Winship, G; Repper, J; Bray, J & Hinshelwood, R D(2009) Collective biography and the legacy of Hildegard Peplau, Annie Altschul & Eileen Skellern; the origins of mental health nursing and its relevance to the current crisis in psychiatry. Journal of Research in Nursing, 14, 6: 505-517.
Aim: To examine to the influence of the work of Hildegard Peplau, Annie Altschul and Eileen Skellern and consider if and how their legacy impacts on the current trajectory of mental health nursing and the role of the nurse as active therapeutic agent.
Background: The current review of mental health nursing and the 'crisis' in psychiatric milieus. Peplau, Altschul and Skellern were arguably the three most influential figures in the foundations of the modern psychiatric nursing in the UK who developed a core idea about the mental health nurse an active therapeutic agent.
Method: Oral history and collective biographical research gathering previously unpublished material directly from Altschul, Peplau and new commentaries on Eileen Skellern from colleagues. Data triangulated with previously published accounts.
Findings: It is noted that Peplau and Altschul were simultaneously working with innovative methods of community based therapy during the Second World War in England with shell shocked soldiers and that both derived their founding ideologies from psychoanalysis and the therapeutic community practice. With Skellern, likewise, we see the centrality of psychoanalysis and the therapeutic community method also played in her work.
Conclusion: It is argued that therapeutic agency and patient advocacy percolate through the thinking of these nursing leaders, and that these are ideas remain relevant to the agenda for social inclusion and user-involvement in mental health nursing today. Their ideas about therapeutic agency remain extant. In considering the collective history of ideas in MHN it is possible to further clarify the prospects of progress and change in the profession.
The current major review of mental health nursing in the United Kingdom announced by the Chief Nursing Officer prompts us to reflect on the trajectory of psychiatric nursing. In re-considering the legacy of three of psychiatric nursing's foremost leaders, our aim here is seek out those ideas which might be of relevance to the future of the mental health nursing profession. The ideological links between Peplau, Altschul & Skellern allow us access to a collective historical consciousness at a time of great change and excitement in international mental health and enable us to trace an established core value of mental health nursing practice that aggregates under the rubric of active and therapeutic interpersonal engagement of patients.
This review is prompted, in part at least, by a concern that the aspirations of therapeutic agency in mental health nursing have been dampened and undermined by a loss of direction in regard to underpinning frames of practice. Developments in health promotion, nurse prescribing and behavioural approaches, while representing avenues of progress for mental health nursing, might have served to de-emphasise the value of interpersonal skills in practice. Indeed, we have lately been alerted to a crisis in some branches of mental health nursing practice. For instance the report Acute Care (SCMH2004) noted the severe absence of therapeutic engagement of patients on psychiatric in-patient ward and highlighted that milieus were characterised by increased levels of boredom and inactivity among patients, leading to frustration, violence and chronic low morale among nurses (Rask & Lavender, 2002; Bennett Inquiry, 2003). The NICE guidelines (2005) for the management of acutely disturbed patients concluded that there was little evidence of any credible advances in milieu research that could identify the characteristics of the human and physical environment that might have an effect in mitigating or preventing the manifestation of violence.
It is therefore with reference to the debate today about therapeutic environments that we gather together historical accounts of the careers of Peplau, Althschul and Skellern exploring the circumstances where their interests intersected with similar matters of concern; how to transform a non-therapeutic custodial environment into a suitably inclined therapeutic milieu. The point of undertaking such a review is to see what we might learn from them, to put it baldly, we study the past in order to be better informed about the future. For the purposes of the research Altschul and Peplau (who were alive at the outset) supplied source information. Both were informed of the nature of the research and both iterated what information could and could not be published at present. Peplau provided three written accounts (28th March 1998; 3rd June, 1998; 4th June 1998) and Altschul two accounts (face to face interview 1997; written account October 19th 1998). Though Skellern died in 1980, new material has been gathered and collated from Skellern's colleagues at the Maudsley; David Russell, Beatrice Stevens, Brian Woollatt and Harry Wright. The written accounts herein have maintained some of the immediacy of an interview insofar as the correspondences were prompted by questions posed by an interviewer in response to previous correspondence and conversations with an interviewee. The methods used to generate data were therefore a combination of documentary and interview procedure situated under the umbrella of 'oral history' (Thompson, 1988; Seldon & Pappworth, 1983). Oral history can be viewed as a tool for "discovering, exploring and evaluating the nature of the process of historical memory, how people make sense of their past, how they connect individual experience and it's social context, how the past becomes part of the present, and how people use it to interpret their lives and the world around them" (Perks & Thomson, 1998: p2).
