Reminiscences and Reflections on My Life in Psychiatry and Psychotherapy

We present this article as a tribute to Malcolm. It was published in Contexts, C68, June 2015
First presented at the IAGP III Regional Mediterranean Congress, 2008

At Cambridge where I was studying pre-clinical medicine in 1943 a friend gave me a book, Woodworth’s Schools of Psychotherapy.  After reading about psychoanalysis my interest and curiosity was highly stimulated and I read whatever I could lay hands on about psychoanalysis.  While lodging in a theological college I even found Ferenczi’s collected papers! I borrowed those and years later my conscience pricked me into returning the book anonymously.  I resolved to train as a psychoanalyst and was able to persuade my father, who was a skilled general practitioner and ophthalmologist, to pay for my analysis.  I began analysis with Dr Adrian Stephen, the younger brother of Virginia Woolf in Upper Harley Street and as I was then a student at University College Hospital which was within walking or running distance I began my analysis there.  I had been interviewed by Major John  Bowlby in his military uniform in 76 Gloucester Place, the then site of the London Institute of Psycho-Analysis.  I vividly recall how scared I was on the couch so when I lay down for the first session I kept one foot on the floor!  Adrian was a gentle giant, much over 6 foot as can be seen in photographs of the Stephen family.  He was in poor health and I noticed how difficult it was for him to climb the stairs from the ground floor to his consulting room on the top floor of number one Upper Harley Street and sadly he had to break off my analysis after not much more than a year and died of heart failure.  His wife Karin, a distinguished and eccentric psychoanalyst I quite often saw in the waiting room or on the stairs.  She was very deaf and had to use an ear trumpet into which her analysands must have had to speak or bellow.  Heinz Wolf and Pat de Mare were amongst her analysands.  The Stephens were an eccentric couple who had a weekend and holiday house in the Essex Marshes to which I paid a visit once.  Very difficult to find, it had a very attractive situation right above a river.  Adrian and Karin spent a lot of time in a small boat and there are photographs of them with Adrian still wearing his suit while on the boat.

I was away from London for some months during my first medical post, at Sheffield where I had the very good fortune to work under Professor E J Wain the very distinguished medical scientist.  On the professorial unit his two assistants were John Goodwin and Graham Bull, both of whom went on to have very distinguished careers, John as a cardiologist, Graham in renal medicine, a professorship at Belfast and a leading member of Medical Research Council.  My own medical professor at UCH to begin with was Harold Hinsworth who left to become head of the Medical Research Council, which greatly developed under his tenure.  I know that he encouraged the development of molecular biology, which at that time was an infant science.  His place as Clinical Professor at UCH was taken by Max Rosenheim who I always vividly remember sitting on the edge of the desk in the lecture theatre swinging his legs and encouraging discussion.  By connection with John Goodwin I was fortunate to get a house post at Hammersmith Hospital, a postgraduate teaching hospital of the University of London.  Through that and with some extra coaching I passed the MRCP exam (Member of the Royal College of Physicians of London) at my second attempt.  It was regarded as quite indecent to pass at the first attempt!  The award ceremony was in a building that the college then occupied on Trafalgar Square, now the Canadian Embassy.  There was a longstanding ritual that those who were to be admitted into membership queued on the grand staircase leading to the first floor rooms.

The MRCP ensured me entry into the Maudsley Hospital, a postgraduate hospital in psychiatry.  Its formidable head was Professor, later Sir, Aubrey Lewis, a Jewish Australian from Adelaide.  Small, dark haired, dark eyed, nearly always wore his RAF tie having been the psychiatric consultant to the RAF during the war.  Aubrey held people in awe: he used the Socratic method of questioning to see those realms of ignorance that we all possessed.  He was merciless, expecting new entrants into psychiatry already to have a good knowledge of the literature of whatever case they were in charge of.  Strong men were reduced to tears at times but I enjoyed the combat.  I quickly learned to anticipate his approach and learnt much from it.  He had been a student of Adolph Meyer in American, the proponent of the psychobiological approach which meant that one looked at each person from the point of view of his/her biography, family history, social position and medical/genetic structure.  Clifford Scott, a distinguished psychoanalyst who was also a consultant at the Maudsley had also studied under Adolph Mayer and got all his patients to write a very detailed autobiography, which was then studied to look at their psychological structure.  Aubrey expected us to develop a treatment plan, which incorporated the psychiatric treatment of the individual, collaborating with social worker and occupational therapist.  I remember how difficult it was to think about how to reply to the question of what were the aims and goals of occupational therapy for the patient.  Aubrey once interviewed me regarding my future in psychiatry and suggested that I might follow an academic career though in order to do that I would have to give up psychoanalysis as in his opinion the best years of an academic’s life are between the ages of 25 and 35 as regards research and if at that time the person is involved in personal analysis then that worked against research.  However, James Anthony, at that time a senior researcher in child psychiatry was favoured by Aubrey and James had an affectionate relationship with him.  He remembers visiting Aubrey after his wife had died and he was living alone in a large house in Barnes.   He noticed how his hands were trembling when he poured out the tea and reflected on “how are the mighty fallen”, this formidable professor now living a life bereft of power and companionship.

