Mapother: The Psychiatrist
"Mapother Memorial", Bethlem Maudsley Hospital Gazette, December 1970, pp. 7-10
When I arrived at the Maudsley in 1931 I found it to be an intensely active school, with a good deal of internal coherence. Evening meetings, easy to arrange when we were most of us bachelors, were held once a week or so in Lewis's rooms and largely under his inspiration. We would take it in turns to start a discussion which nearly always became extremely theoretical. Even the newest of us were made to take turns in leading off, a simple way of doing this being to undertake a minor piece of research and then report on it. When it came to my turn, the enquiry suggested to me by Lewis was into the prevalence and nature of hypnagogic hallucinations in psychiatric patients.
A number of senior colleagues, Tennent, Lewis, Curran, had received the training of Adolf Meyer, and the party line at the Maudsley was Meyerian. Mapother had not himself been subjected to this personal influence, but not long before he had paid a visit to America and had returned with 'ä profound admiration of the state of development of psychiatry in that country. He gave an account of his impressions in an address to the R.S.M., published in the Lancet in 1930. From this it is clear that psychiatry in the United States in 1930 had already reached a state of vitality and maturity very little inferior to that which it enjoys today, and very far ahead of British psychiatry of thirty years ago. Mapother was accordingly satisfied to hear the Meyerian line expounded, although when used in his own formulations in the weekly case conferences it would take on an unwonted robustness and precision.
The individual, we were taught, was a psychobiological unity, unique, to be anatomised and classified at one's peril. Neuroses and psychoses shaded into one another; the distinction between them was arbitrary, misleading, and almost meaningless. Diagnosis was of little service. To distinguish a patient as suffering from a schizophrenic or n affective state was often labour lost, since both conditions could so easily co‑exist in the same individual, and neither was more than a mode of "reaction." So ran the doxology. In practice Mapother instilled a more hard‑boiled attitude. As Desmond Curran has related, he had no hesitation in stigmatising a patient as "a stiff praecox," when that phrase provided an epigrammatic summary of his opinion on aetiology, course and prognosis. In case presentations we were taught to prune the enticing interpretations, in which others elsewhere could indulge so freely, to make room for the hard facts, such as the precise amount of alcohol consumed, which Mapother required. Alcohol was one of the bees in his bonnet; in his view, the patient's own statement of amount taken required multiplication in all cases, by a factor which varied from 2 to 10.
Although he was pleased that the Maudsley should be the home of gifted representatives of psychoanalysis, such as W. H. de B. Hubert, Mapother came in his clinical judgments to stress more and more the organic factors. Above all he was unsympathetic to any sentimentality. When Adolf Meyer paid us a visit and sat in at one of the conferences, he protested against the recounting of the family history as the first item in the presentation; in Meyer's view this gave innate factors an emphasis which would encourage therapeutic nihilism. No change was subsequently made in our habits. In a "longitudinal section" the family history naturally came first, and in the Maudsley of that day orderly comprehension rated a higher priority than therapeutic optimism.
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Mapother has been described in his obituaries as having shown clinical judgment of the highest order. In this field I was less impressed by him than by, say, Hubert or Anderson, and I should have thought him perspicacious and sensible, rather than intwtwely gifted or endowed with a discriminating sensitivity to nuances of behaviour and emotional tone. In original research Mapother made no contribution which now needs to be remembered. "For philosophic thought," wrote Golla in an obituary of historical value, "he had little aptitude and his essays in that direction were unfortunate." How is it then that the total effect of his personality was inspiring? Our affection and admiration were won by gifts of personality rather than intellect. Thus his contribution to the philosophy of psychiatry, which Golla rightly regarded as unsuccessful, was yet so timed and placed as to resound like a batlle-cry. "Tough or Tender: a Plea for Nominalism in Psychiatry” ‑ his presidential address to the psychiatric section of the R.S.M. was regarded by us as an attack on what was then called "Tavistockery.”
After the meeting was over, and we forgathered at a congratulatory dinner, the enthusiasm he had generated overflowed, as I remember,in an elated sense of communal self‑dedication. As we then saw it, the future of British psychiatry hung on the issue of an ideological conflict. The scientific heirs of one side or the other would inherit the future. It would never have occurred to us then that in years to come both Maudsley and Tavistock psychiatry would remain side-shoots of the main stem.
The reasons for that ancient feud between the schools represented by the Maudsley and the Tavistock Clinic are to be sought in part in Mapother's own combative personality. But part of the trouble derived from the fact that Tavistock psychiatty, which seemed to us flabby thinking and uncontrolled verbosity, was to some extent a parody of our own. Its theoretical basis was a logical extension of the Meyerian standpoint to which we paid lip‑service at least. If diagnosis was so fallible and unprofitable, then there could be no harm in neglecting the impartial clinical observation on which alone it could be based. If there was no principal difference between the neurotic and the psychotic, then one and all could be regarded as equally amenable to psychotherapy. The Maudsley objection, that clinical observation was supremely important, and that one could not learn how to recognise and handle schizophrenics from psychotherapising hysterics, was no stronger for Mapother's attempt to found it on a philosophical basis. To display the issues involved in a clear way, quite a new orientation was necessary, and was eventually supplied with the arrival on the scene of Mayer‑Gross and Guttmann.
The obituarist in the B.M.J. wrote of Mapother that "he saw it as his function to encourage serious workers, rather than to prescribe subjects and methods to mediocre and half‑hearted investigators. Perhaps a more masterful policy would have made his personal influence even greater than it was." The comment is interesting in that it brings into sharp contrast two opposed attitudes. Mapother had no need to use his position to dominate his subordinates and thereby aggrandise his own personality; indeed, if he had ever thought of it, such an aim would have seemed to him unworthy. He had no desire to set the mark of his personality on his generation, but only to bring about certain effects which he regarded as immensely desirable and potentially within his power to attain. He worked for his child, which was the Mandsley Hospital and School, and not for himself. The last thing he would have wished would have been to interfere in the free play of the minds of his workers. Ideas flourish and survive by virtue of their own vitality, and not through the energy with which they are imparted by even the most masterful of research directors. For Mapother, the administrator was the servant and not the master, whose duty to research was primarily to see that work of investigation received a fair share of the resources available.
Nevertheless within his tiny kingdom he was in some ways the typical small dictator. Rules and precedents tied us down. Since no two members of the medical staff could take their holidays together, my first summer holiday was spent in making a walking tour of the Sussex downs in mid‑November. At Easter time, though having four days off, we might find that we had to come back for the halfhours from 4 to 4.30 on the Saturday and Sunday afternoons, so as to be present in case visiting relatives wanted to ask about the progress of patients in our care. We all groaned impotently under this, until Desmond Curran broke through it with a plain statement that he would have to resign unless a more human arrangement were made. But Mapother's unreasonable ordinances were made out of anxiety for the security and good name of the Hospital, and not out of any desire for personal dominance. Fundamentally, he was a humble man who knew his limitations; and from this insight he derived the greater force. In time much power was given into his hands: he had the strength to carry it, and the wisdom to use it for purposes ulterior to any personal advancement. The most valuable lessons we had from him were not all psychiatric ones.