mich" (Comrade Doctor, shoot me, shoot me) because of what he feared the secret police would do to him when they collected him. I found myself perplexed and torn amongst all these suffering people, wondering –who were "my patients"? to whom did I owe allegiance? what rules should I obey? Fortunately we were pulled out of Germany a week after VE day and I was spared the demoralisation and corruption of Occupation though I often wondered how I would have coped with that.
It was summer when we came back to England and I was warned for Far Eastern service. I was given a month’s leave which I spent with Mary Rose in Devon. We were already engaged and we talked of marriage but as I thought it very likely I would die in the continuing war against the Japanese, I said we should wait until I came home for good, if I did.
I went back to 225 and found that I was to go to India forthwith with the Brigade Advance Party. We set off from Glasgow and sailed through the Mediterranean, the Suez Canal and the Red Sea to Bombay. It was in Bombay that I heard the news of Japan’s surrender and realised that I had survived the war! Further Army activities over the next few weeks seemed rather pointless. We were sent on a "Jungle Training Course" and it seemed that I might be doing pointless exercises and training indefinitely. When there was a call for medical officers to parachute in to relieve the internment and POW camps in the Japanese occupied areas, I volunteered right away. I thought that here at last was a chance to do some "real medical work". I was parachuted into Sumatra as the medical member of a small relief team to a camp for some 5000 Dutch civilians in the midst of the jungles. Our instructions were "Sort things out, let us know if there is anything you want and if there are any difficulties and wait for the British Army to come and relieve you". After what I had seen in Germany I fully expected that I would have a massive and possibly heroic medical task to do. Instead I discovered the medical services in the camp in excellent order, managed by a group of professors of tropical medicine! For a time I was quite dismayed and felt rather superfluous but then I found that there was a major job to do, liaising within the camps, with the British Forces on the other side of the island and with the local Japanese army, who were the only force maintaining law and order in the district. Then the Indonesian revolution began and it gradually became clear that the British Army was never going to get to that remote part of Sumatra! In the end I had to organise the transfer of 2000 of my internees to the British beach-head on the other side of the island, two hundred miles on primitive roads over a mountain range 3000 foot high. The only transport we could get were the trucks of the Japanese Army, so we had them transport the internees over. All this called for administrative and diplomatic skills that I had never exercised before. However I got them all out and escaped finally with my team just before the revolutionaries sacked the camp and burned it to the ground. Once again I became aware that I seemed to have an ability to get people to work together toward a desirable end without too much quarrelling.
After three months in the jungle I finally emerged just before Christmas 1945 and rejoined the army in Singapore as just another medical officer. From there I was sent to Java to rejoin 225 and then to Palestine in February 1946 where the main Airborne Division was now stationed. By this time I knew that I would be demobilised within the year and it was just a matter of filling in time. I found the Army was in a strange state. Many senior officers and soldiers had returned to civilian life. A few had decided to stay on in the Army but most people were waiting to get out. Experienced officers were few and I was invited to stay on and help to run a unit; I was tempted, but refused. I wanted to get home, get married and start practising medicine again. I was therefore given a series of stop-gap jobs. During these I began to think about my professional future. I had expected to die in the War. I had given little thought to the long term future, for I believed I had none. What sort of doctor did I now want to be? After years in the Army I feared that I might have lost the ability to learn, if not to think. Should I be a GP? Should I go for hospital work? What speciality could I do? I was fairly certain, after six months with Learmonth, that I would not make a surgeon. Then came the chance that determined my future. At a party I met an old friend, a parachuting psychiatrist, who told me that there was a vacancy at the psychiatric unit of the local British Army Hospital at Sarafand – and I got permission to work there for several months.
This was a wonderful experience for me. I was in a medical environment once again; the officers’ mess was full of doctors of all specialities getting ready to go home to take up their careers. But more important was the Unit. It was small – four doctors, three nurses, a dozen nursing orderlies and up to forty soldier patients at a time. We took them from British forces all over the Middle East. The largest group were Englishmen who had broken down in the dreary monotony of pointless Army duty; our main task was to "board" them and send them home as soon as possible. But there were many others from all the flotsam that the Allied Armies had accumulated in the years of War – Jews and Arabs of the Palestine Regiment, Cypriots, Indians, Africans. Many were depressed and demoralised, but some showed psychotic reactions, acute schizophrenia, mania, sullen paranoid states - wonderful "material to learn on". I found them fascinating; I studied their stories (often through interpreters) and attempted to understand them and this fascinating new speciality. The other officers, Manugian, Blair and McComb all of whom had been psychiatrists for years, probably found my naïve enthusiasm refreshing; they certainly gave a lot of time to directing my reading and helping me to understand what I was seeing. I soon decided that this was the speciality for me.
Then, at last, in September my demob number came up. I travelled by train and boat to Egypt, France and England. I was demobilised, given a suit and a hat and sent home. Mary Rose and I got married and took our honeymoon in undamaged Switzerland Then we returned to a flat in Edinburgh to begin family life and for me to take up my medical studies. The winter of 1946/47 was one of the coldest for years; snow lay on the streets of Edinburgh for months, food was short, fuel hard to obtain. But the future was ours. A Labour government was in power and a National Health Service was coming soon.
The Government provided postgraduate posts for doctors just out of the Services. There was a programme at the Royal Infirmary of lectures and clinical attachments; I joined it and soon settled back into the old pattern. The lectures were by our old teachers; many of us had been students together. We discussed our futures and the new National Health Service due the following year. It was important to get qualifications. The Membership of the Royal College of Physicians of Edinburgh seemed an obvious target for me. I studied by the old Edinburgh method – listening to lectures, memorising them, reproducing them, and being examined by those who had taught me. I passed without difficulty in 1947. In the meantime I had seen Professor Henderson (now Sir David) and had been offered a post.
In 1946 I started at the Royal Edinburgh as a House Physician, working in Craig House, the department for private patients. I was there for 3 years, 2 years in sole charge of the 100 bed-male wing and one year in charge of the female wing of 200 beds. Craig House was set upon a hill to the south west of Edinburgh. It had been designed in the 1890s as a place fit for the rich mentally ill. One of the villas, "Ladies Craig", was a fifteenth century castle, all the other buildings were built in the Scottish Baronial style. They were designed to make mad members of the Scottish aristocracy feel at home, with a baronial hall, tennis courts, bowling greens and spacious wooded grounds. The male patients whom I took over were an interesting group. Most were long stay, some from before World War One, though there was an Admission Ward with two or three admissions a week. Some were deep in long term psychosis but many were living a life of leisurely madness. There were 2 peers, 6 medical doctors, an ex MP and most striking of all a hypomanic ex-Indian Army colonel who strode around the grounds in a kilt, playing the bagpipes and abusing those of whom he did not approve which included one of the medical staff. I worked busily, grappling with the new admissions and getting to know the long-term residents – even earning the grudging respect of the Colonel.
Our working arrangements and relations with "The Chief" were unusual even in those days. Sir David Henderson was then at the peak of his renown and power. He was the Professor of Psychiatry in Edinburgh University, giving some 40 lectures every year, he was the author of what was then the recognised standard textbook in British Psychiatry "Henderson and Gillespie"; he was the Physician Superintendent of the Royal Edinburgh Hospital, some 1500 beds, with personal responsibility for every patient; and he also ran 6 private nursing homes; he was the premier psychiatrist in Scotland with a large private practice. He managed this empire with considerable skill and flexibility.