The new biographical data was contextualised and triangulated with other available historical accounts (Clarke, 1999; Sills, 1999; Gregg, 1999; Lee Spray, 1999; Barker & Peplau, 1993; Bethlem & Maudsley Gazette Editorial on Eileen Skellern, 1972; special edition of the Journal of Psychiatric & Mental Health Nursing, 1999 Volume 6: 261-337; Wright, 1996, Callaway, 2002). The summation of the data gathering is presented here as a collective biography. The collective approach (the concurrent gathering of information) has enabled us to cluster data around a particular set of ideas in relation to interpersonal therapy, psychoanalysis and therapeutic community practice. Rather than arriving at presentation of individual profiles we have been able to note themes of intellectual continuity and shared interest that might be said to have been lodged in the substrate of the profession of mental health nursing. We have rendered the data here with due regard to some contemporary issues in a mental health nursing, though our discussion is briefer than the material might merit. We hope however, that the data will be of value to others and might contribute to more extended commentaries on the past, present and future of mental health nursing.
In the 1930s Chestnut Lodge in the USA established its reputation as a 'psychoanalytic hospital' with a progressive and radical treatment regime (Bullard, 1940). The psychoanalyst and psychiatrist Harry Stack Sullivan's innovative work in the 1920s using a modified psychoanalytic treatment with schizophrenics at the Shephard and Enoch Pratt hospital in Maryland, 'the first therapeutic community experiment' as Clark (1964) called it, had already been influential on the development of Chestnut Lodge. The term 'therapeutic community' was used by Sullivan in the 1930s, but he used it to talk of the general world of therapists, who could be said to form a community of professionals or sub-culture within psychiatry, rather than in the sense of a specific model of practice as it became known in the UK from the 1940s. Chestnut Lodge, although not a therapeutic community per se, did establish patient committees, social and work activities alongside the more formal practice of psychotherapy in way that anticipated the development of formal therapeutic community methods later. It was in the progressive climate of Chestnut Lodge in the 1930s that Hildegard Peplau began her career. She recalled her time there and the areas of theory she learned concurrently:
"I received weekly supervision from Dexter Bullard at Chestnut Lodge and he kept me supplied with reading materials which I was to discuss with him (Peplau, letter: 28th March, 1998). I learned so much there (Chestnut Lodge) by reading, observing, seminars and lectures. The orientation of Chestnut Lodge was Sullivanian. However, I also studied Freud, Horney Adler etc at Bennington College under a psychoanalyst Dr J C and Dr Eric Fromm. I studied Klein too. (Peplau, letter 4th June 1998).
Peplau's lectures with Eric Fromm persuaded her that it was possible to link psychoanalysis with sociology and political science and it was his influence that steered Peplau towards social science rather than natural science (Callaway, 2002). Fromm noted Peplau's presence at his seminars and he would later describe her contribution as 'outstanding' (ibid, p88). This psychoanalytic groundwork was augmented at Chestnut Lodge where Peplau attended evening seminars with Harry Stack Sullivan; "these lectures were held at Bethesda Golf & Country Club with those in attendance sitting around the fire. Sullivan sat in a comfortable chair next to the fire, with the Bullards' Great Dane at his feet. In this comfortable and informal setting, Sullivan began to pull together his life work and cumulative observations. Hilda sat behind everyone else, listening but never speaking" (Callaway, 2002; p82).
But it was with Eric Fromm's ex-wife, Frieda Fromm-Reichman, that Peplau sealed her early learning. Peplau (letter, 28th March 1998) attended Fromm-Reichman's lectures on dreams, myths and symbols, among other topics and later Peplau lunched with her every Wednesday in her apartment where they talked about clinical work:
"Frieda was considered an Avant-garde humanistic therapist. But as I know, she wasn't perfect. 'The devil is in the details'. Schizophrenics with whom Frieda worked were very sensitive, highly perceptive and forever observant for the smallest of cues that others don't have their best interests at heart. One time Frieda stopped me in front of the iron gates of a room of one her patients to say that our lunch that week had to be changed to Thursday. The patient heard this then lured naïve me (1935 my first in-patient work on a disturbed ward) into her room to show me something. Trusting soul, that I was, went in and soon got out in a hurry when the patient cornered me and tried to harm me. Live and learn! I did. The patient was jealous about Frieda's comment. And Frieda was oblivious to her action". (Peplau, letter 28th March 1998)
There was a further occasion where Peplau was again alerted to Fromm-Reichman's rather cavalier methods:
"Another patient, a 16-17 year old boy was one I took out for walks - then once with Frieda's permission, I took out for a drive in my car. Several times as I was driving he tried to kiss me on the mouth, then later told me Frieda urged him to do that as he'd never before kissed a girl. No more car rides!". (Peplau, letter June 3rd, 1998)
We might say that Peplau was exposed to the contemporary inclination to collapse the distance between therapist and patient. The influence of Freud was such that the interpersonal relationship between patient and analyst had become subject to deep interest, where the potential for cure of the patient's illness was presumed to lie in the dynamics of the therapist-patient relationship. Fromm-Reichman appears to have stretched this therapeutic axiom. However, while Peplau had been rudely awakened to the moral limits of prescribed enactment in the drama of therapy, she began to shape her own interpersonal theory in practice graduating from Bennington College in 1943 with a BA in Interpersonal Psychology.
