Book Review: Asylum to Action

I appreciated the opportunity to review this book, for having already enjoyed reading Claire Baron's memorable version of events at Paddington Day Hospital in the 1970's, Asylum to Anarchy (1987) I wondered what could be further added to such an interesting story – the story of the demise of a renowned therapeutic community which had been toasted as a radical overture of mental health democracy, with a controversial and charismatic medical director who had employed blanket use of psychoanalytic ideas.

According to Baron, Paddington Day Hospital had descended into anarchy, chaos and tyranny and was, indeed, after the dismissal of the medical director in 1977, eventually closed in 1979. With her main focus being on the therapeutic community movement, Helen Spandler, however, suggests that the fuller history of Paddington Day Hospital, a therapeutic community that was established in West London in the early 1960's and closed in the late 1970's, is less well known and her book is an attempt to remedy this, extending to both a celebration of the social action at Paddington and a critique of Asylum to Anarchy as a one-sided narrative. This book, in essence, attempts to understand how Paddington moved from being so strongly fought for, to being vilified and condemned.

The author methodically documents and explores the meaning of a number of significant events in the life of Paddington Day Hospital and in highlighting particular moments of innovation she recalls some of the radical aspirations of therapeutic communities. This book is comprehensively and impressively well researched; from the Chronology of Key Events at Paddington Day Hospital which turned out to be an invaluable guide in helping to clarify what actually happened to whom and when, to interviews with several key people who were involved in the day hospital as a member of staff or patient. This included Julian Goodburn, the charismatic medical director, who had had a long association with the day hospital since being a junior doctor there in 1964 and who was responsible for introducing the more libertarian methods in 1970 after becoming locus medical director. In Goodburn's more libertarian method patients were not registered, and there were no clinical notes with patient history, no diagnosis and no treatment plan. A very different process and atmosphere to traditional psychiatry and having a strong resonance with the approach to patients adopted by R.D. Laing and members of the Philadelphia Association at Kingsley Hall during the same period.

In 1971, threats to reorganise local psychiatric services, which signalled the end of the day hospital, were met with organised and successful protest by staff and patients. And thus was the beginning of patient's activism. Spandler enthuses on the importance of this, the formation of the Mental Patients Union being the first overtly politicised psychiatric patients' group and precursor to survivors' and advocacy groups, which, she feels, is rarely figured in the numerous accounts of the crisis at Paddington and mentioned only briefly in Asylum to Anarchy. This newly formed politicisation and founding of the MPU the author recognises as collective action towards challenging fundamentally held belief systems about mental illness and psychiatry, and generating the notion of a common identity of opposition. Interestingly, such a perspective can also be linked to the idea of the foundation of the MPU providing a 'seedbed' (Baron 1984) for the patients' later complaint to the Area Health Authority in 1976, when they demanded an inquiry about the functioning of the day hospital and its lack of shared decision making. The patients, in this complaint, also expressed concern about over-reliance on psychoanalytic interpretation at the expense of support for their more immediate problems. The interrogations they received in response to their complaints led many to feel that they were not treated respectfully but with mockery and derision.

Goodburn's suspension and later dismissal (and subsequent demise of Paddington Day Hospital) occurred after he had failed to meet in full the inquiry recommendations of the Area Health Authority, by proposing to offer two distinct categories of treatment in the day hospital – one which fully complied with the inquiry recommendations and the other which continued his method. Patients could choose to attend the method they preferred. Goodburn's proposal not only, in effect, challenged the authority of the Area Health Authority but also officially took Paddington Day Hospital beyond the notion of psychiatric acceptability, e.g. the lacking of any psychiatric assessments, note-taking, follow up and adequate referral procedures figured strongly in the official enquiries. His offer had also raised the fundamental question of what is the most appropriate social system for an institution devoted to psychotherapy?

If you don't play it by whatever rules, or by whatever codes of practice are seen as the usual way of doing things, or the established way of doing things... you're vulnerable... But, you know, fair enough. Because what's going to happen is that as the inquiry extends, it is going to be an inquiry into how authority functions. (Goodburn, 2000:110)

Another important contributory factor in the downfall of Paddington was the use of psychoanalysis as the dominant framework of understanding dynamics in the community itself. Psychoanalysis tends to view people as isolated individuals rather than members of specific social and cultural practices and Spandler suggests that the continued absence of any alternate collective frameworks to psychoanalysis through which to understand community dynamics in therapeutic communities can contribute to irreducible splits, polarisations and complaints. She goes to dismiss, however, the theory and practice of group analysis, despite its focus on the group, as it remains wedded to its psychoanalytic roots and she, therefore, calls for the necessity of developing alternative non-psychoanalytic and non-familial community and group frameworks and concepts.

My overall feeling after reading this book was that the story of Julian Goodburn and Paddington Day Hospital (for they are inseparable!) is primarily one of paradox and that this had been communicated fully and clearly in this book. Goodburn was chastised for maintaining 'rigid autocratic control' ([KCWAHA, 1976:]p25) over patients through manipulation, and yet on the other hand he was criticised for not assuming enough control over patients' behaviour (Spandler 2006:109). This paradox is symptomatic of the dilemma of how can psychoanalytic thinking be employed in a system devoted to the democratization process? Interestingly, Goodburn himself, was well aware of the limited context of psychoanalysis and later called for 'a theory capable of explaining all the facts' (Goodburn, 1986:58)

With the sheer volume of considerations in this book Helen Spandler reveals what an enormous commitment she has made toward the rethinking of events at Paddington Day Hospital. She puts forward the very interesting, and highly relevant idea of the need for 'paradoxical spaces' (Rose 1993) in which the tensions within and beyond the therapeutic community could be revealed, understood and acted upon. This would involve a radical shift from the need for premature and one-sided resolutions, that is normal in our society, toward strategies for engaging and working more creatively with paradoxes. An idea that will appeal to many of the existential therapists reading this journal.

The last word from this thought provoking story has to come from Julian Goodburn in his interview with the author when he reveals his more radical social constructivist if not existential leanings - toward the importance of the socio-cultural context:

How does one understand the transformations and the representations of the external situation in the dynamics of the one which is under immediate study? ....Somewhere or other there is a correlation between the contradiction, or disquiet that they're experiencing, and the contradiction or disquiet that everybody ought to be experiencing a propos some factor of society at large, which... .they are, though circumstances of their particular experience, the bearer of – the victim of, you might even say. [They] will subsequently manifest this as if it were solely going on in them, when in fact, it is going on in them... as a consequence of the fact that these issues are not resolved in the world at large... It just happens that they are the person standing on that particular corner at that particular time who has copped it, as it were. (Goodburn , 2000:33)

References

Baron, C. (1984). The Paddington Day Hospital: Crisis and control in a therapeutic institution. International Journal of Therapeutic Communities, 5, 3, 157-170.

Baron, C. (1987). Asylum to Anarchy. London: Free Association Books.

Goodburn, J. (1986). Paddington Day Hospital or the psyche misunderstood: Implications for therapeutic communities, psychotherapy and psychoanalysis. International Journal of Therapeutic Communities, 7, 1, 57-66.

Goodburn, J. (2000). Interview with Author (28-30 January 2000). In Spandler, H. (2006). Asylum to Action.

KCWAHA. (1976). Kensington and Chelsea and Westminster Area Health Authority Report of the Committee of Enquiry Concerning the Day Hospital at the Paddington Centre for Psychotherapy (September 1976).

Rose, G. (1993). Feminism and Geography: The Limits of Geographical Knowledge. Minneapolis: University of Minnesota Press.

Nick Zinovieff