Life at the Maudsley

It was a heady mix.  Bright young men and women from many different countries, many Australians and Canadians, even Spaniards, many of whom went on to create new professorships in psychiatry principally in the former dominions, Canada and Australia.  I can imagine that Aubrey kept a map of the world into which he could pin flags showing where Maudsley graduates had taken up professorships.  To my mind some of them very unlikely persons to occupy those positions but I can see that Aubrey was right in pushing these young men who nearly all flourished in their professorships and created “mini Maudsleys.”

A Heady Mix

When I started psychiatry it was before the era of modern psychopharmacology.  Chlorpromazine had not yet been introduced and the wards reeked of paraldehyde, the only strong drug to control acute psychotic episodes.  Rapidly the new anti-psychotic and anti-depressive drugs were introduced and tested.  In the hospital canteen we sat around and argued about biological versus psychodynamic approaches and I always joined the table where Henri Rey from Mauritius held sway.  His twin gods and goddesses were Jean Piaget and Melanie Klein.  Before psychoanalysis he had studied veterinary science and had a good grasp of bodily processes.  He and I wrote a paper given in two parts at the Institute of Psycho-Analysis on the developing psychoanalytic and biological knowledge of sexuality.  This was at the time when research into chromosomal development and abnormalities was progressing rapidly and we had the knowledge that the embryo always begins as female and that the male is essentially a variant of the female!  Now women analysts were challenging the orthodox psychoanalytic theories on the nature of the female, emphasising castration complex and female inferiority.  Helene Deutsch’s two-volume textbook on the psychology of women was the bible.  The contribution of women analysts who have emphasised the importance of empathy, reciprocity and the crucial importance of mother-infant bonding and understanding have contributed greatly to psychoanalytic and group analytic knowledge.  Thus the group as a maternal entity through which the group members rework their early beginning, a group as maternal entity, is a major example.  Thus Foulkes’ recognition of the importance of mirroring and resonance has blazed a trail, which I amongst others have followed.  Foulkes’ network theory and matrix concept which he derived from his work with Kurt Goldstein and later Paul Schilder fit well into current research in neuroscience where we find such concepts as “social brain” and “social synapse”, a concept of how persons connect across physical and psychological space are current developments in network theory.

I have always had a strong interest in social psychology and have seen this as an essential contribution to our group analytic theory.  Thus, following the development of the concept of individuality, of the matrix of historical development as so well expressed by Norbert Elias in his Civilising Process, and I have looked for the links between this body of knowledge, of social theory and how it connects with psychoanalytic and group analytic theory.  I have seen psychoanalysis moving towards the viewpoint of Group Analysis as it has moved away from libidinal theory to object relations, self and relational psychoanalysis.  Foulkes used to say how object relations theory focused so much on the object but not on the relational.  In psychoanalysis I have found Hans Loewald outstanding in the breadth and depth of his knowledge, Winnicott and Heinz Lichtenstein outstanding as both of them had a background in philosophy as well as in medicine.

I benefited considerably by sharing, with three or four other young and promising psychoanalysts, in supervision with Anna Freud at 20 Maresfield Gardens, in the rooms that were occupied by Freud when he came to London.  What I learnt from Anna Freud was the application of structural theory to the understanding of the person.  She had little to show us about working with the patient but she did give us a platform upon which to stand and to view the person’s internal structure.  Naturally she was not at all prepared to yield to Melanie Klein’s work.

