The Story Of A Mental

THE STORY OF A MENTAL HOSPITAL: FULBOURN, 1858-1983 by David H. Clark Current policies about 'care in the community' of the mentally ill, along with lurid accounts of abuses, have led to the impression that the old, custodial mental hospitals outside big cities were all dreadful 'bins' where human dignity was sacrificed to staff routines. The author was in charge of a traditional institution near Cambridge for three decades, during which it became internationally renowned for enlightened practices and the nurturing of patients' rights and welfare. He tells the history of the hospital from its founding in the nineteenth century to a period of traditional custodialism, during which it suffered from lack of funds, physical neglect and low morale. He then tells of a number of exciting changes: unlocking the wards, social therapy, administrative therapy, therapeutic communities, and the rehabilitation programmes of the 1970s. It is a moving story, part autobiography, part narrative history, and full of touching incidents - coping with internal wrangles, inertia and relations with the community and reflecting the best tradition of the caring professions. It can be argued that the work being done in some institutions of this kind compares favourably with many current policies for the care of the mentally ill. 'Little has been written by insiders about those great public mental hospitals which, until recently, held in Britain over 100,000 patients. Hence everyone interested in recent psychiatry and the role played in it by the psychiatric hospital will be delighted that David Clark has recorded his personal memories of a life-time spent in running a large, public psychiatric institution Trained at the Maudsley Hospital, Clark joined Fulbourn Hospital, on the outskirts of Cambridge, back in the 1950s; he stayed on and transformed the institution... 'In a book doubling as a history of the hospital and an autobiography Clark discusses the changes he was able to effect and his thoughts about the present crisis in psychiatric care. A rich irony reveals itself: our age, which has seen the agitation for the closing of traditional asylums come to fruition, has also been the time when many of them have been, at long last, most therapeutically innovative and successful. 'Frank, modest and written with a wry sense of humour, David Clark's account of a career in Fulbourn is a rare document, fascinating to read and invaluable as historical evidence. It is a pleasure to see it in print.' - from the foreword by Roy Porter, Professor of the Social History of Medicine, Wellcome Institute, London, author of Mind-Forg'd Manacles, editor of The Faber Book of Madness and Co-editor of Discovering the History of Madness David H. Clark studied Medicine at King's College, Cambridge and Edinburgh University, trained in Psychiatry at the Maudsley Hospital, was appointed Medical Superintendent of Fulbourn Hospital in 1953 and from 1971 until 1983 was Senior

Consultant Psychiatrist at the hospital. He is the author of Administrative Therapy (Tavistock, 1964), Social Therapy in Psychiatry (Penguin, 1974; 2nd ed., Churchill Livingstone, 1982) and Descent into Conflict 1945: A Doctor's War (Book Guild, 1995). Contents Foreword by Roy Porter vii Preface xi Acknowledgements xiii 1. How it Began 1 2. The Asylum Years 4 3. A New Superintendent 39 4. Managed Change: Towards Open Doors 74 5. Difficulties and Challenges 130 6. Social Therapy 184 7. Rehabilitation 218 8. Reflections 234 Postscript (1995) 224 References 246 Index 248 ISBN 1 899209 03 4 Pp. xiv+248 Price £19.95 (British pounds sterling) plus £1.50 postage & packing Process Press, 26 Freegrove Rd., London N7 9RQ

The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 23 August, 1998 10:06 AM 1 HOW IT BEGAN The Chairman of the Appointments Committee said, ‘The Committee has decided to recommend your name for the position of Consultant Psychiatrist and Medical Superintendent of Fulbourn Hospital, conditions as advertised; are you willing to accept?’ Breathless and rather astonished, I muttered ‘Yes’ and wondered if it was all a dreadful mistake. On my first visit to Fulbourn the previous day I had been taken round the wards and found them as dreary as I had expected. In the early 1950s, the back wards of any county mental hospital were depressing; I had visited a number and found Fulbourn like the others. My conductor had to unlock every door; within the ward patients, grey-faced, clad in shapeless, ill-fitting clothes, stood still or moved about aimlessly. There were however a few particularly striking things on the first visit to Fulbourn. The overcrowding was worse than most other hospitals; in some dormitories the black iron bedsteads were so

close together that the patients would have to climb over the foot of their beds to get into them. The men’s dormitories were particularly depressing; the ventilation seemed poor, chipped enamel chamber pots stood everywhere on the bare deal floors, the smell of urine was strong and there were no personal items of any kind to be seen in the cold rooms. The wards seemed bare; there were no curtains on the windows, which were a mosaic of tiny panels of grubby glass set in cast-iron frames; the furniture was massive, deep brown, dingy and battered. The floors were bare scrubbed deal from which the knots stood high while the boards creaked ominously as I walked over them. The corridors between the wards were gloomy, brick passages painted dark green, roofed with glass, with a floor of ancient, worn flagstones, in the hollows of which lay pools of water and slops of food. The patients themselves made little impression on that first visit. I remember a few things: the shapeless grey suits of the men, crumpled by boiling in the laundry, and the corduroy trousers, whitened by many washings; elderly men shuffling up to a guttering gas jet to light their stubby pipes and to spit in a bucket of sand; a group of women passing by in shapeless hospital dresses with unkempt grey hair and coarse lisle stockings sagging down over worn shoes; a disturbed women’s ward full of shouting, with many women in bizarre clothes of colourless quilted cotton; a number of padded rooms with their grey rubber walls, several occupied. I had, however, been shown some more heartening things. I saw ‘The Admission Villas’ – two outlying buildings in which the short-term patients were treated. They were sunlit, pleasantly decorated one-storey buildings with an air of brisk purpose. A number of recently admitted patients lay in bed, some with relatives sitting looking anxious and solicitous, rustling paper bags. Other patients sat at tables, making baskets or playing billiards, looking tidy and almost cheerful. There was a pleasant occupational therapy department, housed in an airy building on a hilltop, where patients were producing fine cabinet work and excellent embroidery under the direction of a gracious and enthusiastic lady. I had looked with particular interest at the staff for it was with them, I believed, that the future lay. In the women’s wards they seemed to be few and harrassed – elderly, greyhaired women in curiously antiquated uniforms, crumpled, untidy and preoccupied. On the men’s wards, however, there seemed to be more staff and some spoke confidently and briskly about their work and seemed to have a warm and protective attitude to their patients. I looked for signs of tension, the surface indications of underlying violence, or brutality. I noted less of this than in some hospitals I knew. In most of the wards the atmosphere was one of friendly if resigned acceptance rather than the tense, hostile watchfulness I had felt in some other hospitals. The overall effect of my tour was, however, disheartening, and I spent some time the night before the interview wondering whether I should withdraw – as several other candidates had. On the other hand, there seemed to be at least a few possibilities: I had talked with several Cambridge people who had said that though the hospital, for various reasons – historical, personal and accidental – had made little progress in recent years,

there was a real desire to see movement and that there would be funds and backing for any vigorous attempt to improve things. I decided to go forward to the interview; it was the first time I had been to an interview for a Consultant post and I wanted to savour the experience. I thought it unlikely that I would get the job and did not greatly care, as I had plenty of interesting work on hand in my current situation as a Senior Registrar at the Maudsley Hospital in London. It may have been this very indifference that won me the post, since it meant I was not over-anxious at the interview. The Appointments Committee was a large one and I knew that they had failed to make an appointment at their first interviews two months earlier. They soon showed that they were split into several factions. I was challenged by the task of trying to answer the questions of one faction so as to please them without alienating their opponents and yet to give my own opinion (where I had one) honestly. I managed a few sallies which raised laughs and presented myself, for all my lack of experience, fairly adequately. Since candidates were seen in alphabetical order I was one of the first interviewed. When I actually was offered it I experienced mingled feelings of elation (at the prospect of a Consultant’s salary at last!), of unworthiness (for I knew how little I knew), and of dismay (at the tremendous, perhaps impossible task I was taking on). However, I did accept and then rushed out to telephone the good news home. 2 The Asylum Years The state of Fulbourn Hospital in the early 1950s had its beginning in the treatment of the mentally ill in the eighteenth and nineteenth centuries. The opening of Fulbourn in 1858 (at the same period as most of the county asylums in England) marked the end of some 60 years of public debate, agitation and concern. The asylums were hailed at the time as a triumph of public benevolence; Lord Shaftesbury, the great Victorian reformer and philanthropist, saw them as his greatest achievement. They were a turning point in the management of the insane; from the early nineteenth century onward in England madness became a matter of public concern and action, rather than a private misfortune. Madness has been known to every society that has left records. The tragedy and misery which occur when a useful member of society loses his wits, the problems that arise if he owns property or wields power and the fear of his violence are chronicled in all national histories – from the biblical Kings Saul and Nebuchadnezzar to our own Henry VI and George III. Primitive societies usually dealt with their mentally disordered members by killing or expelling them. Later came attempts to provide care; most settled societies had shrines, holy wells and places of refuge to which the disordered could be taken in the hope of cure. In Medieval Europe St Dymphna’s shrine at Gheel, Belgium and the Priory of the Order of the Star of Bethlehem in London were famous. After the Reformation in England some of this work was carried on by a few Charity Hospitals and London continued to be served by Bethlem. In the eighteenth century private care of lunatics in small homes developed. However, at the end of the eighteenth century the care of the insane became a matter of growing public concern amongst the informed governing classes of England. There were

many reasons for this. An increasing number of pauper lunatics were blocking the workhouses. The former madhouses were inadequate; in the 1820s conditions at Bethlem Hospital in London were so disgraceful that Parliamentary Committees of Enquiry were needed. The insanity of King George III had caused a major constitutional crisis in 1788. His later periods of insanity from 1801 until he died in 1820 kept the matter before the concerned public, especially as details of the brutal treatment he received from his doctors and attendants became known. Since 1793, increasing attention had focussed on the Retreat at York, a pioneering institution run by Quakers where humane treatment had achieved great successes. All these considerations gave force to those who were pushing for the provision of good public asylums. Much legislation was passed. Forward-looking and prosperous cities set up Lunatic Asylums – Norwich in 1815 and Edinburgh in 1817. In the early part of the nineteenth century a series of scandals caused Parliament to set up Commissioners in Lunacy, at first for the Metropolis and then for the rest of the country. Lord Shaftesbury interested himself in these unfortunates, as well as many others – children in factories, women labourers, barrow boys and chimney sweeps’ climbing boys. He sat on the Bethlem Enquiry, was one of the first Commissioners in Lunacy and pressed through a series of Acts about Asylums. Finally in 1845, came the Act forcing every local authority to set up an asylum. General medical practice in the early nineteenth century was still based on the humoral theories of the Greeks and relied very heavily on bleeding and purging. Remedies were obscure concoctions of herbs, only a few of which were effective. The scientific revolution of medicine was just beginning with new instruments such as effective microscopes and new disciplines like chemistry (which began to clarify the physical basis of many diseases). Medical knowledge about mental disorder was unsophisticated. Little was known about the incidence of mental disorder in the population or how best to manage lunatics in institutions. There was even doubt over which profession was best able to manage lunatics. The care of the mentally disordered in England was in the hands of priests during the Middle Ages and even in the eighteenth century there was a general feeling that a clergyman might be the best person to understand and care for a disordered soul. George III’s physician, Dr Willis, was a doctor of divinity as well as of medicine. The Retreat at York had been set up and run by laymen. Most lunatics were treated harshly and left to the mercies of untrained and frightened attendants who beat and abused them and kept them chained and locked up. Medical knowledge of insanity at the beginning of the nineteenth century was a collection of observations about the characteristics of disorder and accumulated experience about its likely outcome. Treatment was a muddle of traditional remedies and practices – many ineffective, some dangerous and some cruel. The considerable public interest and concern about insanity caused some doctors in the early nineteenth century to become interested in the subject, and it was they who became the superintendents of the new public asylums. They began to study the lunatics sent to them by the magistrates, to try out the various methods of treatment proposed – by people such as Philipe Pinel – and

to publish their reflections. Pinel, a French mathematician, philosopher and friend of the Revolutionaries – as well as a doctor – had taken over the dreadful public hospitals of Paris in 1793, taken the chains off the lunatics and instituted humane treatment. His followers, led by Esquirol, studied their patients, classified them and published extensively. John Conolly was one of the most famous asylum superintendents in nineteenth-century Britain. After a varied career as a militia officer, an unsuccessful country doctor, Mayor, University Professor and journalist, he took charge of the new Middlesex County Asylum at Hanwell for four years (1839–43) and by dramatic action, publications and lectures transformed the hospital. He established ‘non restraint’ and laid the foundations of a successful career as a specialist in mental disorder – or ‘alienist’. By the time that Fulbourn Hospital opened in 1858 there was a small group of English medical superintendents who were becoming recognised as experts on insanity. Cambridgeshire’s response to the Act requiring the setting up of asylums was very much governed by its geographical situation. It was a rural backwater which had enjoyed a quiet eighteenth century with little change. The land was fertile and productive, the peasants settled and industrious. Authority was firmly in the hands of the squires and the clergymen of the Established Church. The ancient University at Cambridge was at its lowest intellectual ebb – there was little scholarship and it functioned mainly as a finishing school for the less stupid younger sons of the gentry, most of whom would become clergymen. Cambridge was a small market town whose politics were firmly in the grip of the corrupt Mortlock family. The area’s prosperity was based on agriculture which flourished during the Napoleonic Wars and the protectionist period afterwards. Things changed with the repeal of the Corn Laws in 1846 which started an economic decline that blighted the area for a hundred years. This, however, had hardly started when the founding of the Asylum was being discussed in the late 1840s. Cambridgeshire’s ‘pauper lunatics’ were lodged in the workhouses and the local jails. If a pauper lunatic was too difficult to handle in the workhouse the Cambridgeshire Justices had to board him out in a private asylum. In 1845 they were faced with a Lunacy Act which said that all rate-levying authorities must provide a Public Asylum. It was not a challenge which the Justices met with much enthusiasm. In the early nineteenth century the Justices of the Peace (Magistrates) in each County were responsible for public affairs and for such public services as existed. These JPs were selected, respected members of the gentry – usually land-owning gentlemen and clergymen of the Established Church. They were responsible for gaols and for police; they discussed public health and government; they had power to levy rates. The task of building asylums, therefore, fell to the Justices and the records of the transactions that led to the founding of Fulbourn Hospital show how the Cambridgeshire gentry responded.

While in some areas Justices acted quickly, this was not the case in Cambridgeshire. They met and discussed, and were dismayed by the task ahead. Finally in 1848 there was an agreement to set up a Pauper Lunatic Asylum between the ‘Justices met in Quarter Session’ of the County of Cambridge, the Isle of Ely, and the Borough of Cambridge (later known as ‘The Three Bodies’) who would have to raise the money to pay for the Asylum. They set up a Committee with representatives from the three authorities to be known as ‘The Committee of Visitors’. The Visitors held their first meeting in Cambridge Town Hall on 28 December 1848 and elected Mr St Quintin as Chairman. This initial meeting was followed by ten difficult years. Having acquired a well-drained site with a good water supply from a local farmer, in September 1850 the committee advertised for architects to compete. They received 50 entries and finally selected that of a Mr Kendall of London. His estimate for building was £26,250. This frightened them so much that they began to cast about for another solution. In 1852 they counted up the lunatics in Huntingdonshire to try to bring them in. They approached Bedfordshire to see if more patients could be accommodated there. However, Bedford Asylum was far too small and needed a new building. After making a series of consultations and references to the Commissioners in Lunacy in London, the committee was told that no asylum should contain more than 300 people, and that, therefore, there could be no merger with Bedfordshire. Having wasted several years, in 1854 the Committee decided to go ahead again with building their own asylum. However, by this time the cost of Mr Kendall’s plan had risen so much that they dropped it. There are several Minutes referring to ‘the vast rise in the cost of materials and labour’. They offered Mr Kendall £150 for his trouble, but he refused and eventually took them to Law. He gained a Judgement for £l,000, and the legal costs to the Visitors were £2,279, so the asylum was three thousand pounds in debt because of ill-judged parsimony before building even began. They then invited Mr Samuel Hill, the Medical Superintendent of West Riding Asylum to prepare plans, which he did along with an architect named Jones. These were accepted and put out to tender. Mr Webster, a local builder, won the contract and the building was begun during 1856. On 30 September 1856 Admiral The Earl of Hardwick, the Lord Lieutenant of the County and a member of the Visitors Committee, laid the Foundation Stone. An account of the occasion which appeared in a local paper gives a flavour of the times and indicates what people hoped of the Asylum when it was built. ‘Laying of Foundation Stone of the new Pauper Lunatic Asylum’, Cambridge Chronicle Oct. 4 1856, p.7. The subject of a Pauper Lunatic Asylum for the County and Borough of Cambridge and the Isle of Ely has long been before the public; it is unnecessary therefore on our part to go into details of all the discussions that have taken place upon it, the law expenses that have been incurred, the differences between architects and builders and the numberless reports that have been presented upon the matter at Quarter Sessions and at Council meetings. It is sufficient that all these difficulties have been satisfactorily mounted,

thanks to the increasing efforts of the Committee of Visitors with Mr St Quintin as their Chairman; and those poor creatures whom it has pleased the Almighty to affect with the loss of reason are at length likely to receive that comfort and attention which their sufferings require and where many of them may be restored to happiness and rationality. Extracts from the Earl of Hardwick’s speech illustrate the attitudes and beliefs held by informed gentry in the mid-nineteenth century towards the mentally ill. Ladies and Gentlemen, allow me to express one ardent wish on this occasion and that is that none of you whom I see present today, or anyone belonging to you may ever be compelled to go within those walls (hear, hear). One of the improvements of our age has been the desire on the part of the rich, of those who govern, to care for the comforts and necessities of those in a different sphere of life from themselves. He spoke of the care of lunatics in the past and said for some time their condition was regarded as incurable, and their acts were sought to be restrained by rules and violent means. The great advancement made by medical professors has convinced the public that insanity is not incurable; and that although there are idiots whose minds are entirely gone, in most cases the patient can be restored to mental soundness. This is a building which will be devoted to the pursuit of that science which has enabled members of the medical profession to effect a cure of insanity in almost every instance. In January 1858 the architect reported that all was going well, and that he would be ready to hand over in May; he handed over in August. In August 1858 the committee interviewed candidates and appointed Dr Edward Langdon Bryan, MD of Hoxton Asylum, as Medical Superintendent and his sister Miss Bryan as Matron. They engaged staff, moved them in and arranged to bring to Fulbourn those Cambridgeshire people who were at present being maintained by their parishes in various asylums. The estate the Visitors had purchased was a stretch of open chalk downland some three miles to the south-east of Cambridge. It was about half a mile square and lay to the north of the main road from Cherryhinton village to Fulbourn village. From the road the land rose gently to an east–west ridge on which they built the asylum. Behind the ridge the land sloped down toward the fen, being crossed by the new Cambridge to Newmarket railway (1832) and a lane, ‘The Old Drift’ which had run since Saxon times from Cherryhinton Church to Fulbourn Church. The buildings they had erected stretched for 400 yards along the crest, two storeys high, built of the grey local brick with stone facings. In the centre stood a three-storey building containing the Board Rooms and the Medical Superintendent’s home; behind it lay the hospital Chapel and the battlemented water tower, at 60 feet the highest point of the building. The two wings contained the wards for the patients, men to the west and women to the east, two wards for each sex, day rooms on the ground floor, dormitories above, and attendants’ rooms in the attics. From the main road it was a fine impressive building.

The opening of Fulbourn Asylum was described by the Cambridge Chronicle for 6 November 1858: Lunatic-Asylum Visitors met at the Asylum on Tuesday last. The main object of the meeting was to open the asylum for the reception of patients, Dr Bryan having been instructed to remove from the Hoxton Asylum the patients chargeable to Cambridge parishes on this day; accordingly shortly after the Visitors had commenced the business of the meeting, the porter announced the arrival of the train containing the poor unfortunates. Nothing could exceed the good arrangements made for removing the patients, by which all had arrived safely and without a single casualty. With the exception of three (who were carried) all walked from the carriages to the Asylum. It was a sad sight to witness, forty-six poor creatures, varying from sixteen to at least seventy years of age, each bearing the unmistakable impress of insanity. We understand several of the patients were very violent cases; but whether from their being accompanied by their own attendants, or from the change of scene, all were quiet and behaved well; in fact several of them took off their hats to the Visitors, and the females curtsied. There were about an equal number of each sex in the forty-six patients. Several of the females were very lively, and laughed heartily on walking across the grounds of the Asylum. From 1858 the annual Reports are our main source of information about the happenings in the Asylum. The Law required the Committee of Visitors to prepare every year a Report on the Asylum, send it to the rate-levying bodies and to publish it. The Visitors’ reports had mostly to do with building, finance and staff difficulties, and had numerous lengthy financial appendices. However, attached each year were the comments of the Lunacy Commissioners, who had made their visit during the year, and the report of the Medical Superintendent. From these, with occasional reference to the Visitors’ Minute Books, we can gain an idea of what happened in the Asylum during the early years. At first all went well. Altogether 106 Cambridgeshire people were transferred from various metropolitan asylums by the end of 1858, and twelve new cases were admitted. The chronic patients (80 of them had been insane for more than two years, and 27 for more than ten years) reacted well to the new environment, and Dr Bryan noted that the physical health of many of them improved materially during the first few months; during the next year two of them were discharged. The patients were busily occupied during the first few years laying out the paths, building a bowling green and bringing the land into cultivation. Dr Bryan’s report for 1859 indicates the active life organised for the patients in the early days. From the Medical Superintendent’s Annual Report 1859 The requirements of a newly opened Asylum have directed my attention chiefly to outdoor labour, namely, the cultivation of the land already under tillage, and the trenching, levelling and bringing into a fit state for farming or gardening, the remaining 5 or 6 acres, consisting of a large and deep clunch pit, and other broken and waste land.

I may also mention, that this kind of employment was indicated by the fact that the greater number of patients are agricultural labourers, the number of artisans being extremely small. The cultivated portion of the garden and farm, consisting of about 40 acres, has received due attention in reference to cropping, gathering the crops, and manuring. The roads and walks extending above a mile in length, have been levelled, rolled, and gravelled. While attending to the profitable employment of the Inmates of this Asylum, we have not been unmindful of their amusement and recreation. Thus, on referring to my journal, I find the following note: ‘At the hour of three in the afternoon, 57 of the male patients left their wards, and sides being chosen they commenced a game of cricket, which the lookers-on as well as the players appeared much to enjoy. At tea-time they were joined by 43 of the female patients, and after tea various games were entered into, a few country dances were gone through with much mirth and spirit; the attendants and a few visitors to the patients (who requested to remain in the grounds) joining in the pastime; all parties appeared much pleased with their afternoon’s entertainment, every thing going off comfortably, and the patients retiring to their wards shortly after eight o’clock’. This mode of passing the afternoon has been of frequent occurrence, and with walks in and beyond the grounds has formed our chief out-door amusements. Within the house, after the hours of labour, books and periodicals are freely distributed; bagatelle boards, drafts and cards have also been supplied, and are in great request; music and dancing have been among our evening amusements on the female side of the house, where one evening weekly is devoted to this very favourite recreation. The Commissioners in Lunacy reported favourably on l December 1859 and noted that ‘Non-restraint is the rule of the establishment’. During the first years the Visitors found it difficult to fill the Asylum. This alarmed them because they could only keep the maintenance cost down by filling it. There were plenty of lunatics in the workhouses in the County, but provided they were quiet the Guardians kept them there for it was cheaper than maintaining them in the Asylum. The reports of the next few years are full of pleas urging on the Guardians the advantages of early treatment, and begging them to send the patients in before they became chronic. Further building was necessary as early as 1860. The parishioners of Fulbourn village had begun to protest against the burial of pauper lunatics in the already overcrowded village churchyard. The Committee proposed to have their own graveyard; the Commissioners in Lunacy disapproved of this because they knew that relatives did not like visiting ‘asylum graveyards’, but the Committee went ahead. They dismantled the mortuary which had stood at the main gate, and re-erected it as a cemetery chapel in the north-west corner of the grounds. The paupers were buried two in a grave and the sad little burying ground continued in use until 1955.

In 1869 Dr Bryan married a local heiress and resigned from his position. The Visitors then appointed Dr George William Lawrence of Camberwell House as Medical Superintendent. Dr Lawrence began work enthusiastically and several Commissioners’ reports comment favourably on his energy. During 1861 we find the first mention of staff misconduct and dismissals. An attendant John Barnes was discharged for leaving his razor on the window-sill of his room, where patient William Gittus found it and cut his throat. The tailor ‘responded to a patient’s challenge to a fight’ and was discharged. Robert Mills struck a patient, was cautioned and later discharged. Dr Lawrence continued to improve things and amongst other changes started a library for the patients and a school for the men to learn to read. In 1862 he turned his attention to the diet. He states in his report his conviction that ‘The proportion of recoveries in this asylum is the highest (of 10 listed County Asylums) … this I attribute chiefly to diet.’ Brewing had been started that year and he notes ‘I have been able to reduce the medical extras this quarter from 31/2d per head to ld in consequence of the excellence of the beer brewed and supplied to the patients.’ We are fortunate in having a contemporary description of the hospital in its early days. Though eulogistic, it does give an idea both of how things actually were and how they were intended to be. In the Journal of Mental Science for 1862 is reprinted a lecture given in Cambridge by Dr J. Lockhart Robertson on ‘The Progress of Psychological Medicine since the days of Dr Caius’ (that is since the sixteenth century) (Robertson, 1862). Dr Robertson spent some time retelling the melancholy tale of earlier asylum brutalities and the lamentable state of affairs at Bethlem in 1815. He then says: In order vividly to see the progress which medical science has made since Dr Caius’ time, let us look at one of our English county asylums of today. A very good specimen is the Cambridge Asylum at Fulbourn, under the able administration of my friend Dr Lawrence. The first great fact observed is the entire absence of all means of mechanical restraint. Neither belt, strait-jacket, manacle, strong chair, or any other means whatever for restraining the patient, are to be found there. All appearance of a prison has also been removed. The windows have no bars, the doors no bolts, the entrance hall stands open, and apparently no external distinction is observed between this and any other large hospital for the treatment of disease. The whole asylum bears the aspect of some large house of industry. The female patients, seated at needlework in their day-rooms, or washing in the laundry, or cooking in the kitchen, or engaged in the various household arrangements, would hardly by a casual observer be recognised as persons of unsound mind. So, also, in turning to the male department. Parties of ten or a dozen working in the garden, or engaged in the detail of agricultural labour present little evidence of insanity. In the several workshops of the tailor, the shoemaker, the carpenter, the smith, the basketmaker, the baker, the brewer, are patients daily engaged at their respective trades. Employment and the confidence shown by the implements and tools entrusted to the patients have evidently replaced the old means of coercion and restraint. In visiting the

several rooms at meal time the greatest order and quiet reign. … The windows apparently open at will (only the opening is so arranged that no patient can throw himself out of it), and look on a wide landscape, and, being generally with a south aspect, the house is filled with the brightness of the morning sun. One constant, careful, and anxious system of watching pervades all this apparent freedom. No patient is ever left at any time alone; the sense of moral control of his attendant is never away from his mind. By night the wards are hourly visited, and the slightest noise or restlessness seen and attended to with the prescribed remedies. The nurses who thus tend the insane are of the stamp of the St John’s Sisterhood, who now have charge of King’s College Hospital. They are generally selected young, it being found by experience that young girls of twenty-three or twenty-four better adapt themselves to the varying character of their patients than those who commence the work with more formed mind and opinions. Alas, things began to change not long after this glowing account appeared. In the course of 1866 Dr Lawrence had become rather more irritable and difficult, and had needed a period of several months’ sick leave. During this time the asylum was looked after by a young medical graduate from Guy’s, Dr George Mackenzie Bacon. Dr Lawrence returned to duty but things were far from well, and in September the Commissioners in Lunacy had to write to the Visitors a hesitant and regretful letter pointing out he was no longer fit to be Superintendent and that ‘he exhibited unequivocal symptoms of incipient general paralysis’. General Paralysis of the Insane (GPI) was in those days a mysterious mental disorder which struck down men in their prime and killed them a few years later (in 1910 it was shown to be a form of syphilis of the brain). The Committee tried to get Dr Lawrence to retire but he refused and they had to dismiss him. The Minutes contain a long rambling letter from him protesting at their decision. They granted him an annuity of £50 a year, but he was dead within two years. The Committee then appointed Dr George Mackenzie Bacon as Medical Superintendent. He was at that time travelling on the Continent perfecting his French and Italian and visiting foreign asylums, but the Visitors sent for him forthwith and offered him charge of the hospital. Dr Bacon is one of the few early figures in the hospital’s history of whom we can gain a picture for he was extensively commemorated in obituaries. He was a bachelor and had independent means. He was a prolific writer and contributed articles to the Lancet, the British Medical Journal and the Journal of Mental Science. He published many case reports, wrote on GPI and Criminal Responsibility and published a small book on the handwriting of the insane. In 1868 Dr Bacon started clinical lectures for the students at Cambridge, on which the Lancet commented favourably. They were so much appreciated that in 1877 the University awarded him an Honorary MA. He seems to have been a quiet, shy man, though within the hospital he pursued his ends with considerable tenacity. Dr Bacon

started well and in 1869 redecorated the Recreation Room at his own expense for the Christmas festivities. In 1869, however, there was a serious row which involved the whole principle of management of the Asylum. Miss Bryan, Dr Bryan’s sister, had been Matron and housekeeper; she stayed on after her brother resigned but left in 1865. The Visitors then rather unwisely decided to appoint as Matron Mrs Norman, the wife of the resident Clerk and Steward. This created a situation whereby the Normans had complete control of all the housekeeping and all the female staff. In June 1869 the laundress alleged that Mrs Norman was sending to the hospital laundry not only her own washing but also that of her relatives. Dr Bacon took this up and the matter went before a Subcommittee of the Visitors. Dr Bacon finally accused the Matron of ‘habitual inebriety’, and at an adjourned meeting in July proved his case by bringing signed depositions from a number of nurses. The Subcommittee came to the opinion that ‘great laxity of discipline has for some time existed, and still exists in the Asylum’. Mrs Norman was allowed to resign provided she left within the week; Mr Norman was to resign within the month, but only after his accounts had been audited. Dr Bacon was told to enforce stricter discipline; the post of Matron – that is, housekeeper – was abolished; a female head attendant was appointed to be in charge of the women attendants; all the ordering and household management was placed under the Clerk and Steward who was to live out of the grounds (and thereby lose the perquisites which accompanied residency in the hospital – free laundry, free domestic servants, free food), and he was to be answerable to the Medical Superintendent. Several other people were dismissed. The Committee appointed as first Female Head Attendant an experienced woman from Hanwell Asylum and in 1875, after various changes, Miss Williams was appointed to the post and held it for the next 19 years. Although there were other rows between senior officers, this was the last change to be made in the formal relationship of the senior members of the hospital hierarchy until 1948. From now on the Chief Officers were a head male attendant, a head female attendant and a Clerk and Steward, all subordinate to the Medical Superintendent. He, in turn, was answerable to the Committee of Visitors for everything that happened in the house and at law for everything that happened to any patient. During this period too, the Committee of Visitors changed and took shape. The first Committee consisted of interested and philanthropic members of a heterogeneous group of magistrates and gentry. The composition of the Committee gradually changed, with the previous dominance of the clergy diminishing, until the Local Government Act of 1889 set up elected County Councils. This produced a radical change: only three of the 1889 visitors appeared among the 20 for 1890 and from then on all were elected Councillors. By 1870 the Asylum was full, and infectious diseases began to appear. In 1874 there was an epidemic of erysipelas, an infectious skin disease, in which four patients died; in 1875 one of diarrhoea in which two patients died. In these years one quarter of the deaths of patients were due to phthisis (pulmonary tuberculosis). In 1877 the gardener Joseph Scott died; shortly afterwards his widow and five children sickened and were all removed to Addenbrooke’s where typhoid was diagnosed. She died but the orphans survived. Investigations at the Lodge revealed that the well from which they drew their water was

‘very foul and full of vegetable matter and impurities’ so a piped supply was laid from the main hospital. In 1878 the Commissioners wrote ‘We cannot report the general bodily health of the patient as being satisfactory. The high rate of mortality and the recurrence of erysipelas and diarrhoea point to a defective sanitary condition, which we think results from the present overcrowding of the Asylum.’ During this period defects of the building, too, became apparent. On 12 March 1872 the asylum caught fire. Fortunately the fire occurred during the daytime, and the engineering staff were able to put it out, although the Chapel was gutted. In 1872 the Committee recorded their opinion that ‘the Asylum building was constructed in a very insubstantial manner which has been, and still continues to be a source of great expense…’. In 1875 an event occurred at Fulbourn Hospital which was to have national repercussions. For the previous half century humanitarians had slowly been bringing to an end the abusive systems of child labour in Britain – the use of children in factories, as barrow boys, chimney sweeps’, climbing boys and so on. Lord Shaftesbury had pushed a series of Bills through Parliament, starting in 1834, limiting and regulating the use that chimney sweeps made of their boy apprentices. Charles Kingsley’s famous book The Water Babies (1863) was part of the campaign. In February 1875 a twelve-year-old boy, George Brewster, was sent up the Fulbourn hospital chimneys by his master, William Wyer. He stuck and smothered. The entire wall had to be pulled down to get him out and although he was still alive, he died shortly afterwards. There was a Coroner’s Inquest which returned a verdict of manslaughter. Everyone was shocked; the Coroner bound over Dr Bacon to prosecute the master sweep. The Committee’s Clerk handled the prosecution and at the Cambridge Assizes Wyer was found guilty of manslaughter and sentenced to six months’ imprisonment with hard labour. Lord Shaftesbury seized on the incident to press his campaign again. He wrote a series of letters to The Times and in September 1875 pushed another Bill through Parliament which finally stopped the practice of sending boys up chimneys. During these years Dr Bacon’s work proceeded; he wrote a number of interesting reports making much of the correlation between pauperism and lunacy. In 1879 Dr Bacon comments in his Medical Superintendent’s report on the use of Extract of Hyoscyamus. He says he finds it a useful sedative, but that he had never obtained the ‘sudden creative results that had been reported’. This entry is noteworthy as the only remark on the medical treatment of the patients’ mental condition between Dr Lawrence’s comments on the benefits of beer in 1860 and Dr Archdale’s first report in 1919. In 1883 Dr Bacon died at the age of 47 of peritonitis following intestinal obstruction. The obituaries were effusive and fulsome; the Journal of Mental Science said he ‘effected numerous alterations and improvement in his Asylum, so that it was more healthy, commodious and cheerful and it will now bear favourable comparison with the majority of English Asylums’. The British Medical Journal remarked ‘The improvements effected while he was in charge of Fulbourn Asylum were very great … so that Fulbourn Asylum

became an asylum which for its arrangements and for the employment of patients in work conducing to their mental and bodily health, may rank with the first.’ By the end of Dr Bacon’s time, Fulbourn Asylum had settled down into a pattern that would show little change for the next 60 years. As successor to Dr Bacon the Committee appointed Dr E.C. Rogers, aged 33. In reporting the appointment the Committee said they ‘have every reason to hope that they have secured an energetic and efficient officer’. It seems that they were mistaken; Dr Rogers’ period of office marks the lowest ebb of the institution. No very clear picture emerges of Dr Rogers himself; his annual reports were very brief, merely reporting staff changes and statistics; he published no articles; he remained in post until the Asylum Officers Superannuation Act became law in 1909 and then retired to enjoy his pension for another 20 years. He was chiefly remembered as a keen gardener and tennis player. For 30 years, 1880–1910, the Asylum was dominated by a group of men who grew old in office together. Mr E.M. Thorne, who had come to Fulbourn a few years earlier from Broadmoor, was appointed Head Male Attendant in 1876 after his predecessor had been caught giving brandy to the construction workers on the new wing; Mr Thorne was already notable as a fine bass singer who took a lead in the hospital entertainments; for years he was leader of the hospital band. His fine flowing moustache and noble paunch dominate the few pictures we have of that time. Mr Henry Archer was appointed Clerk and Steward in 1872 and held the post until 1911. George Miller emerged about this time as the Foreman of Works, though he had been on the Asylum staff for a number of years, coming originally as a journeyman carpenter. Several architects refer to his energy and skill. Miller was a self-educated working man with a great interest in politics. He was said to have been a notable public speaker; he apparently never voted in an election, but he was always ready to address a meeting of any political party at any time on any subject with eloquence and conviction. A major activity of these years was building. The number of patients increased steadily; as soon as the wards became overcrowded the Lunacy Commissioners insisted on the boarding out of patients – a costly procedure. Building of new accommodation began in 1876 and by 1903 places had been provided for altogether 225 men and 378 women. This was the first major building necessary since the opening, and the Visitors had considerable difficulty in raising the money from the Three Bodies. However, during this period the conditions of the patients declined. The Visitors, under pressure to build more with inadequate money, perhaps saved too much on the running costs. The wages that they paid to staff are frequently noted in reports as being too low to attract good recruits. The Commissioners commented sourly in 1897 ‘The duration of service is not satisfactory, indeed it can hardly be expected that attendants will stay here long when they can get higher wages and more comforts and amusements in Asylums at no great distance.’ There is no evidence during the long years of his office that Dr Rogers showed energy, therapeutic enthusiasm or marked concern about the welfare of his patients, and this attitude may have made itself felt within the hospital. There had also been a change in the public attitude toward the mentally ill. The enthusiasms of the 1850s

had faded away as more and more lunatics became a burden on the rates. Misreading of Darwin’s theories and the phrase ‘survival of the fittest’ became a reason for moral and ‘scientific’ disapproval of those who failed in life’s competition. In 1889 the Local Government Act set up the County Councils and transferred to them many of the functions of the Quarter Sessions including Lunacy provision, so a new Committee of Visitors took over. From now on there were no philanthropic clergy on the Committee; all members were representatives of the rate payers and guardians of the public purse, vigilant that pauper lunatics did not absorb too much of the dwindling rates of the rural county. The decline shows most clearly in the yearly comments of the Lunacy Commissioners. For the first decade of the Asylum they were all praise; towards the end of Dr Bacon’s time they were becoming critical, and in the next years they were often quite harsh. In 1892 they said we still have to report that many matters considered by the whole of our Board to be essential to the proper management of the Asylum and the welfare of the patients have not been carried out…. All these matters have been so often and ineffectually urged upon the consideration of the Committee that we merely mentioned them again to show that they have not escaped our notice … rather than with any sanguine hope that any great alteration will be effected. In 1896 they said We have today visited all parts of this Asylum, of which we regret that we cannot write in terms of unmixed praise. In regard to cheerfulness and reasonable decoration it contrasts unfavourably with most County Asylums; and in the older parts the limited amount of window which can be opened prevents that thorough ventilation of the rooms, particularly the dormitories, which is so important, and the absence of which today was very apparent. In 1897 they said The rooms are still dull and cheerless as compared with the majority of County Asylums. Means of amusement in the wards are scanty; pianos are needed and billiard and bagatelle tables for the male patients and attendants. The staff of attendants is only barely sufficient when all are on duty, and as there are no supernumerary attendants to take the place of the sick and on leave, today we found the staff too weak … In 1898 they said The Asylum generally presented a dull, cheerless, and untidy appearance … With reference to the bed linen, many of the old brown counterpanes are quite worn into holes, and are all thin and threadbare. The sheets were of a poor colour, and in one case we

found one of the quilted sheets in a single room, in which a female patient had slept, dirty and fouled. In March 1908 a local weekly paper, the Cambridge Express, filled a complete broadsheet page with a feature article on the Asylum, headed by a photograph. An air of dreary resignation hangs over the article; the feeling behind it being this is how things are, these people are a permanent charge on the community. At no place amongst five thousand words does the article mention treatment or the possibility of cure. It starts: Of all the public buildings and institutions in the County, there is probably not one – except it be His Majesty’s Prison at Chesterton – of which the great ratepaying public, who have created and supported them, know as little as they do of Fulbourn Asylum. And yet the affairs of the publicly supported Institution have been a great deal before us of recent years, and are at the present moment largely occupying the attention of the Councils of the Borough, the County, and the Isle by reason of the additional money these bodies are having to raise to meet the enlargement rendered necessary for the accommodation of the increasing numbers of cases of mental disease, the price we have to pay our higher civilisation and the ‘hustle’ of our modern industrial life. The writer goes on to give his first impressions on visiting the Asylum: The Asylum stands in spacious grounds, laid out as gardens – on which men were at work when I arrived – with a large green, used for a cricket ground, directly in front of the building … Though the Asylum is so fine a place seen either from the road or near to, and has as neat a drive and main entrance as any house of the quality in the County, it is, after all, a prison, and everybody and everything in it is under lock and key. This knowledge has a depressing effect upon the individual who enters for the first time – knowledge which he cannot shut out, for there is an unlocking and locking of doors before and after him wherever he goes. … Having duly satisfied the Medical Superintendent as to my identity and business, the building was literally thrown open to my inspection. ... Circumstances obliged me to betake my steps eastwards, under the courteous guidance of Mr Thorne, the principal male attendant, who, however, was extremely pessimistic as to the possibility of my finding anything worth writing about. I had my own opinion as to that, and his did not discourage me, and so that key which for the next hour and a half was to be industriously employed by him in opening barriers for me began its work, the first door was passed, and we commenced a round of visits to the day rooms, or apartments occupied by the men when not at exercise work, meals or repose. … After visiting the men’s wards, I turned my attention to those set apart for the women, which are situated in the opposite wing of the building. They are similar in character to those occupied by the men, but more extensive, it being a melancholy fact that insanity is more prevalent amongst the weaker sex. … Cleanliness and neatness were, of course, even more noticeable here than in the west wing, though that is not saying a great deal…

In both wings large walled-in exercise yards, officially termed ‘airing courts’, adjoin the day rooms, with broad asphalt paths and grass plots... One of the first things to rivet my attention on visiting the exercise yard was a long string of men and youths, hand in hand, walking ponderously and in a pitifully aimless fashion, backwards and forwards along one of the paths. It was only by such companionship I was assured, that these patients could be induced to take any exercise at all. Left to themselves, they would prop their persons against the walls. It was very pitiable to see so many young people amongst the patients. As Mr Thorne told the reporter, little of note had happened at the Asylum during the previous 30 years. The typhoid epidemic of 1905 was an exception. Infectious diseases always presented a grave danger to the closely packed inmates of an asylum, especially since many were undernourished. At Fulbourn there had been many minor epidemics, but none had ever got out of hand. On 18 March 1905 the first patient sickened with typhoid; on l April ten patients went down and by 14 April 39 patients and eleven staff, including Dr Rogers himself, were all seriously ill. Further cases continued into May and there were finally 68 cases – 11 per cent of the Asylum population. Altogether 16 people died. The whole burden of dealing with this emergency fell upon Dr McCutchan, the Assistant Medical Officer, and all praise him. As soon as he saw it was an epidemic he got in touch with the Medical Officer of Health and they managed to check the outbreak. In July the Medical Officer of Health and Professor Sims Woodhead made a report to the Visitors analysing the whole outbreak. The water supply was exonerated; it seemed almost certain that the infection came from the Asylum milk supply. It also emerged that the drains were blocked, leaking and incompetent. As a result of all the investigations the drainage system was extensively overhauled. A melancholy footnote to the story is the death of Dr McCutchan in June 1906 from a ‘lingering illness’ that had followed the stress of dealing with the epidemic. Dr Rogers retired in 1910 and there followed an unsettled period of 15 years. During that time there were three Superintendents and the First World War came and went, bringing much readjustment with it. In 1917 the institution changed its name from Asylum to Hospital and in 1914 the first woman came on to the Committee, Mrs F.A. Keynes. (Mrs Keynes was a notable Cambridge citizen, the mother of Lord Keynes, the economist; in her time City Councillor, Alderman and Mayor and Chairman of the Visitors (1930).) After 1914 there was always at least one woman on the Committee and as the years went by their numbers increased. There was little building during this period. By 1910 the overcrowding was again bad, but the Committee decided to wait and see if there would be any relief from the passing of the new Mental Deficiency Act (1910); then came the First World War and all building stopped. After the war they built a Nurses’ Home for women staff, which began the process of separating the sleeping accommodation of the staff from that of the patients. When the Asylum was first built everyone had lived together. The Medical Superintendent’s House was an integral part of the main building, the head attendants’ bedrooms were on the wards, and the junior attendants slept in the attics above the wards.

In the early days of moral treatment this was regarded as good practice, to produce the ‘family atmosphere’ so much emphasised by early writers on asylums. As custodial attitudes developed, however, many disadvantages became apparent. Potential recruits, medical and nursing, were put off by the enforced close contact with the patients. Dr Alexander Day Thompson came to Fulbourn as First Assistant Medical Officer in April 1909; when Dr Rogers retired the Committee offered the Superintendent’s post to Dr Thompson. Dr Thompson’s first report immediately strikes a different note. Its 15 pages are in marked contrast to the last by Dr Rogers, of only three pages. Dr Thompson states ‘it shall be my aim to reach the highest efficiency in every department of the Asylum’. He gives a considerable disquisition on the annual statistics; he states that some of the information about the cause of the disease is misleading ‘especially so that relating to heredity’ – this being because the relatives tended to conceal the facts of previous mental illness in the family. He ends this portion of his report: It seems not improbable that a great deal of the increase of certified insanity is due to the marriages of mental defectives in the lower strata of society. In that relation there is at the present day sober truth in the words of the Latin poet – Aetas parentum, pejor avis, tulit Nos nequiores, mox daturos Progeniem vitiosiorem. (Worse than our grandsires, sires beget Ourselves yet baser, soon to curse The world with offspring baser yet.) In this report Dr Thompson also reports that a patient escaped from a ward walking party on 29 September. He was brought back within a few hours, but ‘the Charge Attendant who was in command of the party was deposed to the position of second charge attendant for at least six months’. Dr Thompson’s later reports continue in similar vein, full of high-flown language, studded with quotations and calling for more repressive social legislation; within the hospital there are reports of disciplinary action and dismissals. In 1912 he wrote: In this convention-riddled and hypocrisy-bound England of ours, where the chief mental nutrient of almost all grades of society is the pursuit of a thousand inanities; where the ‘blight of respectability’ still falleth; where Vice, all painted to allure, stalks brazenly along the highways and builds her myriad nests in the cities; where crime and insanity, first cousins, are lurking everywhere; the forces of Reason are at last winning all along the line in the matters that concern us alienists, whose business is the prevention and cure of insanity and the building up of a sounder race. Something is to be done, though tardily, as the result of the findings of the Commission on the Feeble-minded, and the trend of influential scientific and expert public opinion, towards the prevention of the increase of insanity. The tackling of the problem of

prevention and the further efforts to cure will go on side by side. Prevention will be brought about by the legal control and segregation of the unfit, so that defectives will not be added to the community, for the simple truth is that after all law is the main check upon abnormal bias and proclivity; necessary too are early recognition and early treatment of mental disorder before cases become certifiably insane. Cure, so far as is possible, will accrue in time from all the laborious and admirable research work on the nature, causation, and treatment of insanity, that is going on in so many laboratories and asylums, and which should be fostered by every asylum committee, … This period saw considerable changes in the status and functions of the attendants, or nursing staff as they were now called. During the 1880s and 1890s there had been difficulty in recruiting suitable staff and comments of the Commissioners indicated that their work was not very satisfactory. There had been talk for many years of pensions for the staff, but the Committee had not taken any action on the matter. In 1910 Parliament passed the Asylum Officers’ Superannuation Act which made Asylum employment a good deal more attractive, especially to men with families. Instead of being an unpleasant, insecure job with risk to life and limb, long hours and low pay, it now offered retirement at 55 with a pension – a comparatively rare benefit in those days. This Act was one of the first gains of the recently founded Asylum Officers’ Union; in later years they did much to improve pay and conditions of mental nurses. As soon as the Act took effect in 1910 a number of senior hospital servants claimed the pensions they had been waiting for. Dr Rogers, the Medical Superintendent, Mr Thorne, the Head Male Attendant, Mr Miller, the Foreman Artisan, and ten other staff with a total of 433 years of service between them all retired in the one year. The Head Female Attendant had left to get married at the beginning of the year, so that in this one year there were new heads to both nursing departments as well as a new Superintendent. In his first report in 1910 Dr Thompson said: Miss Viney, the Chief Nurse, joined us on the first day of the year, and the condition of the female side has much improved under her experienced control. Mr Mitchell, the new Head Attendant, came on the 10th of October. His credentials were excellent and he has demonstrated their truth. Under these two last officers the discipline of the staff, which had been allowed to reach a very low ebb, is now in a fairly satisfactory condition, a state of affairs that will I am sure be further improved. Dr Thompson, for all his rhetoric, was not a very satisfactory Superintendent; his firmness of discipline, at first welcomed, became harsh and erratic. There were frequent dismissals and difficulties. In 1917 the Visitors had to hold an inquiry into the circumstances under which he had dismissed a laundress summarily, and when another Assistant Medical Officer was appointed in 1917 matters came to a head. There was a major row and a Committee investigation. As a result of what emerged both doctors were asked to resign; the junior man complied but Thompson refused and the Visitors terminated his engagement.

Even 50 years later there were tales told of Dr Thompson’s erratic tyranny. When news of my appointment spread to Fulbourn village an aged pensioner remarked ‘The last Scotsman they had as Superintendent were a right bugger. He set off the Fire Alarm in the middle of the attendants’ Christmas dinner and it was all spoiled by the time we got back. You can’t trust Scotsmen.’ I have been told that Dr Thompson’s behaviour was largely due to morphine addiction and it was the exposure of that which finally brought his dismissal. Dr Mervyn A. Archdale, Dr Thompson’s successor was a man of calibre. In 1909 he had published in the Journal of Mental Science a long and thoughtful article on ‘The Hospital (that is, Asylum) Treatment of the Acutely Insane’ in which he laid great stress on the advantages for the recently admitted patient of protracted bed rest and absolute quiet and isolation from all distracting sounds or experiences; he also discussed at length the different medicines necessary to produce complete elimination of the bodily and bacterial toxins which he believed were the cause of much insanity (Archdale, 1909). The First World War caused considerable disturbance to the hospital and this is reflected in the reports. Forty-one patients from the Norfolk County Asylum were sent to Fulbourn in 1915 to make room for War Casualties, causing substantial overcrowding. The recreation hall was turned into a dormitory. There were few doctors, for much of the war only two. A number of male staff volunteered for the Army or were called back to the Colours. The new cricket ground to the west of the main building which had been developed just before the war in the early days of Dr Thompson’s enthusiasm was ploughed up in 1917 ‘at the insistence of the War Agricultural Committee’. The rations were cut, the patients lost weight and the death rate from tuberculosis rose. Immediately after the war there were complaints of rising prices, shortages of materials and of staff. It was noted that women nurses were becoming difficult to recruit because ‘the necessary discipline of an Institution is irksome to the present type of young woman who during the War had the widest freedom, and who now show an absence of desire to learn their work and an excess of zeal for amusement’. As well as developing his ideas of bed rest and medicinal treatment for the acute admissions, Dr Archdale was also concerned with the work and conditions of the longstay patients; he persuaded the Visitors to introduce a system of rewarding the working patients with paper ‘money’ negotiable within the hospital; this was not, however, popular with the staff and was soon dropped. He was keen on patients being occupied with some kind of activity and in 1921 it is noted that there was a party of ten women employed on the land. In 1919 Dr Archdale attracted to the hospital Dr John Rickman, a young Quaker doctor recently returned from Relief Work in Russia who later became one of the leaders of British Psychoanalysis. Dr Archdale says in his 1919 report … ‘Dr John Rickman of King’s College … a keen student of the mental methods of healing, has thrown the greatest energy into his medical work, and has been most assiduous in lecturing to the nurses.’ In the next few years increasing numbers of the nurses took the certificate of the

Medico-Psychological Association; in 1920 two passed with distinction. Dr Archdale was also interested in providing further medical training for doctors. Just before the war the University of Cambridge started a Diploma in Psychological Medicine (DPM), and he was soon involved in the teaching of this. The Regius Professor of Physic at that time, Clifford Allbutt, had been a Commissioner in Lunacy and pioneering work was being done by Rivers and Myers at the Psychological Laboratory. Archdale arranged clinical demonstrations at Fulbourn and gave a certain number of lectures; in 1922 he took the Cambridge DPM himself. In 1922 Dr Archdale took the opportunity to return to the North to open a new hospital. The Committee expressed their great regret at losing him and appointed Dr Arthur Francis Reardon, his Deputy, as Medical Superintendent. Dr Reardon announced his intention of carrying on Dr Archdale’s work. His particular interest seems to have been the development of domiciliary visiting and he visited a number of patients who were boarded out. In 1924 he began seeing patients at the outpatient department at Addenbrooke’s. In October 1925, however, he suddenly collapsed with heart disease and died a few days later in Addenbrooke’s hospital. To succeed him the Visitors appointed Dr H. Travers Jones. In the period between 1925 and the end of the Second World War, little changed at Fulbourn Hospital. Nationally this was the period which saw the unsettled twenties, the General Strike, the Great Slump, the uneasy depressed thirties and all the upheavals of the Second World War. For English agriculture it was a period of steady decline which seriously affected Cambridgeshire; Fens were allowed to flood and farms and farmers to decay. Agricultural rates were low, the Three Bodies were poor and as a consequence the hospital was held to a restricted budget. As far as treatment for mental disorder was concerned, doctors had not discovered much since 1800. They had clarified the more common disorders and sorted out a small group which were due to physical (organic) causes. They had clarified and elucidated General Paralysis of the Insane, discovered that it was due to syphilic infection and found a cure by 1917 by inducing severe malarial fevers in the patient. For most psychiatric disorders, however, little had been discovered in the way of treatment, let alone cure. Patients were brought to the Asylum, often furiously disordered; they quietened down and often stayed there for the rest of their lives. The disorders were given labels – mania, melancholia, stupor, delirium, paranoia, dementia praecox, schizophrenia. However, these labels made very little difference to how those suffering from such disorders were handled, nor to how their damaged lives developed and ended. This mass of unresponsive apathetic misery aroused the compassion and therapeutic zeal of some of the psychiatrists, especially the ablest ones, those working in famous asylums or in private practice; many forms of treatment, often heroic and sometimes barbaric, were applied to the lunatics. Little of this influenced the practice of Fulbourn Hospital. There were some new ideas. The idea that people might seek treatment voluntarily for their mental disorder was being proposed. The Maudsley Hospital for voluntary patients only, and the Cassel Hospital for Functional Nervous Disorders had opened in the 1920s.

In 1930 the Mental Treatment Act made it possible for a patient to enter a mental hospital voluntarily. Fulbourn’s response to the Act was most cautious. The yearly number of voluntary admissions from 1930 to 1939 were 0, 6, 14, 6, 8, 7, 11, 11, 24, 24. The tardy use of the provision was accompanied by guarded comments in annual reports; in 1933 the then Superintendent, Dr Jones, said that ‘on the whole, the results of “voluntary boarders” were not encouraging’ and later that these voluntary patients tend to discharge themselves before they are cured. It is clear that this new notion of allowing patients to decide whether to enter and whether to leave was found to be disturbing and unsatisfactory. The 1930s also saw the advent of the physical treatments of mental illness which started the great changes in institutional psychiatry – insulin coma therapy for schizophrenia in 1935 and convulsive therapy for depression, first with cardiazol in 1934, then with electricity in 1937 – Electro Convulsive Therapy (ECT). Although in the early 1920s Fulbourn Hospital was in touch with the active growing points of English psychiatry, by 1940 it was well behind. This can be ascertained from the Annual Reports, and from the annual comments of the Commissioners of the Board of Control. In 1924 the Commissioners spoke of the ‘manifest spirit of progress’ in Fulbourn and the improvements that there had been since the last visit. In 1937, the Commissioners commented that the disturbed women’s ward was too noisy, psychotherapy was not possible because the medical staff were too few, the ward gardens could be more attractive, was it not possible for working patients, at least, to have false teeth and could not the occupational treatment be more widely applied, and so forth. There were probably many reasons for the stasis of Fulbourn during this time. Lack of money was certainly important. Another factor may have been the rather conservative character of the senior staff. When Dr H. Travers Jones took office in January 1926 he found Dr J.G.T. Thomas in post, Deputy Superintendent since 1923; Dr F.M. Deighton then joined them during 1926 as Assistant Medical Officer. This team remained together for the next 20 years; they were a quiet group of men who tried to make the hospital a pleasant and contented place. Dr Travers Jones, a little red-faced bachelor, got on well with the Visitors and was famous for his shooting parties. He reared partridges and pheasants in the corn fields surrounding the hospital and was reckoned to have one of the finest partridge shoots in the Eastern Counties. The patients regarded the day out beating as a rare treat. Dr Thomas, a genial giant, knew all his patients by name. He was devoted to the hospital cricket team of which he was captain for 30 years; he was also a most capable conjuror, and wrote, produced and acted in many Christmas pantomimes. There was great pleasure when he married the Deputy Matron in 1939. Dr Deighton, a quiet gentle figure, for years looked after the women patients. Between them the three maintained a peaceful institution, effectively isolated from the outside world – truly an asylum. Miss Fossey was appointed Matron in 1923 and stayed until she retired in 1951. Mr Edward Mitchell, Chief Male Nurse, who took over from Mr Thorne in 1910, remained in post until 1932 when Mr Tucker took over. Mr Kemp, the Clerk and Steward since

1884, was succeeded by his son in 1924. He died in 1939 and Mr Charles Mitchell (son of the former Chief Male Nurse) became Clerk and Steward and stayed in the hospital’s service until 1963. In 1929 the Visitors had appointed the previous year an Engineer, Mr Harry Merrin. He soon built up a most effective department and with slender funds undertook many building projects during the 1930s. He attracted to his staff many of the more vigorous personalities in the hospital and his ‘artisan gang’ of patients led by a group of sturdy epileptics became an elite group, with special privileges and an extra issue of tobacco. Every year the Commissioners of the Board of Control brought the subject of Occupational Therapy up in their report. There was some response at Fulbourn. In 1931 an occupational therapist from the Maudsley Hospital in London spent six months in the hospital and in 1932 Miss Ross was appointed as full-time occupational therapist. In 1938 a new Occupational Therapy Department was built on the top of the chalk knoll behind the hospital; this was designed and erected by the staff and patients of the Engineering Department. It is said that a bottle under the foundation stone contains ribald comments on Fulbourn Hospital of that day – including a speculation as to whether patients would get as much good from using the building as they had from building it. These years also saw the beginnings of organised social work. In 1923 Dr Reardon had started making visits to the homes of those patients about to be discharged. He was helped by the Secretary of the Cambridgeshire Voluntary Association for Mental Welfare. This body had been founded in 1908 by Lady Ida Darwin, Dame Ellen Pinsent and Mrs Florence Keynes to deal with the social problems of the mentally defective in Cambridgeshire which had been uncovered during their work for the Royal Commission on Mental Deficiency (1904–8). In the 1920s the Association began to help Fulbourn Hospital with the work for the adult mentally ill. Dr Reardon had established an outpatient clinic at Addenbrooke’s Hospital in 1922 and for several years Dr Jones visited regularly and saw patients by request of the general practitioners. In 1932, however, a psychiatrist, Dr Ralph Noble, was appointed to the Honorary Staff of Addenbrooke’s Hospital and Dr Jones’ visits were stopped. This unfortunate rift caused difficulties for the next 16 years. No further outpatient clinics were opened despite the Commissioners’ suggestions. Another point the Commissioners of the Board of Control regularly commented on was patients’ freedom. In 1924, 28 patients out of 595 had parole of the grounds; in 1939, 70 patients out of 883. However, all the wards remained firmly locked. Dr Jones’ reports are brief, and mostly concerned with the buildings erected and various social activities. It is only from occasional remarks of the Commissioners that any picture of medical treatment emerges. In 1928 they remark that malaria treatment for General Paralysis of the Insane is not feasible at Fulbourn and that such patients should be transferred elsewhere. In 1939 the Commissioners record that they ‘discussed modern methods of treatment’ and that 13 cases of depression (in twelve months) had been treated by convulsion therapy.

During these years the population of Fulbourn rose steadily, although the admission rate did not change greatly. The rise was probably due to increased survival of long-stay patients after the high death rate of the years of the First World War. Although tuberculosis continued to take its toll, and there were sporadic cases of Enteric fever, the general health of the hospital improved. There was some overcrowding; the traditional exchanging of patients between hospitals continued: from 1923 to 1929, 20 Cambridgeshire women were lodged in Powick Hospital,Worcester; from 1932 to 1939, Fulbourn took 25 patients from Napsbury Hospital, North London, and 15 patients from the Berkshire Hospital at Wallingford. It is an interesting comment on the attitudes of those times that no one thought it unreasonable to send asylum patients to live for long years many miles from their home counties or any relatives who might wish to visit them. The outside world seldom broke in on the rural quiet of Fulbourn Hospital. In 1931 the staff ‘volunteered’ to accept a salary cut because of the Slump, but normal wages were restored in 1933. Later came the first foreshadowings of war. In 1937 the Territorial Army discussed the possibility of a Military Hospital at Fulbourn. In 1938 the Visitors formed an Air Raid Precautions Sub-Committee. The six years of war (1939–45) was a period of striking developments in British psychiatry. Physical treatments were widely applied and new treatments were developed, such as narcoanalysis, abreaction and sleep therapy and were applied to the many psychiatric battle casualties. Army psychiatrists lived and worked among their general medical colleagues who learned to value their contribution. Psychiatrists and psychologists working in intake selection, officer selection, and reassignment of the many misfits, made a great contribution to the deployment of the thousands of men, and laid the foundations for social psychiatry. For rural mental hospitals, however, the Second World War meant another period of overcrowding, underfeeding, understaffing, shortages and an endless struggle to stop standards declining too far. Fulbourn experienced little of the fighting directly. The engineers made sandbag walls and revetments; water tanks were dug and filled and fire drills carried out; all windows were blacked out. But no bombs fell on Fulbourn; the nearest was a small raid on Cambridge early in the war. At the start of the war, most of the London metropolitan asylums were emptied of psychiatric patients to clear beds for the expected casualties from bombing. Hill End Hospital was evacuated to Three Counties Hospital, Bedford and 147 Huntingdonshire patients were moved from there to Fulbourn on 28 August 1939. At the same time Fulbourn Hospital undertook to take in all fresh cases of mental illness occurring in Huntingdonshire. This raised the resident population from 747 to 894 – a rise of nearly 20 per cent – causing grave overcrowding. The men’s occupation centre and for a time the Recreation Hall were filled by beds. A certain number of long-stay patients were discharged in the next two years so that the resident population fell to about 820 by 1941, but the overcrowding and consequent lowered standard of hygiene persisted for many years.