Peplau put into practice what she had learned at Chestnut Lodge between 1943-1944 when she was stationed at the 312th Military hospital in Stafford, England. The shell-shocked soldiers under her care were both depressed and anxious and Peplau took it on herself to implement formal and informal group therapy sessions with soldier casualties (Callaway, 2002). She facilitated discussions over breakfast and in other everyday social situation noticing socially disabled and inhibited her soldier patients were. It was during this time at the 312th that Peplau was also able to attend seminars led by the likes of John Bolwlby and William Menninger and this appears to have deepened her psychoanalytic leanings. It is of particular note that Peplau was in the UK during the years when radical changes were afoot in UK psychiatry. As we see below, Annie Altschul was participating simultaneously in experimental approaches to treating shell-shocked soldiers at Mill Hill. And the use of group and community based social therapy was also evident at Northfield Hospital in Birmingham where traumatised soldiers were being treated by Bion, Rickman and Foulkes among others (cf, Harrison, 2000). So we can see that ideas about participant group approaches were very much in the ascendant at the time where a psychological model of treating trauma was supplanting more the orthodoxy of biological psychiatry, at least in some enclaves. Preliminary accounts of the Northfield experiments were published in a special edition of the Bulletin of the Menninger Clinic in 1944 so it might well be that there was a ripple effect where other practitioners were alerted to the experiments happening in fellow institutions.
While working at the 312th in Staffordshire Peplau had an affair with an officer and became pregnant, giving birth to her daughter later while still in England. As Callaway (2002) notes, it was the outcome of her work at the 312th hospital that Peplau saw as the base for her later academic contributions. England became a geographical source for a 'dual conception' in as much as it was where she conceived her biological baby as well as her intellectual baby. Her experiences in dynamic interpersonal therapy culminated in her major publication Interpersonal Relations in Nursing (Peplau,1952) in which she took Sullivan's teaching and his theory of a 'self system' as a start point. Peplau believed that early experiences influenced relations later in life where the present was reminiscent of familiar elements of the past and applying this psychoanalytic conceptual frame directly to nursing she likened the dynamics of the nurse/patient relationship to that of an early feeding experience with the patient perceiving the nurse as a surrogate mother. Elsewhere in the USA, the increasing realization that psychiatric illness was weighted by a number of interpersonal or social variables led to a surge of sociological research (Bateson, 1951; Sills, 1994). By the late 1950's psychoanalytic principles were core curriculum material in training nurses and though Peplau was no longer clinically involved in milieu therapy she maintained an academic interest acting as consultant to Holly Skodol Wilson's doctoral study which was based on the work of UK TC psychiatrists RD Laing and Tom Main among others and was supported by NIMH funding, the book Soteria House emerging from the thesis. Peplau recalled the work of Maxwell Jones and how it became influential during the 1950s, though she detailed that she had declined his invitation to meet when he came to New York:
Maxwell Jones, MD, came to the USA and spent some time at Greystone State Hospital in New Jersey. I was then director of Rutgers, the State University of NY. Jones had previously been in North Carolina - a friend from there had phoned me and told me that Jones had persuaded a beautiful intelligent young student nurse to have dinner with him - she did - and he either tried or actually seduced this vulnerable student which infuriated me. So when Jones sent me an autographed copy of his book, and came to Rutgers to see me, I refused, made myself unavailable." (Letter 28th March, 1998)
According to Grayce Sills (1999), who had been a student at Peplau's Summer workshops in the 1950s & 60s, Jones' (1953) book The Therapeutic Community became one of a number of essential readings for anyone; "seriously concerned with the field of psychiatric management" (Sills, 1994; p100). Along with the work of sociologists Stanton & Schwartz (1954), who had set about using psychoanalysis in an effort to liberate their mental hospital, a new theoretical tenure was established based on social psychiatry, milieu therapy and therapeutic community practice that sort to address the type of institutional medical insanity that had been portrayed in Ken Kesey's novel One Flew Over the Cuckoo's Nest. As Peplau's stature as a teacher increased she developed a reputation for group sessions for students based on the psychodrama work of Jacob Moreno, later establishing formal group therapy sessions for the students in training (Callaway, 2002). She was committed to re-applying the psychoanalytic procedure of treatment in the service of training and she was emphatic that the principles of psychotherapy could inform the procedure of nursing. If nurses were to begin to start talking meaningfully to patients they needed to be exposed to learning about talking therapy during the course of their training. However, ideas about milieu and therapeutic community practice did not immediately gel in Peplau's thinking until she had made sense if systems theory:
"I did employ a sociologist at Rutgers to help me and the graduate students to develop idea about therapeutic milieu. Very little resulted from that effort. After I studied the systems theory of von Bertalanffy and got the idea of 'illness-maintaining systems' (see Chapter 9 O'Toole & Welt, Interpersonal Theory in Nursing Practice) our practice of milieu began to evolve (see part II Therapeutic Milieu), several RNs who have worked or studied with me have developed TCs also - Dr Grayce M Sills for instance." (Letter 28th March, 1998)
Up until the end of her life Peplau continued to reaffirm her commitment to the interpersonal psychotherapies, arguing that the nurse herself was the true agent of change for the patient rather the mechanism of the therapy (Peplau, 1989, 1994). Far from being a remnant of the past, Peplau maintained that milieu enquiry was an opportunity for development;
"The idea of milieu as therapeutic environment, as it became popular during the 1950s and 1960s, gave recognition to the idea that the nurse-patient interactions within the milieu could be beneficial to patients. However, since at that time the clinical nurse specialist movement and graduate preparation of psychiatric nurses as psychotherapists were still in the early stages of development, consideration of the impingement of hospital systems and ward environments on patients, and the nature of interaction phenomena within the milieu, had to wait. Nurses first had to gain sophistication in theory and theory application before thinking about complex milieu phenomena. It would seem that there are many theoretically orientated nurses who, with knowledge, skill and a computer, could now address this complex task, providing insight and direction." [Peplau, 1989, p.78].
Like Peplau, Annie Altschul was introduced to psychoanalytic ideas early on in her career. Altschul had worked as an assistant counsellor, "Jugend Fuehrerin", in her youth in Germany in a children's summer holiday camp run by Adlerian psychologists:
"I started attending the meetings in 1935 or 1936, at the age of 16 or 17 years, partly as a result of my sister's influence. Danitza Deutsch was one of the Adlerian Psychologists. Rudi Dreikurs…was particularly important, he ran a residential children's home for disturbed children. He later went to the US, his books were available in English". (letter, October 19th 1998)
Alfred Adler's was Altschul's preferred psychoanalytic school. One of Freud's psychoanalytic contemporaries and early followers, Adler had broken away from Freud in 1911 and established his own school of Individual Psychology in Vienna. Adler was a friend and collaborator with Leon Trotsky and developed a more socially focused and less sexually implied version of Freudian analysis; an approach which resonated with Altschul's own socialist beliefs (Nolan, 1999) anticipating her later experiences and valuation of group approaches and social psychiatry.
After emigrating to the UK, Altschul embarked on her nurse training in London. Along with a group of nurses in training Altschul was evacuated between 1940-1942 to Mill Hill Hospital in North London from the Maudsley in South London, when it came under threat from bombing. At Mill Hill Altschul was involved in the treatment of shell shocked soldier casualties and she worked on Maxwell Jones's unit. Jones was a young psychiatrist under the guide of the chief physician Sir Aubrey Lewis, who had been swayed by Freud's idea of talking therapy (Lewis, 1932). Jones had been encouraged along with other trainees to learn the fundamentals of psychoanalysis and had been permitted the scope to develop a talking therapy approaches with his soldier patients as an alternative to the common treatments of deep insulin coma therapy, ECT and Sodium Amytal. In fact Jones established group therapy sessions and soon noted the beneficial factors of mutual learning, especially in informing the soldiers about the causes of their symptoms in relation to effort syndrome (Jones, 1942a; 1942b). Jones did not, ostensibly, work psychoanalytically though he drew from psychoanalysis in some aspects of his later work describing that psychoanalysis had "added a great deal to our knowledge of the therapeutic process" (Jones, 1968; p70).