His expectations of the young men who worked for him were high. He selected us carefully, but worked us hard. Before the war he would only take unmarried men to work for him; if they wanted to marry he would find them a job elsewhere. During the war he had to take on women doctors and married men. But there was no relaxation of his demands on us. We were expected to be available at all times. We had to do a complete ward round seeing and greeting every one of our patients every morning, Sundays included, and an afternoon round on five days of the week. We were allowed one afternoon at the weekend off and one during the week. With me at Craig House were Ivor Batchelor and Kenneth Macrae – all three of us recently out of the Forces.
Sir David’s method of controlling our work was unusual. We reported to him every morning (from Craig House by telephone); he seemed to know everything that was going on (I found out later that he got daily reports from the Matron and the Administrative Staff). Every now and then (about once a fortnight) he would turn up on my wards and start talking to the patients. The nursing staff would summon me and I would rush there and join him. I would have to report on the progress of each patient in front of him and the Chief would decide there and then what treatment should be followed.
We all felt that his system put a great responsibility on us and was a great challenge. How much to do ourselves? When to ask him for advice and support? There were few treatments available. We used ECT but sparingly; no one received it until they had been in for at least a month. The main treatments were sedatives – phenobarbitone, seconal, chloral hydrate, paraldehyde. Nearly all the wards were locked. Violence was controlled by the male nurses and with strait jackets. Being young and strong and vigorous I often helped to put patients into strait jackets. Many of the admissions were depressed, a number were alcoholics and a few were schizophrenics. I also attended the outpatient clinics and was given patients to treat. I listened to them, reassured them and sedated them. Most of them improved.
I was thus learning clinical psychiatry by doing it – treating patients and seeing the results of my activities. The formal instruction was limited. Once a week there was a Case Conference where one of us would present a case to Sir David in front of all the others. I can still remember the people I worked up so thoroughly, writing out my whole presentation in longhand. Apart from this we were expected to organise our learning for ourselves. I constantly discussed the people I was seeing with Ivor Batchelor and Ken Macrae and occasionally with the doctors in other departments of the hospital such as West House, the department for ordinary patients and Jordanburn, the out patient department and neurosis unit. We started an informal peer teaching group. We met once a week and would present papers – occasionally attempts at original papers, but mostly discussions of likely "spots" for the DPM examination.
We were all concerned with obtaining higher qualifications. The favourite psychiatric qualification in those days was the Diploma in Psychological Medicine.(D.P.M.) of the Conjoint Board of England. The exams were held in London twice a year. The first part, in Psychology and Neuro-anatomy we could take at any time, the second part, in Psychiatry, after a year of mental hospital work.
This exam proved a humbling experience for me, for I failed the first part twice. This was the first time I had ever failed a professional exam and I was astonished and ashamed. At my first attempt I was ill prepared, but for the second I had spent many hours in study. I could not understand it. Then I came to realise that this was quite a new type of exam for me. There were no lectures to digest and regurgitate. My examinees were London psychiatrists, complete strangers. I settled down to study the exam and its traditions. I read many books and summarised them. At my third attempt I passed the first part – and went on to take and pass the second part two weeks later on the wave of euphoria. I would never have to take an examination again!
It was during these three years that I truly learned my trade – meeting the patients, learning their stories, deciding their treatment and watching the results – usually recovery and discharge. Some did not recover and were in due course moved to the "back wards" amongst the patients who had been in the hospital for many years. Others were discharged hopefully only to return months or years later. I learned to face disappointed, frightened and angry relatives and to divert their fury. I learned about the staff – ward sisters and charge nurses, elderly staff nurses who had been many years in the hospital and bright keen young occupational therapists. Psychologists and Social Workers, we had none; we had to carry out their special tasks ourselves, administering intelligence tests and taking histories from the relatives when necessary.
I had many moving and even dramatic experiences. Two experiences however are important because of what they taught me and their relevance to my later work. I knew of course that violence occurred; patients attacked staff, some staff responded. But I was shocked when a patient on the admission ward, a young hypomanic doctor, was so badly injured in a struggle with staff that he died during an operation for his injuries. Then a responsible patient on the ward accused the deputy charge nurse of punching him and proved his case. I reported the matter. Sir David was dismayed, but not, it seemed greatly surprised. The genteel Matron was horrified "But he is one of my best men, Doctor, - and trained in general nursing too!" They took over the matter and dealt with it - in the fashion of those days. There was no enquiry and no scandal. After a reprimand the nurse was moved to another ward in another part of the hospital. I gradually learned that he had been routinely beating up troublesome patients. During the war he had been a Chief Petty Officer in charge of the psychiatric unit on a hospital ship and he honestly believed that it was his duty to "keep the ward quiet" and to thrash any patients who failed to behave.
This episode shook me. I realised that even in a famous teaching hospital there might still be covert brutality; that what I had suspected in the Army hospital was not just an aspect of Army brutality. I became zealous to investigate any bruise or black eye and to suspect the glib explanations of the staff nurses. It was not till some years later that I came to know the long history of asylum brutality and the part that medical hypocrisy played in it.
A major group of my patients on the admission ward of the men’s side were the alcoholics. They came in drunken, toxic, often near to delirium tremens. After a few days’ sedation they settled down and revealed themselves as interesting men who told vividly their tales of adventurous lives and prodigious drinking bouts. Their sad relatives told of brilliant careers spoiled and fine jobs lost, of family money squandered and likely ruin. Once sobered and restored to health they enjoyed the grounds of the hospital and the sports facilities. I talked with them earnestly about the folly of their self-destructive drinking and advised them on how to avoid it in future. Soon they left, vowing "never to touch the stuff again".
At first I was pleased at the "cures" I had achieved, but as the months passed I readmitted them, drunk and disreputable again, and I began to despair of my work with them. Then Sir David came back from a visit to Denmark with a new drug – disulfuram (called "Antabus") which was said to stop alcoholics drinking by bringing on an instant and appalling hangover. I tried it out, on myself first and then on the alcoholics. With some it worked dramatically, I had one patient, a pathetic little man who came back to me for years for a fresh supply of his "sweeties" that kept him off drink and prevented him upsetting his elderly, wealthy mother. But with many, Antabus failed because they stopped taking it in order to go back to their drinking. Sometimes their wives put it into their tea – but they soon found out and stopped drinking tea! I began to despair of ever doing anything effective for these attractive and interesting men.
Then one day I was visited by a lively and charming Englishman, Forbes Cheston, who told me that he had been rescued by an American organisation called Alcoholics Anonymous and now wanted to bring its benefits to the Scots. He had seen Sir David and now wanted to talk to the alcoholics on my ward. I took his book home and read it. It seemed that this was an organisation where alcoholics helped one another. They met regularly in intensive meetings. They studied the psychology of their drinking intensively. They admitted that they were incurably addicted, but said " I will not have a drink today" – and kept this up for day after day. They visited one another in hospital and in jail. They had little use for doctors. They said that only an ex- alcoholic could talk sense to a man sunk in drink. I hesitantly agreed that he could talk to the men on the ward. From them he got the names of others and visited them, including a notoriously drunken baronet.
Gradually over the months I began to see changes. The Scottish branch of AA grew steadily; the baronet, sober for the first time in thirty years, became its president. One man, an able businessman of thirty five had had three alcoholic admissions in the last year; I had expected to hear of his death some time soon. To my surprise he came to visit me, sober. He had become an active member of AA. Before long he celebrated his first "dry birthday" and I know he remained sober for many years.