War strains and shortages affected the hospital in many ways. In February 1942 the Board of Control Commissioners checked the weights of patients against those of January 1940. On average the men were lighter by 5lb and the women by 9lb. In 1944 the Commissioners had the diet sheets analysed and suggested some improvements. All possible land was brought into production, and in 1941 the cricket pitch was again ploughed up. The dairy herd was maintained and in 1944 the Visitors bought another farm to extend their farming activities. The general physical health of the patients remained a matter of constant concern to the Commissioners and the medical staff. The Commissioners were also concerned about hygiene; in the summer of 1941 flies were so thick in the sick wards that they suggested ‘use of gauze in protecting the faces of feeble bedridden patients’. They also commented that some of the lavatories were so effectively blacked out that it was not possible to see if they were clean. Dysentery affected eleven patients on the male side in the summer of 1943, but otherwise there were no epidemics. Tuberculosis, however, did spread and a number of new cases were found. The annual deaths from tuberculosis in the hospital rose from four (in 1937–39) to eight (in 1941–43). The gravest difficulty was the shortage of staff. At the beginning of the war all reservists were called to the colours; this removed many male nurses, who had been regular soldiers. Conscription took away other young men, and the war industries soon began to divert potential recruits. In 1939, 43 male nurses and 51 female nurses were considered sufficient for 294 male and 448 female patients. By 1944, 32 men and 37 women, many of them pensioners returned from retirement, were looking after 319 men and 495 women. This shortage was a matter of constant concern. The Medical Staff, however, remained the same. They had permission to employ a fourth medical officer and a number of doctors worked for short periods during the war, but were soon called up or left. The last of them was a retired man so old as to be scarcely capable of carrying out his duties. His main contribution to the Fulbourn story was that he allowed his coal fire to ignite his living room in early 1945. The blaze involved some of the offices and the case papers of all patients admitted before 1903 were destroyed, a considerable historical loss. One of the casualties of the war that is scarcely noticed in the reports was the social life of the patients. In 1940 the patients’ dances were stopped (the hall was a dormitory); in 1941 the cricket stopped (the pitch was ploughed up); in 1943 the Annual Fete was cancelled. The only entertainment maintained was the cinema. By 1945 the senior staff – and the whole hospital – were tired, weary, shabby and spent. There was little enthusiasm for the future which was seen to be full of difficulties and burdens. There was, however, talk of a National Health Service and a Welfare State and there seemed to be a possibility that things might change. The proper organisation of Britain’s hospitals had been under discussion since the early years of the twentieth century. By the 1930s Britain had a mixture of ancient, wealthy voluntary hospitals, seedy poor law infirmaries, inefficient cottage hospitals and special

institutions, such as lunatic asylums and colonies for mental defectives and epileptics. General Practice had been organised into a National Insurance Scheme by the great reforming Liberal Government in 1910, but the hospitals were all separate organisations. After the First World War there had been frequent discussion on how the hospital service might be better organised and social reformers put hospital reorganisation high on their lists. However, nothing happened until the outbreak of the Second World War when the British Government brought all hospitals in Britain into an Emergency Medical Service to cope with the expected air raids. This worked so well that most people wanted it to continue after the war. The political parties all produced plans for a postwar National Health Service, but when the Labour Party won the Election in 1945 it was they, under Aneurin Bevan, who faced the actual task of creating the National Health Service – as part of the great revolution of welfare and health provision that they were bringing in. In this they had the support of most of the country who had been sickened by the unfair muddle and poverty of the Thirties and saw the ‘fair shares’ of the war years as a basis for a juster and healthier society in postwar Britain. The National Health Service (NHS) as it was created in 1948, made a profound difference to British institutional psychiatry and to all hospitals for the mentally ill, including Fulbourn. All the hospitals in Britain were brought into the NHS and all were to be treated equally. No longer were there to be differences in treatment and care between the rich and the poor, between the nursing homes, the voluntary hospitals, the infirmaries and the asylums. Anyone who was sick would be able to get the treatment they needed and would be treated equally. It was a wonderful ideal, and for a decade or two it looked as if Britain might achieve it. Finance was controlled centrally and the accounts of different hospitals openly compared. At once the shocking gulf between the levels of financing, of feeding, staffing and treatment provided in the former voluntary hospitals and in the former local authority infirmaries and asylums became glaringly manifest. Great efforts were made to even out these differences and in a first attempt to do this extra money was put into the deprived institutions. In the Cambridge area all the local hospitals were taken into the NHS, and an attempt was made to link them in order to provide a better service for the sick in Cambridge. Many administrative and professional barriers between them were bridged. Finances were improved. Cooperation to provide better services became the new pattern. The new East Anglian Regional Hospital Board (RHB) appointed as their Senior Medical Officer a rough-hewn, but outstanding Scot – Dr James Ewen, fresh from wartime work as Medical Officer of Health for Middlesex. He was appalled at the neglected state of the hospitals and asylums of East Anglia and set out to make improvements. He found the East Anglian mental hospitals dilapidated, overcrowded, squalid and ill staffed – and Fulbourn the worst of them.

Another important change brought in by the NHS was in the terms of service for doctors. Before the war, the best doctors made their living by private practice and gave free service in the voluntary hospitals. The doctors who took salaried posts in infirmaries and asylums were mostly those resigned to second-class professional status. Conventions and social barriers were created in the twenties to keep salaried doctors from access to private patients. The Fulbourn Hospital doctors were barred from seeing patients in Addenbrooke’s in the early 1930s. Under the new NHS all doctors received substantial salaries. Though some private practice remained, it was not significant in the early postwar years. The doctors, their salaries secure, could work wherever the patients needed them. Cooperation between the psychiatrists at Fulbourn and Addenbrooke’s could flourish and soon did. For the first time, junior doctors in hospitals were adequately paid. Before the war, house doctors in the great teaching hospitals received no pay; only those with well-off parents could afford to take the posts which were the sole route to the honorary posts and affluent private practice. Poor doctors, or those who wished to get married, had to go into general practice or to work in asylums and infirmaries. Now, under the new NHS all hospital doctors of every grade were paid a living wage and could even afford to marry. Nursing pay also changed. The main nursing work force of the pre-war ‘voluntary hospitals’ had been the ‘probationers’, often the daughters of middle-class parents, who received little or no pay, had to live in firmly controlled nurses’ homes and work appallingly long hours. Only the asylums and infirmaries paid a living wage – so their nurses were scorned by the affluent teaching hospitals. With the NHS, all nurses received an adequate salary, similar in all hospitals. In the Cambridge area, Addenbrooke’s was declared a Teaching Hospital and placed under a Board of Governors. The local authority hospitals in the City – the Mill Road Infirmary and the old Workhouse at Chesterton – were also put under the Addenbrooke’s Governors. Fulbourn Hospital was made the responsibility of the Regional Hospital Board and under them of the No.1 Hospital Management Committee, which was also responsible for Newmarket General Hospital. As well as the changes brought about by organisational rearrangements under the new NHS, other factors were causing ferment in the English psychiatric hospitals in the early 1950s. These included the new treatments which doctors were applying to psychiatric patients. After the war came news of another new treatment: brain surgery for mental disorder – prefrontal leucotomy. This operation had been developed in Portugal in the 1940s and taken up enthusiastically in the USA. As with every new form of treatment there were enthusiastic reports from the innovators describing striking recoveries. The new treatments dominated the admission wards of Fulbourn in postwar years. Most patients received some form of physical treatment. Electroplexy (Electro Consulsive Therapy – ECT) given with an anaesthetic and a muscle relaxant, was prescribed for all depressed patients and for many others. Insulin Coma Therapy, carried out in the male

Admission Villa, was prescribed for most schizophrenics. Patients were referred for leucotomy to Norwich or London because there was no one in Cambridge able to do the operation. Patients who were not receiving some form of physical treatment even complained of feeling neglected, or even cheated, when they witnessed the almost miraculous transformation seen in some people receiving electroplexy – from weeping misery and melancholic ruminations to cheerful good humour in a few days. In the immediate postwar years, until the mid-fifties there was not much change in patterns of medication in psychiatry. Effective hypnotics – drugs to promote sleep – were needed as most psychiatric patients complained of difficulty in sleeping. The traditional sedative in the asylums had been paraldehyde, a cheap, safe, but foul-smelling draught which gave peaceful sleep and often calmed the furious. Paraldehyde and chloral hydrate had been available for nearly a century. The barbiturates which had been available for half a century were also widely used. Odourless and easy to swallow, they were preferred in outpatient and private work. They were, however, dangerous as it was easy to take an overdose. There was not much interest in drugs amongst the keen young psychiatrists in the early fifties as all hopes were pinned on the physical treatments. There were many studies published on how to increase the effectiveness of such treatments – ‘swinging’ the insulin dosage, ‘clustering’ the ECT treatments, daily ECT ‘to promote regression’, varying the site of operation in brain surgery – but little was published on the use of drugs in treatment of the mentally ill. The question of whether the new forms of treatment could or should be applied to longterm patients was a matter of discussion. Some treatments had been strikingly successful; prefrontal leucotomies for very violent long-term patients had produced some amazing, almost miraculous, cures. People had left hospital greatly improved after many years on disturbed wards and were able to live outside hospital once again. Electroplexy had relieved some chronic melancholics with persistent suicidal tendencies. However, some doctors still thought that the ‘old asylum chronics’ were best left in peace. It is difficult in the 1990s to convey an impression of the asylum world of the 1940s for that world has now, thankfully, largely disappeared. In those days the hundred or so mental hospitals in England, containing nearly 250,000 people, were accepted as the centre of English psychiatry. These large, ancient institutions – most of them built in the 1850s – stood outside cities and big towns. From a distance one would see the great barracks-like buildings and a water tower rising above the treetops. There was often an imposing gateway with a gatekeeper’s house. The grounds were always impressive and sometimes strikingly beautiful. A broad drive would sweep through woodland, past cricket grounds and shrubberies up to an imposing entrance. Inside were shining floors and spotless corridors with a few uniformed people moving about. It was only as you penetrated further, into the back corridors, the airing courts and the wards that the vast mass of human hopelessness became apparent. Visitors were taken round by a staff member with a key, who unlocked doors and locked them again behind one – the crashing of the keys in the locks was a constant feature of asylum life. You would be shown into big bare rooms, crowded with people, with

scrubbed floors, bare wooden tables, benches screwed to the floor. There was a smell in the air of urine, sweat, paraldehyde, floor polish, boiled cabbage and carbolic soap – the asylum smell. Some wards were full of tousled, apathetic people just sitting – 20 in a row. Other wards were noisy, especially the ‘disturbed wards’. On some, there was an air of tension. The visitor felt frightened the whole time, and watched his back; he knew there was a very real chance that somebody would try to hit him. Outside were the airing courts – big, grey courts, paved with tarmac, surrounded by a high wall with scores of people milling around; a few of them walking, some running, others standing on one leg, posturing, with urine running out of their trouser leg, some sitting in a corner masturbating. Bored young nurses would be standing on ‘point duty’, looking at the patients, ready to check anybody who got out of line, but otherwise not doing anything. The asylum day had its pattern. The patients were turned out to the airing court, counted out, then counted in for meals. They were sat down at tables, spoons and forks were handed out and the food put on the table; the charge nurse said grace and they were allowed to eat. Then the spoons and forks were all taken in and washed by the staff and counted. Nobody was allowed to leave the table until all the cutlery was accounted for. To relieve the tedium there were weekly film shows – only of course for the better patients, and there was Church on Sunday. This was the one occasion when patients had the chance of seeing the opposite sex! There were walking parties going around the grounds – 20 patients, one nurse at the front, one at the back, two at the sides, to make sure that nobody escaped; afterwards everyone was counted in again. Few patients had any property, and none on the disturbed or ‘wet and dirty’ (or incontinent) wards. On many wards, the patients’ clothes were rolled up at night and taken and put in a cupboard, and issued again the following morning. No patient was allowed to have money; that was contraband and they were punished if found with it. The job of the nurses was to watch the patients to see that they did not escape or harm one another. The job of the doctors was to watch the nurses to see they did not steal the patients’ food or abuse them. One of the main tasks of a doctor was to examine bruised people, to be told a story of how the bruises had occurred and then to decide whether the injury was so flagrant that there had to be an inquiry. Deliberate violence by the staff to patients varied a great deal; there were those amongst the staff who said it was their duty to ‘show them who the boss is’. The doctor’s job was to hold the balance, to see that staff violence did not get too far out of hand. A special part of the English asylum was the padded room (‘the pads’). These were small side rooms that had been specially equipped for violent patients. The walls were lined with padding – usually rubber – and there was nothing in them that could cut or injure. Any windows or lights were protected by unbreakable glass and bars. The door, also padded, was massive and fastened by double locks and heavy bolts. ‘Pads’ were to be found on all disturbed wards, and many admission wards. A persistently suicidal person would be stripped naked and put in the pads. Often the pads were the centre of the system of ward punishment. Any patient who showed signs of becoming violent was threatened with the pads; anyone who struck a nurse was automatically put in. It was part of a

doctor’s duty to visit anyone who was in the pads, to check their injuries, to listen to their story and to make a decision whether they should stay in. A wise junior doctor soon learned to endorse the charge nurse’s ‘suggestion’ as to whether a person could be ‘Let out now, Sir’ or whether it would be ‘Better for him to stay in a bit longer, Sir’. In a disturbed women’s ward the women would be in ‘strong clothes’, shapeless garments made of reinforced cotton that could not be torn. Their hair was chopped off short giving them identical wiry grey mops. They would rush up to any visitor and crowd round him. Hands would go into his pockets grabbing, pulling, clamouring for release, for food, for anything, until they were pushed back by the sturdy nurses, who shouted at them to sit down and shut up. At the back of the ward were the padded cells, in which might be a naked woman smeared with faeces, shouting obscenities at anybody who came near. In an asylum there might be pleasant admission wards with flowers and pictures, kind nurses and cooperative patients. But behind these were always the ‘back wards’, filled with people for whom hope had been abandoned – the ‘chronics’, the ‘back ward patients’, the incurables and the intractables. Anyone who came to work in a mental hospital – nurse, doctor or orderly – had in due course to come to terms with the back wards. They learned to tolerate the squalor, smell and brutality and hopelessness – or, if they could not, left the asylum service. Fulbourn Hospital in the postwar period was much like any other somnolent county asylum. It had 950 patients – a middling size – not 2–3,000 patients like some city asylums, nor small and cozy like some hospitals with 2–300 patients. Although undamaged by the war, its aged buildings had been inadequately maintained for years. Seen from the high road, Fulbourn Hospital still looked much as it had in 1858. The range of buildings still stretched along the ridge, dominated by the central water tower and the former Superintendent’s house, now the main administrative block. Over the century the grounds had taken shape. The main drive was flanked by tall lime trees and beech hedges, and there were beech and elm trees along the borders of the estate and scattered through the grounds. The front of the building was hidden behind massive yew hedges, 20 feet high, grown to conceal the airing courts. The newer wards were mostly behind the original front; still much the same design, massive two-storey blocks with day rooms below and dormitories above. To the west, however, were some quite different buildings – low one-storey buildings with gardens and verandahs. These were the Admission Villas, built during the 1920s. Apart from the handsome drive, the rest of the hospital land was farmed intensively. In front of the hospital were fields of cabbage, potatoes and grain. There was a large orchard. The Visitors kept a substantial herd of cows (whose milk yields won prizes) and a large pig herd (fed on hospital scraps). The Visitors leased surrounding fields for their crops and owned a farm on the Fen behind the hospital.

In 1953 Fulbourn Hospital housed 570 women and 380 men. Apart from 80 people in the two Admission Villas, all others were crowded into the main building. In the main building the men’s wards were to the west – Male Ward 1 (M1), M3, M4 (the infirmary ward) and M5 (the ‘disturbed’ ward). The women’s wards containing 530 women, were to the east, F1 and F3 in the 1858 block, F4 (the infirmary ward), F7 and F5 (the women’s ‘disturbed’ ward) in the 1890 blocks at the back of the hospital site (M2 and F2 had disappeared in rearrangements in the 1920s). Apart from the two small infirmary wards containing people in need of physical nursing care, the other wards were all large and overcrowded – up to 100 people in each. All were locked. They were as I have described elsewhere – bare empty places, with big day rooms, crowded dining rooms and bare dormitories upstairs. Outside most of the wards were airing courts – into which most of the patients were turned if the weather was fine. Scattered round the grounds were a few houses for senior hospital officers. In 1950, the Group Secretary, the hospital Engineer and the Chief Male Nurse had houses. The Matron and Deputy Matron lived in flats in the centre of the hospital, as did several of the doctors. Male nurses lived in rooms off the wards, female nurses in a Nurses’ Home at the back of the site. The first task at Fulbourn after the war ended was to repair the damage from years of overcrowding, understaffing and lack of maintenance. Dr Jones was unwell from October 1944; he retired in March 1945 (and died two years later) and Dr Thomas was then appointed Medical Superintendent. Gradually staff began to reappear from war service. Male nurses returned and some ex-service nursing orderlies came to train as psychiatric nurses. However, very few of the women staff returned and consequently the women’s side was very understaffed. The clerical, maintenance and other staff returned and Mr Merrin, the Engineer, began work on overdue maintenance, lamenting the shortage of reliable skilled workmen. The reports of the Visitors, the Superintendent and the Board of Control in 1945 and 1946 register these activities, but the next years are mainly filled with the hopes and fears relating to the approaching National Health Service that was to take over the hospital in 1948. The new NHS settled the areas for which hospitals should be responsible. Fulbourn was to serve Cambridge, Cambridgeshire and the Isle of Ely, as before. It was to continue to serve Huntingdonshire (as it had done since 1939) and also provide for the Saffron Walden district of Essex. This gave Fulbourn Hospital an enlarged catchment population of about 300,000. Its catchment area now stretched from Stansted in the south to Wisbech in the north, nearly 60 miles, and from Kimbolton in the east to Kentford in the west, some 40 miles. This was still a predominantly rural area, with farms, small holdings (in the Fens) and small market towns, such as Huntingdon, Wisbech, Ely and March. The largest town – soon to be called a City – was Cambridge, with a population of 100,000. It became clear that the hospital would no longer belong to or be paid for by the Three Bodies which had financed and controlled it for 90 years. Though the parent bodies were probably relieved, the members who made up the Visitors Committee were filled with doubts and regrets – especially when it emerged that Fulbourn hospital was to be linked with Newmarket (General) Hospital and run by a Joint Management Committee. The

Committee feared that the special needs of the psychiatric patients would be overlooked and the next few years showed that they were right. Although the immediate postwar years were mostly spent making good the damage and deficiencies of the war years, there were some new developments. Young staff returning from the war were keen to try out new ideas. Dr Dewi Jones, who joined the staff in 1945, started an Insulin Coma Therapy Unit in 1946 which the most energetic and bright staff competed to join. Dr Thomas had always been keen to improve the physical medical services within the hospital. He and Mr Merrin planned an operating theatre in the cellars of the central building; they designed and built it with the hospital workmen, and opened it with great pride in 1947. When in 1948 the Regional Board asked for his first postwar priority, Dr Thomas pointed to the infectious patients – those with chronic open tuberculosis and the carriers of typhoid. A special infectious diseases annexe was planned and built as an extension to the women’s sick ward. It was opened in 1954. Another postwar initiative was Outpatient Clinics. The first was started at County Hall, March, in 1947. After 1948 it became easier to work with the general hospitals, and clinics were opened at Huntingdon County Hospital in 1949, at Saffron Walden Hospital in 1950 and at the North Cambridgeshire Hospital in Wisbech in 1952. Outpatients were also seen regularly at Fulbourn Hospital. After 1948 cooperation improved with Addenbrooke’s Hospital and many outpatients were seen there. However, other things did not go so well. The Joint Management Committee was taken up with the development of Newmarket Hospital, especially when it became a Regional Poliomyelitis Centre. The Board of Control became increasingly worried about the neglect of the psychiatric patients’ needs and wrote a very critical report. This was picked up by various interested people in Cambridge who were impatient to see a good modern psychiatric service develop. As a result of the pressure the Regional Board changed their policy. A new Hospital Management Committee (No.13) was created in 1951 and Mrs Hester Adrian, the wife of the Master of Trinity College, was appointed Chairman. Joint appointments between the two hospitals – Fulbourn and Addenbrooke’s – started to be made. One of the first, in 1949, was Dr Edward Beresford Davies who joined with Dr Derek Russell Davis, the University Reader in Psychopathology, to press for change and reform in the psychiatric services in Fulbourn and in Addenbrooke’s. As a result of their pressure, two wards (one male, one female) for the hospital elite workers were declared ‘open’ in 1951. All these pressures for change bore heavily on Dr Thomas. His once magnificent physique, swollen by years of overeating to a gargantuan 22 stones, was at last letting him down. He was short of breath and constantly anxious. He often expressed concern about new developments and distaste for all the postwar bustle and innovation. The new developments worried him, as did the hustling of the bright young men. He was severely

ill with pneumonia and heart failure in 1951 but stayed on until his full pension was due in 1953, when he retired. The new Management Committee faced a major task in choosing a new Superintendent. They wanted someone to change things – but few young psychiatrists wanted to be superintendents in 1952. The pay for the job was no more than for other consultants, carried far more responsibility, and was restrictive since superintendents had to live within the hospital grounds and were barred from private practice. The Committee could not find anyone satisfactory the first time, so they readvertised. It was then that I applied for the post. 3 A New Superintendent At the time of my appointment I was aged 32 and was a Senior Registrar at the Maudsley Hospital. I was the son of a medical scientist and had grown up and been educated in Edinburgh. Having trained in medicine at Cambridge and Edinburgh, I qualified in 1943 and then spent three years in the Army. This was followed by psychiatric training for three years at the Royal Edinburgh Hospital with Sir David Henderson and for another three years at the Maudsley under the redoubtable Sir Aubrey Lewis. While there I had had a personal psychoanalysis and trained in individual and group psychotherapy with the founder of group analytic psychotherapy, S.H. Foulkes. In this, so far, fairly ordinary career, however, there were some periods which would prove to be relevant to the work I undertook at Fulbourn. During my time in the Army I did a limited amount of medical work. I trained as a parachutist and spent much of my time as a Section officer in a Parachute Field Ambulance leading a group of men into action; what was particularly valuable for me was that half my section were Conscientious Objectors, brave, intelligent but argumentative men who did not hesitate to question any order they doubted. I was with the armies that conquered North Germany in 1945 and saw the abominations of the Nazi Concentration Camps. Later in 1945 I was sent to the Far East and for three months was in charge of a camp of 2,000 Dutch civilians in the jungles of Sumatra far beyond the British lines, having to negotiate with the Dutch and their former jailers, the Japanese, to prevent a massacre by the Indonesian nationalists. These experiences taught me something of the perils and responsibilities of command, as well as showing me many of my own personal limitations. They also showed me the abominable things that people would willingly do to one another and left me with a deep distaste for locking anybody up. My motives for applying for the Fulbourn job were mixed. I was married, with three young children and I wanted the security of a Consultant post. We wanted to get out of London and to live in a pleasant town. I also had an enduring desire to do something to improve the lot of the long-stay, back-ward patients. In my early days in mental hospitals, I had felt deeply concerned for these patients; I had seen them left, neglected, to their hallucinatory ramblings, or worse, locked in padded rooms, strait-jacketed or mistreated by staff because of their violence. I had seen a young raging patient, suffering from

psychosis, die of the injuries inflicted by frightened staff. I had enjoyed my time at the Maudsley, but felt guilty whenever I went out to a mental hospital and saw the neglected hundreds. I thought that rather than spending my time on a few people with minor difficulties I should be working for the much greater numbers of suffering and abandoned people incarcerated in long-stay mental wards. I was also keen to see whether the group methods of consultation and decision making which I had seen to be so effective in the Army could be applied to a hospital hierarchy. I was appointed, therefore, with a good general knowledge of clinical psychiatry, and a background of research and academic psychiatry, but no experience of hospital administration. I had never worked in an English County mental hospital. I had worked with long-stay patients in Scotland, but the Lunacy Laws of Scotland were different from those of England. I felt very aware of the deficiencies in my experience. I did, however, have certain strong ideas, feelings and beliefs which I wanted to try out. In the army I had been impressed with how men’s psychological health could be influenced by the way in which they were led. In my psychiatric training I had been struck by the difference between the patients in demoralised, static hospitals and those in hospitals that had lively, vigorous and hopeful leadership. I had studied social science and its psychiatric applications and in particular found fascinating the writings of Stanton and Schwartz, who analysed the daily social life of a private mental hospital in Maryland, USA. They had shown how nurses, doctors, attendants and patients interacted, and how patient upsets could be linked to staff animosities and collusions (Stanton and Schwartz, 1954). I felt that such social studies could teach us a great deal about what really goes on in a mental hospital. I had found group analytic psychotherapy personally rewarding and very valuable for my patients – some of whom made more progress in a group than in individual therapy – and I felt that group therapy was full of promise. All these feelings led me back to the long-stay patients with the belief that somehow with the application of group methods, of ‘human relations’, of lively administration and strong leadership, I could find a way to change the hospital for the benefit of the longstay patients. It was this vision which helped me overcome the offputting first impression I had of Fulbourn. During the three months between April 1953, when I was appointed, and August, when I started, I was busy winding up my London life and preparing for Cambridge. During the last two months of my psychoanalysis I faced again all my anxieties over separation and weaning. I concluded my research projects. I terminated, or handed over, my psychotherapy patients and said farewell to the groups that I had been conducting. More than ever aware of the things I did not know about the Medical Superintendent’s task, I scurried about trying to fill out my knowledge. I read up English Lunacy Law and enquired how to certify a patient and what powers the Board of Control had. I paid visits to a number of mental hospitals and spent a day at the Social Rehabilitation Unit at Belmont run by Maxwell Jones. This unit was just becoming famous and I found the visit exciting and disturbing. Belmont Hospital, at Sutton, in Surrey was a former London County Council mental hospital, damaged by the war and housing several experimental

units. One was the Social Rehabilitation Unit, run by Maxwell Jones which was just becoming famous for its pioneering social therapy. It ran as a ‘therapeutic community’, something I had heard of but never seen. The first event of the day was the ‘community meeting’; about forty people, all dressed informally sat round in a large circle; after a few reports discussion became general. Any visitors were called on to identify themselves. The community meeting was intrigued to hear I was about to become a Medical Superintendent; they commented that I seemed young for the task and told many tales of doctors in mental hospitals – their neglect of patients, lack of concern and hypocrisy and the tyranny exercised by nurses. The Unit itself perplexed me. There were no uniforms – everyone dressed alike. I was confused as to whether the people who addressed me in the community meeting were patients, staff or visitors. However, I felt this atmosphere of free and open discussion to be stimulating, helpful and possibly what was needed at Fulbourn. I asked everyone about Fulbourn Hospital. I could find out little; no one seemed to have even heard of it. I found that many who knew Cambridge did not even know that there was a mental hospital outside it. One or two had heard vaguely – ‘I believe it’s a dump’. ‘It’s said to be pretty backward’, but little else. Dr Walter Maclay, the Senior Commissioner of the Board of Control and a visiting Consultant at the Maudsley, however, told me more. ‘I remember Fulbourn with affection; it was where I was first introduced to psychiatry. Of course, nothing has happened there for years; it’s quite run down. That’s why they want an active person. You can’t go wrong! It’s like taking over a drunkard’s practice – anything you do will be an improvement! Not that the old man was a drunkard – by no means! He was a charming old boy and very fond of his patients. But he just couldn’t stand up to his Management Committee and nothing got done. Of course, there are some pretty live wires there nowadays and you’ll have to watch out and keep your end up. Some of them seem to think that all psychiatry is in the outpatient clinics or the admission wards. You’ll have to look after the back wards. You should find it an interesting job.’ Some of my teachers were reassuring and said they thought I was just the man for the job. However, the more I heard, the more doubtful I felt and I began to wonder if I could get out of it, or whether I could get back to London in a year or two. The time to commence approached; last visits were paid, farewells said, files closed, responsibilities handed over. I was ready to go. We went for a seaside holiday, and then, leaving the family in London, I travelled down to Cambridge and to Fulbourn Hospital. My contract had stipulated that I start on 1 August which was a Bank Holiday Saturday. I assumed I must start literally on the first and it was a measure of my ambivalence about my new task that I left it until the Friday evening after supper to drive down. As a result, I arrived at the hospital in the dark at about 10.30 p.m. on the evening of Bank Holiday Friday. I walked up to the big front door, where I had been welcomed on my previous visit to the hospital, and found it locked. On either side of the door were large brass bell handles, much polished. I pulled one, then the other. Nothing happened; the handles moved, but

there was no peal inside the building. I peered through the glass door; all was dark inside. I wandered along the front of the building; there were other doors, all firmly locked. Finally, I hammered on one of them and after a long time a torch light came bobbing along the passage. The door was unlocked. A squat figure with an uncouth accent asked what I was doing. It was some time before it became clear to him that I was the new doctor about whom he had had a message and I realised that he was the night porter. He rang the duty doctor, and I was welcomed and installed in a little flat which had been allocated to me. Later, I discovered that the porter’s lodge was at the back of the building, not the front; that was the true entrance, which patients, relatives, nurses and callers used. The Front Door was reserved for the Management Committee and Senior Staff and was only ever used in the daytime. My first three days Bank Holiday, Saturday, Sunday and Monday, continued in a curious dreamy fashion. All clerical staff were away; most doctors were on holiday; there was only a skeleton staff on the wards. I was shown the Superintendent’s office, which contained a vast rolltop desk full of papers, a broken swivel chair and three notice-boards covered with notices, curling and dusty, all out of date; there were several relating to wartime air raid precautions (eight years after the end of the war). This first day began the process of getting to know the people I was to work with – a business of mutual exploration that went on for many weeks. I felt anxious and hesitant about them, for I had garnered a few revealing but often discrepant comments on each person before meeting him. They, of course, were all interested, concerned and even frightened about me, as I was to be a major factor in their lives in the coming years. The first to meet me was the Deputy Medical Superintendent, Leslie Buttle. He had come to Fulbourn in 1949 just after the Health Service began, as a Consultant Psychiatrist; he was some ten years older than me and had trained in pre-war asylums and served as a Forces psychiatrist. He showed me where all the papers were, commented how much he had disliked his three months’ curacy of the Medical Superintendent’s post (as his interests were clinical and he did not enjoy administrative work), and left me to its problems. Next came the Group Secretary, Charles Mitchell, a tall, courteous, slow-spoken man. He welcomed me and hoped that I would enjoy my time at the hospital. He told me that he had been brought up on the hospital estate, and had worked all his life in the clerical department, first under the Committee of Visitors and now under the Hospital Management Committee. He spoke with grave precision of the decisions made and with hesitancy of the prospect of their completion. He invited me to call on him whenever I wished for clarification of procedure and showed me the file of minutes of Committee meetings. While we were talking, the Matron, Miss Brock, burst in on us. Several people had spoken of her, saying she was ‘an impossible woman’. She had been Deputy Matron for years and when the old Matron had retired in 1952 there had been an attempt by the Consultants and some members of the Hospital Management Committee to prevent Miss

Brock from being appointed Matron. They had failed in this, partly because my predecessor, Dr Thomas, a close personal friend, had been her vigorous ally. The battle had left a bitter taste with all. Miss Brock had been told of things said at the confidential appointment committee and felt bitter against those who had opposed her. It seemed that I was in for great difficulties here. She briskly demanded that I go round the female wards with her forthwith. During the Saturday afternoon I toured the hospital – first the women’s wards with Matron, then the men’s wards with the Chief Male Nurse, Mr Tucker. The attitudes of my two guides contrasted greatly. Miss Brock introduced to me more people than I could remember; she pointed out many things that were amiss, as if challenging me to do something about them; she told me of the battles she had fought – with junior doctors, with Consultants, with the Management Committee – and how they thwarted her at every turn. ‘You’ve got to fight, doctor, you’ve got to fight. They’ve blocked me at every turn and I know that some of them would like to get rid of me. But no one’s going to stop me doing the right thing by the patients, doctor, no one, not even the Regional Board themselves!’ She left me exhausted by her intensity and combativeness, by the magnitude of the problems, and all the difficulties. With Mr Tucker, I strolled in leisurely fashion around the wards, where I was saluted by deferential patients and staff while he told me little tales of those we met. He spoke modestly of what they had achieved, but indicated that they were just waiting for my help to go ahead. He asked for my consent to certain easily granted proposals and indicated plans for the future. He hinted at difficulties with other departments and slyly indicated their failings, but was on the whole benign and cheerful. ‘Of course, we’ve been held back, Sir. There were a lot of things we wanted to do, Sir, but they were refused. But now that you’re here, Sir, I am sure we shall move ahead. It’ll be a great help having you with us, Sir.’ We wandered out around the farm and inspected the pigs and the vegetable garden and he told me something of the difficulties of gardening on this chalky soil. I left him feeling smoothed, comforted and somehow elevated. I spent Bank Holiday Sunday going through the files and papers. I found very little. It seemed that Dr Thomas relied on his memory rather than a filing system; I found several drawers containing broken pencils, untwisted paper clips and bits of string and one full of jumbled Committee papers, but little else. I read all the notices on the boards and took down all those more than a year old; this certainly made some room. I looked at the books, mostly the ancient journals and out-of-date surgery textbooks. I spent the evening in Mr Mitchell’s office reading back through the minutes of Management Committee meetings. These minutes provided a picture of a strange body, constantly concerning themselves with minutiae of hospital life and passing strongly-worded resolutions on many subjects. I took my meals in the doctors’ dining room and gradually met the medical staff as they came on duty. They were a varied lot, including a man who had been in the Colonial Service, another who had worked in a number of mental hospitals, a young doctor just starting in psychiatry, a former general practitioner and a woman who had taken up

medicine after an academic career. They were pleasant people, but all soon started pouring out dissatisfactions. The food in the doctors’ dining room was poor; the training programme was inadequate; the nursing staff blocked their attempts to help the patients; the Consultants were only interested in their private practices; the administration was incompetent and anti-medical; the Management Committee did not understand their problems. It seemed that their morale was low; several of them had applied for jobs at other hospitals. I remembered Leslie Buttle’s expressed dislike of his three months’ running the hospital; it was clear that it had been a painful period for all concerned. On Tuesday the routine of the hospital resumed. I found that I was expected to sit in my office while various people came to see me to ‘report’ – Leslie Buttle, Miss Brock, Mr Tucker, each of the doctors. This was a lengthy process, especially in the first days, as I had many questions to ask and each person had much to explain. I got in early and went through the mail before my visitors began arriving – a bewildering mass of requests for leave, pathologist’s reports, Official Notifications, drug advertisements and unexpected letters of all kinds. There were two telephones beside the desk, one linked to the internal hospital system, the other a line to the hospital switchboard and the outside world. At first they were mostly silent, but as people began to know my whereabouts frequently both telephones were ringing at once. I asked about secretarial help; I was told that the medical secretaries were in the Admission Villas, where the doctors needed them. In later years, it seemed to me symbolic of the administration I inherited that if the Medical Superintendent wanted to dictate a letter, he telephoned for a secretary who came on a bicycle to take it down in longhand. But there was no time to think of changes. There were new people to meet, and problems began to flood in on me. Part of my appointment was to the Psychiatric Department of Addenbrooke’s. Dr Noble, the senior psychiatrist at Addenbrooke’s called me on my first morning and asked me to come to see him. He told me that he was going on holiday and would like to hand over his patients. Within a day, I discovered that the other two Consultants had also departed on holiday and that they had also given the only Senior Registrar permission to take a fortnight off. Thus, I, the new arrival, found myself singlehandedly responsible for scores of outpatients and about a dozen general hospital inpatients. Many patients had been booked to attend the outpatient clinics without any arrangement as to who was to see them. On one afternoon, I found that two full clinics had been booked and that I was expected to see them all. I arranged to go to Addenbrooke’s daily. After a week or two, I got the clinics down to reasonable proportions. I felt bitter about this and upbraided the Consultants when they returned. It was, however, typical of the disorganisation of this group of senior doctors and the general disregard of the needs of others – both colleagues and patients – that they could all independently arrange to depart without ascertaining who was going to do their work. In one sense, however, the experience proved to be a boon. It kept me busy practising clinical psychiatry – seeing new patients, making diagnoses, arranging treatment, writing to doctors – one of the few

medical tasks that I knew I could do fairly efficiently, and so my confidence increased. Within Fulbourn, too, there was plenty of clinical psychiatry to be done; there, too, the Consultants had left patients in my care, and new patients were being admitted daily. I took to doing regular rounds in the Admission Villas and doing the best I could with the problems presented. I gradually met other important figures. Harry Merrin, the engineer, came to see me about my accommodation. The Medical Superintendent’s house, though built in 1930, was a large, rambling building planned on a nineteenth-century scale; it was said to be very cold in winter. I had heard dire stories of the difficulties of the last tenant. The garden was a barren desert of chalky soil, overrun by rabbits and raided regularly by voracious pigeons. Prior to moving my wife and I said that we must have central heating and had obtained estimates of the cost. We had sent these to Mr Mitchell who in due course informed us that the Management Committee had agreed the work should be done forthwith. (It was only in later years that I realised how exceptional this speedy approval was.) Since this work would take some time, I had arranged for the family to stay on in London. Now, Mr Merrin reported that the work had not yet begun and might take many months. He told lugubrious tales of previous delays and explained that because the HMC could not bribe suppliers as the private builders did, we always had to wait for special parts. Since he told all this with a cheerful grin, I did not believe it could really be so bad, but it was. We did not get into the house until February of the next year! By that time Mr Merrin and I had had many talks. I learned he was a most able engineer who knew everything about the hospital, having worked there for many years, but that he had a puckish sense of humour and a delight in discomfiting the pompous and the important. He had apparently always been enterprising and subversive. He told with delight of his service in the First World War in the Fleet Air Arm when he had been ‘decorated twice and court martialled twice’. He maintained feuds with most other senior officers of the hospital and had been at odds with my predecessor for many years. He particularly despised those who did not fight for their rights or who would not engage in battle with him. After several battles of my own with him, he and I established a jovial comradeship, based on mutual respect. These senior officers, whom I met first, all lived in the hospital grounds – Mr Mitchell, Mr Merrin and Mr Tucker in houses, Miss Brock in a flat adjoining the women’s wards. Several doctors and their families also lived in flats in the central building of the hospital. There was one person whom I did not meet – at least until later – but whose presence pressed in on me from the first day: my predecessor Dr Thomas. Nearly everyone prefaced every request or comment with ‘Dr Thomas always – often – usually – dealt with the matter so’. He came to occupy my mind and even my dreams. I had met him briefly at the appointment interview – a vast man of 6 feet 2 inches who towered over me, with a great belly and two double chins. I began to wonder more and more what sort of a person he was and how I could ever fill his shoes.

I gathered that he had been at the hospital for many years, that he had known every patient and every staff member personally; that he was a talented conjuror and entertainer at Christmas parties and had been for many years a very good cricketer. I was told that he had played for the London Welsh Rugby Team when a medical student and had won a Military Cross as a battalion medical officer on the Western Front in the First World War. He had come to Fulbourn in the twenties and in the thirties had married the Assistant Matron; they had had one son – the darling of the hospital. Although talented in many directions, however, it seemed Dr Thomas could never make a decision and that he was terrified of the Management Committee, especially the powerful ladies on it; Dr Thomas had been a bosom friend of the Matron, but hostile to the Chief Male Nurse and the Group Secretary, and so on and so forth. Clearly, Dr Thomas had been a sick man in his latter years and had let many things slide. I met Dr Thomas again one day when he came up to watch the cricket team play – he was as big as ever, 22 stones and manifestly short of breath. Charming and friendly, he wished me well. Later that month he invited me for dinner when he and Mrs Thomas (also large) provided a gargantuan meal and much friendliness. He told me that he had greatly enjoyed his life at Fulbourn, which had become his home. This was why he had bought a retirement house only half a mile from the hospital – he hoped to keep in touch. He spoke happily of his work on the wards with the patients and the staff but said frankly that he regretted taking the Medical Superintendency in 1945. ‘I didn’t like the administration – the Visitors Committee – the anxieties … . And all this National Health Service and the Regional Hospital Board … it has all been a great strain. I haven’t enjoyed the last years. If it hadn’t been for the pension I would have retired earlier.’ He seemed a decent, defeated man. His health was indeed broken. He was seldom well enough to come up to the hospital and after several bouts of congestive cardiac failure he died in March 1955. As I went to and fro through the hospital, I got to know more and more people – first, those who worked directly with me, such as the fussy, incompetent, mischief-making woman allocated to me as my ‘secretary’, the porters who handled my mail and listened in to my telephone calls and the gnarled elderly patients who brought the food to the ‘doctors’ dining room’. Then there were those that I met frequently about the place – the Matron, the Chief Male Nurse, the Engineer, the hospital chaplain, the hospital messenger, the senior nursing staff, the ward charge nurses and sisters. Some of them immediately stuck in my mind as idiosyncratic figures with marked abilities or manifest faults. One ward sister was a craggy wooden-faced woman, hostile to me and angrily contemptuous of her charges; another was refined, lady-like and sadly resigned to the incompetencies of the world. Some of the charge nurses were clearly former Army noncommissioned officers who saluted me with military precision and scattered their talk with an explosive ‘Sir!’ in every sentence. I got to know patients either because they accosted me with petitions and demands or when I had to see them because of some letter, request or official enquiry. Some soon impressed themselves on me.

I found I could understand the Cambridge accent fairly well but I was for long defeated by the vowels of the people from the Fens, Wisbech and March – the ‘Fen Tigers’. I gradually became accustomed to the excessive deference paid to me – everyone springing to their feet as I came into a room, male nurses and patients constantly saluting me. One group I quickly got to know were the patients who resented their detention. They were few, but they soon demanded my attention. They accosted me as I came in through the locked doors of their wards, protesting that they were illegally detained and that something should be done about it. In one men’s ward I was stopped by a tall whitehaired venerable figure who roared at me in a broad Scots accent ‘Ah am illegally detained in this place! Ah have been brocht here by a perversion of the judeecial process!! There must be an Enquiry!! The Prophetess has spoken!!’ – and then stalked away. In one of the women’s wards a thin gaunt woman sidled up to me and in an educated voice requested me to investigate her case – ‘I am sure there has been a mistake. I fear that my husband told untruths to Dr Beresford Davies to persuade him to certify me. I am sure if you look into it, Dr Clark, you will see that there has been a terrible injustice brought about by that evil man.’ Others pressed petitions on me. Conscientiously I listened to their stories and investigated the case notes and the legality of their detention. In each case the legal papers were in good order; often there was a long and clear history not only of paranoid and deluded utterances, but also of antisocial behaviour. Mr McTavish, the Scotsman, had been a local farmer; a known eccentric, no one had objected to his practice over years of proclaiming the imminent coming of the Prophetess from a wagon in the market square. It was only when he took to attempting to convert his neighbours with a shotgun that the Police had had to take action! His denunciation of the Magistrates from the dock had ensured his committal to the asylum. The staff said he was well-behaved and helpful on the ward – but always protested his detention to any visitor. The lady, Mrs Broadbent, was the wife of a solicitor in a nearby town; for years she had harried him with accusations of infidelity but it was not until she was found lurking in the shrubbery outside his office with a bag full of sharp flints that action had then been taken; it was her disordered rambling in court that had persuaded the Magistrates that she should be sent to us. Again, she had established herself as a leading and privileged citizen of her ward, always critical of the way things were being run, and always insisting on her half-hour interview with the Commissioners of the Board of Control during their annual visit. I walked around the grounds whenever I could in the warm summer days and I soon became aware of the groups of working patients. Some of them were sad groups leaning on hoes being looked at by bored young nurses in overcoats. They seemed to be achieving little and not doing themselves much good either. But other groups were more effective. There was the ‘Farm Gang’, a group of about ten men who were clearly central to the operations of Mr Banyard, the Farm Manager. When harvest came they carried out the main work, forking sheaves and humping sacks. The relations between them and the farm staff seemed cheerful and cooperative; they conversed in an incomprehensible rural dialect with sly jests and outbursts of bucolic laughter. Amongst the Farm Gang I noticed

one man, Hugh, who seemed to do more work than any other two men put together. I tried talking to him, but got nowhere because he turned shyly away and mumbled. His case notes told me that he had come to the hospital 15 years earlier as a perplexed adolescent full of anxious ruminations, hallucinations and thought disorder. He had never been violent or troublesome; he had never had any specific treatment. He had gradually moved to a long-stay ward and then to the Farm Gang where he contentedly did the work to which he had been bred in his village. There it seemed likely he would remain, quiet and contented, for the rest of his days. Another interesting group was the ‘Engineer’s Gang’, those patients who did the labouring work for the Engineer, Mr Merrin. They were always to be seen digging holes, clearing foundations, trundling barrows of building material to and fro. The atmosphere of the groups and the attitudes of the men in charge varied a good deal. Once I came across one group of patients sitting down; up to me bustled a portly figure wearing an overcoat and a brown overall, who hastened to tell me of his charges. ‘I’m just letting them have a rest, Sir. It’s better like that, Sir. You see, Sir, they are mostly EeePees, Sir, and they’re better for a rest at times. I know EeePees, Sir, know them well, Sir; I’ve been doing this job for 20 years, Sir. You can rely on me, Sir!’ At first I could not understand what he was trying to tell me. Then I realised; some of them were epileptics (‘EPs’) and, because such patients were usually difficult to handle, that gave him his cue and justification for idleness and tyranny. As I shook off the toadying creature the one thing of which I felt sure was that I could not rely on him! In contrast, at another time I found eight men digging a ditch vigorously. I asked who was in charge and they pointed to a figure vigorously swinging a pickaxe in the deepest part of the ditch, saying ‘Aubrey, there, he’s in charge’. Out of the ditch came a cheerful friendly man who told me with enthusiasm of the jobs he and the ‘Engineer’s Gang’ were doing, and how good they were at it. I noted the name of Aubrey Gentle; he took the lead in many of our projects in later years. He did not categorize and denigrate his patients; he regarded them as fellow workers in a common, valuable enterprise. Harry Merrin told me about these working patients of his – how he selected them and looked after them. Many of them were epileptics who, he said, were the best workers in the hospital. They knew how to look after one another and to deal with the occasional fit. He gave them extra tobacco and other privileges and they worked for him with devotion. I began to realise that working for the hospital could be many things. At the worst it was dreary, degrading peonage, where people were given worthless things to do just to ‘keep them occupied’. It might even be exploitation. At best it might give a patient challenging and responsible work and an honoured status within the institution. I wondered what I could do that would work to the best advantage of all patients. One day Mr Merrin asked me if he could ‘have Jack back on the gang’. I made enquiries and discovered a strange asylum story. I asked where ‘Jack’ was and found him in Male 5, the male disturbed ward. A massive countryman, broad shouldered, big bellied and round faced, he sat there scowling grimly. The nurses informed me that they did not dare

to interfere with him because he was an epileptic with a furious temper and massive strength who refused to do any ward work because Dr Thomas had said he was never to go out on Mr Merrin’s gang again. It appeared that about a year before, on the day the Commissioners of the Board of Control were visiting the hospital, Jack had cut his throat and had nearly died. Dr Thomas had had to leave the Commissioners to deal with the bleeding and was infuriated and shamed. Matters became worse when it emerged that Jack had done the deed with a knife purloined from the ward and clandestinely honed to razor sharpness. This meant that at some time a knife had gone missing in the ward and that the loss had either not been detected by the ward staff, or worse, had been covered up. I talked to Jack – though with some difficulty because of his dialect. He talked in surly monosyllables. He showed me the long scar on his throat. He said he wished that Dr Thomas had not saved his life, because he was going to have to sit indoors forever now. He told me his story and why he had tried to kill himself. He had been in Fulbourn for 20 years; he had been brought to the hospital from a Fenland village as a young man when his fits and his outbursts of temper had become too much for his family. He had found a good situation for himself as the strongest man on Mr Merrin’s gang – the man they called for when there was a stone or a tree trunk or a sack too heavy for anyone else to lift. He never heard from his family. Then one day he saw a man from his village delivering gravel to the hospital and got into conversation with him. It emerged casually that Jack’s mother had died three years before. She had been buried and the home dispersed – and no one had even bothered to tell him! He had fallen into a state of bitter anger, gloom and resentment and had cut his throat, both to end a miserable existence and to spite them all – his family, the ward staff, Dr Thomas, the lot. His act had, in a perverse way, been successful. His two sisters and his brother, shocked by the news of his act, came to visit him and had kept in touch since. The ward staff treated him better. Mr Merrin wanted him back. But Jack believed the Superintendent would not let him go out to work again. (I think he thought I was another new young ward doctor.) I wondered what to do – then decided to take a chance. I told Jack that Dr Thomas had gone and that I was now in charge, that Mr Merrin had asked for him and that I was willing to let him go back to work. But I pointed out the trouble his throat cutting had made – for the nurses, for Mr Merrin, for Dr Thomas – and asked him to promise me not to do it again. If he felt miserable again, to ask to see me and tell me about it – but not to cut his throat – it made such a mess! Jack went back to work. Mr Merrin was pleased, as was Aubrey Gentle, in charge of the gang. The ward staff were glad to be quit of the rumbling volcano who had sat in the armchair all day. Whenever I saw Jack he gave me a respectful salute and a rumbled ‘Mornin’, Superintendent Clark’. He and his group of epileptics, always an elite group within the disturbed ward, became more cooperative and helpful on the ward. Gradually I discovered contented eccentrics settled in various parts of the hospital. On every ward there were the ‘ward workers’ who did all the heavy and dirty work under the direction of the nurses. Submissive deferential middle-aged people, they showed little

sign of mental disorder when I talked to them. Any suggestion that they might move, however, was contested by the staff with dire tales of breakdowns, suicide attempts and disturbed relatives. The ‘hospital messenger’, William, was a grave, courteous, welldressed man who cycled into Cambridge daily and was always available for any errands or shopping that I might require. If ever I wanted something from Cambridge in a hurry, Mr Tucker would say ‘I’ll just have a word with William, doctor, he’ll get it for you’ – and he did. I sometimes gave him a lift in my car when he would tell me at ponderous length about the latest happenings in the Hospital Chapel where he was a sidesman and a key member of the choir. I discovered that he was the simple-minded son of a well-to-do commercial family in one of the Fenland towns who had worked in the town for many years as an errand boy until he was brought to hospital in a state of acute middle-age depression following his elderly mother’s death. Here he had settled to a similar life. He had a room to himself; he sang in the church choir; he had no desire to move. Attempts by keen young doctors to ‘rehabilitate’ him produced a recurrence of his weeping, distress and agitation and people had learned to leave William alone. Then there was George who worked in the hospital stores. It was some time before I met George for he was never on the ward. It was only when I had to go into the hospital stores – a gloomy warren of shelves and boxes and bales – that I became aware of a tall, baldheaded man with a long, sad face. He was wearing a white apron and was always moving round the back fetching and carrying. Then I met him at ward parties, well dressed and deferential, gravely greeting me. He had been in the hospital many years, having originally come in during a severe depression following his wife’s death. He was well settled in the stores and had no desire to move. The only crisis we ever had with George was at his 65th birthday when someone suggested he should ‘retire’. He became very distressed and begged to be allowed to go back to ‘his place’. So we let him and he remained there serving a very useful role, for he knew exactly where everything was. The Engineer’s Gang had a considerable array of tools – picks, shovels, axes and saws, mauls and drifts – which were kept in a hut in the Engineer’s yard. These were cared for by Ernest, a small wizened man who sat there all day cleaning, mending, sharpening, polishing and oiling them. He had developed a small garden outside the hut by clearing rubble and had a number of roses growing. Discussion revealed no sign of mental disorder and one doctor even tried to discharge him. But a combination of the efforts of Mr Merrin and the ward staff, who valued him as a useful worker, brought a stop to that. There were also elite groups of workers amongst the women. In the laundry, apart from a few paid overseers, all the toil was carried out by squads of sturdy women who heaved the heaps of soiled bed sheets to and fro in great baskets and fed them into the boilers and then on to the great calenders for ironing. In the ‘Sewing Room’ a group of long-stay women under the direction of a sempstress stitched endlessly, mending torn hospital sheets and tattered dresses. There were other women’s groups for rough and hard work. Attached to the kitchen was a ‘Vegetable Preparation Room’ – a phantasmagoric, Dickensian place, full of steam and dripping water where placid red-faced women sat peeling endless tubs of potatoes, carrots, turnips and parsnips with scarlet chapped hands. There was a ‘Scrubbing Gang’ that scrubbed the hospital corridors. I stepped gingerly

past them every day – grey-haired, grey-overalled gnomes, kneeling on wooden boards, scrubbing endlessly at the grey flagstones. One of the most active of the ‘maids’ who served the doctors and the Matron was Caroline. I noticed this short, squat, ugly, bustling figure who cleaned rooms with an angry vigour and tried to talk to her. Her face was marred by a badly mended harelip and the cleft palate behind it made her remarks at first quite incomprehensible to me. Later I got to know her better and at last began to understand her a little; I realised that it was not only a cleft palate, but a strange East Anglian dialect with many odd phrases that puzzled me. I checked the notes; she was classified as a feeble-minded epileptic with behaviour disorder. I could see that she was not very bright but suspected from the way she did her work that her intelligence was not far below normal; certainly she was not feeble minded. She had not had a fit for years. I saw no evidence of antisocial behaviour now. She told me that she was an orphan who had grown up in the Yarmouth Workhouse. When she had fits they used to beat her and when she got too big to beat they put her into the local asylum. At the beginning of the war she was transferred – she did not know why – to Fulbourn Hospital where she soon landed in ‘Fives’ – the disturbed ward and then in the ‘pads’. ‘Many days I spent in them pads, Doctor, till I learned to be’ave meself. I were a proper terror in them days, Sister says.’ For some years now she had been doing better. The Matron liked her thorough, capable work and her cheerful obedience. Caroline was often offered to newly arrived doctors’ wives as a useful servant and nanny. She very much liked working in the flats and homes and looking after the babies. She had known no other life than that of institutions and hardly ever went out of the hospital. She attended the hospital church devotedly and sang loudly and tunelessly in the choir. When I asked her where she might live in the future she said ‘I dunno. I’ve always been in ’ospital. It’s me ’ome like. I don’t know no other.’ I also noticed a tall man stalking freely about the hospital. He was wearing very good clothes – including suits of fine cloth of which the arms and legs were too short for him, so that his bony wrists and ankles stuck out of them. He talked to me cheerfully and deferentially, in rather simple language. He always enquired how my shooting was going. I had had to get a shotgun to rid my garden of raiding pigeons, rabbits and hares and sometimes walked around the estate in the evenings trying to shoot the marauding pigeons. I learned that this was Charles who had for many years been the personal servant of the former Superintendent, Dr Travers Jones. When Dr Jones, a short plump man, died, he left his large wardrobe of good suits to John – who was still wearing them! For many years John had been the only patient in the hospital allowed to have a watch, as he had to go down from his ward to the Medical Superintendent’s house in good time to wake Dr Jones with his morning cup of tea. As Dr Jones’ personal servant, he was responsible for the doctor’s clothes and used to cut the doctor’s hair once a week. Another of his duties was to feed the partridges in the hospital fields. In the 1930s Dr Jones’ partridge shoot had been one of the best in the county and invitations to his shooting parties and the excellent dinners afterward were much prized. Charles had helped with all this. I later found out that Charles, now aged 63, had been admitted to the hospital in 1906 as a disturbed mentally defective adolescent and had remained there ever

since. Charles was one of the first successes of our rehabilitation programme; we got him a job as a potboy and bootblack at one of the best hotels in Cambridge and he left hospital in 1954 – after 48 years’ residence! One day I was shown the ‘hospital library’ which was a small cell full of ancient shabby books and magazines and there I met Arthur ‘the Librarian’, a small deferential greyhaired man with a genteel voice, wearing a good suit. He lost no time in telling me that he was a graduate of Cambridge University, a member of a famous College and that he had been a special protege of the late Sir Arthur Quiller Couch, the famous novelist and Professor of Literature. Intrigued, I chatted with him often; his tales of distinguished acquaintances became gradually more grandiose and he hinted at familiarity with the Royal Family, particularly the Dowager Queen Mary. He showed me the collection of books with great pride and encouraged me to borrow them. Later when my family lived in the grounds he welcomed my daughter into his library and encouraged her reading, presented her with books and instructed her in the degrees of royalty. It was not till years later than I found out the full story of Arthur. He was the son of a local catering family and had been briefly an officer in the First World War during which time he had attended the University on a short wartime course. He had been a consistent fantasist whose continual spinning of tales and running up of bills had exhausted the patience of his parents and then that of the wealthy woman he had persuaded into a wartime marriage. About 1930 he had been put into a private asylum and then when the money ran out he was transferred to Fulbourn where he had remained ever since, always grandiose, somewhat deluded, always deferential to authority, quietly reading and writing in his ‘library’. For quite a time I relished his conversation and was pleased with the attention he gave to me. It was only gradually that I realised that he had made what was supposed to be a library for all the patients into a private and personal one. He was assiduous in finding books for staff and their families and for a few patients whom he regarded as fit to use the library, particularly university graduates, former teachers and other ‘educated people’. But he considered that most of the patients were too ignorant to be fit to handle ‘his’ books and gradually discouraged them from visiting the little room. Apart from the exceptions mentioned, the patients were on the whole fairly shabby in appearance. The men’s suits were crumpled and their shirts did not fit. The women’s dresses hung lopsidedly and their stockings sagged down round their ankles. Overcoats were too tight and buttoned uncomfortably. All this was seen as an indication of their mental disorder and their self-neglect. Sometimes this was the case, but often it was due to their having given up the fight against institutional pressure. All clothing belonged to the hospital. It was regularly gathered and despatched to the hospital laundry and there boiled. There was no individual clothing, not even underwear. In some women’s wards a basketful of knickers would be dumped on the floor and the women would then scramble to get something that might fit. The apathetic invariably ended up with clothes that did not fit.

When I attempted to challenge or change this system I ran into difficulties and many reasons were given for maintaining the status quo – the nurses were overworked and could not be responsible for private clothing; private clothing got lost in the laundry; there was not sufficient competent staff to keep trace of it; many materials disintegrated with boiling, especially wool, so only coarse cotton garments would survive; the laundry costs must be kept down and so on and so forth. ‘Hard wearing’ material for patients’ clothing was chosen by the Visitors Committee from the lowest tender of firms that specialised in ‘asylum clothing’. The budget would not allow for changes. The present system was ‘fairest’ – no one did better than anyone else. It was little wonder that most of the patients, defeated by life and by the system, put on what they were given and shuffled about shabbily in it. The astonishing thing was that there were in fact a few people who still struggled to maintain their personal standards. On the wards for the hospital workers a few men were smartly turned out at weekends with collar and tie and with a suit neatly pressed, and a few women had their hair washed and curled, wore dresses that fitted and had been ironed and had put on a few touches of lipstick. But these attempts at improving appearance were pathetically few. The head and face hair of most patients was untidy and uncouth. They must not be allowed razors or scissors, so the overpressed nurses had to do the work. The male patients were shaved once a week by junior male nurses, with blunt razor blades, so they always looked unshaven. Their hair was cropped once a month. The women’s hair was chopped off in a ‘pudding basin’ style, so that they all had similar mops of dull grey hair. Many patients always seemed to be carrying around lots of things with them. The women had shabby handbags, packed to overflowing. The men’s jackets bulged and investigation showed that their pockets were filled with old envelopes, documents and newspaper cuttings which they would produce earnestly to ‘prove’ their paranoid allegations. This was often cited as another example of behaviour typical of mental disorder – as it sometimes was. But more often it was a reflection of the fact that most patients had no receptacle – no locker, no drawer, no private box – that they could call their own. The only place for treasured oddments was the handbag or the jacket pockets – regularly searched, of course, by the staff. Private storage places were discouraged by the staff – ‘they only hoard rubbish, doctor’ – and were regularly and punitively searched for ‘contraband’ such as sharp instruments, knives, money for escapes and so on. So anything valued had to be carried around all the time. Amongst the women milling around in the women’s disturbed ward, F5, I noticed one who carried herself taller and more upright than most. She seemed to dominate the throng physically, though she was not part of the pushing and shoving. I tried talking to her. She had a perplexed look on her plump face and although she spoke with an educated voice her responses were flat, banal and brief. I was told that Elizabeth was one of the most dangerous women on the ward, very strong, and given to outbursts of raging fury when she attacked staff mercilessly. I checked her story and found out that she was the daughter of a professional family who had entered the Women’s Air Force during the war and had become an officer. She had then had a severe psychotic breakdown. She had been sent to the special officers’ psychiatric hospital where she had spent five years

having all the treatments – insulin coma therapy, electroplexy and a prefrontal leucotomy – to very little effect. After the war ended the officers’ wards were closed and the family had been told that she would have to be transferred to ‘her local county mental hospital’ – namely Fulbourn. She had been several years with us, and everyone accepted that she would probably be with us for the rest of her life. The family had broken up; her parents had divorced, her brothers and sisters had made their own lives; no one visited her. Her strength and violence made her a major problem for the staff and no one knew what to do with her there except ‘put her in the pads with an injection and wait till she cools down’. Certainly I could think of nothing else to do. So I gradually got to know some of the people who inhabited this bizarre asylum world; many seemed fairly settled in their situation and none seemed to expect much change. I often felt utterly daunted by the task of altering and moving things and feared that I might be utterly defeated by the apathy of the place and fail to achieve anything – and, as I put it in a letter to a friend, ‘sink without trace into the mud of the Fens’. One of the first major problems I had to tackle in my early days at Fulbourn concerned the relationship between a staff member and a patient. Miss Brock told me that she was very worried about one of the senior nursing staff and a woman patient who was medically qualified. The patient, who had a long history of alcoholism, instability, drug addiction and obscure physical complaints, had recently been readmitted for treatment of drug addiction. She was a middle-aged foreigner, born to wealth, qualified as a doctor, but had not practised for years, and cut off from her family. During her previous admission, she had met the nurse and they had become friendly; the nurse had tried to help the unfortunate woman. Things had gone wrong and the patient was found in the nurse’s room unconscious from a suicidal dose of drugs. The nurse had been reprimanded, the patient resuscitated and then discharged. Now the patient was back and the nurse, on night duty, was seeing a good deal of her; other staff were saying she spent long periods in the patient’s room. The Matron was distressed and angry with the nurse. ‘She’ll have to go, doctor; she was warned last time. We cannot have this sort of thing going on. Something must be done right away! They should never have readmitted that woman to this hospital; she’s far too troublesome for us with our shortage of staff.’ I thought of the ‘triangular conflict’ described by Stanton and Schwartz in which there is a situation where a patient’s behaviour is fed by a conflict between two staff members. This seemed very likely to be such a case. Could I demonstrate the value of the sociological approach here? The Matron’s suggestion was simple: force the resignation of the nurse and arrange the transfer of the patient to another hospital. I suggested that perhaps this was a challenge to us and that we ought to try and do rather better. I went to see the patient – a woman time-worn but possessing both intelligence and charm, who fluently explained away all her behaviour in terms of a ‘biochemical upset’ due to mistakes by various earlier doctors. As a result of this she needed, she said, constant sedation. She could not help smoking in bed all through the night; she had to call the nurses constantly. One evening, I saw the nurse and talked with her; she told me what a brilliant and charming woman the patient was, with a tragic and misunderstood life story; she felt that she could help her greatly if she were allowed to. The nurse spoke most

bitterly of the other nurses and the Matron – they did not understand, they did not care for the patient, they were only interested in maintaining the rules. I pondered what to do, but realised that I had at least to do something as the Consultant in charge of the case was one of those that had gone on holiday. I told the patient I was taking over her care; I changed her sedation and arranged a medical consultation. I told the Matron we would aim to keep both the nurse and the patient. I talked again at length with the nurse, letting her freely express her anguish and her altruism and then trying to show her how others viewed her excessive zeal. Two nights later there was a fire in the patient’s bed. She suffered extensive, though superficial, burns to her stomach and thighs. It seemed probable that this had been accidental, due to surreptitious smoking in bed while she was fuddled with sedation, but it might have been deliberate self-damage. A surgeon was called, the burns were dressed, and she was moved to the sick ward. I saw the nurse again. She was distressed and inclined to blame herself; she had provided the cigarettes. The Matron was even more incensed and very worried lest the patient might die; then there would be an inquest and an enquiry as to why such an ill patient was smoking in bed. She reiterated the demand that the patient should be moved. I could not decide what to do. The patient was ill, and might die. Then I remembered that Stanton and Schwartz emphasised the importance of the two staff members ‘reaching a consensus’. When I enquired, I found that the nurse and the Matron had not actually spoken to each other for weeks. I arranged a meeting with them both, with adequate time to spare. I prefaced this by seeing each of them and pointing out that they had to work together and then, when we met, I started from the position that this patient’s physical illness and psychopathic personality was a challenge to all of us; that this was the sort of problem our hospital existed for (among others); that we could not pass it on to someone else; that we must work out what to do. The meeting was quite tense and difficult. However, we all displayed our concern and desire to help; the nurse talked about her friendship for the patient and her desire to help her, and offered to resign; the Matron refused the resignation, but pointed out some of the problems created and proposed certain duty shifts so that the nurse was not in direct professional charge of the patient; I agreed to certain changes of sedation and routine. Things continued stormy for a day or two. The patient’s wounds became infected; she developed skin sensitivity to her antibiotics; her demands for medication and sedation were immense. Then, she began to settle. Her wounds healed and she could get up and about. She revealed the charming and cooperative side of her nature. We managed to cut down her sedation. Some weeks later, she became resentful of regulations and quarrelsome and demanded her discharge. Her skin was healed and she was fairly stable, so I gladly let her go. I had succeeded in keeping the nurse, and the patient had recovered at least moderately. I felt strengthened in my ideas, but exhausted by the episode.

On another occasion the Chief Male Nurse brought a nasty problem to me. A patient on the privileged workers’ ward had lost 16 pound notes from his wallet. Mr Tucker said the nurses reckoned they knew who had taken it – a patient with a criminal record – but though they had searched him and later everyone else on the ward as well, they had not found the money. What should they do?, he said, looking at me. I decided to begin by asking questions and this soon led me to the ward and examination of all the people concerned. This ward contained a mixture of recent admissions awaiting discharge and long-stay patients who were good workers. The patient who had lost the money, Jim, was a young schizophrenic, a popular ex-soldier who had been two years in hospital. He had a knack for repairing watches and had mended several for staff members. He regularly bet on the pools and had won the £16 four months earlier and had carried the money round since then in his wallet. The suspect was an evasive, jumpy creature with a long history of military and civilian crime, mostly petty theft, who had been admitted in an acute anxiety depressive state. This had settled satisfactorily, and he was now awaiting discharge. He denied guilt volubly. The staff were upset, anxious and self-defensive. It was clear that the whole ward had been thoroughly upset by the searches; a number of recent patients had demanded to leave because of the indignities to which they had been subjected. I was not sure what to do, or what my powers were, but I put out tentative questions to find what Mr Tucker, the ward staff, or the more articulate patients felt should be done. However, I got very little help and had to judge the matter for myself. Eventually, good sense came to my aid. The money was gone and there seemed little chance of getting it back. Everyone was upset and needed calming down; there was no evidence that any staff member had been remiss or thoughtless. I therefore announced that no further action would be taken; that I saw no purpose in calling in the Police; that this incident showed the necessity of handing in large sums of money to safe custody. If a patient on a crowded ward kept money on his person, it was a temptation to the less honest and that everyone should be more careful in future. This judgement seemed satisfactory; I heard no more. One aspect of my job with which I had to come to terms was how much people lied to me. This was not a complete surprise. In the Army I had often heard the old soldiers saying ‘Never tell the truth to an officer’. For three years I had lived in the corrupt and corrupting society of the Army where I also had to learn to lie fluently and convincingly to senior officers and to accept that anything said to me by soldiers and NCOs might be true, but might equally well be a glib lie designed to divert my attention. But then for seven years, after leaving the Army, I had worked as an ordinary doctor, with people who did their best to tell me the truth in order to obtain my help. For the last two years at the Maudsley I had worked in psychotherapy where many strove strenuously to tell the truth, however painful. Now I was back in a position of authority as Medical Superintendent – the person to whom everybody in the hospital tended to lie. The fact that I had the power summarily to dismiss any member of staff was a further cause for caution. I was frequently called on to investigate mishaps – bruises, broken bones, sudden death, thefts and fights. Always there were shifty-eyed witnesses telling improbable tales – sticking stubbornly to their lies for fear that something worse might be uncovered.