Altschul (interview, 1997) believed "Jones's most productive work" was post Mill Hill in the psychoeducative rehabilitation of 300 British prisoners-of-war (POWs) who had been in the Japanese war camps (circa 1945). The resources for the rehabilitation of the POWs were six 'cottages' with fifty beds each where the men were encouraged to engage in the practical administrative running and day to day decision making procedures of the life in the cottages. By helping the men learn to co-operate with each other, share daily living tasks, as well as find gainful employment, symptoms of paranoia, impotency and anxiety decreased (Jones, 1982). The Department of Health and Labour were so impressed with Jones work that asked him to repeat the approach with one hundred homeless men suffering with concurrent 'mental infirmity'. Altschul later observed the refined development of democratic ideology in the treatment milieu at Belmont Hospital (later called the Henderson) and later at Dingleton TC in Scotland in the 1970s. She offered an account for the rationale of a new anti-authoritarian approach to treatment:
"Jones went to Sutton where he worked with psychopaths. An important issue which he stressed was the inability of psychopaths to accept authority. It was therefore essential for staff not to be experienced as authority. The whole idea of the therapeutic community was that all members of the community, the patients in particular were therapeutic agents. The abolishing of titles, like doctor or nurse or sister, was part of the necessary frame work, as was the use of Christian names". (Letter, October 19th 1998).
Jones (1982) mentioned Altschul's contact with Dingleton when he described her as a "well known nursing instructor". Altschul quipped that she "was one of the few nurses with dark hair nurses who were 'allowed' to work with Jones, who had a preference for blond haired Scandinavian nurses, one of whom he married" (letter October 19th 1998).
Despite the experiments at Mill Hill, by the early 1950s the therapeutic inclination of the Bethlem & Maudsley was still mostly medical. Brian Wolllatt (2005), one of Altschul's students from the first cohorts of specialist mental health nursing trainees at the Maudsley, described the situation thus:
"In 1952 the Bethlem & Maudsley was mainly custodial i.e. locked ward institutions delivering ECT, Insulin Coma Therapy and Sodium Amytal. Insulin played quite a small part in therapy; out of approximately 450 patients in all a maximum of 17 - 18 were treated with Insulin at any one time. There were two open (so called convalescent) wards. The special units then were 2 geriatric and 2 adolescent wards at Bethlem and Epilepsy (Ward 2) and the Children's wards at the Maudsley. Annie Altschul was the principal Tutor at the School of Nursing, which was at Breakspear House, College Road, Dulwich. She was the leader of a three tutor team. Annie at that time was treated with care; she was certainly respected because her teaching sessions were stimulating, challenging and thought provoking.
It was against the grain that Altschul set up group forums for nursing sisters to discuss 'the psychosocial aspects of nursing' where she encouraged peer criticism and the ventilation of feelings (Russell 1997). She recalled how these groups came to be established and the rationale behind them:
"When I became a tutor it seemed important to be involved in clinical work in order to be credible to the students. We (the tutors) attached ourselves to specific wards where relationships. Three of the consultants were important in the development of 'groups' for ward sisters. One was Brian Acker, who edited the Red Handbook, (he later committed suicide). One was Bennett who became sold on group therapy in the USA, he was the person who introduced us to Schwartz: The Mental Nurse and he introduced us to 'the other 23 hours' when patients are not in psychoanalytic treatment, 23 hours which are spent with other patients and with nurses. The third was Hobson, an analytic psychologist". (Letter October 19th, 1998)
Altschul's two early text books; Psychiatric Nursing (1957) and Aids to Psychology for Nurses (1962) brought together her developing ideas and were the first dedicated texts in the UK about the wider clinical applicability of social psychology for nurses becoming a key philosophic hinge in shaping nurse training. Importantly Altschul offered significant theoretical direction for nurses attempting to find alternatives to the medical model. Two of her papers, one about group work and the other about systems theory which arose from her direct encounter with therapeutic communities and built on Von Bertalanffy's General Systems Theory, are among the most cited papers in psychiatric nursing (Altschul, 1964; 1978). Her late 1960s study of 'nurse-patient interaction' in acute psychiatric care explored the complex processes involved in the development of therapeutic relationships, especially in the early stages of care and treatment confirming some of the attachment hypotheses of the psychoanalyst John Bowlby whom she had known from her time in London (Barker, 1999). Her book Patient-nurse Interaction (Altschul, 1972) was an important interlocutor in the development of a specialist discourse for mental health nursing, establishing a distinctive tone for nurses presence, language in communication with patients and research interest in evidence of effectiveness offering a bridge between American and UK mental health nursing (Tilley, 1999). Patient-Nurse Interaction contributed to the generation of professional nursing esteem with a methodical set of premises of practice and evaluation at a time when psychiatric nursing was struggling to step out of the shadow of its medical forbearance.