This experience – of seeing AA start and flourish in Scotland – taught me some lessons. Here was a disorder where I, the Doctor, had been ineffective, while ex patients had helped the sufferers. They could speak to the drunks in their own language and convince them with tales of their own degradation; they would accept his advice where a neat tidy sober doctor who had never known the temptation would carry no conviction. Further I was impressed by the power and the camaraderie of the group; I was forced to realise that in some situations fellow sufferers could understand and help where doctors could not.
So, the three years, 1947-1950, sped by. I worked hard and studied industriously. Our family life prospered despite the post war shortages of food and the cold Edinburgh winters. Our first child was born. We were given a hospital flat with a garden. When the NHS came in in 1948 I was graded a registrar and received a substantial salary increase. As other trainees moved on I became more senior and it was clear that I had Sir David’s approval. In 1950 I was graded Senior Registrar and it was clear that there was a secure future for me in Scots psychiatry.
But I was restless and dissatisfied with what seemed the parochial and limited scope of Edinburgh psychiatry. We kept hearing of new methods and treatments being applied in London by people like William Sargant and Maxwell Jones. There appeared to be no chance of having a personal psycho-analysis in Edinburgh. I began to think I would learn more if I went to the Maudsley, so I applied in the summer of 1950. I was offered a registrarship and we moved to London that Autumn.
My three years at the Maudsley Hospital, 1950-1953 were the most valuable for the learning of my trade. I had my personal psychoanalysis, I worked with Dr Foulkes as he was developing group analytic psychotherapy and I learned an effective style of individual psychotherapy. But the most important influence on me was the atmosphere of the Maudsley itself. Those were stirring times just after the war. The Maudsley was the only effective centre of postgraduate psychiatry in Britain, and one of the best in the world. To it came all those doctors who had committed themselves to psychiatry but who wanted to push their learning further. Some had come to psychiatry while in the Army, others had been at mental hospitals that they found dull and discouraging, a few came to start their psychiatric training. The intellectual atmosphere was intense, bright people seeking new and better knowledge, questioning, arguing, researching. It was also intensely competitive, with individuals presenting cases, studies, research projects. I entered this game with glee. I presented at the Professor’s Monday Conference. I digested articles and presented them to the Journal Club. I attended any seminars and groups I could find.
This atmosphere and environment, which had both positive and negative aspects, was the creation of Aubrey Lewis, who was pursuing his dream of psychiatric excellence – a doctor who knew all there was to know about every aspect of the speciality. Aubrey’s erudition was formidable; it seemed that he had read everything psychiatric ever written in English, French, German and Italian and remembered them all! He delighted in argument and the play of logic – what he called "Socratic teaching". For those who could stand it, it was highly stimulating but for many registrars the way he deployed his logical skills and formidable knowledge was devastating and discouraging. If you took an idea or a project to him, he would demolish it either by demonstrating faults in the reasoning or by quoting texts to show that it had been tried before. He valued examination skills and preferred his trainees to have taken the MRCP before they started psychiatry; all were of course expected to obtain a qualification in psychiatry. I came down from Edinburgh with a DPM and an Edinburgh MRCP, so I was fairly acceptable to him. My first posting as a Registrar was to the Professorial Unit itself, under the Professor, Dr Stengel and Dr Davies.
I had been practising hospital psychiatry for 4 years and was fairly confident of my ability to handle the ordinary problems of psychosis, to manage a ward and lead a team of nurses. I soon found that all this experience was of little account at the Maudsley. Where before I had been responsible for a hundred patients, I now had no more than six – but I was expected to study them with an intensity far greater. I had to present them to one case conference after another and to justify every finding that I reported and every conclusion I reached. Before any treatment could start I had to get the permission of the consultants who examined my proposals most critically. Although I chafed at this, it was valuable discipline for me, though I sometimes wondered how much it helped the patients!
But it was from my fellows, the other registrars, that I learned most. I heard of other hospitals, of differing treatment methods, of the newest fashions in treatment. This drove me to the journals which were so constantly quoted and I learned to read original papers and assess them, sifting the valuable from the unsubstantiated. This led me to the library – probably the best psychiatric library in England – and to reading many of the classics of psychiatry. I felt great freedom at this time. For the first time for many years I was not reading for an examination. I could explore what interested me and could wander freely in by-ways. It was then that I came on the writing of the sociologists of psychiatry, Stanton, Schwartz, Goffman.
Even more important for me was the interplay between the various theoretical schools especially the rival psychotherapies. About half the Maudsley trainees were in analysis – despite the Professor’s trenchant criticisms of the illogicality of their theories. There were Freudian, Kleinian and Jungian trainees, all vociferously defending their schools. One of my reasons for coming South was to have a personal analysis and I began to explore the possibilities and seek advice. After many discussions I decided that I wanted a Freudian analysis, in order to understand myself and my patients better. I did not want to commit myself to a full training analysis so I started analysis, five days a week, with Dr Gilbert Debenham. I followed this for 18 months and gained greatly from it.
Our "postings" around the Maudsley were decided by the Dean, Dr Davies and were a matter of intense speculation, jockeying and fantasy. The registrars were, of course, convinced that they were moved for deeply conspiratorial reasons to serve the purpose of the institution! After my initiation of 6 months on the Professorial unit, I was sent to the Children’s Department for 6 months. This was dominated by psycho-analysts which I found most congenial. Then I applied for and obtained one of the coveted Senior Registrar posts; this gave me added income and job security for several years. To my surprise and delight Dr Davies sent me to the Outpatients Department where I could explore my psychotherapeutic interests: I stayed there for the rest of my Maudsley time. It was there that I met and worked with Dr. S. H. Foulkes who was actively developing groupanalytic psychotherapy and exploring ways of teaching it. I became a key member of his team and greatly enjoyed learning from him, both about group analysis and in general about psychotherapy.
Apart from my peers, the psychiatric trainees, there were many other interesting people at the Maudsley. The psychologists, led by Eysenck were a vocal and powerful group, many of them impressive and convincing individuals. There were many research workers engaged on exciting projects. I was particularly interested in Sainsbury’s work on the ecology of suicide in London and the work of Carstairs, Tizard and O’Connor in the training and empowerment of the inmates of long term institutions, particularly those for the mentally defective.
Another group who impressed me greatly were the psychiatric social workers, all of them graduates, most of them analysed, many of them wise in the ways of the world. Some were powerful and arrogant dragons like the Professor’s personal PSW who told me "The task of the registrar at the Maudsley is to learn to cooperate with the social worker!" but many were wise and helpful people such as Edgar Myers who worked with me in the Outpatient Department and taught me a great deal about how English and especially London services worked.
One of the most disturbing tasks I had to do was overnight and weekend duty at the St Francis Observation ward at Dulwich. All Registrars had to take turns doing this. The Observation Ward was an archaic holding institution. All through the night Duty Authorised Officers of the London County Council brought in people who had been picked up by the police and who seemed to be mentally disturbed. The duty doctor’s task was to examine them to see if there was any urgent or treatable physical disorder and if necessary sedate them. The daytime medical staff, we were told, sorted them out, diagnosed their disorders and despatched them, legally "certified", to appropriate mental hospitals. I found the place revolting. It was dominated by tough uncaring staff who, I felt sure, used brutality to control the unfortunates dumped in their "care". This was more brutal and inhuman than anything I had seen before and I was appalled that the Maudsley with its high principles of voluntary treatment was associated with it. I was more shocked to find that Professor Lewis valued the link with the St Francis and went there regularly. It was he said "a wonderful source of interesting clinical material". I began to suspect that concentration on research and teaching did not necessarily lead to good treatment for patients.