I also came to spot the warning systems used by staff when I was going round the hospital to signal my impending arrival in the next ward. Such signalling systems were used in most mental hospitals. In Fulbourn they passed the message from ward to ward by tapping with a key on the central heating pipes, one tap for the junior doctors, two for the Chief Male Nurse, three for the Superintendent. Another method was to have ‘trusties’ on watch. In the ‘disturbed’ men’s ward there was one patient who always sat by the door; whenever I came in he leapt to his feet and shouted ‘Doctor’ at the top of his voice. At first I thought he was welcoming and saluting me but then I realised that his real function was to warn the Charge Nurses so that they could conceal any improper practice before I reached them. As people got to know me they told me tales – of Superintendents, of my predecessors, of doctors at other hospitals, and so on – which showed malignant perversity, devilish investigative ingenuity and even deliberate sadism by Superintendents. I realised that the staff half expected that I would behave like that, too. There were tales of Medical Superintendents who were on the constant lookout for slackness by the staff, Superintendents who crept round the hospital at night in soft shoes trying to catch night nurses sleeping on duty, Superintendents who went round removing the valves from staff bicycles left unattended. At times I even felt myself being pushed toward this sort of behaviour. In one case I had to try to deal with, a husband complained that his wife had been beaten by the women nurses and dragged round the ward by her hair. The woman was certainly bruised but was too muddled herself to say how she got the bruises. Some of the onlooking patients confirmed the story, others denied it. The nurses all told the same story denying culpability – which I felt sure was untrue. Finally all I could do was to come up with the ancient and illogical verdict ‘I find the case not proven – but if you ever do something like this again, I shall dismiss you forthwith.’ The calm way in which this was accepted showed that I was right in my suspicions – but also that I had behaved in the way expected of a Superintendent. I had shown the nurses that I knew that they were lying, but had let them keep their jobs. Some of the other tasks brought to me as Superintendent seemed rather bizarre. A patient died, and I was informed that at Fulbourn the Medical Superintendent always did a postmortem. Slightly surprised, I complied, calling on some brief experience of morbid anatomy. I was assisted by an overactive and garrulous charge nurse, who flattered me constantly on my technique – ‘Ah, I can see you know this job, Sir; I can see you are an old hand. You have a very deft touch with the knife, Sir; I can see I shall have to keep them especially sharp for you, Sir.’ As he chattered, I gained the impression that my predecessor had done postmortems partly because he enjoyed doing them, partly as a way of checking up on the medical skill of the junior doctors (by checking whether they had missed some major illness) and possibly in order personally to obscure evidence that might be embarrassing at a coroner’s inquest. As I pondered on this, I wondered whether doing incompetent postmortems on patients who had died of natural old age was really a sound use of the time of a Consultant Psychiatrist, and further whether it would not be

better to improve the medical diagnosis and treatment available for the patients while they were alive, rather than seeking to catch the doctors out when the patient was dead. I began to ask on the sick wards for more frequent consultations with the specialist physicians, and to suggest that if a postmortem was really needed, then a competent pathologist was the man to do it. On my very first Tuesday, I had had to attend a meeting with two members of the Management Committee. A Subcommittee was holding an Enquiry, and I was asked to join them for lunch. Major Symonds was a middle-aged man, a former school teacher and army officer, who had until recently been the Member of Parliament for Cambridge; Mr Boyle was an elderly businessman who seemed to know a lot about labour relations. They were both very friendly and helpful with suggestions about life in the area; most of lunch was spent discussing the difficulties of growing vegetables in the differing local soils. It was only gradually I sensed some of the under-currents – that the ex-MP was one of the bright young men of the postwar Labour Party, with a background of boyhood and university socialism, while the businessman had spent his life defeating Union men in negotiations; that ‘the Major’ had seen war service and Mr Boyle had not, and seemed resentful of it; that Mr Boyle was a local boy made good, while the Major talked like a university graduate. They were worlds apart, but they seemed to get on well together and to be united in their interest in the hospital and its welfare. Only towards the end of lunch did they talk about their Enquiry. Some months earlier, it had been discovered that a good deal of ‘ward stock’ –that is, bed linen, patients’ clothing, cutlery, equipment – was missing from the men’s wards. Everyone had been very upset and these two members had been asked by the HMC to investigate and find out what had gone wrong. At present, they were conducting hearings; the only certainty was that far more was missing than they had at first thought, but how it had gone, whether it had been stolen or been lost and who was to blame – all this was unclear. They asked me if I wanted to be in on the hearings; I said I thought not, and since the incident had taken place before my time, they agreed. On another occasion Mr Mitchell called me because the cook had reported the loss of a leg of mutton; would I hold an Enquiry? Somewhat surprised, I complied, and spent the morning cross-questioning cooks – surly men with strange rustic accents, using curious words of special local meaning – and kitchen workers, voluble Latins and taciturn Eastern Europeans. I established that there had been a leg of mutton in a double-locked larder and that now it had gone. But who had taken it, and how, I never discovered. The Enquiry was finally closed and the matter reported to the Management Committee. Again I wondered whether this was really the proper use of a doctor’s time. Alongside constant problem solving, I was also gradually meeting other people connected with the running of the hospital. One day, I had a message that Mrs Adrian, the Chairman of the Management Committee, would like to come and see me if it was convenient. My trepidation in preparing to meet her was quite unnecessary; unassuming and charming, she spent an hour with me in my office, talking of common acquaintances and her hopes and plans for the future. Mrs Adrian was the wife of E.D. Adrian, Professor of Physiology, Nobel Prizewinner and Master of Trinity College. She told me she had

always been interested in the welfare of the mentally ill and handicapped. Two years before, she had undertaken the Chairmanship of the new HMC of Fulbourn Hospital. I realised that she was an intelligent, well-informed, tolerant and well-intentioned lady, but she spoke so modestly of her own contribution that it was only as the months went by that I came to understand why she held so many important positions in the town and was so widely respected. She was Chairman of both the Magistrates’ Bench and of Cambridgeshire Mental Welfare Association. Whenever there was an insoluble situation in the welfare field, Mrs Adrian was asked to head the Committee to sort it out. She brought a powerful intellect to the study and assimilation of documents and would give endless time to mastering the details of any situation. More important was her ability to see the positive in all the diverse people she worked with and to draw out their best contributions to the common aim. However, this first meeting was merely for her to see what sort of a young man they had got for Fulbourn. I felt comforted and reassured by her kindness. Miss Brock and Mr Tucker both took their holidays and I had to deal with their deputies. Miss Legge, Miss Brock’s deputy, was a good soul, devoted to her absent chief, and totally under her guidance. All matters had to be left until Miss Brock’s return. Mr Allen, Mr Tucker’s deputy, was very different: an able, thrusting, vigorous man, he was full of schemes. He had been at the hospital only a few years and had poured his energy into anything that came to hand. People had pointed out to me a small building going up in one corner of the grounds, which was to be a new staff social club house. The club had been founded by Mr Allen, who had persuaded Mrs Adrian and the HMC to put up amenity money for the building. Mr Allen had restarted the hospital flower show. He had been active in starting football and cricket teams among the patients; the cricket team had won a cup from the other mental hospitals of the region that summer. He told me of all these activities, but also laid before me some other projects he would like to see go ahead. In particular, he felt that the male patients could do much more and better work. I was excited by his enthusiasm and gave Mr Allen encouragement; he soon brought me many plans, some of which seemed eminently reasonable. However, he also started voicing criticisms of Mr Tucker’s regime and I realised that there would be a problem here. How grave it might be became clear to me when Mr Mitchell mentioned that the enquiry into the missing stock had originally started when Mr Allen, acting in Mr Tucker’s absence, had carried out a thorough check of the stock on one ward and found many things missing. As the long hot days of August raced by, I slept fitfully in my little flat and longed for the easy, uncomplicated life of a Senior Registrar. I began, however, to recognise the people I met, and even to remember their names, and began to feel some familiarity with my work. One aspect of hospital practice in which I quickly became involved at Fulbourn was that of the English laws relating to mental illness. At the Maudsley Hospital everyone came as a Voluntary Patient; they had to agree to come in and agree to stay, and indeed many clamoured to be admitted. But at Fulbourn I came face to face with the archaic and often degrading process of enforced admission to a public mental hospital. This procedure had

evolved to some extent during the history of asylums, but for the past 50 years little had changed. Fulbourn Asylum was originally set up in 1858 by the Magistrates who also controlled the workhouses. They and the parish overseers decided who should go into the workhouse. If in the workhouse a pauper was found to be insane the Magistrate called for medical advice and then signed a Receiving Order directing the Medical Superintendent of the Asylum to take the patient in. The 1890 and 1891 Amended Lunacy Acts standardised these procedures and in 1953 these Acts were still current law. The Magistrates had to receive advice from two doctors. This advice was recorded on certificates – and thus patients were ‘certified’. In the 1950s the details of this process were carried out by an officer of the local authority, for many years known as a ‘Receiving Officer’ but now known as a ‘Duly Authorised Officer’ (DAO). As Medical Superintendent I found myself receiving certified patients most days of the week. I had to scrutinise the documents to see if they were in order; I had then to examine the patient and see if he was indeed mentally disordered and a proper person to be detained. In the majority of cases there was no doubt, but there were sometimes challenging problems – people who were ill physically rather than mentally, people who did not seem to be mentally disordered, people who were drunk rather than mad. The local DAOs were a mixed bunch. Fulbourn served seven different independent local authorities and each had a Medical Officer of Health, jealous of his independence, who controlled and instructed his DAOs. The DAO for Cambridge County, Mr Monty Bowyer, was a quiet compassionate man with a vast memory, who had been looking after the mentally ill and mentally defective of Cambridgeshire for over 20 years. He knew them, he knew their histories and he knew their families; he would bring them to the hospital with understanding and firmness. But some of the others were quite different. I recall one DAO, an ex-policeman, telling me with glee how he tricked one unfortunate person by telling her that he was just taking her for a ‘nice ride in the car – to see your auntie’. Another small man seemed to relish violence and would turn up at the hospital with a posse of policemen and the patient handcuffed and lashed onto a stretcher. For many people admission to Fulbourn Hospital in the early 1950s was a terrifying and degrading experience. After weeks of mounting tension, mental disorder and distress, things came to a crisis. There were secret conclaves of relatives and doctors; doctors whom they did not know came to talk to the patient. Finally, policemen, ambulances, motor cars and a Magistrate all arrived at the house, to the fascination and horror of the neighbours. The patient was dragged into the ambulance and whisked off to Fulbourn, there to be stripped, bathed, roughly examined and drugged. Little wonder that many of them were confused, angry, paranoid and resentful by the time I saw them. Many members of the Management Committee of the HMC were also Magistrates and sometimes they would chat to me about their experiences of ‘certifying’ people. Some disliked it and would evade it by opting for other even nastier magisterial tasks, such as

inspecting slaughterhouses. Others clearly enjoyed it and prided themselves on their skill in interrogation and the detection of madness. Once a month I had to prepare a list of certified patients ready for discharge and present it to two Magistrate members of the HMC for their approval. Mostly they accepted the list and signed it, but sometimes they would spot an acquaintance on the list and ask me many questions – How had she got on? Was she really better? Did she still accuse her husband of having an affair with a barmaid? Had I talked to the mother-in-law? I resented these enquiries; not only were they questioning my medical judgement, but it often seemed that this was just prurient probing and gossip. I then discovered that in some hospitals the HMC insisted that the patient proposed for discharge was actually paraded before the HMC members and questioned. If the committee members were not satisfied by the answers of a patient and his cringing relatives, he was not allowed to leave! Our Fulbourn HMC, it seemed, was comparatively enlightened! I was also required to examine regularly people who had been in the hospital for years. The regulations stated that every patient must have one physical examination and one mental examination every year, and every few years the Medical Superintendent had to sign a statement justifying a patient’s continued detention. I used to spend one half-day a week doing these ‘Board of Control Examinations’. I would be shown into a dormitory full of people lying naked on beds and invited to do ‘physical examinations’ on them all. No one cared how brief or perfunctory the examinations were, the patients did not comment or complain, but I became unpopular with the nurses waiting to clear the dormitory if I insisted on doing the job properly. The ‘mental examinations’ were brief interviews in a ward office, with the Charge Nurse standing behind me and briefing me on each person (‘just a mental defective, Sir, no trouble’ ... ‘this one’s an EP, Sir, a lying treacherous little sneak’ ... ‘This one’s cunning, Sir, but ask him about Queen Victoria ... and you’ll get him’). Many of the patients had gone through this routine before and would rattle off the day of the week, the date, the year and the name of the Queen, her children and the current Prime Minister before I even started asking questions. Some were wily and great skill was needed to trap them into admitting their strange beliefs or talking about their bizarre experiences of hallucinatory voices. All this was watched with amusement by the Charge Nurse. His main interest was to see if the new Superintendent was as clever at interrogation as his predecessor had been. The antiquated Lunacy Acts gave us many unnecessary difficulties and caused a great deal of paperwork. But more worrying was the underlying social contract. The Medical Superintendent was personally responsible for the custody of every certified patient that he received. It was his duty to see that they did not escape. If one of them did escape and caused some harm, the person harmed could sue the Superintendent, though not the patient, who being certified was legally not responsible for his actions. The Lunacy Laws and their interpretation over the years by the Law Courts, by the Commissioners of the Board of Control and by successive Superintendents of Fulbourn had produced a vast amount of folklore and anecdotal history – all of which operated to check spontaneity, to discourage initiative and certainly to prevent any risk-taking. No Fulbourn patient might have money – he might use it to escape. No patient might have a knife – he might use it

to cut his throat. All cutlery must be counted and checked after every meal – in case someone took a knife and used it. No patient must be allowed to handle a key – a former Medical Superintendent had sacked without a reference a nurse he saw hand a key to a patient to open a door. All patients, by definition, were irresponsible, incapable of intelligent or reasonable behaviour, potentially violent, always on the lookout for chances to escape. The Law, therefore – or what was alleged to be the Law – was a constant check on us, forcing us into rigid, restrictive, punitive behaviour. I wondered if it had to be like that. I felt that the Laws themselves were hopelessly out of date and hoped that some day they might be changed. I was not alone in feeling that these 1890 Laws hindered us in practising modern psychiatry. The feeling was widespread and in 1954 the Government set up a Royal Commission to examine the Lunacy Laws and report on them. To our delight, Mrs Adrian was named a member. Over the next three years she often discussed what she heard and saw at her meetings; she brought back many good ideas to Cambridge and also asked many pertinent questions of me. My birthday falls toward the end of August. I started the day gloomy and oppressed. Nobody at Fulbourn knew it was my birthday and there was nothing to mark the day. I had always reviewed my year’s work at the time of my birthday and this year I concluded that I had taken on a job that was too big for me, for which I was too young and inexperienced. I also missed my family, my wife and children; I missed my analyst, who had been a constant companion and supporter (if also an irritant and disturber of my mental peace) for the last two years; I felt far from home and those who loved me, far from anyone who cared that it was my birthday. My feelings of gloom were well justified as it was on that day that what was to be one of my major tests and lessons occurred. On my morning round I stepped into the women’s Admission Villa to find an atmosphere of crisis. The ward doctor, harrassed and concerned, asked for my help with a patient who had collapsed while having ECT. I was taken into a room where an obviously shocked and ill woman was gasping for breath; I involved myself in the emergency, giving oxygen, ordering stimulants, lifting the bed ends, rushing about. As we worked, I gathered the story – a middle-aged melancholic patient, second course of ECT, third treatment, sudden collapse after the treatment. Listening to the chest, I could hear much bubbling which suggested lung oedema, but I was puzzled by what I heard, and did not really know what was wrong or what to do. We got her into the ward and into bed, and she seemed to improve but shortly before lunch I heard that she had died. I was puzzled by this death, uncertain what had to be done, fearful of what might emerge. I did not have long to ruminate, however, for events swept on their inevitable course. The Matron was on to me at once. The coroner must be told! This was terrible! She must have had a bad heart! Who would see the relatives? Why did these things always happen when certain staff were on duty? When would the postmortem be?

I got on with the necessary tasks. I told the coroner, who seemed little concerned; a postmortem was arranged. The relatives came up, a stolid brother and sister-in-law; I began talking, full of anxiety and remorse and promising a full investigation. I soon realised, however, that they were thinking quite differently. Poor Annie, it was very sad; but she had never had much of a life; perhaps it was all for the best, poor dear; she was probably much better off now; there was no point in making a fuss; they certainly did not want anything in the newspapers. They were not very keen on a postmortem, and were rather upset when they realised that the matter was now out of our hands; the coroner had been informed and the machinery of investigation must go forward. That evening one of the doctors sidled up to me and said he had been making some enquiries and had discovered that the patient had by some oversight been given a cup of tea and a biscuit before her treatment. (The danger of electroplexy with anaesthesia was that foodstuff might be vomited up and then sucked down the air passages; a rigid rule was therefore enforced that patients must not have anything to eat the morning before they had ECT and that if they had eaten anything, the treatment must be stopped.) I thought of rushing down to the ward there and then and making immediate enquiries, but then refrained because I knew how upset all the staff were already. Next day, I attended the postmortem. The pathologist was a cheerful fellow, who chatted about cricket and the prospects of partridge shooting while going about his grisly work. He knew the hospital well and did many coroners’ postmortems. Little unusual was seen until he came to the lungs, which were heavy with fluid. When he cut them open, they showed what to my eye was indubitable food material in the air passages. However, the pathologist merely said, ‘Some terminal oedema’, and turned to the heart. He commented on its flabby state and continued his search. When nothing further emerged he said, ‘Well, nothing very definite, is there, doctor? Still I think there’s enough in that heart. We’ll say acute heart failure with subsequent pulmonary oedema. I think that should satisfy everyone.’ That night, I pondered long. I had no doubt in my own mind that the patient had died because she had inhaled food contents and that if she had not had tea and biscuits that morning, or if her treatment had been cancelled when this was known, she would now be alive; I was certain that the ward staff, the nurses and doctors, had been careless. I also felt that if I had been more competent when I was called in, I might have saved her life. But what was to be done now? The patient was dead; we could not help her now. The relatives wanted as little fuss as possible. The pathologist either had not seen the cause of her death, or worse, had seen it, realised the possible consequences of drawing attention to it, and had decided to keep silent; perhaps (horrid thought) he was accustomed to incidents like this at Fulbourn Hospital. Should I hold an Enquiry and harry the staff? But the coroner was going to do that anyway. I finally decided to await the inquest, but determined to take steps to see that such a thing never happened again. The inquest was brief and uneventful. It was held in a room in the hospital and apart from the patient’s brother and a sleepy reporter, all present were hospital staff or officials of

the Court. The expected evidence was given. The coroner, a friendly local solicitor, found a verdict of misadventure and commented that this was one of those things that happened in the best of hospitals and that he was satisfied that no one was to blame. The crisis was over; there had been no public scandal. But now I had to concentrate on preventing any further tragedies of this kind. My first impulse was to descend on the ward, cross-question everybody, possibly sack someone and then issue written orders that patients must not have food before ECT. But then I stopped and thought. Everyone knew this before – yet they had allowed it to happen. Writing orders was apparently of little value. Was it an individual failing? But the people at the Admission Villa were regarded as some of the best staff in the hospital; we had no chance of getting any better! My task was to help them to do a better job next time. I thought of interviewing everyone individually and telling them off. But then I remembered that this, from what they said of him, was precisely what my predecessor had done. ‘Always after an inquest, Dr Thomas used to go round all the wards questioning everybody’, they said with a laugh. It appeared that this had upset everyone and made them irritated with him, without doing much to improve things. I decided to try and find a positive rather than a negative solution to this crisis. A week later, when everyone was calmer, I called a doctors’ meeting and said that I thought we should all discuss this episode openly, since we had all been thinking about it, and that maybe we could evolve a better ECT procedure. A very lively and positive discussion developed. First, we discussed the actual incident and pooled our knowledge. We agreed that whatever the coroner might have said death was due to food material going down the air passages. We discussed whether we could have done better first aid and I was told that several requests for suction apparatus had been turned down on grounds of economy. Several doctors contributed tales of patients that they had lost (or saved) in similar crises; I told a tale of a patient I had lost; a warm group feeling of shared catharsis and confession developed. Practical suggestions soon emerged. Two of the doctors volunteered to write some formal ECT instructions for all staff. I undertook to get the suction apparatus; and by making a great fuss, I obtained it within two weeks. We decided to carry on with medical meetings, since they were so valuable. This was the beginning of clinical meetings at the hospital. Some time later, I discussed the whole incident with the Matron; the ‘nurse’ in charge of the ward on that day had been unqualified and possibly did not realise the danger of allowing the patient tea and biscuits. The Matron suggested that we confine ECT to certain days and she said she would see that adequate trained staff were present. I agreed gratefully. Towards the end of my first month came two major hurdles – the annual visit of the Commissioners of the Board of Control and my first meeting with the full Managment Committee. Everyone else in the hospital seemed to regard these as very important events. Endless myths had gathered around the yearly Board of Control inspection. Fulbourn, like every other mental hospital, had many tales of ‘the day the Commissioners came’. Some of this I had met in other hospitals, but I now experienced the full blast of

communal anxiety when I mentioned that I had had a little note saying that the Commissioners would be coming in a few weeks. Alarm and scurry was apparent everywhere. Miss Brock related all the things the Commissioners had seen and commented on last time, which had not yet been put right. Mr Tucker said he would check all the drug cupboards at once, and asked whether we had better lock up Jack whom I had just freed as it was he who cut his throat the previous year when the Commissioners were visiting. Even Mr Mitchell’s department sprang into activity, producing masses of statistics and depositing on my desk a vast leather-bound volume, containing the reports of previous visiting Commissioners. All sorts of curious lists were produced for my inspection – all the foreign-born patients by name, all those who had ever had a Police conviction, the number of broken bones during the year, the number of people placed in seclusion, the number of escapes – and each time I was told that the Commissioners ‘always ask for this’. I was taken to see all sorts of things and places in which Commissioners had expressed an interest at one time or another; I was taken into departments and workshops that I had never yet seen and I was led to much that was squalid and inadequate, especially plumbing. I went round the hospital again and again, looking at lavatories (shabby and smelly), bathrooms (steamy and rusty), drug cupboards (containing hoarded sugar, nurses’ purses, bunches of keys and everything except drugs) and kitchens (with battered plates swilling in lukewarm greasy water in chipped basins). I spent all one evening reading back through the reports of the Commissioners. They were exhaustive – they seemed to have looked at everything and usually commented unfavourably. I felt that they could not fail to be dissatisfied with what they saw of the hospital and its new Superintendent. In the last few days the tension mounted steadily higher. Wards and windows were washed and polished; patients appeared in new clothes; flowers appeared in the wards, and even picture magazines. The paranoid patients served notice that they wanted interviews in private with the Commissioners. Fortified by an adequate sedative the night before, I faced the morning of the visit, with all the necessary lists piled on my desk. At a leisurely hour, two elderly gentlemen arrived at the front door by taxi. Instead of rushing to business forthwith, they settled into my office to savour the coffee and biscuits provided. Waving aside the proferred lists, they asked me how I was getting on; they told funny stories about Dr Thomas; they enquired about the local crops, the prospects for shooting that season, and the local medical gossip. Not until an hour had passed did they decide to go and look at the wards. As we went round, however, I realised that their lethargy was only apparent. Their questions were shrewd and their enquiries were pressed. They looked into lavatories, drug cupboards and kitchens; they talked with patients, they tasted the lunch, they went to the workshops. They gave long private interviews to the paranoids. They questioned Mr Mitchell at length about the recent administrative rearrangements. Then, to my surprise, they invited me out to dinner that evening.

We had an excellent dinner at a good hotel; they told me many tales of the Lunacy Service and of great personalities from the past, and they drew me out about myself. The next day was pleasant and relaxed, and one of them spent a good deal of time advising me on the garden I was just starting. He also gave me a short list of hospitals which I might profitably visit. That afternoon they wrote their report, a critical but fair assessment of the hospital, with a warm and friendly reference to myself. It was a better report than for several years and I was delighted. I went round the hospital and thanked the members of staff for all that they had done. I had survived the visit by the Board of Control and now the week was to end with my first meeting with the full Hospital Management Committee. Although I had already met a number of members, I had yet to see them all together, and again the staff attitudes prepared me for an ordeal. On almost everything, it seemed, the final damper was the HMC: ‘Well, we’d like to, but the Committee won’t allow it’, or ‘It’s been like that for years, but the Committee always refused to mend/repaint/replace/improve it.’ After lunch, we went into the ‘Board Room’ and some fifteen members arranged themselves round the big table with Mrs Adrian at the head, Mr Mitchell at her right hand, and myself on her left. The other officers, Mr Merrin, the Engineer, the Supplies Officer and the Finance Officer, sat at a little table by the window; a clerk sat in one corner, and a press reporter in another. Every person had a pile of papers before them. Much of the business seemed to consist of going through minutes of previous meetings and of subcommittees. In each case they would be lengthily introduced and then discussed in a rambling, irrelevant fashion. There seemed to be a good deal of irritability in the room and gradually various characters defined themselves by their frequent interjections. There was a tiny white-haired woman with a fierce authoritative voice, who was sharp in her condemnations; her remarks nearly always drew rumblings from a very fat man, whose bright red face seemed on the point of apoplexy. Mr Boyle was often on his feet, ‘explaining’ a point so as to obfuscate it further. This particularly irritated a tall woman with the precise tones of an academic, who often corrected him. Mrs Adrian, using a gavel, did her best to maintain order among this strange group, and the business slowly progressed. Most of the members of the HMC were elderly – in their sixties and seventies – but a few were younger, like Major Symonds. I noticed one tall young woman, Mrs Pauline Burnet; Mrs Adrian said she had just recruited her to mental health work. She appeared cheerful and friendly. I did not guess how long we would work together. The Committee’s concerns seemed to be material and financial – buildings and their maintenance, fields and their rents, clothing and its repair, food supplies and their cooking. The Committee seemed to me at that time to take little account of the treatment and welfare of the patients, which I saw as the only reason for any of us being there. They took the news of a number of deaths of patients and the inquest with equanimity, but

when it was announced that swine fever had broken out in the pig herd, they were deeply concerned. A long discussion ensued with much heat; I found it difficult to follow as the accents of the speakers were so broad; a lean grey-faced man in old-fashioned clothing with a broad gold watch chain across his waistcoat was criticising another red-faced man who hotly defended his policies, while the apoplectic member constantly interjected remarks in a broad North Country accent. It was clear that something had gone wrong and that everyone was keen to pin down or to evade responsibility for it. The members frequently directed questions at the officers, but spoke little to me after my initial official welcome until the very end, when several asked about things they had seen or heard that morning. I answered these questions smartly and brightly and was pleased to win a ripple of laughter – but not so pleased when I saw the remarks in cold print the following evening in the local paper! I went home to London that weekend much relieved. I felt that I had survived two major tests and done fairly well. I felt that I now knew the hospital and could see some prospect of doing this terrifying job. 4 Managed Change: Towards Open Doors The next few months were filled with adjustments – of myself to the hospital, of the hospital to me. I had resolved that I would make no major changes during the first year as I wanted to spend time getting to know the people and the job. In one sense I maintained that resolve, for I started no deliberate changes in the life of the hospital until the following summer. Nevertheless, some changes did occur of their own accord without my doing anything at all. One of my first moves, during August, was to rearrange my working space. The ground floor of the central administration building contained three large rooms. To the left of the entrance was the ‘Board Room’ in which the Hospital Management Committee met; it was a handsome room with a marble fireplace surmounted by an elaborately carved oak overmantel, which framed a mirror. There was a fine view out over the drive and the front of the hospital; in the centre of the room stood a long table, covered in green baize and surrounded by comfortable chairs. On the walls hung maps of the hospital. This room stood empty most of the time. To the right of the entrance were two rooms. That to the rear was the Medical Superintendent’s office, a dark and dingy room. The windows were overshadowed by the nearby buildings and their small grimy panes obscured much of the light. The electric light had to be on most of the day even in summer. The other room at the front to the right of the door seemed to me to be empty all the time. It was a high, airy room with a fine view over the grounds, and another grand fireplace. I was told that it was the ‘Committee Dining Room’; that they lunched there at their monthly meetings. As the month of August passed, I saw no sign of anyone using it at all. It stood there, fine and empty while I worked in the grubby dark room behind. I found these arrangements inefficient and inconvenient. All sorts of people came wandering into the office with messages, parcels, report books, and so on. Whenever the

hospital switchboard operator (the porter on duty) had a call about which he was in doubt he plugged it through to me; I seemed to spend half my time putting enquirers in touch with the departments they really wanted. I felt that the situation was symptomatic of a larger problem from which Fulbourn suffered. The hospital had no medical heart, no centre. There was no place to which information and enquiries could flow or to which people could turn. I, therefore, proposed that I should use the Committee Dining Room as my office, and that the medical secretaries should be brought together in the room next door. I discussed this with Mr Mitchell and Mr Merrin. There seemed no unsurmountable reasons against it. I arranged for an extension telephone, for some furniture and a new filing cabinet and moved in. This new plan worked very well. The medical secretaries’ office became a medical centre for the hospital, where mail was sorted, messages left and where doctors could linger for a chat. The telephone was manned constantly, problems were sorted out and only those passed through to me which needed my personal attention. My office became an effective workplace for me, where I often stayed long into the evening. The room was excellent for small meetings, which gradually became more frequent. The fact that every other Friday all the furniture was changed around for the Committee’s lunch remained an irritant but not a major problem. The rearrangement of the rooms, as far as I was concerned, worked well; for me, that was enough. It was not until many months later that I appreciated the significance of my action. The Committee Dining Room, in which a cheery fire was always maintained, had been a very pleasant club room for some of the members; in it they could sit and chat and smoke a pipe while other members were busy in the Board Room. It was pleasant for them too, to be served lunch there whenever they had occasion to be in the hospital. Now this had gone; a young upstart had moved himself in there and they could only get in by permission. At times, they had to hang about in the hall. In particular the Chairman of the Farm Committee, Alderman Street, who came up to the hospital at least twice a week and had long been accustomed to take his ease in the Dining Room after doing a round of the grounds, never ceased to resent my action. To the staff of the hospital, too, this move was seen as a revolution and a portent. Dr Thomas had always been terrified of the Management Committee; he was an easily frightened man, and before 1948, as the Board of Visitors, they had had the power to raise or lower his salary. Everyone knew that the prospect of the Committee’s displeasure filled him with dismay, even terror. Here was the new Superintendent turning the Committee out of their dining room apparently without a qualm! During September, there were other important meetings as people came back from their holidays and the routine of Health Service business took up again. My consultant colleagues returned and took over the patients I had been looking after. I made it clear how inconsiderate I felt they had been in leaving so much to me without notifying me in advance; I think they were surprised at my vehemence. Each explained in his different

way that it was his custom to depart on holiday when he wished and that there had never been trouble before. I suggested that if we were all to work together, we should have to think more of the needs of others. This seemed obvious; yet as time went on, I realised that it was really a revolutionary idea for Fulbourn and even more for Addenbrooke’s, where they never before cooperated over holiday arrangements. The senior psychiatrist at Addenbrooke’s, Ralph Noble, had worked there for over 20 years, during most of which time he had no psychiatrist colleagues. Always a headstrong, choleric man, it did not occur to him to consult with the youngsters now coming on the scene. He told me of his great plans for the development of what he grandly called the ‘Psychiatric Department’ of Addenbrooke’s – of which I was now the junior member. Derek Russell Davis was Reader in Psychopathology in the University with honorary appointments at Addenbrooke’s and Fulbourn. He told me that he was primarily a university teacher, not greatly concerned in the web of Health Service responsibilities. He took some time to tell me of local affairs, emphasising how much had already been done and indicating the role he saw me fulfilling. He was very kind personally to me and the family in our move down from London. Edward Beresford Davies, who was emerging as the leading clinician, was an able, shrewd, intuitive man who had been appointed a few years earlier and had managed to build up a most successful private practice in the City. He showed a warm interest in the plans I was beginning to develop for the division of work among the doctors and welcomed my plans to improve the doctors’ training. Beresford Davies and Russell Davis told me of the troubles of recent years. They said that neither Dr Noble at Addenbrooke’s nor Dr Thomas at Fulbourn had realised that, as Consultants, they were entitled to facilities to enable them to treat their patients properly. They told how Dr Thomas, full of anxieties about his position as Medical Superintendent and still clinging to the pre-1948 position when the Medical Superintendent was personally responsible for the treatment of every patient in the hospital, had interfered unwarrantably again and again in their clinical practice, changing medication they had ordered, holding back their letters or moving their patients from ward to ward without consultation. The pattern of medical action and responsibility for the treatment of patients was at this time changing within Fulbourn Hospital – as it was in all the mental hospitals in the NHS. Before 1948 the Medical Superintendent had been responsible, legally and personally, for all treatment of all patients. Although all Medical Superintendents had to delegate much day-to-day work to the Assistant Medical Officers, they still remained responsible and often altered treatment plans and medication. The NHS Act had created new medical grades of which the top was the ‘Consultant’. He was personally responsible for the treatment of his named patients. Some of the more senior asylum doctors were appointed Consultants. In many hospitals there were tussles between the newly created Consultants and Superintendents still operating on the old pattern. At Fulbourn in 1953, Leslie Buttle was a Consultant, as were Beresford Davies and Russell Davis. Dr Thomas had regarded them as upstart boys and had often altered their treatment prescriptions. This had caused great rows in 1952 and speeded Dr Thomas’ desire to retire. This issue

gave me no trouble. It never occurred to me to interfere with another Consultant’s treatment for his patients, even if I disagreed with it. I knew the Consultants were responsible at law and could do what they saw fit. Furthermore, they were all older than me, more experienced and probably wiser. It would have been an impertinence for me to interfere – as well as being bad for the patients. All I wished to do was to define responsibilities, so that we each knew who our patients were and to try and promote a spirit of cooperation rather than the backbiting, mistrust and intrigue which seemed to have prevailed before. It had always seemed to me obvious that if a group of people had to do a job together, the sensible thing was to assemble, discuss the task, work out what everyone had to do, and then let them get on with it. It never occurred to me to proceed otherwise at Fulbourn; whenever there was a problem, I assembled those involved and discussed it with them. During these early months of my appointment I learned that the Minister of Health was planning to spend a million pounds on English Mental Hospitals – ‘the Mental Million’, and that if we hurried a plan for Fulbourn Hospital up to the Ministry it might be selected. We decided to ask for a 40-bed Villa for women patients to relieve the current congestion. The sketch plans began to come from the Regional Board, so I asked the Consultants to come and see them. They were delighted, interested and had a number of suggestions. It soon emerged that on previous occasions, Dr Thomas had not told them anything until after all the plans were decided. We had a lively discussion; it went on all morning and we began to air our ideas on the future development of the hospital. I realised that these men had very valuable ideas about how we could best serve the patients. I suggested that perhaps we should meet again, and a date was fixed. Soon, these meetings became a regular monthly fixture. We hammered out the differences and problems that arose between us, planned the recruitment and training of the junior doctors and discussed problems at the hospital as they emerged. Every morning the Matron, the Chief Male Nurse and the junior doctors used to come in and see me individually. Each of them would discuss problems and often spend a good deal of time insinuating that the trouble was due to someone else I was to see later in the day. The Matron spoke of the grave difficulty she had in getting the doctors to see patients who became suddenly ill; the doctors complained that the nurses – especially the Matron – would move patients suddenly without telling them. Another problem arose because the porters deposited all hospital mail on my desk each morning; I had to open it and go through it. Most of the enquiries would relate to patients I did not know, and I would then have to put them aside until I found someone who knew about it. Sometimes the doctors did not come up for a day or two and letters would lie until it was too late to do anything about them. I was sure things could be improved. Then, an incident one evening in September forced a crisis. As I was walking down a corridor late one evening, I met a nurse carrying a bundle of clothing, followed by a bedraggled woman in a shapeless nightgown, who wept

bitterly as she stumbled barefoot over the cold flagstones. I enquired what was amiss; I was told that she was being moved to another ward and it had been necessary to wake her up and get her out of bed to make the move. This seemed unnecessarily barbaric, so I started making enquiries the following morning. It emerged that one of the doctors had sent up a new patient for admission that afternoon from the outpatient department at Addenbrooke’s. No one had been told and the patient arrived in the evening to a full admission ward. A patient was hurriedly moved to the sick ward, from which someone had to be displaced. The task had been left to the Matron, who was thus forced to turn people out of bed to make the necessary moves, thus finally producing the sad spectacle that I had seen. As I elicited each part of this sorry tale, there was a flood of recriminations and accusations: the nurses said the doctors never told them about impending admissions; the doctors said the nurses moved patients without consultation. I called a meeting of everyone concerned and suggested we discuss what had happened and how we might improve things. After a period of polite fencing, they began to express openly the bitterness that they had revealed privately to me. Miss Brock and one of the women doctors became particularly angry with one another. I hurried to interpose, to point out that we were all trying to help the patients, that everyone was anxious to give of their best, that we all appreciated one another’s difficulties, and other emollient platitudes. The tension declined, but the problem remained. Finally, I suggested that we had better meet more frequently. This was welcomed and daily meetings were agreed. I extended it to include the Chief Male Nurse and the doctors working on the male side, and said that I would deal with the correspondence at that time each day. Thus the ‘morning meeting’ started, which was to endure for a number of years. At the beginning, the concern was with transfers. A rule was made that there should be no transfers until they had been discussed at the meeting, except for emergencies. This was agreed and then broken. It soon fell to me to reprimand Miss Brock in front of the junior doctors, for moving a patient without consultation. She took this very badly. Fortunately, the next day, I was able to reprimand the woman doctor who had been most critical of Miss Brock for just the same sort of inconsiderate behaviour. I demonstrated in each case how the patient had suffered because of their failure to work together. The formal business of the morning meeting was the distribution of the mail which had come addressed to the Medical Superintendent, the consideration of the night report and the major happenings of the previous 24 hours – as well as anything else anyone wanted to bring up. For a long time, it was my main instrument for keeping in touch with the activities of the hospital and for disseminating information and trying out new ideas. In it, I learned many lessons. The atmosphere varied from that of the celebration supper of a victorious team to the bitterness of a shareholders’ meeting of a bankrupt company. I was aware that I tended to talk too much and I tried to limit this by keeping my own business until last and calling on the doctors, the most junior first, for their items. There were,

however, times when I felt hostility welling out at me or the enduring personal antipathies rising to the surface again. One major cause of problems at Fulbourn arose over staff working hours – the ‘shift system’ of the day and night duties. In the early fifties there were several different arrangements. On the women’s wards the nurses worked a two-shift, ‘long day’ system. The night staff were on permanent night duty and were never seen on the wards during the day. There was little communication between day and night staff. The men’s wards had a three-shift system, with a separate Charge Nurse in the morning and in the afternoon. Inevitably there were clashes between different approaches and attitudes – and much ‘losing’ of messages between shifts. Student nurses during their three years did most of their training on day duty, but had to do two much-disliked periods of night duty. The doctors were required to share night duties between them. Depending on the number of doctors available it came round once or twice a week. As we began to change ward routines, the gap between the shifts caused many problems. Early during the first autumn I set up a meeting with the male charge nurses because I knew that these senior men were the backbone of the hospital. It was a most successful meeting. I found a group of twelve middle-aged men, speaking most of the dialects of Britain – Welsh, Geordie, Scots and Cockney – but predominantly, the flat local dialect. At first, they were slow to speak up in the presence of the Chief Male Nurse and the Medical Superintendent, but they gradually got talking. I asked for their views on what needed to be done and many things came forward: their difficulty in keeping their wards tidy and in getting good worker patients; the lack of good recruits to nursing (young men nowadays were not what they used to be); their lack of professional status (they had to wear the same sort of short white jackets as untrained orderlies, why could they not have distinctive uniforms?); the poor repute of the hospital in the district (could it not be changed to something better – like St Ethelburga’s?). To all these points, I responded as best I could. I told them I believed we could make this a good hospital if we worked together. I tried to still some of their anxieties about changes. I agreed to take up various remediable material problems. To the suggestion of changing the name of the hospital, I told them of two bad hospitals I knew which had changed their titles without affecting their (deservedly) bad reputations. What we must do, I said, was to change the nature of the hospital, not its name! The meeting closed on a gratifying note. The oldest charge nurse rose and thanked me humbly for calling them together. It was the first time, he said, that anyone at Fulbourn had ever asked for the charge nurses’ opinions. He felt sure that we would achieve much together. Encouraged by this I then called a meeting of the ward sisters; however, this did not go so well. A group of weary, irritable elderly women assembled and poured forth floods of complaint. They had not enough staff – they could not get the work done; the student nurses were useless – too much was expected of them; the doctors were discourteous; the duty lists were unreasonable; the administrative office did not understand their problems. Much of this could have seemed to be implied criticism of Miss Brock and she immediately took it that way, launching into fierce personal attacks on the sisters and

their competence. Before I knew what was happening, I had three or four angry women all talking at once. Many of the sister’s remarks began ‘in Miss Fossey’s time …’ (referring to the Matron’s revered and beloved predecessor). Many of Miss Brock’s began ‘As long as I am Matron here …’. At times, I had the feeling that many present thought and even hoped, that this might not be for long! I was appalled by the outcome of this meeting and I searched for some way in which to draw it to a close but the subject then moved on to uniforms. The sisters did not care for their traditional uniforms (which looked rather like that of an Edwardian parlourmaid), Miss Brock also wanted to change them. This gave me a chance to lead them into an amicable discussion of different forms of bonnets. I then suggested that this was an important matter, requiring further extended consideration at another meeting, and thus drew the meeting to a close. Only years later did I realise why I had touched off such a volcano of feeling. Appointed only a year earlier, after a contested appointment that had made her feel bitterly insecure, Miss Brock had thrown all her prodigious energy into whipping a lethargic and inadequate staff to higher standards. Smarting under her reproofs, frustrated by all their shortages, resentful of the pressures on them, my assembling them together provided a much-needed chance to let off steam. Unfortunately after this meeting I committed a faux pas which made things worse. I had made notes on these meetings in which I had noted the Matron’s ‘aggressive outbursts’, one sister’s ‘sulky reply’ and that another ‘seems stupid’. I put these notes in a file, from which they dropped in the corridor. A few days later, Miss Brock returned them to me suggesting that it might be better to keep them more securely! It was clear that she and several of the sisters named had read the notes and disliked my comments. Her understanding tolerance was almost harder to bear than her indignation! Though these meetings varied in their effectiveness, this method of coordination seemed the obvious one to me. I only gradually realised how radical it all seemed to Fulbourn where there had apparently hardly ever been meetings before. All information was given out individually, all projects were pushed through surreptitiously. One doctor said that he had been there a year, and never seen all the medical staff together in one place. Dr Thomas, they told me, never liked to see more than one person at once; it worried him to have too many people in the room. Gradually, it emerged that he had maintained himself by a variant of the ‘divide and rule’ system. Three different doctors told me how Dr Thomas had confided in them personally how irritated he was by the behaviour of some other doctor. Another favourite tale told how Dr Thomas had confided consecutively to two social workers how appalling the other social worker was. Unfortunately, they had met going down the drive, compared notes and found that he had criticised each of them, to the other, in identical terms! I began to see why Fulbourn seemed a disunited, unhappy hospital, where everyone was only concerned for himself and hardly anyone considered the needs of the patients. What started as an instinctive way of operating became a method. I tried to make it a principle always to reach decisions in open meetings, with everyone present who was legitimately interested. I tried as far as I could to refuse to make decisions when a person captured me alone. At times I found this difficult; it was easier to say that I would decide

later than to give my reasons in an open meeting, but I came to believe that this might eventually influence the way in which the important decisions about the patients were reached. During the first autumn, I also gradually met those who held power or authority over me. The full complexity of the Hospital Management Committee’s operations gradually unfolded. Once a month on a Friday afternoon, there was the full meeting, which went on for several hours. But there were many subcommittees, almost one a week, all of which I had to attend. Some were well run and relevant, such as the Finance Committee, and the Stock Losses Enquiry. Others were ill-managed and seemed concerned with irrelevancies. The Farm Committee spent much of its time considering lists of minor supplies, and querying whether two or three balls of binder twine would be enough for the harvest. One curious committee, the Staff Liaison Subcommittee, contained ‘representatives of the staff of the hospital’. I could see little virtue in it, but was told that ‘the Union’ had demanded it, and that the Ministry insisted on such meetings. A Nursing Committee, consisting of lady members of the Management Committee, met with Matron. These meetings were of great length and were usually bogged down in endless discussions of suitable uniforms for student nurses. The fact that we had practically no student nurses was not felt relevant, nor did anyone suggest that the young women who were to wear the uniforms might have something to say! As time went on, however, I began to get to know individual members of the Committee and to realise that they were an able group of people who were honestly attempting to improve the hospital and the lot of the patients in it. Baffled and frustrated by the incompetence and deviousness of the hospital staff, the constant complaints of the patients and their relatives and the apparent indifference of the Regional Hospital Board and the Ministry, their standard response to a problem was to set up yet another subcommittee of their own members. The Regional Hospital Board and its powers and functions gradually became clear to me. It was they and not the Hospital Management Committee who were my employers and it was they who sent me my monthly cheque. I realised that the Senior Administrative Medical Officer was my particular ‘boss’, but it was not clear how the Board itself affected the hospital. Soon enough, however, I learned that finance was the key to virtually every issue in the hospital. Nearly every time I pointed to something necessary, from new beds for the patients to a coat of paint on the front door, I was referred to the current Government policy of limiting Health Service expenditure and told of some ruling of the Minister, of the Auditors, or of the Regional Board which made action impossible. Particularly outspoken in these matters was the Finance Officer who constantly exhorted the Committee to ‘Remember the Interests of the Ratepayer’. In time, I came to appreciate that all these people, and particularly the Regional Board Officers, were trying to share out inadequate funds fairly and to develop a comprehensive service for the area. But in those early days, I could only see indifference to our crying needs and an inexhaustible ability to think of different ways of saying ‘no’.

During the early months, I also addressed myself to the training of the doctors. In the past, medical staff appointed at Fulbourn had trained themselves in the specialism of psychiatry as best they could. Only recently had there been any significant number of young doctors working at Fulbourn, or any official recognition of their need for training. A Registrar who was leaving poured out to me a mass of dissatisfactions – no library, no clinical meetings, no seminars, no classes, no adequate supervision. I had just come from a teaching hospital and could see how this could be put right. I started clinical meetings and ran a series of seminars. I tried to make the morning meetings into teaching occasions as well. I organised ward rounds, going regularly round with the doctors, answering their queries, stimulating them with questions and teaching on suitable problems. I asked the other Consultants to do the same. I put my own psychiatric library in my office and made it available to all the doctors. I persuaded the Committee to give a small grant and bought new medical textbooks for the doctors. I found some junior doctors complaining of lack of interesting work, so I took them down to Addenbrooke’s with me on outpatient days so that they could sit in on my clinics. I worked out a plan by which all the junior posts could be regraded as training ones. This was well received by the Consultants and to my surprise, accepted by Addenbrooke’s and the Regional Hospital Board without demur. The group of doctors began to change. The last months of Dr Thomas’ regime and the interregnum had been trying times. When I arrived, two of the doctors had found jobs elsewhere. During the coming months, three others decided to move on. A number of new people came, unspoilt by the sour dispirited former atmosphere of bickering. By the spring of 1954 only two of the original group of junior doctors remained and the new group was working together well. For the first two months of my appointment I lived in a room in the nurses’ home during the week and went back to London each weekend. Then the flat on the top floor of the administrative building became vacant and my wife and family joined me in early October 1953. We lived there for five months. We were very crowded, and all prams and shopping had to be carried up two flights of stairs, but we were at least together again. The work on the Superintendent’s house went on, though slowly. There were difficulties with the new central heating, our alterations and the painting and paperhanging, which was done by the hospital’s workmen. However, finally, in February 1954, we were able to move in and were well pleased with our new home. We had a housewarming party and felt at home at last. I was absorbed in my work, to which I walked every morning through the hospital grounds. We gradually got to know people in Cambridge. My professional work began to settle. Apart from my major concern, the running of the hospital, I was expected to do a good deal of clinical work. I took a substantial proportion of the new admissions and followed them through. I held outpatient clinics at Huntingdon County Hospital and also at Addenbrooke’s seeing a number of new patients and taking on a few for psychotherapy. During my first two months at Fulbourn Hospital – August and September 1953 – I had very little contact with Cambridge. This was partly because I rushed off to London each weekend, partly because most things closed down in Cambridge during these months of

university vacation and town holidays. I made contact with my College, King’s, where to my pleasure the Head Porter recognised me immediately. The University Library, the bookshops, the cinemas, the University Swimming Sheds (for 1953 was a hot summer), all seemed much the same as when I was a student 15 years earlier. A few people asked me out to dinner. Several general practitioners asked me to do home visits to patients and I had some requests for second opinions on inpatients on the wards of Addenbrooke’s from physicians and surgeons. These came partly because all the other psychiatric consultants were out of town on holiday, but I think some were attempts to put the new man through his paces to see if he was any good. Once my family joined me in September we became more involved in Cambridge life. My elder daughter went to the Fulbourn Village School. My wife began shopping in Fulbourn and in Cherryhinton and got to know our neighbours. Gradually we began meeting colleagues and making friends. I was welcomed to his department, colleagues and excellent library by Oliver Zangwill, recently appointed Professor of Experimental Psychology. I got to know some of the social scientists then working in Cambridge, particularly Meyer Fortes, Professor of Social Anthropology, who as a former clinical psychologist showed great interest in some of my developing ideas about Social Therapy. I began to frequent my College more often. I held to my intention of doing nothing new for the first year and started no major projects for many months. However, as I later came to realise, the very way in which I dealt with people in my first year caused shifts in the hospital. Prior to my arrival the basic premise of Fulbourn had been the traditional humane custodialism of British asylum management: look after patients kindly until they die, or perhaps, by chance, recover. Their illnesses were viewed as being hereditary with a natural relapsing course and therefore it was felt that such people were probably better off in hospital. If a doctor or nurse had enthusiasm or drive, it was probably better turned away from trying to help such patients into other fields – outpatient psychiatry, short-stay patients, the football club, the Union or professional advancement. My view was that chronic patients could be actively helped toward recovery and that furthermore the way to do this was to change the way they lived within the asylum. The fact that I treated a patient’s remarks as being of equal importance to those of a nurse caused some surprise; traditionally, patients were considered insane until proved otherwise, and any comments they made disregarded if they clashed with the views of a staff member. Even without planned initiatives on my part, projects kept emerging and to each I could give either support or discouragement. I used this as a way of gradually redefining policy. Over every idea that came forward, I asked myself – how does it help the patients? Then I determined, more or less consciously, the support I would give to it. The clamour for differential uniforms seemed to me nonsense, so I gave it no support and it made slow progress. A plan to recruit French girls as assistant nurses seemed to me most valuable and I gave it much support. Miss Brock had heard of foreign recruitment producing recruits for other hospitals and had then met a cheerful advertising man who promised to plan the campaign. Miss Brock and I worked hard together on this project, drafting advertisements for the French press, scrutinising the scores of applications that poured in,

filling out forms, corresponding with parents. After Christmas 1953 the first of them started arriving; by Easter 1954, we had a dozen on the staff and had incurred a reprimand from the Regional Board for overspending our allowance for nursing staff. I remained ashamed of the shabbiness of the grounds and was impatient to get things smartened up. The front gate hung lopsided, shabby and dilapidated. Mr Merrin said he was not allowed to repaint or repair it. I had a squad of patients lift it off the hinges and throw it into the shrubbery. The male nurses drew my attention to the cricket pavilion, originally a black and white building which now looked horribly shabby. Half its paint was off and its timbers were bleached and bare. Mr Merrin said there was no need to worry; it was western Red Cedar and weatherproof. I grumbled to the Commissioners of the Board of Control, who put a sour little comment in their report. The Committee picked this up and at my prompting, Mrs Adrian instructed Mr Merrin to get the pavilion painted. The work on the Staff Recreation Hut was going very slowly; the nurses said cynically that Mr Merrin, who had made his distaste for the project known, would see it was never finished. I worried at it like a terrier , bringing it up at every Committee meeting, taking all official visitors there, talking about it constantly. The work was finished just before Christmas and there was an opening ceremony. I invited the Press and Mrs Adrian was persuaded to pour the first drink. Mr Allen and the staff were delighted and held a number of Christmas parties there. As time passed, however, I began to see another side to Mr Merrin. I would meet him on Sunday mornings prowling round the works in progress. One morning, he seemed rather tired and I heard he had been up all night driving an iron lung 50 miles across the county to a desperately ill child. When a patient broke her arm on a Sunday, he came up and Xrayed it for us there and then, producing a picture of professional standard. When we sounded the fire alarm, he was on site before the first of the fire fighters, and when the boilers broke down one weekend, he spent all night inside the boiler until the heating restarted. I realised that for all his surface cynicism, he was a highly skilled man with exacting professional standards, who was devoted to maintaining the hospital in sound condition – according to his own system of priorities. As winter started, the patients’ dances began. They were dreary affairs with recorded music played over inadequate amplifiers from a stock of scratched and out-of-date records. Mr Tucker suggested to me that one of the male nurses would be glad to arrange some live music. One of the doctors volunteered to play the trumpet and a clerk the drums and quite a lively little band emerged. I asked the Committee for money for music stands, and other necessities and the patients’ dances livened up considerably. The Regional Board granted us some money for long-overdue repainting inside some of the wards. No one wanted to perpetuate the dark green paint, but they were not sure how to improve the existing colour scheme. I discovered that we could get free advice from one of the big paint firms and I spent several days with the adviser from London, who produced colourful but pleasant schemes which pleased everyone. Even Mr Merrin, while

pointing out that it would be cheaper to paint everything in one colour, admitted that the paints proposed were durable and up to standard. This first repainting was a great success. The ward day rooms were brighter and more cheerful than anything previously seen at Fulbourn. As the year moved on, the months brought the recurring festivals. At each one I took the role allotted to me, and tried to fulfil it to the best of my ability. This involved some curious tasks. I took the Chair at the Annual Meeting of the Patients’ Social Club, a curious body dominated by a grandiose paranoid ex-soldier. I chaired the Annual Meeting of the Staff Cricket Club, but declined the captaincy of the cricket team. This caused consternation. Apparently, Dr Thomas had been ‘Captain’ for 30 years. In his youth, he had been a keen cricketer and he always watched the hospital team on every possible occasion. The cricket team enjoyed all sorts of traditional favours from the Management Committee; cricketing was regarded as a duty and nurses were paid for time spent playing; their equipment was provided from hospital funds; free meals were regularly supplied. All this became clear as they pleaded for me to continue to be ‘Captain’. Cricket was a game I had disliked and played badly at school; I had managed to evade participation as either player or spectator for many years. No arguments of the patients’ interest or welfare could persuade me to undertake this! Then I realised what worried them: they did not care whether I played or not, but they feared they would lose all their special amenities and subsidies if I did not champion their cause. I assured them that I felt the staff cricket team to be an essential part of the life of the hospital and that of course I would support the continuing subsidy! I was enthusiastically voted honorary Vice-president and a respected fast bowler was elected Captain. As Christmas approached, I realised that other traditional tasks would fall to me. All English institutions, like English families, made much of Christmas, but for the custodial asylums it was a tremendous occasion. A focus of great attention were the ward decorations. From the time the staff returned from their summer holidays, they began planning their displays and spent long evenings making paper flowers and streamers. A few days before Christmas the decorations were put up, and on Christmas Day, they were at their finest. Christmas afternoon was the only time in the year when the Matron of Fulbourn entered the male side, or the Chief Male Nurse entered the women’s wards. Much else, I gathered, went on, but Mr Tucker, who was gently preparing me for my part in all this, indicated that the Medical Superintendent was never seen in the hospital after lunchtime on Christmas Day! I gained the impression that this was a sort of Saturnalia, when the forbidden was permitted and actions which would earn instant dismissal at any other time – such as being drunk on the ward – were tolerated. However, I prepared to play the part allotted to me. Dr Thomas had always been Santa Claus at the Staff Children’s party; many told of the conjuring tricks he performed to delight the children. They produced an immense scarlet robe, edged with cotton wool, which had obviously clothed his bulk majestically, but hung around my slighter frame like a collapsed balloon. I donned the cottonwool whiskers, daubed my cheeks with rouge and boomed hollow pleasantries at some 200

children to such effect that my own daughter wept in terrified ignorance of the identity of the strange, red-faced man! On Christmas Eve, I read the lesson in the hospital chapel and the following morning early went briskly round the hospital, wishing all the Charge Nurses and Sisters a Merry Christmas. Later I took the Chairman, Mrs Adrian and members of the Committee around. I took them into every ward and compelled them to admire every decoration, however inadequate. After the Committee had left, I went into the staff lunches to wish everyone a happy Christmas and finally retired exhausted to the bosom of my family. I felt convinced that however else I might have improved things, at Christmas I had been inadequate in my roles and a poor substitute for my vast jovial predecessor. To my surprise, however, I heard months later that the thing which had caused most favourable comment was something I had done without any special consideration – namely going round all the wards early on Christmas morning on my own and greeting all the Sisters and Charge Nurses. This, they said, had never happened before. Gradually, as my first year wore on and I got to know my position and tasks in the hospital, I began to evolve a plan of action for bringing about changes. I had looked for books on how to run a mental hospital, but could find very few. However, a pamphlet recently published by the World Health Organisation seemed to express much of what I was groping toward. A chapter on ‘The Community Mental Hospital’ filled me with excitement. The hospital, the report said, should be a ‘therapeutic community’. In clear and telling phrases, it spelled out some of the things I was feeling – that patients’ individuality should be preserved, that locks and keys were largely unnecessary, that patients had a far greater capacity for responsibility and independence than was generally recognised; that they required a full day of well-organised work and activity, and finally, that the atmosphere of the hospital and the quality of the staff interrelationships were most important aspects of the total treatment programme and the special responsibility of the medical director (World Health Organisation, 1953). This seemed to me a blueprint for action. Paradoxically, my first act within a few days of my arrival had been to lock up a ward. Mr Tucker had told me that the male nurses in charge of the Admission Villa were very worried about the situation there. It emerged that they had been ordered a few weeks earlier to run it as an open ward. On investigation I found that Derek Russell Davis, full of enthusiasm for the new ideas, had persuaded Leslie Buttle to order that the Villa be unlocked. I went and talked to the Charge Nurses of the Villa; obviously capable men, they seemed very worried. They said they felt they could not be responsible for the patients they had to contain if they were forced to try and run the ward with the doors open. When I asked Leslie Buttle, he said that he had never really been in favour of it, but Derek Russell Davis had persuaded him. I felt that little would be gained by forcing the nurses to do something that made them frightened, so I agreed that the door should be locked again. Three years later it was unlocked – and stayed open.

In the autumn of 1953 the Lancet printed an article describing the three ‘Open Door’ hospitals operating at that time in Britain – Dingleton Hospital in Melrose (open since 1948 and the pioneer in advancing these new ideas), Mapperley Hospital, Nottingham and Warlingham Park Hospital, Croydon. I had this article copied and distributed to the Charge Nurses and Sisters of the hospital. The following spring, I made a special journey to Croydon to see Warlingham Park, where T.P. Rees was at the height of his activity. This was a most important visit for me and for Fulbourn. I was tremendously impressed with what I saw – the open wards, the busy workshops, the patients going about their business, sensibly and briskly, dressed in ordinary clothes, well turned out, cheerful and friendly towards Dr Rees. The flamboyant touches excited me – the small piece of railing left standing to show ‘how it used to be’, Dr Rees’ tales of battles and storms with reluctant nurses over patients’ freedom, the big land movement jobs undertaken by patients. Of some things I felt a little doubtful: the ‘habit training’ wards where incontinent patients were taught how to become continent through rigid discipline and ladders of promotion and demotion seemed rather authoritarian to me; I also felt that I could not copy Dr Rees’ constant emphasis on personal communication with him – as a framed newspaper cutting put it ‘the Medical Superintendent whose door is always open to all comers’. But there was much to admire and we at Fulbourn were so far behind. It was a revelation to me of what a mental hospital could be. I also visited Mapperley Hospital, Nottingham and Graylingwell Hospital, Chichester during that first year; after each visit I returned dismayed with how far behind them we were at Fulbourn. The plan set out in the WHO pamphlet, together with what I had seen at Warlingham, gave me something to aim for and, perhaps more important, a tangible goal to put before the staff. But much had to be done first. The first challenge was to get patients doing something, instead of sitting around passively. I discussed the matter with Mr Tucker and he began to agree. It would be a good thing, he said, to get more patients occupied; they had tried to do it in the past, but they had been blocked; they would like to start again. I discussed the idea with the Charge Nurses, leaving aside the delicate question of their ‘good workers’ and concentrating on the large group of ‘unemployable patients’ who sat around the wards. Gradually, interest in patient occupation rose. At first it was probably just a response to my professed interest; this was the current bee in the bonnet of the new Medical Superintendent; any wise or ambitious man should note the new direction of the wind and trim his sails accordingly. However, by spring 1954 I felt that the male nurses were also ready. I had many talks with Mr Tucker about the importance of full occupation and how much work it would involve. We dubbed Mr Allen ‘Occupation Officer’ with the task of getting as many male patients working as possible. He plunged into the task with happy vigour. All working parties – on the farm, on the gardens, in the Engineering Department – were increased in size. Ward orderlies were taken off menial tasks and put in charge of squads of patients. We looked everywhere for tasks which patients could undertake. The dilapidated grounds were an immediate focus. Parties were sent out to weed paths, to cut undergrowth, to clear rubbish, to dig out weeds. The rusty railings at the front gate were rubbed with wire brushes and then repainted. The lampposts around the grounds were repainted. All the shabby cast-iron garden seats were brought in and repainted. Even the front door was given a coat of varnish. As the easier

tasks were done, others were found. An area of broken ground, a mess of weeds and builders’ rubble, was laboriously levelled. A shrubbery that obstructed the view was grubbed out root by root. The male patients who went out on these jobs were the most pathetic and helpless, mute individuals who had done nothing for years. Many of them achieved little at first, but gradually they became more active and it was soon clear that their physical health was improving with the fresh air and gentle exercise. Although my overall aim was to arouse the enthusiasm of the staff gently, I did not hesitate at this time to apply direct pressure. Daily, I would go round the wards with Mr Allen and if I found a patient sitting idle, would demand a full explanation from the Charge Nurse. I visited each of the work gangs, commending the staff in charge and chatting to the patients. I would ask each Charge Nurse ‘What are you doing for the patients today?’ and would show little sympathy or patience for excuses based on other people’s inaction or disinterest. We reviewed the patients’ rewards. A system of pay for the patients had been instituted in 1950, when reward by tobacco and sweets had stopped. However, the money was allotted rather haphazardly; I was interested to discover that, owing to Mr Merrin’s vigour, patients working for the engineers got half a crown a week extra above anything they might get on the wards. With Mr Allen’s help, I revised all the pay scales; I stopped all pay to patients who would not work, and rewarded others according to the skill or responsibility they carried. Some of these revisions caused indignation and there was one stormy meeting with the Charge Nurses, when they protested against the withdrawal of many established doles. I made it clear that I stood behind Mr Allen; that I regarded work as an essential part of treatment and that I expected every patient to be occupied in some way. I further made it clear that I regarded this as one of the major tasks of the Charge Nurses and that I thought a group of well-occupied patients far more creditable than wellpolished door knobs. This mixture of pressure, threats, rewards and flexibility gradually produced results. During the summer of 1954 we got more and more men out on some kind of work or another and as the staff began to see for themselves how the patients’ physical health and behaviour improved, they grew keener. They gradually began to bring forward their own ideas, especially at the Charge Nurses’ meetings, of tasks that needed to be done, ways to rearrange work, small projects for groups of patients and so on. However, not all projects worked. For years, there had been dissatisfaction among the cricketers over the state of the cricket ‘table’, where the pitch was laid. On our chalky soil grass grew poorly. On our cricket field it was especially poor and the teams had to play on matting. Even then, the grass was poor – rough, full of bare patches and slippery areas. The cricketing nurses were convinced that the Farm Manager did not give enough care to the task. At Mr Tucker’s suggestion, I arranged that a nurse who was a prominent cricketer should be freed of all other duties and given a squad of patients every day and any other necessary facilities, so that he could get the cricket field into really good condition. I was assured he would do it easily. He did not. The task was undoubtedly more difficult than the nurses had realised, but the main failing was in the man in charge.