When I qualified as a psychoanalyst towards the end of the 1950s the “scientific life” of the Institute consisted of meetings on Wednesday evenings when psychoanalytic cases and theories were presented.  I well remember Bion as President of the Society who followed Winnicott who often sat as if he had fallen asleep with his eyes shut and looking up at the ceiling and I also well remember the attacks upon him and his work that were made by “Prince” Masud Khan, his former analysand.  The scandal around Khan’s acting out with his patients eventually led to his expulsion.  But there are two major issues that I have some pride in regarding my participation in the Psychoanalytic Society.  The first is the creation of the “Applied Section”.  To create this I worked with Pearl King, a great historian of psychoanalysis, who is also aware that the application of psychoanalytic thinking can inform the practice of those working with groups, children, organisations and societal problems.  I presided over that section for several years and was able to bring in distinguished biologists and intellectuals including George Steiner and ethologists.  The second that I take pride in is when I was appointed Chair of the Publications Committee, a prestigious post which oversaw the publication of the International Journal of Psychoanalysis and the International Library of Psychoanalysis, I pushed for the critical examination of the Strachey translation of Freud’s collected papers.  We held strong debates with the critics of Strachey and I well remember Jacques Derrida speaking about archives and saying that though he had only been allocated one hour for his talk he would not be able to do it in under four!  I went away and returned to find him still speaking.

I ran seminars for several years on American contributions to psychoanalysis in which I was able to introduce the work of Kohut and other self-psychologists as well as some of what I thought were very interesting developments from North America.  The reason why I was asked to do this was that no one else seemed to have any interest in it!  People were still solely preoccupied with the conflict between Anna Freud and Melanie Klein with the Independent Group, consisting of Bowlby, Winnicott, Balint and Rycroft, being a third force.  I took part with Balint and Tom Main in a research project on brief psychotherapy which eventually resulted in David Malan’s acclaimed book on short-term psychotherapy.

Therapeutic Communities

When I left the Maudsley where I was expected to combine work in outpatient psychotherapy with giving ECT, I went to the Cassel Hospital then headed by Tom Main.  The Cassel was founded after World War One to provide treatment for shell-shocked soldiers of the “officer class”.  But gradually over the years it became more and more psychodynamic. After the war Tom Main took the directorship and the Cassel became a breeding ground for psychoanalysts, as we were able to take positions in the hospital, receive a salary but had an understanding that we were expected to go into psychoanalytic training and that time was allowed for this.  Main’s brilliant mind and personality were greatly stimulating.  He worked out a method whereby inpatients were given individual psychotherapy but during the group context of their lives in hospital were closely watched through a well-trained nursing staff, some of whom also went on to train as psychoanalysts.  After several years I left to go to St George’s Hospital where I was asked to reorganise the inpatient unit on psychodynamic lines and where we pioneered working with large and small groups.  Another word about the Cassel:  we were the first hospital to offer inpatient psychotherapy to women who had suffered psychiatric illness after childbirth and mother and baby were admitted together, later fathers and even whole families.

Self and Relational Theory

In the Psychoanalytic Society I entered as a member of the Anna Freud Group, so called B Group.  The Kleinians were the A Group.  In later years I also became a member of the Independent Group.  Through work on borderline personality disorders, of which I had considerable and painful experiences, I carefully studied the work of Otto Kernberg and Heinz Kohut.  Whilst admiring the precision of Kernberg’s work and the strength of the structural diagnosis of these patients I was more influenced by Kohut’s understanding of norempathaological narcissism.  I presented his work to the Anna Freud Group and well remember how Anna did not receive it warmly.  The same coldness appeared when I talked about Erickson.  A number of us in the Independent Group met to discuss Kohut’s work and we eventually arranged exchange visits with those members of the Chicago Institute of Psychoanalysis who were his close associates.  We had exchange visits, we going to Chicago, they coming to London.  Their group was headed by Ernie Wolff whose work I much admire.  Then, developing from self-psychology comes relational psychoanalysis, whose work draws close to the group analytic viewpoint.  I was invited to California once and spoke about the relationship between psychoanalysis and Group Analysis.  I had published a well-received paper on this some time before.