Even into the third age of her career Altschul was still producing thought provoking work. In the early 1980s when she had her first bout of serious depression and she wrote candidly about her suicidal feelings, going public about the reality of psychiatric professionals suffering from mental illness. Her disclosures lent impetus to the user movement in the UK challenging the stigma about those who might suffer from mental illness by demonstrating that even professionals are faced with mental illness.
After Eileen Skellern completed her state registered nurse training (SRN) she joined the Cassel Hospital in Richmond in 1950. The Cassel was a renowned Therapeutic Community and the foremost psychoanalytic hospital in the UK. Tom Main, the psychiatrist-medical director during Skellern's time at Cassel, had been involved in the war-time group experiments at Northfield Hospital in Birmingham treating shell shocked soldiers using methods of group and milieu based approaches to therapy. The Northfield experiments coincided with the group experiments at Mill Hill and Peplau's milieu work at the 312th at Staffordshire. Concurrently then, a model of treatment based on social and group methods, emerged from these separate sources and Tom Main went on to hone these therapeutic community ideas at the Cassel Hospital maintaining close connections with the Institute of Psychoanalysis (cf; Pines, 1996). The Cassel version of therapeutic communities differed to the way that Maxwell Jones had advanced the idea; whereas the Henderson was committed to the idea of democracy (as Altschul noted), the Cassel was more inclined to explore the vertical dynamics of hierarchy. It was in the ferment of these community based innovations that Skellern entered nursing.
At the Cassel, Skellern became close friends and roomed with Isabel Menzies Lyth who later carried out important studies of nursing systems (Russell, 1997). During this time Skellern herself underwent psychoanalysis and it appears that subsequently Skellern was more inclined to working with medical staff who were psychoanalytically orientated (Russell, 1997). With non-psychoanalytic psychiatrists she was less able to forge easy alliances (Russell, 1998). During Skellern's time at the Cassel ideas of note emerged, in particular a model of practice that was called 'psychosocial nursing' (Barnes, 1968; Barnes et al, 1998) which defined the idea of the nurse 'working-alongside' the patient by engaging in day to day activities and 'problem-solving'. The key to this approach was the concept of the therapeutic 'use of self' and the matron Doreen Wadell was an important theoretician who unfolded the idea. Wadell collaborated with the medical director Tom Main running clinical supervision groups that were described in Main's memorable paper 'The Ailment' (1957) which highlighted how counter-transferential self-consciousness on the part of the nurse was a valuable adjunct in understanding the patient.
Skellern left the Cassel in 1952 to go to the Belmont Hospital (the forerunner to the Henderson Hospital) where she worked as Sister-in Charge of the Social Rehabilitation Unit of 100 beds. Skellern and Maxwell Jones published a clutch of papers in the Lancet and the Nursing Times (Skellern, 1955; Jones & Skellern, 1957; Jones, Pomryn & Skellern, 1956). Skellern's leadership was noted in particular by the Rapoport in his major sociological research study of the Henderson, Community as Doctor (Rapoport, 1960), a book which set the timbre for the first era of social psychiatry. Skellern's leadership was again noted in Jones's (1968) later book Social Psychiatry which was: "dedicated to the work of Eileen Skellern and the other nurses at the Henderson". Skellern developed a reputation as an inspiring teacher and leader, and this was apparent in Briggs (2002) account of his first visit to see the Henderson at work in 1956. Briggs, who became Maxwell Jones' friend, collaborator and biographer, made a particular note of his attendance at one of Skellern's seminars:
"I was especially interested in the training of the social therapists whose energy, like that of the patients, seemed to be boundless. Their daily 'tutorial' with the senior staff was a cauldron of ideas. I was especially impressed by the sessions that Eileen Skellern conducted. In one, the matter of emotional attachment to a patient and his subsequent 'sexual blackmail' was the initial focus. By the end of the tutorial Eileen was reviewing David Henderson's types of psychopaths and strategies for dealing with each.' (ibid: p21).
