Classic Text No. 133: ‘Maxwell Jones and the Therapeutic Community’,by David Millard (1996)

Abstract

This text was David Millard’s departing gift to a field to which he had contributed for 30 years, as practitioner and later as Lecturer in Applied Social Studies and editor of the International Journal of Therapeutic Communities. Charting the chronology of Maxwell Jones’s career as a world-renowned psychiatrist and therapeutic community pioneer, Millard contrasts Jones’s contribution at Mill Hill with Tom Main’s at Northfield. Jones’s most distinctive contribution was allowing patients to become auxiliary therapists and freeing nurses from the nursing hierarchy. Focusing on a subset of therapeutic communities in adult psychiatry, Millard’s paper is not an academic history of therapeutic communities as such. The roles of happenstance and positive deviance are demonstrated in the way change occurs in therapeutic communities. The ‘charisma question’ is briefly explored.

Introduction: ‘I concur as a clinician’

Biography of David Walter Millard

David Walter Millard was born in Stroud, Gloucestershire, in 1931; his mother was a nurse and his father was a chemistry teacher. He qualified as a doctor at Birmingham University in 1955. Following house jobs at Burnley General Hospital, he took a Short Service Regular Commission in the Royal Army Medical Corps, serving in Germany 1957–60.

Millard’s interests moved from General Practice to Psychiatry, and he returned to Birmingham to a Registrar post at Rubery Hill Hospital, where he was introduced to therapeutic community practice by John Yerburgh. Taking his Diploma in Psychological Medicine (DPM), Millard joined Sir William Trethowan’s newly established Psychiatric Professorial Unit at Queen Elizabeth Hospital in 1962 as his first Registrar, and established a therapeutic community in Ward North 5A. In 1965–66 he became the first holder of a newly created Senior Registrar Post in Child Psychiatry before returning to Rubery Hill in 1966 as Consultant Psychiatrist, where he was involved in establishing two further therapeutic communities.

Millard acquired a range of teaching experiences, including Visiting Lecturer in Social Studies at the Selly Oak Colleges and giving courses in psychology to social work and theology students at the university. A fellow consultant, RA Lambourne, had obtained a lectureship in the Theology Department at Birmingham University, where he established a post-graduate Diploma in Pastoral Studies. This represented an attractive career move for Millard, who had developed a growing interest in the overlap between medicine and social science and wanted to ‘find a cross-disciplinary role for myself in life’ (Millard and Fees, 2001). In 1970 he applied for a lectureship in Applied Social Studies in the University of Oxford.

Once in Oxford, Millard became involved with the newly formed Association of Therapeutic Communities, joining its Steering Group in 1977, convening its Research Group (1977–83) and becoming Editor of the International Journal of Therapeutic Communities (1983–91). He also took on clinical and teaching positions within the university and the local NHS, including individual psychotherapy in Professor Michael Gelder’s newly established department of psychiatry at the Warneford Hospital, and extending his work to London as Consultant Psychotherapist to mental health day-centres in Kensington and Chelsea. He was a member of the Council of the Institute of Religion and Medicine (1970–90). Almost certainly uniquely for a psychiatrist, Millard was instrumental in the creation and development of a new Oxford College: he was a founding governor of Green College, later Green Templeton College (Dixon, 2021).

On retiring from his university post in 1991, he took a number of locum consultant psychiatrist appointments with the Oxfordshire Health Authority, before moving to a substantive post as a psychogeriatrician for the Oxfordshire Mental Healthcare Trust (1994–2000). He maintained his interest in this field as a Trustee of Vale House in Botley (an Alzheimer’s home) (2000–6), the facility in which he eventually spent the last days of his final illness. An accomplished musician, he obtained an MA in musicology in 2005 (Millard 2006; Millard and Agulnik 2021).

David Millard, FRCPsych, MD, MA (Mus), died on 13 January 2021, while this special issue of History of Psychiatry was in preparation.

The clinician moves to academia

Millard’s move to Oxford in 1970 limited his direct clinical involvement in therapeutic communities. It allowed him to develop his teaching and his intellectual interest in multidisciplinary work and in the overlaps between medicine and the social sciences. It also allowed him to make significant academic and practical contributions to the therapeutic community movement. The launch of the Association of Therapeutic Communities (ATC) at a conference at Littlemore Hospital in 1972, and the developing apparatus of a newly self-conscious field, attracted and gave scope to his personal and professional interests (Kennard 2010). Settling into Oxford and the university, Millard gradually brought his academic focus to bear, beginning to write about therapeutic community more frequently from 1976. In 1983 he was invited by RD Hinshelwood to become joint editor of the International Journal of Therapeutic Communities (later, simply Therapeutic Communities), a position he held until David Kennard succeeded him in 1991.