Forming the Institute of Group Analysis

Around 1963, although there was a busy Group Analytic Practice, which included groups of De Mare, Skynner, Home and myself, there was still no formal teaching arrangement.  The first request came from psychiatric social workers and was met by Skynner and De Mare.  Each year the numbers grew rapidly and we recognised that it was necessary to make a formal teaching institute.  Foulkes himself was not very enthusiastic about this because, I think, he preferred to have a position as a central figure with supportive colleagues and was not enthusiastic about a teaching institute which would be more formal in its methods and would present Group Analysis within the spectrum of the group psychotherapies.  However, he agreed to teach the students group analytic theory in a seminar which I shared with him and which later was shared with the late Dennis Brown.  There was a great demand for what we called our Introductory Course which lasted for one year and which involved personal participation in a group analytic situation and later in a group analytic large group.  As psychotherapy as a whole made claims for recognition within the National Health Service we devised a Qualifying Course which would be recognised as a high level qualification on a par with psychoanalysis, analytical psychology and other psychotherapeutic approaches.  The duration was four years or more as it included participation in the one year Introductory Course and then the three years of the Qualifying Course.  Many persons believed themselves to be sufficiently experienced and senior in the profession and asked to be exempted from the introductory year but we held the line.  So experienced psychoanalysts and analytical psychologists found themselves sharing groups with novice therapists, lay persons with little or no clinical experience.  There was a levelling of status in these groups which was always a healthy experience for those who had considered themselves already fully trained as individual psychotherapists but who had little or no experience of participating in or leading a therapy group.  This first year opened up the professional defences of therapists and was followed by three years in groups meeting twice a week which were therapeutic groups for non-psychotherapists. Each group was a mixture of patients coming for their therapy and those training in Group Analysis.  This mixture for us has been vital in that the collusive professional defences which occur when the groups consist entirely of members of the psychotherapeutic professions can flourish.  Consequently the Group-Analytic Society (London) which retained a separate identity to the Institute was increasingly recognised as an important centre for those wanting to study and practise Group Analysis.  Each year we held a winter workshop when particular themes such as the healing process, the problem of shame, the listening process, were explored.  Increasingly we made use of median and large groups along the model initiated by Pat De Mare and written about in Lionel Kreeger’s “The Large Group.”

The journal Group Analysis developed out of the group analytic correspondence journal which Foulkes had initiated after his retirement from the Maudsley Hospital.  Based again upon his theory about the network and the matrix for some years the journal consisted of letters and short articles sent in for him to recognise and to comment on.  Members of his close circle helped with the editing.  Eventually we recognised that it was important that Group Analysis should be represented by a proper journal that would be taken by international libraries, by societies and by individuals and this is the journal that I had the privilege of editing for some 14 years until very recently.

S H Foulkes and Myself

I entered analysis with Foulkes as an innocent.  I knew nothing about him other than that he was a training analyst for the Anna Freud Group.  We began the analysis in his room in the Outpatient Department of the Maudsley Hospital which struck me as being a very unusual situation and caused me considerable anxiety.  He was a quiet analyst, not intervening much in the process of free association, and skilfully managing the boundaries between the psychoanalytic situation and meetings of the Group Analytic Society and group supervisions at the Maudsley.  Nowadays I would say that this was something of an insufficient style and that I would have benefited from a more active psychoanalytic approach.  However, as Foulkes said at the end of the analysis that he knew that he hadn’t done me very much harm and hoped that he had done me some good.  After that we continued on more of a collegial basis and sometimes he would ask me over to his house at the weekend where I would act as a sounding board for his ideas.  I think he had the narcissism of the discoverer, valuing his own findings, not wanting to explore or to reveal their origins in the minds of other persons. It has been suggested, and I think there is some correctness in this view, that he shut out the trauma of self-imposed exile from Germany which he left in 1933, and that he tried to “ride two horses”, that is keeping his position as a training analyst within the psychoanalytic movement and as the originator of Group Analysis.  There is undoubtedly a creative mind, a radically thinking mind, at work in his 1948 book, a vision which he went on refining and extending throughout the rest of his life.

The International Library of Group Analysis, an important publisher, to take us on

After the first volume Earl withdrew and nowadays is engaged in creating a new International Library of Group Analysis.  The series has been well received and has raised the study of Group Analysis to a higher academic level.

