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Dr. Richard Crocket.

Diary of a Trip to the United States, 13 May 1968 – 15 June 1968.

Week 5: 11 June 1968 – 15 June 1968

(13.6.68 Thursday.

The run down from the top of the Pass continued on Monday afternoon, and became a model road. There were no direction signs, however, and in due course it became a dust track again and I got lost in a military reservation. But one hit the freeway at last and in due course reached Palo Alto where I chanced on by far the pleasantest and most comfortable motel of the tour, the Mermaid Inn).

11.6.68 (Tuesday).

On Tuesday morning I went to see Mr. Preston Cutler at the Center for Advanced Studies in the Behavioral Sciences. This had been suggested to me by Al Scheflen in New York. Eric Trist had also mentioned it. To find the Center I went through Stanford University campus, and found a complex of elegant buildings in a large park-like setting, scattered with trees, and apparently unlimited space. The network of roads was self-contained, however, and it took me nearly 20 minutes to find my way out again, and I was correspondingly late for my appointment. Nevertheless, the visit to the Center for Advanced Studies was most instructive, and Mr. Preston Cutler showed himself very well aware of the nature of my own professional concerns. He provided me with a list of people in the social sciences who would have allied interests if I were to approach them. The Center is under the Ford Foundation in association with Stanford University, and provides a setting for work by distinguished scholars, with every facility made available to them. I believe there are some 40 resident fellowships. I had lunch with Preston Cutler in the open air in the rural setting of the Center on the hillside, overlooking Palo Alto and San Francisco Bay.

From the Center I made my way to the Palo Alto V.A. Hospital, and once again lectured on the theme of the therapeutic community. This was a somewhat more sophisticated audience as it included members of the staff of Stanford University but the same questions came up.

After finishing my lecture and receiving an invitation to return I went to the Stanford University Medical Center and was met by Dr. Gulevich who showed me the psychiatric unit in this 400 bedded teaching hospital. The hospital is partly staffed by University faculty members and partly by Palo Alto physicians and surgeons, and the inherent schizophrenia in this arrangement has become a nuisance. It matches the kind of problems we used to have in Britain. The psychiatric unit consists of 17 beds carved out of space originally designed for general medicine. It is a classical pattern which seems to have emerged all over the world! The unit is run as a therapeutic community by Dr. Gulevich with the assistance of 2 or 3 students who do clerking, and 2 post-graduate trainees. Patients pay $54 per day for board and lodging only and other medical expenses are additional, including doctor’s fees. Total cost for two weeks’ treatment may easily reach £1,000. It is not surprising that the average stay is 12 days. Treatment is then continued on an out-patient or day-patient basis. They mix day-patients and out-patients as we do, although in much smaller numbers. Dr. Gulevich readily agreed that these arrangements were clinically poor, but did not seem able to conceive of altering them. Teaching is carried out at the V.A. Hospital where a number of interesting attempts to experiment with therapeutic community ideas have apparently been under way, including one unit for rehabilitation purposes, matched with a control using traditional methods. The situation here is more like that in England, in that V.A. patients have nothing to pay and have many facilities offered them, and few incentives to leave hospital. This particular unit has been under the supervision of a Dr. David Daniels and the experiment is now in its second phase, a follow-up evaluation. Dr. Gulevich is a youngish man, a typical product of a teaching department. Intellectualising the situation is sufficient reward for him, at this stage at least.

After leaving the psychiatric unit I made my way back again to the office on the third floor of the luxurious hospital and met Dr. John Bowlby for about 3/4 hour. Bowlby mentioned Eric Lindemann as an important figure at Stanford, although retired from Harvard. Others have done the same, although my brief contact with him as a member of the audience at Boston left me doubtful about why he had this reputation.

The conversation with John Bowlby was free-ranging and not directed closely to specific issues, but recognised the general elements in the American scene and problems of organisation and the differences between the two countries in the way of dealing with them. Bowlby has been acting as a visiting professor at Stanford and Lindemann also.

