Psychiatric Epiphany Part 3: The winter of discontent

Having decided to become a psychiatrist, I watched the autumn of 1978 fade into the notorious Winter of Discontent, the prelude to Margaret Thatcher’s first election victory. Leaving aside public sector strikes and severe cold weather, rather a lot of significant events in my life happened in the last three months of 1978. My long association with Dr Aggrey Burke began, my girl-friend and I got married slightly by accident, and there was a soft fruit incident in our flat. My grandfather died suddenly, so there was a funeral too.

I will start with the most dramatic of these events, the soft fruit incident. In the late 1970s, home-brewing and wine-making were popular amongst impecunious students. I had some success with elderberry wine, meaning that the resultant drink was strong and not completely unpalatable, although it bore little resemblance to a wine that a French person would be prepared to drink. My girl-friend’s parents said they would support my efforts by picking some blackberries for me. Neither of them could drive, so they took a train out to the Kentish countryside and filled an enormous Tupperware container with ripe dark red berries. They presented them to me on a Sunday. I did not get around to doing anything with them until the following Saturday, when I was at a loose end because my girlfriend was at work. When I finally opened the lid, the blackberries were a bit mouldy. I was horrified. I could not bring myself to throw them away, because my future parents-in-law had put so much effort into picking them for me.

As you will see, the unfortunate soft fruit incident illustrates how my efforts to apply scientific thought to everyday problems can lead me into serious error. From early childhood, I have been told that my clumsiness and profound lack of practical skills are offset by alleged intelligence. In fact, some faults, such as poor handwriting and talking too much, were rationalised by sympathetic teachers as the consequences of excess, or possibly toxic levels, of intelligence. Eventually you just have to accept that convoluted explanations cannot convincingly reframe stupidity as surplus cleverness. Sometimes stupid is just stupid.

I had a rich source of fruit juice and I had mould, and they could not be separated. The best idea, I thought, would be to autoclave the fruit, which would sterilise it, kill the mould and, in all probability, inactivate any toxins. Luckily (or possibly not) we possessed an old-fashioned pressure cooker. I crammed the blackberries in, filling the pressure cooker to the brim. I crushed the berries so that they sat in their own juice. Just to be on the safe side, I added sugar, which would be necessary later in the wine-making process. I calculated that by adding the sugar at this stage, I would raise the temperature of the pressurised fluid to about 122 degrees Celsius, ensuring a really thorough sterilisation. I put the pressure cooker on the hob, and went to the living room to read a book.

Photograph of a pressure cooker

It was probably 45 minutes later that I realised that I had not heard the pressure cooker hissing. The onset of loud hissing meant that the internal pressure was sufficient to raise the valve weights (see image), and indicated that the heat should be reduced. On investigating, I found that there was no steam escaping from the main valve, but the tiny safety valve was wide open. At this stage, I remembered that the pressure cooker was not meant to be filled more than three quarters full. In a moment of horrible insight, I realised that I had over filled it and that skins and seeds had choked the main valve. I had a bomb on my cooker and it might explode at any moment. This light bulb moment was followed by some panicky reasoning that was not so much wrong as not properly thought-through. If the pressure was dangerously high, the best thing would be to reduce it as quickly as possible. This could be achieved by removing the weights from the valve.

The procedure was successful up to a point. As soon as the weights were removed, the inactive unexploded bomb became a very active geyser. A column of very hot blackberry and sugar mixture hit the ceiling with so much force that it dislodged some plaster. It gushed loudly for two interminable minutes, forming a sweet aerosol that settled on every surface. It was Hendrix’s Purple Haze made real. The cooker was purple, the floor was purple, ceiling was purple and so was I. All I could do was to ring Steve and Eileen’s door bell, so that they could come down and see what I had done. They laughed quite a lot, and they were definitely laughing at me, not with me. Ever loyal friends, they helped clear up the worst of the mess. The kitchen ceiling bore a very noticeable deep purple stain until the day we moved out.

