Commentary 4 ‘Developing practice: from the private to the public’ David Glenister
David Glenister; Lecturer; School of Nursing, Social Work and Applied Health Studies; University of Hull
Introduction The focus of this paper is the life of the 20th Century’s foremost British exponent of mental nursing, Emeritus Professor Annie Altschul CBE, FRCN, and addresses personal and public life. I will focus upon ‘people who are nursed’, specifically, Mrs. X., Miss Altschul, and myself. The primary sources used in this paper are the papers recently uncovered by Dr. Steve Tilley, Senior Lecturer, University of Edinburgh, which reported upon Miss Altschul’s British Commonwealth for Nurses Scholarship Fund funded visit to the United States of America. I also draw upon my own interviews with Miss Altschul. While I was fumbling with tape recorder and cassettes Miss Altschul told me ‘I am not a historian, but I have lived such a long time people come to speak to me about history’ - one of those unrecorded casual reflections so frustrating to oral historians. There is, I wish to suggest, something to be learnt from Miss Altschul’s personal reflections in public, that take us towards a fuller understanding of mental nursing, and perhaps even of being human in a complex world today. The first part of this paper addresses the private. Mrs X Miss Altschul did not accept Mrs. X’s ‘setting of the stage’ for psychoanalytic psychotherapy, and refused the offer of a low armchair beside her bed. She offered instead, ‘simply being together, enjoying companionship, liking each other’ [Altschul 1960:2001a:62]. For Mrs. X. this was ‘second rate therapy’ [Altschul 1960:2001a:1].
Miss Altschul noted Mrs. X.’s ‘inability to pursue emotional topics’. When Miss Altschul [1960:2001a:3] encouraged Mrs. X. to reflect upon herself, the result is ‘verbal cliché, without emotion’ [1960:2001a:62]. ‘It is obviously too difficult to look at herself. She blocks completely and says she cannot remember, or talks of her guilty feelings without evidence of feeling at all’ [Altschul 1960:2001a:63]. ‘When anything approaches the topic of sex, she immediately stops talking altogether’ [Altschul 1960:2001a:64]. ‘She refers to her children’s problems as it (sic) she were talking of case material’ [Altschul 1960:2001a:63]. ‘She blocks or changes subject, and with me found it easy to draw red herrings’ [Altschul 1960:2001a:64]. Mrs. X. ‘values material possessions for their own sake and professes interest in middle-class cultural values such as music, of which, however, she has no knowledge’ [Altschul 1960:2001a:63].
Mrs. X is emotionally hollow, with only clichés, empty gestures and distractions to protect this inner emptiness. She does not know herself, or her feelings, especially her sexual feelings. She is unable to please herself, or others. Her social ambitions and materialism emphasise this hollowness. There is no secure sense of being, or being with others. Miss Altschul’s exact prose reveals this emotional hollowness.
I wish nevertheless to suggest there is something of substance here that is not specified. This is alluded to in Miss Altschul’s use of religious words, such as ‘reverence’. Miss Altschul also refers to the ‘new philosophy’ of existentialism, but this is not referenced, or pursued. [In passing: Dr. R.D. Laing published ‘The Divided Self: An Existential Study in Sanity and Madness’, a few years earlier in 1959]. I wish to suggest the Jewish existentialist philosopher Martin Buber’s work is useful here when attempting to articulate something so subtle yet so substantial.
Buber contrasted the ‘eternal thou’, with the limitations of things [Buber 1937]. Individuals could acknowledge the eternal thou in their relationships with others, and the eternal thou that transcended all individuals. This would also involve individuals ceasing to use each other as things. This acknowledgement, or turning, could transform individuals and institutions. The eternal thou could transform the hollow world of things to the hallowed world of thou in relation to thou. Miss Altschul acknowledged the hollowness of Mrs. X, but there was no transformation. Despite this, I wish to suggest her combination of existentialism and religious language promises something more.
To grasp something so substantial yet so subtle, I wish to move beyond the texts, and the hints within them, to my own experience of Miss Altschul.