During these years I learned something of other psychiatric facilities in and around London. I became a member of the Royal Medical Psychological Association, (the only professional body then for psychiatrists) and went on their visits to the LCC mental hospitals – vast improverished barracks full of neglected long term inmates. Psychiatry was still a low status speciality amongst the English. There were few psychiatrists on the staff of the great London teaching hospitals, and hardly any in-patient units. The aim of the Maudsley psychiatric trainees seemed to be to reach Harley Street, either as psychoanalysts or as private practitioners treating wealthy neurotics. The thought of "going to work in a bin" was regarded by most as a confession of failure.
During these years our family life changed. My mother had died in 1949 and I inherited enough to buy a house in Bromley. Two more children were born, making three and the eldest started going to school. Mary Rose found these years hard; the pregnancies debilitated her; she was glad to be South again, away from Scotland and the Scots, but did not care for suburban life. I did not see much of the family except at weekends. I caught a train at 6am to get to my analyst (in St John’s Wood) by 8am and then back to the Maudsley for my day’s work. Many evenings were spent at meetings. By the time I got home the children were in bed. For me these were very good years; for my family, not so good.
After three years at the Maudsley we began to discuss our future. Where might I find a consultant post? Other Senior Registrars were busy applying and often failing to be appointed. It was clearly a challenging lottery. What kind of work did I want to do? Who would have me? It was at this point that Desmond Pond, who had been a fellow student with me at Cambridge but was now the youngest consultant at the Maudsley, told me that there was a consultant post vacant in Cambridge and that they were looking for someone with vigour to pull up a stagnant mental hospital called Fulbourn. I decided to apply in order to get experience of being interviewed; I did not expect to get the job. I was astonished when it was offered to me.
We came to Cambridge and to Fulbourn Hospital in August 1953 and I have told the full tale of my time there, especially the early years, in "The Story of a Mental Hospital; Fulbourn 1858-1983."
This book is an account of how I learned my trade, and it might seem that such learning would cease when I gained my permanent post as a consultant. Certainly all of us as registrars and senior registrars saw gaining a consultant post as the end point of our studies, our exams, our little research projects and all our competitive strivings. Yet it was not so for me, at any rate. Once I came to Cambridge I found myself studying and learning more than before! This study was however different. For many years I had been studying what other people thought I should learn, studying to pass exams, to gain qualifications, to make professional progress. Now it was quite different. I was studying because I wanted to; I was studying in order to understand the problems I was facing, I was studying in order to do my job better.
The first challenge that faced me was the strange world of Fulbourn Hospital in 1953 – the century old culture of the static English county asylum. If I was to improve it, to change it, I had to understand it. This led me in various directions. I visited progressive hospitals, such as Warlingham Park under T.P. Rees, and discovered from him that asylums had a history. They had not always been dreary static places. I was led to the writings of Tuke, Pinel, Conolly and WAF Browne who wrote "What Asylums were, Are and Ought to be" in 1837 – a clarion call that I found relevant in 1954. I spent much time in the library of the RMPA and learned much of asylum history from Alexander Walk, the erudite librarian
I studied Fulbourn Hospital itself. I read through the reports of the Medical Superintendents and the Committees of Visitors and of Management over the century since it opened in 1858 and discovered many fascinating tales – such as the chimney sweep’s boy who suffocated in the hospital chimneys and the typhoid epidemic which decimated the hospital in 1905. I was astonished to discover that even Fulbourn had had a time of hope and promise in the 1850s. I began to give talks on the curiosities I had discovered..
I was led further to learn something of this strange part of England where I was making my life. I spent many winter Saturday afternoons in the County Library leafing through the pages of nineteenth century newspapers with the stirring tales of the building of the hospital and the rows and turmoil that had arisen. I began to savour the excitement and arcane satisfaction that feeds the passion of the antiquarian.
I studied the history of the locality, the stirring tales of the seventeenth century when Cromwell raised his Ironsides from the district and the legends of Hereward the Wake, the last of the Saxons, who held Ely against the armies of William the Conqueror. I became interested in even earlier antiquities and spent summer days excavating an Iron Age site only half a mile from our house at the hospital. Within 5 miles of the hospital we had a Saxon dyke, a Roman road, Iron age hill forts, Bronze Age barrows and a Neolithic highway; I got to know them all.
Another major area of study and learning during these years was the sociology of the mental hospital. I had first seen the writings of Goffman & Schwartz at the Maudsley but now they became directly relevant to what I was doing and I devoured their articles, books and conference reports as they emerged. Their constant theme was that the hospital was a total culture, that the staff and patients were interlinked and that anything that affected one group very soon affected the others. I began to use this thinking in dealing with crises in the hospital, seeing the good sense in some patients’ responses and the madness in some of the staff. I discussed all this with Morris Carstairs and with Meyer Fortes, the professor of Social Anthropology, and made contacts with these Americans. As a result many of them came to visit us in Fulbourn "to see the new things that were being done in England" and some of them encouraged me to think of visiting the USA – and offered me lecturing fees!
I began giving talks on what I had learned and on what I was doing, and discovered that I had a talent for this. I gave many talks to local societies on "the New Psychiatry" and what we were hoping to do at Fulbourn. They were well received and I enjoyed them. Gradually I started being invited to address professional groups about how we were changing and opening the hospital and began to develop my ideas on how a psychiatrist could use the social structure of the mental hospital to improve the lives of the patients. In 1961 I was invited to make a lecture tour in the United States telling of our new open door policy. All this work developed my verbal fluency and ability to speak engagingly and spontaneously. I enjoyed the pleasure that many audiences took in the good news I brought them.
It was during my first ten years at Fulbourn that writing – professional writing – began to play a major part in my intellectual life. As a schoolboy and as a student I had done a little imaginative writing for journals, but then for years I had written little but examination papers and case records. In my last years at the Maudsley I had completed two rather pedestrian "research" studies.
At Fulbourn I found new challenges. Each year I had to write the "Annual Report of the Medical Superintendent". I started these as statistical summaries but soon developed them as reports of achievement and blueprints for future advances. To my surprise they were widely read. I then started turning some of my talks into articles and had several published, some in the Lancet, "The Functions of the Mental Hospital", "The Open Door Hospital", "Administrative Therapy", and "The Concept of the Therapeutic Community". I realised that I had a talent for a combination of statistical detail, professional comment and heartening rhetoric which many found attractive.
All this writing was an important learning experience. I had to learn how to read for myself, to seek out useful comments and quotes, to arrange my material, and to revise and complete the paper. I began to wonder whether I could "write a book"! In 1958 I tried to write a centennial history of the hospital – and failed ignominiously. I realised that writing a book was very different from writing an article. In 1962 I put my historical material into a slim volume entitled "A Brief History of Fulbourn Hospital" which circulated for many years until I included the material in my definitive history in 1996. But it was not until I had a year’s sabbatical in California in 1962/3 that I managed to complete my first published book "Administrative Therapy".