Propagating Group Analysis

We began a policy of automating winter workshops between London and other European centres that were developing Group Analysis.  Thus we held our meetings in Italy, Germany, Yugoslavia and Denmark.  Denmark was an important chapter in the development of Group Analysis in that I was asked to come to some meetings in Copenhagen to speak about and to demonstrate the practice of Group Analysis which was then converted into a full group analytic training conducted by a team coming from London several times a year.  This led to the Danes establishing their own Institute of Group Analysis and was followed by the Norwegian Psychiatric Association asking us to develop a course for Oslo.  This has been highly successful and led to a very strong Norwegian Institute of Group Analysis.  Altogether we can say that a very large number of psychiatrists, psychologists and other therapists in Denmark and Norway have been through the group analytic training experience and this has considerably influenced the practice of psychiatry in these countries.  To some extent this can also be said of Britain, in that Introductory Courses have been held in many parts of the country and that formal qualifying training programmes have been held in Manchester, Glasgow and Dublin.  There is now an Irish Institute of Group Analysis which will be hosting the next European Symposium in Dublin next year.

Group Analysis and Psychiatry in Britain

I always knew that it was important that as a representative of Group Analysis I should remain in working relations with general psychiatrists within the Royal College of Psychiatrists.  Without this collegial relationship Group Analysis would have been isolated and have little say in the general development of psychiatry in Britain.  Through my position in the College I was able to help in the planning for centres of psychotherapy throughout the country, breaking away from the old pattern that London was the only centre where psychoanalytic psychotherapy was available and that training always took place in the centre.  Thus we developed places in the periphery which became their own centres of initiative so that training experiences became available without having to come to London.  Manchester, the Barcelona of the United Kingdom, has been the main centre for this work which involved creating a “block” system with therapists from outside Manchester coming for intensive work over weekends.  The debate as to the advantages and disadvantages of the block system as compared to the “drip-feed” of regular twice a week groups is still going on.  The strongest arguments against the blocks system have come from Yannis Tsegos, a Greek psychiatrist, who trained in London and who has formed a very successful Institute of Group Analysis in Athens, part of the “Open Therapy Centre”, a very successful day hospital providing facilities for aftercare or for treatment of the neuroses and psychoses on an outpatient basis which were not available previously in Greece.

Similarly I was privileged to have the position of the Chair of  the Psychiatry Section of the Royal Society of Medicine which is a centre for general and specialised psychiatry and which had become a meeting point for psychotherapists and their opponents.  My programme for the year of my Presidency was organised round the theme of boundaries. We looked at boundaries in: neurology, ego boundaries, therapeutic frame works and therapeutic communities.  Regarding therapeutic communities, I was a founding member of the Association of Therapeutic Communities, which has helped the survival of these therapy centres, which throughout their long history have had to struggle to maintain their positions, such as Maxwell Jones’ Henderson Hospital, Tom Main’s Cassel Hospital, David Clarke’s Fulbourne.  There is a significant input into forensic psychotherapy through the group wing at Grendon Underwood Prison.

Transmission of Group Analysis

This involves writing for textbooks, thereby ensuring that Group Analysis is included in the sphere of psychiatry.  It is transmitted through workshops and symposia but above all by group analysts remaining significant members of the psychiatric and psychotherapeutic professions and working alongside colleagues with different orientations.

I am honoured to be called the standard bearer for Group Analysis and I have planted the flag in many countries.  I recognise the importance of working within the International Association of Group Psychotherapy, which had originally been formed by Moreno, Foulkes and Joshua Bierer, a social psychiatrist.  However, it has become very largely a Morenian organisation, principally of psychodramatists and with relatively few representatives of Group Analysis.  I met with Moreno in his dying days at the Zurich Conference of IAGP and was convinced by his sincere wish that IAGP should become a broadly based organisation.  Through my work in IAGP I was honoured with the Presidency which led me to travel on its behalf, for instance to Taiwan, Mexico and Argentina.

The Broad Basis for Group Analysis

It is fascinating to try to draw together strands from different disciplines and to strengthen the theoretical model for Group Analysis.  The strands come from evolutionary psychology, from anthropology, primatology, neuroscience, sociology and social psychology.  Drawing strands together is a task, which we can all take part in.  The theme of this conference, The Mediterranean as a Bridge, seems to me to draw on the history of culture and civilisation, ethnicity, religion and economic geography, for instance the work of Braudel.  I hope that you will allow an Englishman, one from the North of Europe, and whose parents came from Russia to England in 1919 to escape the terrors of the civil war.  My Jewish heritage connects me to Europe as a whole and possibly to Spain in particular as it is possible that my ancestors left Spain in the expulsion of 1492.  I have been asked to speak about my own life within Group Analysis and I hope that in doing so I have cast some light on its history.  There is much more to tell but I fear that I have already exceeded the limits of your patients and I look forward to the ensuing discussion.

Malcolm Pines