There was a time, almost two years ago now, when I experienced unspeakable terror, and was beyond everyday reality. Miss Altschul invited me to stay for a weekend, after I had written to her at the suggestion of a friend. She wrote back indicating that she knew of my aloneness, and suggested I was disturbed and deluded. Afterwards, I wrote of my understanding of the relationship between mental health and mental illness.
Mental illness and mental health are not mutually exclusive, since one can be deeply depressed, even beyond standard reality, and yet more true to oneself, more true to others, than one has even had the courage to be before. Thus, mental illness, in the form of psychosis, and mental health, in the sense of a terrifying and exotic authenticity can exist together, in the same person, in the same time, in the same place [Glenister 1999].
The issue here for me was that of being authentic in the world, and the awful realization of inauthenticity. This realization was terrifying.
To be truly sick is to discover health, and this necessarily involves a savage tearing of the veil of illusions, the petty illusions and lies of one's life story, and the bigger illusions and lies of the world in which most of us live, most of the time. This rape of innocence is a disgusting and
desperate act, yet it is necessary if we are to move beyond both private and public non-reality. Whether an act courted, or threatened and then endured is somewhat irrelevant. To enjoy the wineglass of blood red wine of life to the full, one must taste, and even learn to enjoy, the last mouthful of foul and fetid dregs [Glenister 1999].
To be nursed, I discovered, was to discover the authentic within the inauthentic.
I found being nursed humiliating and hurtful, not because of her, but because she left me alone with my own torment. No cloying words of comfort, but the simple acknowledgement of the way things were. A simple refusal of lies and illusions. Few words were said, for we mostly spoke and listened telepathically, sometimes when I was awake, and sometimes when I was asleep. She was like a mirror, in which my deformities were starkly exposed. She simply was. Profoundly reconciled to herself and the world, yet aware of the possibility of change [Glenister 1999].
I have taken the rather unusual step of the disclosure of the personal in public because it may reveal something of Miss Altschul’s mental nursing practice. Authentic being, resolute ontology, was, and indeed still is, it appears to me, central to Miss Altschul’s mental nursing practice. This is a severe challenge to the ontological insecurity to be found in mental illness, as indicated in Dr. Laing’s  early work. This conflict between one’s own ontological insecurity and someone else’s relative ontological security is greatly disturbing. However, there is something ultimately satisfying in discovering something trustworthy within, of finding something hallowed rather than hollow.
The second part of the paper addresses making private knowledge public. The content of Miss Altschul’s  contribution to ‘The Wounded Healer’ is mostly unremarkable in its lack of detail of the experience of mental illness, and mental nursing and its style. There is a intimation of ‘very real and overwhelming personal problems’ [Altschul 1985:168], but there is a tacit agreement that the past will not be discussed [Altschul 1985:170], and good nursing is described as little more than tactful observation to ensure safety, the serving of tea, accompanied walks, and the inevitable game of Scrabble [Altschul 1985:170]. At best, nurses were ‘respectful’, and ‘never condescending’ [Altschul 1985:170]. There is no suggestion of constructive conversations, other than ‘small talk’ [Altschul 1985:170], but as indicated above sometimes physical and psychological presence can be affirming, or few words, or even no words. This text indicates again the difficulty of writing about nursing, its substance not being articulated even by the seasoned observer, such as Miss Altschul.
The existence of the chapter is nevertheless remarkable, for it is a public discussion of private events; more particularly, in its discussion of psychiatric patienthood by someone who was at the time an esteemed professional. Altschul revealed herself not just as someone who studied and taught mental illness, but as someone who for a time was mentally ill. This was a subversion of the public proper.
A comparison is helpful here to reveal the situation. Another nurse tutor, Ms. Mary Barnes, who died this year, was the most famous resident of Kingsley Hall, where she undertook a journey to the depths of madness and back. Ms. Mary Barnes and Dr. Jo Burke, influenced by Dr. R. D. Laing, sought to
understand recovery from psychosis and schizophrenia. This famously involved not only a breakdown of standard reality, but a breakthrough to a new ontologically sounder reality. Later, Ms. Mary Barnes herself established a refuge for those in emotional turmoil. She was, like Miss Altschul, a missionary into madness. It is of note that both Miss. Annie Altschul and Ms. Mary Barnes were women who sought to turned their private pain into public politics. This personification contrasts with that traditionally male prerogative of pontificating. Dr. R. D. Laing, for example, a most eloquent speaker, never moved beyond the quagmire of his own despair [Huxley 2001].