A glib talker, he had radiated confidence and determination; as I passed the field each day, however, I would see him and the patients sitting chatting. After a few months, the pitch was worse than it had ever been and it had to be returned to the Farm Manager, who reported the matter in full to the Farm Committee. They were obviously amused and perhaps pleased to see one of ‘the doctor’s projects’ fall flat on its face! Although we were seeing great success in improving the daily life of the patients, I felt aware of other rather depressing cross-currents and undercurrents during this first year. By the autumn, the Enquiry on the missing stock was concluded. The two members reported that some £10,000 worth of material could not be accounted for. However, they did not think there had been mass thefts; they thought the losses were due to the fact that Mr Tucker – always anxious to avoid upsetting anybody – had failed to carry out adequate inventory checks for at least ten years and possibly longer, so that the annual wastages by damage, minor theft and loss had gone unrecorded and had accumulated to this large sum. They reported this conclusion to the Management Committee, who unanimously resolved to censure Mr Tucker severely. I had not been directly involved in either the losses or the Enquiry, but I was shocked at the situation which had suddenly blown up. I did not know much of Health Service rules, but I knew enough of elementary justice to know that you should not condemn anyone without allowing him to challenge the evidence and to put his point of view. Though I thought that the conclusion was almost certainly correct, I suspected that much of the Enquiry had been managed rather casually. A great deal of gossip had been repeated; the Subcommittee had not examined Dr Thomas, who was certainly partly involved; Mr Mitchell, the Hospital Secretary, who was surely partly responsible, had been the secretary to the Enquiry Committee; no evidence had been recorded, nor had anyone been on oath. I wondered whether I should intervene or let them fumble themselves into a real mess? Then I thought of the patients and the hospital. Mr Tucker was very popular with the staff and the Union; many would feel an injustice had been done. There might well be a public enquiry, running on for months and doing the hospital great damage. At the very least, all the old canards would be given further publicity and all the old animosities reinforced, at a time when I was trying to draw people together in a united effort to help the patients. I decided I must do everything I could to stop the disturbance spreading. I spoke to Mrs Adrian who had realised things had gone awry, but was not sure what to do. I saw Mr Tucker and discovered that he had no idea that he was in such severe trouble; he thought he had cleared himself! I decided to breach confidence and I gave him some notice of the censure that was in store for him. As he gradually realised how bad things were, he asked me what he should do. I advised him to get a Union adviser forthwith, which he did. Soon I heard, and passed on to Mrs Adrian, that the Union official had advised Mr Tucker to refuse to accept the reprimand, to challenge the whole conduct of the Enquiry, and to demand a public hearing. At this stage, I saw Mr Tucker again. I told him that a public hearing, though gratifying, would be very painful for him; that though he might succeed in blackening many reputations, it would finally, I felt sure, also lay the blame on him, and might well result in his dismissal and loss of pension; that I should deplore it because it would do so much harm to the hospital. I finally asked him to accept the reprimand. After a sleepless night, he agreed to do so and the reprimand was

given in private by Mrs Adrian. Although unpleasant for all, especially Mr Tucker, it was not humiliating. It was recorded in the Management Committee minutes, but no further publicity was given to the matter. The hospital heard no more of the affair. A year later, when nearly everyone had forgotten it, the Public Auditor asked to have the whole matter reopened with a full public enquiry and possible criminal charges. The Management Committee refused, pointing out that they had taken all necessary action at the time and fortunately the Auditor did not press it. Such episodes were not uncommon in the early years of the National Health Service. They were the result of decades of parochial administration, the stresses and lowered standards of the war years and the lack of proper control procedures. Hospitals dealt with them in different ways; sometimes Ministerial public enquiries did major damage to the morale of a hospital. There were also other drives to clean up inefficiencies surviving from earlier times. The hospital food was poor. The patients in the far wards, in particular, received stone-cold food on icy plates in winter time, and in summer time their bread, which had gone through a ‘bread and buttering machine’ became parched, cockled slabs, which had quite soaked up the dabs of greasy margarine. Much of the food sent to the wards went straight into the swill bins and only the hospital pig herd benefited. The Catering Committee of the Management Committee had tried to improve things without effect; the Catering Officer, a pleasant ineffectual woman, was quite incapable of dealing with the group of surly, lazy, dirty men who had been in the hospital kitchen for years; the Head Chef was Secretary of the main Union in the hospital. The Regional Board hired a firm of National Caterers to advise them. They visited the hospital and wrote a blistering report. They pointed out how bad the food was; they said the kitchens were antiquated and inadequate; they said the whole delivery system would have to be reorganised; but most important, they said that nothing could be done unless both the Catering Officer and the Head Chef were discharged. This gave the Committee the chance they needed and they acted with firmness. Both officers were given three months’ notice to go. The Catering Officer departed without complaint and got herself a job at a smaller hospital where she did well. The Chef called in Union advice and appealed; his appeals were heard, but the dismissal confirmed. During the summer of 1954, new staff were appointed and the cooking steadily improved. The Regional Board, on the Caterer’s advice, put in a system of steam-heated services, and some years later built us an entirely new kitchen. They also, gradually, increased the food allowances, so that the food supplied to staff and to patients improved steadily. Over the months, I also had to manage a series of discipline problems. A patient asked for an interview and said he had seen two male nurses mishandling a disturbed man; the relatives of an elderly patient complained that the ward sister had slapped the old lady’s face and pulled her by the hair; a husband complained that his wife had been bruised by the brutality of nurses. In every case, I investigated the matter fully in the company of the

Chief Nurse – examining the patient, listening to the story, hearing what the nurses had to say – and then gave my conclusion, first on the facts I found, and then on what action I proposed to take. I found these enquiries fraught with difficulties. I resented the attack on the hospital and felt sorry for the desperately overworked staff trying to do their best. I had to call on all that I had ever learned in the Army and elsewhere about the process of judgement, both to establish the facts and to get the best result for the hospital and the patients. As a psychiatrist, too, I found the role of reprimander most difficult; I wanted to help the culprit, to understand why he had erred, rather than to inflict on him the necessary punishment. Always afterward I felt exhausted, inadequate and dissatisfied. But no one ever challenged one of my decisions or appealed further. The drive for full employment was managed in the traditional way, as something done by energetic staff to passive patients – people without responsibility or opinions. However, the patients’ response to the opportunity to work gradually won them respect in the eyes of the staff. I had one particular piece of good fortune in 1954 when Fred Houston joined us as Senior Hospital Medical Officer (SHMO) – a grade for those experienced doctors who were not well-enough qualified to be Consultants. There were two applicants – one a dreary, tired man, the other an eager little man, who came from De La Pole Hospital, Hull, then becoming known for its active treatment of patients. He poured forth an enthusiastic tale of all that had been done there and I felt attracted to him at once. He was a godsend to me, and we worked very happily together for years. During the summer, it became clear that full occupation for the patients raised many administrative problems: there was competition between departments for the best patients; there were problems over who supervised squads of working parties; there were difficulties over supplies of raw materials. To grapple with these problems I started a regular meeting every Monday at noon. Though other meetings waxed and waned, this one dealing with the challenges of the working life of the patients and the hospital continued throughout my career at Fulbourn. To begin with, the members were Mr Allen (recently designated ‘Occupation Officer’ of the male side), the Head Occupational Therapist, the Deputy Matron, Miss Legge and myself. Soon after his arrival, Fred joined as a regular member. Our first concern in the summer of 1954 was the occupation of the men and the problems that arose. A typical difficulty was the supervision of the garden workers. Under the old regime, a gardener came up to the hospital every morning and went round the wards collecting the patients who were members of the ‘garden gang’. Often, the nurses had not got the patients ready and he had to wait. Then he took them to the garden office but by then it was almost time for their mid-morning break; later in the morning he took them back to the wards in time to get off for his own lunch. The result was that the patients did very little work, but spent most of the morning standing around waiting for someone to collect them and walk them somewhere. Until now, no one had been greatly concerned and it served to confirm the staff view of the unimportance of patient work.

It took weeks of discussions to change this; we had the Farm Manager to the Occupation meeting and also the men in charge of the squads. The talks were very revealing. The gardeners did not like squad duty; they told tales of a gardener discharged years ago for allowing a patient to escape; they revealed fears of violent patients; yet at the same time, they told tales of men who had regained sanity and interest by working with them. We tried to meet their fears and to encourage their therapeutic interest. We assured them that they were not responsible for preventing escapes, but we did want the patients stimulated and challenged by their work. Point by point, we clarified things. It was agreed that some patients did not need to be escorted, so these men were told to report at the gardener’s office for work at starting time. They were told that they would lose pay if they were late. All the patients’ pay rates were adjusted and we arranged that the gardener and Mr Allen would review them regularly and promote those who were working well. Ward orderlies, released from other work, were put in charge of the patients thought to need supervision. The gardeners were thus freed from ‘escort duty’ and could give more time to supervising the patients actual gardening and providing more skilled work. Gradually, over the months, the quality of patients’ work improved and they were given better and more varied jobs; more of them got themselves to work in the mornings; many worked individually on fairly skilled tasks. Finally, the six most skilled were given allotments to cultivate in their own time and an annual prize was awarded for the best allotment. This was just one of many problems. In each case, we brought the staff into discussion; nearly always, they disclosed ancient fears and insecurities – especially of their responsibility for escapes or damage. Often, they revealed considerable therapeutic zeal, making suggestions of what the patients might do, putting forward the names of men who had improved greatly, suggesting new projects. Always I tried to increase the opportunities and responsibility offered to the patients and to challenge any assumption that they were incompetent merely because they were patients. Most of the projects were worked out in the Charge Nurses’ meetings, which we were now holding every few weeks. As activities developed, I was delighted to find the nurses themselves coming forward with ideas. The mens’ admission ward asked permission to develop its garden. They had a fairly large area, divided up by thick hedges; they asked permission to grub these out and to develop flower beds. The Farm Manager expressed grave doubts and pointed to the recent debacle over the cricket pitch. Somewhat daunted I asked the nurses if they really could do it. However, they seemed confident and so I backed them. On this occasion, my confidence was justified; the admission ward garden went from strength to strength and was never handed back to the Farm Manager. First, they grubbed up the hedges and made their flower beds. Then, they tackled the lawn. It was level enough for bowls, but was a mass of weeds. They had in the ward a patient who was a groundsman, recovering from a melancholia episode; he undertook to make them a bowling green and by high summer, they were able to announce the opening of a hospital bowling green, with matches most evenings. Later the ward raised money and bought themselves roses and herbaceous perennials and made their garden the envy of the hospital. Even on this project though, there were administrative difficulties. The ward had

no gardening tools; the Farm Manager would not lend them his. We appealed to the Friends of Fulbourn, a donation of £10 started us off and over the years, a full stock of tools was built up. In my meetings with the Charge Nurses, I came increasingly to respect their quality, their knowledge of the patients and their initiative. There were two Charge Nurses on each ward, one on each shift. I found that nearly everyone deplored this as no ward policy could develop with two alternating masters and messages were frequently lost between the two shifts. Some wards were also too large; two contained over 100 patients. The staff complained particularly about the mens’ refractory ward. This contained all those people who were a problem elsewhere in the hospital – the violent, the escapers, those with criminal records, and all the incontinent patients. As they were all crowded into one ward, constant conflicts arose. During my first months, an angry man rose during the night and struck a noisy man so hard that he died, leading to an unpleasant inquest. Now Mr Tucker and the Charge Nurses suggested that this ward might be split in two, separating the violent patients, who needed restraint, from the regressed patients who needed training and prompting. They were in a two-storey building – day rooms, kitchen, bathroom and office downstairs, dormitories upstairs; this could be divided to give a separate ward on each floor. Thinking things over one evening, I realised that this division could be combined with changing the staffing so that there was only one Charge Nurse per ward, throughout the men’s side. Even the Finance Officer was pleased, for the rearrangement reduced the wages bill slightly. The Management Committee accepted the plan with pleasure. At the same time, I took note of the plea which the Charge Nurses had made repeatedly to me, that they should be allowed distinctive uniforms. Thinking it over, I could see no sound social argument against it and, since they begged for it so earnestly, I agreed. They soon appeared in long white coats, which pleased them greatly. The change to single Charge Nurses had many valuable effects. With only one nurse in charge on each ward, responsibility was much clearer. Men with capacity had a real chance to do something distinctive and several of them took the chance to develop very lively units. The division of the disturbed ward was a great success. The two Charge Nurses responsible were both Welshmen in their early forties – Joe Pattemore and Tom Lewis. Pattemore took the disturbed patients, Lewis the regressed. They asked how the patients should be divided, and left me a list of the 100 men on the ward since this was considered a job for a doctor. As I went through the list that night, I found that I only knew about 15 of the 100 men. I realised that I would have to go through all the case-notes and interview all 100 patients – a task that would take weeks. I then called Pattemore and Lewis to me next morning and asked them to divide up the patients between them. This they did in one day, for they knew them all well. I accepted their division. At the time, my only conscious motive was to evade a wearisome task, but later I saw that I had been wiser than I knew. By giving the Charge Nurses the task, I had showed my respect for their judgement in what was officially regarded as an exclusively

medical area. By letting them choose the men they would work with, I had made them even more committed to making the scheme succeed. Furthermore, I had clarified for myself the principle that a doctor should never do a task that a nurse could do – from which it might follow, by extension, that a nurse should never do what a patient could do. The building work to turn the upper floor into an adequate ward, which had been sanctioned by the Committee, had not started yet. I asked Pattemore and Lewis if they wished to wait, but they were so keen to get on with the division that they asked to start at once, despite the disadvantages. We arranged for Lewis, who was going to take the regressed patients, to spend a week at Warlingham Park to see their system of habit training. He came back enthusiastic about the approach, but convinced that we could do better at Fulbourn. He threw himself into the task with exuberant enthusiasm and soon began to show results. Before he began, it had been necessary to collect a gallon jar of paraldehyde mixture every week from the dispensary for use as a sedative for 50 patients; by Christmas time, the weekly dose for the ward was down to one small half-pint bottle! He got his men going regularly to the lavatory, so that the wet stained trousers became a thing of the past and the ammoniacal smell of urine no longer hung permanently about the ward. Nearly all his men had hitherto been regarded as unemployable. He soon got a number of them out on working parties, and when the weather improved, he started taking the others for walks around the nearby villages. Within the ward, he started improving their life. At first, it was fairly spartan, but as we installed the kitchen, the new furniture and the new curtains, the ward became pleasant. He taught the men to care for their new home and to maintain a higher standard of cleanliness. In Pattemore’s downstairs ward things too began to change. When the irritating and helpless patients had been removed, the staff could concentrate more attention on the ‘disturbed’ patients, who were younger, more active and more capable. The staff reviewed each man and his work and moved many of them to more testing tasks. They rearranged the ward life, with more games and parties. They endeavoured to get everybody out for some time each day. They soon found that with better attention, there was less need for restraint and coercion, the amount of emergency sedation fell and the use of the padded room decreased. Thus, within six months during my second year the programme of ‘Work for All’ began to pay dividends for the men and the male staff became increasingly enthusiastic about the general concept of treatment by social planning and reorganisation. During this time, we also conceived the Sports Ground Project that was to keep all of us – the patients, male staff and myself – busy for several years. When I first visited the hospital, I was impressed by the fine sweep of land in front of the main building, and was sad to see that it was devoted to crops. Old pictures showed that it had once been a sports field but that during the First and Second World Wars it had been ploughed up. The present sports field, behind the hospital, was unsatisfactory – ill-sited, poorly levelled and bare of grass. I suggested using the front for sport, but I was told that it was ‘the best farming land in the hospital grounds’ – that it had been manured for a century and the Chairman of the Farm Committee, Alderman Street, would never let it go.

The more I looked at it, however, the keener I became on the idea. I talked to Mrs Adrian and selected members of the Committee about my idea and found them receptive. I wrote to the National Playing Fields Association, who referred me to an architect who specialised in Sports Grounds. In the autumn of 1954 I put the plans before the Committee. I had taken some care to prepare the climate of Committee opinion. All summer, they had heard a string of complaints about the present pitch and about the need for patient occupation. I had talked persuasively to a number of key members. I had even got the architect to prepare an alternative scheme, which had manifest drawbacks. The strategy worked. Despite the voluble protests of Alderman Street and the Farm Committee over losing their precious well-manured field, and the doubts of the Engineer and the Finance Officer about the feasibility and the cost of the project, the Committee voted to develop the front of the hospital as a sports field by patient labour. Mr Allen and I were delighted and went about saying that in five years’ time the cricket team would be playing on grass (rather than matting) for the first time in Fulbourn’s history, while the Farm Manager and Alderman Street were sullen and disgruntled, predicting that no good would come of it all. The first task was to clear and level the land. This was a good project for unskilled workers, and all through the summer of 1955 we had every possible male patient and staff member out on the field, digging, shifting soil, excavating chalk and levelling land. At first, some of them did pathetically little; they would just stand behind a wheelbarrow until it was full, push it a few yards, and then wait for someone to empty it. But even they gradually took more interest and, in fact, one of our more striking rehabilitation successes occurred on this particular project. Jacob, a 45-year-old man, had been in hospital seven years, diagnosed with catatonic schizophrenia and was mute, unoccupied and incontinent. We put him out on the squad, and at first he just pushed a barrow. Then he began to show more interest; we were grading some ground and he began to hold the levelling rods for the orderly in charge. We then recalled that he had been a surveyor, and deliberately involved him in the planning of projects; he began to comment on what we were doing and show us better ways of doing it. His behaviour began to improve; his incontinence ceased, he dressed himself properly, he began to help the staff on the ward. He was moved to a better ward, where he fitted in well and began to take an active part in ward life, playing cards with skill and cunning. A member of the Management Committee who had known him before his admission was delighted by this change and took Jacob home for several weekends. Jacob had no close relatives in his village, but he owned a small house there and had a number of friends who wished him well. Finally, about two years after he first went to work on the sports field project, Jacob left hospital for good. Only a few recoveries were as dramatic as this, but nearly all the men who worked out on the project made some progress. The Charge Nurses reported a marked decline in violence and incontinence on the wards, and less sedation was needed. One group which was soon affected by the new atmosphere in the hospital was the ‘Farm Gang’. They were competent labourers, strong, biddable and well-behaved. Their Charge Nurse, Eric Raines, found many of them jobs in Cambridge (though they still lived at Fulbourn) and they became comparatively affluent, acquiring clothes, bicycles and radios.

One of those who moved on at that time was Hugh who had several labouring jobs around Cambridge. The foreman on one building site became quite fond of him. When the night watchman left, they offered Hugh the caravan. The situation suited his solitary nature and he laboured by day and slept in the caravan at night. No one pilfered from the site when Hugh was there! They moved the caravan from job to job and Hugh stayed contentedly with them for years. During the winter of 1954, I discussed these projects with various London friends and, as a result, Morris Carstairs and Neil O’Connor of the Maudsley Social Psychiatry Research Unit invited me to accompany them during the spring of 1955 on a tour of Dutch mental hospitals specialising in work and rehabilitation. This ten-day tour was most valuable to me and to Fulbourn. I was amazed at the quality of work being done by psychotic and mentally handicapped patients in Dutch hospitals. They were not content to stick to ‘hospital work’, but were producing goods for the commercial market, up to commercial standards. They were assembling pens and shop displays; smoothing, polishing and painting clogs; assembling army equipment and putting together parts of wireless sets. I could see that their finished products were up to market standards. No such work had ever been done by patients in English mental hospitals and I would not have believed it possible unless I had seen it. I had accepted that the best that patients could do was unskilled labour, such as levelling the sports ground. I now realised that the scope for patient work was far greater than I had thought and I returned determined to start commercial work at Fulbourn. This turned out to be a harder task than I had realised, and many sessions of the Monday Occupational Meeting were given to plans, high hopes and false starts. Mr Allen suggested making and selling decorated matchboxes. We bought the materials and made several score. When we tried to sell them, no shops found them attractive and they were left on our hands. We then thought of brush making. We got a stock of material – hair and pierced wooden backs – and set up a workshop. We trained a group of patients until they were making brushes well and fast and we offered them to the Supplies Officer. He took them willingly, but then careful costing showed that the cost of raw materials for each of our brushes was rather more than the manufacturer’s price for a finished brush! Then Fred Houston took a hand. With a suitcase full of samples of patients’ work which I had brought back from Holland, he went round business after business in Cambridge. Time and again he was rebuffed, but his enthusiasm was undiminished and after about 30 unsuccessful visits, he found an interested listener in the manager of a local electronics factory, who had a number of small assembly jobs to be done. We got together a small group of patients and started. However, it was not long before we realised we needed a workshop. The hospital was so crowded that we could not clear a ward to serve this purpose, but by this time the idea had attracted the enthusiasm of Alderman Holmes, the new Vice-Chairman of the Management Committee, and we persuaded him to suggest that amenity funds be used to

purchase and erect a wooden hut – as this could be done fairly quickly without waiting for Regional Board money. Even then there were still further problems to solve. We wanted to pass on to the patients all they earned; the Finance Officer wished to take most of the money into the hospital accounts. A battle seemed about to develop, but fortunately Morris Carstairs and Neil O’Connor had established an appropriate model when working at the Manor hospital in Surrey. With Ministry permission, they deducted only five per cent for hospital expenses and passed over 95 per cent of what the manufacturers paid to the patients who did the work. This constituted a ‘precedent’; after long arguments in front of Mrs Adrian, the Finance Officer was defeated and we were able to pass 95 per cent of the money on to the patient workers. We set up the wooden hut in the airing court of the women’s wards and in the autumn of 1956, we opened our workshop. We called it ‘Fulbourn Industries’ and it remained a key rehabilitation facility for years. At first it provided employment for 24 women, then two years later it took in men. It did not become very large – never more than 40 patients and three staff. The type of work was always complex and challenging, though over the years we worked for a number of different manufacturers, assembling car radio aerials, television aerials and circuits, painting toys, assembling Christmas games, making straw mats for cheeses and tinsel Christmas trees. The patients made about 15 shillings per week on average, with a ceiling of £2; for many of them, this was riches and the first step to independence. One of the first recruits to Fulbourn Industries was a patient called Dr Winkel. I had first noticed her as a silent, grey-haired, bowed figure who sat in a corner of the occupational therapy department doing embroidery. I learned that she was a medical doctor from Germany, a refugee who had been admitted to Fulbourn during the war in a melancholic paranoid state and was now mute, refusing to speak to anyone. For years she had been a star member of the select group who were allowed to attend the Occupational Therapy Department; she produced embroidery of meticulous workmanship but bizarre design, sought-after by medical staff as ‘schizophrenic art’. She appeared to have settled for a silent life in the asylum. To our surprise she asked to try Fulbourn Industries and soon proved one of the most capable electrical assembly workers. She used her earnings for new clothes and belongings and became more lively and talkative. I asked her how it was that she preferred this rather dirty work to embroidery. She replied, ‘Well, they appreciate it, don’t they?’ When I queried further she retorted, ‘If people pay you for what you do, it shows they appreciate it, doesn’t it?’ I realised that she had never been paid for the ‘creative work’ which she had done for years in the genteel OT Department. Gradually she became more talkative, discussing the outside world with the staff of the Industrial Hut. She made some trips into Cambridge and started writing to old friends. One of them, who lived in Cornwall, came to visit her, then took her for a visit and finally took her out of hospital permanently – cured by Industrial Therapy.

During my first year I found myself gradually being drawn into attempting to improve the public relations of the hospital. When I first arrived in 1953 I realised that nobody in the Cambridge area knew much about Fulbourn Hospital, and that what they did know was bad. The comments quoted by the Charge Nurses at their first meeting to support their plea for a new name for the hospital confirmed this. ‘Fulbourn is a name to frighten children with’ – ‘They only think of it as the place the loonies go – I don’t care to tell my relatives that I work at Fulbourn’, and so on. Miss Brock had quite a bit to say about this – ‘The Press are very unfair to us, doctor. All they ever print about us are the inquests and the silly things that are said at the Management Committee meetings. Why, one day, I complained about the cakes and the next thing I knew, there it was in the paper ‘Rock Buns too Hard to Eat, says Matron’ – I felt so foolish!’ All our inquests were reported – often with the witnesses’ comments in full. In my first month, we had a particularly nasty inquest after one man on the disturbed ward hit another so hard that he fell and fatally fractured his skull. The inquest was given a full page of the Cambridge Daily News with full (and slightly inaccurate) details of what everyone said including the allegation of a woman juror that ‘the poor man’s body looked as if he had been starved to death’. To a casual reader the impression was clear: Fulbourn Hospital was a seedy institution where patients were starved and fatally injured in uncontrolled brawling. Dr Thomas’ policy – and, indeed, the traditional mental hospital practice – was to keep the Press out at all costs. He regarded them as dangerous and hostile; the less they heard the better. This of course worked as a self- confirming hypothesis. Since the Press were excluded, they only heard about the hospital when something went wrong and required public enquiry – an inquest or a hostile HMC meeting. This they printed and, since it was all they printed, the reader got the impression that nothing but bad things happened at Fulbourn Hospital. Gradually during the first year I worked out a different policy – of giving the Press as much good material as possible about the hospital. The reporters who came to the hospital were usually junior, inexperienced, pleasant youngsters, who were keen and enthusiastic and who responded very readily to courtesy and consideration. They were only too glad to take down anything and try to get it printed. Every time we had any sort of a party or function I would ring them up and invite them to attend. They came to the opening of the Sports Club and took the picture of Mrs Adrian pouring the first drink (which won her a rebuke from a Temperance fanatic!). They came to see the Christmas festivities and took pictures of the Friends of Fulbourn presenting their Christmas presents – which gave their activities a useful boost. They came to the Staff Children’s Christmas party and took a picture of me dressed as Father Christmas. They came to the opening of the new Tuberculosis Wing in the second spring and took many photos of the gathering and repeated the speeches in full. All this began to present a different picture of Fulbourn Hospital to the people of Cambridge. I gradually began to think that perhaps I should apply myself more actively to this matter of public relations. In those days, the early fifties, the phrase was little heard, and was

usually regarded with some distaste. Doctors in particular were very hostile to and frightened of publicity. As medical students, we had been taught that ‘advertising’ was one of the worst medical sins; some doctors had been struck off the Medical Register for committing this offence. So I felt very nervous about starting to promote the hospital – and one of my colleagues warned me – ‘It will do you no good, David, with the people who matter.’ However, when I saw how much good publicity helped the hospital and how directly it benefited the patients, I began actively to cultivate the local press. A reporter always attended the meetings of the Hospital Management Committee and it was clearly right that the meetings of a public body running a public institution should be open. I found it difficult, however, to speak spontaneously and vividly when I knew that what I said might be in headlines the next day, to be read by acquaintances, friends, enemies and, worst of all, the staff and patients of the hospital (who saw the paper long before any official information could reach them). I suggested to Mrs Adrian, who put it to the Committee, that the Press be asked to withdraw at the end of the formal proceedings. This was accepted and became standard practice. It meant that after the reporter left, we could all speak more freely and that if members raised unexpected questions, I could give an extempore answer without having it broadcast. At the same time, I started a practice of going through the agenda with the reporter, indicating which subjects might give rise to lively discussion and which might be of interest to the general reader. This they enjoyed and they took to ringing me the next day and discussing the material before writing it up. This worked well as I could show them the encouraging aspects of a situation and often get them to give prominence to some report the Committee had received. Equally, I sometimes could steer them away from emphasising some unfortunate happening or some unhappy remarks. As a result of this work, I came to know the reporters personally and since I was always ready to give them help, they would often ring me on other subjects. All this helped to ensure that references to the hospital were helpful and optimistic, rather than critical or disheartening as they had been before. Every month, the Medical Superintendent had to give the HMC a written report and every year an annual one. In his later years, Dr Thomas kept these very brief and in March 1953 he had simply repeated his Annual Report verbatim, just changing the figures! This seemed to me a opportunity missed, and I gave a good deal of care and attention to the Annual Reports I wrote about the hospital. I came to use them as an opportunity to tell the hospital (and the Committee) what they had been doing, to remind them of their achievements and to suggest what they should do next. I distributed them to the senior staff as well as to friends and colleagues; the material was often quoted in the local newspaper. However, in spite of all these efforts, Fulbourn still had by and large, a poor reputation. On reading the local paper during my first Christmas, I saw that the Mayor of Cambridge and the Chairman of the County Council visited all the other local hospitals, including the old workhouse, but none of them came to us. I commented acidly on this and one of our Committee members, a City Councillor, persuaded the Mayor, a personal friend, to visit us unofficially in February. The next year, I wrote early to the Mayor asking him to visit

us at Christmas. He agreed and came on Christmas Day 1954 in the afternoon. The precedent was established and every Christmas thereafter the Mayor visited us – and was photographed doing so by the Press. Apart from handling the Press and thus indirectly affecting what the people of Cambridge heard about their mental hospital, I was also gradually drawn into public speaking in Cambridge. Not long after my arrival, I received a letter inviting me to speak to a meeting of a ‘Men’s Fireside’. Rather flattered, I agreed to speak on ‘Modern Psychiatry’. Other invitations followed. I discovered that in rural England at that time there was a great network of meetings (usually weekly through the winter) – desperately seeking speakers who were at least audible, preferably entertaining and ideally informative as well. Women’s Institutes, the Church Groups, business/philanthropic groups, political groups, medical groups and university groups for students were all avid for speakers. I found that I enjoyed these occasions and seemed to be quite successful with them. At first I talked in general terms, but I soon realised from the questions that they wanted to hear about their own local mental hospital, so I began to talk about that. As we began to do things we were proud of, such as opening the doors, I spoke about that too. Gradually, I began to see this voluntary speaking as a major part of my work to change the way in which Cambridge people viewed Fulbourn Hospital. In 1955 we began to increase the patients’ freedom. This had been in my mind as a possibility from the first since I had always been unhappy about locking people up, and even worse, secluding them in padded cells. It was only gradually, however, that I came to see the question of patient freedom as one of the most important parts of Social Therapy. Shortly after my arrival, in 1953, I had distributed the Lancet articles on patient freedom and open doors to the Fulbourn nursing staff. My visit to Warlingham, an Open Door Hospital, in 1954 had shown me the truth of what the WHO report had asserted – that there was no need for the majority of mental patients to be locked up. A visit to Dingleton Hospital, Melrose – the first British Open Door Hospital (opened in 1949), further confirmed my conviction that we could – and should – have more freedom at Fulbourn. In 1951, three wards, one male and two female, had actually been opened. These were the wards in which the ‘hospital workers’ lived – long-term patients who worked in the laundry, in the gardens or in the staff houses. They were all quiet, reliable people and no trouble had arisen when the doors of their wards were unlocked. These wards were near the centre of the building; the wards beyond were still locked – as were the communicating doors on the corridors and the main entrance at the porter’s lodge. All visitors and patients had to be let in and out, and often escorted for considerable distances along corridors through doors marked ‘This door must be kept locked at all times, by order Medical Superintendent.’ Everyone in the hospital knew of the great importance of keys and the need for their careful custody. At the end of the working day, all staff had to hand their keys in at the porter’s lodge and there were penalties for any who mislaid their keys or even took them home. Keys were always in evidence, rattling in male nurses pockets, jangling in doors, hanging on chains from women nurses’ waists, even twirled on the ends of their glistening chains by strolling nurses. They were the ever-present sign

of the barrier between the locked-up and the lockers-up, the imprisoned and their warders. In 1954 we began to talk about opening more wards and I looked round for one that was suitable. A women’s ward looked satisfactory – Female 7, housing 80 long-stay women patients, many of them paranoid. I discussed the idea with the nurses, who expressed grave doubts. I then asked them to name any patient on the ward who might cause difficulties or run away. They could name very few; I moved them to other wards. They then asked who would ‘take the rap’ if a patient escaped. In the old days if a patient escaped, a scapegoat had always been found. There would be a full Enquiry, and finally blame would have been placed on one person, who was then demoted or sacked. I assured them that this would not happen. If a patient in an open-door ward left the hospital there need be no Enquiry, and no nurse would be blamed. The mistake, if there was one, would have been mine in allocating that patient to that ward. But I also made it clear that I did not regard a patient’s unauthorised departure from hospital as inevitably a bad thing. It was only unfortunate if harm to the patient, or to people outside, resulted from it. It might actually be a way of starting rehabilitation. To some of the older staff, this was a novel view. There were still many discussions and many doubts. One day in 1955, then, the door of F7 was left unlocked. Nothing dramatic happened. A few patients were seen to go in and out of the door during the first day, apparently just to taste the delight of it. Several elderly women approached the nurse in charge and pointed out that someone had foolishly left the door unlocked – intending to save the nurses from a reprimand. Soon, all became accustomed to the open door. A review after a week or two showed that there had been no difficulties, but the nurses said they were amazed how much time was saved now that they did not have constantly to answer the bell or go down the ward to let out a patient going to work. This was the first step in the policy of opening ward doors which was to occupy – and preoccupy – the hospital over the next three years. Each time there would be discussions to be held, doubts to be aired and practical layout problems to be solved. In some wards it was physically easy – just a matter of agreeing to open the door; in others it was genuinely difficult because they opened into other units. In some we had to build partitions, or remove barriers. But underlying the practical issues were deeper ones such as staff fears of losing authority, of scandals, of madness out of control. We all had to work through a great deal. The open-door policy had interesting effects on the paranoid people who had long protested their detention. Mrs Broadbent, the solicitor’s wife, was at first most upset at the opening of the door of her ward. She spoke anxiously to the staff telling them that someone had left the door open by accident. When told it was a new policy she was very perturbed. Finally she accosted me, protesting that an open door was most unwelcome as all sorts of riff-raff might get in. Later, however, she came to enjoy the freedom of the grounds; she acquired pets, especially a tortoise which she carried everywhere with her in a shopping basket. Then she slipped off and paid a visit to her native town. The staff discovered it had happened and told me. We were all most alarmed – but there were no

messages and we gradually realised that nothing untoward had happened! Her husband had seen her and been terrified, but she had paid him no attention. Eventually, she went to live in Devon with a friend who seemed as eccentric as Mrs Broadbent herself. Mr McTavish, the big old Scotsman who proclaimed the coming of the Prophetess, continued to protest his detention to me every time I went through the ward. Finally I said to him ‘Mr McTavish, the door is open; if you want to go, go!’ Drawing himself up to his full height he roared ‘Ah willna leave this place until Ah get ma Legal Discharrge!’ and stalked away to his room. He continued to live on the ward, a respected and helpful senior citizen and to protest to all visitors, until a stroke and then heart failure brought his stormy life to its close. About this time, we also reviewed our visiting arrangements. Visitors had always had to meet patients in the main hall of the hospital – a large gloomy place, where they sat under the eye of a nurse on ‘point duty’ (rather like visiting rooms in a jail). We discussed this policy at a joint meeting of Sisters and Charge Nurses, with the explicit aim of seeing how we could improve the visiting arrangements – which all agreed were unsatisfactory. One of the nurses mentioned that other hospitals allowed visitors to go to the wards and asked why we did not. It was difficult to find a good reason why we did not. Some said that it was not good for relatives to see how shabby and bare the wards were; someone else pointed out that the visitors had already heard a far worse tale from the patients anyway. Some said that the visitors would interrupt the ward work; others pointed out that getting the patients dressed in their best and escorting them to the visiting hall and back took up a lot of staff time anyway. It became clear that a majority of the senior nurses were in favour of having the visitors come to the wards and so I happily agreed. This turned out to be a great improvement and staff, visitors and patients all approved. The most important gain was an unexpected one. Relatives mentioned to me how nice it was to meet the people who looked after their sick relatives; staff said that for the first time, they saw something of the parents, wives and husbands that their patients so often mentioned. The previous method had kept them apart, for the duty nurse in the visiting room seldom knew the patients he was watching. From these meetings many advances slowly came. In some rehabilitation wards, the nurses were able to open discussions with the relatives about possible weekend trips to the home. Misunderstandings, based on patients’ misconceptions and delusions were checked; the nurses found that the relatives were more tolerant than they had been told and the relatives found the nurses less harsh than they had been described. In the old women’s ward, the Sister made tea for the relatives; they began to contribute towards its cost and she was soon able to take up substantial collections for the Friends of Fulbourn. All these steps served to break down the isolation of the wards; gradually, they became less of a bizarre, sealed world and some of their strange ways were modified. Neither patients nor staff were so willing to show their less pleasant side when people from outside were in the ward – foul language, stripping off clothing, obscenity all became rarer. As more wards were opened, lively discussions took place among the staff. Some who had seen other hospitals or had experienced the relief of opening a ward argued

persuasively with the older or more cautious members, who constantly stressed the past histories or unreliable habits of the patients. I took an active part in all these discussions. They all knew I believed in greater freedom, but I stressed constantly the need for full discussion and being sure about what we were doing. At that time I myself was not even sure how far we could actually go. I knew that most patients did not need to be locked up, and that we could go further than we had done, but I was not convinced that every single ward door could be unlocked. There was much general discussion on the topic in psychiatric circles. In England in the mid-1950s the Royal Medico-Psychological Association held a debate between Dr McDonald Bell of Dingleton who put a passionate case for open doors and Dr Joshua Carse of Graylingwell, a Superintendent well-known for his advanced and liberal views, who told dire tales of patients invading neighbourhood kitchens with choppers and stressed the need for some wards to remain locked. In October 1955, I gave the Annual Address to the Cambridgeshire Mental Welfare Association and discussed among other things the question of Open Doors. This was printed in the Lancet in 1956. Drafting my address forced me to clarify the issues in my own mind and I realised that at that point I did not believe we could run Fulbourn with all the doors open, though I wished we could. In my address, therefore, I hedged. After discussing the open doors of Dingleton with enthusiasm I said: This has raised the demand that the principle [of open doors] should be applied elsewhere, and there has been criticism of hospitals where doors are still locked. The open door is a great ideal and it is certainly possible in any mental hospital to have all but two or three wards open. But hospitals which are near large towns and receive disturbed urban patients cannot, I think, go further than this. (Clark, 1956) Only two years later I was happy to be proved wrong, when we opened the last ward doors at Fulbourn. There were two particularly challenging areas on the men’s side: the Admission Villa and the ‘disturbed’ ward, Male 5 (M5). The Admission Villa was ‘open’ in 1953 when I came to Fulbourn, but the anxiety of the staff about this was so great that I had agreed to them closing it a few weeks after I arrived. By the summer of 1957, only the Admission Villa and the disturbed ward on the men’s side were locked, and the other Charge Nurses now challenged the need to lock the Admission Villa. The Charge Nurse of the Villa, a former RAF Warrant Officer and a most conscientious man, was certain that the patients must be locked in. He pointed out that many of them were admitted direct from their villages; how would it look, he said, if the patient escaped and arrived home before the duly authorised officer who brought him in? Finally, the Charge Nurse of the disturbed ward offered to take any admissions that the Villa could not handle. Having discussed it with my Consultant colleagues, I said that we doctors would be answerable if any nasty questions were asked about escapes. The Admission Ward Charge Nurse continued to protest, until one day at a Charge Nurses’ meeting the

excessiveness of his anxiety became ludicrous and the other Charge Nurses started to laugh at him. This was too much and he agreed to take the plunge. We all reassured him and I took good care that no really troublesome or worrying patients were left with him for the next few weeks. The door of the Villa was unlocked, and everyone watched to see what would happen. Nothing very striking occurred at first; the life of the patients went on as before. Recent admissions commented that they had been terrified by the door being locked on them – it was now much better. The junior nurses commented on reduced tension in the ward. In due course a patient did run away, but by the traditional escape route, the lavatory window, not by the open front door! At the Charge Nurses’ meeting we all agreed that the open door on the Villa was a great success. The last men’s ward, Male 5, was more difficult as by now it contained every man whom other wards had felt to be unsuitable for liberty or an open door. This was Pattemore’s ward, the ‘disturbed’ or ‘refractory’ ward. It also took about ten per cent of the admissions – all those men thought to be too difficult or too violent for the Admission Villa. Pattemore was keen to see how much liberty was possible, but was understandably alarmed about some of his patients. We had a number of discussions, privately and in meetings. Fred Houston, who was in clinical charge of the patients on the ward, was keen to try opening the door and the other Consultants said they would back him. In discussions with the nurses, all the old fears came up again. What would the relatives, the duly authorised officers, the police, the coroner say? Who would carry the can for an escape? Who would answer the Hospital Management Committee, the City Council, the Board of Control? Once again, we went through all the arguments and I gave all the reassurances I could. Finally, we agreed that the door should be open, but that the nurse in charge should have the authority to lock it again at any time he felt necessary. I re-emphasised that this was a step that we were all taking together and that if anything went wrong, I would bear the criticism. By this time, the nurses knew me well enough to know that I meant this. My own anxiety was, however, high. Many of these men had been violent; many had made suicide attempts; two or three had committed homicide; many had recently needed to be locked in padded cells; many had attempted escapes. What might they not do? Was I making a dreadful mistake? Might someone – a patient, a person outside, a child – perhaps be injured or die because of my lack of judgement? In February of 1957 we cautiously opened the door of the last men’s ward. For the first days and weeks we all waited tensely for something dreadful to happen. The runaways and potentially violent patients were closely watched. Nothing went wrong and the close watch gradually declined. After two months, the staff began to feel more comfortable and more confident with their new plan. The door was never locked again. The staff and the patients commented on the change in the ward. There were fewer violent episodes, fewer black eyes and much less use of the padded room for seclusion. This ward contained a number of patients who were effective hospital citizens; some were epileptics who were in the ward to be under observation in case they had an unexpected fit, fell and damaged themselves. Several of them told me how pleasant it was

to be able to go out when they wished, without having to ask someone to unlock the door. The staff were amazed at the reduction of tension; they said that they no longer felt surging hostility on the ward, as they used to. One of them said he could almost enjoy his spell of duty, instead of dreading it. The Charge Nurse, Pattemore, was so impressed that he wrote an article for a nursing magazine about the change (Pattemore, 1957). It was while working with this last group of male patients that we finally clarified our ideas about open doors. At first, we continued to use the padded room, bed rest, confinement to the ward and restriction of privileges routinely. Then, we also began to question these. We stopped using the padded rooms, and had them removed in 1961. We continued to use compulsory bed rest for patients in a phase of acute mental disorder. We had let some people go into Cambridge, but then had to stop them when we heard they were making a nuisance of themselves. Gradually, we worked out methods that were effective and fair. Some of the men could not have complete freedom; some were not allowed to go out of the hospital grounds; some were kept in the ward; some were kept in a dressing gown or in bed (for a few days at least). This we did because they were so disordered mentally that if they had been allowed out they would have damaged themselves, done foolish things or attacked other people. Some critics said that this meant we were compromising the Open Door Principle. What did Open Doors mean if some people’s liberty was curtailed? I had many discussions about this with eager reformers, who accused me of cowardice, or of hypocrisy in proclaiming an ‘Open Door Principle’ but still depriving some people of liberty. At the other extreme, frightened conservatives accused me of irresponsibility towards the outside community – and even towards the patients themselves, who they said needed to be locked up for their own good, to protect them against their own impulses; some even told stories of patients who begged to be locked up, because they felt safer. I was forced, slowly, to realise that this matter was more complex than I had at first realised. It was not just a battle between liberty and oppression. Some patients at various stages of their mental disorder would not be fit to have full liberty, but the fact that five men were unfit for full liberty was no reason to lock up 50 – especially as we had now discovered how bad it had been for the 45 to be locked up in a crowded ward amidst tension and violence. When the staff locked the door some patients saw them as gaolers; when it was open it was easier to see them as nurses. Bunches of keys had stood between nurse and patients and did much to hamper treatment. However, I realised that for some of the patients, at certain times, restrictions on their liberty would be necessary. We had to have a flexible policy which could be adapted to the needs of the people in the ward at any one time, and a variety of devices for limiting an individual’s freedom or responsibility when the disorder or the needs of the ward required it. I slowly realised too, how many other issues, conscious and unconscious, related to this matter – age-old conflicts of liberty and oppression, order and disorder, licence and discipline – the eternal social argument of how society controls the disruptive forces within it and deeper still, the conflict in each of us between instinctive drives and social controls. And I saw too how much my own inner fears, fantasies, hopes and desires were bound up in all this struggle.

While the male staff were opening doors in 1955 and 1956, the women staff became rather envious of the men’s acclaim. The women staff had opened several wards, and during 1957 the women’s Admission Villa, but they pointed out that a group of their wards were so interconnected that we could not open one without opening all of them. Also the ward nearest the door contained a number of simple-minded, unreliable patients who might well wander away and come to harm. We had several other problems among the women’s wards as the number of very frail elderly women was increasing and we did not have enough downstairs wards for them. Then Miss Brock came up with a plan for rearranging six wards, which allowed us to meet nearly all the problems. It enabled us to increase the number of open wards substantially; it gave us two extra downstairs wards for elderly and frail women; it moved the disturbed women’s ward into better quarters, while reducing the number of their patients. The project involved some building of partitions and an extra kitchen, but the Committee agreed to these. They also took the opportunity to redecorate several of the wards. Just before Christmas 1957, we carried out the rearrangement and opened three women’s wards at once. This left only the women’s disturbed ward and the ward for frail old women locked. We had more demented and confused women than men and they were more restless. They were not likely to improve mentally and they were failing physically; our task was to look after them as humanely as possible for the remainder of their days and to try to prevent them coming to harm. The old men were mostly content to sit quietly in front of the fire, but the old women were often constantly active, pottering about aimlessly. If they found a door, they would open it and might wander out into bad weather and come to harm. We had heard of one open door hospital where an 80-year-old woman had wandered out into a snowstorm in a nightdress and died in a ditch. The coroner and the relatives had been very critical of the ‘care’ given her. So we were doubtful about opening the old women’s ward door. Finally, we compromised by putting a latch on the door above the ordinary handle. Any person in possession of their faculties could open the door easily, but the old ladies would rattle the knob fruitlessly and then wander away. I wondered if it was sophistry to call this an Open Door, but it was open to visitors, to staff and to anyone who had enough sense to observe and act simply. In one sense, it could be regarded as a test of competence; if any old lady got out of the ward, she was better mentally than we thought. The visitors were certainly glad that they could get into the ward without having to wait in the corridor until a nurse came to let them in. The women’s disturbed ward Female 5 (F5) was a greater challenge, as this contained a number of disturbed young women with suicidal and at times homicidal drives, who wanted to run away. We put to the ward sister the same proposal that we had made to Male 5, that she could open and close the ward at her discretion. She was doubtful and hesitant, but about six months after the move round, the door was opened in September 1958. On quite a number of occasions, however, the door was locked again for a few hours, days or even weeks. The nurses were apologetic, but felt it was necessary; there

were so few of them and the patients were so disturbed. For some years, this continued and it was not until 1961 that it was open all the time. By now, all our intervening doors had been unlocked and when the last ward was opened, in 1958, I stopped carrying a key. From my first days in mental hospitals I had always carried a key, often a bunch of keys, so that I could get in and out of wards. Now, I left the key lying on my desk and went around without one. At times, I found doors locked and had to ring bells or knock on them, but I felt that this was good; it enabled me to see what sort of a service was given to those members of the hospital community who did not have keys. I was sometimes mildly amused on seeing the face of a staff member fall as she opened a door, to find that the knocking which she had been disregarding came from the Superintendent. It made it no better when she said ‘Oh, I’m so sorry, Sir, I thought it was only a patient!’ Now, keys were of much less importance. Nurses in charge of a ward carried drug cupboard keys, but the hospital keys mattered less. It was no longer necessary to check them in with the porter. Some staff did not carry them at all. These were also the years when tranquillisers, notably Chlorpromazine (Largactil) were coming into use. After a hesitant start, we used more and more Chlorpromazine, so that by the time we had all the doors open, about half the patients were on Chlorpromazine and many receiving large doses. Could we have done what we did without Chlorpromazine? For quite a time I said that we could, pointing to the fact that Dingleton Hospital was open in 1949 and Mapperly Hospital in 1953, before any Chlorpromazine was available. Further, I would point to hospitals where Chlorpromazine was being freely used, but where all the doors were still locked and tension and violence were as bad as ever. As years went by, however, I came to feel that the tranquillisers had helped us to open the doors. Some patients’ delusions and hallucinations were checked by tranquillisers; others had their tension much diminished. For many, the drugs acted to keep them quieter, less inclined to violence or panic, without dulling their minds. Altogether, by reducing the general tension in a ward and by eliminating some of the terrifying violence, the drugs made it easier for nurses (and other patients) to make better contact with the most disordered people and made the ward life easier. I finally settled to the opinion that Open Doors and tranquillisers are two necessary and complementary parts of good hospital treatment. The years 1955–57 were good years during which work and freedom flourished in the hospital and life at Fulbourn changed amazingly. They were also exciting, exhiliarating years for me personally as I started seeing the results of my efforts. The morale of the hospital was high, its atmosphere changed and our reputation in the neighbourhood altered. ‘I hear things are going well at Fulbourn’ was a comment frequently made to me at university parties. My general pattern of government was fairly settled by 1956. The morning meeting with the doctors was my main instrument of medical policy; all new plans and projects were discussed here and many minor difficulties sorted out. After the early turmoils new

doctors accepted that the senior nurses had legitimate comment to make on any matter. Fred Houston was, of course, a member and after the second summer, Leslie Buttle became a member. Although he was officially the Deputy Superintendent, and took charge of the hospital when I was away, he involved himself little in my plans and projects. He had always said that he was ‘interested primarily in clinical work’, especially with outpatients and short-term inpatients. He was responsible for the long-stay women’s wards for my first two years, but as soon as Fred Houston was settled in charge of the men’s wards, I took over personal charge of the long-stay women’s wards from Leslie Buttle. The doctors’ morning meetings had many other functions. There was the obvious one of exchanging information. The doctors told me and the others about major happenings; the night duty doctor reported on any overnight turmoils. I distributed letters which had been addressed to me but which really concerned others, especially those about particular patients. There was also the more important function of clearing misunderstandings and ventilating conflicts. Sometimes this failed, particularly where differences arose from personal antipathies; at times I would feel surges of irritation run through the meeting without being able to discern the cause, though sometimes I heard months later what lay behind a blow up. One doctor had made one of the maids pregnant and another persisted in having his girlfriend to stay overnight in the residency; one doctor was at odds with his wife, who set her cap at other doctors. Miss Brock knew about these situations, but nobody told me. They contributed undercurrents which I did not understand, sometimes for months. I was often unsure how much gossip I should heed, or seek to find out, about my colleagues’ personal affairs. I finally decided to ignore personal undercurrents unless it was clear to me and to the meeting that they were affecting the welfare of the patients. It was also in these meetings that the new doctors learned how the hospital worked and what their powers and responsibilities were – toward their patients, the other doctors, the Consultants and the nurses. I found that all new doctors would make a few mistakes which could be corrected in the meeting but more important, that they learned from the comments they heard about others’ mistakes, and they saw how decisions were made. I also came to hope that they learned my approach to a problem and gradually gave up the traditional model of decision-making (in which the doctor gathers the facts, decides the diagnosis and prescribes the treatment, largely unaided) for a method of group discussion. In these discussions all involved in the problem had their say and the summing up, formulating and implementing of the group decision often fell to some other member of the group than the doctor. I was attempting to extend government by group decision-making throughout the hospital. I welcomed the Charge Nurses’ meetings – it was in and through them that the issues raised by increasing the patients’ freedom were debated to and fro and there that the key decisions to open doors were taken. I gradually developed Sisters’ meetings; however, although there was never another debacle like the first, they went less well. At times, all the women would become very angry – something I found difficult to endure. However, we worked through quite a few problems in the meetings, though Miss Brock always preferred to deal with knotty problems herself by personal interview.

Mrs Adrian, the Chairman of the HMC, was also fond of informal meetings. At least once a month, she met the Officers of the HMC – myself, Mr Mitchell, the Finance Officer, the Supplies Officer, the Engineer and her Vice-Chairman – and discussed all the forthcoming HMC business and many other general matters. These meetings were often lengthy, as everything was fully thrashed out, but it certainly clarified the business, and it often avoided the Officers disagreeing openly in front of the Committee. However, basic differences in approach would sometimes erupt in major Committee battles. The drug bill for Chlorpromazine (Largactil) was an example. In 1953 the annual drug bill for the hospital was small and did not vary much. Then the doctors started prescribing the new ‘tranquillisers’, at first on the admission wards, then on the long-stay wards; they seemed amazingly effective. As Superintendent, however, I had to deal with unexpected repercussions. The hospital drug bill soared because Largactil was quite expensive. The Finance Officer reported this to the HMC, pointing out that the hospital was exceeding its budget, and demanded that I order the doctors to stop this prescribing. I refused, citing clinical freedom – while anxiously asking my colleagues what on earth they were up to, and whether there was any foreseeable limit to their demands. There was a great debate in the HMC with some members emphasising the need of the patients to have the best treatment available, others the need to protect the public purse from the extravagance of the doctors. This went on for months. I kept careful records of Largactil usage and tried to predict how high the cost would go. Fortunately this was happening all over England, and in all the psychiatric hospitals of East Anglia so that finally the Regional Board made a special allowance of money for the increased bill for psychiatric drugs. The cost of Largactil dropped and its use in the hospital levelled out. The Finance Officer and I settled back into our previous state of uneasy truce. During the summer of 1955 Mr Mitchell spoke to me, wondering whether there might be value in a Hospital Officers’ meeting. I jumped at this and, taking the impending opening of a new ward, Adrian, as a theme, called the Hospital Officers together one Wednesday morning. In the group were Mr Mitchell, the Group Secretary, Miss Brock, the Matron, Mr Tucker, the Chief Male Nurse, the Hospital Engineer Mr Kelly, the Hospital Catering Officer, Mr Chappell, the Estate Officer Mr Banyard and myself. The hospital officers proved a challenging group to weld together. At first several of them could see little point in the meetings and would fail to arrive. They felt the tug of divided loyalties – the Engineer, Mr Kelly, was responsible to Mr Merrin, while Mr Banyard took direct orders from Alderman Street, the Chairman of the Farm Committee. There were ancient feuds dividing the departments and in the first years of the meetings we spent much time hammering these out. Miss Brock felt that the Engineering Department was slow in its maintenance work and for months she brought up lists of overdue work. I had to reassure the Engineer privately about what he called ‘the weekly game of shooting down the Engineers’. As he explained each time the difficulties he faced, and at the same time did his best to meet her requirements, she gradually eased the pressure.

The male nurses and the gardeners had feuded for years and Mr Banyard constantly brought these squabbles into the meetings; here again careful elucidation, allowing each person to put his view, and working out a solution explicitly related to the needs of the patients, gradually improved things. I found that I had to be quite open about the conflicts of loyalties and tell the Engineer and the Farm Manager my views, but admit that if their masters refused to accept them they must endure the situation until the conflict was resolved at Management Committee level. The opening of the new Villa, Adrian, in the spring of 1956 was the focus of the first winter’s meetings of the Hospital Officers. By the autumn of 1956 the meetings were well established as a central part of my system of management. Their manifest function was to coordinate the work of the hospital officers and departments, both for special occasions, such as Fetes, Christmas festivities, Opening Ceremonies and Open Days, and for the general running of the hospital. They also served for the passage of information. The Officers reported on developments in their departments, especially those that would affect other people, such as excavations that would block roads, parties or visitors requiring food, or Ministry auditors making enquiries. I tried to pass on all things of interest that I had heard from the Hospital Management Committee, from the Regional Board or from the Ministry. For years the Officers and departments at Fulbourn had bickered and had often used the patients as shuttlecocks in their games of administrative badminton; now I was able to control this. Of course there were some recurring conflicts of interest or basic differences of viewpoint which always persisted. An engineer, mindful of long-term dangers such as boiler failure, saw repair priorities differently from a charge nurse irritated by a blocked lavatory. Gardeners like to put plants up walls, engineers like to keep walls clear of vegetation. Administrators wanted stocks carefully controlled, occupational therapists wanted materials to hand and did not like to be bothered with frequent counting. But the effects of even these traditional differences could be modified when each officer heard the other’s viewpoint, and when all plans were submitted to the test – ‘What is best for the patients?’ Over the first few years of meetings we worked through some of the chronic hospital squabbles; gradually the gardeners came to see the nurses’ problems and the nurses the engineers’. As mutual respect grew, they began to settle things beforehand and the principle was established that they only brought to the meeting problems they could not resolve between themselves. In 1953 Mr Mitchell and I were the only Officers who attended the full meetings of the Hospital Management Committee, and other Officers therefore could not always understand what happened at the meetings. I came to feel that the responsible Officers should be more in touch with the Committee. I disliked being the sole channel of communication between them and having to argue for matters, such as nurses’ uniforms, that I did not care about or understand, or having to pass back decisions with which I did not agree. As a result, I was able to persuade Mrs Adrian and the Management Committee that the Matron and Chief Male Nurse should attend, first the meetings of the Finance Committee and then a year later, the meetings of the main Management Committee. Some of my friends criticised my actions, saying that if I had remained the

sole channel of communication my authority would have been stronger. But I did not find this to be the case. Miss Brock and Mr Tucker were grateful to me for pressing for their entry and my rapport with Miss Brock improved greatly. Whereas before she had suspected that I did not press sufficiently vigorously for the things that were needed, she now saw something of the problems involved, the shortness of money and some of the opposition I faced on the Committee. The Hospital officers’ meetings improved communications, ironed out difficulties, supplied missing channels of executive command and thus were valuable. To me, however, these manifest gains were much less important than the more subtle ones. The meetings gave the hospital work a purpose that was lacking before. My belief that the value of any project lay in the good it did the patients gradually penetrated even such technical departments as gardening and engineering. In the past other aims, such as economy, preservation of stocks of goods, neatness of the gardens or smartness of the hospital transport had outweighed considerations about the good of the patients. Sometimes this was very apparent. Once we were discussing some inappropriate Ministry memorandum and its effect on the hospital. Mr Mitchell finally said ‘After all, our job is to receive the instructions of the Ministry and of the Management Committee and to implement them to the best of our ability.’ I exploded. ‘Not at all, Mr Mitchell’, I cried ‘Our job is to treat the patients as well as we can, and to make the Committee, the Regional Board and the Ministry understand and meet our needs and help us to do it!’ I tried to ensure that there was always something ahead for the Hospital Officers to work toward. The recurring events of the year’s calendar helped; there was Christmas – with special meals, parties and entertainments; Easter – with the need for special flowers; the Open Day – with the need for guides and special catering; the Fete – with the problem of getting all the patients out on the grounds; the Hospital Flower Show – the big event for the Estate Officer. We always spent time trying to surpass the previous year’s achievements, and afterwards I made a point of congratulating warmly those who had done well. Special events were even more of a challenge: the Officers’ Meetings began with the arrangements for the Opening of Adrian Ward by the Minister of Health in May 1956 and there were other occasions, as when the Royal Medico-Psychological Association held a meeting at Fulbourn, or the Association of Hospital Management Committees, or when we opened our new Occupational Therapy Unit. Perhaps our greatest triumph was the Royal Opening in 1964. Each of these served as a focus for effort and enthusiasm (and, of course, lots of pictures in the Cambridge Daily News). The most rewarding of my meetings during these years was the Occupation Meeting on Mondays. Fred Houston and Mr Allen both poured in their enthusiasm and each week we worked on the problems and rewards of our ‘Work-for-all’ programme. Mr Tucker seldom came, but Miss Brock began to attend regularly and was soon enthused. A key and founding member was, of course, our Head Occupational Therapist. Fulbourn had had an Occupational Therapy Department since the early 1930s. They occupied a pleasant building, specially built for them, on top of a hillock behind the hospital. In the postwar years, however, they had limited their work to the small group of long-stay patients who were skilled enough to do fairly good work and to the short-stay patients.

The Head OT was most skilled and deeply interested in helping those she found congenial – especially the better-educated. She had, however, been disappointed in earlier years in her attempts to get work going on the wards and had rather withdrawn from this. Assisting her was a series of young women, recently graduated from schools of Occupational Therapy who would stay a year or two and then move on. Though temporary and rather uncommitted, they were most valuable to the hospital for they brought youth, enthusiasm and new ideas to the constant question of what would be most stimulating to the patients. Miss Brock had now taken on board the idea of ‘Work-for-all’ and wanted to start her long-stay women working. She put nursing assistants in charge of groups and asked for materials and help. This led to many difficulties, and much of the first years of the Occupation Meeting was spent sorting these out. Miss Brock found a group of patients sitting idle and scolded the nurse, who said that they had no materials. Miss Brock went to the Department and told the Head OT that she was letting her down. The Head OT telephoned me to complain of Miss Brock’s remarks and we spent all the next Monday’s hour hammering this out. It was slow and wearisome at times, but gradually supplies improved, classes improved and the young occupational therapists started going onto the wards. One person who responded to the outdoor work was Elizabeth. She went out with the women’s gardening squad and seemed to enjoy herself. She began to look better physically, although in talk she was as bland, curt and uncommunicative as ever. At the first patients’ sports day, Elizabeth excelled. She won the women’s sprint, the egg and spoon race and the sack race; she won more races than anyone else, man or woman. She received her rewards with her usual offhand calm. But the ward reported that the next day she had asked to have her hair washed and set. Her hair was permed and she kept it neat. Her dresses were well looked after. She started using some lipstick and enjoyed the weekly dances. I made enquiries about violent outbursts. These had been far fewer. Another affected by the new atmosphere was Caroline, the handicapped, simple-minded ‘doctors’ maid’. On her ward she had a friend, Mary, an elderly widow; they sang in the choir together and had beds next to each other. Mary had had a fairly full life before a prolonged depressive state had brought her to hospital; over the years in hospital she had settled into a state of genteel grumbling. Caroline’s energy matched Mary’s faded refinement and they were good friends. As the hospital became more open Caroline and Mary began going out – first to hospital parties, then on shopping trips to Cambridge, then on the Women’s Institute outings. Mary helped Caroline with her clothes and her hair until they looked just like any two middle-aged country women in town. When we tried a Boarding Out scheme, in 1955, Caroline was one of those we managed to place. However, her landlady became ill and had to let her boarders go, so Caroline came back to hospital. Then we found her a place in an old people’s home as a resident domestic and she settled happily there. The energy, good humour, obedience and religiosity which had made her so useful in hospital fitted very well there.

It was about this time that the Head Occupational Therapist resigned to work at a small private hospital, so she could work, she said ‘more selectively and intensively’. We then had several Head OTs. One of them was a woman of many diverse enthusiasms, who started exuberant activities all over the hospital; she was followed by a quiet, conscientious girl – which was just as well, for the exuberant lady had so disorganised the stocks and records that the auditors and finance officers descended on the department and nearly paralysed it by their demands for an adequate accounting of all the raw materials that had been used up! Our ‘Work-for-all’ drive was started by using the ward orderlies and nursing assistants as leaders of working parties. These excellent people were warm-hearted local men and women from diverse backgrounds who had come to work at the hospital in middle life. They had been hired as ‘untrained’ staff and were originally intended to be used for menial tasks, such as making beds, cleaning toilets, sorting laundry and polishing floors. However, the shortage of staff had meant that many of them had taken on more responsibility. Nonetheless, they had always felt disregarded and despised and they were delighted with the opportunities that the work programme offered – especially since they could often use skills they had learned in other work. Of the men in charge of the Sports Field project, one had been a military policeman, two had worked on public works projects and knew a little of surveying, and one had been a county roadman. The knitting classes attracted women with high skills in handicraft, knitting and embroidery. An exArmy Physical Training Instructor took on a group of elderly men. To all of them, it gave a degree of recognition they had not experienced before and they responded warmly. As the work extended, however, we felt that there was a need for more skilled staff. I began putting in applications at regular intervals to the Regional Board and the Ministry; we got permission to engage the tradesmen for whom we had asked. Between 1956 and 1958 we gained an instructional carpenter, a physical training instructor, an industrial supervisor, a librarian and two more occupational therapists. When we advertised the post of occupational carpenter, one of the applicants was Percy Burgess, from a local carpentry firm. Although he was not impressive when interviewed our external adviser commended him warmly and I agreed reluctantly. We got him a set of carpentry tools and put him in one of the old workshops. He was a tremendous success. He gathered together a group of men from long-stay wards – mostly East Europeans, Poles, Ukrainians, Russians, Yugoslavs, who had come to England from Displaced Persons’ Camps and who were withdrawn, psychotic, thought-disordered and suspicious. The first task was to create the workshop. Percy built all his own benches, racks and cupboards. He took old hospital tables and cupboards and repaired them. He built new furniture. He even made church furnishings and a lectern. His workshop became a favourite spot to take visitors. But far more important was what he did for the patients. These men had been suspicious, cut off and demoralised; they had stood about the wards idle and silent since no one could speak their language. When we fetched interpreters, they said the speech was disordered nonsense. Percy at first communicated with these men by signs and then by leafing through an illustrated carpentry catalogue with them; all of them knew wood and woodworking and one had been a cabinet maker.

