by Donald West
Even before Dr Rhine’s visit to England I was preparing for a move to a different career by attending a course in psychiatry at St Ebba’s Hospital, Epsom. It was run by Dr Peter Kraupl Taylor, who had been a mathematician and later a practising physician in Prague. He had experienced confinement as a Jew in a concentration camp. After escaping to England he finally became a consultant in psychotherapy at Maudsley Hospital London, an important centre for psychiatric teaching and research. He was an expert on Freud and believed in applying objective appraisal to Freudian psychopathology, which impressed me greatly. He did not drive and I was able to offer him lifts to and from the hospital in the sidecar of my motorcycle. We became friendly and indeed remained so until his death many years later. I needed to find a junior hospital post and made two applications. One was to an addiction clinic in East London, directed by William Sargant. He was an expert on physical treatments in psychiatry and on the physiological basis of mental phenomena, such as political and religious brain washing, about which he had published a popular book Battle for the Mind. I was turned down for that job, but the second application, to Maudsley Hospital, was successful, doubtless thanks to a helpful nudge from Dr Taylor. By 1951 I was on the lowest rung of the National Health Service ladder, working as a trainee psychiatrist, but with no experience of general hospital medicine. This anomalous situation would be unthinkable today when every medical graduate is required to work full time in hospital for a year before achieving registration as a qualified practitioner.
I entered hospital psychiatry just before modern anti-psychotic drugs came into use, when violent and disruptive behaviour were brought under better control, the wards became more peaceful, and a path was opened to the massive reduction in the number of mental hospital beds in favour of “treatment in the community”. Maudsley, in the fifties, was a small, privileged teaching hospital. Patients difficult to manage were soon transferred to larger institutions with more locked wards. Given the limitations of available medication, there was emphasis on the value of a regular, structured routine for patients and their engagement, whenever possible, in normal activities. My first placement was in a ward for schizophrenics, where I was allotted, among others, a handsome, powerfully-built young man with paranoid delusions. I was expected to converse with him and assess and record his changing moods and any developments in his disordered thinking and delusions. I could also take him for walks in the grounds. All went well and I convinced myself that he was improving as a result of my attentions. During a clinical seminar conducted by the senior consultant, one of my fellow trainees, remarking on my particular interest in this patient, referred to our “homosexual” relationship. In those days, when Freudian jargon was in regular use, the phrase was not meant to be taken literally, but it troubled me that colleagues might suspect my secret sexual feelings. That risk soon came to an end. While I was absent, the patient absconded from the ward, climbed the stairs to the flat roof of the psychology building, where there was a roof garden, and started heaving furniture over the wall onto the ground below. He was immediately dispatched elsewhere.
Interaction with a young female patient, a student from Cambridge, had a still more distressing outcome. She was a severe depressive with a history of suicide attempts and some schizoid features. She was able to talk calmly and rationally and assured me, with normal-seeming social poise, that she was feeling much better. The head of her college, New Hall, took the trouble to pay her a visit. I was required to see this imposing visitor and present an optimistic picture of the student’s progress. Soon after, while on a short leave from hospital, the patient killed herself. It was my first lesson in the difficulty of penetrating the true feelings of someone resolutely determined to conceal them.
Learning to take systematic case histories according to an established protocol, noting the symptoms that determined the limited number of psychiatric diagnoses, and studying the conflicting theories of causation gave me no great trouble. I participated in seminars conscientiously, answered questions appropriately and must have seemed a satisfactory trainee, but I was worried by lack of practical experience of physical medicine. We had to make a routine physical examination of every new patient and I was never confident that I had not missed something important, such as the signs of gross brain damage that might be responsible for psychiatric symptoms. Fortunately no disaster occurred. Only rarely was one required to attempt some physical intervention (other than sticking needles into veins), but once I had to do a lumbar puncture to tap cerebro-spinal fluid, a procedure I had never done as a student. I asked a friendly and more experienced fellow trainee to watch me and, although I was fearful, it went off well.
One evening when I was on night duty, I was called to a ward where a man had slit his throat with a broken glass, penetrated a jugular vein, and lay gushing blood while nurses tried to hold him still. All I had to do was to order an immediate morphine injection so he could be restrained and, under the guidance of a sensible senior nurse, wheeled to the accident and emergency unit at the general hospital just across the road. Someone congratulated me on handling the situation, but unless they were being sarcastic I must have miraculously concealed my feelings. The man was very ill for some time, but recovered and returned to the ward.
The organisation of the hospital was indisputably hierarchical. This was reflected in the staff cafeteria where people chose their tables in an unwritten but strict order of seniority. The atmosphere smacked of paranoia. Our performance at case presentations before a large audience was under critical scrutiny and we were conscious of the fact that our futures depended on the outcome of annual reappointments, which were far from automatic and frighteningly unpredictable. The head of the hospital, the austere and demanding Sir Aubrey Lewis, expected academic precision, provoking anxiety at conference presentations. It was only some years later, when I was acting as assistant at his out-patient clinic, that I was surprised to find he could sometimes descend from his lofty pedestal. When watching the approach of a colourful lady patient he remarked, with out-of character flippancy, that one might judge the depth of the neurosis by the height of the high heels.
