2003: Introduction (to two papers by Richard Crocket)

Craig Fees, “Introduction”, THERAPEUTIC COMMUNITIES 24:3 (2003), pp. 227-231

 

Introduction to two archive articles by Richard Crocket, “Notes on the architectural requirements of the therapeutic community approach to psychiatry in district general hospitals” (1972) and “Therapeutic community adaptation of standard plans for district general hospital psychiatric wards” (1973)

 

 

Richard Crocket (now retired) was Consultant in charge of the Ingrebourne Centre in Hornchurch, Essex, from 1954-1979. He saw an acute general hospital psychiatric unit evolve into a dynamic psychotherapeutic community and contributed much to the early phases of the therapeutic community movement.

Richard Crocket (b.1914) is probably best known in current therapeutic community circles as the founding Director of the Ingrebourne Centre, and, as he was preparing to retire some twenty years later, as the psychiatrist appointed to take the helm of the Paddington Day Hospital from 1977-1979 during the second (and final) Inquiry there. It is less well-known that he turned down the opportunity of becoming Director of the Henderson Hospital when Maxwell Jones left for America (“I was interested in tactics, methods, and individuals, groups, but not the person who went overboard in psychopathy, delinquency, that sort of thing. I think now it was a mistake.”).

A member of the post-war wave of psychiatric innovators, he came to therapeutic community in his own individual way, and having discovered others working similarly, entered energetically into the intellectual and practical maelstrom around it, becoming an active member of the Therapeutic Community Round Table and its successor, the Association of Therapeutic Communities. He stands out among that very powerful group of early figures for his intense academic concern for developing the theory underlying the practice of therapeutic community, and for putting that theory on a rigorously scientific footing.

Richard Crocket was born in Scotland into an engaged, mobile and enquiring family. His mother had been a teacher, his father a medical missionary to China before returning to Scotland to become Medical Superintendent of William Quarrier’s Orphan Homes of Scotland, a largely self-contained cottage-based village of about twelve hundred children at Bridge of Weir, south of Glasgow. They lived here until Richard was fifteen, when his father, having also worked in Quarrier’s adjacent sanatorium, was appointed lecturer in tuberculosis at the University of Glasgow. The family left the “cheery kind of country house existence” (where “we didn’t mix with the children in the Homes … who were to be pitied, to whom we were superior in some way”) and moved to Glasgow, where Richard attended the High School. He passed the university examinations at sixteen but, considered too young to begin university, continued his studies at Monkton Combe in Somerset for four terms before returning to Glasgow to take up medicine, where he was licensed to practice in 1937. Because of his special interest in mental illness and psychology, having done his first house job in surgery, he was invited to do his second as assistant physician at Glasgow Royal Mental Hospital (until 1931 Glasgow Royal Lunatic Asylum; from 1963 Gartnavel Royal Hospital) where he started his Diploma in Psychological Medicine. Characteristically, he chose to pursue the more academic London University Diploma stream rather than the more practical Maudsley Hospital Diploma.

His time at Gartnavel was formative. His colleagues there (where there was a “nest of analysts, or proto-analysts … My subjectivity came home to roost”) included Jock Sutherland, Henry Ezriel and Susan Davidson, as well as Ferguson Rodger, who later became Professor of Psychiatry in Glasgow, and both supported Maxwell Jones at Dingleton and introduced R.D. Laing to Sutherland at the Tavistock. During his stay he passed the examinations for the London Diploma in Psychological Medicine just as war broke out in 1939, cutting off the traditional Glasgow/Edinburgh year at Johns Hopkins University with Adolf Meyer in Maryland. Instead he sat the examination for Fellowship of the Faculty of Physicians and Surgeons of Glasgow, with Mental Illness as his special subject, and in the spring of 1940 went south to Swaylands in Kent, as locum psychotherapist at the Cassel Hospital in its original home.

CF What was that like?