They worked together; he would show them what he wanted and they got on with it. Gradually, they built up a team; at mid-morning and mid-afternoon, they brewed tea and chatted in broken English. Percy began bringing in his daily paper, discussing the news and telling them of English life; he took them into town with him and to his home. The men became livelier, brighter and more active; their appearance smartened and their English improved. All of them moved from back wards to privilege wards and several of them left hospital. Percy remained as slow-spoken as ever, but I came to have a deep respect for this outstanding craftsman, who had come to work with us because he ‘had always wanted to do something for other people’. When we rearranged the wards in 1954 in order to put one Charge Nurse on each, we offered ‘Male Open Ward’ Male 1 (M1) to Eric Raines – a bluff cheerful man who was a leading figure amongst the male staff, an outstanding cricketer, a former RAMC Sergeant Major, and a lively raconteur. This ward contained all those men who were useful and well-behaved and deemed fit for privileges. All the top grade hospital workers were there – Arthur the librarian, George the storeman, the cricket team’s scorer and others. Other useful skilled men in M1 were an amateur watch repairer and a barber. There, too, were lodged Hugh and most of the Farm Gang, the strong agricultural labourers who did the hard work on the hospital farm. There were also many quiet men who had been in the hospital many years, held some minor quiet job, did what they were told and gave no trouble. Eric Raines accepted the job with enthusiasm and soon began making changes. The men in M1 were some of the first beneficiaries of the new property-owning in the hospital. They were on the higher wage rates and began to acquire personal possessions – suits, shirts, soft shoes (instead of boots) shirts with collars that fitted, suitcases, watches, books, bicycles – all things forbidden before. More important, Eric began to change their lives and to encourage initiative. He encouraged them to take part in the work of the ward, distributing the food, managing stocks – tasks traditionally reserved for the nurses. He started ward meetings to discuss problems of life together and they developed a system of open justice with Eric as Chairman – where ward conflicts, struggles for power and the curbing of delinquents was worked out in open and simple terms. They started having parties, first their own and then inviting the ladies of the women’s open ward to join them – a great break with tradition. Eric encouraged his charges to venture into Cambridge and explore the outside world, so long unknown to them. He then started suggesting to them that they might get paid work outside. At this stage his cricketing contacts proved useful. He knew foremen, gangers and small employers all over Cambridge. The 1950s were a time of full employment in England, when employers found it very difficult to get reliable men for low-paid, dirty, heavy work. Some of Eric’s men wanted freedom – both economic and personal. He was able to recommend them to bosses who were often very pleased with these docile, industrious men. Gradually he developed an unofficial employment agency. The men also started arranging outings and trips – taking up a collection from those interested and hiring a bus. This caused the Finance Officer some anxiety. The HMC

already hired a bus for ‘patients’ outings’. Why should they not use that? I found it quite difficult to explain to him the therapeutic difference between raising your own money, choosing your own destination and your own time and going with your own friends after work as opposed to going passively on a dull, predetermined trip on a bus provided by the management. In 1957 we got permission to appoint a Librarian and after several tries, had the good fortune to get a jovial woman who accepted the task with enthusiasm. She treated Arthur, the patient ‘librarian’, with courtesy and consideration, letting him stay on, but she got the Library properly open and got the books out on to the wards; she got books from the County Library and increased the circulation. She treated all borrowers, patients and staff, with equal courtesy, enthusiasm and efficiency. She badgered me constantly about the horrid little room she had to use and so I persuaded the Management Committee to replaster and repaint a room marked for demolition and stock it with bookshelves made by Percy Burgess. Thus, we had made ourselves an attractive Library and Reading Room. Arthur moved in with the books and sat contentedly in one corner, rearranging his filing system and his collection of cuttings about the Royal Family. During 1956 the Regional Board, who were responsible for all major building projects in the hospital, examined the Occupational Therapy building and decided it would make a good ward. We pointed out that they must rehouse Occupational Therapy and they obtained money to build us a new department. Originally it was only to be workshops, but they had appointed an imaginative young architect and from the discussions which he and I had a delightful building emerged with wide glass windows, spacious work rooms and pleasant views. We moved into it in 1958 and celebrated by arranging a loan exhibition of paintings by hospital patients to which we asked many local artists and connoisseurs. More money was coming from the Government during these years, as they had become aware of – and, consequently, ashamed of – the state of Britain’s dilapidated mental hospitals. The money was doled out by the Regional Boards, but hospitals did have some choice in how the money allotted to them was spent. In many areas, Management Committees put their money into long-term projects; they would empty a ward of patients, redesign it, put in new heating and lighting and windows – then reopen it, magnificently re-equipped, and decant back into it the pathetic, long-term patients who had been jammed up elsewhere during the two years of rebuilding. This process was, of course, popular with Regional Boards and the Ministry because it created impressive buildings, but I fought against it. I asked for more staff – especially to help with occupation (getting the patients working) – and specifically more nurses, with the slogan ‘Brains not Bricks!’. When we had money for physical improvement, I demanded that it be spread throughout the hospital and be used directly for the patients. We put in new mattresses and new windows throughout the hospital; we supplied lockers wherever we could squeeze them in; we repainted each ward; we put in new furniture, some in every ward; we supplied all day rooms with curtains and finally even the dormitories. As a result, no group of patients or staff felt

neglected and forgotten (as happens when all work is concentrated on one building) and each ward got the things that they felt they needed most – rather than what the Regional Board or the Management Committee thought would be best for them. The method was, however, somewhat piecemeal. The Engineer and Supplies Officer complained that no one ward was ever in first-class condition and the Finance Officer said that we were not getting full value for our money. However, I believed that in this way, we got better value in patient improvement, as the staff saw that those in power cared about what they asked for and were therefore better motivated in their work. We brightened up the whole hospital with new and cheerful paint, new furniture and colourful curtains. I felt happy and proud of the hospital and felt that I personally had done a lot to bring about the improvements at Fulbourn. The climax of the early years was in 1957. The work programme was going well. We had got nearly all the men and many of the women working and the sports field had made visible progress. We had opened a number of wards. Our local reputation had changed – partly because we were doing better work, but mainly because we were actually telling people of the work we were doing. My work with the Press was paying off. The new ward which was first suggested in 1953 had been built and named Adrian Ward. In May 1956 we had had a grand opening ceremony, performed by the Minister of Health. This was our first great public event, and for weeks beforehand the hospital officers planned anxiously. Everyone of consequence in the district was invited. There were Members of Parliament, Lords and Ladies and a handful of Mayors. We even had as guest of honour the 95-year-old Mrs Florence Keynes, the mother of Lord Keynes, who had been the first woman Chairman of the Visitors Committee in the 1930s. She observed the proceedings with approving, but acerbic wit. We erected a marquee for the ceremony (hired at considerable cost, the subject of later recriminations) and the distinguished audience heard the Minister, a distinguished figure, make an undistinguished address; however, it was smooth and polished and, though full of platitudes, contained some amusing quips. The Bishop blessed the building, the Minister opened the door. After a tour of the building, the visitors were served with tea and then duly departed in their limousines. Everything went as it should. That evening I was exhausted, proud and delighted. I rushed round the hospital thanking everyone for all they had done. The following day, a full page of the Cambridge Daily News was filled with pictures of the great and admirable doings at the once despised Fulbourn Hospital. Another part of our drive to inform the public about our work was the staging of Open Days, starting in 1955. We found that all kinds of people were asking about the hospital, so we set aside one day in the summer to show them what we were doing. For the first Open Day all our guests were invited – City and County councillors, social workers, probation officers, district nurses, General Practitioners – and about 200 people came. I welcomed them and we sent them round the departments and wards in groups led by Charge Nurses and Sisters. We then gave them tea in the hall with a question and answer discussion afterwards. This was a most successful exercise; most of the visitors were pleasantly surprised at what they saw; it was far better than they had believed. Even more

striking was the effect on the nurses and sisters who acted as guides; many of them went into parts of the hospital they had never entered before; the questions the visitors asked them challenged their knowledge of their own hospital; the admiration made them proud of what they were doing. Over the years we gradually extended this, having one or two Open Days every summer. We invited many groups – and then the general public. We placed advertisements in the local paper inviting people to apply for invitations; hundreds responded the first time. Many people came to see what we were doing – including potential clients. There were remarkably few problems. The patients on the long-term wards were delighted, and often hailed old friends from their villages. A few people who had come in more recently were less pleased to be seen in Fulbourn – so we set aside areas to which those who wished might withdraw. Once the hospital was fully Open Door, of course, taking people round became easier and we began to arrange for groups to go around by appointment. In 1956 we held our first Nurses’ Badge Day. Our nurses had never had badges to mark their graduation as Registered Mental Nurses. Miss Brock and I managed to persuade the HMC to find the money for some handsome silver badges with a fine heraldic design incorporating the arms of the City of Cambridge. That summer, we gathered many who had trained at Fulbourn in earlier years, and they received their badges from Dame Elizabeth Cockayne, the Senior Nurse at the Ministry of Health and a Dame of the British Empire. The occasion passed off well and Miss Brock was delighted; she felt that at long last her hospital and her nurses had become respectable. More importantly, the patients, the very reason for the hospital’s existence, were doing better. They were more active and looked healthier; many more of them had freedom and a number expressed their gratitude openly. Instead of shambling about the airing courts, they were to be seen going off into Cambridge at the weekend, smartly attired in their Sunday suits and dresses. In 1957 the King Edward’s Fund Staff College, London ran a refresher course for Medical Superintendents ‘known to be doing outstanding work’. To my surprise and delight I was invited. This I felt was real recognition; my peers, the men in the same job, thought my work was good. In February and March of 1957 I spent four weeks at the Staff College in Bayswater. I found myself with some of the most admired Superintendents in England – men like Duncan Macmillan of Mapperley, Rudolf Freudenberg of Netherne and Francis Pilkington of Moorhaven. Best of all, for me, was Maxwell Jones of Belmont, bubbling, irreverent, charismatic, fascinating. We were a group of ten. I was amongst my masters and eager to learn. Many experienced people came to talk to us – T.P. Rees of Warlingham, Aubrey Lewis from the Maudsley, Walter Maclay from the Board of Control, Alexander Walk the psychiatric historian, Members of Parliament, top Civil Servants, even the Chief Auditor. Our Course Director was Sir Wilson Jameson, a wily old Scots public health doctor who, as Senior Medical Officer at the Department of Health in 1946, had helped Aneurin Bevan create the National Health Service.

The most valuable talk was over meals and in the evenings. At first we talked of the good things we were doing and had done. Then, in the second week, as we came to trust one another, we talked of our difficulties, our frustrations and our failures and then finally, in the last week, we began to talk of how we might overcome some of them and where we might go next. All the month I was learning, thinking and picking up ideas. I came back to Fulbourn with enough to keep me going for several years – Open Doors, Therapeutic Workshops, Industrial Units, Halfway Houses, Therapeutic Communities – there was no end to what we might do. During the late fifties and early sixties I became more involved with the work of the Cambridgeshire Mental Welfare Association and gradually came to realise what an exceptional organisation it was. One of the oldest mental welfare organisations in Britain, it had been founded in 1909 by some high-minded Cambridge University ladies, notably Lady Ida Darwin and Dame Ellen Pinsent, because of their concern about neglect of the mental defectives in those days. In later years the CMWA had started many projects – the first psychiatric social worker in Cambridge in the 1920s, the first occupation centre in the 1930s and the first child guidance clinic. Now, filled with ideas from her Royal Commission work, Mrs Adrian was pushing it to new projects, such as Halfway Houses. She had recruited Pauline Burnet to help her, making her Secretary and later Chairman. I got to know Pauline better, particularly after we discovered that we were almost twins, being born on consecutive days in August 1920. By 1957 our family and social life was fairly steady. We were well settled in the Medical Superintendent’s house in the south-west corner of the hospital grounds. We filled the house with young people, au pair nannies, young relatives and Hungarian refugees and gave frequent and large parties. We grew our own food (with the help of patient gardeners) and raised chickens, ducks, geese, rabbits, hamsters. Our three children attended Cambridge schools but made the whole hospital their playground – to the delight of many of the patients and staff (and the irritation of some others). They made friends among the patients and came home with tales of Chinese princesses unjustly detained and strange happenings in the water tower. In 1956 Dr Noble retired and there was a vacancy at Addenbrooke’s. Beresford urged me to apply for it, so that I could concentrate on clinical work, rid myself of the ‘burden of administration’, and develop a private practice. This seemed a most attractive prospect and I was tempted. My wife and I discussed it at length, but I concluded that I would rather go on with the task that intrigued and challenged me most – turning Fulbourn into a good hospital and relieving the degraded life of the long-stay patients. About this time Winston House started. I had spoken often about how difficult it was for our long-stay patients to move out of hospital, even when they were no longer mentally disordered and were holding a job in Cambridge earning a good wage. The transition from the regulated, ordered, supported and disciplined ward life, where meals, clothes and entertainment were provided, to the life of a boarding house or bedsitting room where one had to manage, cater, plan and organise for oneself, was too difficult for many and they came back to hospital defeated after a spell ‘outside’. There was a need for

transitional facilities between hospital and life in the community. In 1956 Mrs Adrian heard that a building in Cambridge named Winston House – which had been used as a hostel for delinquent youths – was vacant. It was funded by the Cambridge Rotarians and run by the ‘SOS Society’ – a national organisation that ran homes for homeless people. She talked to them and persuaded them to work with the Cambridgeshire Mental Welfare Association to develop Winston House as a Halfway House for recovering psychiatric patients. These negotiations took many months, but by 1958 Winston House was ready to open. When I first went to Fulbourn my prime aim was to do a good job running the hospital. I was not much interested in anything else and it took all my energies. I kept some contacts with my professional friends in London and attended some psychiatric meetings – but not very actively. I kept in touch with the Social Psychiatry Unit at the Maudsley and Morris Carstairs, who was then running it, and it was he who invited me to go with him and Neil O’Connor on the trip to Dutch mental hospitals in 1955 which gave me such an exciting idea of what industrial therapy could do for the mentally ill. From that trip came an article in the prestigious medical journal, the Lancet. Apparently the word began to go around English psychiatry that lively things were happening at the mental hospital at Cambridge and people started coming to visit us. In the late 1950s a number of American psychiatric reformers were paying visits to England to see the British Social Psychiatry of which they had heard so much. They went first to the British mental hospitals which were leading the country at that time (such as Mapperley Hospital, Nottingham and Warlingham Park Hospital, Croydon), but some of them added Fulbourn to this trip. Alfred Stanton and Morris Schwartz, the authors of the revolutionary book The Mental Hospital which had been the first analysis of a hospital as a society of people (both sane and insane) acting and interacting on one another, came to us in 1955. Leading mental health sociologists also visited us – John and Elaine Cumming in 1956 and Warren Dunham in 1957. In preparation for the centenary of the hospital in 1958 I had been reading through the old Annual Reports and getting to know something about the early days of Fulbourn Hospital. I was conscious of the importance of the occasion and invited the Royal Medico-Psychological Association to hold a meeting at Fulbourn. I told the HMC of the anniversary and offered to write them a centenary book, telling something of the doings of their predecessors. In 1957 I was looking forward to increasing activity and renown. Sadly, this was not how things turned out. 5 Difficulties and Challenges All seemed well in 1957, for the hospital and for me. However, this situation was not to last. The year which followed was a bad one – a period of defeat and of hesitating purpose. Many things went wrong, few things went well. I had, of course, experienced problems before – when accidents occurred within the hospital, when hostility and opposition to me had been marked, when policies had been

baulked at or reversed, when patients did badly and suicides occurred – but these had passed and we were undoubtedly progressing. The general mood of the first four years had been of advance, confidence and enthusiasm. The hospital had prospered and the patients benefited. As a result, my exuberance flourished and I may have grown overconfident – instructing those who knew better, talking down those entitled to a hearing, pushing my own ideas brashly. Perhaps a reaction was inevitable. My first hint of difficulties came in the meetings of the Hospital Management Committee. I knew that I had upset some of them and I had become accustomed to hostile criticism, particularly from Alderman Street. A retired businessman, Mr Street was often in the hospital; he came over at least once a week to go round the estate and give the Farm Manager his working orders; he was always ready to serve on any ad hoc committee. I had made several attempts to mollify him, without success. He made little secret of his view that I had too much to say for myself. On other bodies on which he served, he said, officers spoke when they were called upon. They were becoming, said Mr Street, ‘the managed committee’ not ‘the Management Committee’ and by what right had the doctor taken over the Committee Dining Room as his office? These and other of his comments were passed on to me by mischief-makers. While in Committee meetings, Mr Street was the first to make objections to any proposal I put forward. The ‘airing courts’ and exercise yards had stood in front of the wards for a century – asphalted areas bounded by walls or high railings in which unoccupied patients were exercised. As we got everyone working, these areas stood empty and began to look derelict. One summer I led a delighted group of nurses and patients in tearing down the eight-foot iron railings that surrounded the male airing court. At the next Committee Meeting in the autumn, Mr Street stated that this was quite unjustified; these were valuable, antique railings of fine cast-iron. He had been assured they were worth hundreds of pounds. Who, he said, had given authority for this act of vandalism? When I had a shrubbery cleared by a group of patients, it was he who called attention to an ancient ruling that no tree might be felled on the hospital grounds except by resolution of the Management Committee, and he had the ancient rule reaffirmed ‘to check unwise acts by officers’. I managed to talk my way out of most of these situations, but always felt grateful to Mrs Adrian for her support. To my dismay, in the summer of 1957, she announced her intention of resigning the Chairmanship. The favoured replacement was Alderman Holmes of St Ives, an energetic man whom Mr Street had persuaded to join the Committee a year earlier. I was most alarmed. However, the Regional Board chose an exMayor of Cambridge, Alderman Howard Mallett, as the new Chairman. He joined the Committee in the spring of 1958 and, after a few meetings, took over the Chair; Mr Holmes became the Vice-Chairman. I immediately felt things change and realised how much I had depended on the support and protection of Mrs Adrian. Mr Street became even more outspoken in his attacks on me and I began to dread Committee Fridays. Plans were turned down, deferred or mangled. The Chairman’s meetings with the Officers of the Group changed markedly.

Instead of the long cosy rambling discussions that Mrs Adrian enjoyed, in which I could often carry my projects with my ready tongue, the meetings became briefer and more formal. Mr Mallett and Mr Holmes, both Aldermen and ex-Mayors with years of Town Council experience as guardians of the ratepayers’ interests, were quick to see the financial implications of any plan. They were also keen on proper procedure and believed that a Medical Superintendent was a paid official, liable to dismissal and subordinate to the Chairman of the Health Committee. They clearly felt that my view of myself as leader of the hospital, like the headmaster of a school, was inappropriate and incorrect. At Chairmen’s meetings I was chagrined to hear the financial or formal administrative viewpoint increasingly overrule the medical. During 1957 Mr Tucker, the Chief Male Nurse, announced his intention to retire. Though I had got on quite well with him, I had been aware of how little control he had actually exercised and I felt a change might be a good thing. I looked forward to having Mr Allen, who had pushed through the work programme, take over the role and I promised I would do all within my power to get him the job. Though my promise contained the usual caveat ‘It is of course a Committee decision’, I had little doubt of my ability to have him appointed and my certainty must have conveyed itself to him. He went round the hospital talking of what he would do ‘when I am Chief Male Nurse’. However, at the Appointment Committee things began to go wrong and as the afternoon progressed I became aware that things were not going my way. Mr Allen did not show up very well at interview and came in for detailed hostile questioning. In the discussion, it became clear that several members of the Committee felt that Mr Allen was unpopular with the staff. I was puzzled as to why they thought this as I had not observed it myself. (Many months later, I discovered that a few senior nurses had been assiduously pouring poison into the ears of members of the Subcommittee.) Mr Allen was soon out of the running and an outsider was appointed. Mr Allen was bitterly humiliated. I was disappointed for him, angry that the hospital had been deprived of an excellent Chief Male Nurse, ashamed that my promise to him had not been fulfilled and dismayed that my inability to get my favoured candidate appointed had been so publicly displayed. In the coming weeks, I began to appreciate that certain posts were not mine to allot and that I had better realise this and not make promises I could not carry out. My power was limited – I could persuade, but I could not order and I had better accept this. I also realised there were quite a few people glad to see my wings clipped. I saw Mr Allen at length to apologise for my failure and to attempt to assuage his bitterness. However, he continued to be angry and to apply for every Chief Male Nurse post that came up; I did my very best for him with references and fortunately he was appointed Chief Male Nurse to a much larger hospital, with a bigger salary than he would have got at Fulbourn. At about this time, Fred Houston also left. Since his arrival in 1954 he had done more than anyone else to reform the hospital. He had organised the industrial programme and had implemented the open doors policy. He had run a very good clinic at Huntingdon. I loved him for his enthusiasm, industry, goodwill and good humour. For several years, he had been applying for Consultant posts up and down the country, and I had written many glowing references, for I knew he would make a very good Consultant. But the fact that

he had no higher medical qualification had told against him again and again. He gave up hoping for preferment in Britain and emigrated to Canada. I was desolate at his going and angry that there could be no assured place in British psychiatry for a man of such goodwill, compassion and energy. I was thus bereft, in 1957, of my two main lieutenants, Fred Houston and Mr Allen, and I felt sad and isolated. True, my relations with Miss Brock were now excellent, and we were working well together to get the women’s side busy and working. But I missed Houston and Allen and wondered whether I had been justified in letting them pour so much of their energies into our common task for such shabby rewards. The doctors during the winter of 1957 were rather restless. Two Senior Registrars were in the same position as Fred – they had their DPM but no higher qualifications and kept failing to get the Consultant jobs they applied for. They were despairing of finding a place in Britain and started to think about emigrating. They began to say that success at Fulbourn was the kiss of death; that no one from Fulbourn ever won promotion. This affected the morale of the doctors and created a depressed working environment. I then experienced a bigger blow over my favourite project, the conversion of the sports field into a better cricket pitch. During the summers of 1955 and 1956, we had made great progress on this. I had had many conferences with the architect, and the local Grasslands Adviser. The challenge was to get good turf to grow on the central cricket ‘square’; we knew that grass had never done well on our dry chalky soil, but we hoped to make a cricket pitch that could be played on. We decided to treat a portion of Fulbourn’s own natural turf with weedkillers and fertilizers until it was in really fine condition and then to move it to the carefully prepared site. We did this in the autumn of 1957, so that it would be ready to play on in the centenary summer. Alas, as the spring of 1958 opened, the turf grew rank couch grass instead of close, fine leafed fescues. The plan had been a failure and the table was unsatisfactory. Before we could discuss what should be done, Mr Street swept in. He pointed out to the Management Committee that the table was a failure and suggesting that all had been mismanaged. I had to sit helplessly listening to a tirade of allegations and half truths and see the Committee empower him to take over the whole Sports Field Project. Mr Street’s crowning phrase ‘The doctor was not the right man for the job!’ made headlines in the local paper that night. Within the next few days, the cricket table was ploughed up and the architect and the Grasslands Adviser were paid off without a word of thanks. As I thought it over, I came to the conclusion that it was mostly my own fault. In a limited sense, Mr Street was right; I was not the right man to lay out a sports field; I was a doctor, not a landscape architect, I would do better in future to stick to my own job and not attempt those of others. During the winter of 1957–58, the men’s side went through an unsettled phase. The new Chief Male Nurse, Jack Long had arrived at Fulbourn fresh from an excellent hospital, Netherne. A tall, cheerful, lively man, his bonhomie covered a steely determination and integrity that came from wartime experiences as a Conscientious Objector and from his personal Quaker faith. However, he faced a difficult task with Fulbourn male nurses who had for years been allowed great latitude by Mr Tucker’s policy of ‘keeping everyone

happy’. This policy had often meant giving way to everyone and never asking awkward questions; it was this attitude that had landed him in trouble over the missing stock. Mr Long’s attempt to bring some order and competence into the administration of the men’s wards was little liked. The men’s wards were all open; the employment programme seemed to have reached its limit. The Charge Nurses asked me to meet them and to discuss the future. We held a series of weekly meetings in the spring of 1958 with the title ‘Where do we go from here?’ We discussed with pleasure the achievements of the last few years, the immense progress made by the patients and the improved reputation of the hospital. We cleared up a number of minor difficulties and made small improvements, but the problem remained – the patients were active and free, so what next? Rehabilitation was certainly a general aim, as was further improvement of the patients’ living conditions. Some of the Charge Nurses also mentioned the apathy of the patients as a problem – they just sat about and waited for someone to tell them what to do. The nurses looked to me for guidance, but by this time I had no major aims to lay before them. Being unable to reach any specific conclusions about our future goals, we stopped the meetings after six sessions. By this time, in April 1958, I was beginning to feel very low. I was irritable at home, tired at the end of the day, had lost interest in work and play and my sleep was broken. It had, however, been a long hard winter, spring was very late and Easter Day was the coldest for half a century; I thought my gloom would lift with better weather. It was at this time that I met a strange but fascinating man, Richard Hauser, at a mental health conference in London. Even now, years after, I find it difficult to write about him with detachment, for he stormed through our lives like a Pied Piper. He was a middle-aged Austrian who claimed great experience in working with groups and propounded novel theories of leadership. He was charming, talented and well read, quoting the sociology classics freely; he spoke with authority and conviction, referring to the research he had done all over the world and the transformation he had wrought in several institutions. I found his ideas fascinating, his personality charming, his conversation stimulating and his new approach exciting. I talked of some of our doubts and problems at Fulbourn and asked what he was doing at present. He said he was engaged in research on many major social problems – crime, adolescence, homosexuality, addiction – but would be willing to give some time to the problems of Fulbourn; he could come down at weekends; there would be no fee. As I travelled home from my first encounter with him, I was elated by my good fortune in meeting him. He seemed like the answer to my problems. Although I did have some vague doubts – I did not know what his training or qualifications were, who had worked with him or where, or exactly how universally applicable were his theories – but there was no question of his brilliance, charm and experience in working with groups. There could be no harm in having him down; after all, it cost nothing. I would see how others at Fulbourn reacted to him. He came down for a weekend with his wife, Hephzibah, the sister of Yehudi Menuhin. Richard charmed the hospital and Hephzibah charmed my wife, who was musical. They

made an excellent impression in the hospital, especially with Miss Brock and a number of other senior nurses. Richard was enthusiastic about the possibilities of further research at Fulbourn and said he would like to come down again. Hephzibah was devoted to Richard and told us many tales of the wonderful work he had done in Sydney, Australia and how they had transformed the old Sydney Asylum, Callan Park; Richard propounded his sociological theories of leadership. Hephzibah gave impromptu piano concerts. My wife and I were both delighted with these talented and charming visitors and filled with hope for what they could do for the hospital. After he had gone, I discussed things with those that had met him. I asked if they wanted to see him again – they certainly did! Some did because they felt he had something to teach them, others because there were questions they wanted to ask which they had failed to ask before he left. Some asked for his credentials, but I pointed out that he had apparently worked with many famous and eminent people. Everyone seemed to think we should have him back, especially as he did not ask for any money. Then began a strange summer. Every other weekend, Richard and some of his family would come down and stay with us, talking in the hospital, talking in the house, talking till all hours. Hephzibah took my wife to great concerts and to meet Yehudi and other eminent figures in the world of music. Richard always had lots to say on any subject and welcomed a group of listeners. He was convinced of the value of his work and his theories of leadership and that lessons of vital importance for mankind would emerge from his studies. Hephzibah shared his assessment of his greatness. Whenever he talked she would sit meekly at his feet noting down all that he said; one day it would make a great book. He talked with groups of staff and patients and with visitors to the hospital; it was fascinating to watch him draw out their ideas, juggle with them, rephrase them and feed them back again; it was striking to see his charm working to stimulate the most dreary and withdrawn. Hephzibah started a patients’ choir. I felt that we had found someone who was going to uncover all the hidden talents in Fulbourn Hospital and who would lead us through to new and more valuable methods of patient care. I longed to know more about his theories and waited for him to expound them. However, I was still finding other things difficult. My tiredness and lack of energy and insomnia did not clear up and after a full week’s work, a weekend of endless discussions with the Hausers left me little time for rest. I could not seem to get on with the centenary history which I had promised the Management Committee. They had set aside £100 to print it and it was to be a major item of the centenary celebrations. I had begun work in the summer of 1957 – collecting photographs and information, reading musty volumes of reports and minutes and spending hours in the City Library looking through ancient copies of local newspapers. During the winter I had written about half the volume, but now, in the spring of 1958, I was finding the next part very difficult. I tried writing it in the evenings – but I was too tired; I tried getting up at 6 a.m. and writing before breakfast, but that was little better. I tried setting afternoons aside – but there was too much else to do. I began to worry more and more about it and lost more sleep. Finally, in May 1958, I was forced to acknowledge that I just could not manage it in time. I told the Management Committee that I could not get the job done and felt miserably aware of this, my first failure to complete a task which I had publicly announced.

Unfortunately, a number of the other centenary celebrations had also fallen through. The cricket square had been ploughed up, so we could not open the sports field that summer. A proposal for a Grand Fete which I had floated had aroused no answering enthusiasm. We had hosted a meeting of the Royal Medico-Psychological Association at the hospital in May, but otherwise no anniversary enthusiasm seemed to be developing. This perplexed me; previously, all I had to do was to float a good idea and then other people would take it up, add their own ideas and together we would construct an exciting occasion. This did not seem to be happening with the centenary; I remarked on this lack of interest to the Management Committee and Mr Street remarked that he was not surprised; he could see little to celebrate in what had been done at Fulbourn during the last 100 years; it was much better forgotten! Mr Street’s words stung me bitterly, as did the ripple of agreement that ran round the Committee table. At first I thought this was just another of his attacks; then I realised that in his forthright way, he had expressed what a number of other people had been feeling and what I had been too obtuse to sense, that there was a complete lack of enthusiasm within the hospital for the centenary. I now recalled a number of occasions when my references to it had fallen flat. I realised then that in future, if I floated a bright idea, I should listen for an answering echo of enthusiasm; if people came back with further ideas, I could go ahead, but if there was a dull silence and no response, I should let it drop. Then came another blow. Alderman Holmes, who had been becoming more and more active in helping the hospital and very friendly toward me personally, suddenly died. Again I felt lost and bereft and greatly feared that Mr Street would become ViceChairman. I began to long for my holidays and hope that I would feel better after them. I looked forward to getting away. Richard and Hephzibah Hauser said they wanted to do more work in the hospital and asked if they could live in my house while I was away. I gladly accepted and went off to the seaside with the family. The weather was poor, and our holiday was not a great success. On our return, Richard took my wife and me aside with deep gravity and informed us that during his survey of the hospital he had discovered what was wrong. The doctors, he had found, were deeply hostile toward me and critical of us for keeping our private life separate from that of the hospital. He gave us many details of what had been said and left us feeling very dismayed. We were deeply shocked by what he had revealed, repentant of our failings and then, gradually, incensed at the sadistic enthusiasm with which he had thrown this at us. He left next day for London to prepare his report on the hospital. I felt relieved to see him go. When I went up to the hospital next day, I found things in a very strange state. A few people, doctors and nurses, were enthusiastic – Mr Hauser was wonderful, he had shown them what to do and they had great plans. Many had much less to say, but watched to see my attitude. I made it clear I wanted to hear what they thought and gradually comments emerged. Some were interested, but puzzled because however hard and long they

listened, his talks seemed to be full of repetition and woolliness. They still wondered who he was, and what his background and training were. No one, after six months, had been able to find out. He seemed to say different things to different people. A few people were frankly hostile; they just did not like him and pointed contemptuously to his vague professional pretensions, to his name dropping, to his foreignness, to his constant yearning for an audience. Then Richard’s report arrived. I was appalled. It was a lamentable document, badly written, clumsily put together, ill-balanced and containing nothing that we did not know already. He seemed to have assembled all the idle comment he had heard in the hospital. The recommendations were vague and grandiose – ‘the total community’ must be interested in the hospital. There was need for ‘rededification’ and so on. In October we went up to London to hear him address the Social Psychiatry Section of the Royal Medico-Psychological Association, which I had persuaded to give him a hearing. This was to be the statement of his theories for which I had been waiting. It was an embarrassing disaster – a long rambling talk, full of anecdotes and diversions, containing no theory, only the few, woolly ideas that we had heard many times before. There was no argument, no theory, no structure. Afterwards I felt obliged to speak warmly in praise of what he had shown us at Fulbourn, but could not say more and the other psychiatrists showed their dismay. At his request, his ‘report’ was widely circulated throughout the hospital, and those who disliked Richard began to point out the faults in it that I could so clearly see myself. Other tales began to come in about outbursts of rudeness to various inoffensive but pompous people and I realised Fulbourn Hospital wished to have no more to do with Mr Hauser and his theories. I felt that I had mounted a tiger and I could not see how to get off it. Richard, Hephzibah and family then came to spend another weekend with us to see what reactions there had been to the report. He talked with various groups and found nothing being done. Several people found it convenient to be out of the hospital that weekend. He upbraided his chief disciple for failing to make progress. When she pointed out that, according to his theory, you must wait for a spontaneous uprising of activity, he said that there was a time to order people to be active and that this was now. He left Fulbourn after the weekend and never returned. He wrote us no further letters and did not acknowledge those we sent him. When people from Fulbourn met him, he was coldly hostile to them. I heard from other sources that he blamed it all on me – I had turned the hospital against him and revealed myself as a rigid authoritarian tyrant, incapable of appreciating the wonderful message vouchsafed me. I realise now that this man was the stuff of which both prophets and charlatans are made. He had great intuitive skill in assessing the feelings of a group, in telling them what they wanted to hear, and by a combination of charm and frankness prodding them into action. Like all prophets, he gathered a few disciples from whom he had no scruple in exacting devotion and service. If I had not been personally discouraged and seeking for help, I doubt whether I would have fallen under his spell and invited him to Fulbourn in the first

place. As it turned out he disrupted the hospital thoroughly and made a bad summer far worse for me. Several of the people, patients and staff, whom he made especial proteges were deeply disturbed by his abandonment of them and the flood of dammed-up hostility that washed back over them; several had further breakdowns. However, the whole unfortunate episode did serve to benefit the hospital in one way. By laying bare a number of our concealed tensions so that we could then deal with them, both the hospital and I moved forward after he left – perhaps united by the very act of rejecting him. Following the disastrous earlier months of 1958 I had now to pick up the pieces and put myself together again. The remaining months of 1958 were spent on the task. Hauser’s report, for all its failings, made a good basis for discussion – and friends and colleagues who read it, aware of my evident dismay and perplexity, offered comment which was often valuable. During that winter my wife and I, conscious of Hauser’s criticism of our non-involvement, made several attempts to involve ourselves more in the life of the hospital, giving parties, taking part in festivities. Gradually, however, we realised that this was not working well. It was certainly uncomfortable for us. It coincided with the time when the needs of our children were changing as they grew up, so that a home on the isolated hospital estate was no longer satisfactory. A final push came when a Ministry change of policy once again raised the rent of my tied house. We decided to move out of the hospital grounds. We found a house in Cambridge and moved during the summer of 1959. Beresford Davies, my senior colleague, had some wise and useful comments to make on the happenings of the summer of 1958. Hauser he dismissed as clever and intuitive, but essentially destructive. He pointed to the outbursts of ferocity and the way in which he attacked those who disagreed with him. But Beresford also pointed out that I had been pushing the hospital pretty hard; the pace of change in the last few years had been tremendous and though some, like the male nurses, might beg me to provide them with new goals, perhaps it would be better to sit back a bit and let other people make some contributions. Beresford suggested that though a good push was necessary to launch a boat, it ought to be able to sail without continual pushing. Several academic friends at Cambridge University such as Meyer Fortes, Professor of Social Anthropology, and Oliver Zangwill, Professor of Psychology, also saw Hauser’s memorandum and criticised it even more than I had done myself. They pointed out that he had made use of a few catchwords borrowed from other writers, but that no one could call it an analysis. From all these discussions, I gradually emerged with one or two general conclusions and lines of development. I now felt that Hauser’s ‘theories’, especially about leadership, were not of great value, but that his observations on the hospital were factual and possibly of some use. I decided to float no new ideas all during the coming winter of 1958–59, but to relax and let other people put forward their thoughts. I would also try to find outlets for my energies outside the hospital. Fortunately, there were requests at that time from Cambridgeshire County Council for a psychiatrist’s time to develop seminars for social workers. Winston House, the halfway house, was nearly ready to open and I was to be the ‘psychiatric adviser’; there was a lot to do. I felt, too, that I should not any more assume

that all advancement at Fulbourn was to my individual credit, nor that all misfortunes were my fault. I would just do my best and let things turn out as they might. Immediately after Hauser’s last visit I felt a striking relief; the gloom, anxiety and insomnia that had been plaguing me for months lifted and I faced my work with a new confidence and zest. I took up some new hobbies and interests, and the family commented that I was much more cheerful at weekends. Hauser had made several specific observations including the obvious irritation of the junior doctors towards me. I now asked them what was wrong. Many things were brought up. They resented the daily morning meetings, when I did so much talking; I cut these down to three and later two per week. They did not like having their mail handed out to them with my comments; I arranged for a secretary to sort the mail and to pass it directly to the doctors. They felt that their training programme was unsatisfactory; I asked them to propose a better one and after a good deal of frank discussion of needs, wishes and time available, they did. They expressed a number of other dissatisfactions, many quite justified, with their dining and living quarters. I had not eaten in their dining room in recent years; they invited me in and I was appalled at the overcrowding. It became clear that while I had been busy working with the nurses, the social situation of the junior doctors had changed. In the early 1950s, there were just a few doctors at Fulbourn – several were non-resident, and there was little feeling of solidarity. We had gradually employed more doctors and had continued packing them into the same unsatisfactory accommodation and had regarded their problems as individual ones. Suddenly, under the pressure of the dissatisfactions of 1958 they had become a group with aims, aspirations and grievances in common. The main target of their dissatisfactions had, however, been me – my failings as a Superintendent, as a doctor, and as a person. I learned later that they had spent long sessions discussing my faults and the inadequacies of the hospital as a place of treatment or of training. They had criticised my dependence on the nurses, my anxiety, my garrulity, my authoritarianism, and had talked about much of this round the hospital. The senior nurses knew of it, but felt they could not tell me; it was one of the factors that had soured the atmosphere in early 1958. Fortunately, I was able to meet some of the doctors’ needs. The Regional Board had just built some staff houses. I managed to get some of these allocated to doctors at present living in flats in the hospital. The larger flat at the top of the administration building was turned into resident doctors’ quarters and I invited the doctors who were moving into it to advise us on planning, facilities required and furniture. When the things they requested were later turned down I arranged for the doctors to meet some Committee members directly. As a result of their energetic lobbying and with my help we got nearly all they had asked for. The experience of meeting the Management Committee directly made them realise, as Miss Brock had at an earlier time, some of the difficulties I faced and, I think, made them more tolerant towards me. Since a doctors’ group had now formed (even though it was largely an ‘antiSuperintendent’ group) I encouraged them to formalise it, with a Chairman and a Secretary with whom I corresponded. They drew up sets of rules about who might use

their dining room as full members, and who might come in as guests. I was pleased that they allowed me to be a guest. When my family moved from our hospital house and I started taking lunches in the hospital, I arranged to lunch with the doctors on one day each week, but I never went in at other times without asking their permission. In the midst of this concern with social reorganisation and psychological atmosphere, something happened which emphasised our common bond as doctors. An elderly patient developed a severe form of dysentery; the staff on her ward were dilatory about isolating her and carrying out tests, so that a number of other patients were infected and we rapidly had many ill old women on our hands. We were plunged into a turmoil of traditional medical activities; isolation dormitories had to be set up, scores of patients treated and many others screened and examined, innumerable specimens of faeces had to be sent daily to the Public Health laboratories and reports examined and assessed. For the first time in years, I had to wear a white coat to go on the wards. After great toil and effort we checked the spread of the dysentery epidemic, cured the sufferers and gradually isolated and cleared up the convalescent carriers. Gradually things improved between me and the doctors. They had for some time been suspicious about the references I gave when doctors applied for other jobs. A secretary under notice had leaked some unfavourable references to them. I agreed to show them references before I sent them off, so that they would have an opportunity to correct anything which was unfair. In other ways, I demonstrated my willingness to listen to them and to change what could be improved. They began to put their energies back into the common task of treating and improving the condition of the patients and into their own personal tasks of learning psychiatry and passing their qualifying examination. I began to find rewards again in my work now that I was involved in projects outside the hospital. In October 1958 the first four residents from Fulbourn Hospital were admitted to Winston House. They were all in work of some kind and were to stay for a few months until they were ready to establish themselves on their own. Over 50 people moved from Fulbourn through Winston House to independence in the first year. Its fame spread, and patients were referred from other hospitals. Over the next four years Winston house was a major and gratifying part of my work and my life. Every Tuesday evening I saw residents as outpatients, at first in the House, later in the outpatient department of Addenbrooke’s. Talking with these Winston House residents week after week was an education for me. I saw them flower into lively people again, from the dull subservient inmates I had known on the wards. I began to see how the tremendous power that the hospital doctor has over the patient distorts any conversation there might be between patient and doctor. However relaxed and friendly a doctor might try to be, the fact that he had the power to deny discharge, to order confinement, seclusion or ECT meant that a patient must always be very careful of how much he says and how he says it. Gradually I learned other and more subtle lessons and began to respect patients’ judgement of their own needs. Some of them said they felt no need to see a psychiatrist again and I learned to accept that. Others were guardedly polite; their referring psychiatrist had spoken enthusiastically about how their psychoses had been cured and their state stabilised on Largactil; gradually, as they came

to trust me, they revealed that for many months they had been putting the pills down the lavatory. I soon learned that the details of their former delusions and hallucinations were irrelevant; what mattered was whether they had the willpower to stick at a boring job until they had enough money to live on their own. Some had to learn not to talk about their hallucinations; after years of discussing them freely in hospital, they found that workmates looked at them oddly and that it was better to keep quiet and not be labelled a ‘nutter’. I began to realise what a painful journey ‘rehabilitation’ was and from these brave men and women I learned how difficult the path back to social acceptance was. They brought home to me the disadvantages of a long period of seclusion from society; even the world of Cambridge had changed in the ten or twenty years that they had been away from it. Cars and traffic had multiplied, prices had increased, well-known pubs, cinemas and shops had vanished. It was a new and difficult world to re-enter. Although we had our disagreements, I got on well with Mr Cooper, the Warden, a former Salvation Army missionary. He was a strong-minded man with a firm conviction of divine approval for his views, but I enjoyed having a working relationship with someone who was not under my authority. At the end of the first year we reviewed the work of Winston House and prepared a paper. To our surprise and gratification it was accepted by the Lancet in 1960 and published as an account of a notable and successful experiment in Social Psychiatry. The article attracted a lot of attention, since many hospitals and local authorities were trying to set up halfway houses at that time; I had many requests for reprints and visitors started coming to see the pioneering work (Clark and Cooper, 1960). Back at the hospital, Fulbourn Industries was making steady progress despite the departure of Fred Houston and Mr Allen. The patients worked consistently at the demanding and complex work and they used their earnings to improve their lives. They bought new dresses, made trips into Cambridge and took holidays; several of them left hospital completely. The supervisors established good relations with the suppliers and encouraged the managers to come up and see the work. One of those who made good use of the Fulbourn Industries Workshop was big Elizabeth. Her task was to put different coloured wires together in a complex bundle (a ‘cable form’). Although she grasped what was required, she was painfully slow at first. Gradually, over the months, her speed improved until she was one of the better workers, and was working at a level comparable with paid workers outside. Then a vacancy occurred at one of the firm’s regular workshops and we recommended Elizabeth. She went into town every day and came back without incident. We asked the foreman about her and he said her work was up to standard, though the other women found her puzzling as she seemed to have little to say and so little interest in what went on around her. Elizabeth was one of the early residents in Winston House where she got on well, though making few friends. In due course she moved out of hospital to a bedsitting room. She remained bland and emotionless with always a slightly puzzled look on her plump face. However, she managed life outside without difficulty and I would see her occasionally, at the Therapeutic Social Club where she was a regular attender.

Within the hospital I was now able to take a fresh look at what was happening. I found that quite a number of interesting projects had developed of which I had not fully recognised the value. As various projects run by Charge Nurses and Sisters achieved success – such as the splitting of the men’s disturbed ward and the creating of a bowling green behind the admission ward – I began to see the staff as a source of valuable suggestions. I realised that patients who worked on these projects, particularly the ones who had specific roles, tended to do well. Their symptoms declined, their appearance smartened up and they began to plan towards going home. On talking to some of them I learned how rewarding the projects had been for them. Nearly all mentioned two things – how gratifying it was to exercise skill, responsibility and judgement, qualities which they feared they had lost altogether, and how important some sign of public approval (perhaps from a visitor, a member of the Committee or myself) had been in giving them the feeling that they were not entirely useless. I realised that many people recovering from mental disorder were burdened by strong feelings of failure, incompetence and social uselessness which were a grave handicap to recovery. I now saw that one of our tasks must be to provide them with opportunities to dispel these feelings. I began to see that many occupational projects, though useful in getting people physically active or gainfully occupied, did not provide any scope for enterprise and responsibility. We had to provide opportunities for initiative – something far more difficult than just getting people to work. This was in fact an answer to the male nurses’ questions in the spring. To propagate these ideas I started using slogans such as ‘Activation’, ‘Self-Government’ and ‘Social Therapy’ and these became the catchwords of the next few years. I realised that encouraging the Charge Nurses and Sisters to run their own projects was an excellent vehicle for achieving these new goals. If I allowed them freedom, responsibility and a chance to show initiative while still providing a degree of protection, there was a fair chance that they would allow the same to the patients. Some months previously, the Sister of a women’s rehabilitation ward had asked me if I minded her getting a gas stove and doing a little baking on the ward. She was an energetic woman known throughout the hospital for her sharp tongue. I gave consent because I thought this might be an outlet for her formidable energy. She borrowed an old gas stove and persuaded the engineers to fix it up for her in the tiny ward servery. She bought flour and began to teach some of the patients to bake; she was an excellent cook. They sold the cakes to their visitors to pay for more materials. The cakes were very good and the demand expanded. Soon, they had paid off all their expenses and were making a surplus, which they began to spend on the ward. They bought plants and pictures and wall ornaments, equipment for their kitchen, a record player and a floor polisher. The ward became a different place from the dreary environment it had previously been. The patients who had been defeated and discouraged, and looked shabby and odd now seemed to have an air of purposefulness. When I went into the ward now the odour of cooking met me on the stairs, and all within was bustle and activity. The Sister, who used to be sitting fiercely in her office, was now often flushed with baking with flour in her

hair. The patients were bustling about, sometimes harried but often cheerful and always busy, and I was never allowed to leave the ward without sampling several delicious cakes. I began to notice women who had been static for months or years making striking progress. Of course, these changes did not pass unnoticed by others less favourably inclined. The Engineer commented on equipment being introduced and pointed out the dangers of overloading the ancient electrical wiring. The Supplies Officer was concerned with unauthorised purchases and ‘additions to stock’ and asked to whom the floor polisher belonged? Who would pay for its repairs and who would have to replace it? The Finance Officer was also most alarmed and asked who had allowed this Sister to collect the money? Were the takings properly listed? Where was the money stored? Were her accounts properly audited? What would happen if somebody filched some money and the HMC was sued? All these considerations were brought up at the Chairman’s meetings and at the Management Committee. In one sense, they were legitimate as the concerns of experienced officers, who had seen the trouble irregular projects caused in the past and who were issuing proper warnings. But the implied message was that irregular activities should be discouraged and, when discovered, stopped; that if anybody required anything, they should get it through ‘normal channels’ – and, of course, if it was not available, they should do without and wait. Although recognising the validity of their comments, I also knew that I must fight them if I were to create an atmosphere in which initiative could flourish. I argued all the way. I took influential and impressionable Committee members to the ward and expounded on the therapeutic value of the project. As a result, it was allowed to go on – even when the Sister and the ward began to present polishers and floor scrubbers to other wards in the hospital. The project expanded for two years with increasing enthusiasm. They took to catering for parties and receptions, to making wedding and christening cakes. Cooking dominated the life of the ward. The final check, however, came from an unexpected quarter. The Catering Officer had never greatly cared for this activity, with the implicit criticism it contained of the food he provided, and he steered a visiting Catering Adviser to the ward. This Adviser reported back to the Regional Board, criticising the hygiene of the project. I was tipped off that this visit was impending so invited Pat Tyser, the local Medical Officer of Health and a good friend, to look over the ward unofficially. He found squalor behind the enthusiasm; there were cakes in the linen cupboard, flour in shoe boxes, margarine in the broom closet, mouse droppings in the flour bin and decaying scraps of food in corners. He told me that had he found any commercial concern like that he would have closed it at once and prosecuted! Though it might be possible to get away with such squalor in a domestic kitchen, it was inexcusable when products were being sold to the public. I saw that I had to act. I brought the Sister in and discussed the problem. She admitted that her operations had spread far beyond the space available and in contemplating the evidence of decay and infestation, agreed that she had let her enthusiasm outrun her discretion. We agreed to cut down. The surplus stock was used up and the storage places cleansed; public sale stopped, and cakes were made only for eating on the ward; the financial side was cut down. I then reported all this to the HMC before the Regional Board Catering Adviser’s report came through.

Despite the necessity for this action and the Sister’s acquiescence, there was a sharp reaction on the ward. For months afterwards patients seemed gloomy and sad and the discharge rate fell. Even more strikingly, during the next six months, two patients from the ward committed suicide while at home on leave. Although both had depressive illnesses and ample personal reasons for killing themselves and although there had been suicides from that ward in earlier years, nevertheless, there had been no suicides from the ward in the previous two years of excited cooking. I could not help thinking then that maybe there was a price to be paid for a surge of group enthusiasm – when it ebbed some people might be damaged by the trough of discouragement. Other good things were starting at this time. For some years, Miss Brock had been giving talks to Women’s Institutes in nearby villages, telling them about the work of the hospital. She had also shown WI parties round during the summer and often the visitors had asked what they could do to help. Miss Brock had encouraged them to adopt friendless women patients and to invite them out to their WI meetings. Then, it had occurred to her that perhaps they could have a Women’s Institute within the hospital itself! After many months of discussion with the national organisation, permission was granted and they started their first meeting during the summer of 1958 – the very first time there had ever been a Women’s Institute within a mental hospital. Although as a male I could not attend their meetings, in due course I was asked to speak to them. I was delighted to find that in the meetings there was genuine equality between staff and patients. The nurses did not wear their uniforms at meetings and they voted and took part as ordinary members. I was fascinated to find the proceedings and the atmosphere to be just like the many other WIs at which I had spoken during the days of our intensive public relations campaign. There were the same Minutes, order of procedure, writing of resolutions to be forwarded to headquarters, outings planned, competition for the best flower garden in a saucer and, of course, the singing of ‘Jerusalem’. The members of the meeting were 20 women nurses and 60 patients, all of whom I knew well. Had I not known before, I could not have told them from one another, nor could I have differentiated their plump middle-aged faces, grey heads and comfortable figures from those I had seen in so many Cambridgeshire village halls. Remembering the traditional atmosphere that had existed in Fulbourn up until a few years ago in which such a mixing of staff and patients would have been impossible, I was delighted and astonished at how far the women had come. I was also pleased to reflect that here at least no one could say that I had directed, organised or imposed the development. It had come entirely from the women themselves and especially from Miss Brock – the same woman whom foolish people had once called a block to progress. Other smaller projects were also developing. When the new hospital kitchen was built, the old buildings were left empty. The Physical Training Instructor asked us to let him take over the biggest room. He persuaded the engineers to remove the big pipes and level the floor, a group of patients painted it and it was then used as a gymnasium, badminton court and winter exercise room for the football team. A smaller room we allotted to the Occupational Therapy class from the disturbed women’s ward and they gradually

developed a little workshop, painting their own furniture and decorating the walls themselves. Not long after I first arrived at Fulbourn, my attention had been drawn to one particular male staff nurse, Jack Wheatley. He was, I was told, an interesting man – talented but rebellious. He was a skilled craftsman and an excellent cricket player; at times, he had run small workshops. On the other hand, he had often been in trouble and had received more reprimands than any other member of the staff. In 1956 he applied for a Charge Nurse post. I suggested he be appointed and we gave him M2, a newly opened ward, to run. This ward was a discouraging prospect as the patients had been in the hospital for many years. They were mostly middle-aged, quiet, apathetic men, often with considerable thought disorder – not good enough for the privileged workers’ ward and not bad enough for the disturbed ward. The ward was a bare dormitory with scrubbed deal floors and painted brick walls. There were no curtains and little furniture. We promised him that furniture would be provided, but we did not know when. The rest was up to him; we could not give him any other regular staff to help with the 40 men. Jack Wheatley’s response to the challenge was outstanding. He had known many of these patients for years and believed that they had more initiative than was apparent. He gathered them together and talked to them about the purpose of the ward; he said it was to equip them for life outside. They named the ward Mitchell, after the former Chief Male Nurse. Jack divided up the housework and put groups of men in charge of each task. At first, he ran the kitchen and served the meals himself, but he soon picked and trained men to do these tasks. The furniture began to arrive, but the rooms still looked shabby. He asked if he could try improving things. In order to plaster the painted brick walls in Fulbourn Hospital, the bricks had to be ‘chipped’ to enable the plaster to bond. This chipping was a slow, laborious, dirty job, producing much dust; normally, we would vacate a room for several months to allow for chipping, application of plaster, drying of plaster and painting. Having asked if he could do one or two side rooms, Jack donned an overall and led a team of patients who soon had the walls chipped. He then persuaded the hospital plasterers to fit this room into their schedule and finally got the hospital painters to paint the walls. We had never had rooms done so quickly and I was delighted. He then asked if they might do the day rooms. I pointed out that this would make a mess that would last months and that there was no alternative accommodation. He put this to the men, who agreed to put up with the mess and, over a number of months, they finished all the walls. During this time, I persuaded the HMC to lay linoleum floors in the ward and install large windows. They also received new curtains and new carpets as their share of some upgrading money. As a result, within two years of his taking over, what had been a disheartening, shabby ward became one of the most attractive in the hospital – largely as a result of the patients’ own efforts. At the same time, the men had progressed greatly.

A number went home, and other wards were so anxious to get people on to the ward that there was a waiting list for transfer to Mitchell! Jack Wheatley’s men then addressed themselves to the iron bedsteads. The black paint was much chipped and rusty where it had chipped; the bedsteads looked horrible, but could not be condemned because they still held up the bed. A team of the patients set aside a room, took in one bed at a time, dismembered it, scraped it clear of rust and applied two good coats of paint, usually in a pastel colour. The painting team did all the beds in the ward and were then asked to do others; the women saw the results and begged to have theirs done. Over three years, the Mitchell team repainted all the old beds in the hospital – and the original team of workers had changed three times over as the men were discharged. These are but a few examples of projects started independently by nurses in the hospital. Many wards also ran raffles to pay for their outings. As I thought about these excellent activities and my lack of involvement in them I felt that I had actually helped in some way and gradually I clarified my concept of the ‘Umbrella Function’. By this, I meant that my task was to protect developing projects from influences that might blight them in their early tender stages – such as Committee criticism, ill-judged publicity, the attentions of the auditors or the queries of administrators who would wish to tie things up in red tape. I began to see my role as that of facilitator – a creator of an atmosphere in which other people could try experiments. I saw that the frantic activity of my earlier years was no longer necessary. While we were working on all these changes within the wards at Fulbourn, there came a major change in the English Mental Health Laws which had striking effects on our practice. In 1957 the Royal Commission, of which Mrs Adrian had been a member, produced their report. It was a massive document – 306 closely packed pages with 882 paragraphs – and surveyed English lunacy law since the first Lunacy Statute in the fourteenth century. The Commission now proposed that all this ancient legislation be swept away and an entirely new system established, so that entering a mental hospital (and getting out of it) should be as easy for most people as entering a general hospital. They also made many other revolutionary and exciting proposals and suggested how community treatment might be developed. Pessimists thought that the report would be pigeonholed and forgotten. To our surprise and delight, the Government produced a Bill within a year and started it through Parliament. There followed a most active period of debate within the professions, in Parliament and in the public newspapers. After the Act was passed in July 1959 we had over a year to work out its implications before it came fully into force on l November 1960. We found that the main effect of the Act was to make easier (and in some cases more lawful) what we were doing already. For some years, nearly all our patients had been free to come and go from their open wards; the new ‘informal status’ removed the anomaly of having certified patients going out to work, making money and owning property. The new admission procedure meant that there was much less fuss about bringing in someone

who needed admission and brought to an end the previously humiliating process by which a Duly Authorised Officer, a Magistrate, ambulance and the police all descended on the family home. The service for our patients outside hospital, both before admission and after discharge, became more appropriate, more flexible and more effective. All sorts of pointless activities which had been required by the Law now ceased. We no longer had to present to the HMC lists of people ready for discharge. The old ‘Board of Control examination’ – the bizarre ritual when a wily paranoid patient and a skilled psychiatrist fenced verbally until enough was elicited to warrant further detention – now ceased. When I had a talk with a long-stay patient, it could be a discussion to promote his welfare, speed his rehabilitation and advance his interests, rather than a series of tricks to get evidence to justify prolonging his detention. The Act also changed our relationship with the people who sent in patients. Under the 1890 Act the Receiving Order was a legal Order from a Magistrate and we in the hospital could not disobey or even question it. There were Magistrates, doctors and DAOs who would commit a person to Fulbourn Hospital without any consultation with us – or even any warning. Sometimes the committal was quite unsuitable. There were two particularly worrying categories. Confused elderly patients in local authority institutions, the former workhouses, were sometimes sent to us when they became troublesome – before any one discovered that they were actually physically ill, with pneumonia or heart failure. People picked up by the police and found to be confused were handled summarily at the police station by an elderly local general practitioner who had been a police surgeon for many years and believed that he knew better than anyone else who was suitable for the asylum. He often lost his temper at the police station and on occasion had committed as insane someone who was merely drunk. He always resolutely refused to call psychiatrists to help him in assessments for admission. Now, at last, we in the mental hospital could control who came in, in the same way that the staff of the general hospital could. We insisted that there should be prior consultation about all proposed admissions; where necessary we went to see the patients beforehand. We insisted that the confused elderly should be properly examined physically and treated medically before we took them. We insisted on reviewing people in the city police station. This so infuriated the elderly GP that he resigned his position as Police Surgeon – to everyone’s relief including, we discovered later, the long-suffering staff of the police station. In 1959 Oliver Hodgson was appointed to a Consultant vacancy – for me one of the best appointments made at Fulbourn. He was a quiet, unassuming man who soon showed himself a skilled and able psychiatrist, a hard worker and a most pleasant colleague. A distant descendant of Lord Protector Cromwell and a quintessential Englishman, he recommended himself quickly to the male staff by his skill and devotion to cricket and was soon elected Captain of the Hospital team – to my relief. I found him an ideal comrade and he soon came to act as my assistant in many matters. In 1962 we persuaded

Leslie Buttle to give up his nominal Deputyship and Oliver took the post. It was a great relief to me to be able to leave things in his hands. Dr Noble, the senior psychiatrist at Addenbrooke’s retired in 1957 and we appointed Bernard Zeitlyn. I was very pleased with this appointment as I had known Bernard as a fellow Registrar at the Maudsley. He was now a fully trained psychoanalyst and strengthened our team greatly. He proved an invaluable colleague and delightful friend over the coming years: charming, talented and witty. Although I had thought constantly about the attitudes of the nursing staff since my arrival at Fulbourn, it was not until 1958 that I attended to the question of their training. At that point we had a miscellaneous group of staff of different ages, backgrounds and cultures, of differing intelligence and education and with very different qualifications, previous training and experience. They ranged from ward orderlies who had been certified mental defectives to university graduates; they came from England, Ireland, France and further afield; some had no training, others were fully qualified psychiatric and general nurses. Before the war during the 1930s, the staff of Fulbourn Hospital were similar to those in most English mental hospitals. Many were local youths and girls, but others came from the Welsh hills and from Tyneside – driven into a secure, if unpleasant job by the shortage of work during the Depression. The two questions that were asked of men who applied to work at Fulbourn were ‘Do you play cricket?’ and ‘Can you play a band instrument?’ Proficiency in either field won a place forthwith. Some could not stand the life and left after a short time, but those who remained settled in. They lived in cramped and spartan staff quarters, studied for their examinations and waited for promotion. Many married another hospital employee, and ultimately got a hospital house in which to live and raise their children – who often became hospital employees themselves. In those days grading of nurses was clear. Recruits came in as student nurses. After a few years’ experience and study, if they passed the examination, they became trained nurses (‘Staff Nurses’). After many years as staff nurses they might be promoted to be in charge of a ward; they were then known as ‘Charge Nurses’ (on the women’s side ‘Ward Sisters’). For many that was the limit of their ambitions – to retire as a Charge Nurse. All nurses were ‘full time’ – working a week of some 60 hours. If a nurse could not work full hours – as women who had children could not – they had to resign. For a minority of able and ambitious men and women there was a ladder of promotion culminating in the positions of Chief Male Nurse and Matron. On the way there were posts as Assistant Chief Male Nurse, Assistant Matron, Deputy Chief Male Nurse and Deputy Matron. Some of these ambitious people qualified themselves further by going into general hospitals for three years and taking the training as general nurses (SRN – State Registered Nurse). The post of nursing tutor had always been an important one at Fulbourn. The holder had the task of teaching anatomy, physiology, first aid and simple psychiatry to the new nurses and helping them to pass their examinations. The tutors were qualified nurses,

holding a psychiatric and often a general nursing qualification, but usually they had no training as teachers. The post was normally the first step into administrative nursing for an ambitious nurse hoping to rise towards a Matron or Chief Male Nurse position. Miss Brock, now Matron, had originally come to Fulbourn as a Nursing Tutor. In the postwar years the position was held by a succession of able men who had all moved on to administrative posts after a year or two. During the war, as staff numbers fell, other people were recruited to Fulbourn. Married women who were trained nurses came back as ‘part-timers’. People without qualifications were taken on as ‘assistant nurses’. Other people were tried as ‘ward orderlies’, originally to assist with simple tasks about the ward – washing up, cleaning floors, clearing rubbish, and so on. Gradually, over the wartime years, some of these people proved so helpful and became so experienced that they gradually moved into positions of trust and responsibility. After the war, the men who had been away fighting returned to their wives and homes. With them, as student nurses, came a number of other men who, during the war, had found their life’s vocation in nursing, but then discovered that male nurses were only welcome in psychiatric nursing. These were good recruits, devoted and interested, many of them of superior ability. While National Service continued, this recruitment went on; they were mostly industrious lads, who worked for their exams and passed them. The male nursing side had, therefore, maintained its numbers and standards fairly well through the 1940s and 1950s. However the war brought a taste of economic freedom to many younger women. After the war former nurses did not return to the hospital to replace the married part-timers who had been filling in for them. For the same reason it was difficult to recruit new women staff to Fulbourn in the postwar period. The women’s side was gradually weakened. By 1953, an ageing group of women, a few full-time, but mostly part-time and many without training were struggling to serve an increasing, ageing and grossly overcrowded mass of women patients. There had been very few recruits for nearly 20 years and between 1940 and 1950 only two women nurses at Fulbourn passed the final nursing examination. The search for people to take on the work on mental hospital back wards became more desperate. Various recruiting experiments were tried at Fulbourn, as at other English mental hospitals. At Fulbourn many immigrants, particularly refugees from Eastern Europe, were taken on – people who could often speak very little English. The challenge to integrate these staff and help them become more effective, as well as to enlist their loyalty and altruism, was enormous. When Miss Brock became Matron in 1952 she was determined to do something about the inadequate staffing of the women’s wards. Various ideas were tried – a scheme for Nursing Cadets, employing foreigners as Nursing Assistants, improvement of the nurses’ uniforms with differential rank colouring, the use of trained nurses or student nurses from general hospitals. All these projects were endlessly discussed by a Subcommittee of the Management Committee, composed entirely of lady members. Shortly before I arrived,

two Inspectors of the General Nursing Council had visited the hospital and submitted a very long report, full of criticisms of the teaching arrangements, the ward duty arrangements and the accommodation available for the nurses. When I started as Superintendent, I listened to the various ideas for improving nursing and threw myself behind those that seemed promising, such as the recruitment of foreigners. An engaging publicity man drafted advertisements for us in the French provincial press, which brought in over 100 applications. Miss Brock and I sorted them out and sent for the girls. This involved much planning as few of them spoke English. We interviewed them all, arranged English classes for them and gradually started them in simple work on the wards. By the spring of the second year, we had about 20 French girls working in the hospital and had drawn a rebuke from the Regional Board for exceeding our budget for nursing salaries – the first time this had happened for over 20 years. This was my first clash with the budgeting accountants and it set a pattern for me. The most grievous problem of the hospital – because it did most to harm the patients – was the shortage of women staff. We had done something effective to remedy it – and the financiers’ only response was to fuss about their budget. I stormed against them in righteous indignation; Mrs Adrian and the Management Committee backed me and the Regional Board found the money. The recruitment of the French girls was like a blood transfusion to the staff of the women’s side – though like a blood transfusion, the effect was a tonic rather than sustained. Despite the doubts that the elderly Sisters expressed, it was a great boon to have a considerable number of strong healthy girls on the wards. Even if their English was poor, they soon learned to make beds, serve meals and do all the necessary household tasks. The standards of physical cleanliness and order at last began to rise. The girls were pleasant, cheerful, reasonably educated and did well at first. It gradually became clear, however, that many had little continuing interest in nursing and most of them went home after about a year having acquired a smattering of English. Only a handful persevered, became student nurses and finally qualified as psychiatric nurses. Employing these girls also brought its own share of problems. One started acting oddly and then took to her bed. With an interpreter’s help, I found that she was severely mentally disordered, with developing schizophrenia and I had to arrange hastily for her admission to another hospital, where she required many months’ treatment. Another girl slashed her wrists; the door of her room had to be broken down and she nearly died; it then emerged that she had been discharged directly from a French psychiatric hospital to come to work for us. Her psychiatrist thought that the change would be therapeutic for her and had written me a letter of recommendation about her, concealing her illness. Another problem was a quarrel which developed among the girls and over which they split into two factions; one group appeared to win, and about six girls resigned, including two of our best students. A few months later, two of the victorious faction were found to be pregnant. One persuaded a male student nurse to marry her; the other could not name the man and was deported back to France (standard British procedure at the time). I heard that both said their babies were conceived in the Nurses’ Home and before long lurid tales and complaints about the goings on there began to reach me.

