Clinical Work in the Public Service

The NHS had been actively adopting the new public management throughout the 1990s. Although I had been drawn into this a bit at St Bernards, I applied and got a post as a Director of a sizeable unit. This was the Cassel Hospital, arguable the first therapeutic community in the British psychiatric services – or at least developed in the 1940s by Tom Main who first employed the term ‘therapeutic community’, in 1946. So, in 1993, moving a step away from direct clinical work in the public service, it seemed perhaps a bit like a swan song. There I immersed myself in the management culture and sought to explore the possibilities of using the experience, and the methods in the more human, democratised therapeutic community for the benefit of the new NHS culture. I was at first greatly assisted by the Chief Executive of the Trust, Chris Higinbotham, although when he left in 1995, I found the culture increasingly inclement, and ultimately felt my foray into management a failure.

1993 Locked in role.
Journal of Forensic Psychiatry 4 427-440.
In the 1970s, I worked as a psychotherapist in Wormwood Scrubbs prison when there was a considerable psychological input to prisoners treatment and rehabilitation. I left after a couple of years with the sense that psychotherapy was not going to make much headway against the culture of the prison, which was based on evasion of the emotions of guilt and helplessness – by both staff as well as prisoners. It took some considerable time to write up and publish a view on how the culture developed and was rigidly maintained. A schism between toughness and weakness seemed to play out a defensiveness at the social level.

1994 The relevance of psychotherapy.
Psycho-Analytic Psychotherapy 8 283-294
Like the previous paper on prisons, I became interested in the culture of psychiatric services and units. This too was rigid and appeared to be schismatic – in this case a schism between an emotionally distanced scientific attitude, and a sentimentalised empathy represented by the biological psychiatrists and the therapeutically oriented staff.

1994 Integrity of the person and the day hospital: evidence from a therapeutic community.
International Journal of Therapeutic Communities 15 29-38. Italian translation, Il Day Hospital e la figura genitriale combinata.  Il vaso di Pandora 2
I returned here to reflect on the possibilities of a day therapeutic relation of personality disordered people in a therapeutic community. There is a sense in which there is a potential Oedipal relationship of each individual to the institution which is in itself structured with other people and groups. The relations between multiple others offer the possibilities of working with the sense of exclusion – replicating Oedipal exclusion from the parental couple. In a day hospital that Oedipal configuration comes and goes, and gives a variety of experiences of exclusion and entry, constantly moving.

1996 (with Kingsley Norton) Severe personality disorder: treatment issues and selection for in:patient psychotherapy.
British Journal of Psychiatry 168 723-731. Republished 2009, in Adshead, Gwen and Jacob, Caroline Personality
This was one of the collaborative ventures between the Cassel and Henderson Hospitals; I and Kingsley were Clinical Directors of each. The paper intended to present to a psychiatric readership the possibilities of a social therapeutic approach to the behavioural and relational disturbances of personality disorders.

1996 Communities and their health
Therapeutic Communities 17 173-182.
This was an invited lecture that attempted to spell out an overview of therapeutic community dynamics that need following, as the various players manoeuvre in the social space to easy their discontents, or to work through them.

1996 Psychiatry and psychotherapy.
Psychoanalytic Psychotherapy 10 Supplement 5-10.
This follows on the 1994 paper above on the culture(s) of the psychiatric services which exist in a more or less permanent schismatic state. I attempted to give circumstantial evidence from my experience in the past – particularly from St Bernard’s Hospital – of these two cultures, and how they supported each other, whilst undermining each others’ efforts.