The wonderful year in California at the Centre for Advanced Studies in the Behavioural Sciences enabled me to review and change my whole way of learning. I had all the time I wanted to read and to study; the Fellows were intensely stimulating company, Californian psychiatry was experimenting with many forms of Social Therapy, I felt a strong desire to write. I learned new ways of reading for a purpose, of recording, and managing my material and of turning first awkward drafts into acceptable and lively prose.
The years after California led me into other kinds of Learning. Within Fulbourn we were experimenting with Therapeutic Communities and I was forced by the comments and criticisms of my colleagues and patients to review and change much of my style of working. I began to see how defensive many of my "professional" attitudes were and how they prevented me from either understanding or helping those in my care.
During these years I received many invitations to lecture – to professional audiences and to conferences national and international. I was also invited to consult overseas, in USA, in Japan, in Latin America and in Europe. On these trips I talked about what we had done at Fulbourn, but I also learned a great deal, especially in Japan. I came to see that some of our ideas would not work in other cultures though the principle, that the way of life in the hospital was the major influence, for good or ill, for most patients remained true. I saw compassionate hospitals, efficient heartless hospitals and in some countries squalor, degradation and brutality worse that I had ever dreamed of. I realised that some of our ideas were culture bound and limited by the society in which we operated.
In the 1970s we developed a Rehabilitation Service at Fulbourn and I had to study a new world, the Rehabilitation of the disabled, physical and mental and the problems of stigma, disability and uselessness in our society.
In 1983 I retired from the hospital and the National Health Service. I ceased to practise psychiatry so my professional learning could be said to have come to an end. However there were plenty more things to learn. I became active in the new world of the retired and the University of the Third Age. I found that some of my methods of "mastering a subject" no longer worked and explored why. Rote memorisation, which served me so well in youth, no longer worked. I could not retain new vocabularies or grasp masses of new material; my "memory" did not work as it used to. But I was able to move into some entirely new areas such as Yoga, Meditation and Spiritual Practice and develop new knowledge and insight.
I did some studies of the problems and opportunities of Life in the Third Age and produced several books of memoirs and reminiscences, including the definitive account of our years of change and progress at Fulbourn.Learning went on all the time. Always there were new challenges and new learning needed to master them.
So the process of my learning continued and does to this day. I realised that learning never ceases, that every period brings new challenges and new opportunities for personal change and also for personal learning.
The last chapter described how I acquired knowledge –a necessary part of learning a complex academically based trade. But this is only part of the process of becoming a psychiatrist – the long pilgrimage of growing into a certain kind of person. In the tale so far there have been some hints but it is now time to look at the process in some detail – both in general and how it affected me.
Any calling leaves its mark on those who practise it – the labourer becomes heavyhanded, the miner twisted, black and muscular, the watchmaker myopic and deft. But callings that deal with people leave a different mark. Gradually the individual’s social behaviour changes – the teacher becomes authoritative and assured, the policeman becomes solid, unflappable and reassuring, the Army Officer crisp and commanding etc etc. The practice of medicine soon leaves its mark on a person and psychiatry even more so. I shall attempt to discuss – with such insight as I can – how I changed over the years since I first entered medical school aged 17.
As I have indicated I was then cheerful, vigorous, apparently confident and tiresomely garrulous. I knew what I was going to do and determined to do it well and be applauded for that. Underneath I was anxious and uncertain. I was unpopular with my fellows, rather a loner, irritating and ingratiating to my seniors. I looked forward to learning to be a doctor – but had little idea of what that would mean.
Many of my early experiences were those of any medical student. For two years I spent part of every day dissecting the pickled corpses of aged paupers until I knew every tendon, artery, bone and nerve. I acquired the casual flippancy of the medical students, playing cricket in the dissecting room with thigh bones and kidneys. I did not realise that this was part of a traditional process of desensitisation which taught us to handle bodies as objects to be studied rather than the remains of people.
In due course came clinical practice especially surgery when I learned to handle living bodies, without being unduly disturbed. This was less easy; mangled limbs and blood were hard to bear. I found corruption particularly hard – the running, stinking, pus of osteomyelitis, the decay of gangrene, the outpouring of abscesses and carbuncles. But I gradually learned to handle them all and when appropriate to make jokes to show my apparently clinical detachment. I thus acquired one of the skills of a doctor that is so valuable socially in times of emergency and disaster – the ability to look at wounds and torn bodies, to ignore the screams and sobs and anguish, to assess what needs to be done and what can be done, and to get on with doing it. This was invaluable in battle and has since been useful occasionally in traffic accidents but was almost a disadvantage to a psychiatrist – who should be listening to the despair and anguish.
As I have told, much of my student time was spent in lecture theatres, taking endless notes, memorising them and reproducing them in examinations. This was tiresome but made little emotional demand. Clinical work, however, was different and affected me strongly. I got to know the patients in the Royal Infirmary and to like them. In those days before the NHS the Infirmary was for the very poor who accepted the clumsy attentions of students as part of the price to be paid for treatment by the great specialists. I found their personal tales – the trials and sufferings of the very poor, fascinating. I had to learn to "take a history," to draw out the patient’s tale and then make medical sense of it. I found listening rather than telling quite a challenging exercise. At first I was merely listening to them but as I became more senior I became responsible for treatments – bleeding their veins, shaving their bodies (before operations), catheterising their bladders, delivering their babies and talking to them while I did these things. I was amazed and humbled at the respect they gave me, calling me "Doctor" thanking me humbly, giving me credit when things went well and even reassuring me when things went amiss. I felt challenged to be worthy of this.
The peak of this period of my life and development was my half year as a house surgeon. The desperately long hours strained my endurance, and I learned some of my limits. Operating was a new skill to be learned – and I gradually discovered that I had not the deftness, the manual dexterity, to be a skilful surgeon although I was fairly competent with minor surgical procedures. More important for my growth was what happened with the patients. Some – many – died. Sometimes it was unavoidable, but sometimes it was my failings, my ignorance, my incompetence or even my sheer tiredness that tipped the balance. Facing that and accepting it was a key step in becoming a doctor – accepting that patients will die, that things will go wrong, that accidents will happen and that if you cannot stand or bear that knowledge and responsibility you have to get out – of surgery, of clinical practice, even out of medicine. By the time I entered the Army I had learned that lesson and accepted that burden as one of the prices of practising this absorbing trade.
Then came my years in the army. It was only occasionally and briefly that I had to use my medical skills though my knowledge was often relevant. I did have to learn to function in disaster situations such as the dressing stations when wounded men were brought in hour after hour and I had to do what I could for them in dirty and inappropriate settings. I also had to attend to my own comrades shattered and bleeding and crippled and just pass them down the line. I had to acquire another level of emotional armour as my friends were killed or wounded. I learned to forget those who had disappeared and drink cheerfully with those who, like me, had survived so far. However the main changes that occurred in me in those years were those that turned me into a fairly competent army officer. I had to learn to take and to give unwelcome orders – such as sending my men into dangerous situations. I had to learn to accept responsibility when things went wrong and if possible avoid blaming others for my stupidities and omissions. In Sumatra, responsible for the welfare of over two thousand internees amid an exploding revolution, I had to negotiate with both the Japanese and the British armies to get what my people needed. I learned to grasp responsibility and to accept the blame and guilt when things went wrong.