All these matters were brought straight to me and I spent many hours during 1954 and 1955 dealing with the individual and general problems of these young women and conferring with Miss Brock about them. Gradually, I realised that some of the troubles actually arose from our method of governing the lives of student nurses. In the thirties, the Matron had policed the Nurses’ Home herself. Such an arrangement became intolerable in the postwar period when nurses everywhere revolted against petty restrictions and demanded their rights and freedom. At Fulbourn, we had abandoned fussy interference. The Matron seldom visited the Home and let them rule themselves. This worked well as long as there were very few resident staff, most of them middleaged, long-term staff members. With a rush of newcomers, the system broke down. I wondered what could now be done about maintaining a modicum of decency and order. We tried calling meetings to set up a committee to run the Home, but the girls did not attend and they were clearly little interested in self-government of the Home. We finally decided to appoint a Home Sister and were fortunate to find a pleasant, motherly, qualified nurse, who had excellent French and had been a governess in her time. She soon brought order into the Home, though a few of the more turbulent girls moved out into lodgings rather than conform. The Home Sister in due course set up a Home Committee, which served to ventilate some grievances and, over the years, we persuaded the Management Committee to redecorate and re-equip the Nurses’ Home. My relations with the male nurses went quite well. Meetings with the Charge Nurses were lively and we achieved much together. I persuaded the nurses to reorganise the Staff Club (started by Mr Allen) as an independent body, open to all. This brought in the clerical workers and the engineers and made the Club generally more popular. It was largely an independent body – and rightly so – but I was always ready to help its members get the things they needed from the Management Committee. By 1955 I had begun to realise that the nursing staff were good-hearted people, anxious to do their best for their patients and to take pride in their jobs, but that they were not very well equipped for the task. The training provided for student nurses was dully presented. Apart from them, nobody else in the hospital was receiving any instruction at all. Many male nurses and some of the women were qualified RMNs (registered mental nurses) but most of them had passed the exam many years before and their knowledge was out of date. When I studied the staff lists, I was disturbed to see that over half of the women on the nursing staff had never had any organised training at all. They had first been employed as ‘nursing assistants’. While a number of them had a great deal of experience, very few had received any formal instruction. As a result of Fulbourn’s staffing difficulties, I began to take a view of nursing training which was radically different from that of the General Nursing Council at that time. To obtain the best possible care for the patients, it seemed to me necessary to provide all staff with good teaching at as advanced a level as they could manage or their tasks required. I came to feel that it was our responsibility to take the people we had and make the best we could of them, and that anyone who was fit to be employed to care for our

patients was fit to be given training of some kind. Here, I came into conflict with the elitists at the General Nursing Council, whose solution to the problems of nursing was to raise standards of entry. The effect of this was to limit training to highly selected student nurses – and to deny it to those not selected. In a hospital like Fulbourn, this meant that many of the staff hired were given no training at all – so that the patients suffered. I also believed that the process of learning was something that never ceased. I felt qualification should be the beginning, not the end of learning and decided that my aim should be to provide learning opportunities for all grades of staff. As I worked on this, however, I came to understand more about the process of learning. I began to see that though teaching (the process of pushing knowledge at people) was important, learning – the active process of assimilating information and applying it to one’s work – was very much more important. I saw that much formal nurse education failed because students felt that what they learned in the classroom bore little relationship to what they actually did on the wards. My ideas developed slowly and were mixed up with reflections on my own slow and painful learning of the tasks of the Medical Superintendent, and my observation of the development of our junior doctors. I myself had been taught medicine by the Scots system of lectures and didactic instruction and had endured the postwar programme of the Maudsley, which instructed the trainee about every conceivable theoretical aspect of psychiatry, while attaching little importance to the growth of skill by practice and experience. As I watched our medical trainees, I began to feel that they gained more by being given responsibility and the chance to make mistakes (with the support of more experienced colleagues) than they did by lectures, seminars, teaching, rounds, and so on. I had had to learn the job of Superintendent by doing it and only found out how to improve myself by discussion, reading and reflection. I came to see learning as an active process, in which one was challenged by experience and thus caused to enquire, study, digest and apply. I tended to contrast two models of education – the mechanical and the horticultural, the assembly line and the garden. Many doctors seemed to think that training was like making a machine. If the teacher assembled the right cogs and wheels of knowledge and put them together correctly, then the machine, the student, would function. I preferred the model of the garden, where the teacher is seen as a gardener who can trim, prune, water, fertilise and spray; his activities are very important – but the stock and the soil set the limitations. Time, chance and the weather affect the growth and health of the plant and the final bloom is only partly a result of the gardener’s efforts. Another problem was that the subject of psychiatry was changing so much that earlier instruction was becoming outdated. What the tasks of the psychiatrist and psychiatric nurse would be in coming years was so uncertain that training needed to produce nurses who were ready to adapt to new demands and acquire new skills when needed. I believed this could only be achieved through a training which developed active, motivated learning that would continue through life. My theories clarified slowly, under the pressure of events. In 1956 I was simply doing what seemed to be necessary to raise the standard of care of the patients. I saw that the nursing assistants who were doing the nursing had never been given any training. I felt that we must give them some and so

spoke with Miss Brock, enlisted the tutor’s help and arranged for a week’s course in the spring of 1956 for a selected group of nursing assistants. There was no syllabus to guide us, so we provided what we thought they needed. They were taken on a tour of the hospital; Miss Brock and I talked to them, other senior officers talked to them; we arranged discussion periods and encouraged them to ask questions; the tutor gave a few talks on first aid, mental health, law and modern psychiatry. I found talking to these nursing assistants excitingly different from lecturing to student nurses. Instead of a group of callow youths, sullenly listening to stuff that they did not understand or care about, I found a group of lively middle-aged men and women, experienced in the hospital and its ways, deeply interested in all the changes they saw and grateful for the opportunity to study. At the end of the week the nursing assistants expressed great satisfaction and I found that all who had talked to them had found them a stimulating group. They asked me many questions, recounted tales of how things used to be and made suggestions about how they might be in the future. We asked their advice on how to plan another course and, from then on, we ran about three courses a year. These courses had a striking effect on the nursing assistants, their morale and their work with the patients. All felt their status had been raised and some were stimulated to study further. The nursing assistants went back to their tasks with greatly increased enthusiasm and a number of them took up key positions in the developing occupation programme. At our Nurses’ Badge Days, certificates were presented to those nursing assistants who had worked for two years in the hospital, had attended one of these courses and had passed a simple examination. Not long after the courses began, the Charge Nurses began to enquire about further training for themselves. It appeared that the nursing assistants and student nurses were starting to ask them questions that they could not answer. I responded happily to this. Feeling that straight instruction would be inappropriate to these older people with many years of qualified service behind them, we started a ‘Senior Nurses’ Meeting’ once a month. We asked local experts – the Duly Authorised Officer, our psychiatric social worker, the Disablement Resettlement Officer, the consultant psychiatrists – to give talks about recent developments, followed by a period for questions. The meetings were for qualified nurses only; most of the Sisters and Charge Nurses came to them, as well as some of the Staff Nurses. Discussion was often lively and I did all I could to encourage it. The meetings began during 1957 and continued steadily; sometimes attendance fell, but at other times this meeting was rather like a Parliament of the hospital at which some new proposal was propounded, modified and accepted. In later years, whenever I foresaw some major development in patient treatment or staff organisation, I would present it to the Senior Nurses’ Meeting as soon as I could, to get their comments, criticisms and contributions. From 1957 to 1960 there was a period of national activity in mental nurse training, arising from the parlous staffing situation of Britain’s mental hospitals. The national situation was very similar to that of Fulbourn – a fair number of male nurses, very few trained women nurses, practically no recruits and many untrained assistants and orderlies. Many ideas were being discussed – mostly by interested parties. These included a raised

standard of entry to ‘attract a better class of girl’, a lowered standard of entry ‘to make training more freely available’, the recruitment of foreigners, the banning of foreigners, the recruitment of nursing cadets, the banning of young people from disturbing work and so on and so forth. Pay and conditions of mental nurses rose strikingly over the years, as the Unions pressed successfully for more money, shorter hours and better conditions. The professional educators of the General Nursing Council worked steadily to raise the level of the formal education. They pushed the pay of Nursing Tutors up until it matched that of Nursing Administrators and they tried to eliminate unqualified tutors in favour of nurses who had received a formal training in teaching. They revised the syllabus for mental nurses deferring instruction in anatomy and physiology and emphasised instead more relevant issues such as ward and bedside teaching, discussion and seminar learning and a programme which was directly relevant to students working on the wards of psychiatric hospitals, that is one stressing human development and emotional needs. These national currents all swept through Fulbourn. In the early 1950s, the tutors had taught in a converted cellar. The classroom was well lit and reasonably equipped with a skeleton, anatomy charts and textbooks, but its underground position was a fair measure of the standing of nursing training in the life of Fulbourn. In 1957 we appointed a trained tutor, Frank Tudgay. Miss Brock, Mr Tucker and I formed an ad hoc Committee to oversee the training programme, and to help Tudgay. This was at the time when the male nurses were active on their work programme and the influx of French girls had freed the women nurses so that they were regaining pre-war standards of care. Probably as a result of this improvement in our standards, the Matron of Addenbrooke’s, who in the early days of the NHS had spurned the idea of cooperation with Fulbourn, now requested that some of her student nurses be allowed to work at Fulbourn. In the summer of 1956 six Addenbrooke’s students came to spend three months with us. I insisted that we should not regard them merely as extra hands to be put to work (though we sorely needed them), but should try to give them useful experience, providing special seminars and posting them to wards where they would learn. This policy paid off. The Fulbourn secondment was soon the most popular available at Addenbrooke’s and the girls, enjoying themselves greatly, took good tidings of us back to Addenbrooke’s. They in turn brought into Fulbourn a burst of youthful life and enthusiasm and their unabashed questions were often healthy for us. They became a lively part of our social life and several of them married male nurses they met at Fulbourn. Mr Tudgay started using the new GNC Experimental Syllabus, which we found a great improvement. The student nurses found that their lectures taught them useful things about their work on the wards and thus stimulated they became more interesting to teach. At about this time, we also began to send selected nurses off on refresher courses. We began to get places on the excellent four-week courses run by the King Edward VII Hospital Fund for London at their Staff Colleges. The two Colleges, one for Ward Sisters and one for Matrons, ran occasional courses for psychiatric staff in which the emphasis was on discussion and mutual examination of their work and attitudes. Over the years, we managed to send all our administrative nursing staff and most of our Charge Nurses and Sisters on one of these courses. Invariably they came back refreshed. By talking to people

working in other hospitals and through having to defend and explain the work of Fulbourn to others, they came to see new possibilities in their own work. The attitude of our nurses towards their own hospital gradually changed. From being apologetic about working at Fulbourn they now became proud of the hospital – especially when they met nurses from other hospitals and heard how static these other institutions were. This feeling was greatly strengthened in 1957 when we were asked by the Regional Nursing Officer to host a ‘Regional Refresher Course’ for Charge Nurses and Sisters from the other East Anglian Hospitals. Miss Brock and I joined eagerly with the newly arrived Chief Male Nurse, Jack Long, and the Nursing Tutor, Frank Tudgay, to put on a two-week course in September of that year. We structured it according to the ideas of the new GNC syllabus – focussing on what nurses had to do on the wards, rather than giving them lectures on medical topics. We asked our Charge Nurses and Sisters to talk to them, to tell them what they did and to show them round their wards. This was a striking experience for these long-stay nurses from the old custodial hospitals. One of our star performers was Eric Raines who told great tales of his self-governing ward to the Charge Nurses from other hospitals, still taken up with security, counting spoons and polishing door handles. Whether this Refresher Course did any good to the other East Anglian Hospitals, I never heard. But the tonic effect on the Fulbourn staff was great. Recounting the tales of their achievements of the last four years, the open doors, the work programme, the selfgovernment, the recoveries, reminded our staff of how much they had done. As they learnt how little had changed at the other hospitals, Fulbourn staff were filled with pride and pleasure in their own hospital. In 1958, Mr Tudgay moved on and we appointed Reg Salisbury, a lively man with a zest for teaching. The school was moved from its cellar to an outside building. In 1959, when I moved my family out of the hospital grounds, the vacated Superintendent’s House was made into the nurse training school. This move into quarters that were not only comfortable, roomy and with a garden, but which had also been symbolically the seat of the hospital government, was a measure of the changed status of training in the hospital. Reg built up a good training organisation, for which we now had a fair inflow of student nurses; he instructed the seconded Addenbrooke’s student nurses and the nursing assistants; he organised the Senior Nurses’ Meetings and the Refresher Courses and took an active and lively part in all the increasing learning activity of the hospital. He also took the students onto the wards and encouraged the Charge Nurses and Sisters to teach them directly. Recruitment had now ceased to be a matter of so much concern. As our reputation increased, students began to trickle in. They were never a flood, but there were always enough to fill our preliminary training schools and to maintain the staff numbers. We began to get general trained nurses coming for psychiatric experience. Our former students gave good reports of us and encouraged others to come. Gradually our numbers built up; we always felt short of staff, but each year found we had a few more. In 1961,

after one of the national rises of pay and decrease in hours, we were able to eliminate nearly all part-time working and a count showed that about half the women staff were now trained nurses or students. By this time the general standards of care – in cleanliness, hygiene, sympathy and efficiency – had risen greatly throughout the hospital. When we started to apply the suggestions of the WHO report in 1954, we still thought of patients as mostly passive – people to be got working and ‘activated’, people to be treated or cured. We – the nurses, doctors and planners – saw ourselves as the active ones. However, we had gradually to revise this view when it became clear that, given the chance to work, patients displayed surprising capacity and given the chance to run the affairs of a ward, they showed good sense and responsibility. Gradually, our notions about how we should organise the hospital began to change. I had hitherto accepted the prevailing medical view of patients as pathetic beings, only kept from recovery by the failure of their illnesses to respond to medical treatment or their wilful inability to do what doctors prescribed for them. It was several years before I even began to consider the possibility that patients could actually help each other – and that there might be patients who could help others better than doctors could. Patients had shown individual initiative in the past, but the hospital had either ignored or suppressed it because such action seemed either insane or directed against the organisation. Several men in Fulbourn used to write long letters of delusional complaint to the Superintendent. One man made aeroplanes out of lead wires, which could not fly; a woman knitted crazy patterns of brilliant colours; a man made false keys out of spoons; another man fashioned bizarre guns out of scrap metal. Even projects which served some better purpose were usually stopped if discovered. Jim mended watches for staff; a recovered melancholic, Herbert, repaired bicycles and created new ones from discarded old parts taken from the parish rubbish pit behind the hospital; several men had small vegetable plots hidden in the shrubberies or amongst the engineers’ lumber. But these activities had all had to be concealed from those in power, especially the Superintendent. As we changed our basic attitudes toward patients, we began to see that our job should be to encourage patients’ initiatives, not suppress them – especially where it led towards a recovery of independence and the possibility of returning to outside life. We therefore made Herbert’s bicycle workshop official. We gave him better facilities and allowed him to sell the bicycles that he made and to bank the money. We then got him an interview with the Ministry of Labour, who tried to find a job for him. The first job failed and Herbert came back to bicycle repairing for some months. Then his brother-in-law asked him to help in his butchery business; for some months Herbert went out to work daily from hospital, and then he moved out into lodgings. Leonard, the maker of lead aeroplanes, was also very fond of drawing schizophrenic diagrams – highly meticulous but strange works of art; they were much sought after by medical staff as souvenirs and regularly demonstrated to visiting medical students. We talked to him and found that he was interested in working in Percy Burgess’ workshop. At first Leonard just made aeroplanes, even bigger than before, but then he became interested in the tasks going on in the room and Percy Burgess allowed him to join in.

Leonard became fairly skilled at painting the finished furniture. He had been in hospital for about 15 years; now that he was rather better he started writing to his wife, whom he had not seen since coming in. This upset her and she started divorce proceedings. I looked into the matter and it seemed that in reality she meant nothing to him as a person, but was a link with the outside world. For her part she had made a complete life for herself and her daughter and was terrified at the thought of a mad stranger bursting back into her life. I gave the necessary affidavits and the divorce went through. Leonard’s brothers, who kept a small farm, then got in touch with us and asked if they could have him to stay for weekends. They found him useful and pleasant, though rather odd, and after a few visits, had him home for good. Not all stories went so smoothly. Dick, the maker of the bizarre guns, had a ferocious reputation because he had broken a policeman’s arm when they arrested him. He responded to increased hospital freedom by growing a black beard and stalking round the grounds with a scowl on his face. He built himself a little hut at the back of the grounds which he filled with all sorts of strange inventions and contraptions – a windmill to make electricity, a bicycle with extendable handlebars and a pigeon coop filled with feral pigeons that he had snared in a trap of his own design. I was under constant pressure to limit his activities, but it was the pigeons which finally did it. A tender-hearted member of the Management Committee was led to the pigeon coop by a disapproving staff member and found the pigeons sadly neglected. I had to bow to the storm, free the pigeons and dispossess Dick. However, he gradually settled; he took off the beard and then went out to work; he moved to Winston House. While there he sardonically presented me with a large, hoarded collection of Largactil to which the ward doctor had given all the credit for his recovery. After some months at Winston House, he moved off quietly to a working men’s hostel. These experiences underlined patients’ ability to help themselves toward recovery if given the chance. We next began to notice their capacity to help others. For years individual patients, especially in follow-up and outpatient clinics, had told me how much help they got from talking to other patients and of how the patients helped one another. I had merely regarded this as a measure of the failure of the nurses or myself to give them the psychotherapy they needed. Gradually, I began to look at this positively. What could we do actively to encourage patients to help one another? At first, the principle was only applied spasmodically. When two certified patients, John, a middle-aged, depressed rascal, and Doris, a young simple-minded woman, escaped together during 1953, in my first year, I shared the fury of the staff. The pair had been away for nearly two weeks when Edna’s sister told the police, who swooped and caught them in a caravan, living as man and wife and making a good living at fruit picking. On their return, I immediately clapped them into the disturbed wards (M5 and F5) with deprivation of all privileges. It was only as I pondered on their exploit, that I began to realise that someone clever enough to plan this should be clever enough to live outside. I saw both John and Doris and began to work on their discharges. Within a year, he was out at a job and within two she had rejoined her family. They showed no interest in one another once they were out of hospital, and sought other mates. I kept in touch with them over the years. They both remembered the other with affection for the support given at a critical time.

The traditional staff reaction to hospital friendships had been to ‘break it up’ by moving the partners to inaccessible wards. Now I persuaded the staff to let the affairs run on for a time to see how things went. Sometimes it was clear that one patient was harming or taking advantage of a vulnerable person, but on a number of occasions, one patient helped another to regain enough self-confidence to face the plunge back into the outer world. The shock of failing, of having to come into a mental hospital, the stigma and the rejection of their families had destroyed their self-esteem and often made them feel that they were of no value to anyone. That someone had actually sought out their particular company and valued it was a first step towards a more hopeful view of themselves. Unfortunately, not all recoveries were successes. In one of our long-term wards was a woman, Mrs Elsie Thompson, grossly mentally disordered though quiet and wellbehaved. I only noticed her because some members of the HMC always asked about her when they visited the ward. It emerged that she was the wife of the Town Clerk of one of Fenland’s ancient boroughs. She had broken down years ago after the birth of her third daughter and remained in the Asylum ever since. Everyone in the Town knew of the tragic situation and respected the Town Clerk and the faithful and noble way he visited her regularly every other weekend. Elsie was one of those who responded dramatically to Largactil. Her mental disorder quietened, her behaviour settled, she began to help on the ward and began to care for herself. She emerged as a quiet, self-effacing, pleasant woman in late middle age. The ward staff were delighted and told the Town Clerk when he came to visit. They suggested weekends at home and then periods of trial leave. We were all delighted and triumphant. We did not notice that not everyone shared our enthusiasm. Elsie went home. Two months later she was readmitted, certified again – and once again manifestly mad – unkempt, shabby and talking mentally-disordered nonsense. We settled her down and reinstated Largactil. In a few weeks she was well again, no longer mentally disordered, neat and tidy. We decided that the relapse had been due to a failure to take her Largactil pills regularly. She looked forward to her husband’s visits and we suggested he try her at home again, but this time to make sure that she took her pills regularly. Once again Elsie went ‘home’. The next thing we heard, three months later, was that her body had been found in the river. There was an inquest conducted by the Local Coroner, a friend of the Town Clerk and a fellow solicitor. A verdict of suicide while of unsound mind was recorded and everyone expressed great sympathy for the Town Clerk. It was only several months later in conversation with the Mayor of that town that I learned that the Town Clerk had recently remarried – the secretary who had been such a support to him over many troubled years. It was much later that I learned that she had in fact been his mistress for many years and a second mother to his daughters. All those years while he came to Fulbourn every other weekend to visit his ‘poor mad wife’ he spent the alternate weekends at Newmarket with his mistress. We had done Elsie no service in removing her insanity and pushing her back into a respectable home where no one wanted her, where the husband yearned for his loving mistress and the daughters resented this stranger

forced into their lives. Little wonder that Elsie finally drowned herself. As a result of this tragedy we learned to do rather more preparation before rushing people ‘home to their loving families’. As I read autobiographical accounts by former patients and reflected on their stories of medical indifference, nursing cruelty and the helpful kindness of other patients, my ideas developed. I was also reading social scientists’ accounts of hospital life, especially Caudill’s story of his time as a ‘patient’ in a neurosis unit where the other people taught him how to be a ‘good patient’, and his tales of how groups of unfortunates had helped one another (Caudill, 1958). About this time a personal friend of mine in another city made a suicide attempt and found herself in a custodial mental hospital. She later told me of her resentment of the ‘close observation’ maintained on her; the anti-suicide precautions; her contempt for the nurses and most of the doctors, and her tremendous appreciation of the help she received from other patients in learning the rituals of the hospital, in circumventing the regulations and later in working out an approach to her intolerable domestic problem. This made me ponder hard on how we could further facilitate the therapeutic potential of the patients. Some of our doctors attempted group therapy within the hospital, but it did not seem to go down very well. They assembled a group of selected patients from different wards and told them they would be meeting regularly and could discuss all matters freely. This was a method I had used successfully with outpatients. However, something seemed to go wrong with this scheme. At first, I heard a good deal from the doctors about how interesting it was and then nothing. Enquiry revealed that the meetings had stopped; the time was not convenient, the Sisters failed to send the patients down, the doctor had too much other work to do; there was always some reason. Another attempt at group therapy ended but more strikingly. Two doctors and a psychologist had been reading about Bateson’s ‘double-bind’ hypothesis, which suggested that schizophrenia was due to the patient getting equivocal messages from his parents during early childhood, so that his later communication with the world became permanently disordered. The two doctors proposed to set up a group for young schizophrenics in which the doctors would act as group leaders, taking the roles of mother and father and giving interpretations of the patients’ responses based on the theory. It sounded a bit far-fetched to me, but, in accordance with my principles of encouraging experimentation, I let them go ahead. They had about ten meetings. Several of the patients attending became very disturbed and were withdrawn from the group by the ward doctors. Several parents complained of the strange things their children were saying when they came home at weekends from the hospital; they did not enjoy being called ‘schizophrenogenic mothers’. Charge Nurses and Sisters began to complain that the doctors were undoing the work of months. Then the prime mover announced that he was going to London for further (and, he implied, better) training and the groups stopped. None of the patients suffered any obvious harm – there were no suicides – though several were very disturbed for months and it took a long time to win the confidence of some of the parents again. Group therapy inside hospital seemed different from outpatient groups.

In 1958 one of our Registrars, Eddie Oram, took over Adrian Ward, the women’s convalescent ward. He came and asked me if he might try to run it as a ‘Therapeutic Community’. I remembered my visit to Belmont in 1953 and what Maxwell Jones had told me about therapeutic communities during our four weeks at the King Edward’s Fund course in 1957. I had begun to wonder whether the Therapeutic Community approach might not be a good way to involve the nurses more and, in particular, to make the patients partners in the treatment process. I agreed to let him try. However, having heard tales of the upsets that these therapeutic communities caused, I was quite anxious about what might happen. Still, Eddie Oram was a level-headed man who had worked in many parts of the hospital and who was trusted by the Consultants, respected by the senior nurses and well liked by his fellow doctors. If he could not carry it through, no one could. I put the idea to Miss Brock, who was enthusiastic. The elderly sister of Adrian Ward was due to retire and we picked a younger woman to run the ward, Kay Kinnear, whom we thought might cooperate in these new ideas. We sent Dr Oram down to Belmont for a few days to see the work of Maxwell Jones and he read the books about other similar projects. Since its opening two years earlier Adrian Ward had been used for the overflow from the women’s Admission Villa. As the pressure of new admissions mounted, patients who were improving but were not yet well enough to leave were sent to Adrian Ward. The ward held up to 40 women, some about to leave, going out regularly on weekends, others still upset and confused or having the last of their ECT treatments; others moderately well and receiving psychotherapy, but not yet thinking of leaving. The ward doctor on Adrian had spent his time seeing patients, assessing progress, adjusting medication and providing supportive individual psychotherapy; the elderly sister had organised the nurses to run the ward and the patients tended to sit about knitting and talking sadly about their symptoms, their illnesses and their difficulties at home. In its brand new building, it was the most handsome ward in the hospital with the most comfortable accommodation and we had expected that patients would wish to go there, especially to escape the Admission Villa, which was often clamorous with the noise of new arrivals. However, they would often refuse, and even go home before time, saying that Adrian was unfriendly, ‘snooty’, dreary and unpleasant. It was not clear to us why this should be so. Eddie Oram proceeded with caution and good sense. He drafted his plan and discussed it with the Consultants, with Miss Brock and with the nurses. He then called the patients together and told them that the ward was going to change and that they were going to run it. They would be responsible for all housekeeping; there would be a series of group meetings, of which the most important was the weekly ward meeting, where everyone – doctor, sister, nurses and patients – would be present and where all important decisions would be taken; he said further that he would rarely see them individually and then only by appointment. After the protests had subsided, he explained that all this was to prepare them for the responsibilities they would shortly be facing outside. I heard all this at second hand. Eddie would tell the doctors’ morning meeting of his latest moves. I encouraged him to come and talk to me of what he was doing, but he seldom did so – partly I think from a desire to work things out for himself, partly for fear of the repercussions that would arise if people knew he was telling things to the

Superintendent. I gradually came to see my task as tempering the complaints and other complications that arose and particularly in reassuring Miss Brock who was upset when the standard of cleanliness fell after self-government began. After a period of disorganisation when beds were left unmade, when women stayed in bed all day and when the first comers to meals ate the best of the food, the women began to organise themselves, set up work rotas, and lay down general rules for their group life. The nurses were at first upset at having ‘nothing to do’, but soon found plenty of work in counselling and discussions with the patients. After some weeks of exploration, the meetings became very active and the women began to talk openly of their fears of leaving hospital, of the stigma they would face, of the problems from which they had taken asylum and which they must now face again – the unsympathetic husband, the complaining mother-in-law, the demanding children. A number of ward feuds, which had been covert for months, came into the open, and the tyranny of one well-established, dominant woman, Marion, was challenged. Marion was an artistic, attractive women of histrionic and dominating personality who had been in the ward a long time. She had received a great deal of personal psychotherapy from junior doctors and had for long claimed the best of everything; this right was now challenged by the other women in a series of stormy meetings. All this time, Eddie Oram was maintaining the usual service, assessing drug dosages, arranging leaves, and writing discharge letters. The Consultants were satisfied. The junior doctors had rather more night calls to the ward, but they were mollified by his explanations. The other nurses in the hospital were, however, very critical. Some of them disapproved of all the freedom and of the long sessions of discussion between the doctor and the nurses. They expressed these feelings so forcibly in jibes and veiled remarks that Sister Kinnear stopped going to the staff dining room for a time, saying that she preferred to take sandwiches on the ward. One morning, at 6 a.m., before any staff had arrived, a fire broke out in the sitting room of the ward; the patients called the duty staff and the fire brigade and started putting the fire out. By the time that I and the fire brigade arrived the blaze was under control, and very soon cups of tea appeared for everybody. This incident was a turning point. The patients of Adrian Ward had coped with an emergency without panicking; the rest of the hospital had to admit that these patients could look after themselves quite well. Within the ward, too, they felt more confident. We never found the exact cause of the fire; it had started in a wastepaper basket that had then ignited the curtains; Eddie and I suspected that it was a deliberate act of spite by Marion against the new regime, but we could not prove it. The Adrian Ward meetings continued actively. They arranged a number of outings, set up a welcoming committee to help patients just transferred from the Admission Villa and made several trips to the Admission Villa to improve relations. In an attempt to overcome their fears of the ‘main building’, some Adrian patients arranged to have a tour of the long-stay wards; several reacted to what they saw by trying to help – some gave singing and piano sessions on long-stay wards and Marion ran painting classes for a group of regressed women on a long-term ward. This class was a turning point for her, as it made

her feel that there were people she could help; some months later she got a job in Cambridge to which she cycled daily. The change in Marion’s behaviour demonstrated clearly how the changed atmosphere operated. Previously, she had been very skilled at being a patient; she attended her psychotherapy sessions, she painted ‘schizophrenic paintings’ for the doctors she liked, she dominated the sitting room but dared not think of leaving. After the change, she found herself in an atmosphere of rehabilitation where her domination was challenged by other patients; she was provided with chances to help others, then to work, and finally to re-establish herself in the outside world. I heard of many of these things in a roundabout way, or months afterwards, but I could see for myself how different Adrian Ward was. It was less tidy, but more homelike. The women did much more. Patients from the Admission Villas seemed to pass through more effectively and rapidly and often seemed to make more stable recoveries. There were, however, problems. Just before the annual Open Day Miss Brock, going round, had found the ward untidy and ordered Sister Kinnear to get it clean – an instruction which annoyed the ward meeting but which was obeyed. Some experiments failed altogether. Dr Oram proposed to the nurses that the staff should use each other’s Christian name and that they should call him ‘Eddie’ not ‘Dr Oram’. They complied, though awkwardly. After a week, the patients came to him in a deputation asking for things to revert to the way they had been. The Adrian therapeutic community ran for 18 months under Eddie Oram and Kay Kinnear, from 1958 to 1960. After she left another Sister was appointed, but was so disturbed by the patients’ freedom to comment on what they did and did not like that after six weeks she asked Miss Brock for a change. Another Sister took it on and settled in well. In due course, Eddie Oram handed over to another Registrar. By that time however the pattern of self-government was well settled and the weekly meetings went on regularly, some doctors contributing more than others. Under the leadership of one extrovert doctor, the patients adopted a group of crippled children and gave a series of lively parties; under another quieter doctor they held more discussions. I was very pleased that the project had worked so well and survived its various crises, and wondered where we could next apply the notion. The general principle of self-government was by now accepted in the hospital as a desirable aim, but there were doubts as to how far it might go. Eddie Oram and I, with Douglas Hooper, our research social psychologist, wrote and published an article about the Adrian experiment (Clark, Hooper and Oram, 1962). The men’s disturbed ward had also begun to develop their own pattern of patient government. The first Charge Nurse, Joe Pattemore, who had opened the ward door, had always consulted the patients about any major development or excursion and had shared his plans very openly with the other nurses on the ward. When he moved to other work, Tom Lewis took over as Charge Nurse and decided to explore self-government. The main problems of the ward at the time were certain schizophrenic men who repeatedly misbehaved; one ran away frequently, another shouted obscene abuse at passers-by from the ward windows, a third absconded and broke into churches. Lewis called a patients’ meeting to discuss ward problems, in particular the behaviour of these particular

offenders. This proved to be a very lively meeting and became a regular feature of ward life. The Chairman and Secretary were patients, selected by staff and patients and holding office for a few weeks; they conducted the business and kept the minutes. The Charge Nurse and the ward doctor attended but held no office. All proceedings were kept fairly strictly to order, but many ward subjects were discussed. At times the meeting wrote to the Management Committee; at one period, when they had an accumulation of problems, they invited me to attend and put their difficulties to me, courteously and firmly. One of their Chairmen, a former Naval Officer, sat with ‘Chairman’s Rules of Debate’ on one side of his table and ‘The Mental Health Act’ on the other. At a later period, they produced a ward magazine, which featured a letter from a recovering catatonic youth, thanking all for their understanding of his behaviour in his confused phase. This gratitude was appropriate, for when he was very psychotic he had rushed round the ward alternately kissing and hitting the other patients. They had found this very annoying, but a ward discussion had defeated a motion to ask the staff to lock him into a side room in favour of one proposing a policy of greater understanding. Again, I was only involved marginally in this project; I was happy to see it develop, and pleased when I received petitions from the patients that I could take to the Management Committee. This irregularity would irritate some of the stuffier hospital officers, who would mutter that this matter should have been brought up through ‘the proper channels’ – which gave me the chance to remind them that as far as I was concerned the only purpose of the Management Committee was to serve the patients. I personally found all these developments in patient government most interesting and longed to do some of it myself. It became clear, however, that the doctors running these projects, while gratified by my interest, only welcomed me as an occasional visitor and were not keen to have me there very often. Once again I realised that my function as Medical Superintendent was to protect their work, particularly from administrative interference, but that they had to run their own shows and that I could not directly take part. My own chance to do some work of this kind came eventually in 1960 after we had reorganised the long-stay women’s wards. During the late 1950s the patterns of consultant responsibility within the hospital changed as a result of the 1959 Mental Health Act. In 1953 I had accepted the job of Medical Superintendent on the traditional terms (based on the 1890 Lunacy Acts), that I was responsible at law for the custody and treatment of every patient in the hospital. After 1959 each patient now had a named ‘Responsible Medical Officer’, who was answerable for the treatment given to that patient. This was quite clear on the admission wards, where each Consultant admitted, treated and discharged the patients for whom he was Responsible Medical Officer. For the long-stay patients the position needed clarification as they had previously all been the responsibility of the Medical Superintendent. Now we divided the responsibility for the long-stay patients between the three full-time Consultants: Leslie Buttle, Oliver Hodgson and myself. We rearranged this several times during the 1960s; these changes gave me a chance to concentrate my personal attention on the long-stay patients, particularly the most disturbed.

At first, in 1960, I took on a group of long-stay women patients which included all those most disordered mentally and most in need of rehabilitation. Amongst my wards was the one which had been known as the Women’s Disturbed Ward, F5. I was glad, at last, to be able to turn my attention to this group of patients and nurses; when I first came to Fulbourn it was this ward which had dismayed me most. On my very first visit in 1953 this ward was filled with turbulent women, shouting and screaming. Though I became inured to many things in my early months, entering ward F5 never failed to dismay me. As I unlocked the door I would be surrounded by a mob, clamouring and grabbing at my clothing and fingering my pockets. The Charge Nurse, Sister John, would soon loom up, craggy and forbidding, shouting at them to get back, which they hastily did. Making it clear that she resented my interruption of her work, she would escort me round the dreary ward, which was floored with hard terrazzo and had a dark green dado up the walls and no decorations. In the far room sat the ‘wet and dirties’; pitiful creatures forced to sit on hard wooden benches, dressed in ‘strong clothes’ – indestructible, shapeless, colourless garments of quilted cotton, stained by food and urine and bleached by innumerable boilings. If they got up, they were curtly ordered to sit down again. Beyond them again were the padded rooms, nearly always occupied, sometimes by a jovial and truculent manic woman, squatting naked and roaring obscenities, or else by a terrified creature who would shrink back into a corner, as if expecting to be hit again. I was disturbed, too, by the attitudes of the staff in this ward; they seemed harsh and unfeeling, shouting contemptuously at the patients and using phrases that dismayed me. ‘That’s a bad one, doctor – murder you as soon as look at you!’ a nurse said once, pointing at an apparently harmless woman cowering in a corner. In 1953 I was disturbed and revolted by F5 but did not know what to do about it. A compassionate doctor bitterly recounted the tale of an attempt by one of the occupational therapists to organise knitting for these unhappy people, which had stopped after the Sister had gathered all the knitting and locked it away, saying that it made the patients too excited and difficult to handle. I knew that tales of this ward circulated round the rest of the hospital. Any woman who misbehaved might be sent there as punishment; offenders would beg with tears in their eyes ‘Please don’t send me to Fives, Doctor!’ When I had to go into F5, I tried to indicate my disapproval of the staff attitudes. I would stop and talk to patients who asked to speak to me, sitting down beside them on their greasy benches or squatting on the floor of the padded room to chat, trying to ignore the gathering squad of strong nurses, ready to pounce on the woman if she attempted to strike ‘The Doctor’. I knew the nurses did not like my chatting to the women like this, but felt I had to show how much I disliked the way they themselves treated the patients. My efforts, however, seemed to make little difference. I was also forced to admit the utility of the ward for the rest of the hospital; this was dramatically shown when the epileptic sister of a famous boxer was admitted in a raging temper, after she had severely damaged several policemen. No other ward could handle her, but after a few days with Sister John, she was as gentle as a dove. Feeling that I could not yet deal adequately with F5, I made no attempt to change it in my first year. The staff there had a nasty and tough job to do controlling the violent women; I

did not like the way they did it, but with the shortage of women staff, I could not see how else it could be done. Tentative explorations with Miss Brock showed that she would not tolerate any attempts to change Sister John’s ways; she was thankful that the ward at least managed to do its job and was not prepared to interfere with it. Towards the end of 1954, when Fred Houston took over clinical control of the men’s side, I took over the women’s wards from Leslie Buttle. I was now responsible for what happened in F5 and even more worried about it. However, I had to start by concentrating on another ward – F4, the infirmary ward – and trying to raise the standard of physical nursing there. Meanwhile, Miss Brock was attempting to get better clothing and belongings for the patients in Ward Five. She managed to substitute new, floral-patterned strong dresses for the old bleached ones. As junior doctors spent more time on the ward (because they found it less unpleasant than it had been in the past), some of the consequences of inadequate medical attention for many years were remedied. Epileptic fits were better controlled, medication was increased, decayed teeth were drawn and spectacles supplied. At the end of 1955, we rearranged the women’s wards and this gave us a chance to make a major change for the disturbed women. We offered Sister John new premises for her patients upstairs in a nearby building. At first she was unwilling to go, but when she discovered that it was to be repainted (in colours of her choosing), to have rugs and curtains and entirely new furniture, she became reluctantly and then excitedly interested. She complained, however, of the lack of a padded room, and brought this up truculently at a Sisters’ meeting. I said I thought she could manage without one, but said that if after three months’ trial she still felt she needed it, I would ask the Management Committee to install one. At the end of 1956, we moved the wards and Sister John and Ward Five moved just before Christmas. In 1957, I put Arnold Orwin on to Sister John’s ward for a number of months. He was an able young doctor with a strong sympathy for the unfortunate and an active approach to suffering. He was always ready to try any remedy – on another ward he was experimenting with hypnosis, which he found congenial. Although he began his time in the ward disapproving of some of Sister John’s ways – and she his brashness – he and the sister soon established a mutual respect which blossomed into a confident partnership. He respected her vast knowledge of the patients, with whom she had worked for nearly a quarter of a century; she liked the energy with which he took action on any problem presented to him. He reviewed all the patients, in some cases recording the first adequate assessment for years, and applied relevant treatment; for many patients, he arranged prolonged courses of ECT (15–20 treatments) as proposed by Kalinowsky, the American expert; for others, trials of the tranquillisers that were then becoming available. A number of patients were given a chance to try occupational therapy or work assignments and contacts were re-established with some of their families. I, as Consultant, was of course asked to approve these treatments, but I nearly always consented, feeling that this active approach was far better for these women than the the neglect of the previous years.

The ward was now a different place to look at. It had a name, Hillview, rather than a number and was an attractive, light, airy place, painted in pastel colours, with bright rugs and curtains. When I entered it, I would see a group of neatly dressed women sitting round the fireplace doing embroidery. By this time, the general increase in numbers of women nurses had enabled Miss Brock to increase Sister John’s staff and there were more nurses to be seen about. At the far end the incontinent patients were still congregated, but they looked less repulsive; their dresses were colourful, their faces washed and their hair combed; they no longer stank of urine and paraldehyde. Occasionally, a disturbed patient would be shown to me locked in her side room with the shutters closed, but this was far better than the smelly, grey, padded cells. There seemed to be far less shouting by the nurses, and even Sister John, though still stern and forbidding, no longer talked of the patients so disparagingly. I felt I could take visitors into the ward and often did so. We were gradually opening the doors of the women’s wards and in the spring of 1958, Sister John yielded to the general pressure – from her fellow Sisters and nurses and from Miss Brock and myself and declared the ward door open. This was the last ward in the hospital to be opened and we could now claim that Fulbourn was an Open Door Hospital – a great day for us all. However, Sister John retained the right to lock the door when she felt it necessary and exercised this right frequently. In my early days at Fulbourn, I had hoped to get a social scientist to work at the hospital, both to inform us about the processes going on (as Schwartz had done at Chestnut Lodge) and also to record the old asylum life as it changed to something better. During 1955 and 1956, I discussed the possibility with Oliver Zangwill, put up reports to research foundations, and interviewed promising young social psychologists. It took a long time, but in 1957 Douglas Hooper, a social psychologist, started work on a three-year grant. I suggested that he study Hillview Ward. He had seen the women in the old days in Female 5 and agreed to study the changes in the social pattern as the ward door of Hillview was opened. He spent long periods on the ward observing the life of the staff and the patients and recording the type and frequency of their interactions. A charming, quiet man, he was soon accepted by the staff as unthreatening and he gained a very good picture of the way the ward operated. A year later, after the opening of the ward door, he repeated his observations. Douglas Hooper’s period in the hospital was of great value and importance to me. I found it immensely helpful to be able to talk to someone who saw the hospital as a functioning social organism and who approached things sociologically. Douglas was a discreet man and I found I could ventilate to him freely my hopes and fears about the hospital and its functioning. He was with us all through the Hauser episode and had behaved with great good sense and restraint. During my tensions with the junior doctors – with whom he lunched regularly – he kept their confidences and mine without losing the trust of either and probably contributed a good deal to their final resolution. He was very useful in the hospital in showing the contribution the social sciences could make to the understanding of hospital or ward happenings and in arousing in many people a better understanding of what they could contribute. He helped with a number of other social studies, particularly on Adrian Ward, but his central work was on Hillview.

Initially, I was quite perturbed to learn of his findings on Hillview, because he showed that though the place now looked different, there had been really remarkably little change in the social structure. Though the door was open, very few patients were free to go out. There had always been a group of privileged patients who did much of the housework of the ward and led a fairly good life, even in F5. Now they were more obvious, but the membership of the group had not changed. There was a group of less privileged women and then the ‘wet and dirties’, without any privileges at all. Though they were more presentable than in the old days, they were still kept sitting down, with practically nothing to do, and seldom hearing anything from the staff but curt orders. He showed, too, that though episodically disturbed patients from other wards moved in and out of Hillview, there had been very little movement amongst the main residents of the ward, some of whom had been there many years. In short, Douglas Hooper showed that though the ward had been made much more presentable there had been no change in the social structure of the ward and the long-stay patients were making no progress toward recovery. This presented me with a challenge, which I could see no way of meeting at that time, so I decided to let things run on for a bit. During 1959 I was forced to realise I could not leave things as they were for much longer. Two deeply disturbed adolescent patients were transferred to Hillview, which proved incapable of handling them, despite locked doors and massive sedation. One of them attacked Sister John and injured her, so that she had to go off sick for a time. This shook her self-confidence; in the past she had always prided herself on her ability to tackle any woman, however tough, and to absorb bruises and violence. She was now over 60 and realised that she was not as strong as she used to be. She began to talk of retiring. Towards the end of 1959 Sister John finally announced her intention of retiring in a few months. Here now was a chance for me to tackle the challenge of the disturbed women – a problem I had been dithering about for six years. At last there was a real chance to apply social reorganisation to a difficult and challenging group and, what was more, a chance to do it myself. I wanted to see whether the Therapeutic Community approach would work with these people as it had with others in Fulbourn. I spoke to Sister Kinnear, who had done so well with Eddie Oram on Adrian Ward, and found that she also felt the challenge of these women and wanted to help them. Miss Brock revealed that she too had always been unhappy about the way that ward was run and we decided to make changes when Sister John retired in the spring. Sister Kinnear took over in the spring of 1960 with a new group of staff. She immediately began treating the patients more tolerantly and relaxing the firm discipline. I started coming to the ward more frequently and discussing the problems with her. At this stage, the junior doctor was a bright, intense young man who also believed that a more understanding therapeutic approach was needed. All went well for a few months, and then I had to transfer to the ward a deeply disturbed, middle-aged Scots woman, Mary Bruce. A year earlier, she had been admitted to the admission ward following a determined effort to kill herself; she had persistently attempted self-damage and at times

there had to be two nurses on constant duty to prevent her beating her head on the floor. This behaviour persisted despite tranquillisers, antidepressants and courses of ECT; discussion was of little value, for she remained sullen and out of contact, just reiterating that she wished to die because her husband had left her for another woman. She then started attacking the nurses and at this stage, I was asked to take her over and so transferred her to Hillview. Her disturbances were now episodic, and for periods one could hold conversations with her, though one could make little real contact. She soon settled in Hillview, but got together with a group of other violent women. They would sit together at their table, chatting in low voices and laughing; the nurses said that they egged each other on to acts of violence. A few windows had been broken previously on the ward, but now the number rose sharply, until they were being broken every day. The nurses asked for more sedation and control; we broke up the group, putting them on separate tables, increased their sedation and provided them with other activities. I began to hold staff meetings one morning a week when we would discuss major problems on the ward. As the summer wore on, there were more difficulties. Mary Bruce began attacking members of staff, putting her hands round their throats and throttling them. She was strong, and this frightened the smaller nurses. I talked with her, but she could not explain what caused these episodes. On one occasion she did it with me, passing into a sort of trance and twining her fingers round my neck to strangle me. I found that I could disengage her fingers but could still not make contact with her. I discussed this with the staff group, sharing their anxieties. We ensured that no one was left alone with Mary, especially not young or small nurses. One day Mary, rushing towards the door, pushed Sister Kinnear down the stairs so that her ankle was broken; she was off duty for many weeks and her deputy had to take charge. At the next staff meeting, I found a shaken group. One nurse had asked for a transfer, another was off duty with a cold; that morning it had been difficult to get anyone to take Mary Bruce’s breakfast in to her. They were all afraid of being hurt and soon admitted it. I too felt frightened and dismayed. I wondered if Sister John had not perhaps been right, and that the only thing to do with these women was to hold them under rigid control. I realised I must do something. I put Mary on regular ECT, which checked her overactivity; I increased sedation all round; I got some extra nurses on the ward. The nurses became more confident and the whole ward settled down. I felt, however, that what I had done was a step back, a return to authoritarian control. One of the nursing assistants, Jean Salter, had been making an especial effort with another patient – a leucotomised, schizophrenic ex-nurse called Katherine – taking her with her during her duties, talking to her, attempting to understand her. Despite this, the patient constantly struck others and at times staff. We often discussed Katherine and her family at the staff meetings, but could not understand her behaviour. Then one morning I heard that Jean Salter had just gone to the Matron with her resignation. The day before she had lost her temper with Katherine and slapped her face; she felt that such behaviour showed that she was unfit to be a nurse and that she must leave. I saw her and heard her

story; I realised that we had failed Jean in letting her carry all the burden of Katharine herself. I felt we must bring her back into the team and I persuaded her to tell the staff group about it at the meeting next day. She told her story with great feeling, stressing how she had given Katherine all the affection of which she was capable and how ashamed she was of her outburst of anger. This honest and painful story affected all of us and provoked a flood of response from all the staff there, trained nurses, student nurses and doctors. We began to talk of our own occasional feelings of fury toward the patients and our difficulty in accepting or controlling these. A strong feeling of fellowship emerged as we discussed how these seemingly ungrateful, hostile, bitter women upset us and how we found it difficult to go on being understanding and kind. We realised that we had all been happy to let Jean carry the burden of Katherine and we acknowledged that we should have shared it more. This deeply moving meeting was the beginning of real team work on Hillview; from it emerged a common policy for helping Jean and Katherine and sharing of our own disturbed feelings; Jean withdrew her resignation and remained a valued member of the team. I began to realise that if I was to do a good job of making a Therapeutic Community in Hillview, I must make it a higher personal priority. I started weekly ward meetings on Hillview on Wednesday morning, followed by staff meetings. I told the porters and my secretary that I was not available at those times and that I would not answer the telephone. The ward meetings were conducted in the Belmont Therapeutic Community manner. All patients and staff sat in a circle and anyone might speak of anything they wished; the meeting went on for an hour. I was the conductor and at first all remarks were addressed to me. For the first few meetings the talk was of necessary repairs on the ward, windows, cupboards and doors, but soon we came to discuss individuals and their behaviour and the ways they reacted on one another. I tried whenever I could to bring other people in, to pass queries to other staff members and to turn the talk to enquiring the causes of disturbing behaviour, rather than discussing methods of controlling it. However, it was not easy. A number of patients were simple-minded or poorly educated, and many of my long-winded polysyllabic statements were lost on them. They tended to shout at one another, and often three women would be yelling at once. They would then become violent, and many early meetings were punctuated, or even terminated, by brawls. One patient, Jane, was a major problem; the simple-minded adolescent daughter of a professional family, she had developed a catatonic schizophrenic disorder and was constantly hallucinating. She would suddenly yell ‘Tick-tock! Tick-tock! Deathwatching my life away!’ and hit her neighbour hard. Naturally, this frightened and annoyed the other patients. In the meeting we got Jane to talk of the voices that tormented her and the others became more understanding. However, they still did not like being hit and asked for her to be controlled. Though the nurses were able to manage Jane, they were still upset by Mary Bruce’s throttling attacks, which had now returned, and Katherine’s occasional outbursts of violence, as well as competitive window smashing – which not only made the ward very draughty but brought a good deal of heavy humour from the maintenance man who was constantly being called in to replace the glass.

All these problems gave us plenty to discuss at the staff meetings which were attended by the ward doctor, myself, Sister Kinnear, the student nurses, the nursing assistants and the occupational therapist. We soon developed a strong team feeling. I tried to bring about open and equal discussion, but found that the bulk of the conversation fell to me, with Sister and the ward doctor contributing a little. I was greatly pleased the day the staff actively criticised something I had done earlier at the ward meeting. Jane had been sitting beside me holding my hand and had then leapt up to cross the circle to hit Mary Bruce, who had been taunting her. I held on to her hand, and was towed across the room by the beefy girl; the nurses leapt up and had difficulty in sorting out the melee. They said afterwards that I should not have got into the fight; that was their job, not mine; mine was to conduct the meeting, which found itself without direction during the scuffle. I had to admit that they were right and furthermore that though I might know a lot about psychiatry and psychotherapy, I did not know much about how to separate fighting women – a skill which the psychiatric nurses certainly had. The nurses went on to talk about how they resented doctors who invaded the nurses’ areas of responsibility by taking over the feeding of catatonic patients, or by the soothing of disturbed hallucinated ones. They pointed out that this was often an implicit criticism of the nurses and they commented that the doctors, after spending half an hour doing this, would then get up and go from the ward, leaving them with the patient for the next eight hours. As I listened to all this, I remembered how I used to irritate Sister John by going into the padded cells and chatting to her patients; I began to realise what she must have faced in the wartime years when, owing to shortage of staff, she was left alone for hours with 50 women like Mary, Jane and Katherine, with no tranquillisers and no ECT, only paraldehyde and her own good sense to keep them all from chaos and homicide. I began to realise that I had been hasty in my condemnation and that the management of violently disturbed patients was far less easy than I had thought. However, the ward meetings continued and Hillview began to change. This was now the most exciting part of my work in the hospital and I greatly enjoyed being closely involved with the patients. Gradually the violence settled down, both in the meetings and in the ward. Slowly the occupational programme became more effective and more varied until everybody was doing something most of the day. Katherine made marked progress; her homicidal attacks ceased and after severe trial visits she went home for good. We also successfully analysed Mary Bruce’s strangling attacks in the meeting; it emerged that she was seeking revenge on her husband’s mistress and was doing it by going into dissociation (she was a Spiritualist and an amateur medium) and attacking the nearest person. As the staff and patients came to understand this their terror left them and gradually Mary was weaned from the strangling attacks. In due course, she started going out to work. Jane remained hallucinated but gradually came into much better social and emotional contact with others and was seldom violent. Other disturbed and disturbing women were transferred to the ward and we attempted to understand and help them too. The standard of cooperation and ward work rose markedly and the patients took over many tasks, such as washing up and cleaning. The ward meeting became well-established so that Sister or the ward doctor could conduct it when I

was away. It became a point of interest for visitors and Reg Salisbury, the Nursing Tutor, brought so many student nurses to experience it that we eventually had to limit the number of visitors! The Hillview nurses developed a high level of understanding of personal and social dynamics and, more importantly, an ability to feel their way into what was tormenting a particular patient at a particular time. I heard that Hillview had become a sought-after assignment with the junior nurses, instead of a place to be avoided, as Ward Five had been. It was, they said ‘real mental nursing’. The seconded student nurses from Addenbrooke’s had at first been kept away from the disturbed ward at their Matron’s request; now they clamoured to come to Hillview and, when permitted, pressed for more time there. Although all this was most gratifying, the real test was whether this reorganisation had truly changed either the life of the ward or the fate of the patients. Douglas Hooper repeated some of his measurements and some statistical assessments; now there was no question that a change had occurred. The staff–patient and patient–patient interactions formed an entirely different pattern from the old days, when most patients heard little but ‘No!’ and ‘Sit down!’ and ‘Stop that!’. Now, the responses tended to be positive; there were attempts to involve them in conversation, to explore alternatives, to engage them in positive action. The approaches often came from other patients as well as staff. The analysis also showed that several of the long-stay patients had moved from that ward to better wards and even on to their homes. Social movement and rehabilitation were occurring, where before there had been stasis. This proved at last that though the old method of impersonal control had been effective in checking violence among a group of deeply disturbed women, and was economical of staff, it did tend, like all custodial methods, to produce dependence and social regression. It had also dehumanised the patients. The Therapeutic Community, on the other hand, tended to promote social recovery and gave the patients human dignity. It was more satisfying to intelligent and sensitive staff and was more humane and dignified. However, it did require more staff and it was perplexing and exhausting work. To open oneself fully to the tortured feelings of the deeply mentally ill is very disturbing. It was clear that the full and informed support of a good staff team was necessary for people undertaking this kind of work. In 1959 the Hospital Management Committee asked me to visit the other East Anglian Mental Hospitals to see what they were doing and to see if they had any useful new ideas. During December 1959 and January 1960 I visited each one with the professed aim of seeing their work and gathering comparative statistics. I produced a report in which I noted that I entered 65 wards in two months. For the benefit of the HMC I gave accounts of how the hospitals looked and what they were doing as well as many comparative figures on staffing, overcrowding, facilities and suchlike. I saw much that I envied; Hellesdon Hospital at Norwich had new spacious buildings and a delightful admission unit built in the 1930s. St Audrey’s Hospital at Woodbridge had excellent workshops for their male patients. St Clements Hospital was a cosy little hospital in the centre of Ipswich. However, I found the visits depressing overall because

many of the practices in these hospitals were still backward and oppressive. I saw padded cells in regular use and occupied (we had removed ours two years earlier). I saw locked wards full of tensions and violence – we had been an Open Door hospital for two years. I saw hordes of idle patients milling around vast, overcrowded wards. Although there were some good traditional workshops, the level of patient activity was low. None of the hospitals had an Industrial Workshop, as we had. None of them had patients going out of hospital to work, nor did they think it possible, while we had about 30 people going out to work in Cambridge every day. None of them had a halfway house. The vists in this respect served as an important tonic for me – especially after the uncertainty and selfdoubts of 1958. In October 1957 I had addressed the Social Psychiatry Section of the Royal MedicoPsychological Association about how I thought a mental hospital should be run. I called the talk ‘Administrative Therapy’; it was published in the Lancet in 1958 (Clark, 1958) and in a revised version in the American Journal of Psychiatry in 1960 (Clark, 1960). As a result, I was invited to go on a lecture tour of American psychiatric hospitals; in October 1961 I spent six weeks there, going from coast to coast. I was very excited at the prospect of my trip. Like every restless young man in postwar Britain, I had yearned to go to America. The United States in those days was the land of dreams – of unlimited wealth, opportunities and riches, the country which had conquered the world, the land of the films we had all seen, of mountains and prairies, of Cadillacs and film stars. Some of my friends had gone there for postgraduate study; a number had emigrated and prospered. Now at last I was going to visit it, and see what it was actually like. The tour was delightful. I experienced the heartwarming generous hospitality of Americans – so much more open than anything in Europe. I saw something of the breathtaking beauty of the great continent. I tasted the heady intoxication of American lecture audiences – so courteous, so appreciative, so flattering with none of the carping, penetrating, deflating comments I knew so well from Cambridge and the Maudsley. I talked everywhere of what we were doing in Fulbourn and other British mental hospitals, of open doors, of activity, freedom and responsibility for the patients, of Industrial Workshops, of halfway houses and of Administrative Therapy. My talks were well, even enthusiastically, received. I went to ten cities, including Boston, New York, Washington, St Louis, Omaha and San Francisco, visited 25 hospitals and gave 18 lectures, all in six weeks. However, I drove myself so hard that I collapsed with acute lumbago and had to be flown home in a corset. This trip was personally fulfilling for me but was also an important event for the hospital. Never before had anyone from Fulbourn been asked to lecture internationally, never before had any East Anglian Superintendent been asked to cross oceans to tell of the work of an East Anglian mental hospital. It was an external validation of what we were doing which confounded some of my critics, both in the hospital and within the region. There was of course envy, jealousy and backbiting, and I had to endure a good deal of ‘humorous’ comments about ‘superintending from a distance of 5,000 miles’.

Nonetheless, the fact that the Americans wanted to hear about the work of Fulbourn Hospital, and in particular admired and wanted to copy our Open Door policy, was noted in the local newspaper and elsewhere. I also brought back a number of useful ideas with me from the States. I saw volunteers being used very widely in some American hospitals. We had a few volunteers working at Fulbourn, but somehow they seldom stayed long. I noted that the American hospitals with successful volunteer schemes took good care to support and organise them well. I suggested to the HMC that we should have a Voluntary Services Organiser. Over the next two years funds were obtained (from the Nuffield Provincial Hospitals Trust) and an Organiser was appointed in 1963 – another first for Fulbourn. I also saw that some American hospitals had a wide range of specialist technicians helping their occupational therapy departments and that some of these were very valuable for selected patients. I visited several halfway houses, but was particularly impressed by Fountain House, New York – a fascinating and stimulating self-governing day centre for discharged patients from mental hospitals. Another place I visited was Stanford University near San Francisco in California, where Dr David Hamburg was starting a pioneering department of psychiatry. Nearby was a postgraduate institute, the Center for Advanced Study in Behavior Sciences; some of my Cambridge academic friends, notably Meyer Fortes, the Professor of Social Anthropology, had told me about the Center. They apparently invited scholars of the Social Sciences from all over the world to spend a year there. Scholars were flown in with their families from wherever they lived, given a house, a salary, a study, a secretary and unlimited leisure for a year; all their expenses were paid, and there were no obligations on them to lecture, teach or treat patients – merely the hope that they would use the time to forward their academic work. It sounded like an academic’s heaven. Some months after my return I was amazed to be offered a place at the Center for 1962– 63. My wife and family were delighted by the idea and so I asked the Regional Board for a year’s leave without pay; they could hardly refuse, since it would cost them nothing. A locum was hired to do my clinical work while I was away and Oliver Hodgson agreed to act as Medical Superintendent for the year. Gradually, I ran things down and hectically tried to ‘tidy everything up’; finally at the end of August 1962 I emplaned for San Francisco with my family. There followed an amazing and delightful year for all of us. California and the USA were then at the height of their confidence; John Kennedy was President, the world was full of hope. The American Government had declared war on poverty and, more important for us, war on mental illness. Federal funds were flowing freely into many mental health projects, particularly Community Mental Health Centers. While we were there Kennedy faced down Khrushchev in the Cuban missile crisis and world peace seemed assured. California had had 20 years of boom and there was ample money available to use for any good cause. I bustled about visiting mental health centres and mental hospitals, lecturing

about British Open Door psychiatry and hearing about American ideas. I went up to Oregon where Maxwell Jones was revolutionising the State Hospital at Salem. My main effort during my year at the Center went into trying to write a book about what I had learned and demonstrated during my first nine years at Fulbourn. I found the task dauntingly difficult, writing draft after draft and discussing it with some of the very talented people available; at the Center, Carl Rogers and Erik Erikson; at Stanford, David Hamburg and Irvin Yalom; at Berkeley, Erving Goffman, the author of Asylums; in Palo Alto, Ken Kesey, the author of One Flew Over the Cuckoo’s Nest. I revised my ideas again and again under the comments of so many brilliant, disturbing and provocative men. Gradually the book came together. I entitled it Administrative Therapy. By the time I got home in September 1963 it was ready for the publisher and it came out in 1964 (Clark, 1964). I returned to Fulbourn Hospital on 1 September 1963 – ten years and one month exactly since I had started work there on 1 August 1953. What a contrast there was this time with my initial furtive entry into a locked and gloomy asylum. The staff were delighted to see me back; they even hung a banner across the front of the main building proclaiming ‘Welcome Home, Doctor Clark’! The HMC welcomed me, and Oliver Hodgson was happy to hand back the Superintendency. I resumed my responsibilities and spent much of the early months telling tales of my travels. I even constructed an illustrated lecture based on my many slides, and presented it to Women’s Institutes and evening classes round the town. I then prepared a report reflecting on what I had learned in the USA about Social Psychiatry and presented it to the HMC and to the Regional Board.