In his inaugural editorial, Kennard (1991) wrote that Millard had ‘devoted considerable talent and energy to establishing it as a respected academic journal’. Millard wrote many lengthy editorials on topics ranging from the history of mental health legislation, reforms of the NHS and the nursing profession, to reflections on the philosophy of science and scientific explanation. Much of this writing was subsequently brought together post-retirement in his 1994 MD thesis, which also included one newly written and two previously unpublished documents.

Millard’s final act as the editor in 1991 was to oversee publication of a special double issue devoted to the life and work of Maxwell Jones, who had died in Nova Scotia the year before (Millard, 1991). Compiled by guest editor Stuart Whiteley, its objective for Millard was to convince a sceptical professional world that here was a therapeutic method which was clearly defined, empirically grounded and with ‘an intellectually convincing set of theories’, effective in clinical practice and successful independently of charismatic individuals. ‘Jones was a figure larger than many,’ Millard wrote in the Classic Text, ‘but a succession of others have found that they also have sufficient gifts to employ this technical apparatus effectively and to the great benefit of their patients’ (Millard, 1996: 602).

The relative contributions of Maxwell Jones at Mill Hill and Tom Main at Northfield

In the late 1960s Maxwell Jones’s name was ‘probably better known throughout the world than that of any other British psychiatrist’, according to Morris Carstairs (1968: 9). Millard’s text affirms Jones’s place in the history of psychiatry, taking the reader chronologically through Jones’s career: charting his transition from biological psychiatrist/researcher to pioneer of a therapeutic method whose working material was social interaction, through to an international reputation as a champion of the therapeutic community.

Millard wrote of Maxwell Jones working at Mill Hill, and Tom Main working quite independently at Northfield Military Psychiatric Hospital. The most striking thing was how, from different starting points, they arrived at a similar conclusion: that there are therapeutic benefits to be gained from professional staff withdrawing some of their authority and handing over some of their responsibilities to patients. How much authority and which responsibilities are matters for judgement and debate. The assertion was that acquiring this agency and exercising these responsibilities, and discovering and working through the consequences, constitute the whole or at least a major part of treatment.

This conclusion was arrived at by different routes, as the institutions Northfield and Mill Hill were different in many respects. Northfield was a military hospital, Mill Hill was civilian, although largely given over to treating military personnel. More importantly, Northfield was staffed by psychoanalytically oriented colleagues selected for their independence from mainstream psychiatry, while Mill Hill, sited in an evacuated North London public school, had been commandeered by the Maudsley, the UK’s pre-eminent psychiatric teaching hospital. Group psychotherapy and group-based programmes were at the heart of the work at Northfield with full support from the Directorate of Army Psychiatry (Bridger, 1990), while for Jones this was new and uncharted territory. For all these reasons the odds would have favoured Northfield as the birthplace of the therapeutic community, despite an early miscarriage.

In 1942 the psychoanalyst Wilfrid Bion started his tenure on the ‘somewhat chaotic’ Training Wing at Northfield by diagnosing an organisational problem: ‘what was required was the sort of discipline achieved in a theatre of war by an experienced officer in command of a rather scallywag battalion’. He formulated a working hypothesis that the discipline required in this situation depended on the presence of: (i) ‘the enemy who provided a common danger and a common aim’, and (ii) an officer who ‘being experienced, knows something of his own failings, respects the integrity of his men, and is not afraid of either their good-will or their hostility’ (Bion, 1961: 12–13). The gist of the experiment was to get the men to regard neurosis as the common enemy, to be defeated by their own common efforts. Millard describes in some detail what happened next, and the outcome is well known: Bion was transferred before the experiment had time to bear fruit, although not before the patients ‘began to bear at least a recognizable resemblance to soldiers’ (Bion, 1946/1996: 90). A longer-term outcome was that Harold Bridger and Tom Main, arriving at Northfield some two years after Bion had left and learning of his fate, were mindful of the importance of working with the wider hospital system (Bridger, 1985; Main, 1983).