In all these ways I had been transformed into a toughened, effective, responsible young doctor, vigorous but rather insensitive, hardened to death and pain, able to play my part in disaster – the part of the doctor, the expert who got on with his work in apparent unconcern despite the blood and confusion about him.
Then I began to learn psychiatry. First there were the three months at Sarafand where I saw madness in people from different cultures and tried to understand them. Then to Craig House and three years practising clinical psychiatry. These were my apprentice years. I found learning about psychiatry difficult. I found the practice strange. I had to learn to take a "psychiatric history" far more extensive and detailed than a medical one, probing intimate and private areas of people’s lives and then rearranging then to clarify the diagnosis. I had to try to learn how to converse with the mentally disordered, the profoundly melancholic, the hallucinated schizophrenic or the deluded paranoid, trying to make and keep contact with the person despite the madness. With depressed and anxious outpatients I had to listen to distressing stories not so different from my own and try to be open and helpful without identifying so much with them that I lost the ability to help. This was a long process that ran on through my Maudsley days and early Fulbourn years. I gradually dropped much of the emotional guarding that I had acquired in my early medical years and learned to be more spontaneous and open with people.
During these early years practising as a doctor on the locked wards of a traditional hospital, I had to grapple with another dilemma. I became aware that the nurses, respectful and friendly to me, often kept order in their wards by coercion and brutality, beating patients, throwing them into padded cells, stealing their food etc. One of my patients in Edinburgh died as a direct result of staff brutality; others were injured. As the doctor it was my duty investigate all complaints, bruises etc. If I pushed too hard the nurses protested; if I did not investigate the patients suffered. I was a pivotal figure in an oppressive and at times brutal system. When I expressed my dismay an older psychiatrist put it bluntly "Dinna’ fash yersel, so, laddie. They nurses have a hard time and we rely on them tae keep order. Dinna upset them with ower many enquiries". The alternatives seem to be - accept the brutal system, or get out. Many young psychiatrists took the latter course and went off to work in private practice. Others left psychiatry. I decided to stay and try to change the situation. This became a major driving force in my years at Fulbourn, in pressing first for Open Doors and later for the Open Society of the Therapeutic Community.
My three years at the Maudsley led to other personal developments and changes. Much of this started from my own personal psychoanalysis. During the long painful hours on the couch, five days a week for nearly two years, I faced some of my own anxieties, guilt, fears and shames. I gained some insights into the forces that had driven me into medicine – my father’s dream that I would follow him into biological research, my desire to please him and to win my formidable mother’s approval. However even after I had seen this, I still felt glad that I was a doctor and was becoming a psychiatrist. I felt an increased resolve to help the oppressed of the asylums. I also faced some of my sexual guilt and inhibitions and the overpowering work ethic that I had acquired from my father’s Quakerism, my mother’s spartan philosophy and the Calvinistic values of my Scots youth.
During these three years I spent much time practising and learning analytic psychotherapy, individual and group. I realised how naïve and superficial had been the jovial reassurances and heavy persuasionism which I had practised in Sarafand and Edinburgh. I began to learn to listen rather than to talk – very difficult for me, always garrulous and fluent. I began to listen too, for the things that were not said - the confidences withheld, the anxieties not revealed nor even realised. I began to learn to "listen with the third ear". I became aware of the patients’ transference and even more my own counter-transference and how they obscured and distorted my perceptions and my practice. I gradually acquired a moderate competence in individual psychotherapy and gained more confidence.
I found Group Analytic Psychotherapy, which I learned directly from S.H. Foulkes, fascinating and congenial. I learned to become aware of, to recognise, and to manage some of the unspoken undercurrents of a group; I saw the members change over the months and drop many of their self-defeating, neurotic and fruitless strategies. Working with a co-conductor and reviewing the group afterward I become aware of some of my own idiosyncratic and repetitive behaviour and how this limited the progress of the group – such as my tendency to respond at didactic length to requests for information and my tendency to defuse tension with a joke. As the members of the group began to learn about psychological manoeuvres, they spotted them, first in other members and then in me, the conductor and finally, sometimes, in themselves. I learned a lot about myself from them.
The next major change in me came when I went to Fulbourn as medical superintendent, living in the asylum grounds as nominal master of its hierarchical Victorian society. Everywhere staff stood to attention and saluted me – while hiding what they were doing. I was offered the traditional perquisites – patients to dig my garden, patients to help with housework and care for the children, personal valeting and haircuts if I wished. I was called on to read the lesson in the hospital chapel and to be chairman of the hospital cricket team and to perform post mortems. Disciplinary matters soon came to me – kitchen thefts to be investigated, errant nurses to be arraigned and if necessary discharged. I fumbled my way through all these challenges as best I could, calling in particular on my experiences in the Army of taking Company Orders and dispensing rough justice as both judge and jury.
I had to learn to present myself to the Management Committee, a perceptive group of Councillors, aldermen and dons who quickly punctured rhetoric. I had to appear at inquests and at times attempt to excuse the inexcusable. I had to deal with Mayors and Chief Constables, Heads of Colleges and Professors, - all of them more experienced than me, and often more intelligent. I took part in many public occasions – openings, celebrations, funerals and was often asked to "say a few words". I started by being open and spontaneous but after one or two headlines in the local paper (and a reprimand from the Chairman of the Regional Board) I learned to be circumspect and even mealy mouthed.
I had some awareness of what was happening to me, for in 1958 in an article on "Administrative Therapy" I wrote of the effect that being a medical superintendent would have on anyone who took the post
"The role of medical superintendent, like every other worth-while role in life, will have a moulding effect on him. To the characteristics developed by years of medical responsibility will be added characteristics of the wielder of power – the cautious utterance, the guarded promise, the ready excuse that saves the need of self-scrutiny, the specious justification, the growing pomposity and intolerance of criticism, the diminution of scientific detachment. All these will come, and his friends and colleagues will commiserate with his wife as they become more obvious"
I was perhaps saved from the worst of this by the work I did in Therapeutic Communities through the 1960s and 1970s particularly in Hereward House. In this unit were the most difficult, disturbed and even dangerous patients in the hospital. I met them daily but faced them particularly in the weekly community meeting where open expression was encouraged. Some of them were bright and bitterly perceptive as well as destructively disturbed. They relished the opportunity to point out my evasions and challenge the inconsistencies of my decisions. This unit attracted some of the liveliest and most enterprising of staff nurses, social workers, junior doctors who also relished the opportunity to challenge the Consultant and analyse his way of operating. They pointed out to me some of the malignant effects of my social style – particularly the confusion that my erudite formulations produced for the simpler minded patients. I was gradually weaned from my tendency to the polysyllabic and obscure utterances that I used with my colleagues or in my writings and I learned to speak in a plain and open way. Most of the residents had been through the hands of many psychiatrists and were bitter about the mystification and pompous double talk to which they had been subjected. They demanded straight answers from me – and I gradually learned to give them. The staff review sessions that analysed ruthlessly my errors in the community meeting helped me both to speak more clearly and openly and to admit my own evasions and uncertainties. I probably changed more in the decade of the therapeutic communities and the Rehabilitation Service than at any time since my student days. I certainly came to speak more simply, more openly and, I believe, more honestly than I had done. I hope I became too a more open and tolerant person. But - I still talked too much and too often!
What drove me in the paths that I followed – into medicine, into psychiatry, into Social Therapy? Was it merely opportunism – taking the job that offered, aiming for the best rewards – or were there underlying drives and if so, what were they?