6 Social Therapy My year in America had clarified my thinking about Fulbourn Hospital and helped me plan goals for the coming years. As I settled back into life in England in 1963 I began to see that there were various priorities. First, we had to reorganise the administrative structure of the hospital to meet the needs of the patients better. This would entail integrating the male and female divisions of the nursing service, bringing Consultants more closely in touch with wards, promoting new forms of occupation and providing patients with the material means for a better life – money, lockers, privacy and personal clothing. Second, there was the need to develop new social structures to allow patients more control over their lives. This meant encouraging self-government of various kinds, especially extending the practice of therapeutic communities. Third, we needed to develop more Transitional Facilities to ease the painful process of rehabilitation for longterm patients – sheltered workshops, halfway houses, group homes and so on. Fourthly there was the important task of recording, studying, analysing, and reporting what we were doing at Fulbourn so that we could manage ourselves better – as well as share what we had discovered with others. My year abroad had also been an important turning point for me personally. For nine years I had thrown myself without reservation into the job of Superintendent. This task

had entailed getting to know a despondent and demoralised institution and helping it to find new goals. I had led it through exciting changes until it had become a high-quality mental hospital, doing pioneering work and with a good reputation. During my year away, I learnt about sociology, reflected on the work I had done, wrote my book and tried out my ideas on lively and advanced thinkers. As a result I began to see the hospital, myself, and my professional future differently; perhaps there were other things I could do beyond Fulbourn. My absence was also a turning point for Fulbourn Hospital – though they missed me, they had managed very well. They realised that it was true, as I had often told them, that their work and their advancement did not depend on one person alone; that many other people had valuable ideas and the initiative to drive them through. Oliver Hodgson had acted as Medical Superintendent – and done it very well. Bernard Zeitlyn had been Chairman of the Consultants’ Committee and managed their meetings with charm and droll humour. A locum, Norman Todd had looked after my admission ward patients, and Eddie Oram had sustained Winston House. All had done well – or at least quite as well as when I was there. The nursing officers, Miss Brock and Mr Long were now working well together, and within a week of my return in 1963 I was invited to lunch in Miss Brock’s dining room with Mr Long and Oliver Hodgson to discuss how we should plan the operation in 1964 of Kent House, the new admission unit. These lunches soon became a permanent feature; every Thursday Oliver, Jack Long and I would eat a lunch with Miss Brock and discuss the ongoing problems of the hospital. We continued to do this over the next three years until Miss Brock retired in 1966. One of the things I tackled soon after my return was the division of Consultant responsibility between myself, Oliver Hodgson and Leslie Buttle. We agreed that we would each have a functional unit of wards both male and female. I took on all the deeply disturbed patients, male and female, in what I called the ‘Intensive Nursing Unit’. Oliver Hodgson took on all the wards of active and recovering patients into what we called the ‘Rehabilitation Unit’, and we persuaded Leslie Buttle to accept responsibility for the two sick wards and several wards full of elderly patients as a ‘Geriatric Unit’. My new ‘Intensive Nursing Unit’ had seven wards, three male and four female. These were the wards for the very regressed patients (formerly incontinent but now busily engaged in simple work) and the wards for long-stay, quiet people. However, the most interesting to me were the two former ‘disturbed’ wards, once Female 5 and Male 5, now Hillview and James Wards. The community meetings had continued in Hillview in my absence and things were not so stormy as they had been in early 1962. James Ward, under Joe Pattemore and later Tom Lewis, had also developed its own pattern of ward meetings; they were very formal – with a chairman and rules of debate – but had been effective in opening up the rules of the ward and involving everyone in projects and planning. I now proposed that these two wards should move into the old Admission Villas (Sunnydale and Westerlands) when the long-planned new admission unit – Kent House – opened in 1964. This was a bold move, for it meant bringing the most disturbed

and disturbing people out of their wards deep in the main building and putting them in one of the most public parts of the hospital. My nurses were keen, but many other staff felt uncertain and hesitant about the move. However, in the end this worked very well and was a great and permanent success; developing the therapeutic communities of Hereward House, Westerlands and Burnet House became for me the source of my most exciting experiments. After my return I felt I had resumed work which was following a pleasant and promising pattern. But in one area there was a major change. Soon after I had gone to California in the autumn of 1962, Alderman Mallett had to resign the Chairmanship because of increasing illness and Sir Henry Willinck, QC, Master of Magdalene College and a former Minister of Health, was appointed Chairman. In the summer of 1963, just before I got back, Mr Mitchell, the Group Secretary retired – after 43 years’ service in the hospital. His place was taken by a pleasant, able man, Mr Alan Young. The arrival of these two men caused a major shift in my relationship with the hospital administration. Although Sir Henry was always perfectly courteous to me, his many years in Whitehall had accustomed him to accepting the advice of his Civil Servants and listening to the warnings of Finance Officers. Mr Young, too, as Chief Officer, expected to take the initiative in running the hospital. There was no longer any place – or for that matter, any need – for me to take the lead in non-medical matters as I had done in my first nine years. Several times Mr Young warned me off his patch and gradually I came to see that the laying out of the cricket fields, or the management of the coal stocks, was indeed none of my business. I had slipped into leadership in such matters in my early years because of the passivity of earlier officers, especially Charles Mitchell – who learned under the old Visitors Committee in the thirties to avoid taking any initiative or responsibility whenever he could. However, I had plenty of other things to concentrate on. The main focus of everyone’s attention at this time was the new admission unit, Kent House, soon to open. The planning, designing, building and operating of this new unit occupied a great deal of my time over several years. In the 1950s Fulbourn Hospital had been the most overcrowded mental hospital in East Anglia, so the Regional Board had proposed that an entirely new admission unit should be built. The Ministry of health granted permission in 1958 and we had started planning. I had been sent off to visit recently-built units. An enterprising young architect had been appointed and started producing working plans. I insisted that the new building should be structured like a resort hotel, rather than a general hospital unit; that there should be wide spaces for daytime activity – a central dining room that could be made into a concert hall, billiard rooms, craft rooms, lounges. I wanted male and female patients to be able to mix by day (a revolutionary proposal in the 1960s), but agreed that there should be separate dormitories and wards at night for men and women. These would consist of an admission ward downstairs and a ‘convalescent ward’ upstairs, one for each sex. My colleagues, concerned as ever about individual (rather than social) treatments, insisted on the inclusion of a special unit for ECT that could serve both inpatients and outpatients. A range of Consultants’ offices were also provided.

The plans were of course argued about, changed and modified but we had finally settled for a 95-bed unit. Building work began in 1961. When I went off to California in September 1962 the first stage had started; colours and fabrics were being chosen and furniture ordered. When I came back in September 1963 we were almost ready to begin to use the new building. New staff for the unit and for the four wards were appointed. After the 1963 Christmas celebrations the first patients were admitted to Kent House in January 1964. The new unit was a delight and a revelation with its wide spacious corridors and large public areas. Everyone was pleased, especially the patients and their relatives. Many people from Cambridge came to visit it, as well as official visitors from all over the country. This admission unit was a notable first for the East Anglian Regional Hospital Board and they decided to make the most of it by making a bid for a Royal Opening. Fulbourn was of course only a mental hospital, so we could not have the Queen, but they succeeded in getting the Duchess of Kent, the charming and fascinating Greek-born Princess Marina; the fact that she had been a nurse and was the patron of the National Association for Mental Health (of which Lady Adrian was Vice-Chairman), of course helped greatly. There were endless discussions and meetings to arrange the great day. Protocol officers came down from London and instructed us on the proper etiquette. Officials we had never heard of before – such as the Lord Lieutenant of the County, the High Sheriff of the County and the Ministry’s Adviser on Protocol (a Major General) came bustling along to see if we were presentable. The Opening Day, 6 May 1964, finally arrived and was a great success. The Princess arrived in a Royal Helicopter which landed on the playing field at the front of the hospital to the amazement of the patients. Speeches were made and bouquets presented. All the great and good were there – the Lord Lieutenant in uniform and a cocked hat with plumes, the Mayors of five local towns wearing their robes and chains, the High Sheriff in breeches and garters, the Bishop in purple. Miss Brock was delighted to escort a Princess around her own new hospital; this was the peak of her professional career. The Princess herself was a charming, interested, intelligent woman, asking probing and informed questions about our work, and insisting on meeting and talking at length to long-serving members of the staff. It was a notable day for Fulbourn. Other building was going on in the early 1960s. During the 1950s the Regional Board decided to make hospital provision in Cambridge for the local mentally handicapped (who, since 1948, had had to go to Norwich). They opted to build on the hospital land behind Fulbourn Hospital toward Fulbourn Village and they called on our Hospital Management Committee to run the new hospital. The work began in 1963, and the first patients were admitted in 1965. The unit was named ‘The Ida Darwin Hospital’ after the famous Cambridge woman philanthropist who did so much for the mentally handicapped before the First World War. They appointed as Medical Superintendent Gwyn Roberts, a talented paediatrician who became an excellent colleague and a good friend to me over the next 15 years. The HMC was kept very busy with matters concerning the new buildings, including an Official Opening by the Health Minister of the day, Sir Keith

Joseph. However, the development of Ida Darwin had little impact on the lives of the Fulbourn patients. During the two years 1965 and 1966 we made one of the most important changes in the traditional organisation of the hospital – we united the male and female nursing services. This made possible many of the most notable achievements of Social Therapy over the next 20 years. But it did not happen without a lot of discussion and quite a lot of pain for some of the staff. In Fulbourn Hospital in 1953, as in most traditional asylums, male and female staff and patients were kept absolutely separate – and a great deal of managerial energy went into keeping them so. The Matron ran the female side; the Chief Male Nurse ran the male side; their territories were clearly defined and separate. Neither went into the other’s territory, nor did their staff. The male wards were staffed by male nurses, female wards by female nurses. This had always been so since the opening of the Asylum in 1858 and anything else was unthinkable. The only people who went freely into both sides of the hospital were the Chaplain and the Medical Superintendent. Even the Assistant Medical officers usually had their work confined to one side or the other. The patients were strictly segregated, and attempts to communicate with the other sex were severely punished. I had always found this rigid separation rather absurd. I had worked in units and hospitals where male and female nurses worked side by side on wards. I had also visited units where male and female patients mixed in their activities. But, on my arrival at Fulbourn it was clear that there was nothing to be done about it especially since Miss Brock, the Matron, only recently in charge, and Mr Tucker, the Chief Male Nurse, in post since 1933, disliked and distrusted one another. I had to wait my time. As hospital meetings proliferated, Miss Brock and Mr Tucker were obliged to work together rather more than before; they were both at my morning meetings with the doctors and my Hospital Officers’ meetings. As we increased patient freedom and began to open wards, patients began to meet each other more frequently in the grounds and one ward even gave parties for visitors of the other sex. The first major break, however, came when Mr Tucker retired in 1957 and Jack Long was appointed Chief Male Nurse. He had run a mixed unit at Netherne Hospital and knew that not only could male and female nurses work comfortably together, but also that men and women patients could safely be mixed. He was an open, friendly man and soon got on well with Miss Brock. Kent House, the new admission unit, was in use from 1964. In designing it I had done all I could to break down the barriers between the sexes. Although there were two male wards and two female wards all the daytime areas were used in common, as was the dining room. Very soon most of the patients were mixing freely all through the day, and the new younger nursing staff were working cooperatively together.

The idea of men and women nurses working together gradually became more acceptable. In 1965 Miss Brock advertised a vacancy for an Assistant Matron. As there were very few suitable women applicants, Maurice Fenn, the highly regarded Charge Nurse of one of the admission wards in Kent House, applied and was appointed. Once the Royal Opening of Kent House was over, Miss Brock began to talk of retirement. She would soon be 55; she had earned her full pension and could go; she had always said she would go at 55. But, not unnaturally, as the time approached she began to have doubts. Fulbourn Hospital was her home; she had lived in it for over 25 years, since her arrival as a bright energetic nursing tutor just before the war. She had been Miss Fossey’s deputy and succeeded her in 1952. She lived in the Matron’s flat in the centre of the hospital, served by a group of maids and long-stay patients; this was her whole life. Finally, however, she decided to go, and I persuaded the Hospital Management Committee to appoint a Chief Nursing Officer in charge of all the nurses, male and female. There were several good candidates, but Mr Long was clearly the best and was appointed. Miss Legge, Miss Brock’s deputy and close friend, was appointed Deputy Chief Nursing Officer and the Assistant Matron and Assistant Chief Male Nurses became ‘Nursing Officers’. We gave Miss Brock a magnificent send-off party which filled the Recreation Hall and included a presentation by the Chairman of the Management Committee. Mr Long, very wisely, proceeded slowly and made no immediate attempt to change things, although there was at first great trepidation amongst the women nurses. Then in 1966 came an opportunity. We had been working in Kent House for two years; at first it had all been novel and exciting but gradually complaints had increased. We were trying to do our admission work in several different wards. Each ward had its own Charge Nurse and team of nurses, but patients were moved as necessary, so that a Consultant seeking a particular patient might find the person on any one of five wards. ‘Ward Rounds’ became almost impossible as doctors and nurses spent most of their time trying to find patients. Equally the patients and nurses complained that they never saw the doctors. We could not go on this way. It was clearly more than just a problem of medical organisation as it involved nursing administration and the whole physical layout of the admission units. We decided to set up a multi-disciplinary working party to look into the problem under Ross Mitchell who had just joined us. A radical solution was recommended – creating three mixed-sex self-contained admission units with their own nursing and medical teams based on Street, Friends and Adrian Wards. Each team would centre on a Charge Nurse and a Senior Registrar. Two Consultants would admit to each unit and would be able to see their own patients on their own ward. After much discussion we adopted this plan and it was a great success. Quite a lot of construction work had to be done over the next years on Adrian to upgrade its facilities but Friends and Street were able to adapt quite easily to the new pattern from the start.

These units quickly developed their own cultures and their own ways of operating. The Senior Registrars soon emerged as powerful leaders, developing new ideas of their own. The wards started holding ward meetings and in due course therapeutic community practice developed on Friends Ward in 1971 and Street Ward in 1978. For me this reorganisation made a further change. I no longer had occasion regularly to visit either Street or Adrian. Instead of vague oversight over the whole hospital I now had much stronger and closer bonds with a few specific parts – those where I was the Responsible Medical Officer for most of the patients. In 1966 both Leslie Buttle and Christopher Scott, the psychotherapist at Addenbrooke’s, retired and we made two excellent new Consultant appointments – Ross Mitchell at Fulbourn and Malcolm Heron at Addenbrooke’s. Both men were to make major contributions to Fulbourn Hospital in the coming years. Products of postwar psychiatry, both were deeply committed to a social view of work with the mentally ill. Ross Mitchell had learned his psychiatry in the Army, where he had become aware of the importance of social factors in contributing to mental health. A vigorous Scot of great energy and infectious enthusiasm, he threw himself into many projects. He took over Leslie Buttle’s outpatient clinics in the Fens and soon began working closely with local general practitioners and the Mental Welfare Officers to take psychiatry out into the Fen countryside and into patients’ homes. He took over the quiet, long-stay wards and began an active rehabilitation programme. One of the units he took over was a ‘workers’ hostel’ which we had developed in the former Occupational Therapy building. We had used it to house men who were going out to work in Cambridge. Ross encouraged the staff to extend its functions, first offering lunches to patients out on leave in Cambridge and then developing a formal Day Centre. He brought in the Disablement Resettlement Officers of the Ministry of Labour and began moving patients out of hospital. Malcolm Heron was appointed as psychotherapist to the Outpatient Department of Addenbrooke’s, but he took a keen interest in what was going on at Fulbourn Hospital. Malcolm had worked in the therapeutic communities at Claybury and was fully committed to group and social therapy. He went to a number of ward meetings, and then began to attend the doctors’ meetings in my office. At first he observed and said little, but then began to comment on process. He pointed out how the setting (my office) inhibited the group, so we moved the meeting to a seminar room downstairs. Gradually the meeting became a sensitivity group for the medical staff. The discussion became less structured and more spontaneous, with Malcolm offering facilitative interpretations on the group process. We stopped bringing administrative problems to it, and Mr Long, now Chief Nursing Officer, stopped attending. When the Postgraduate Medical Centre was opened in 1970 we moved there. This ‘doctors’ meeting’ was held every Friday morning from 9.00 until 10.30 a.m. and became a key part of the programme of social therapy of Fulbourn Hospital. By the early 1970s the notion of ‘Social Therapy’ was becoming clearer in my mind and was also beginning to be discussed in the hospital. Concepts of how the asylum should run and what should be its guiding principles had only occasionally surfaced in the first

century of Fulbourn’s history. Dr Bryan, the unfortunate Dr Lawrence and Dr Bacon all had clear ideas on the management of an asylum. They had lived through the great years of medical and public debate on this subject in the first half of the nineteenth century. They knew of John Conolly’s ‘No Restraint’ System; W.A.F. Browne, the author of What Asylums Were, Are, and Ought to Be was still dominating Scots psychiatry (Browne, 1837); the notions of ‘Moral Treatment’ put forward by Tuke, Pinel and Equirol were still dominating principles. They knew that the way the asylum was run, the pattern of patients’ work and play, rewards and punishments, were the most valuable form of treatment that they had. They spoke with enthusiasm of the cures they had achieved. During the long reign of Dr Rodgers and Mr Thorne (1883–1910) these ideas were gradually forgotten in a climate of Social Darwinism and ever-increasing legal controls. Quite different ideas were clearly stated by the irascible Dr Thompson (1910–17) who told the Visitors that the prime purpose of the asylum was to prevent lunatics breeding so as to check further spread of moral degeneracy. He did not speak of cures, but only of reduced costs. Dr Archdale (1917–23) set out clear ideas about the treatment a hospital should provide but his was a very different and very medical view. Patients were to be isolated from the noxious influences of their homes; they were to spend at least a month in bed after admission; indeed, some spent many years in bed. There were experiments with better individual treatment for patients – outpatient clinics, social work home visits – but not much work on the general life of the asylum, especially the long-stay people. In the long inter-war regime of Dr Travers Jones and Dr Thomas (1922–53) little was said about the way the asylum was run. Everyone knew how mental hospitals should be – custodial but humane – an enclosed world where nothing changed from generation to generation, where long-stay patients and staff grew old together watching cricket, enjoying social events such as balls and dances and regarding innovations with distaste. I had few preconceived notions when I came to Fulbourn in 1953, except for a deep distaste for the brutality I had seen inflicted on patients in other hospitals, a conviction that the life of the long-stay patients did not need to be so degraded, and a notion that the ideas of consultation and group discussion which Montgomery had taught us during the war might be appropriate to the running of a psychiatric hospital. I had a strong personal commitment to what was later known as open government, free communication and decision-making by consensus. The five years 1953–58 saw Fulbourn Hospital change from a locked hospital of very low morale to an Open Door hospital of high morale and good spirits. In our campaign of changing the hospital we had developed certain themes and slogans. The first was ‘Work for All’; the next was ‘Open Doors’; and later there emerged the slogan ‘Freedom, Activity, Responsibility’. These latter three were what we aimed to provide for our patients. I had been gratified at what we had achieved but also puzzled because I knew I had not achieved it alone. As I began to ponder exactly what it was that I had contributed I developed the idea of ‘Administrative Therapy’ – that is the use of the administrative

structure to produce social changes that would not only make the hospital pleasant, but actually help the patients towards recovery and departure from hospital. I studied the sociological publications that were becoming available on the life of mental hospitals and tried to apply some of their lessons. At first I looked at the actual tasks which I was performing as Superintendent. Although I did some clinical work and even psychotherapy with individual patients, most of my effort was going into working with the staff, creating a secure environment for them by efficient, just and comprehensible administration. I attempted to refocus their idealism and altruism and create an atmosphere of change, experiment and hope. I came to see this as my most important task and called it ‘Administrative Therapy’. In the late 1950s I gave lectures with this title and changed my views as a result of various comments I received. I published articles on ‘Administrative Therapy’ in 1958 and 1959 and spent my year at the Center at Palo Alto writing a book with that title aimed primarily at psychiatrists. It aroused modest interest and sold well. I chose the title of my book to demonstrate a paradox I discovered that in the USA young psychiatrists viewed their future as a choice between ‘administration’, a shabby job dealing with shady politicians, corrupt building contractors and venal Trade Unions, and ‘therapy’ – a highly esteemed, well-paid occupation dealing with the troubles of the affluent middle classes. Administration was shabby and low class; therapy was prestigious and well paid. In my book I tried to suggest that it might be better to devote oneself to helping the suffering poor than indulging the worried rich, but more important, that it was possible to use an administrative position to give effective therapy to the inmates of a hospital. In 1970 I was commissioned by Penguin Books to expound these ideas again in a small paperback for nurses, social workers, occupational therapists and patients. As I worked on it I realised how much my ideas had moved on since I had first lectured on ‘administrative therapy’. I now adopted a different phrase – ‘social therapy’ – to cover all that we were doing to help patients progress. This term included activities such as carpentry workshops, plays and pantomimes, halfway houses, therapeutic communities, rehabilitation clinics and so on – everything that used social structures to help patients. It also included the ideas emerging from our therapeutic communities. These were that everyone in the hospital, but especially the patients, had valuable contributions to make, and that while communications, authority and power patterns were an essential part of the treatment process, they must be constantly reviewed, surveyed and changed. The book finally emerged in 1974 as a Pelican paperback entitled Social Therapy in Psychiatry (Clark, 1964) and was priced cheaply enough for anyone to afford it. Widely-read and translated into seven languages, this little book brought many visitors to the hospital and also a number of recruits to the staff. I continued to reflect on these ideas, to modify them in the light of criticism and adapt them to changing circumstances, especially the development of therapeutic communities as alternative environments for patients. After the Penguin book went out of print, Churchill Livingston took the book on and published a second edition in 1982 (Clark,

1982), two years before I retired. Much of what appears in this tale is covered in those books. Many of the illustrations were taken from experiences at Fulbourn and many of the methods described were tried out there. Two major themes are relevant to this story. First was my realisation that when people were held for years in an institution, the forces that changed them, for better or worse, were social rather than medical. It was the environment, its messages of fear, or hope, or recovery, rather than the pills they were given which determined how they recovered. From this followed the realisation that a doctor who wanted to help long-term patients would achieve little if he spent his time just talking to them and giving them pills. Rather, he must concern himself with the morale and function of the ward; he must work with the staff and their anxieties, fears and tensions. He must press for worthwhile work, freedom and responsibility for both patients and staff. Such a creative administrative action was far more valuable to the patient than clever diagnostics. Later came the realisation that everyone in the organisation, especially the junior staff and the other patients, had to be involved in the process of helping a patient understand and change the way he had been running and ruining his life. Social analysis was one of the most valuable and important therapies a psychiatrist could deploy. It was these insights which I continued to operate, propound and share as long as I worked at Fulbourn. Many heard them, especially the nurses and even a number of doctors. But many doctors continued to regard these ideas of mine as irrelevant and devoted their attention to abstruse diagnostics and complex pharmacotherapy. Of the changes that occurred at Fulbourn Hospital in the sixties and seventies, the development of Therapeutic Communities was the most radical. For some people these changes were exciting, for others they were difficult and controversial. The phrase ‘Therapeutic Community’ was coined by Main in 1946 to describe what had developed in an army psychiatric hospital, Northfield, near Birmingham in the later years of the war. A group of young Army psychiatrists led by senior psychoanalysts were working with demoralised soldiers awaiting psychiatric discharge from the Army. These psychiatrists developed a pattern of group and social treatments which transformed the hospital and helped the patients far more than the traditional pattern of individual treatment by medical officers. Several important discoveries emerged – that the soldiers learned more from each other than they did from doctors; that being allowed to take responsibility for the running of their lives within the hospital hastened recovery from their state of demoralisation, despair and helplessness (induced by their psychiatric ‘boarding’ from the Army); that taking part in a skilled group activity, such as a football team or a hospital band, was not only pleasurable but also therapeutic. The concept of the Therapeutic Community was further developed in the 1950s by Maxwell Jones at Belmont Hospital at the Social Rehabilitation Unit (later the Henderson Hospital). This special unit took patients with long-term social relationship problems. Many were originally referred from the Ministry of Labour because of their inability to

keep jobs. Most had been labelled by psychiatrists as ‘psychopaths’ – people who showed irrational, irritating, disturbing and self-defeating behaviour, but who, on psychiatric examination, showed no obvious mental disorder. Maxwell Jones tried many forms of treatment at Belmont before gradually developing a way of running this unit which was quite unlike any other psychiatric unit in the country. This new method was the ‘Therapeutic Community’ which became the model for experiments all over Britain, the USA and Europe during the 1960s and 1970s. At Belmont there were no distinctions between people – staff and patients, doctors and nurses dressed alike in similar casual clothes and were addressed by their first names. Even the Director was simply known as ‘Max’ by everyone. The focus of the life and work of Belmont was Social Analysis – attempting to understand why a particular incident had occurred or why a person had behaved as they did. A major forum for this was the Community Meeting, held every morning and attended by everyone in the unit – patients, professional staff, domestic help and so on. At this meeting the events of the previous day were reviewed and analysed. These large gatherings of 60 to 80 people were lively and even stormy, with very free interchange and confrontation that spared the feelings of no one. At Belmont there were workshops where carpentry and metalwork were practised – but far more important than the craftwork these provided were the discussions in which the way the workers interacted was examined. Throughout the hospital there were small groups and large groups, staff groups and workshop groups. Always and everywhere people examined, questioned and analysed what they were doing and saying to one another. It seemed that many people learned more from other patients and from low-ranking staff about how to cope with their behaviour than they did from doctors and specialists. Maxwell Jones said that ‘a therapeutic community is distinctive amongst other comparable treatment centres in the way the institution’s total resources, both staff and patients, are self-consciously pooled in furthering treatment’. Main had earlier said of the Northfield Experiment that it was ‘an attempt to use a hospital not as an organisation run by doctors in the interest of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society. Ideally it has been conceived as a therapeutic setting with a spontaneous and emotionally structured (rather than medically dictated) organisation in which all staff and patients engage.’ Like many who visited Belmont in the 1950s, I found it a fascinating, exhilarating, exciting and disturbing place. There were many visitors – psychiatrists, nurses, social workers and psychologists as well as teachers, writers, artists, lawyers and politicians. Everyone who went to Belmont was stirred and excited; some were infuriated and repelled. Emotions were very much on the surface and a visitor might be vigorously criticised for his pomposity or his assumptions. Not only were there no uniforms but many people at Belmont actually looked scruffy and the rooms were shabby, disorderly and often dirty. It was ‘nothing like a hospital’. However, the results from Belmont were impressive. People with disheartening records of job losses, prison sentences and

psychiatric admissions, changed and became effective people, displaying notable talents. They testified vehemently that it was the non-judgemental, egalitarian environment that had allowed them for the first time to see and understand what they were doing to themselves and then to change. Some professionals were still sceptical and said that Belmont only worked because the patients were psychopaths – the method would not work with mentally disordered people, such as those in ordinary mental hospitals. Some people also felt that Belmont only worked because Maxwell Jones was such a charismatic personality. This he certainly was; charming, brilliant, puckish, mischievous and yet earnest, he drew around himself a talented team from all over the world. Sceptics said that the method would not work in the hands of ordinary doctors and nurses. There were dark rumours of emotional turmoil amongst the Belmont staff – breakdowns, broken marriages, orgies. However Belmont continued to flourish and evolved into Henderson Hospital after Maxwell Jones left in 1959. It continued to take in seemingly impossible people and help some of them to achieve stability. As I began to think about the challenges and problems of Fulbourn Hospital I wondered how successfully we could use the revolutionary method of Maxwell Jones, with its abolition of rank and distinctions. Would it help our patients and could we stand it? We had taken a first step at Fulbourn in 1958 in Adrian Ward when Eddie Oram and Kay Kinnear transformed it from a sullen dispirited ‘convalescent ward’ into a lively therapeutic community. The rate of departures had risen and the number of readmissions fallen. The atmosphere had improved dramatically. The next Fulbourn attempt at a therapeutic community was my own project in 1960 on Hillview, the women’s disturbed ward. While in California I thought a good deal about therapeutic communities and on my return gave a lecture to the Mental Health Research Fund (Clark, 1964, 1965). Amongst other issues I made the point that the ‘Therapeutic Community Approach’ was fairly easily applied to any psychiatric institution, without unduly upsetting anyone’s position. but that the ‘Therapeutic Community Proper’ (as practised by Maxwell Jones) was a revolutionary change which might be too much for many doctors and nurses. In the sixties and seventies we explored whether we could actually make this revolution at Fulbourn. Having decided to extend our attempts at using the therapeutic community method in Fulbourn, the greatest challenge and excitement of the years after my return from California was using this approach with the most deeply disturbed patients in the hospital. I had always felt that the deeply disturbed and psychotic people – the violently mad – were the most challenging. Unlike many of my contemporaries, who seemed to be repelled or frightened by the very disturbed, I had always wanted to work with them. In my early days in psychiatry in the army and at the Royal Edinburgh Hospital, I had voluntarily spent long hours in padded cells or shuttered side rooms attempting to make contact with terrified and terrifying people gripped in severe psychosis. I had physically struggled with wild manics who attacked anyone who came near, with schizophrenics in homicidal fury and with melancholics desperate to kill themselves. I had often involved

myself in restraining patients or helping the nurses to put them into strait jackets. This was partly pride in my young strength and wrestling skills, but also a genuine desire to get closer to these people in order to try and understand and help them. At the Maudsley I often spent time on ‘the Villa’ – the isolated unit at the back to which recalcitrant patients were sent before certification and removal to the county asylums. These attempts of mine to make contact with dangerous patients were not very successful. I was told that this was because ‘their psychoses are intractable’ but I also suspected that it might be because as a doctor I was trespassing on an area which the nurses regarded as their own – particularly if they were using illicit violence. On my first psychiatric unit, in the Army, the orderlies openly boasted of their ability to ‘tame the psychopaths’ sent to them from the Army prison. I began to learn about the savage underlife of hospital psychiatry. In one hospital I was involved in uncovering the activities of an ex-Naval Petty Officer who as Deputy Charge Nurse was routinely beating up patients who caused trouble. I discovered that he believed that it was his duty to maintain discipline. He had a method of punching a man’s belly that was very painful but left no marks to be seen by a doctor. On his ward one patient died after a savage beating by the male nurses. Over the years in other hospitals ‘old hands’ instructed me about ‘towel treatment’ – garrotting a violent man with a wet towel over his nose and mouth until he became unconscious, or ‘sock therapy’ – the use of a bar of soap in a sock as a cosh. When I first came to Fulbourn I looked for signs of such brutalities; to my relief I could not see much evidence of illicit violence by staff. The two ‘disturbed wards’, M5 and F5, each had two padded cells, which were in fairly constant use. There was tension on M5 and frantic noise on F5; there were always a few bruises to be seen on ‘difficult’ patients, but nothing worse. As Superintendent I was always closely watched and chaperoned by the staff, so that it was seldom that I could probe deeply. However, there did not seem to be clear evidence of systematic brutality – and I had so much else to do in getting the whole hospital into a better shape that I did not spend too much time probing violent incidents. As we opened the ward doors through the hospital, the general atmosphere of tension in the hospital dropped. When we opened the doors of M5 in 1957, the tension there dropped dramatically. Having realised in California that I had put too much of myself into running the hospital (laying out sports fields, for example) and not enough into working directly with the ward staff and the patients, I came back determined to make this a higher priority. At that time (1963) nobody in England, as far as I knew, was trying the therapeutic community approach with the most deeply disturbed. When we rearranged Consultant Responsibilities for long-stay wards in October 1963 I took on both the disturbed wards F5 (Hillview) and M5 (James) and became the Responsible Medical Officer for all the most difficult patients in the hospital. I gave more of my time to the two disturbed wards. Every Thursday morning I attended the community meeting in Hillview, followed by the staff meeting. I also began going regularly to James Ward and often attended their rather formal ward meetings.

In 1964, we moved the disturbed patients and staff from the main building into the former Admission Villas, Sunnydale (for men) and Westerlands (for women). This brought them from the back of the hospital to the front, and was, I felt, a sign of our intention to improve their lot. I got more and better staff for them – trained nurses, occupational therapists and social workers. By now the women’s disturbed ward was being led by Ruby Mungovan and had several ward meetings each week. The male disturbed ward under Norman Harwin had been operating ward meetings for some years; they were rather structured, with a chairman, rule books, and formal debates. I persuaded the staff to change to a pattern of more open, less structured community meetings. Now that these two wards were in more attractive surroundings and nearer the front of the hospital, other hospital staff became more willing to visit and work in them. Occupational therapists, social workers and psychologists began to visit and to join the ward teams – and come into the ward meetings. The two wards began to work together and joint staff conferences developed. The idea of combining their work began to be discussed. In 1966, after the appointment of Mr Long as Chief Nursing Officer for all the nurses, and the integration of the separate male and female nursing services, the idea of combining Westerlands and Sunnydale was raised. We held joint staff meetings and then joint community meetings. Gradually enthusiasm rose and we began to look at the logistical problems – living space, dormitories, meeting rooms, and we saw that integration was possible. The debate however went on and on. Then one weekend the nurses and patients decided that there had been enough debate and reorganised the wards themselves. I came in on the Monday morning to find that it had all been done. We decided to name the new unit Hereward House, in memory of the local hero of the eleventh-century Saxon resistance to the Norman Conquest. For the next five years, 1966–71, Hereward House was the centre of my therapeutic community work in Fulbourn Hospital. There were daily community meetings of all the patients, some 60 men and women, and all the staff. As Consultant in charge and Responsible Medical Officer for every patient, I always attended the ward meeting on Thursdays – as well as often being in the ward at other times. In the meetings the activities and the problems of these distressed, disturbed and disturbing people were discussed, probed and analysed. The staff team in Hereward House attracted some of the brightest and liveliest people working in the hospital, and many interested people from Cambridge came to visit us – research workers, students and others in those stirring turbulent times of the late 1960s. The leader of the team was Ruby Mungovan, a talented imaginative woman who had begun in psychiatric nursing in a former LCC asylum. She never forgot that grim, brutal, custodial background as we developed a new way of responding to deeply disturbed people (Mungovan, 1968). Her deputy was John Wise, another who had known the bad old ways and was keen to try new and better methods. The rest of the hospital became more willing to refer people to us and many recently admitted people were transferred to Hereward House from the admission wards. Nowhere in Britain had anyone attempted to gather in one open-door, mixed-sex therapeutic community all the most disturbed patients from an ordinary mental hospital; reporters, film makers and professional colleagues came to see what we were doing. For many of

the patients, long trapped in rigidly controlled back wards, it was greatly liberating to be in charge of their own lives and to be able to participate in making decisions about the running of their wards. For many staff, too, challenging charge nurses, doctors and consultants and helping to decide policy was very exciting. A succession of bright Registrars worked with me for a year at a time as we eagerly explored new patterns of working together. Working in this way was hard and frightening at times. Many of the patients had been violent, some seriously so. Some had been through the courts and in prison. A few had been in Broadmoor; a few had committed homicide. Violence lay near the surface; challenges and even fights were not uncommon – but these were examined at length at the next community meeting. Rumours ran round the rest of Fulbourn telling of filth, disorganisation, violence, subversion and sexual orgies going on in Hereward House. The forbearance of the nursing officers and the administrators was sorely tried. However the administrators, who had lived and worked long years in the hospital, saw patients whom they had known as crazy troublemakers change and become pleasant, cooperative and cheerful people. They could see the method was working. The striking thing about Hereward House was how many of the very turbulent people made remarkable recoveries. One of the doctors, Kenneth Myers, after training as a Registrar and Senior Registrar, asked me if he could do a research project on Hereward House. We obtained a grant and over four years carried out a study comparing the results with men transferred into Hereward House against a control group transferred into the disturbed ward at another nearby hospital. The two groups were very similar – long-term patients who had recently become more difficult to manage – and they spent similar lengths of time on the two disturbed wards. The striking difference was that many of the Fulbourn men improved as a result of their stay in Hereward House – and even more remarkable, many were later discharged from hospital. At the other hospital they were just moved back to long-stay wards and remained in hospital. Ken and I published two articles about this study (Clark and Myers, 1970; Myers and Clark, 1972). However, our very success in dealing with the problems of severely disturbed behaviour in Hereward House by the use of social, therapeutic community methods brought the original experiment gradually to an end. By 1970, the three admission units of Fulbourn Hospital were moving towards becoming therapeutic communities themselves and developing greater skill in managing disturbance, so that fewer people were being transferred to Hereward House. The unit gradually got smaller and in 1971 it was divided into two units. The smaller, in Sunnydale Ward, designated for less disturbed patients ran for another three years, then closed for lack of referrals. The larger, in Westerlands Ward, led by a succession of talented charge nurses continued the work of helping the deeply disturbed all through the 1970s and 1980s. In 1971 it was warmly commended by a Hospital Advisory Service visiting team who said it was ‘psychiatric nursing at its best’. They advised staff in many other psychiatric hospitals to come and see the work. As a result we had a steady stream of visitors. In 1979 the dilapidated building was evacuated for a year and upgraded, and reopened as Burnet House. It still operated as an open door,

mixed sex, therapeutic community for deeply disturbed men and women, and in 1982 was the subject of a highly regarded television film The Way Back (BBC TV, 1982). It was during these years that our relationships with the Secure Hospitals – Broadmoor, Rampton, Moss Side – changed and clarified. In the 1950s we had little to do with them. Broadmoor was the ultimate custodial asylum; people who committed murder and were found ‘guilty but insane’ were sent there and remained until they died. In the 1960s Broadmoor began to review their long-term quiet patients and if they felt they were harmless, to propose them for transfer to hospitals nearer their homes. Since I was responsible for the long-stay wards, the requests came to me and I began making visits to Broadmoor to assess the proposed patients. The first Broadmoor transfers did very well with us. Vernon was a bright student at Cambridge University when he had his first schizophrenic breakdown and was admitted to Fulbourn for treatment. He responded well, went out, but then relapsed and had several readmissions. He became convinced that he had a message to give to the world and committed a series of spectacular acts of sacrilege which brought him before the courts, from which he was sent to Broadmoor. He spent several years there and his psychotic state gradually settled. He was then discharged to Fulbourn and sent to Hereward House. A gentle, charming, intelligent man with a wispy, blond beard, he became a leading citizen of Hereward House and a most useful member, helping simpler sufferers to come to terms with their plight. He developed a friendship with a woman he met in hospital and finally moved out to live with her. He took a clerical job and then a post in a government department. Eventually he went overseas to work for an international welfare organisation and did very well. He occasionally came to visit us and spoke of his time in Hereward House as the ‘time I forgot bitterness, learned compassion and learned to work within the system’. Kasimir was a middle-aged, Eastern European businessman long resident in Britain, who killed his sister-in-law while in a state of paranoid melancholia. He was found guilty and sent to Broadmoor where his condition responded to ECT and substantial tranquilliser medication. After a number of years he was transferred to Fulbourn and to my care. We found him a quiet, pleasant, conforming man. He compared the turmoil of Hereward House unfavourably with the well-ordered life of the pre-discharge wards of Broadmoor, so we moved him to one of our quiet wards where he settled in peaceably. We sent him home to his wife for periods of leave and then discharged him home. He continued to see me as an outpatient and pressed me to cut down his medication. Finally I did so. After two months he felt much better; he was playing chess again, reading the papers, taking an interest in his grandchildren. Then after four months he had an episode of three days of terrifying hallucinations and he begged me to put him back on the tranquillisers again. I did so and he settled back to a quiet home life. During the 1960s and 1970s pressure on Broadmoor from the courts mounted and they pushed more people for discharge. Some hospitals refused to take them, but we took about a dozen. I would go down to Broadmoor with nurses and a social worker and

interview the candidate. We would go into the story and see the family. If all this was satisfactory we would accept the person. Some did very well, passing quickly on to discharge. Others found it more difficult, had relapses, or preferred to stay in hospital. In 1974 the Hospital Advisory Service was asked to put together an inspection team to advise Broadmoor – and Ruby Mungovan and I were asked to serve on it. It was a strange and disturbing experience. For a month we lived in a hotel in Berkshire and visited Broadmoor daily. We were greeted with suspicion – they refused us keys to the hospital and were very guarded. It gradually became clear that this inspection had been forced on them and was resented. We laboured hard and advised earnestly; they took no notice of our advice and the whole month was a wasted exercise. It was, however, educative for me to experience the culture of Broadmoor at close quarters. It was a paranoid, siege culture, full of hatred, fear and contempt. Determined to resist any suggestions for change, the sturdy male staff in their heavy uniforms took pride in their membership of the Prison Officers’ Association; they despised their ‘patients’, telling with relish stories of the revolting killings some had committed. They were operating in a way reminiscent of the worst of the old asylum regime, counting patients in and out of the wards, strip-searching randomly, checking security constantly. The clash of keys in locks was constant. They took great pride in an electronic checking system which enabled them to determine in a few minutes where every inmate was. They felt themselves hated by the Berkshire people, attacked by tabloid journalists and opportunistic MPs, let down by faint-hearted liberals in the Home Office and misunderstood by society in general and the psychiatric profession in particular. They had nothing but contempt for what we were doing in what they called ‘the county hospitals’ – as one burly oaf put it ‘The Counties – I tell you they’ve gone to pot. They’re just dosshouses for layabouts and skivers these days and the staff are no better. I started in a “county” but I came to Broadmoor because I couldn’t stand their soft way of going on.’ That month in Broadmoor showed me that old asylum culture was still alive and flourishing in at least one English institution and I realised how easily it could come back again. In due course I visited the other secure hospitals. Rampton was even more oppressive – isolated in the Lincolnshire Fens, and without strong medical leadership. The staff had developed a system of ‘control’ of their mostly simple-minded patients that I could sense was brutally oppressive. I was not surprised when its malpractices were exposed on television a few years later. We continued to go to the secure hospitals to see people whom we might be able to rescue. It was always a risk. Many of them were much less stable than the first people we had taken and I was always afraid that one day we might have an horrendous episode. By 1970 interest in the therapeutic community method to wards management was widespread through the hospital. The three admission units – Street, Friends and Adrian – had all experimented with it. In 1970 both Street and Friends Ward began with ward meetings and restructuring the authority system on the wards. From 1971 to 1973 on Friends Ward the staff team, led by Junichi Suzuki, Senior Registrar, and Agi Lloyd, Charge Nurse, developed a system of small groups run by junior staff as the main therapeutic instruments on the ward. Patients were encouraged to talk together and to help each other. Staff discussion and confrontations were impassioned and a lively,

turbulent, egalitarian culture developed. Many of us enjoyed and welcomed this, though some did not. Although Street Ward had made some changes in 1970, it was from 1976 to 1980 under the leadership of Geoffrey Pullen, Senior Registrar, and Larry Nicholas, Charge Nurse, that the most striking developments occurred. A strong pattern of interpretation and confrontation developed linked with a very active community follow-up system. This greatly reduced patients’ length of stay in hospital, as well as improving the quality of their recoveries, so that there were always vacancies on Street Ward – unlike in the other two admission units. In Adrian Ward, which had become a mixed-sex admission unit in 1966, they gave up uniforms, encouraged staff and patients to engage in psychotherapeutic discussions and made the weekly ward meeting the focus of the work. They did not, however, push the restructuring of the staff team as far or challenge established authority as much as in Friends and Street. The pre-discharge ward of the rehabilitation unit, Mitchell Ward, also used therapeutic community ideas with a lively, independent-minded staff team supporting an increasing number of patients in the community. Their community meetings focussed on the problems of living in the outside community for people who still had residual symptoms of psychosis. The stigma of having been in a mental hospital for years, and the difficulty of finding jobs amidst rising unemployment were discussed, faced and circumvented. For those of us who went through changing a traditional ward to a therapeutic community, it was one of the most liberating and exciting experiences of our whole professional lives. Although each ward worked out the therapeutic community model differently, all these units had some things in common. Most important was the egalitarian atmosphere. All in the ward were addressed by first names – from regressed patients to Consultants. The uniforms and trappings of rank were discarded; the nurses did not wear uniforms, the doctors gave up white coats. The ward meetings – usually daily – were unlike anything seen before in Fulbourn. Patients and staff sat round discussing the happenings and affairs of the ward as equals. Matters previously held secret or discussed only in selected groups were openly considered – why a certain patient was to be detained, or another discharged; why a nurse was leaving the ward; which doctor would be coming next; the hostility of ‘the Establishment’ to the experiment and the possibility of the ward being closed down. Open criticism of a person’s actions, and exposure of its unconscious roots was encouraged – by both patients and staff. I heard more truths about my failings in those meetings than I had for many years. Patients no longer suffered the mystification and professional doubletalk to which they had been subjected for years and they began to feel that they might once more gain control of their own lives and destinies. The staff abandoned many of the professional barriers that had so long separated doctors, nurses, occupational therapists, social workers and patients. Although confrontations were sometimes fierce and even bruising, there

developed a team spirit and commitment to the work of the units which most of us had never known before. The work of the therapeutic communities at Fulbourn Hospital aroused interest outside the hospital. Teams from other hospitals engaged in similar experiments. Littlemore Hospital, Oxford, Claybury Hospital, London and Dingleton Hospital, Melrose paid us fraternal visits – out of which, in 1969, the Association of Therapeutic Communities was born. Reporters from the local newspaper, students of sociology from the University and visitors from overseas came to see us and in some cases stayed to become members of the team as volunteers or assistant nurses. In 1971 a government Hospital Advisory Service team was deeply impressed with the way Westerlands was handling disturbed patients. As they went round Britain afterwards, they advised other hospitals to go and see what Fulbourn was doing. For a year or two there was a stream of teams of visitors – so many that we had to space them throughout the year to avoid disrupting the therapeutic work. In the early 1970s we at Fulbourn were able to say that out of the 23 wards at Fulbourn Hospital, four – Friends, Street, Westerlands and Mitchell – were functioning fully as therapeutic communities proper and that several others were functioning as modified therapeutic communities. How the staff dressed had been the subject of much interest throughout the history of Fulbourn. There had been uniforms for staff from the earliest days. When young men and women were recruited as attendants in the nineteenth century they were issued with uniforms and required to wear them at all times, except when on leave – as were, in those Victorian times, Army recruits, footmen, parlourmaids and gamekeepers. These nineteenth-century uniforms can be seen in photos of the time – long skirts, aprons and bonnets for the women, like parlourmaids, short serge jackets buttoning to the neck and pill box hats for the men, like prison warders. The proper maintenance and wearing of these uniforms, which were ‘the Property of the Visitors Committee’, was used for discipline and control of the staff and much energy was spent harrying the recruits about their dress and turnout, as in any uniformed service. Staff uniforms often became a matter of pride, or even obsession, for senior staff. In the twentieth century the Fulbourn uniform began to alter, but only after long and heated discussion. Badges of rank were introduced. The Matrons, Miss Fossey and Miss Brock, strove gradually to change the women’s uniforms to look more like those of general hospital nurses. The men had long disliked the tunic and peaked cap, and the Union finally persuaded the Visitors Committee to issue them with sturdy suits instead. Then, in the 1960s, it was discovered that some units in some hospitals had found that patients got on better with staff who were not in uniform, trusting them more and talking more freely to them. This was the practice at Maxwell Jones’ therapeutic community at Belmont Hospital. Some daring members of staff began to suggest that we might do without uniforms at Fulbourn too. When staff took patients out from the hospital – on

outings, trips, shopping trips and so on – they found these went better if they were not dressed like warders in charge of prisoners. We began to hear of other hospitals where staff had gone out of uniform (usually on experimental units) with good results. In 1968 the staff on Hereward House were allowed to try coming to work in casual clothing. This was a marked success. The patients said how much easier it was to talk to the staff, how much more relaxed and friendly the ward now was. Giving up staff uniforms was clearly a valuable part of building a therapeutic community. Other wards began to talk about doing this. The Senior Nursing Officer, Jack Long, said that any ward could go out of uniform if the majority of the nurses declared in favour of it, and if they could give considered therapeutic reasons for making the change. Several rehabilitation wards made the move and by 1972 all my wards were out of uniform. The big debate came on the admission units in the early 1970s, where opinions were divided. Polls were taken and questionnaires administered. It emerged that some of the older patients felt ‘safer’ if nurses were in uniform and clearly identifiable, but many newly admitted and younger patients preferred the informality. An interesting social experiment was carried out on Friends Ward in the early 1970s – at the time when it was changing over to a therapeutic community pattern of working. Several of the more vocal members of the nursing staff were keen that they should go out of uniform, but some doubts were expressed. A confidential poll of the ward staff was carried out which showed that though most of the qualified nurses on the ward, and all the doctors, social workers and psychologists were in favour of giving up uniform, the young student nurses wished to keep theirs. This apparently surprising result led us to discuss the matter with the student nurses. It soon emerged that the students were puzzled, confused and even frightened by all the changes that were going on and felt that no one was concerned about their distress. Their uniform was one of the few things that gave them security and a sense of identity; they did not want to give that up as well. This shocked us, and we wondered how to help this understandable insecurity. We decided that the senior nurses on the ward would set up a system of counselling under which each qualified nurse on the ward was named as counsellor to two or three of the students, with the task of helping them over the painful and frightening work of responding to recently admitted, acutely disturbed, mentally disordered people. These staff support groups soon became a regular part of Friends Ward activities. Six months later, the nurses as a group quietly asked for permission to go out of uniforms. This episode helped some of us to understand one function of uniforms – that they give uncertain and anxious new staff a sense of protection and security. As the debates went on we began to appreciate even more how much significance and feeling were invested in uniforms. Some people who became hospital staff wanted and welcomed uniforms. ‘One of the reasons I became a nurse was to have a uniform like that!’ Many remembered the pride with which they donned their first uniform and the loving care they took to keep it spotless. They also recalled the pleasure in moving from grade to grade, changing to different colours. They were unwilling to give all this up without very good cause. They said ‘If we have lots of uniforms, the patients and relatives will think we are like the general hospital and as good as them.’ Some of the

male staff had spent years during the war proudly wearing the uniforms of the Army, Air Force or Navy and longed for the sense of identity, of confirmed rank and of power that a neat uniform gives. These were legitimate feelings. We felt we should not demand that people abandon them unless we could show real gain for the patients. But such gains did gradually emerge and during the 1970s, ward after ward went out of uniform. There was no great pressure. If any individual insisted, she was allowed to continue in uniform. Some of the older women, particularly the Sisters, continued to wear their uniforms until the day they retired. There were, however, some problems with the new lack of uniformity. Some informal dress became too informal, particularly as women’s skirt lengths went up and down in the eras of miniskirts and then maxiskirts. Some staff, when reprimanded for scruffiness protested that they were ‘being therapeutic’. One doctor was admonished publicly by a Coroner for coming into Court without a tie. As we debated these problems, we began to realise that the clothes we wore gave out messages to the people we met. The message might be reassuring, but could be perplexing or disturbing. People on a long-stay ward, who knew staff members personally, felt easier seeing them comfortably and informally dressed – rather than strutting around in starch and white linen. But a newly admitted patient, seeking reassurance that she was in a safe, clean and orderly place, might be understandably dismayed at the sight of sandalled feet under a ragged dress with dirty toes capped by cracked nail paint, or an unshaven face behind long dirty locks. Gradually codes of dress and turnout evolved. We realised that whilst it was good to be comfortable and friendly, our dress should not offend or startle and that professional people did well to appear to be clean and orderly in their persons and dress. In part these changes were an outward expression of differing views of the very function of the hospital. If the task of the hospital was control (control of disordered behaviour, control of disordered thoughts) as in the old asylum days, then uniforms were an appropriate part of the system. They set staff apart and made them available for summons and direction. If, however, the task of the hospital was to assist and befriend the mentally confused, then casual clothing reduced the barrier between staff and patients and made counselling and friendship easier. A CULTURE OF CHANGE AND LEARNING During the years of change, learning how to be more effective in our jobs became more important and more organised at Fulbourn. Indeed for a time the way we did this at Fulbourn took on a unique flavour. Learning about one’s job had always been important for staff at Fulbourn since the very earliest days. Young men and women came in from the Cambridgeshire villages as attendants and had to learn about lunacy. Mostly they learned from the old hands who taught them the tricks of the trade, but sometimes doctors would share knowledge with them. The Medico-Psychological Association first organised a national examination for Attendants of the Insane in 1893 and the Fulbourn Visitors agreed to extra pay for any

attendant who passed the MPA Exam. A post of Nursing Tutor was established in 1937 (with Miss Brock as the first Tutor) and lectures were organised for the young nurses. For doctors the Diploma in Psychological Medicine developed in the 1920s: any doctor who obtained it received £50 a year extra pay from the Visitors. However, there were very few junior doctors at Fulbourn before 1945 and it was left to those few to organise their studies for themselves as best they could. The idea that psychiatric nursing and doctoring were skills that needed to be learned had been accepted at Fulbourn; but this was seen as the individual’s own business. There was little idea that Fulbourn itself could be a place of learning, discovery or research. When I arrived in 1953 I found no organised training for the doctors, no library and no research. There were only a few student nurses and only dull, unimaginative instruction offered to them. I discovered that most of the nursing of long-stay patients was being done by people hired as ‘Nursing Assistants’ or ‘Ward Orderlies’ who had no qualifications and had received no formal training at all. So we began to develop education for the staff at Fulbourn Hospital. In this there were three main tasks which sometimes ran together and sometimes at cross purposes. The first was helping people to acquire professional qualifications – helping nurses to get their RMPA Certificate and doctors to gain their Diploma in Psychological Medicine. This was apparently a straightforward task which could be tackled along traditional lines using set books. The second task was learning how to help our patients better; how to achieve this was less clear. Traditional methods – of sedation, control, and regulation – were clearly unsatisfactory. It was the wish to do better that forced us to investigate Social Therapy and led to new kinds of learning, changed practices and research – and much controversy. For these new practices there were no text books. At first we followed the practice of more advanced hospitals, but by the 1960s we found we were moving into new uncharted areas. This process too, involved all of us; ‘trained’ staff had perhaps more to learn – and unlearn – than those without qualifications. Out of all this came the third task – a quite new notion of facilitating growth. This meant producing a culture in which anyone – student, nurse, long-term senior consultant or patient – would find it safe to change and grow. For those who could allow themselves to do it, this was the most exciting. But some people found it too stressful. Learning to pass exams was the first challenge we tackled. In the fifties there were few student nurses and educating nurses was not recognised as a separate skill. It was not until 1956 that our first qualified Nursing Tutor was appointed and not until 1958 when Reg Salisbury joined us that nurse education was properly addressed at Fulbourn Hospital. We trained young men and women for the State RMN Examination. We began to hold ‘Training Weeks’ for ‘Nursing Assistants’ so that they could gain a better understanding of what they were doing. Later the Ministry of Health established the new category of State Enrolled Nurse and we began to provide formal training for it. Many people who were good and sympathetic nurses but not very academic found this syllabus more manageable. It was a useful starting point, too, for nurses for whom English was their second language. Some of them, after qualifying as State Enrolled Nurses, then went on to train and qualify as Registered Mental Nurses.

Doctors starting in the old asylum service had had to learn their psychiatry by themselves, studying in their spare time. We, the Consultants, had taught ourselves that way when we were junior doctors in the thirties and the forties. We studied the books and in due course passed the examination for the Diploma in Psychological Medicine. At Fulbourn in the 1950s the Consultants decided to try to do better and help our junior doctors with their learning. We assembled a medical library; we arranged clinical meetings; we arranged for money to pay doctors to go on courses. For a number of years I acted informally as ‘Clinical Tutor’; in 1965 the Regional Board made this appointment official and in 1968 Ross Mitchell took over the post. An old dormitory was reorganised as a Postgraduate Training Centre with lecture room, seminar room and library. By now there were a dozen doctors at Fulbourn designated as trainees and most of them passed their DPM while working with us. That examination, however, was not too difficult. More important was to arrange the medical posts so that each doctor gained a wide range of experience of different disorders and different ways of working – in outpatient clinics, admission wards, long-stay wards, and so on. Our plan was to allow each doctor to learn what he felt he needed to know; doctors passed from one unit to another in the hospital when they were ready for it. This allowed them time to mature and to grow into jobs that interested them, such as in Hereward House, Child Psychiatry or Psychotherapy. In the early 1970s the national training of psychiatrists was formalised and became more academic. In 1971, the Royal Medico-Psychological Association transformed itself into the Royal College of Psychiatrists and started a Membership examination. They also began inspecting and upgrading psychiatric training programmes. Gradually through the 1970s the examinations became increasingly academic. The first Royal College Approval team to visit Fulbourn in 1971 was very favourably impressed with our rather unusual training for doctors. But later Approval Visitors were more critical. In particular they insisted that doctors in training should ‘rotate’ in order to have varied experience. Admirable though this was in intention, it meant that young doctors had little chance to become committed members of ward or unit teams, or to follow patients through for any length of time. The application of Social Therapy in the 1950s was fairly easy. We were applying the measures which had been known as good asylum practice (though often not achieved) for a century and a half. We were following the current leaders of practice, such as T.P. Rees of Warlingham and Duncan MacMillan of Mapperley. We got the patients active; we got them out into the open air. We started workshops and let the patients earn, handle and accumulate money; we reviewed their incentives and made them more meaningful. We extended parole and freedom and challenged restrictive practices; we reviewed patterns of seclusion and sedation, removed the padded rooms and eliminated excessive dosing with paraldehyde. We gave the whole hospital an air of purpose, cheerfulness and hope. It was hard work but it did not challenge any established ideas. Our Open Doors policy was more controversial; this led to many discussions and arguments within the hospital and with our neighbours in the villages of Cherryhinton and Fulbourn. But again, pioneering hospitals such as Dingleton, Mapperley and

Warlingham had led the way and we were following their lead. Like them, we found immediate gain; the patients were more cheerful and less violent. Many improved markedly. The nurses found the Open Wards more relaxed and enjoyed becoming the patients’ friends rather than their gaolers. It was during the 1960s, as we began to explore therapeutic communities and mixed-sex wards, that we entered areas where there were no guidelines. We knew we wanted to change the hospital and improve life for the patients and staff, but we were not sure what would work and what would fail. Some experiments – such as the Adrian Therapeutic Community and Hereward House – went well. Others failed. Some doctors ran groups which made people more rather than less disturbed and which had to be terminated. These incidents taught us that discussion groups could unleash powerful forces, that they should be assembled with care and that the ward staff must also be involved in them. One of the most important lessons I learned about how group methods could – and could not – be applied in a mental hospital, was that all experiments depended on the long-stay staff. If they were not involved the experiment failed; if they were committed to the experiment, it was often successful. I had also long wondered what part formal psychotherapy could play in the mental hospital. In the early 1950s psychoanalysts were very confident of their ability to right many social ills. They asserted that psychoanalytic understanding and therapy could not only cure all neuroses and psychoses but could also solve the problems of industrial management, prevent strikes, and, by curing the neuroses of statesmen, prevent wars. I had benefited greatly from my personal psychoanalysis and had practised psychotherapy, individual and group, for years. I had no doubt of its effectiveness for emotional disorders in the outpatient setting. As soon as I began working at the Psychiatric Outpatient Department of Addenbrooke’s Hospital in 1953 I started to do individual and group psychotherapy. Several other colleagues, Beresford Davies, Russell Davis and Christopher Scott, the Consultant Psychotherapist, also had patients in individual outpatient psychotherapy, often long term. We encouraged the trainee doctors, registrars and senior registrars to try to develop psychotherapeutic skills. But did this mean that psychotherapy could be imported into the mental hospital? Would it benefit long-term inpatients? This was an issue constantly debated at that time. Psychoanalytic enthusiasts spoke of a time when all patients, however psychotic or long term, would receive and benefit from psychoanalysis and quoted the work of John Rosen, Frieda Fromm-Reichmann and others doing ‘Direct Analysis’ with deeply disordered people. Many of the Fulbourn inpatients, especially on the admission wards, received informal psychotherapeutic support from the doctors as they told of their domestic difficulties and their problems at work. But some of the registrars attempted to conduct more structured psychotherapy, arranging to see selected patients for regular intensive sessions on the wards. However, I noticed that somehow this seldom seemed to work. Sometimes the patient discharged herself, sometimes the doctor would move to another ward. Often there would be ‘administrative difficulties’; the room selected would not be available; the time was not convenient. Sometimes the Sister would complain that ‘these treatments’ were making the patient worse, and ask the Consultant to tell the doctor to stop them. I

was puzzled by this. I did however notice that the patients selected from the ward as ‘suitable for psychotherapy’ were nearly always attractive and well-spoken young women. It was Eddie Oram’s work on Adrian Ward in the late fifties that finally helped me understand why individual psychotherapy of patients specially selected by the ward doctor did little good to the woman selected and often quite a lot of harm – to her, to the ward and to the doctor’s morale. Eddie had selected patients for psychotherapy when he first went to Adrian Ward. However, when he changed over to a therapeutic community style he stopped seeing selected people. Soon the other patients and the nurses began to reveal how much envy and jealousy the former selection had caused; how the favoured woman had used her ‘special relationship’ with the doctor to attempt to exercise tyranny and had brought hatred and contempt down on herself. We came to realise that to give anyone in the ward privileged access to a major power holder was to put them into a painful and damaging position. From then on, if we were convinced that an inpatient should have individual regular psychotherapy, we arranged for her to go down to the outpatient department for it – and not to receive it from the doctor of the ward, whose time was better shared with the whole community of the ward. In the later 1960s world-wide student revolts occurred and at Cambridge University, as elsewhere, there were riots and sit-ins. Some of this excitement washed out as far as Fulbourn. Many more students came to the hospital, as volunteers, to help with the patients’ recreation, and some worked on the wards as Nursing Assistants during vacations. The writings of R.D. Laing, the revolutionary psychiatrist poet, attracted some of the brightest to the plight of the schizophrenics, though they found the reality very different from his idealistic pictures. Another challenging theme was patient self-government. This started with the experiments of Eric Raines in 1956 in inviting the patients to draw up rules for his ‘Male Open Ward’ and in Adrian Ward in 1958 when Eddie Oram and Kay Kinnear made the patients responsible for cleaning the ward. But it was within Hereward House in the mid1960s that patient government developed furthest. I well remember how difficult I found it when the patients voted that I should reduce one man’s sedation – a great trespass on the prerogatives of the doctor. It turned out that they were right; I did reduce the dosage and his disorder did improve. These experiments challenged the roles of all on the ward, but especially the authority of the doctor and the Charge Nurse. Junior nurses revelled in the freedom to criticise their elders. Many staff nurses and some doctors felt very insecure when challenged. If, and when, things went wrong there was of course an immediate cry to return to the old ways. The staff at Fulbourn began to write, talk and think about what we were doing. Nurses and doctors published articles about our work. We presented papers at other hospitals and conferences and listened to the criticisms. We invited speakers from other hospitals and arranged informal visits. Gradually we clarified and organised our experience and I put much of it into my book Social Therapy in Psychiatry, in 1974.

