Clinical Work in the Public Service
The NHS had been actively adopting the new public management throughout the 1990s.  I had left the Marlborough Day Hospital therapeutic community in 1976, to take up a Consultant post at St Bernard’s Hospital, Ealing. I continued to make contributions on therapeutic communities, and continued reflecting on therapeutic communities through supervision work, ultimately to write my own book, in 1987.
 
1969 Hallucinosis and propranolol
British Medical Journal 1969; 2: 445 (Letter 17th May).
I remember when I was a young psychiatrist, I ahd a patient treated for cardiac arrhythmia with the new Beta-blocker (Propanolol) who became psychotic with visual hallucinations and suicidal intention.  On admission we stopped the Propanolol with immediate relief of his MH symptoms. When restarted those symptoms recurred. A single case was not worth more than a letter, but it was one of the first reports of such side-effects of the new beta-blockers.  It is memorable as it raised y life-long puzzlement over the chemical versus experiential basis of a human personality.
 
1979 Demoralisation in the hospital community (Paper given to Napsbury Hospital Staff). 
Published in Group-Analysis 11: 84-93.  Re-published in Hinshelwood, R.D. (2000) Thinking about Institutions.  London: Jessica Kingsley].
In the late 1970s, I became interested in the dynamics of the whole organisation, St Bernards being a very large group of thousands -- staff plus inmates. This paper was about the distinctly quirky kinds of phenomena that occurred in these highly institutionalised old places.
 
1982 Models of demoralisation
(Paper presented at 4th Windsor Conference: Anglo-Dutch Workshop on Therapeutic Communities, September 1982)
Published 1988 British Journal of Psychotherapy 5: 218-227
This was another attempt at understanding the disaffection of the therapeutic community at the Marlborough Day Hospital, and the way that demoralisation became endemic, and the organisation caught in a rut it could not extricate itself from.
 
1987 The psychotherapist’s role in a large mental institution.
Psycho-Analytic Psychotherapy 2: 207-215
Psychotherapy has an ambiguous position within the psychiatric services, both needed and somewhat devalued. This paper addresses psychodynamic issues embedded in the unfortunate professional contest between psychological and biological approaches.
 
1993 Locked in role.
Journal of Forensic Psychiatry 4L 427-440.
In the 1970s, I worked as a psychotherapist in Wormwood Scrubbs prison when there was a considerable psychological input to prisoners’ treatment and rehabilitation. I left after a couple of years with the sense that psychotherapy was not going to make much headway against the culture of the prison, which was based on evasion of the emotions of guilt and helplessness – by both staff as well as prisoners. It took some considerable time to write up and publish a view on how the culture developed and was rigidly maintained. A schism between toughness and weakness seemed to play out a defensiveness at the social level.
 
1994 The relevance of psychotherapy
Psycho-Analytic Psychotherapy 8: 283-294
ike the previous paper on prisons, I became interested in the culture of psychiatric services and units. This too was rigid and appeared to be schismatic – in this case a schism between an emotionally distanced scientific attitude, and a sentimentalised empathy represented by the biological psychiatrists and the therapeutically oriented staff.
 
1996 Psychiatry and psychotherapy.
Psychoanalytic Psychotherapy 10 Supplement: pp 5-10
This follows on the 1994 paper above on the culture(s) of the psychiatric services which exist in a more or less permanent schismatic state. I attempted to give circumstantial evidence from my experience in the past – particularly from St Bernard’s Hospital – of these two cultures, and how they supported each other, whilst undermining each others’ efforts.
 
1998 Creatures of each other: Some historical considerations of responsibility and care and some present undercurrents.
In Angela Foster and Vega Roberts (Eds.) Managing Mental Health in the Community: Chaos and Containment in Community Care. London: Routledge.
Finally in this flurry of papers stimulated by revisiting all the stress and strain of working in an organisation that had set me off 30 years before to puzzle about MH institutions, I responded enthusiastically to this invitation to write about community care as the attempt to thrust beyond the institutional care of the large mental hospital. Whist thoroughly supporting the whole move to the community, I was concerned that not enough had been learned about the dynamics of care to avoid a similar defensiveness creeping into the new forms of care out there.
 
1994 Integrity of the person and the day hospital: evidence from a therapeutic community.
International Journal of Therapeutic Communities 15: 29-38.  Italian translation, Il Day Hospital e la figura genitriale combinata.  Il vaso di Pandora 2.
I returned here to reflect on the possibilities of a day therapeutic relation of personality disordered people in a therapeutic community. There is a sense in which there is a potential Oedipal relationship of each individual to the institution which is in itself structured with other people and groups. The relations with multiple others offer the possibilities of working with the sense of exclusion – replicating Oedipal exclusion from the parental couple. In a day hospital that Oedipal configuration and the sense of exclusion comes and goes on a  daily basis, and gives a variety of experiences of exclusion and entry, constantly moving.
 
2014 Whose suffering – Carers and curers. 
Psychosis 6: 278-287. I have remained interested in the psychodynamics of the caring institution and the unconscious influences which may obstruct carers.  Such people come with the best of intentions and serve in institutions whose cultures are often far from caring, but mechanical and institutionalising.  It is no fault of the staff, who align inevitably with the cultural attitudes that depersonalise persons (in fact staff as well as those they care for).  The ‘fault’ if it must be laid somewhere is in the unconscious quality of these attitudes, processes and practices.
 
2004 Suffering Insanity: Three Psychoanalytic Essays on Psychosis.
London: Routledge
Then eventually in 2004, I wrote the book, Suffering Insanity, I had really wanted to write 30 or more years before, about the experience of suffering from a psychosis, and the experience of caring professionally for such people, and how such experiences might be actually useful to the carers.
When I started out as a trainee psychiatrist I became concerned about the treatment of people with psychosis, and the extraordinary difficult in understanding them. And this included the limitations in understanding that exist amongst professional carers. This books became therefore a late culmination of what I had learned in my 30 years in psychiatry. It is in three parts, the first detailing the experience of professional carers. The second deals with some psychoanalytic theories of what it is like to be such a person – the experience of being psychotic. And the third part is an attempt to detail what happens when the suffering of both sides – the professional carers and the afflicted patients – come together, and influence or distort the organisations within which care occurs. In a sense this demonstrates a move during my career from a concern with those people with psychosis, to a concern with how their experiences, affect the carers and then in turn the whole establishment of the institutions created to care.
 
2013  Schizophrenia, meaninglessness and personal stress.
Chapter in David Bell and Aleksandra Novakovic Living on the Border: Psychotic Processes in the Individual, The Couple, and the Group.  London: Karnac.
Having considered on many occasions the stress for staff dealing with people I  schizophrenic states, this Chapter Homes in on the problems for carers of living with meaninglessness, and the destruction of meaning.  The human mind abhors meaninglessness as nature abhors a vacuum.