RC It was a revelation to me. I’d done a certain amount of psychotherapy in training, and also child psychiatry. T.H. Rogerson was the Superintendent, and there were three assistant medical officers, psychotherapists, and we were all dynamic in orientation. It was a private place, well fitted out, comfortable country house atmosphere. We each had our list of patients, normally about twenty each, or fifteen or sixteen, down to about eight, seven or eight each because of the war. I conscientiously made my patients lie on a couch and listened to them, and tried to understand what was going on. But it was disturbed by the war: In 1940 the Battle of Britain began, and there were constant dogfights overhead, and there we would be sitting or lying in this comfortable country house hospital in Kent, with aircraft above circling, shooting each other down, people floating down on parachutes, sometimes bullets hitting the earth a few yards from where you were sitting in a deckchair having afternoon tea.

Bizarre, but that’s how it was. And then came Dunkirk, and one of my patients disappeared, came back three days later. He had been to Dunkirk, with the boat he owned, a sailing boat with an engine, gone across the Channel backwards and forwards, and he was away three days, came back, lay down on the couch, didn’t say a word about it. Of course we had a stick of bombs across the hospital, never actually hit any of the buildings, but there was a series of craters. This stick of bombs persuaded the governors of the committee managing the hospital to move, and it was closed down and they went to Derby.

This brought his appointment to an end and he then, from the beginning of 1941, spent a varied six years in the Royal Air Force, publishing his first professional paper (“Observations on the Incidence of Neuroses in R.A.F. Ground Personnel”, Glasgow Medical Journal, 1945), working with R.D. Gillespie, co-author with D.K. Henderson of A Textbook of Psychiatry, and eventually being demobbed from Germany where he’d spent a year with the Disarmament Wing. He went to practice psychiatry at St. Andrew’s Hospital – “academically a very sound place … the most distinguished of the private hospitals, not in the NHS … But it was very hierarchical and … I didn’t really care for the directive way things were done”, so got in touch with D.K. Henderson and spent a post-graduate year at Edinburgh’s Morningside Hospital (the Royal Edinburgh Hospital for Mental and Nervous Disorders, Morningside), before successfully taking the Edinburgh exam for membership of the Royal Medical Psychological Association. He continued for a further year in the hospital doing clinical work under D.K. Henderson before moving to the University of Leeds where, from 1950-1954, he was tutor in psychiatry.

Then came the series of steps which drew him directly into therapeutic community, beginning with his appointment as consultant in charge of a psychiatric unit located within St. George’s District General Hospital at Hornchurch, in Essex, previously an outpost of Warley Hospital, the local mental hospital some ten miles away. Crocket describes himself at the time as a “very traditional and proper kind of figure … orthodox, oriented towards getting through exams and giving value to people who did; academic in a kind of detached, intellectual way.” He did have “an interest in groups and social psychiatry”, but the shift from one-to-one to group therapy within the unit came with his appointment of an SHMO, Hamish Anderson, who had been working with Dr. George Macdonald Bell, Maxwell Jones’s predecessor at Dingleton Hospital in Scotland; Bell having pioneered, of course, the fully open door mental hospital, and laid the liberalising groundwork upon which Maxwell Jones built.

Anderson introduced a programme of group work which, with some trial and error, was “dramatically successful in changing the outlook of staff, the outlook of patients, and the atmosphere in the place”. It wasn’t, however, what Crocket had been hired to do, and having already changed the name of the unit from “Ward G3” to “The Ingrebourne Centre for Psychological Medicine” without consulting the parent hospital or the wider administrative hierarchy (“Ingrebourne” for the name of the river flowing through the hospital; “Centre” because “I had this kind of Jungian picture, I suppose, of a centre with ramifications amongst general practitioners and hospitals, and functioning as an exchange rather like the telephone exchange”), Crocket found himself “being quizzed by the Regional Medical Officer, and Regional Psychiatrist, and I was also having to validate what I was doing with Warley [Hospital] and Sir Geoff Nightingale, who was the Superintendent there.”