Certainly a major theme in my life has been pragmatism – a tendency to identify a task to be done and then to tackle it. I early came on Ecclesiastes 9,10 – "Whatever is to thy hand, do it with all thy might", and found and have ever since found that it made great sense. It was this tendency which guided me into a number of earlier choices.
I was interested in biology as a schoolboy and my father decided that I should become a biological research worker. That had been his life choice and he could not think of anything better. However, he put me down for medical training as a safe preliminary. I accepted all this and worked hard at my school exams, especially the science subjects like physics and chemistry. They were there to do and I got on with them.
It was at Cambridge in 1940 that I first began to doubt whether the life of a research scientist was for me but it was in my clinical years that I came to realise that what I wanted was to "be a real doctor". I found the patients fascinating and the task of helping them immensely rewarding, especially the poor, the weak and the unfortunate. I knew that I wanted to be a good doctor who helped people, especially poor people.
I felt the usual altruistic stirrings of youth, the desire to help people and to improve the world. Medicine was clearly good and desirable. Growing up in Edinburgh during the Depression sharpened my social concern. I saw widespread unemployment and considerable suffering. Like any young person I saw that the world created by our fathers was cruel and inequitable and yearned to put it right. "Socialism" seemed to be the answer and I espoused the creed with enthusiasm in my teens; later I gradually learned something of what it meant. When I worked on the wards of the Infirmary in my clinical years I saw the poor of Edinburgh dying from tuberculosis, rheumatic fever, anaemia, malnutrition – all preventable diseases and began to agitate for a Socialist solution to the manifest medical problems of our society.
In the late thirties the war against German Fascism loomed, became inevitable and finally started. This became a new personal objective for me. I wanted to be part of this struggle. I adopted the goal of being an effective army doctor. I worked hard at my Surgery and did a surgical house job. I entered the Army and worked hard to make myself a better medical officer. As my Army time progressed, however, I found other challenges and satisfaction. I enjoyed running a good Field Ambulance Section. I enjoyed the challenge of administering the Sumatran internment camp.
It was in the later years in the Army that I clarified my professional goals. I knew by then that I wanted to be a doctor treating people. I was prepared to be a GP but wanted something intellectually more challenging. I thought of hospital clinical medicine, but the months in the Sarafand Psychiatric Unit made my decision. I knew that I wanted to become a psychiatrist so I went to work with D K Henderson. As I worked at Craig House I became more and more interested in the bizarre problems of the psychotics and challenged by the problem of contacting them and helping them.
The years at the Maudsley helped me to clarify what kind of psychiatrist I wanted to be. Although I became a competent psychotherapist I felt little desire to devote myself to the "worried well". I wanted to help the mentally ill, especially those abandoned in the back wards of the mental hospitals. I also wanted to see what I could do to change the culture of the hospital by working with the staff in the ways that I had learned in the Army. It was these motives that led me to the Fulbourn post.
The first challenge at Fulbourn was to run the demoralised incompetent hospital efficiently. I applied myself to learning and practising administration. Then came the challenge to improve the hospital; this led to the Open Door programme. By then I was fascinated by the social factors at work in the institution; this led me to attempt Therapeutic Communities, at first tentatively and then whole-heartedly. I was thus led on by tasks and challenges.
As I wrote and published more, writing itself became a challenge. My first attempt to write a book (in 1958) failed – and I was stimulated to try harder. With each book, came the challenge to tell the story clearer and better next time.
An interviewer probing my story – (for his research programme) asked some pointed questions. "What was your political motivation in your work as a social psychiatrist?" "Where did you get your ideas on leadership and responsibility?" and "Who were you role models?" Each of these made me think hard and look back over the tale as I have told it. Some of the questions may have been implicitly answered in the story but it may be of use to discuss them explicitly.
Political Motivation - I justified my social psychiatry explorations in pragmatic terms – I wanted to improve the lot of the long term patients so I tried many ideas. When they worked I expanded them further. Nevertheless I recognise that there was a political philosophy behind my work. I grew up in the thirties, and saw slump, unemployment and demoralisation under ineffective laissez faire conservatism. I became convinced that the answer was vigorous effective government action – "Socialism". Effective management – the Welfare State, the National Health Service – benefited many of the medical problems of the nineteen thirties – tuberculosis, rheumatic fever, anaemia. It changed vastly the lot of those in medical institutions – tuberculosis sanatoria, lunatic asylums, mental deficiency colonies. This was the way to help people – rather than by struggling with the individual. Nearly all of us involved in Social Psychiatry had been left-wingers in the thirties and forties; some of the most effective had been Communists. Social Psychiatry was amongst other things Socialism applied to psychiatry.
Leadership and responsibility – These were vitally important issues in running a mental hospital, in changing a mental hospital, in leading a therapeutic community. As I thought about these issues, in myself and in others, through the 1950s, 1960s and 1970s, I realised that medical training had been of little use to me – almost a disadvantage, Traditional medical training taught one to concentrate on the individual – on the processes going on inside his body and his mind – and to work with him and keep him alive and well. An effective social psychiatrist had to learn to think of the group, the ward, the institution and to work on them in order ultimately to benefit the individual patients. I saw some doctors – kind, concerned devoted men – make lamentable administrators because they could never see beyond the individual.
The time when I learned most about Leadership and Responsibility was in the Army when I was a Section Officer leading a group of men into battle. It was in those years that I saw the result of bad leadership, of the abdication of responsibility. It was then that I learned to think first of the group, of its tasks, of its inner structure – and only later of the individual and how he fitted in. These were vital lessons for running the hospital and for analysing the happenings in a Therapeutic Community.
Role Models - It was a revealing question for me to consider this. I realised that six men, all doctors, had been vitally important in my learning years – my father, A.J. Clark, my surgical chief, James Learmouth, my first Colonel in the Army, E Bruce Harvey, my first teacher in psychiatry, DK Henderson, the professor at the Maudsley, Aubrey Lewis and my group therapy teacher, SH Foulkes. All had a major impact on me. Each of them was for a time the dominant figure in my life and work. I had many feeling towards them; I respected all of them, for they were all intelligent and skilled at their jobs; at times I feared them, as they saw clearly my failings, weaknesses, and disasters. I disapproved of some, like Aubrey Lewis (because of his sadistic style of teaching) but towards most of them I felt gratitude for the efforts they had made to force me to learn my job. From each of them, of course, I took tricks and devices and copied small skills in handling people or issues. From some of them – such as Aubrey Lewis - I took vivid lessons in how not to do things (how not to handle registrars). Some were easy to mimic, others less so. D.K. Henderson in particular had a number of highly effective emollient and evasive responses "You’re doing very well" – "You’ll just have to do the best you can" – which were difficult to avoid copying. How much of my final professional style of operating can be traced back to any of them, I do not know. Only a skilled observer, who had known the teachers and then saw me in action could tell which trick, device, mannerism came from which teacher.
