Dr Peter Bruggen
Who is in charge? A man of integrity who survived swimming with sharks
Dr Peter Bruggen (17 July 1934 – 20 September 2018) has been one of the great influences on adolescent mental health and on innovative ‘group-analytic’ psychotherapy
When World War II broke out Peter Bruggen was 5. He had previously been separated from his parents – a difficult experience for him. As an older adult, he would intimate to me that in time of danger and uncertainty we all have even greater need for unity and for secure attachments.
I met Dr Bruggen at the Tavistock Clinic in 1984, on my arrival in London to train in child and adolescent psychiatry and in psychoanalytic psychotherapy. He was my supervising consultant and my research tutor from 1984 to 1993, and my mentor from 1994 until 2016, when his health started to deteriorate. We had worked so closely together for more than 30 years that my gratitude became an existential debt. I didn’t know how to pay him back. Last year, I wrote a book chapter on his work, “Authority and attachment in adolescence” (Ezquerro, 2017), in an attempt to pay tribute to him, while he was still alive. I also invited him to write a chapter for a book I am editing on the theme of Life and Death. He initially declined. I pushed. He then asked our colleague Rik Lambert to write it up jointly with him. The chapter explores blood as a symbol of death.
Last October, Maria (my wife) and I invited Peter and Joan Bruggen to our holiday home in Ametlla de Mar, a small fishing village in north-eastern Spain. They stayed with us for two weeks. It was beautiful, though painful and difficult at times. Before the trip, I had dreamt that Peter and I were swimming open waters, in a real blue Mediterranean sea, for hours and hours, non-stop. In Spain, we did in fact enjoy swimming together every day. He revelled in the beauty of the scenery and submerged into new explorations. At one point, he said: “Hey, Arturo, I am swimming with docile fish, at last”. Peter had been a serious swimmer all his life but now tired after a few minutes – and there were a few thunderstorms. I must confess that I sometimes failed him. He had been one of my heroes; I felt unable to accept his sharp decline. Reflecting back, I wish I had been able to look after him as he had previously looked after me.
Near the end of his prolific career, Dr Bruggen was appointed medical director in one of a new wave of NHS Trusts, when major reforms were introduced in 1991. He thought that public health services needed a good shaking, tougher management, proper costing and better accountability structures. Things turned out differently from what he had expected; he retired in 1994, aged 60. In a revealing book, “Who cares? True stories of the NHS reforms” (Bruggen, 1997), he confessed that during his last two years as medical director he rarely slept through the night; he had headaches and other psychosomatic complaints. The NHS was insidiously being engulfed by the new neoliberal religion, the market, under the auspices of Margaret Thatcher and her followers. That was difficult for a committed socialist like Peter Bruggen; but not so for other socialists, like Tony Blair, who would later exploit market forces conspicuously as a basis for New Labour.
At the point of his retirement, I asked Peter to be my mentor and we agreed to meet monthly to talk about my NHS work as a consultant psychiatrist and as Head of NHS medical psychotherapy services, in Brent. I no longer had a formal need for mentorship. However, I thought that learning is an open-ended task and that in looking after myself I would also be working for the benefit of my team and of our patients. I might not have survived without him. I enjoyed his wisdom and his creativity until my own recent retirement. Well …, as a matter of fact, I am not in retirement and, like Peter, I may never quit. I can recall a time when I was pushed to the limit. He gave me a paper: “How to swim with sharks”, written for sponge divers by Voltaire Cousteau in Paris, in 1812. At first, I thought Peter was being humorous but, no, he was deadly serious and told me not to bleed!
In the paper, I did learn this is a cardinal principle: if you are injured you must not bleed. Bleeding prompts an aggressive attack from sharks and might often provoke the participation of docile fish. Not to bleed when injured is difficult and may indeed seem impossible. However, diligent practice will permit the experienced swimmer to sustain a serious laceration without bleeding or even exhibiting any loss of composure. Unless you learn to control your bleeding you should not attempt to swim with sharks, for the peril is too great. I thanked Peter and was haunted by reading:
“The control of bleeding has a positive protective element for the swimmer. The shark will be confused as to whether or not his attack has injured you and confusion is to the swimmer’s advantage. On the other hand, the shark may know he has injured you and be puzzled as to why you do not bleed or show distress. This also has a profound effect on sharks. They begin to question their own potency” (Cousteau, 1987).
Since 1987, year after year, Peter and I have participated in a charity marathon swim (swimathon) – a newly created event which runs annually across the country to raise money in support of Marie Curie cancer care. Peter Bruggen in fact died in one of Marie Curie’s hospices, in Hampstead. Poignantly, prostate cancer killed him.
The authority of the adolescent peer group
Dr Bruggen was a charismatic, unconventional and democratic leader. He made his mark in the mental health world by creating and developing an innovative adolescent unit; which opened in St. Albans, in 1969. Covering a population of over four million, the Unit primarily provided ongoing specialist consultation and support to families and professionals in the community, as well as short-term in-patient group treatment for troubled and troubling adolescents up to the age of 16. At the point of referral, the adolescent would be assessed together with their family or the professionals caring for them.