Skellern was not disinclined to training social therapists (who would be something of the equivalent of graduate mental health workers today). Maxwell Jones had, from the 1950s onwards, been keen to employ 'social therapists' at the Henderson. His aim was to 'de-professionalise' the hospital in order to foster an atmosphere where the patients could be treated more like persons and less like medical cases. Likewise, Joshua Bierer employed Occupational Therapists at the Marlborough Day Hospital in London in order that the therapeutic relationship would be a practically based and social, less wedded to a medical model approach. And at Kingsley Hall, London, RD Laing was starting to employ colleague sufferers as caregivers, and later at the Arbours Crisis Centre in North London, established by Laing's colleague Joseph Berke, the community was staffed intentionally by psychotherapists or trainees and not nurses. So the idea that non mental health nurses might take on the challenge of everyday running of a psychiatric unit was not an anathema to Skellern. Indeed, as Woollatt (2005) has pointed out Skellern was not actually qualified as a mental health nurse herself and it was only after she left the Henderson that she completed a mental health nurse training;
"A point worth making is that the staff at the Cassel were not trained mental nurses, but SRN's. Skellern did a short post-graduate course at the Creighton Royal Hospital before starting at the Bethlem and Maudsley. She left the Henderson in 1962 and after her RMN training and a period of study leave during in which she visited psychiatric hospitals in the United States, she started at the Bethlem & Maudsley in 1963. The Superintendent of Nursing at the Bethlem had been in post from the inception of the NHS in 1948 until the early 60's. Eileen Skellern was possibly head-hunted for the post. During the 60's with a group of like minded Senior Nurses from in and around London she started an ongoing group with an analytical psychotherapist. Its aim was to explore group dynamics and was reviewed in a paper she wrote for the Nursing Times (or Mirror as it was then). She had to give it up when her National Working Party task with Richard Crossman became too demanding". (Woollatt, 2005)
Her senior position and growing reputation provided her with new scope to exert influence not only at the Bethlem & Maudsley but also nationally. Russell (1998) recorded:
"From 1969 to 1974 she gave large numbers of talks and lectures on nursing, the introduction of change and on stress. Committee work inside and outside the hospital (for example, at the King's Fund) became an important part of her life. She was the first ever nurse to become an Associate of what is now the Royal College of Psychiatrists. One project of particular note was her participation in the 1969 national working party, chaired by Richard Crossman, the then Secretary of State, to review policy on mental subnormality following revelations of malpractice and the enquiry at Ely Hospital, Cardiff. The work involved her with persons such as Professor Brian Able Smith, Baroness Serota and other major figures. Eileen took this work very seriously, and devoted much time to it. Unfortunately, before it could be completed, the Government fell and brought the work to a premature end. However, some results were eventually recognised and included in the White Paper of 1972, Better Services for the Mentally Handicapped". In 1972 she was awarded the OBE". (Russell, 1998).
At the Bethlem & Maudsley Hospitals she was instrumental in establishing the Charles Hood therapeutic community unit, the first dedicated TC at the Maudsley offering a day programme of dynamic psychotherapy where the nursing staff carried individual case loads. This was an innovation which influenced the development of other nurses who were keen to develop dynamic psychotherapy skills (cf; Strang, 1981). Bob Hobson, the leader of the Charles Hood TC at the Bethlem acknowledged Skellern's "sage-like" influence on the project (Hobson, 1979) and Dietrich's (1976) seminal paper about nursing in the therapeutic community captured the atmosphere of progressive thinking that emerged under Skellern's stewardship. Likewise, under Skellern's wing Beatrice Stevens (1995) and Harry Wright (1996) described the atmosphere of the Maudsley during the seventies as conducive to the development and embedding of psychoanalytic ideas in the practice of nurses throughout the joint hospitals that remained pertinent for generations that followed (Winship, 1995).
One of Skellern's last contributions was the planning of the First International Psychiatric Nursing Congress in 1980. This took place in London, two months after her death though she had prepared an address of welcome which was given to the delegates. The inaugural Eileen Skellern Memorial Lecture was established two years later to remember her career and influence and was delivered in 1982 by Baroness McFarlane: Nursing Values and Nursing Action, 1984 by Professor Annie Altschul Psychiatric Nursing: Does Good Practice need Good Principles? 1986 by Baroness Caroline Cox: The Sharp Compassion, 1988 by Professor Jennifer Wilson-Barnett: Nursing Practice & the University, 1990 by Professor Tony Butterworth: Generating Research in Mental Health Nursing, 1993 Professor David Sines: The Arrogance of Power, 1997 Mr Ben Thomas Past Insights for Present Problems. Skellern's death at the height of her career meant that the TC movement had lost one of its most important supporters and mental health nursing one of its most influential advocates of interpersonal practice. While her name has been remembered at the Bethlem & Maudsley since the naming of new ward block after her (the first nurse to have this accolade in the 750 year history of the hospital), her ideological interests have probably been less well known.
The history of therapeutic community and milieu therapy movements usually features accounts of the key male psychiatrist figure-heads like Harry Stack-Sullivan, Dexter Bullard, Maxwell Jones, Michael Foulkes, Wilfred Bion, Tom Main and Ronnie Laing among others (Main, 1983; deMare, 1983; Pines, 1983; 1985; Kennard, 1998; Harrison, 2000). Suffice it to say, reports specific to nursing practice in the history of the therapeutic community tradition have been limited to a handful of accounts (Main, 1957; Barnes, 1968; Dietrich, 1976; Ploye, 1977; James, 1984; Clarke, 1994; Benbow & Bowers, 1998; Barnes, et al, 1998). In re-appraising the legacy of the eminent founders of mental health nursing, firstly it is possible to note the intrinsic influence of therapeutic practice in shaping a vision of mental health nursing practice, but also the way in which mental health nurses have offered a reciprocal underpinning that has helped embed TC philosophy in mainstream psychiatry.