The third part of this paper addresses psychiatric politics. English social psychiatry: Altschul wrote of California ‘our concept of Social Psychiatry has great appeal’, and specifically mentioned a forthcoming visit by Maxwell Jones [Altschul 1961/2001:21]. This is elaborated when topics of discussion are noted in the California visit
Among topics most frequently raised, apart from questions about England, were problems related to Ward Management, Therapeutic Community and Patient Government [Altschul 1960b/2001: 40]
Miss Altschul’s use of the possessive case, ‘our concept of Social Psychiatry’ tellingly denotes both national and therapeutic affinities.
The development of democratic psychiatric services, and the critique of authoritarianism is evident in the California report [Altschul 1960:9], and owes much to the work of Dr. Eric Fromm, and the largely Jewish refugees of the Frankfurt School in exile. Dr. Hildehard Peplau was supervised by Dr. Fromm [Barker 1998], and his influence upon her work is readily evident, in its focus upon patients developing skills in participating in wards, hospitals and society at large.
In his American history of psychiatry, Shorter  referred to social psychiatry as the English contribution to global psychiatry. This is an understandable mistake. Dr. Joshua Bierer, Dr. Maxwell Jones, Dr. J.R. Rees and Dr. T.P. Rees, the most prominent proponents, were resident in England, but not English. Dr. J.R. Rees and Dr. T.P. Rees were Welsh, and Maxwell Jones was a South African, of Welsh descent, who was resident in Scotland at the outbreak of war. Dr. Joshua Bierer, like Miss Altschul, was a Jewish refugee. His contribution to English social psychiatry was the establishment of Marlborough Day Hospital, democratic Social Clubs [later to evolve into Clubhouses], and self-help networks. Nevertheless, his work has been largely ignored in the history of social psychiatry. Until Shorter  his place within the history of psychiatry is almost entirely marginal. His eccentricity, grandiosity and thick Germanic accent may not have helped in this matter [Clarke 1998], but nor can his status as a Jewish refugee be discounted as irrelevant.
Mental nurses were central to social psychiatry, because they were integral to the ‘therapeutic environment’, but not to consulting room psychotherapeutic psychiatry. Their role was not ‘thought out’ in the latter, but had been in the former [Altschul 1961:2001:21]. There can be little doubt that Miss Altschul sought to ‘think out’ the role of the nurse in social psychiatry. As such, she was one of its chief
practitioners and propagandists, and this becomes more remarkable when the general absence of women in the history of psychiatry is considered. Despite this, Altschul does not yet have a place in the history of social psychiatry. This may simply be a matter of not being a psychiatrist, but then being a Jewish woman may be relevant too.
A public and political life After the Second World War Altschul was an active member of the Socialist Medical Association, and relished the company of other socialists. Unlike Dr. Peplau, who briefly under the influence of Eric Fromm criticised authoritarian practices and advocated democratic practice but thereafter sought the narrower aims of ensuring nurses were not second class citizens [Lego 1999], Miss Altschul remained faithful to her early political vision.
In British 20th century mental nursing, it is not easy to find a peer of anything like Miss Altschul’s standing. There is nevertheless one individual who shared her socialist commitments, political aptitude, and willingness to enter the public sphere in pursuit of political aims, namely, Mr. George Gibson. English eugenic legislation was presented in 1931 by Major Church, but unlike the German legislation two years later relied upon voluntary rather than involuntary sterilization, and did not address penal cases [Blacker 1933-4]. Mr. Gibson, as General Secretary of National Asylum Workers Union [NAWU], and Dr. Hyacinith Morgan, a NAWU-sponsored MP, played significant roles in defeating this legislation [Carpenter 1988]. Dr. Blacker [1952-3:17], the General Secretary of the Eugenics Society, later undertook a study of German National Socialist eugenics and vivisection. He concluded that ‘on a scale of moral turpitude, the euthanasia of the insane ranks lower than the vivisection of human beings’ and that ‘the principle of the inviolability of human life goes by the board in war time…when human life is held cheap’ but acts of ‘vivisection of human beings’ were ‘atrocities’. The defeat of the British 1931 eugenic legislation was perhaps a defining moment in the history of mental nursing, when an alliance of the trade union movement and the labour movement sought to defend the working class, and individuals with disabilities within it.