Dr Bruggen’s initial question inevitably was: “Who is in charge?” This would sometimes be followed by another question: “Who wants what?” I found these probes powerful and insightful: therapeutic shortcuts that invited everyone in the family to think together, and to try to understand other members’ motives and expectations. Dr Bruggen told me he had first heard of these ideas from John Bowlby at the Tavistock Clinic in 1966. He had also been inspired by Bowlby’s (1949) landmark paper “The study and reduction of group tensions in the family” – a pioneering publication on family therapy.
The primary task of the initial assessment was to work with the family’s resources, and to support the authority of parents and professionals, with a view to keeping the young person living in the community. Dr Bruggen literally meant this, even when it might not be politically correct. He and the team were so successful that a number of the Unit’s 30 beds remained empty. This achievement was not properly understood by the Department of Health’s advisors who soon recommended that he be removed from the job. But he was a good fighter and managed to persuade the Health Authority to see merit in the empty beds. He reframed these as promoting care in the community (Bruggen & O’Brian, 1986). Additionally, he thought, having enough empty beds would be of help in case of a sudden increase of illness, like in epidemics.
In spite of strong opposition, Dr Bruggen kept his job during 4 decades until his retirement. And he provided a good role model for those of us who worked with him. I was fortunate enough to belong to a unique generation of psychiatric senior registrars who worked at the Unit, including the late Freddie Gainza, Tony Kaplan, Tony Jaffa, Morris Zwi and Jane Roberts.
Dr Bruggen trained at the Tavistock Clinic in the mid- and late 1960s; after which he worked there as a consultant until 1990. Derek Miller (director of the Adolescent Department) was his tutor at the Tavistock, while Donald Winnicott was the supervisor for his training in adult psychoanalysis, which led to his membership of the independent group of the British Psychoanalytical Society. Miller encouraged him to use ‘authority’ in his work with young people, and this concept became one of his foundations at the in-patient adolescent unit.
The bottom line was about how to integrate authority, parental care and self-care in order to grow. Dr Bruggen supported the authority of the parents and, also, the developing authority of the adolescents – with a view to helping young people develop a sense of inner authority which they could recognise as their own. The Unit’s young patients learned fast and took over from the staff the role of chairing the community meeting (as well as other adult-like roles). Their handling of this piece of delegated authority was far more creative than the staff had ever achieved. Peer group support, analysis and sanction proved to be sensitive and effective.
A flexibly designed group-analytic approach was the backbone of Dr Bruggen’s adolescent unit. The entire therapeutic programme took place in family group or peer group sessions, based on a modified therapeutic community model. He was inspired by Tom Main and by SH Foulkes, ‘father’ of group analysis. One-to-one therapy sessions were not available at the Unit.
So, what happened when an adolescent became very distressed and felt in need of individual support? The answer was this: they were offered the possibility of calling a group meeting. This would be attended by all (staff and patients) available at that particular moment. Allowing adolescents to exercise their own authority flexibly, to expose their vulnerability within an unambiguous boundary structure, paid off. At the ad hoc therapeutic group meetings, there were moving episodes of open communication among the adolescents who became more able to empower one another.
Looking back, I could see a process through which adolescents at the Unit projected their incipient sense of personal authority and identity onto their peer group. This investment proved to be an effective way, for most of them, to develop their own views and status. For these youngsters, it was easier to recognise in their peers the parts of themselves that they had projected onto them. The authority of the peer group was helping them to become more assertive, rather than aggressive, and to regulate the distance from and to their attachment relationships.
Having had three daughters (Emma, Camilla and Alice), a less known contribution of Peter Bruggen was his fight against gender discrimination. He and his Tavistock colleague Sandy Bourne published over half a dozen papers on distinctions awards for consultants. They criticised the allocation by committees in secret and focussed on sexism in NHS management. They examined all sorts of factors: age and specialty of recipients, specialty of members of committees, collection of data. They demonstrated that women were grossly under-represented, both, on the committees and as recipients of awards.
From my perspective, Peter Bruggen was a wounded child; an insecure adolescent; a confused medical student … But he survived through personal resilience, psychoanalysis, newly-formed attachments and consistent group work – and he became a distinguished psychoanalyst; a creative consultant child and adolescent psychiatrist; an innovative family therapist; a prolific author; a true socialist; an authentic group person … The list is longer. If I had to choose two qualities to his overwhelming humanity, I would say he was a devoted family man and a loyal friend who shall stay with me until my time comes. Thank you Peter!
References
Bowlby, J. (1949). ‘The study and reduction of group tensions in the family’. Human Relations, 2, 123-128.
Bruggen, P. (1997). Who Cares? True Stories of the NHS Reforms. Charlbury, UK: John Carpenter.
Bruggen, P., & O’Brian, C. (1986). Surviving Adolescence: A Handbook for Adolescents and Their Parents. London, UK: Faber and Faber.
Cousteau, V. (1987). ‘How to Swim with Sharks: a Primer’. Perspectives in Biology and Medicine, 30(4), 486-489.
Ezquerro, A. (2017). ‘Authority and attachment in adolescence’, in Encounters with John Bowlby: Tales of Attachment (pp. 121-141). London, UK and New York, USA: Routledge.