Psychiatry encompassed contrasting approaches, from psycho-analysis to brain surgery, from social engineering to drug treatment. The teaching was remarkably eclectic. Junior doctors were allocated on rotation, every six months, to different units headed by consultants with widely differing methods and clientele. There was a broad division between those with a predominantly psychological approach, interested in patients’ personal problems and stressful social circumstances, and those concerned with derangements of the central nervous system susceptible to strictly medical intervention. In recent decades, the increasingly sophisticated manipulation of brain functions with drugs and the introduction of brain scanning techniques has increased both understanding and treatment of conditions such as schizophrenia, insane mood swings (‘bipolar’ disorder) and brain injury and degeneration, but the correct management of the more common problems of humanity, ‘neurosis’, sexual deviance (‘paraphilias’), and the so-called ‘personality disorders’, remains more problematic. I have always been more fascinated by these latter categories.
Back in 1951, Freudian interpretations of behavioural and emotional problems were still influential and I was inclined to go along with them, although conscious of the difficulty of demonstrating their scientific validity. It was asserted that one could not be an effective analyst unless one had been analysed oneself. I had tried to obtain some such experience by attending a Jungian analyst, hoping to gain insight into my homosexuality, perhaps even achieve a cure, but I proved an unresponsive patient. My diligent attempts to verbalise a stream of thought on the subject succeeded only in putting the analyst to sleep. He actually snored! Scepticism of psychoanalysis was encouraged by Hans Eysenck, Professor of Psychology at Maudsley, who lectured us and cited studies suggesting that recovery rates among neurotic patents were no different among those given analytically-oriented psychotherapy t
han among those left untreated. I spent six months on a unit headed by a Freudian psychoanalyst, S.H.Foulkes, who conducted treatment with groups of patients. He would lead group interviews in the presence of his trainees and ask us afterwards to suggest interpretations of the problems discussed. I was as unsuccessful a student of analysis as I had been a patient. Foulkes complained from time to time of painful stiff neck, which happened rather noticeably whenever I ventured a remark.
A Step Backwards
After just one year at the Maudsley hothouse I was not reappointed. Aubrey Lewis advised me to seek experience in general medicine before pursuing psychiatry further. Disappointed, I took the easier step of securing, in 1952, a non-residential job in London at a small private mental hospital, Northumberland House, where few doctors anxious for promotion in the National Health Service would have thought to apply. The experience was in stark contrast to the high-powered organisation and sanitised atmosphere at Maudsley. The private hospital building, long since demolished, was of eighteenth century vintage and had been a hunting lodge for the Duke of Northumberland. The appearance on first entering was reassuringly respectable, but the dreary wards behind were filled with elderly and mostly dementing patients whose families could afford to keep them out of sight. The doctor who ran the place almost single handed was many years beyond retirement age and he liked to take week ends away at a spa in the north. When interviewing me for the job and asking about previous employment I mentioned the Society for Psychical Research. He exclaimed “Don’t you realise those people are patients!” Of course he meant mental patients.
No great psychiatric skill was required of me at Northumberland House. The main clinical duty was periodic ward visits to read nurses notes and enter something in the files; “no change” being the most frequent comment. An even less onerous task, certifying deaths, was rewarded by a statutory fee for signing the form. The bodies were usually cold and stiff on mortuary slabs before I was called to see them. A fairly frequent visitor to the hospital for the purpose of signing legal certificates was Dr William Sargant, who had rejected my application to his addiction clinic. He tended to come at week ends and stay chatting when the director was away and I was alone on duty. He too had visited Durham in the US, not to see the Parapsychology Laboratory but to witness the activities of a local religious sect who believed their faith gave them immunity from poisonous snakes. He had photographs of them holding snakes and dancing round the coffin of one who had sustained a fatal bite, his faith having been insufficient.
With the help of a senior nurse, a relative of the medical director, a few patients were being given the active physical treatments then in vogue, one of which consisted of administering high doses of insulin to induce coma and convulsions. This was thought to help schizophrenics, but the method was soon to be abandoned when controlled trials conducted at Maudsley showed it had no beneficial effect save that produced by the extra nursing attention given while the patients were recovering from the experience. Electro-convulsive therapy (ECT), the artificial induction of epileptic fits by repeated passing of a current through the head, was also in use at Northumberland House. This is a method of proven benefit, sometimes even life-saving for patients with severe psychotic depression unresponsive to drug treatment. Today, the procedure normally includes a preliminary anesthetising injection and the administration of a paralysing, curare-like agent to suppress the muscular spasms that might otherwise cause patients to injure themselves. At that time ECT was being applied ‘unmodified’ by any injections, and although the patients were rendered unconscious the moment the current was first passed, they had to be held down and their limbs forcibly restrained during the convulsions.