Photograph of the front of Atkinson-Morley Hospital

Atkinson Morley Hospital (AMH) in Copse Hill, Wimbledon was opened as the convalescent hospital for St George’s in 1869. From the Second World War until its closure in 2003, it was devoted to neurology, neurosurgery and psychiatry. The AMH Professorial Psychiatric Inpatient Unit was, in retrospect, a curious place. The dominant treatment approach was psychotherapeutic, but medication was also used. There was a small number of patients being assessed for, or recovering from, a form of psychosurgery. They participated in the psychotherapeutic activities alongside all of the other patients and staff. The unit was run as a sort of an attenuated therapeutic community.  The idea was that staff and patients lived and worked together in a flattened hierarchy, with lots of opportunity to interact and reflect about what went on in groups. Therapeutic communities certainly had powerful effects, but, as I learned later in my career, these were not automatically therapeutic. I saw that it could have a life-changing positive effect for some people, but damaging effects where insufficient attention was paid to the management of destructive group dynamics.

Each day started with a community meeting of the patients and staff, followed by a staff group to discuss what had happened in the community meeting. After this there were small groups, which were followed by further staff debriefs. There was group supervision, which was conducted by psychoanalytical psychotherapists. Some groups were conducted in front of a two-way mirror, with staff observing. For a medical student, it was all rather intense and exciting.  The overflowing ashtray could have been adopted as the international symbol of therapeutic communities, as cigarettes and strong coffee were constantly consumed by patients and staff alike.

Aggrey Burke was in his mid-thirties when I first met him. He had been Senior Lecturer in Psychiatry at St George’s for two years, having trained in Birmingham. There were two of us attached to his team, me and Dagmar. I got on well with Dagmar. She was altogether quieter and less flamboyant than me, but she was bright and fun to be with. Aggrey was an enthusiastic teacher, who taught us both the basic stuff that we needed to learn to pass our exams and more interesting ideas about the reasons why people behaved as they did. He was a highly skilled psychiatric interviewer. He could get people to talk freely about difficult parts of their lives and he recognised that Dagmar was someone who had similar abilities, albeit much more quietly expressed.

Aggrey got us involved in psychotherapy with patients. He involved me in family sessions with a patient in their own home. He was good at making people feel that their opinions were taken seriously, and he made space for you to contribute without jumping in to exercise his own expertise. It was an engaging and effective way of teaching. His team tended to turbulent and intense discussion, which he encouraged rather than suppressed. The clinical psychologist in the team, Juliet Greenup, was a woman with interesting and forcefully expressed ideas, and she exerted a strong influence . I loved this environment, seething with ideas, debate and controversy. I was completely hooked and I still bear the mark of those formative experiences . I returned to work with Aggrey as a psychiatric trainee four years later.

When I was a student, I asked Aggrey what he did to relax. “Independent cinema, free jazz and walks in the country” he told me. In the currency of AMH at the time, these were typically schizoid-obsessional interests, and we discussed that. He recommended the film “Girlfriends” to me, and I went and saw it in a cinema in Soho. It was a box office flop at the time, but it is now regarded as a classic, a low budget film directed by a woman about a friendship between two young women. When Aggrey gave me a lift, I looked at the music cassettes in his car.  They were contemporary jazz, Art Blakey and Miles Davis. When I worked with him four years later, the cassette in his car was the radical roots reggae of Burning Spear. In between, Aggrey had become heavily involved in supporting the families of the victims of the New Cross fire.

Aggrey’s patients were not predominantly people with primary diagnoses of personality disorder. Instead, they had a broad range of problems that had not proven amenable to standard approaches to treatment elsewhere. Understanding how personalities work was central to his approach. The mixture of patients at AMH created interesting challenges for psychotherapy. Professor Arthur Crisp was one of the world’s leading authorities on eating disorders, so there was a significant group of seriously underweight young women who were treated in a very specific regime that included group and individual psychotherapy, but also involved a behavioural refeeding programme. Then there were the psychosurgery patients. The people I met while I was there had severe and intractable obsessive-compulsive disorder that was very incapacitating. From what I saw, they did not experience the kind of outcome of psychosurgery depicted in One Flew Over The Cuckoo’s Nest. In that film, McMurphy, played by Jack Nicholson, changes from a troublesome free spirit into someone who is blank to the point of being decerebrated. In contrast, in the very small sample of people I met at AMH, the effects were hardly noticeable. What was striking was that they seemed unchanged for good or ill. Psychosurgery ended at St George’s before I started training in psychiatry there.