Main is perhaps best known for the rousing 1946 paper in which he influentially used the term ‘a therapeutic community’ (the origins of which are contested; see Fees, 2005) to describe developments at Northfield:

The Northfield Experiment is an attempt to use a hospital not as an organization run by doctors in the interests of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the individual for life in ordinary society. (Main, 1946, our emphasis; see Editorial note for explanation)

In marked contrast, Jones brought no professional background or prior involvement in group or organisational dynamics to his work at Mill Hill. Recruited for his experience in research on psychosomatic disorders, Jones was put in charge, together with cardiologist Paul Wood, of the ‘effort syndrome’ (or, more colloquially, ‘soldier’s heart’) unit. Like Bion, Jones too embarked on an experiment, but from a pragmatic rather than theoretical starting point. Once it became clear that effort syndrome was generally a psychosomatic complaint, ‘it seemed reasonable to explain to the patients the psychological mechanisms involved in the production of the symptoms’ (Jones, 1952: 3), and an educational programme was set up. What was more revolutionary was Jones’s attitude towards the nursing staff, whom he came to treat as professional equals, involving them in reading and discussing the medical notes. In an account of the making of a documentary film of the work at Mill Hill, Edgar Jones comments:

Doctors allowed nurses to approach them directly rather than through the ward sister; they also encouraged the nurses to communicate freely with patients and take an active role. In part, this relaxation of protocol was a function of wartime circumstances. [Maxwell] Jones recalled that ‘educated mature women from the professions’ often chose nursing as their war work and ‘such people expected and deserved an active role in the treatment programme’. (Jones, 2014: 313)

This placed Maxwell Jones on a collision course with the nursing hierarchy. As he later wrote:

These early changes in the community structure threw a considerable strain on the Ward Sister who felt that her authority was being undermined; in fact the whole development almost broke down as a result of the anxiety aroused in the senior nursing group. Luckily the Medical Superintendent and Matron supported the reform and without this sanction the development would have had to be postponed. (Jones, 1952: 2)

This does not appear to have been a problem at Northfield, where the role of the nurse was integrated into the developments taking place and nurses ‘explored over a long period the nature of their role in such a therapeutic community’ (Bridger, 1985: 105).

Millard makes a point of seeking to specify those innovations introduced by Jones that have made a lasting contribution to therapeutic community practice. However, it is difficult to maintain a clear distinction between specific innovations at Northfield and Mill Hill. Millard’s claim that Jones introduced, ‘apparently for the first time in psychiatry, the use of the large group’ is questioned by Harrison (2000: 228), who notes that the approach was ‘didactic rather than psychotherapeutic’. (Jones made this observation himself, when watching the Mill Hill film at his home in Nova Scotia with Craig Fees in 1990.) The idea developed by Jones that ‘treatment was considered a continuous process operating throughout the waking day and over every aspect of the life of the patient’ was also shared with Bion, who noted as a guiding principle that ‘Study of the problem of intra-group tensions never ceased – the day consisted of 24 hours’ (Bion, 1946/1996). The development at Mill Hill of small groups, including informal nurse–patient working groups, was similar to developments in the Hospital Club at Northfield (Bridger, 1946/1996), although Millard notes that an emphasis on patients being responsible for creating and selecting their own group activities was a feature at Northfield but not at Mill Hill.

Perhaps the most distinctive feature at Mill Hill was what Millard identifies as a ‘flattening of the hierarchical relationship between doctors, nurses and other staff, and the patients’ (Millard, 1996: 585, our emphasis). Main had famously railed against, even lampooned, ‘the anarchical rights of the doctor in the traditional hospital’ with his ‘captive children, obedient in nursery-like activities’ (Main, 1946: 67). His target was the doctor–patient relationship, but at Mill Hill the key challenge was the nurse–doctor relationship. We suggest that the two most distinctive and long-lasting innovations under Jones at Mill Hill were, firstly, allowing a didactic educational programme to develop into an educational-cum-therapeutic role for patients in relation to each other as they acquired knowledge and understanding of their symptoms; and secondly, the freeing up of the role and personality of the nurse from the tight reigns of the traditional nursing hierarchy.

It was only after Jones’s time at Mill Hill, when he was at Belmont and later at Dingleton, that his reputation burgeoned into the charismatic figurehead of the therapeutic community movement. At the end of the war, the work at Northfield was more widely known, thanks to the visit by a team of American psychiatrists headed by Karl Menninger in 1945 and the resulting publication of papers by Main, Bridger, Bion, Foulkes and others in the Bulletin of the Menninger Clinic in 1946.

Unknown to Millard in the early 1990s when he was writing, Main and Jones converged briefly again, when the post-war Cassel Hospital was seeking a new Medical Director and both men applied. Main was appointed, and remained the Director until he retired in 1976. The more mercurial Jones went on to establish what became the Henderson Hospital on the other side of London, and subsequently, leaving the Henderson in 1959, had a complex cross-Atlantic career (Fees, 1998; Vandevelde, 1999).