The work of Peplau, Altschul and Skellern can be seen emerging from the progressive traditions of user-involvement and social psychiatry which have coalesced in the steady flow of descriptions of democratically inclined TC practice (Clark, 1964; Jones 1968; Jones, 1976; Hinselwood & Manning, 1979; Main, 1983; Cullen, 1997; Kennard, 1998, Haigh & Campling, 2000). We can see trace a direct link from the TC movement and social psychiatry to the current agenda for social inclusion and recovery in mental health practice where the aim is one of bringing about an optimal level of social agency for the patient (ODPM, 2004; Repper & Perkins, 2003). This re-vitalised social inclusion agenda has emerged in response to criticisms about mental health care in the community where an absence of therapy, as Cox (1998) argued, has continued to be a cause concern. The National Health Service Plan (DoH, 2000) explicated the type of active patient engagement espoused by Peplau, Altshcul & Skellern Skellen, in an ambitious agenda of collaborative relations between patients and staff (often couched in terms of 'users' & 'providers') challenging the orthodoxy of medical pedagogy; "medicine is not an exact science" (8:29) arguing that a new philosophy was needed to succeed the old one because; "the relationship between service and patient is too hierarchical and paternalistic" (NHS Plan 2.33).
The NHS plan also asserted that the key to the future of mental health care lay in the process of patient involvement from grass root to board level where "Patients forums will elect representatives to sit on every NHS trust board" (NHS Plan: 10.24). The report argued that: "Giving patients new powers in the NHS is one of the keys to unlocking patient centred services" (NHS Plan: 2.34) aiming to establish "By 2002 a Patient Advocacy & Liaison Service [PALS] in every trust" (NHS Plan: 10.17). The NHS plan went some way, in principle at least, to restoring a level of democratic accountability in the NHS that might prevent the further erosion of public confidence in the NHS. The aspiration to increase user-involvement has been manifest in more focused guidelines for clinical practice. Take for example the guidelines on acute in-patient care (DoH, 2002) which impressed that democratic engagement be given scope even in the psychiatric environs where patient participation might be least expected:
"4.42 Inpatient nursing and related care depends primarily on relationships, staff need to have the time to talk with and listen to service users and carers. Ward arrangements need to be organised to foster a milieu and culture of engagement and to maximise the time that staff spend therapeutically engaged with service users.
4.43 There must be regular means and forums for encouraging service user involvement in determining how the ward is run, what rules of conduct apply and what activities are available. Each ward should have regular time tabled user/ staff meetings with advocacy input as requested.
4.44 A code of conduct should be drawn up identifying clearly unacceptable behaviour such as racial or sexual harassment, theft etc. This code of conduct should be negotiated with service users.
4.4.20 Overall there must be absolute commitment to service user and staff collaboration in running the inpatient ward. (Similar but not necessarily the same forums/means are needed to ensure effective carer input)."
These new guidelines suggest familiar givens to those advanced by Peplau, Altschul and Skellern; harking back to the patients committee's that Peplau observed at Chestnut Lodge and the breakfast meetings she held at the 312th; the democratic houses for POWs that Altschul encountered at Mill and the initiation to TCs that Skellern experienced at the Cassel. That group based inclusive ideologies of democratic practice and regulation of therapeutic milieu have re-emerged as an aspiration for mental health practice might seem like re-charting old territory, but it might also be re-assuring to re-discover a vision that was deemed valuable before.
However, democratic social inclusion (as per guidelines above) as an indicator of a progressive therapeutic milieu remains largely anecdotal. There is some emerging evidence that democratic administration and collective rule-setting on in-patient wards might have a positive impact on reducing levels of aggression, violence, seclusion and staff sickness and increasing staff morale (Mistral et al, 2002) but more research is needed. Ideologically, in the realms of social and interpersonal clinical practice that we might re-claim the future of psychiatric nursing. In the progress of therapeutic community practice, as a model of social inclusion and recovery, the type of psychosocial and interpersonal approaches to nursing practice can be re-rooted. The TC movement was once an enclave for a progressive psychiatric nursing agenda, and it may again offer a potential arena for rejuvenating the interpersonal practices that interested Peplau, Altschul & Skellern.
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