The different needs of the various patient groups in the AMH therapeutic milieu was a rich source of conflict between the consultants, and this was evident even to the students. I was associated with AMH between 1978 and 1985, and during the whole of that time, Aggrey and Arthur were locked in polite conflict, with Arthur tangentially sniping at Aggrey in staff meetings. In his prime, Arthur was probably the most powerful psychiatrist in British medicine, but he never managed to prevail over Aggrey. Amazingly, I managed to have cordial and enduring relationships with both of them, which was some feat. In contrast, when Tom Burns said something too left wing and displeased Arthur, he was sent into exile for several years. He was later rehabilitated and returned, which is how autocracies often work.


The Socialist Party of Great Britain logo

I was always close to my paternal grandfather, Arthur Poole, artisan plumber, trade union activist and autodidact left-wing intellectual. By 1978, he was becoming frail. He had recently survived a mysterious episode of acute pancreatitis. The doctors could not explain what had caused it. While he was still in hospital, I asked him what he had told the doctors about his drinking. As I suspected, he had admitted to an occasional pint, and, no doubt misled by his advanced age, they had accepted this. I knew that he went to the Bull public house in Silver Street, Edmonton, every lunch time on his way back from the betting shop. A corner of the public bar was his private domain where he engaged all comers in political debate, mainly concerning the inevitable collapse of capitalism in accordance with the indestructible logic of dialectical materialism. I asked him what had happened the day before he had developed abdominal pain. It turned out that he had got into a prolonged lunchtime discussion with some Irish blokes, who had bought him six pints of Guinness. He was quite certain that this had nothing to do with the subsequent pancreatitis. He was in his mid-80s.

It was obvious that my grandfather was not going to go on forever. My girlfriend and I had been together more or less continuously for five years and we seemed committed to the relationship; we jointly owned quite a lot of good quality kitchen utensils. I really wanted my grandfather to be present when I got married. One evening, beneath the purple stain in the kitchen, I said “Shall we get married so that my grandfather can be there?”. “Yeah, ok” she said. Later that week, dizzied by this vortex of romance, she booked the earliest available slot at our local registry office. We were to be married at 10 o’clock on a December morning in Woolwich, just across the road from the Director General, the fine old Victorian pub where the relationship had started in 1973.

Photograph of the Director General pub

We visited my grandparents in Edmonton to share the news. I had the distinct impression that my grandfather was a bit disappointed that we were doing something so conventional. We discussed the ethics of the Fireman’s Strike, which had just been announced. “At the end of the day,” he said “the only weapon the workers have is to withdraw their labour. You have to be prepared to use it or they’ll walk all over you.” A few days later, he went back to bed after breakfast, complaining to my grandmother that he felt a bit ill. About 15 minutes later, he called out to her. By the time she got to the bedroom, he was dead. At post mortem, he had a ruptured aortic aneurysm, just like the Chelsea Pensioner I had assessed a year earlier. It is likely that he would have regarded this as a highly satisfactory way to die, but it was a terrible experience for my poor grandmother. His death removed the main rationale for getting married at that particular time, but it would have been a lot hassle to cancel. This was how we came to marry more or less by accident. It would have happened sooner or later in any case, but probably not for a few years.

The funeral was a rather splendid affair. There was no religious element whatsoever. Various people spoke about my grandfather, including Cyril May, an old comrade from the Socialist Party of Great Britain. We all sang the Internationale and then we went back to the house for a few beers. It was a funeral dominated by laughter. My apostate Conservative-voting aunt from the posher part of the family said that it was great that I was going to continue to carry the red flag for the family from now on, which was strangely touching.  It was unusual to be able to say in all sincerity that a working class man, who had been born into an itinerant rural family, had led his life entirely on his own terms. I still miss our long games of Cribbage, which frequently ended with mutual accusations of cheating.