The Classic Text and beyond: from history to happenstance

Writing ‘Maxwell Jones and the Therapeutic Community’ was a departure for Millard (1996). He had a significant body of writing concerning therapeutic community theory and practice behind him when he was encouraged by his friend and colleague Hugh Freeman to contribute a chapter about the history of the therapeutic community to the second volume of 150 Years of British Psychiatry (Freeman and Berrios, 1996). Given his personal and professional knowledge of many of the protagonists, and his depth of reading and theoretical engagement, it would be difficult to know who could have been better placed to take on the task at the time; and it met with his reflective turn towards his personal and professional history, as manifested and gathered into his MD thesis.

Volume 1 of 150 Years of British Psychiatry was given out free to delegates at the Royal College of Psychiatrists’ Annual Meeting in 1991 (Berrios and Freeman, 1991). As its title ‘Aftermath’ implies, Volume 2, published in 1996, picked up some key institutions, ideas, and people missed from Volume 1. ‘Maxwell Jones and the Therapeutic Community’ was its final chapter. The President of the Royal College of Psychiatrists, John Cox, said Maxwell Jones would have approved of this, as it gave him the last word (Cox, 1998: 249). It was also the first extended treatment of the history of the twentieth-century therapeutic community as a discrete, consistent, coherent and meaningful narrative to appear in such an academically and professionally prestigious setting. It fairly quickly became an influential and much-cited baseline for medical historians, psychiatrists and therapeutic community practitioners alike (e.g. Adams 2009; Cox, 1998; Fussinger, 2010; Gallagher, 2020; Harrison, 2000; Jones, 2004).

Although the chapter is called ‘Maxwell Jones and the Therapeutic Community’ (our emphasis), it is worth noting that Millard confined himself to addressing Jones’s impact within a specific stream of adult psychiatric therapeutic community. Millard was aware of the wide range of therapeutic communities, and touches briefly on these, including those for children and young people, and for adults in prisons and in addictions. But they were not part of the story he chose to tell, and he justified this by saying: ‘the version associated with Maxwell Jones, sometimes referred to as the democratic model, has had the widest influence and is perhaps that towards which all have tended to converge’ (Millard, 1996: 597, our emphasis).

Nor was it an academic history. Millard only used readily available published sources and personal knowledge. His narrative is in the ‘Great Man’ tradition of historiography, focused on the acts and agency of influential individuals. He approaches therapeutic community as a therapeutic technology which has been arrived at through a series of discrete, identifiable innovations: ‘I concur as a clinician’, he wrote, ‘in viewing the therapeutic community as a technique – similar in status to, perhaps, a new family of surgical interventions, or a new class of psychomotor drugs . . .’ (p. 602).

It is notable that the Classic Text does not address the actual ‘how’ of how innovation happens. In taking the reader along the narrative path of therapeutic community’s history, Millard steps from stone to stone of ‘what happened’ but avoids addressing the river of flowing process underneath. But, by paying attention to his narrative of the ‘discovery’ of the therapeutic community we can already discern the role of chance, which comes to interest him more explicitly later. ‘Therapeutic community’ gradually emerges in history as an organised enabling of happenstance: discovering, enabling, and facilitating the generation of solutions from within the community itself which are original, positive, productive and useful, and which deviate from the standard repertoire of responses to the problems around which the unit, ward, or hospital had originally been organised.

For example, establishing the baseline from which the Maxwell Jones therapeutic community diverged, Millard writes: ‘At first (in 1940), the wards of the Effort Syndrome Unit were indistinguishable from those of a general hospital, as was the regime and the roles of the nursing staff. However, matters were to change’ (p. 583, our emphasis). He quotes Harrison and Clarke’s interpretation of the process of change and divergence which happened at Northfield (Harrison and Clarke, 1992: 704):

The soldiers were given opportunities to realise that the solutions were largely in their own hands. (Bion) achieved this by apparently relinquishing his responsibility for solving all the problems presented to him and forcing the group to fall back on their own resources. (Millard, 1996: 587, our emphasis)

Millard then gives Jones’s own even more radical formulation of the process, from his interview with Brian Barraclough (1984). In this conversation Jones describes how even problems which the unit at Mill Hill had not set out to solve – e.g. ‘unpopularity’ – were nevertheless unpicked by relationships and flattened hierarchies, and by ‘open ears’; and by the unplanned evolution of solutions which could not have been commanded or taught or even hypothesised from the top down, in the standard model of a psychiatric hospital, but were arrived at by what would later be called ‘positive deviance’ (Pascale, Sternin and Sternin, 2010):

It was tremendously exciting as patients and staff were working together in furthering treatment with the patients themselves being a valuable resource for teaching. Moreover it helped to undermine our unpopularity as we were inevitably trying to get them back into army service. So they listened with open ears to their peers. We were there as resource people and didn’t say too much . . . (Millard, 1996: 584–5, quoting Barraclough, 1984: 167)

Highlighting the immanence of happenstance and positive deviance in the invention and development of therapeutic community in Millard’s narrative links the Classic Text to the other papers in this special issue, both thematically and historically.