Before the Nurses Act 1943, Mr. Gibson thwarted the attempt to introduce the second-level mental nurse, while Mrs. Bedford-Fenwick failed in the same endeavour with regard to the second level general nurse. In 1945 Mr. Gibson sought to establish undergraduate and post-graduate nurse education, including doctoral nurse education, and to link grading with education. Mr. Gibson rose to become the General Secretary of the Trades Union Congress, arguably the most prestigious and powerful post within the male working class public sphere. These two individuals shared a commitment to socialism and an opposition to eugenics. One working class male, one middle class female; one sought the occupational advancement of mental nursing through trade unionism and the other through academia. The routes taken by these two individuals into the public sphere were structured within gendered and classed opportunities.
The public and the private Several boundaries between the public and the private have been examined in the paper. First, the fluid boundary between spiritual and temporal time, the former involving the covenantal authentic acknowledgement of thou, sometimes even transcendence of time itself, and the acknowledgement of things in contractual clock time. This fluid boundary has been recently explored by Tilley and Pollock . Second, disruptions to the boundary of private pain and public politics. Two
women have been described who disrupted the boundary between private and public through their assumption of patienthood, one temporarily and one almost permanently. The notion of redemptive sacrifice cannot be ignored here. Thirdly, the more stable geographical boundaries between social class-based and gendered spheres. The occupational opportunities for advancement of a middle class woman were addressed. The absence of women in the almost entirely male history of psychiatry was noted. The specific difficulties faced by Jewish refugees in medicine and nursing were also noted briefly. In short, the boundaries between private and public can be demarcated by time, feeling and thought and geography, and these boundaries cannot be separated from considerations of class, gender, and religion. Summers [2000:18] usefully argues that when women [such as Miss Altschul ]entered public life they brought with them into the public sphere formerly private traditions, such as the covenant rather than the contract, and the spiritual rather than the secular. ‘Lineages’ [Summers [2000:18] transmitted these traditions. I do not mean to appear discourteous when I suggest Miss Altschul’s work may at present be most sympathetically received by migrants, emigrés, and others who have crossed boundaries.
The fifth part of the paper addresses epistemology Living the past in the present The historian seeks to discover the past in its remnants. Usually these remnants of the past are material, e.g. documents, tape recordings and badges. However, these remnants are also mentalities. These mentalities have a continued existence, more subtle yet stronger than material remnants. Historians in a sense are the living past, just as others of today are, but the difference is that historians seek to know the past they live.
Before presenting themselves as master craftsmen of stories made out of the past, historians must stand as heirs to the past. This idea of inheritance presupposes that the past in some sense lives in the present and therefore affects it. It is this passive dimension of historical inheritance that is best expressed by the idea of historical debt. Before even forming the idea of re-presenting the past, we are in debt to the men and women of the past who contributed to making us what we are. Before we can represent the past we must live as beings affected by the past [Ricoeur 1981:23:italics in original].
Thus Ricoeur indicates the primacy of ontology, of temporal being in this world, and from this follows an epistemology which seeks to acknowledge the lives of the living past. In this paper, I have attempted to work reflexively, drawing upon my own struggle towards humanity in the presence of a humane other, and at the same time to address social and political realities.
Conclusion: As a nurse historian, I am conscious of Ricoeur’s emphasis upon the idea of historical debt, and I have attempted to make a small payment against this debt by attempting to articulate the relationship between the private and the public. The crossing of boundaries, between the private and the public, has formed a theme in this paper about the life of Emeritus Professor Miss Altschul CBE, FRCN. These boundaries have been between the sacred and secular, the public and the personal, and classed and gendered social spheres. These boundaries have formed the background to Miss Altschul’s daily search for the authentic spiritually hallowed within the inauthentic emotionally hollow. That this is the life of a Jewish socialist middle class woman refugee cannot be ignored, and indeed this personal experience may have informed
many public actions. Reverence for words and books, and the importance of ensuring that reverence is appropriately placed, is explicitly indicated in Miss Altschul’s report upon her visit to the United States of America, and perhaps without her lifelong search for reverant words of substance we would not be meeting here today.