Professor David Hamberg is on sabbatical leave at present and has, in fact, spent it at the Center for Advanced Studies. I met him briefly there. He is a surprisingly young-looking man. His interest has been in stress and adreno-cortical hormonal research. I regret now that I did not have lunch with him at the Center when invited as I discovered later that he has become interested in gorillas and is visiting Africa for some months to study gorilla behaviour in the wild. This is in association with a social psychologist in Berkeley whose name Preston Cutler gave me also and of whom I had heard previously in this connection.

On leaving Stanford I made my way in the rush hour along the freeway bordering San Francisco Bay, delivered the car back to the rental firm and enplaned for Seattle and Vancouver, with dinner en route. It was a glorious trip with the sun setting. I had no idea that Puget Sound, on the shores of which Seattle is built, is an extension of the same gulf where Vancouver lies, or was so beautiful. On reaching Vancouver about 10 p.m. I went straight to the Travelogue where my room had been booked that morning through the reservation ‘phone call to Kansas (part of the remarkable free service offered in the States, whereby making this long-distance call one can reserve a room anywhere in a chain of motels all over North America). These final two days in Vancouver have been social ones in that apart from this tape recording I have not felt obliged to concentrate on professional commitments. This has been a surprising relief subjectively; I had not really realised how single minded I had become while in America.

General Reflections.

At this point it seems worthwhile to note one or two impressions before they escape.

The American psychiatric scene is different in very many ways, but there is an underlying basic similarity in organisation. Hospitals are better equipped materially as a rule, and the more recent are outstandingly luxurious compared with anything I know of in England. Staffing is considerably more generous. Training is systematised, but within this system there is much more flexibility than in Britain. I have the impression that people attempt things with a rush, have much more at stake and can succeed or fail much more spectacularly than in our system. More research money is available and people gear their programmes to the available research money. Money is also available for services and similarly people will adapt what they are doing to the source of money.

The system of honoraria in America on which I have been subsisting during these travels also facilitates change. Anybody with something to say can move around, talking about it, and there is a resultant network of contacts which has an effect leading towards flexibility once again. Behind the whole situation there is the security of private practice although also its ties.

On this trip I had no real contact with the nursing services except at Fort Logan; and there they seemed to be very good indeed. But one does hear that it is not the same in other State hospitals. Certainly at the Bronx State Hospital nursing was almost untrained but, on the other hand, in this particular setting it seemed to me to provide opportunities for a more basic approach to some of the realities of the situation in this relatively poverty-stricken district of New York.

With regard to therapeutic community ideas my impression has been that these are certainly quite widespread but in a relatively limited and naive form. Nobody seems to be facing the two key issues which have emerged in our own experience and which I have been discussing in my lectures. These are, first of all, the significance for psychotherapy of the use of drugs in psychiatry; and secondly, understanding the psychotherapeutic relationship in the context of an induced community situation.

Further, it is clear to me that the notion of a self-contained community is artificial and that one must go back to basic network ideas for a full understanding of social psychiatric method.

The only community I found that had any really close similarity to our own (apart from the indirect contact with Daytop through the theatrical performance in New York) was Harry Wilmer’s so-called "electronic" community. But this was being conducted without insight and with many faulty elements in technique from my own point of view.

Looking back at the British situation from here, I can see that isolation at Hornchurch has, in fact, led to some rigidity of outlook both about administrative funds and about our relationship with the rest of the psychiatric treatment network. It is all right to continue the psychotherapeutic community work but unless one is also alive to the realities of the needs of other patients than those who present one, is missing out on the scientific needs of psychiatry as a whole in the same sense that Wilmer is. To have a full impact on treatment one really needs, essentially, to have a unit for psychotic as well as neurotic patients.

Similarly, the question of finding funds to put matters on a research basis needs to be tackled in a more complete way, despite all the difficulties. Thoughts about this include approaching the Ampex Foundation, the formulation of projects in writing, maintaining network contacts with people who are influential and getting an N.I.M.H and also a Ministry of Health grant if possible. It also requires reorganisation of the writing-up arrangements in the Centre. These must become much more realistic, and incorporated into the time schedule, instead of being left to chance as at present.

LAST WEEK / CURRENT WEEK (END OF TRIP)

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