While defending the developments and protecting Anderson’s work, Crocket himself initially held back from direct participation. But one morning “I found one of the patients with a motor bike dismantled on the corridor – in the corridor outside his bedroom, oily rags around, nuts and bolts lying loose.” The Matron was a traditionalist, used to running the ward as a general hospital ward, where “cleanliness was an absolute” and the “floor shone with polish.” “I had to decide what to do about it. So I walked past it, said, `Good morning,’ and said nothing. Just left it. And then began to take part in the groups. … I was a convert to Hamish Anderson’s groups.”

Crocket then “began to develop theories and ideas about what we were doing” publishing his first reflective paper (“Doctors, Administrators, and Therapeutic Community”) in The Lancet in 1960 (he had read a paper on “Initiation of the Therapeutic Community Approach to Treatment in a Neurosis Centre” at Runwell Hospital in 1957, and delivered another on “The Therapeutic Community Approach to Neurosis” at the First Czechoslovakian Psychiatric Conference in Prague in 1959). Although aware of Maxwell Jones, and aware “that we must be doing things similar to what he had been doing”, he emphasizes that the dynamics of the Ingrebourne’s development “came from within our own groups, our own contacts with GPs, with consultants and so on.” Underpinned by his personal interest in interpretive group therapy, the Centre evolved in its own way from an active acute general psychiatric unit “taking people who’d attempted suicide, schizophrenic patients, drug addicts and so on, treating them with drugs and E.C.T.” to a “much more interpretive and permissive, and group orientated” psychotherapeutic community.

*

Given the depth and intensity of the thinking he has put into the field, Richard Crocket has published surprisingly little. Much of his output, like the papers presented here – and there are a significant number of typescript and manuscript papers among his material in the Archive and Study Centre, much of it heavily annotated – remain unpublished or published ephemerally, as in the ATC Newsletter. Indeed, his major anvil is an unpublished book, begun in the 1990s in association with David Millard, which attempts to capture and hand over the experience, thinking and research won through his work at the Ingrebourne and in forty years of vigorous engagement in the field, the working title of which is “The Theory of the Therapeutic Community. An Approach to Structural Psychiatry and the Use of Intensive Treatment Networks in Psychiatry. An Essay in Space, Time, Love and Hate.

The first paper published here – “Notes on the Architectural Requirements of the Therapeutic Community Approach to Psychiatry in District General Hospitals” – was prepared by Richard Crocket in 1972 as a memo to the Department of Health and Social Security in response to proposals to build a series of new psychiatric units within General District Hospitals according to a set of Standard Architectural Plans. In the event, by the date of the memo the plans were already too far advanced to be influenced, and the second paper, “Therapeutic Community Adaptation of Standard Plans….” from 1973 was an attempt to see what could be salvaged.

Lending subtext to the vigorous tone of the second memo is the fact that Crocket had already publicly broached the subject almost a year earlier, in a detailed letter published on December 18th, 1971, in The Lancet, and that his had been followed by supporting letters in The Lancet from no less than G.M. Carstairs and H.J. Walton of Edinburgh University on January 15th, from J.K.W. Morrice of the Ross Clinic in Aberdeen and from Heinz Wolff of University College Hospital, London, on January 29th, and from Bernard Heine of Runwell Hospital on February 5th. In Morrice’s letter, he evinces “as much surprise as agreement …”

“Surprise that in the N.H.S. of the ’70s we still need to plead for close collaboration between planners and clinicians … In a specialty in which the rate of change is steadily accelerating it is important to look well ahead, to build flexible units, and to match structure with function as far as all this is humanly possible. Are there really hospital authorities and architects unaware of such needs?”

Apparently there were, but the arguments became academic when the new building programme was largely abandoned, and the documents published here became, effectively, historic. Did they have an effect, either on architectural or government thinking? Was there an effect or influence among therapeutic community practitioners?