Altschul, A. (1960/2001a) ‘Report on the one-to-one relationship with Mrs. X, Boston’, Pages 61-64 IN Altschul, A. (2001) A Festschrift for Annie Altschul, Department of Nursing Studies, The University of Edinburgh, and UK Centre for the History of Nursing.
Altschul, A. (1960b/2001) Report on visits to state hospitals in California etc. in June, July and August 1960. Pages 37-49 IN Altschul, A. (2001) A Festschrift for Annie Altschul, Department of Nursing Studies, The University of Edinburgh, and UK Centre for the History of Nursing.
Altschul, A. (1961:/2001) Report on a tour of the United States of America, Canada and Australia to study psychiatric nursing. May 1960-April 1961. Report to the Commonwealth Fund. Pages 2-36 IN Altschul, A. (2001) A Festschrift for Annie Altschul, Department of Nursing Studies, The University of Edinburgh, and UK Centre for the History of Nursing.
Altschul, A. (1985) ‘There won’t be a next time’, Pages 167-175 IN Rippere, V. & Williams, R. (eds.) (1985) Wounded healers: mental health workers’ experiences of depression, John Wiley, Chichester.
Blacker, C.P. (1952-3) ‘Eugenic’ experiments conducted by the Nazis upon human subjects, Eugenics Review 22 9-19.
Buber, M. (1937) I and Thou Trans. Smith, R. G. Edinburgh: T and T Clark
Burleigh, M. (1994) Death and Deliverance: 'Euthanasia' in Germany 1900-1945, Cambridge: Cambridge University Press
Carpenter, M.  Working for Health: the history of the Confederation Of Health Service Employees, London: Laurence and Wishart
Clarke, L. (1997) 'Joshua Bierer: Striving for Power', History of Psychiatry, viii, 319-332.
Glenister, D. (1999) ‘Discovering health in sickness’, Hull: Unpublished Paper
Huxley, F. (2001) ‘Shamanism, Healing and R.D. Laing’: The Second R. D. Laing Conference Royal College of Psychiatrists: Philosopy Special Interest Group Saturday 21 October 2000 London: School of Oriental and African Studies
Laing, R. D. (1959) The Divided Self: An Existential Study in Sanity and Madness, London: Tavistock Books
Lego, S. (1996) 'Psychoanalysis and Psychiatric Nursing in America. An historical and current perspective', Association of Psychoanalytic Psychotherapy Conference, "The Culture of Nursing:Psychoanalytic Perspectives". October 12, 1996, Tavistock Clinic, London.
Ricour, P. (1981) Hermeneutics and the Human Sciences, [Trans. J.B. Thompson] Cambridge: Cambridge University Press
Shorter, E. (1997) A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, New York: John Wiley and Sons
Summers, A. (2000) Female Lives, Moral States: Women, Religion and Public Life 1800-1930, Newbury: Threshold Press
Tilley, S. and Pollock, L. (1999) The two cultures of the Community Psychiatric Nurse: 'twixt contract and covenant in work with 'people with enduring mental disorders', Paper presented at the 22nd International Council of Nurses Congress, London, 29-6-99.
Recommended citation format Glenister D. ‘Developing practice: from the private to the public’. : 44 pars. IN 'A Festschrift for Annie Altschul', 2001: Online UKCHN. Available at: http://www.ukchnm.org [Accessed: insert date accessed].
1 Assenmacher, Christian 2 Baitz, Christoph 3 Baitz, Michael 4 Bandrowski, Rudi 5 Berg, Richard 6 Blum, Katharina 7 Boonen, Noel 8 Braun, Michael 9 Breitbach, Christoph 10 Breitbach, Thomas 11 Bumke, Heike 12 Bumke, Margit 13 Carstesen, Uwe 14 Cipriani, Ciovanni 15 Corleis, Reiner 16 Dammers, Wolfgang 17 Dombois, Alexander von 18 Eichberger, Mir
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