How much is the man, how much the method?

Turning back to the main protagonist of the Classic Text, Millard (1996: 602) rounds off by returning to the knotty question arising from Jones’s success: ‘how much is the man and how much the method?’ In the commemorative double issue of the International Journal of Therapeutic Communities devoted to Jones, the anthropologist Robert Rapoport wrote an article entitled ‘Maxwell Jones and the charisma question’. He examines the concept of charismatic leadership and charisma in therapy and notes that Jones was ‘able to play a heroic reformer role outside the unit while eschewing leadership within as a matter of principle’ (Rapoport, 1991: 104). Of his personal qualities, Rapoport echoes Millard, writing that Jones had ‘a blend of Irish charm, Scottish superego and a British sense of protest towards a dehumanizing bureaucracy’. His conclusion was that Jones:

did not have the genius of some of the other therapeutic community innovators, but he did have the sense to spot an idea with potential, the creativity to develop it in its social application, and the doggedness continuously to ward off enemies at the gate. He did this with brio. (p. 108)

Millard might have gone a step further, and looking between the stepping stones of ‘what’ at the flowing process of ‘how’, might well have said the question was posed wrongly. As the papers in this special issue show, the creation of novel and effective solutions to intractable problems is not a straightforward either/or.

Editorial note on the Classic Text

The Classic Text as originally published contained a number of errors which we have identified with the help of the copy-editor and, with one exception, have corrected. The errors fall into the categories of those which affect the meaning of the text, and those which do not.

Examples of the latter include sources cited in the text, but not included in the list of references, such as Jones and Rapoport (1955), which contained another error: originally ascribed to 1956, there was a dating error in the citation itself. We have corrected mistakes such as these, and added a few missing sources to the reference list. We have also silently corrected other mistakes: substituting Maricopa for Manicopa (a county in Arizona); changing Willmer to Wilmer in psychoanalyst Harry Wilmer’s name (Wilmer later became an eminent analytical psychologist, but at the time referred to was still working in the Freudian tradition); changing Woolfville to Wolfville (Nova Scotia); changing Arcadia University and Woolfville University to Acadia University (which is in Wolfville); and changing ‘a’ to ‘the’ in One Flew Over a Cuckoo’s Nest, and Dennis to Dean in the name of Dean Brooks, Medical Director of the hospital in which the film was made.

In one instance, we have made a silent change in the text which does affect meaning. When Millard calls one of Maxwell Jones’s books ‘arguably the single most influential book in promoting the therapeutic community world-wide’, his citation gives the date for Jones (1962), but the title for Jones (1968a). They are different books, although both drew on lectures Jones had written as a Visiting Professor at Stanford University in 1961, which is the additional information Millard gives. Without outside empirical evidence, and without anything more from Millard, a case could be made for either publication: the first was published by the prestigious specialist American publisher Charles C Thomas, and will have been given significant academic and professional weight because of that; the second was published in paperback by the more generalist and accessible British publisher Penguin Books. Through Kennard’s personal and professional experience and knowledge, as a participant in the period and events described, we have chosen to go with the later text: Jones (1968a).

The one instance in which we have identified an error, but chosen not to correct it, is in Millard’s quotation of Tom Main’s well-known, and indeed classic, definition of a therapeutic community (Main, 1946). Millard uses it correctly elsewhere (Millard, 1994: 14), and we have given the correct quote in our Introduction. Here, Millard substitutes the spatial term ‘central’ for Main’s temporal term ‘eventual’, substituting ‘essential’ for ‘immediate’: keeping the process in the fixed present, and removing the temporal pivot from ‘immediate’ to ‘eventual’ through which Main conveys the dynamic and time-based nature of the therapeutic intention as a sequence from process to outcome. We have not corrected it because, though small, the change itself is critical; and as Millard’s text has been so widely and influentially read, and the incorrect quote or its interpretation may well have made its way into other texts and others’ thinking, we feel it is historically important to retain a record of the source.