One way of monitoring the new ideas we were trying out was to examine the results scientifically and to publish them. Through the fifties, sixties and seventies a series of research workers probed and studied our new ideas and published articles. In 1955 Fred Houston did a double blind trial of a new drug alleged to ‘activate apathetic schizophrenics’ (Houston, 1956). He taught Tom Lewis and the staff on Ward M6 (the male incontinent ward) to give out pills not knowing which were potent and which were dummies, to rate the patients’ activity daily and to chart their findings. Everyone was fascinated; never before had a senior doctor spent so much time on such a back ward. Many of the patients improved greatly, but when the code was broken it was found that the people on dummy tablets had improved as much as the people on the drug. This proved that the drug was ineffective. But it also showed that increased staff attention and enthusiasm was highly effective in improving the behaviour of apathetic patients. In 1957–60 Douglas Hooper spent months as a participant observer on Ward F5, the women’s disturbed ward, while it was moved from its old squalid quarters to a newly decorated airy ward, Hillview, without any padded cells. He had shown that despite the Open Door, the old system of social control and repression was as effective as ever in keeping most of the patients cowed and inactive. He contrasted this with what happened in Eddie Oram’s experiment on Adrian Ward about the same time, where giving responsibility for the running of the ward to the ‘convalescent ladies’ had not only changed the ward from a dull, resentful, static ward to a lively, active, therapeutic community, but had also cut down lengths of stay without any increase of readmissions. These studies taught us that merely tidying things up and making them pleasanter – though a legitimate aim in itself – was not enough to help patients trapped in long-term resentful apathy. We had to change the social structure of a ward if we were to change its effect on the patients and help them recover. Douglas, Eddie and I published a paper on Adrian’s therapeutic community (Clark, Hooper and Oram, 1962) and Douglas completed a PhD on his work on Hillview (Hooper, 1960). In 1960–63 Eddie Oram obtained a research grant to study the problem of long-term patients leaving the hospital. He followed up everyone who had left Fulbourn after staying two years or more. To our surprise he traced quite a number and found them well settled in their villages. This did much to dispel the myth that long-stay patients never left hospital permanently and that if they did they did not do well. This work laid the basis for our later rehabilitation work. In 1966–68 Kenneth Myers’ controlled study of the work of Hereward House showed that far more of the men sent to Hereward House left hospital later than did those from the ward in the other hospital. He considered that this was due to the atmosphere of hope, excitement and involvement in the therapeutic community and the fact that it attracted exceptional staff, such as creative therapists and social workers – who were never seen on the traditional control ward (Myers and Clark, 1972). All these studies established a tradition at Fulbourn of action research. When we were faced by a problem we asked first ‘What is the problem?’ and then ‘What are the facts?’ before we looked for solutions. Often we found the facts different from what we had at

first believed; sometimes the problem changed as we examined it. After we implemented our solutions we measured and followed up to see whether or how they had worked. This approach was formalised in 1972 in the Hospital Innovation Project. The project was funded by the Department of Health and Social Security working through the Tavistock Institute of Human Relations. A project officer was appointed who was available to help any group of staff who wanted to change the way they were operating. The results of this experiment were written up in Innovation in Patient Care (1979), a collection of essays by Fulbourn staff edited by David Towell and Clive Harries, successive project officers (Towell and Harries, 1979). These showed how action research had proved effective in many parts of the hospital, including geriatric wards and even the stores department. As well as these research reports, many members of staff published descriptive articles about the work at Fulbourn, particularly the Social Therapy and the adventures in rehabilitation. All this experimenting and writing was very different from what the Royal Colleges of Nursing and Psychiatry called ‘Learning’ which to them was a process of studying text books, memorising the teachings of others and reproducing them at examinations. Instead, we were changing our practice and then studying what we had achieved, analysing it, comparing it with the work of others, writing it up and publishing it as articles and books. During the late 1960s and early 1970s a subtle change occurred in the atmosphere of Fulbourn Hospital which can best be described as the development of a ‘culture of growth’. This was not recognised by many people at the time, even those most affected by it, and did not affect everyone. But it was this, I believe, that made Fulbourn so exceptional during the 1970s. In the first 90 years of its existence the Fulbourn Asylum was a social institution devoted to containing madness, to quietening furore, to maintaining the fabric of society and to discouraging change. Patients were sent there to be quietened down. Staff joined the hospital because it offered steady pay and a good pension. During the 1960s and 1970s the ethos of Fulbourn was quite different. Staff came to Fulbourn because it was reputed to be different, to be challenging, to be ‘progressive’. When they arrived they were stimulated, questioned, offered opportunities, invited to take risks and were often upset. Some left, finding it all too unsettling. Others attempted projects which failed and also left, discouraged and disappointed. But many responded – and in doing so found themselves changed. People came to Fulbourn as staff members, especially as student nurses, and having worked and trained there left for other more challenging life roles. Amongst our student nurses of the sixties two became doctors, three social workers, two teachers and one a monk. One of the more unusual learning developments of the ‘Culture of Change’ at Fulbourn was the ‘Doctors’ Friday Meeting’ mentioned earlier; this was a unique experiment in egalitarian sharing between doctors of all grades. This started from the meetings in the Medical Superintendent’s office which I had begun shortly after I arrived. Through the fifties I met every morning with all the hospital doctors and the Nursing Officers. We focussed on day-to-day affairs, sorting out the mail, arranging patient transfers, and so on, and getting to know and trust one another. The style of the meeting was open and saw a good deal of plain speaking. By the mid-sixties we were meeting three times a week

and spending more time on major differences, policies and medical staff training. Then came a number of changes in the hospital. Oliver Hodgson was appointed Consultant in 1959 and in 1962 took over as Deputy Medical Superintendent; in 1966 Ross Mitchell was appointed Consultant. Both attended the meetings regularly and worked with me and challenged me as issues arose. The meetings began to concern themselves more with relationships between the doctors, especially doctors of different grades. In 1966 Malcolm Heron as Consultant Psychotherapist began to attend the doctors’ meetings at Fulbourn and to move the group towards examining its own structure and function. The meeting moved out of the Medical Superintendent’s office and settled on meeting once a week, every Friday morning for an hour and a half. This continued for about ten years and is remembered by many doctors who worked in those years as one of the most interesting parts of their psychiatric training. The meeting had no agenda and no Chairman. The discussion was free-floating and spontaneous with an emphasis on open expression. The focus was on our medical work within the hospital, in particular the stresses and problems we could not talk about elsewhere – the struggles and rivalries between doctors, the pressures on us from other hospital staff and people outside (general practitioners, social workers and general hospital consultants), the drives which brought us into psychiatry in the first place and the pains of becoming a psychiatrist. We often became very personal and talked of our own private problems. Although it was not compulsory, nearly all the medical staff working in the hospital attended regularly. The Fulbourn Hospital Consultants, Oliver Hodgson, Ross Mitchell and I, attended every week, the Addenbrooke’s Hospital Consultants less often. Malcolm Heron came consistently and was the chief facilitator until his untimely death from cancer in 1974. The meetings varied greatly – sometimes being passionate confrontations or bitter personal rows, at other times quiet relaxed discussions of current medical political happenings. Sometimes they were flat, boring and repetitive, but not often – for the stresses of psychiatric hospital life meant that there was always some doctor distressed or enraged by recent challenges from his work. Doctors starting in psychiatry were often able to share their distresses with those of us who had lived through similar turmoils, and could begin to come to terms with our stressful specialty. People used the meetings differently at different times. I found it helpful to share with them the pressures that came on me, as Superintendent (and later as Chairman of the Division of Psychiatry) from Management Committee, police and Magistrates. I also valued being challenged over my mistakes and ineptitudes in my way of working. Both Oliver Hodgson and Ross Mitchell used the meeting as a sounding board during their periods as Chairmen of the Division of Psychiatry. Sometimes the meetings were painful but often very warm and supportive. Few of us will forget how Malcolm shared with us the knowledge that he was soon going to die, and allowed us to express some of our despair, grief and anger at this news. Oliver, Ross, Malcolm and I saw these meetings as an essential part of the psychiatric trainees’ introduction to their chosen speciality and spent a lot of time attending to the reactions of newcomers. Some young doctors welcomed this atmosphere and took to it with glee, revelling in the chance to challenge Senior Registrars and Consultants openly

and to learn more about themselves. Others found the departure from traditional medical relationships disturbing and distasteful. It was particularly stressful to more senior doctors, Senior Registrars and Consultants who had come from other hospitals and more traditional ways of working and who could not tolerate being challenged or confronted by their juniors. The Friday meeting continued through the early 1970s, but ran into difficulties in the mid-1970s, after several new Consultants joined the staff. Some of them found the meetings intolerable; one even cried out in fury ‘It’s a Communist attempt to brainwash me!’ as he left the meeting for ever. The arrival of the university academics in 1977 brought a major change. They made it clear that they disliked this meeting and thought it of no value. They believed that psychiatric training should consist of instruction given by the skilled and experienced to the unskilled and inexperienced, and that egalitarian discussions were of little value. After a few visits to the Friday meeting they stayed away and advised other doctors to do so too. As the academic model became dominant in Cambridge psychiatry during the late 1970s, the Fulbourn doctors’ meeting withered. The numbers at the Friday meetings dwindled; the discussions became flatter and the meetings finally stopped in 1979.

7 Rehabilitation From the late 1970s Fulbourn’s interest in social therapy shifted to the people who were moving out of hospital – the people requiring rehabilitation. During the next decade a unique psychiatric rehabilitation service was developed in Cambridge making use of the skills, insights and attitudes that had been developed in years of ward social therapy with inpatients. In the 1940s the word ‘rehabilitation’ was seldom heard in British psychiatry. The hope was that a person’s mental illness would be totally cured by medical skill and that he would then manage without future help. In those days ‘rehabilitation’ was a medical term reserved for those who worked with war wounded, helping them back to full function. Only gradually was the medical use of the word extended – in the 1950s to those with chronic physical diseases, such as asthma and stroke, and then in the 1960s to psychiatric disorders. By then, at Fulbourn we were just beginning to realise that the process of regaining social competence was far harder for long-term patients from mental hospitals than we had at first thought. It was not enough for us to provide freedom, activity and responsibility or work and opportunities to leave hospital. Many long-stay people were too crippled (either by their long incarceration or by their original psychotic disorders) to manage the transition on their own. It was at Winston House that I first became aware of the magnitude of the problem. For the first decade after its opening in 1958 ex-patients passed through rapidly – 360 in the first eight years – but then the flow slowed. Some people seemed unable to move further and stayed in Winston House for years. In the hospital, too, we found that long-stay people were coming back because they had found life outside too difficult.

Within the hospital the need for rehabilitation gradually emerged. Immediately after the war, all the long-stay patients – some 850 of them – had been housed in the main building, strictly divided into male and female wings. There was limited specialisation amongst these wards, apart from the two ‘sick wards’ (M4 and F4) and the two ‘disturbed wards’ (M5 and F5). Most of the long-stay patients were quietly living on wards with no specified function, which held a mixture of people at different levels of social capacity, from helpless people who had to be fed and cleaned to competent ‘ward workers’ who did most of the domestic work of the wards. The wards were locked and firmly controlled by nurses. Many of the patients worked in departments of the hospital – men on the Garden Gang; the Farm Gang, the Engineer’s digging gang, women in the kitchen, the vegetable preparation room, the laundry, the corridor scrubbing party. It was all lowgrade work, indifferently and sloppily performed, ill-supervised and unchallenging – but at least it got them off the wards. A few elite patients had fairly skilled and responsible jobs – elite ward worker, hospital messenger, hospital librarian, assistant storekeeper, gardener to the resident doctors, or domestic maid for the Superintendent, the Matron or the doctors. All these activities were traditional in the asylum. They were justified as being necessary to keep the institution running at a low cost to the ratepayers. Their value as therapy or rehabilitation was seldom considered – some ward nurses were even quite open about ‘holding on to the key workers’ in order to get the housekeeping tasks done. In the 1950s, we began to change the life of the patients, with the ‘Work for All’ programme, the open doors and the ‘Activity, Freedom and Responsibility’ ethos. The wards were opened, but few changes in their functions were made. It gradually became clear that wards with a mixture of patients were an obstacle to effective work programmes. When Kent House was opened in 1964 a major rearrangement of the longterm wards at last became possible. The medical responsibilities for the long-stay patients in the main building were rearranged several times during the 1960s, each time towards better-defined functions. When the Nursing Service was unified under Jack Long in 1966 it became possible to regroup the wards and we created the psychogeriatric, intensive nursing and rehabilitation areas. With a Nursing Officer in charge, each of these areas now had clear leadership, a Consultant and a Nursing Officer, for each area. All the nurses (especially the Charge Nurses) were answerable to them. Treatment teams were formed and examined their tasks with zest. This rearrangement tapped much therapeutic potential and Charge Nurses, who now worked in wards with clearly defined functions, began to develop their work energetically. Oliver Hodgson’s Geriatric Area began to face the problems of the increasing number of very frail elderly and developed links with the other Geriatric Services in the City. My Intensive Nursing Area plunged into the excitement of Therapeutic Communities – on Hereward House, Mitchell Ward and others. Ross Mitchell threw himself into the tasks of the Rehabilitation Area and over the next three years started many new projects. The rehabilitation wards had been open for years. Some now became mixed-sex wards and promoted social activities. Others began to encourage their patients to go out to work. The number of patients on Ross Mitchell’s wards dropped sharply.

The building on the hill, the Occupational Therapy Department, became available for ward use in 1957. This building was named Ely Ward (because Ely Cathedral was visible from it on a clear day). In the early 1960s it had been used as a dormitory for male patients who were doing privileged work within the hospital and then as a hostel for the men going out to work in Cambridge by day. When Ross Mitchell took it over in 1966 he began to develop it as a Day Centre for ex-patients now living in Cambridge. They used it as a lunchtime canteen, a club and a place where they could spend a few nights if necessary. This gradually developed and it became known as the Ely Day Centre. In 1977 the Ely Day Centre and its treatment team moved to a church hall in Cambridge and operated from there. This ‘Day Clinic’ became a central part in the developing system of Day Care in Cambridge City. Ross Mitchell also started a Rehabilitation Clinic, where each week selected patients were reviewed by the Consultant, Nurses and the Disablement Resettlement Officer (DRO) of the Ministry of Labour. In those days of full employment they were often able to suggest appropriate work and then move the patient out to it. In 1969, when Ross Mitchell took on other tasks, the remaining Rehabilitation Wards – Mitchell, Ferndale and Ely – were handed over to me, to form a new unit with the Intensive Nursing Wards. We decided to call this the ‘Social Therapy Area’ (STA). It became the centre of the Rehabilitation Programme at Fulbourn Hospital and my main clinical work for my last 14 years. I was fortunate in getting a succession of able and devoted Nursing Officers working with me over these years – Eric Raines, Maurice Fenn, Ruby Mungovan, John Wise, John Lambert, and others. We gradually became more specialised. In 1977 I gave up admission ward work and routine outpatient work to concentrate on the problems of the long-term patients. Gradually I recruited occupational therapists, psychologists and social workers who like me were interested in long-term patients and their rehabilitation and growth. As the focus of our work sharpened we became steadily more aware of the needs of this kind of patient and developed a pattern which became a model for similar rehabilitation services that developed elsewhere in the country during the 1980s. The Social Therapy Area developed a special flavour and many staff who had been active in ward social therapy and therapeutic community work in Fulbourn Hospital gravitated there; lively and innovative nurses and creative therapists competed for the chance to work there. They were keen to maintain the tradition of egalitarian working together and the multi-disciplinary approach they had enjoyed in therapeutic community wards. They all accepted the need constantly to review and change the work we were doing, and to alter the social structure in which we worked. Every Thursday all the staff at the STA met for an hour in what became the ‘Parliament’ of the STA. At first I took the chair, but members pointed out the disadvantages of investing too much power in one person and so we elected a Chairman annually. Chairing a session was a challenging task for it was a turbulent meeting with many new ideas and an over-talkative Consultant! However, it worked very well and was a forum for innovations. It was here we developed our pattern of first acknowledging a problem and then investigating it fully before we took action. We began to survey and analyse our work and issue regular reports and papers.

We carefully examined our relationship with other parts of the hospital. In the first year or two we transferred a few elderly people to the Psychogeriatric Area but then decided that as long as our patients remained active and alert, however old they were, they should stay with us. The case of the hospital assistant storeman, George – who had been an inpatient for some 30 years – changed our view on this. George had always resisted any suggestion that he should ‘retire’ at 65. We allowed him to stay on one of the rehabilitation wards and he continued to go to the stores daily. He was thereby able to live an active and useful life until he succumbed to a brief pneumonia at the age of 83. Some patients from the Admission Wards found their way into the Social Therapy Area. How and why this happened was not entirely clear. The belief of psychiatrists in the fifties and sixties had been that modern treatment would cure all acute episodes of mental illness and that therefore no one in future would need to become a long-stay patient. By the 1970s it was becoming clear that this was not the case and there was talk of ‘new long-stay’ patients. In 1972 Junichi Suzuki, one of our Senior Registrars, obtained a research grant to investigate the problem in Fulbourn. He soon showed that the hospital was recruiting about 17 new long-stay patients every year. He investigated their characteristics and made analyses of these. He came up with a most interesting finding – that most of these patients had been moved from the admission to the long-stay wards almost by accident. Often he could find nothing in the records to explain why the change had been made – or even that it has happened. There was nothing written down in the clinical notes as the move had often been done at a weekend to ‘ease overcrowding’. This finding forced the rehabilitation team to think hard about the process by which a ‘shortterm patient’ became a ‘long-term resident’. We realised that it was a complex social event containing a lot of disappointment and despair for all parties concerned – for the short-term treatment staff, for the patient himself and for the family. We decided to bring some of this out into the open and set up an Assessment team. Their job was to interview and assess anyone whom admission wards proposed for a move to the Social Therapy Area and to investigate all alternatives before agreeing to the transfer. Other cherished theories were also explored and challenged. In the 1950s we had a notion of a ‘ladder of rehabilitation’ by which people would pass from one rehabilitation task to another until they were ready for discharge. This idea was very popular in other hospitals’ Rehabilitation Programmes. An analysis by Eddie Oram in 1964 of discharges showed that this ‘ladder’ was a myth. Some people were discharged when quite low on the ladder, while patients in top-level jobs hardly ever seemed to leave. Eddie and I wrote a paper about this entitled ‘Working for the Hospital’ (Clark and Oram, 1966), in which we pointed out that gaining an elite job in the hospital seemed to be very prejudicial to one’s chances of discharge. As a result of our finding we actively encouraged discharges from all of our wards. Later, we realised that discharged patients liked to keep in touch with their ward, their former friends, and the nurses they had known. Their relatives also valued a continuing contact with the ward staff. We therefore gradually developed in the late 1970s a system of community visiting by ward staff. These staff were allowed to go out to visit their former clients any time the ward could spare them. This was greatly valued by the

patients and their relatives and often avoided a readmission. This policy, however, was anathema to tidy-minded administrators. Treasurers objected to paying travelling expenses to staff who were not ‘registered car users’. Central offices were much annoyed to ring a ward and have a patient tell them that ‘All the nurses are out on visits.’ Some social workers and qualified community psychiatric nurses felt they should be the only people to visit patients’ homes – ‘because we alone are competent to do this important work’. We were even criticised by a nurse administrator member of a Hospital Advisory Service team when she discovered that we did not require all outside visits to be programmed and authorised days ahead. All these criticisms we met and countered one by one. We showed how long-stay patients in the community benefited from an arrangement whereby they could be visited (at short notice if necessary) by a member of the ward team who knew them personally. During the 1960s we had begun to explore the provision of Group Homes for long-term patients who could be released to live in the community. The Cambridgeshire Mental Welfare Association, which had helped to get Winston House started in 1958, took up this new idea of small homes for ex-patients. They opened their first Group Home in 1965 and provided a series of them over the years. As the idea succeeded other bodies helped – local authorities, the hospital and the Granta Housing Association. Whenever we found on a ward a group of congenial friends who were willing to move out, we would persuade a local authority to lease them a house. Initially, these were highly successful and several groups of steady patients moved out and kept going well. Later, when we tried this with more crippled people, difficulties arose. We soon found that many longstay patients were woefully deficient in domestic skills; they did not know how to cook, to budget, or to shop in the supermarkets of the 1970s. Some had lost these skills; many had never had them. Many, after 20 or 30 years in the Institution, were appalled at the clamour, bustle and high prices in the shops. We therefore took over a former staff house in the grounds and made it into a ‘Rehabilitation Cottage’. We would move into it a group of people who seemed ready and willing to depart and over several months the occupational therapists would work with them, taking them out shopping, helping them to prepare meals and to look after the house. It was a useful testing ground; several patients decided that domestic life was too much for them and moved back to the wards. But any group who did finally move out were well-prepared for life outside. Amongst those who benefited from the Group Homes was my old friend Jane who had been at the centre of the storms and fights in Hillview when I started the ward meetings in 1960. Over the years her hallucinations and violence had become less marked and she was now a cheerful, sturdy middle-aged woman. She was, however, still simple-minded and impulsive and could erupt in rage if thwarted. She lived on a quiet ward and worked in Fulbourn Industries on simple work. It seemed as if she would live out her days in the mental hospital. Then she expressed an interest in a Group Home. The first attempt was a disaster and she had to return after a fight in a village shop. We then proceeded more slowly; she had a long period in the Rehabilitation Cottage acquiring simple domestic skills and we then tried her in a Group Home in Fulbourn Village, with two other simpleminded, long-term people. This threesome seemed quiet and content, but then came complaints of their level of hygiene. I went to inspect and was appalled; the stove was

thick with grease, the lavatory was blocked, cockroaches were everywhere. We had to help them. We arranged for regular visits from a Community Psychiatric Nurse, and weekly visits from a Home Help. The home became clean, tidy and welcoming. Jane lived there peacefully for years – but the team kept in touch. We set aside some rooms in the hospital as flats where people could live independently for a time before going out. They received Social Security money, paid rent to the hospital and bought and cooked all their own food. This again was an excellent testing area for people’s domestic skills. We began to publish what we were doing in our Social Therapy Area, and to welcome visitors. The first publicity came for Westerlands in the early 1970s, after a visiting Hospital Advisory Service team in 1971 wrote in their report ‘this is psychiatric nursing at its best’. Later John Wise and John Lambert, Charge Nurses of Westerlands, put on a one-day conference on ‘Nursing the Disturbed Patient’ which was attended by staff from many other hospitals. Many visitors came to see our service, particularly parties from Japan (following the trip I made there in 1967–68). In 1981 a BBC team from the Everyman series spent several weeks in the hospital. After reviewing all the work being done at Fulbourn they decided to concentrate on Burnet House (as Westerlands was now called). They produced the outstanding and moving programme entitled The Way Back (BBC TV, 1982). During the early 1970s we made a Case Register of people who had passed through the Social Therapy Area and reviewed regularly how all the patients were getting on. In 1979 we made a count and discovered that we had 137 clients in the community and only 176 patients within the hospital. We realised that we were not so much running an ‘Area’ within the hospital as providing a service for people with long-term mental disability in both the community and the hospital. We therefore changed our name to the ‘Cambridge Psychiatric Rehabilitation Service’. At that time, too, we reviewed our work and set out a number of principles for our service for the mentally disabled. We rejected the medical concepts of ‘cure’ and of ‘discharge’. We accepted that our clients were disabled and that this disability would probably not go away. We said that we intended to concentrate on their strengths and residual skills rather than endlessly reexamining their disabilities and weaknesses (as doctors usually did). We accepted that we would probably never ‘discharge’ them and we accepted a commitment to help them for the rest of their lives. We declared that we had no simple goal which could be applied to all patients – certainly not the former one of discharge from hospital. We believed that all our clients were capable of some growth – but that the degree of that growth would be different for each one. For some it might be moving from a group home to independent living; for some moving from hospital to a Group Home; for some moving from the disturbing environment of Burnet House to a settled, productive life on a quieter ward. By the early 1980s we had a well-established team with good morale and high effectiveness, which was nationally recognised as a ‘Demonstration Project’ in 1985.

In 1971 my post of Medical Superintendent was formally abolished, though it had been withering away for years. When I first arrived at Fulbourn in 1953 I had accepted the role of Medical Superintendent with its nineteenth-century functions, and also the real power to start change. I used it as a base from which to pull the whole asylum forward and get it functioning as a lively, up-to-date mental hospital, with full employment for the patients, open doors and a high staff morale. In the years after my return from California in 1963, I was active in developing Social Therapy – in promoting and operating therapeutic communities and devolving authority to the patients and staff. While I was involved in doing this the role of the Medical Superintendent was gradually disappearing. There were a number of factors helping this process, some general in England and others specific to Fulbourn. The Mental Health Act 1959 made consultants in mental hospitals into Responsible Medical Officers, answerable for the treatment and legal detention of their own patients. There was, therefore, no longer any legal need for a Medical Superintendent. In many English mental hospitals this change was welcomed because it freed young consultants from the irritating interference of elderly, anxious Superintendents. Throughout the National Health Service, the quality of administrative officers was rising and more competent men were being appointed. In Fulbourn there was a marked change after Charles Mitchell retired in 1962 from the post of Group Secretary. Charles was an excellent and charming man with a very sound judgement of people, but he had lived all his life on asylum premises and had spent most of it as a servant of the Committee of Visitors under the direct authority of Medical Superintendents. He did not want more responsibility in the last years of his working life and was happy to leave the leadership of the hospital to me. After he retired we had a succession of able men, several of whom insisted (quite rightly) that they should take the leadership in non-medical matters. I went along with this. Thus my activities in non-medical spheres of the hospital – building plans, sports fields, annual reports – gradually ceased. The rearrangement of consultant responsibilities in the 1960s suited me very well. As far as I was concerned it meant relief from a number of irritating and unnecessary activities and allowed me to concentrate on the patients in whom I was most interested, the most disturbed long-stay people. It did, however, also mean that I went less often on to those wards for which I was no longer personally responsible. My Medical Superintendency was becoming nominal – though it was still my task to attend the Hospital Management Committee meetings and to speak for the doctors when necessary. In 1971 this, too, changed. As part of the reorganisation of medical representation within the National Health Service a ‘Division of Psychiatry’ was formed in Cambridge. All Consultants were members and it encompassed mental illness, child psychiatry and mental handicap. I was elected the first Chairman, Gwyn Roberts of the Ida Darwin the first Secretary and our Superintendencies were abolished. We continued to attend the HMC of our hospitals until the HMC was abolished in the NHS reorganisation of 1974. In 1975 I came to the end of my period as Chairman, and from that time onward I no longer held any position in the management structure of Fulbourn Hospital, or the District Health Authority which after 1974 ruled our affairs. I was, however, still a Consultant Psychiatrist. I was

Responsible Medical Officer for all the long-stay non-geriatric patients in the hospital (about 400 in 1970) and I ran the Social Therapy Area, later the Cambridge Psychiatric Rehabilitation Service. My role in the hospital was not the only area of my life which was changing at this time. After my year in the USA I was still primarily centred on the hospital and the therapeutic communities, but I developed other activities. I wrote and published two books and a number of articles on aspects of Social Psychiatry. I took part in national activities; I headed a Ministry of Health Working Party that produced a Report ‘Psychiatric Nursing; Today and Tomorrow’ in 1968 (Ministry of Health, 1968). As well as lecture tours (such as the one in 1961), I was asked to do international consulting work. The World Health Organisation began to use me, first on a Working Party in Geneva in 1965 and then in Japan for four months in 1967–68, advising the Japanese Government on their mental hospital system. I lectured up and down that country; my books were translated into Japanese and circulated widely; in the 1970s and 1980s I went back to Japan several times. As a result we had a flow of Japanese visitors to look at Fulbourn and a steady trickle of Japanese doctors, social workers and others to join the staff at Fulbourn for a year or two. Some of them, notably Junichi Suzuki (1970–73), made most valuable contributions to the Social Therapy of the hospital. The British Council sent me to Peru and Argentina in 1968. In 1974 WHO sent me to Poland for three weeks. Some of the appalling wards and hospitals I saw on these trips showed me how truly awful some psychiatric institutions still were. I also travelled to the USA in 1966, 1968 and 1971 lecturing and consulting. I sat on Committees of the Royal Medico-Psychological Association, and took an active part in its reshaping as the Royal College of Psychiatrists in 1971. For six exciting years, 1966–72, I was Vice-Chairman of the National Association for Mental Health (now MIND) chairing conferences, meeting Ministers, MPs and Princesses. It was all heady and exciting – but also very exhausting. My personal situation radically changed in the mid-1970s. In 1974 I was offered a fulltime post at the WHO in Geneva which was withdrawn at the last moment. The intensity of my disappointment forced me to realise how wearisome both my work and my personal life had become. The children had left home and my wife and I had drifted apart. Even my garden had ceased to be a joy and had become a burden. My wife and I separated, the home broke up and in January 1976 I went to live on my own in a small flat. I applied for a job in Australia, was offered it and almost took it. However, I decided to stay in Cambridge, but live differently. I took up yoga and meditation. I gradually became calmer and more insightful and pleasure began to return to my life. The Rehabilitation Service and the long-term patients were a great joy to me during those troubled years and I worked hard to develop new methods of psychiatric rehabilitation. I was particularly fortunate that Geoffrey Shepherd, a clinical psychologist and a distinguished rehabilitator, joined me in 1981 and gradually took over the leadership of the unit.

Around 1980 my life took a turn for the better. I remarried and began to look to the future. I was getting near to the time for my retirement. I decided to set an exact time limit to my service to Fulbourn, and I retired on 31 July 1983, exactly 30 years from the evening when I first knocked on the front door of the locked asylum. I was given a fine send-off, parties and presentations from my colleagues, and best of all a great party in the main hall attended by all the patients of the CPRS. I then went off round the world on a lecture tour. After my return I continued to live in Cambridge, but took no active part in the work of the hospital. I continued to see my friends, my former colleagues and, more important, my former patients about the city, in the shops and libraries and swimming pools. I worked in the University of the Third Age, but spent much of my time writing this book, attempting to record the story of our exciting times at Fulbourn and trying to make sense of what we did, what succeeded and what failed and why. CAMBRIDGE PSYCHIATRY CHANGES During the 1970s and 1980s the Psychiatric Services in Cambridge expanded greatly and Fulbourn Hospital gradually diminished in importance. From the opening of Fulbourn Asylum in 1858 until the founding of the National Health Service in 1948, there was no other psychiatric institution for the people of Cambridgeshire and there were practically no other psychiatric services. Then things began to change. Outpatient clinics were set up; the psychiatrists at Addenbrooke’s gained a detached outpatient department and began to provide psychotherapy; a Child Psychiatric service was set up in 1954 and gradually extended. However, until the 1960s Fulbourn Hospital was still the centre of the psychiatric services in Cambridgeshire. It was there that new buildings were put up (Adrian Ward in 1956, Kent House in 1964) and much money went into upgrading the ancient main building. In the 1950s the policy-makers of the Ministry of Health saw building at mental hospitals as the solution to problems of mental health. In the 1960s ideas altered. After proposing essential changes in the Mental Illness Laws, the Royal Commission in their 1957 Report went on to say that what was needed were developments in ‘Community Mental Health Services’. In 1961, in his ‘water tower’ speech Enoch Powell, then Minister of Health, announced that the Government would not spend any more money on mental hospitals which, he said, were going to become redundant. In Cambridge other facilities began to develop. Winston House was opened in 1958. In 1965 the Cambridgeshire Mental Welfare Association opened its first group home and in 1969 the St Columba Day Centre was started. The Duly Authorised Officers of the Counties became Mental Welfare Officers in 1959 and steadily developed and extended preventive and supportive services for the mentally ill throughout the district. The opening of the Ida Darwin Hospital in 1965 led to the development of an effective service for the mentally-handicapped people of Cambridgeshire. For a time Fulbourn Hospital carried on as if it was providing the major service in the area, but gradually activities in the community became more important.

A major change came in 1971 when Social Service Departments were set up in every local authority, centralising and professionalising the work of various groups of Social Workers. In Cambridgeshire after several difficult years, the department began to develop and improve the facilities for the mentally disordered in the community. The psychiatric outpatient department of Addenbrooke’s had been in its own building at 2 Bene’t Place since 1953 and grew steadily in size, importance and sophistication during the 1960s and 1970s. It developed a more active psychotherapy service under Malcolm Heron and then Bernard Zeitlyn. A Student Mental Health Service was developed by Brian Davy and Ruth Young. The department responded to Society’s new demands on psychiatry by developing clinics for advice on Termination of Pregnancy, a Drug Containment Unit, an Alcoholism Service and a Consultation Service for patients who had taken suicidal overdoses. During the same period voluntary efforts in the mental health field expanded and diversified – the Samaritans, Alcoholics Anonymous, Cruse, the National Schizophrenia Fellowship – all started groups in Cambridge. In the early 1970s, things appeared to be going well in the field of mental health care in Cambridge. Fulbourn Hospital had been transformed and many patients had moved out. Other mental health services were developing. Cooperation was good and money available for new projects. We did not realise then that this would soon change as the money began to run out. The world-wide oil crisis in 1974 and the start of an economic recession in Britain began to affect us. Government funds for mental health care became short during the later seventies and the squeeze began to be felt. New developments requiring money were refused. No new building projects were started. The Alcoholism Unit (1974) was the last new building at Fulbourn Hospital. Maintenance money became limited; each year the budget was scrutinised more severely; even small developments were stopped. Projects which merely needed a few extra staff – which would have been granted easily in the 1960s – were refused or postponed for years. The administrative atmosphere of the NHS became one of shortages, refusals, wrangling and discouragement, with constant pressures for economy. Instead of looking at new ideas, senior staff spent much of their time defending established services and trying to avert cuts. There were also other difficulties. In 1974, after many years of discussion, an administrative reorganisation of the National Health Service was carried out, to coincide with a reshaping of the ancient counties and local authorities of Britain. The reorganisation had been debated for years, and had many admirable aims, but somehow, in the event, it did not work out well. The reorganisation was originally proposed by a Labour Government but was finally implemented by a Conservative one. They hired American organisational advisers who offered suggestions which, when turned into British bureaucratic regulations, produced a structure of Byzantine complexity where many people and groups had the power to prevent change and hardly anyone had the authority to make decisions or to force effective action. It may be that the reorganisation would have done better if its introduction had not coincided with the economic crisis. As

it was, there was never enough money to do what the planners intended, or even to hire the staff to carry out their plans. The 1974 reorganisation abolished Hospital Management Committees. For Fulbourn Hospital this was a great loss. For 116 years, since 1858, the final responsibility for the government of the hospital had been in the hands of concerned local people: in the 1850s squires and parsons; after 1890 elected representatives from county and borough councils; after 1948 selected concerned people representing many local interests. This body of sagacious, experienced citizens – mayors, councillors, professors and others – had been most valuable to the hospital throughout the century but particularly during the postwar years. Led, in succession, by Lady Adrian, Alderman Mallett, Sir Henry Willinck and Mrs Pauline Burnet, they were a continual source of wise counsel to me and the other officers. They told the Cambridge public about the hospital and its changes; they told us what the local public wanted, and also what it would not stand. The Committee provided a forum where disputes between officers or departments could be firmly resolved. After 1974 this was no longer available to us. In 1974 all the hospitals in Cambridge were brought into one organisation. This seemed an admirable step forward, and there was certainly greater cooperation between Addenbrooke’s and Fulbourn at all levels. The snag, however, was once again the shortage of money. In 1974 Addenbrooke’s was in the middle of a protracted 20-year move from their old eighteenth-century building in the centre of Cambridge to a modern site in the south of the City. The original planning in the 1960s had not allowed enough funds and budgets were fixed too low. As the New Addenbrooke’s Hospital opened up in the 1970s the budget was regularly overrun and there were cries for economy. Any money for local development in Cambridge hospitals had to be poured into Addenbrooke’s – with the result that there was little money for Fulbourn. There was even a tendency to look for savings at Fulbourn to help out with Addenbrooke’s difficulties. From 1974 to 1982 an Area Health Authority was responsible for all medical services in an enlarged Cambridgeshire. This proved most unwieldy and the people in charge at Area level – officers and committee members – floundered in increasing despair over the eight years. Pauline Burnet became steadily more central in Mental Health in Cambridgeshire. When Lady Adrian died unexpectedly in 1968, Pauline took over the Chairmanship of the Cambridgeshire Mental Welfare Association. When in 1969 Sir Henry Willinck had to give up the Chairmanship of the Fulbourn Hospital Management Committee because of increasing ill health, she became Chairman and led it with aplomb until it was abolished in 1974. She was Chairman of the Cambridgeshire Area Health Authority during its difficult existence from 1974 to 1982. She was active, cheerful and compassionate; she helped many of those who worked for her, and took social casualties into her own home. I got to know her well and developed great admiration for her compassion, devotion and personal courage in times of difficulty. The 1974 reorganisation turned out to be so unsatisfactory that there was another national reorganisation in 1982 which abolished Area Health Authorities and shifted power to District Health Authorities. A new Cambridge District Health Authority became

responsible for all hospital and medical services in the Cambridge District. This and other reorganisations in the 1980s swept away the last vestiges of voluntary or representative local involvement in the NHS. By 1990 all management and authority was vested in paid officers answerable to and under control of Central Government. Another development in Cambridge psychiatry in the 1970s was the establishment of an Academic Department of Psychiatry. Ever since the asylum was founded in 1858 there had been hopes that links could develop between it and Cambridge University and that university study of mental disorder might develop. Although personal links with the university and the asylum sprang up in every generation, and university people contributed much to the welfare of the patients, attempts at formal links foundered. Not until the government accepted the Todd Commission’s recommendations in 1968 did the University of Cambridge reluctantly accept that it would have to have a Clinical Medical School. After the economic and educational expansion of Britain in the 1960s everyone believed that the university and the National Health Service would have ample funds to support steady development and expansion of new teaching departments. In 1976 the university appointed a Professor of Psychiatry. They chose Professor Sir Martin Roth of Newcastle, first President of the Royal College of Psychiatrists, a senior figure famous for his encyclopaedic knowledge and notable academic achievements. Sir Martin came to Cambridge expecting generous funding, plentiful staff and ample hospital facilities. Unfortunately he could not have come at a worse time. The Clinical School had been planned in the euphoria of the late sixties. It was assumed that the University Grants Committee would fund professorships, that the Medical Research Council would fund research projects and that the National Health Service would provide the extra wards, beds, nurses and other staff to house the academic clinical units. Alas, people forgot that all of these bodies were funded from the same national purse! After the 1974 oil crisis, the Government cut funds all round. As a consequence there was little money available for Cambridge’s struggling Clinical School and none for the Department of Psychiatry. Sir Martin had constantly to battle for funds, facilities and services. Since these could only come from someone else’s budget he faced constant opposition and many disappointing struggles. He had hoped to develop a professorial inpatient psychiatric unit within Addenbrooke’s – but was unable to do so. He had hoped to attract teachers and research workers – but could barely get funds for secretaries. His manifest dissatisfaction brought constant tensions within the psychiatric group. Further, Sir Martin found much that he disliked about psychiatry in Cambridge – and he made his distaste apparent. He found the culture of open discussion which we had developed at Fulbourn quite unacceptable. The fact that junior doctors, social workers and nurses argued and challenged the views and instructions of consultants – and even his opinions – appalled him. He could see no value in the therapeutic community approach. Gradually a sour atmosphere developed amongst Cambridge psychiatrists, erupting in rows on Committees and struggles over resources. A polarisation began amongst the doctors; academic psychiatry began to be seen as preferable to social psychiatry; the Friday morning doctors’ meeting with its egalitarian culture gradually declined and

withered. I withdrew into my work in the Rehabilitation Service. The nurses, social workers and occupational therapists in Fulbourn who enjoyed therapeutic community work gradually moved there to work with me and we became an isolated bastion of social therapy. At first the changes outside did not much affect the work within the hospital. The work of treating acute psychiatric admissions on Street, Friends and Adrian Wards improved, flourished and expanded through the late 1960s and the 1970s. The flourishing of Social Therapy for the long-term patients has already been described, and the Rehabilitation Service moved more and more people out to sheltered accommodation. Numbers of inpatients fell steadily. Only on the geriatric wards did pressure increase. After we created a defined Psychogeriatric Area in 1966, the service for a time improved. During the 1970s, however, the increasing pressure to take in elderly and demented people overloaded the service and standards and morale fell. The appointment of Peter Brook as Consultant in Psychogeriatrics in 1979, however, started a steady rise in the quality of the service afforded to the confused elderly and their carers, both in the community and within the hospital. By the early 1980s Fulbourn Hospital had become very different, both in appearance and function. Active work was still going on in the admission units, Kent House and Adrian, and in various outlying buildings. The main building was becoming empty. Wards were being closed down as the physically active long-term population left hospital. Only the ground floor wards were actively filled with the confused elderly. But most of the work of the psychiatrists was being done elsewhere, in Addenbrooke’s, in the outpatient clinics and in the many special units being developed throughout Cambridge. I retired from the National Health Service in 1983 and ended my involvement with Fulbourn Hospital. This tale might have ended at that point but, of course, the work goes on. The Cambridge Psychiatric Rehabilitation Service won national recognition under Graham Petrie (who succeeded me) and Geoffrey Shepherd, and visitors continued to come (especially from Japan) to observe the work. I retired from Fulbourn in 1983, just 30 years to the day since I went there – green, naive, enthusiastic, determined to do something for those packed into the squalid, brutal back wards. I left well satisfied; we had indeed released the people from the back wards, and in the process abolished the back wards themselves. In Cambridge, at least, they were a memory, now being forgotten, a memory of padded cells, brutality and the asylum stink of urine, paraldehyde, carbolic soap and boiled cabbage. In the process of opening the wards and freeing the people, we had discovered and demonstrated Social Therapy and established the basis of a better kind of psychiatric nursing – a nursing of caring, counselling and helping rather than a nursing of control, coercion and occasional brutality. Some of our more exciting experiments had proved transient – the therapeutic communities, the Fulbourn culture of growth, the doctors’ sensitivity meetings – but

much remained, especially the advanced psychiatric nursing and the model Rehabilitation Service.

8 Reflections In 1970 there were four wards in Fulbourn functioning as therapeutic communities and proudly boasting of it. In 1982 the BBC came to Fulbourn and made a film about the therapeutic community in Burnet House. By 1990 there was no ward left in Fulbourn which called itself a therapeutic community. From a peak in the late 1960s the number of therapeutic communities in British psychiatric hospitals steadily declined until by the 1990s most therapeutic communities in England were in probation hostels, halfway houses, residential homes and so on – not within the National Health Service. How did this change come about and why? Within Fulbourn, a number of reasons can be seen for the decline of the therapeutic community in its original form. The group that benefited most from the therapeutic communities were the patients (and staff) trapped in long-stay wards. By 1980 most of those patients had left hospital. Quite a few of the practices of the therapeutic community were by now accepted as normal in Fulbourn – mixed-sex wards, no staff uniforms, ward meetings, staff discussion groups and open and free discussion between professions. There was plenty of encouragement for patients to help each other and to talk openly with staff, as well as active involvement of and discussion with relatives of patients. However, some of the more unusual experiments of the seventies, such as the Doctors’ Sensitivity Meeting on Fridays (with its egalitarian sharing), the Hospital Innovation project and the culture of growth, had disappeared. The doctors’ meeting stopped in the late seventies with the development of academic psychiatry. Several of the therapeutic community wards stopped working in that mode; others stopped using the term. By 1990 there were only two wards in Fulbourn Hospital still operating as therapeutic communities – Burnet House and Street Ward – and in both of these the meetings consisted of patients and nurses only; the ward doctors seldom attended, the consultants never. There are, however, two therapeutic communities still operating in the Cambridge area – Winston House and Glebe House (a facility for disturbed adolescents) and there are many operating in Britain and overseas. This retreat from therapeutic community work was seen throughout British psychiatry. During the 1960s therapeutic communities had started in many psychiatric hospitals; Henderson, Claybury, Littlemore, Fulbourn, Dingleton and Ingrebourne became well known. In the 1980s therapeutic community wards stopped operating, units were closed, hospitals famous for being committed to therapeutic community principles, such as Claybury, dwindled in size and ultimately were being closed down. The causes of this change have been much debated and different views prevail. In my opinion the root cause is the incompatibility of an egalitarian, democratic ward culture with the authoritarian, bureaucratic organisation which the National Health Service has gradually become. A therapeutic community is an excellent system in which troubled

people can come to understand and modify their disturbed and disturbing behaviour. It works well when it meets a major social need and has a flexible management to support it. But it does make great demands on the staff and often causes difficulties and embarrassments for managers. In the 1950s the NHS was a new organisation keen to find new ways of handling ancient problems – such as the awful old county asylums. Experiments were applauded and supported. Money was forthcoming for funding new ideas and departments and to improve conditions for patients and staff. At Fulbourn we were fortunate to have an effective and supportive Hospital Management Committee led by flexible, far-sighted Chairmen (especially Lady Adrian and Pauline Burnet) who were prepared to back our experiments, and more important, to speak up for us when things went wrong. By the 1990s the NHS was a beleaguered, battered and demoralised organisation, starved of funds and under criticism from a government devoted to ‘market economics’ and private medicine. NHS hospitals were now run by managers who were under constant pressure from Central Government to save money, cut costs and to keep things generally under tight control. Most of their time and energy was given to general hospitals which had a clear traditional social structure of doctors doing their skilled work, nurses assisting and organising, and patients lying passively in bed awaiting cure. A unit where patients make decisions, where disorder is apparent and from which unacceptable demands may come, perplexes and angers tidy-minded and harrassed managers so that they readily support demands for enquiries, disciplinary action and closure. Basic premises of the therapeutic community are the abolition of hierarchy and authority, the establishment of all contributions as equally valid, the tolerance of open confrontation and challenge, and the acknowledgement of patients’ responsibility for their own lives and for the running of their wards. These have proved unacceptable in a National Health Service where power and authority is statutorily entrenched with administrators, consultant doctors and senior nurses and where patients are usually treated as passive, incompetent, ignorant people whose only task is to await the attention, skill and compassion of those paid to look after them. During the 1990s too, British psychiatry has moved away from an interest in social therapy. With a wider range of new drugs available, many young psychiatrists concentrate on improving their skill in diagnosing, assessing symptoms, prescribing drugs and monitoring side effects. They tend to ignore what goes on around them and their patients in the psychiatric ward. Psychoanalysts and psychotherapists have withdrawn into their consulting room – and the one-doctor, one-patient situation. Both groups say they are doing this because it is good for their patients – but it also removes them from the open challenge of a ward meeting. The insecure and inadequate doctor feels far safer in a white coat examining a half-naked patient with a stethoscope or in a comfortable armchair out of sight behind the psychoanalytic couch, than working in an environment where he would be open to scrutiny and criticism by patients and nursing staff.

The phrase ‘Therapeutic Community’ was coined by a psychiatrist, Tom Main, and developed by another, Maxwell Jones. These communities are one of the most effective ways of helping people in residential institutions who show disturbed and disturbing behaviour, but who are fairly competent socially and have a capacity to develop insight. In a therapeutic community they can explore themselves, reach a greater understanding, change and grow. Therapeutic communities work well in adolescent units, rehabilitation hostels, probation hostels and units for drug addicts. It may be that future social historians will see it as accidental that therapeutic communities were first developed by psychiatrists, and that for a time, in the sixties, they flourished in some of the old mental hospitals during their final decades. During the 1970s I came to realise that the vitality of a therapeutic culture derived from the people in it – junior nurses, occupational therapists, young doctors, social workers, porters and nursing assistants and, of course, the patients themselves. It was their attitudes that determined whether a person’s stay in hospital was a time of change, growth and progress – or whether it was a time of defeat, shame, misery, degradation and brutality, as was common in the old custodial hospitals and in jails and security hospitals. The task of senior officers like myself, the power holders in the organisation, was supportive – creating an atmosphere where hope could develop. This support was, however, essential since bureaucratic forces would always be pushing for economy, stasis and predictability, forever stifling personal growth, initiative and risk taking. By the early 1980s, we were fairly clear in Fulbourn what we meant by Social Therapy. The basic premise was that of the Moral Treatment pioneers – the belief that the way that patients lived in a mental hospital was a potent factor in deciding whether they progressed, became better and took their discharge or whether they sank into stultified, resentful chronicity. By now, however, we had the advantage of the insights of social science research. We had learned how damaging many of the traditional practices of the asylum were, even when they had been adopted for the best of motives. The official practices (such as the locking of doors, constant oppressive security, continual counting of people, cutlery, bed linen and so on) were bad enough, but far worse were the unofficial happenings – the beating up, the garrotting, the use of padded cells and ECT as punishments, the occasional killing. Social science studies had helped us to discover for ourselves the value of open doors and open communication which made everything public and open to scrutiny. We had become aware of the malignant effects of a punitive, fault-finding authority structure on the altruism and enterprise of nursing staff. This had led us to adopt open community methods and consensus decision-making, giving staff the freedom to challenge and change obstructive management. We had become aware of the social gulf between the stifling, though supportive, cocoon of the asylum and the frightening world outside it and the consequent need for transitional facilities of every kind. By 1980 we still retained our original triad of aims – Freedom, Activity and Responsibility – but we had now added to it Rehabilitation and Personal Growth. We had realised that these were important for everyone in the hospital community – possibly even more for the staff than the patients.

In retrospect the development of Fulbourn’s Social Therapy can be seen to fall into three separate phases, each a response to a particular problem and each leaving certain permanent lessons. The first phase, the Open Doors campaign of the 1950s, had the effect of changing the stultifyingly custodial, therapeutically nihilistic pattern of the first century of the asylum. It created in Fulbourn an open, humane, liberal way of life. By the 1980s similar changes had taken place in most British mental hospitals, but it is worth remembering that this has still not happened world-wide. As I learned during my travels, the majority of mentally disordered people in the world are still locked up, confined in impoverished idleness and often brutally treated. The value of the Open Door Hospital is still not appreciated yet in many countries. The second phase was that of the Therapeutic Community, during the 1960s and 1970s. We tried out the revolutionary ideas of Maxwell Jones and found they were very successful with long-stay active patients, nearly all of whom were able to leave hospital. It taught us to value the contributions of all the people who worked with patients and showed us the immense power of social forces in the life of the ward. Though it remains a valuable ideal, it has not remained part of Fulbourn Hospital. This was partly because its success removed many of the problems; the patients capable of self-government mostly left the hospital. But the hostility of powerful senior doctors to a system that devalued their expertise and challenged their power worked against it and the National Health Service Bureaucracy of the 1990s, with its emphasis on ‘business management’, strict economy, and answerability upward could not tolerate a system so challenging, so revolutionary and so irregular. Enthusiasm and hope do not appear in accounting systems. There were still flourishing therapeutic communities in Britain in the early 1990s but they were mostly in small residential units not tied into any major ‘accountable’ bureaucracy – halfway houses, probation hostels, Concept Houses, Richmond Fellowship houses. In them Maxwell Jones’ ideas of equality, confrontation, reality testing and a systems approach are still valued. The third phase was that of the Rehabilitation Service, which started in the 1970s and developed fully in the 1980s. We had moved most of our long-term patients out of hospital into group homes, halfway houses, sheltered accommodation and so on. We were visiting and supporting them there. We had developed an effective system of Care in the Community – long before it became official government policy. But the Cambridge Psychiatric Rehabilitation Service developed its own principles based on our previous 30 years’ work. We emphasised lifetime support, individual, skilled help for patients and transitional facilities but the Cambridge Service also retained many of the beliefs established in the therapeutic community period. These included the idea that clients should make their own choices of where to live and what to do; that entry to hospital and exit from it should be flexible and sensitive to individual needs; that transfer of patients between wards should be fully explored by discussion with all concerned; that all patients were capable of some progress. It is these attitudes that made the Cambridge Psychiatric Rehabilitation Service different from some which rely on depot injections, constant surveillance, and the use of legal methods of control.

When I finished writing this account of my time at Fulbourn I felt there were some questions to be answered, such as – ‘Was Fulbourn unusual in what it did?’, ‘Were the results we achieved really so very different from those of other mental hospitals at that time (who were also emptying their back wards, changing their functions and finally withering away in the 1990s)?’ and ‘Has the old mental hospital and its story any relevance to the work and challenges to British psychiatry in the twenty-first century?’ What follows is my attempt to answer these questions. The passage of time will prove whether I am right or wrong, but for what they are worth, these are my conclusions. WHY AT FULBOURN AND WHY THEN? There were several reasons why there was such a ferment of activity at Fulbourn Hospital in the 1950s. Fulbourn in 1953 was demoralised; for 30 years (1923–53) nothing much had happened there at a time when other psychiatric hospitals were actively adopting the new methods of treatment. By 1953 Fulbourn Hospital was dilapidated, grossly overcrowded and understaffed – in a worse state than most other county asylums. The staff were looking for a new lead. There had been paralysis higher up; the old Visitors Committee had been disbanded in 1948 and Fulbourn placed under the Committee for Newmarket Hospital. It was only in 1951 that a new Management Committee was set up headed by Mrs Adrian. Next, I was appointed as Superintendent and brought two useful personal characteristics with me – a passionate desire to do something better for the longstay patients, and the brash over-confidence of youth and inexperience. The fact that I had never before worked in an English County Asylum turned out to be an advantage (though I did not feel it to be so at the time). What mattered for the staff and the hospital was that I had youth, energy and apparent confidence. Because I cared about the longstay patients, it became possible for the rest of the staff to start caring about them too and then begin doing new things. Their leadership came from the combination of a new Management Committee led by an energetic reformer, Mrs Adrian, a young enthusiastic Superintendent and a Regional Board prepared to spend money and back experiments. All this happened at a time when mental hospitals were on the brink of change because English society as a whole wanted authoritarian institutions to become more liberal. For these reasons the changes at Fulbourn happened fast. In 1950 all the ward doors of Fulbourn were locked, as they had been for 92 years. By 1958 they were all open. Was the speed and degree of change at Fulbourn unique? Nearly so, I believe. In 1953 three other British hospitals were already Open Door (Dingleton, Mapperley and Warlingham) and others were soon to be. But few changed as fast as Fulbourn. Dingleton, Mapperley and Warlingham all had Superintendents personally committed to patient freedom, but Bell, McMillan and Rees had all been in charge of their hospitals for years, since the war, and had prepared for Open Doors slowly. It was only in a few hospitals that the conjunction of a hospital ready to change and a Superintendent who wanted to change things quickly coincided so happily as at Fulbourn. Many senior psychiatrists in the fifties had other priorities – research, psychotherapy, physical treatments; many lacked the energy or the resolve to push for changes and were

defeated by the inertia of staff wedded to the old ways and reluctant to change. In some hospitals strong senior nursing figures and a strongly entrenched custodial culture amongst the nurses delayed the changes. WHAT WAS ACHIEVED? What did the Fulbourn revolution achieve? Most importantly in the 1950s, it improved the life of the long-stay patients immensely; from being locked up in squalid congestion, they were allowed a lifestyle providing more freedom and dignity. In the sixties these patients began to move out of hospital and with the aid of Winston House, the group homes and the rehabilitation programme many achieved and maintained good, independent lives despite their continuing psychological disabilities. When I meet my former patients in the streets of Cambridge many still express gratitude at being delivered from their confinement in the 1950s. During the 1970s and 1980s tens of thousands of long-term patients were discharged from mental hospitals in England and the USA. Did we carry out this process at Fulbourn better than other places? I think we did. Many hospitals emptied the wards too quickly, with inadequate support facilities. We took longer over the process. We set up a wider range of transitional facilities. We prepared people carefully for discharge. We supported them in the community. We certainly had remarkably few episodes of suicide, social breakdown or public disaster over the years while we were opening the doors. The people of Cambridge, even the people of our two neighbouring villages of Cherryhinton and Fulbourn, welcomed the change and were proud of what their local institution had done for a pathetic group of people. Even in the 1990s I often meet people who recall with pleasure and pride how ‘their’ asylum changed in the 1950s and 1960s. Another group of people who benefited from the Fulbourn Social Revolution were the staff, particularly the long-stay nursing staff. For most of them work in the locked asylum had been a dispiriting job in a place of which they were ashamed, only alleviated by the cricket, the staff club and the early pension. After the changes they took pride in their hospital and the public and professional admiration it received. They found their work more challenging and interesting, and most important, they found the relationship with their patients radically changed. As one said ‘I’m glad the keys have gone. Before I felt like a gaoler. The patients saw me as the man who locked them up. Now they see me as a friend.’ All these changes have lasted. In Cambridge and in the general hospital psychiatric units throughout Britain there are nurses and other staff who spent time working at Fulbourn. There they learned a way of relating to disturbed, unhappy people which makes them more effective as staff than those trained in traditional ways. IS SOCIAL THERAPY RELEVANT ANY MORE? Those of us who changed and opened psychiatric hospitals in the 1950s learned about Social Therapy on the job. First we rediscovered the principles of early nineteenthcentury care for the mentally ill – the principles called ‘moral management’ by Tuke, Pinel, Conolly and others. The founders of humane asylum management asserted that

wards should be small, home-like and friendly; that there should be plenty of activity – both work and play – for the patients; that staff should work with the rational and responsible part of the disordered person and ignore or minimise the irrational; that coercion and restraint should be minimal; that there should be no violence, brutality, oppression or degradation. We relearned all those lessons in the fifties. Then, applying the findings of the twentieth-century social scientists, we took our ideas further. We developed transitional facilities, halfway houses, group homes, sheltered accommodation. We set up sheltered workshops and industrial units and organised supportive rehabilitation using networks of social workers, community psychiatric nurses and community occupational therapists, and so on. We then went even further and experimented with the social structure of the hospital ward, developing self-governing wards and finally therapeutic communities. Is any of what we learned and taught still relevant? I believe most of it is. Some of the effects of the social revolution in postwar British psychiatry remain and will I believe be permanent. Psychiatric nurses today see their main tasks as listening to patients, counselling them and understanding them. They know they do this best in a supportive, friendly humane culture. Most British psychiatric wards and units are now Open Door. In many units nurses, patients and creative therapists meet in groups and in ward meetings. This is a far cry from the psychiatric nursing culture of the forties with its emphasis on order, uniforms, discipline and its undertone of brutal oppression. The care of people with long-term psychiatric disability in England has changed utterly. Very few of them are now in hospital wards. Many live in the community, with their families or in sheltered accommodation. They attend day centres and workshops and are supported by teams of social workers and community nurses. We have created in Britain a framework of Psychiatric Rehabilitation and a range of trained professionals to support it. It is true that this framework sometimes fails, particularly in the big cities where people with chronic mental illness live as tramps, finding their food in garbage dumps and sleeping in cardboard boxes. But these are the exceptions. Most long-term mentally ill people in Britain now live good lives out in the community. It is fashionable in the 1990s for some mental health activists, when criticising the shortcomings of the present ‘care in the community’ system, to speak nostalgically about the advantages of ‘the old asylum’. I feel these people should talk to those who worked, or worse, were imprisoned, in the old county asylums. Although people may sometimes reminisce about good things which happened in ‘the old days’, I have never heard a former patient express a wish to be back in one of the old locked wards. Major principles of Social Therapy were that when people are gathered in an institution the way that they live and interact is more important for their welfare and recovery than any individual attention they may receive; that it is more important to work with the whole institution than with the individual; that attention must be paid to the beliefs held by the staff and the patients and to what they do to one another.

It was these principles that led us to open the doors and to introduce activity, freedom, responsibility, rehabilitation and choice into the life of the patients and the staff at Fulbourn Hospital. In following these principles we constantly looked at what we were all doing and how we interacted with each other. That, in turn, led us to set up discussion groups, ward meetings, sensitivity groups and to examine constantly our patterns of authority and responsibility. Has this all been forgotten? Some psychiatrists believe and indeed, hope so. Although they welcome a more humane atmosphere in their wards they do not believe that such an atmosphere is really important. They do not realise that by retreating to authority-based positions and refusing to look at what really happens on their wards, they are in danger of sliding into a repressive culture as bad as that of the old asylums. A malignant trend in English society in the 1990s is the growth in the number of gaols and secure institutions. England has the dubious distinction of having a higher proportion of its citizens locked up than any other European country. The ‘secure hospitals’ – Broadmoor, Rampton, Ashdown – are now being refurbished and extended. ‘Regional Secure Units’ are being created and developed and enlarged. There is pressure from frightened managers and uncaring psychiatrists to lock up wards again. All the melancholy patterns of institutional oppression which created the old asylum culture is being repeated. The conditions that created the need for Social Therapy in asylums are being set up again in gaols, secure institutions and locked wards. Wherever society locks up people it dislikes and pays other people to keep them in, an oppressive and cruel culture is likely to develop. If society designates these prisoners ‘insane’ and hires doctors and nurses as gaolers, they will create the same medicalised, hypocritical gaol culture as in the old asylums. British secure hospitals are racked by scandals which reveal all the old patterns of staff brutality, corruption and medical tyranny. The Secure Units and locked wards are growing in number and size and it will not be long before scandals erupt in them. So all the patterns of the old country asylums will be created again and a Social Therapy Revolution may once again be necessary. Social Therapy – its lessons and its methods – will always be relevant wherever people considered mentally disordered are gathered into residential institutions and doctors and nurses are hired to care for them. The choice for doctors and nurses is not whether or not to practice social therapy. The choice is to do bad social therapy by default or to do good social therapy by active attention to the social structure of the institution. If the staff do not attend to what goes on on the ward, malignant social therapy is occurring by default. Locked doors, over-medication, oppressive custodial nursing practices will lead to staff brutality and squalid deaths in cells and side rooms. After a few years of this we shall once again see the crowds of apathetic people locked into resentful institutional dependence that characterised the worst of the old asylum. It will then become necessary to rediscover the methods of positive Social Therapy to lead the imprisoned people once again to independence and human dignity.

Postscript I have told this tale primarily to record and celebrate the great days of Fulbourn Hospital, an Open Door hospital for 30 years, which developed Social Therapy, Therapeutic Communities and Rehabilitation and was a centre of national and international reputation. Much has happened to Fulbourn Hospital in the years since 1983. The number of people in mental hospitals over Britain has continued to decline. The attitudes of Margaret Thatcher, of denigrating public service, of running down public hospitals, building up private enterprise, and of mean-minded economising have filtered down through the NHS bureaucracy. At Fulbourn it had particular effects. All Ward operations were moved to the outlying villas. All patients were removed from the old main building and attempts were made to sell it off as a hotel, or as offices. Wards have been moved to and fro for administrative rather than therapeutic reasons – elderly patients have been moved into the Ida Darwin, designed for mentally handicapped children, a psychogeriatric admission unit has been inappropriately squeezed into Kent House, and so on and so forth. The administration, which now comes under Addenbrooke’s Hospital, has been chopped and changed about. Managers without any knowledge of the problems of psychiatry or the needs of long-term resident patients have been appointed, then shifted, then replaced as another administrative reshuffle takes place. Two Trusts have been set up in Cambridge, the Addenbrooke's Hospital Trust and the Lifespan Trust responsible for Community Services. This has split the network developed in the 1970s and 1980s by the Cambridge Psychiatric Rehabilitation Service. Even more damaging to Social Therapy and risk-taking has been the development of a mean, carping, fault-finding spirit amongst the administrators and managers. Battered by public enquiries and outcries, pressured by harrassed Ministers, they have reverted to the kind of administrative behaviour that marked the worst of the asylum days – issuing memoranda forbidding activities, putting up warning notices, setting up disciplinary enquiries and penalising staff who take risks or show initiative. Staff have learned to be cautious, to get everything in writing, to avoid initiative. As one student nurse of the 1990s put it to me – ‘The main message I learned on the wards at Fulbourn is CYA – Cover Your Arse!’ The Cambridge psychiatrists too have mostly retreated from Social Therapy. Many of them prefer working in the general hospital; several small psychiatric units have started at Addenbrooke’s and the psychiatrists now wish to remove all the other admission units there. When the Department of Health proposed to build a locked unit at Fulbourn they agreed and it was built in 1994 on the old playing field. Euphemistically entitled the ‘Intensive Therapy Unit’, it is ringed with flood-lit high fences and firmly locked, thus ending Fulbourn’s years – over 30 – as an Open Door Hospital. Much of what we achieved has been lost and much is being forgotten. It was partly for that reason that I decided to publish this story, to put on record what we achieved.

Despite all the changes away from the liberal and open regimes of the 1960s and 1970s some of the spirit remains. On most wards the nurses are out of uniform; on many admission wards, ward meetings are still held (though the doctors do not attend them); nurses see their work as counselling and befriending the patients, and resist attempts to push them into counting, guarding and ‘specialing’ patients. The spirit of the best of psychiatric nursing still persists despite the disinterest of the doctors, and the conformist pressure of the managers. So before all that we did is forgotten, I have told this tale of what we were able to do at Fulbourn Hospital in the 1950s, 1960s and 1970s, and how we turned a dreary locked up asylum into an Open Door Hospital, a centre for Therapeutic Communities and Rehabilitation of world-wide repute. References Archdale, M.A. (1909) ‘The hospital (i.e. asylum) treatment of the acutely insane’. Journal of Mental Science 55: 453–73. BBC Television (1982) The Way Back, Everyman Series. Browne, W.A.F. (1837) What Asylums Were, Are, and Ought to Be. Edinburgh: Black. Caudill, W.A. (1958) The Psychiatric Hospital as a Small Society. Cambridge, Mass.: Harvard University Press. Clark, D.H. (1956) ‘Functions of the mental hospital’, the Lancet 2: 1005–9. Clark, D.H. (1958) ‘Administrative therapy: its clinical importance in the mental hospital’, Lancet 1: 805. Clark, D.H. (1960) ‘Principles of administrative therapy’, American Journal of Psychiatry 117: 506. Clark, D.H. (1964) Administrative Therapy. London: Tavistock Publications. Clark, D.H. (1965) ‘The developing concept of the therapeutic community’. Proceedings of the 6th International Congress of Psychotherapy, London, 1964. Psychotherapy and Psychosomatics 13: 238–45. Clark, D.H. (1965) ‘The therapeutic community – concept, practice and future’, British Journal of Psychiatry 111: 947–54. Clark, D.H. (1974) Social Therapy in Psychiatry. Harmondsworth: Penguin Books. Clark, D.H. (1982) Social Therapy in Psychiatry. (2nd Edn) Churchill Livingstone.

Clark, D.H. and Cooper, L.W. (1960) ‘Psychiatric halfway house: a Cambridge experiment’, the Lancet 1: 588. Clark, D.H., Hooper, D.F. and Oram, E.G. (1962) ‘Creating a therapeutic community in a psychiatric ward’, Human Relations 15: 123. Clark, D.H. and Myers, K. (1970) ‘Themes in a therapeutic community’, British Journal of Psychiatry 117: 389–95. Clark, D.H. and Oram, E.G. (1966) ‘Working for the hospital’, British Journal of Psychiatry 112: 997–1005. Hooper, D.F. (1960) ‘Change in the mental hospital: a social psychological study’, PhD Thesis: University of Cambridge. Houston, F. (1956) ‘Group behaviour in chronic schizophrenics treated with Meratran’, British Medical Journal 1: 949. Ministry of Health (1968) ‘Psychiatric nursing: today and tomorrow’, (Report of the Joint Subcommittee of the Standing Mental Health and the Standing Nursing Advisory Committees). London: HMSO. Mungovan, R. (1968) ‘The evolution of a therapeutic community’, Nursing Times 15 March, 365–6. Myers, K. and Clark, D.H. (1972) ‘Results in a therapeutic community’, British Journal of Psychiatry 120: 51–8. Pattemore, J.C. (1957) ‘The development of a disturbed ward between 1937 and 1956’, Nursing Times 18 January, 73–5. Robertson, J.L. (1862) ‘The Progress of Psychological Medicine since the Days of Dr Caius’, Journal of Mental Science 8: 197–210. Stanton, A.H. and Schwartz, M. (1954) The Mental Hospital. London: Tavistock. Towell, D. and Harries, C. (eds) (1979) Innovation in Patient Care. London: Croom Helm. World Health Organization (1953) Third Report of the Expert Committee on Mental Health. Geneva: World Health Organization.