Less spectacular, but more dangerous, was treatment by ‘continuous narcosis’ which involved repeated injections of barbiturates to keep patients asleep for a week or more. On one occasion, when I was left to keep this going over a weekend, the patient unexpectedly stopped breathing and had to be given artificial respiration. He was revived, but during the procedure a young nurse murmured in my ear in a gloating tone: “I think it’s going to be a ‘case’ doctor”. I realised afterwards that my lack of response to her hints of sexual availability was the likely cause of this spiteful outburst. Another incident, a year or two later, again brought home the danger of heterosexual insensitivity. A friendly social worker at the clinic where I was then working telephoned to say she was not feeling well and hinted that I might come round to see her. I did so and found her dressed in a provocative nightgown and in a pose of pretty unmistakeable intent. My facial expression must have indicated consternation rather than pleasant surprise, for immediately she gave me a nasty look and told me I was sick and should not be in my job. Fortunately, the danger of one’s homosexuality disappointing women in this way subsides with increasing age.
The worst experience at Northumberland House, in fact the worst experience in all my life, happened one Sunday when I was at work alone. A middle-aged, mentally subnormal, woman patient, unable to communicate, was suffering persistent vomiting and had not emptied her bowels for some time. I feared intestinal obstruction, but did not appreciate the severity of her condition and imagined that some small leakage from the anus meant my fears were ungrounded. That evening I left the hospital and went ‘cruising’ at Speaker’s Corner in Hyde Park, lingering till a late hour ostensibly listening to the half-crazy orators droning on, and afterwards, not being on duty the following day, returning home. Next day, a call came to return to the hospital. The medical director, returning from a weekend break, had found the patient much worse and arranged her admission to a general hospital, where an obstructed femoral hernia was diagnosed, and where she died under a delayed emergency operation. I was appalled, even more so on finding that her voluminous medical records, which I had looked through too hastily, included a note of a previous observation of femoral hernia. Although knowing about this diagnosis in theory, through inexperience, when examining her I had failed to discover the lump in her upper inner thigh that would have shown immediately what was the matter. Inexperience and haste to get away were no excuse for criminal negligence. The patient’s next of kin was a doctor and no legal or other action was taken, but painful remorse and guilt over this incident has never left me. The circumstances leading to what happened would not be allowed to occur today.
A Change of Scene
I left Northumberland House to take up a less than full time appointment (eleven half day sessions per week) at a National Health Service psychiatric clinic in Hampstead, the Marlborough Day Hospital, known then as a social psychotherapy centre. The unit was being run by a charismatic director, Dr Joshua Bierer, an early pioneer of group therapy and supporter of the closure of large mental hospitals and treatment in the community. He was a follower of the Adlerian school of psychotherapy that acknowledges the importance of contemporary social pressures in the genesis of neurotic disorders, in contrast to the exclusive preoccupation with past trauma characteristic of the traditional Freudians. Bierer was thought by some people to be too fond of publicity. As Editor of the International Journal of Social Psychiatry, he was ready to accept papers without too much in the way of peer reviewing. A number of contributions from me were accepted over the years. Bierer liked to encourage celebrity visitors to the clinic, among them Yehudi Menuhin. Homosexuality was in the news, following the scandal about Lord Montague’s gay parties and the imprisonment of Peter Wildeblood and other guests. The subsequent setting up of the Wolfenden Committee to review the law aroused Bierer’s interest. Wildeblood had published a book about his imprisonment (Against the Law), and was asked to talk to the clinic staff. As a result we became friends and Peter introduced me to his elderly parents who were living quietly in the country. I realised then what a shock to relatives such publicity could cause and how lasting the effects could be in those censorious days. Many years later Peter was working on films for TV and was invited to the United States, but was refused entry. He asked me to write a medical t
estimonial, which I did, emphasising that he was no threat to anyone. That was of no avail at the time, although they did relent years later.
Among other newsworthy visitors Bierer attracted were the American criminologists Sheldon and Eleanor Glueck, experts in predicting the criminal careers of juvenile delinquents, and on psychological theories about predisposition to crime. Little did I realise at the time that I was destined to mount similar research in England and ultimately to contribute a history of the Glueck works to an Encyclopaedia of Theoretical Criminology.
The emphasis at the Marlborough Clinic was on talking therapies more than medication. The patients were mostly chronic neurotics or mild depressives. A few were partially recovered schizophrenics, but active psychotics requiring hospitalisation were not admitted, so the atmosphere was comparatively relaxed and the routine easy-going. The psychotherapy, practiced both individually and in groups, involved listening without premature interpretation, and was more like counselling than exploration of the ‘unconscious’. With a few patients, relaxation and talkativeness were induced with slow injections of methedrine, or small doses of LSD, which was then available for medical purposes. I felt that some of the patients, notably those who had had long periods of psychoanalysis, experienced little alleviation of their dissatisfaction with life, but got pleasure from endless recitals, couched in psycho-babble jargon, of what they conceived to be their problems. One memorable patient, an elderly vicar, supposedly contentedly married for many years, professed concern about homosexual incidents when he was young. He dwelt so unremittingly upon these stories I felt sure he was using the sessions to indulge in forbidden but pleasurable fantasy.