When reflecting on my Role Models, I realised that I had not hung pictures of any of them on my office walls – a standard practice of American, German and Japanese colleagues - and I wondered why. I then realised that mingled with my gratitude to each of them for the many hours they had spent licking a rough bear cub into shape was a mild resentment that most of them were trying to make me into what they thought I should be, rather than discovering what I might be, or wanted to be. My father wanted to make me into a biological scientist; James Learmouth wanted to make me into a surgeon; Bruce Harvey wanted to make me into an effective Army Officer; DK Henderson and Aubrey Lewis wanted to make me into a psychiatrist – but strictly in their image, DK as a shrewd wily manipulator, Aubrey as a polymath who could quote everything. Of all my teachers I felt that only the last, SH Foulkes, wanted to help me find out what I could do and become, rather than forcing me into a mould. He did not push me into psychoanalytic training, nor insist that I follow any school. Instead he listened to what I said I was doing and then helped me to see what might be the reasons why I did it. I feel a warmth and gratitude to him quite different to the guarded respect I owe to all the others.
These were my "Role Models". But I learned from many others, all the time. I learned from fellow trainees, I learned from nurses and social workers , and later, as I learned to relax some of my learned "professional distance" I learned a vast amount from my patients especially in the therapeutic communities. I learned from other medical superintendents and consultants who were struggling with similar challenges to mine. Of all my contemporaries I think I gained most from Morris Carstairs and Maxwell Jones, both Edinburgh graduates, both social psychiatrists and both close personal friends. Morris advised me wisely at several critical points in my career; Max was always there teasing and challenging, forcing me to think again about what I was doing.
That then, is the story of how I learned my trade, and a few reflections on the story. I have gained a lot from putting it together, setting it down and reflecting on all the factors that have influenced me over eighty years. The exercise has been valuable, even enjoyable for me and I hope that the result has been comprehensible and at least readable for others.
Several senior psychiatrists reflecting on their careers have recently listed books which had a strong effect on them. This seemed revealing so I have carried out the same exercise.
First, of course, were my basic textbooks. Henderson and Gillespie’s "Textbook of Psychiatry" from which D.K. lectured to us as students and on which he examined us and to which I turned again and again in the years I worked for him. Then Curran and Guttmann’s "Psychological Medicine" the elegant slim first edition with its pithy and witty comments, an excellent guide for a young doctor facing psychotics for the first time.
The next group of books that affected me profoundly were the writings of the American sociologists studying the asylums of the post war period; first Stanton and Schwartz, then Belknap, Dunham and Weinberg, and Caudill. They helped me to see a hospital as a bizarre but functioning society of inmates, attendants and doctors acting and interacting on one another. Finally, of course, most powerful was Erving Goffmann’s "Asylums" setting out his penetrating paranoid vision of life in St Elizabeth’s Hospital, Washington, D.C.
Over the years came other writings which mordantly sharpened these views of asylum life from underneath. "If a man be Mad" by Maine first opened my eyes how the apparently humane assertions of asylum doctors could be seen as hypocritical endorsement of appalling brutalities. Ken Kesey’s "One Flew over the Cuckoo’s Nest" and even better the film that Milos Forman created from it fixed that vision for ever. The "Manual of Psychiatry for Dissidents" produced in a Soviet prison by Vladimir Bukovski, a "patient" and Semyon Gluzman, a psychiatrist, showed how the apparently benign "Mental State Examination" beloved of the Maudsley professors could be an instrument for validating cruel imprisonment.
On reviewing this list, I am struck by some absences. There were men whose practices profoundly affected me, such as Maxwell Jones, T.P. Rees, and Duncan Macmillan. There were others whose personalities left lasting impression, such as S.H. Foulkes, Aubrey Lewis, Carl Rogers, and Thomas Szasz. But this was a list of the books, which hit me, made me stop, think, and change my ways.
Belknap, I. (1956). Human Problems of a State Mental Hospital. New York: McGraw Hill.
Bukhovski V & Gluzman S. "A Manual on Psychiatry for Dissidents" in Bloch S & Reddaway P (1977) "Russia’s Political Hospitals". Gollancz p419-440.
Caudill, W.(1958). The Psychiatric Hospital as a Small Community. Cambridge: Harvard University Press.
Curran, D. & Guttmann, E. (1943) "Psychological Medicine". Edinburgh, Livingstone.
Dunham, W., and Weinberg, S.K. (1960). The Culture of the State Mental Hospital. Detroit: Wayne State University Press.
Goffman, E. (1961). Asylums. New York: Doubleday.
Henderson, D. K. & Gillespie, R. D. (1944). "A Textbook of Psychiatry". London. Oxford University Press.
Kesey, K. (1962). One Flew over the Cuckoo’s Nest. New York Viking Press.
Maine, H. (1947). If a Man be Mad. New York. Doubleday.
Stanton, A., and Schwartz, M. (1954). The Mental Hospital. London: Tavistock Publications.
After I retired from the hospital in 1983 I spent time taking discussion groups in the University of the Third Age. It became clear to us that the strategies of learning for us in our seventies had to be quite different from those that had worked so well in our teens. These discussions prompted me to review the different methods I had used during my life in order to learn. I realised that over the years I had used at least five different learning strategies.
At school and in my early years at Edinburgh University I relied successfully on Rote Learning. At school I had little difficulty in memorising poetry, lists of dates, lists of irregular verbs. At University I listened to the lectures, wrote the material down, learned it and regurgitated it successfully in the exams. I hardly ever questioned or examined it. This method worked well up to the Medical Finals and the Membership Examination of the Edinburgh Royal College of Physicians.
When I came to study for the DPM, this method failed! I failed the exam – twice!! I, who had never failed an exam before! I had to analyse what had gone wrong. I realised that there were no lectures to memorise. There were many textbooks – but often at variance with one another (especially in psychology). I had to learn to read textbooks critically, make my own summaries, and even decide what I believed - quite a new method for me. Once I had mastered this new technique I passed the exam.
After passing the DPM I realised that there were no more exams for me to take! I no longer had to read texts prescribed by other people. I could read anything I wished – or not read at all! By this time I was at the Maudsley with the best psychiatric library in London. I began reading everything that caught my eye. I read most of Freud’s writings while travelling on underground trains, to and from my analytic sessions. I explored Social Psychology and attempted to understand the methods of Kurt Lewin. I began two small research projects and covered the relevant literature. I learned to precis books and arguments and to discard those of no value to me. I found books that were too difficult or abstruse for me to comprehend and suddenly realised that I didn’t have to finish them – no one was going to examine me on them!
When I went to Fulbourn there were new areas of knowledge to explore, subjects I needed to learn to do my job - asylum history, management practice, local history. In each case I proceeded by wide and indiscriminate reading followed by critical and selective analysis. I had at last, in my thirties, learned to acquire and consolidate book knowledge for myself.
A few years later I started writing articles and then books. This called for another kind of reading and learning. I had to read all the relevant papers, precis them and decide what to use. I had to assess them, criticise them and discard some. When I wrote an MD thesis, I had to cover everything ever written on the subject (psychiatric half-way houses) including some lamentable articles, and review them all fairly. Later I carried out and published comprehensive reviews of all the literature on administrative psychiatry, and later on therapeutic communities. This method of critical analysis and selection was yet another form of learning to by mastered.
Finally came learning in my old age. I could no longer rely on my memory. I had to precis and write down anything I read, for I found that facts no longer stayed in my mind as they had done in the heyday of youthful Rote Learning. Now, if it is not written down, it goes. Exploring new fields is far more difficult, and I find it very difficult to master a new jargon, such as the Sanskrit terms in Yoga, or the vocabulary of the Internet. However I find that if I take it much more slowly and make summaries and reviews I can still gradually master a subject at a low level.
© David H. Clark 2000
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