When Careers Masters asked me what I wished to do when I left school, I experienced great unease. I compiled a list of 12 occupations, with psychiatry at the top, and biophysics next. At the time I had no idea that a psychiatrist was medically qualified, and based my very sketchy views on the books I had read. Nor did I know that there really was a subject called biophysics – they were just the two subjects that most interested me. Later, I was given a book by Oliver Zangwill called ‘An Introduction to Modern Psychology’, which made me tell my father that I wanted to be a psychologist. My father was an Arts man, whose idea of psychology was based on popular books about psycho-analysis, which he looked upon with great distaste. His condition for my studying psychology was for me to read Medicine as well – a subject in which I had no interest whatever, but he assured me was necessary for psychiatry.
He won the argument, so while at Oxford (1952–1957) I combined Medicine with a degree in Psychology and Physiology, and learned to consult mainly original texts and to argue things out for myself. In medicine, my basic activity was committing lists of facts to memory, but I learned to use a library and consult original sources. I was taught to ask myself three questions: ‘Do the conclusions of a paper follow from the data? If not, what conclusions do follow? Where should the research go now?’ In psychology I had to think, and argue things out for myself. By the I time I left Oxford I had learned what psychiatry was really like – and although I was at first slightly disappointed, I persisted in my original ambition.
My clinical training and four subsequent jobs at St Thomas’ Hospital (1957–1963) were thoroughly enjoyable, despite the fact that at that time hunting, shooting and fishing were considered important accomplishments, and I was once more reduced to memorizing lists of facts. I won a St Thomas’ Exhibition in psychological medicine, and managed to win a BMA national prize for an essay on community care.
The turning point in my life was when, as a medical student, I read a paper called ‘Between Doubt and Certainty in Psychiatry’ by Professor Sir Aubrey Lewis in the Lancet. I had, and continue to have, doubts about psychiatry – but I had no doubt at all that the author of this article was the man from whom I wanted to learn psychiatry.
Before that could be done, a higher qualification in internal medicine was necessary in those days. So, jobs at the National Hospital for Nervous Diseases and the Brompton Hospital for Diseases of the Chest followed, and psychiatry for a long while seemed a distant prospect. Between medical jobs I carried out locum work as Medical Officer to Nigeria Airways, and for the first time became fascinated by the problems of providing good mental illness services in the developing world. At that time I had not had any psychiatric training, and had a rather literal understanding of David Hume’s work. The next figure shows me, dressed for the tropics, on my way to my morning clinic in Nigeria
After Africa I went to the Maudsley (1963–1969) – and I felt I was back in a University. By the time I came to work for him, Sir Aubrey was only a few years from retirement, and was no longer as terrifying as I was told he had been as a younger man when tormented by pain from his peptic ulcer. He had an encyclopaedic knowledge of psychiatry, and took a keen and kindly interest in the young psychiatrists he trained. When presenting a paper at a Journal Club to Sir Aubrey one was expected to have read around the subject, and to have consulted the author of the paper to clarify any points that seemed unclear. One nervous colleague took a plane to Zurich to do this, and Aubrey listened impassively to his findings.
In presenting a psychiatric case to Sir Aubrey, one learned to assemble the facts in such a way that one began with things that were indisputably true, and only gradually worked outwards towards propositions that were matters of opinion, or inferences. Otherwise, one was interrupted – and that was never a good thing. One had to complete a form before one’s presentation saying giving brief details of the case being presented, and I recall that the section on psychological treatments was particularly threatening, as it gave one three alternatives only: Supportive, Oryxic and Distributive. The first seemed cowardly, the second (‘with a spade’, that is, dynamic!) was definitely inadvisable; so, Distributive it usually was. This meant that one was following the psychobiological approach described by Adolf Meyer. As Aubrey had studied with Dr Meyer in Baltimore, it was definitely the safest thing to say.
The Maudsley at that time had a very academic atmosphere, where straying from what was undoubtedly true about a patient was an unsafe thing to do. The teachers who helped me to branch out from this defensible but unexciting approach included Heinz Wolf, F. Kraupl Taylor, and Douglas Bennett. Dr Wolf supported me in taking my first tentative steps in psychotherapy, while Dr Taylor helped me gain confidence in treating patients with severe personality disorders, most of whom would lazily be described as ‘borderline’ today. Dr Bennett was the teacher who allowed me to see that help could be given to the most disabled psychotic patients – but one had to be content with a much slower rate of change in their behaviour. In his hands, drugs were more effective than they were when prescribed by others. With such teachers, I began to understand that the practice of psychiatry needed more than numerical data – I learned to save David Hume for research projects.
During my training Michael Shepherd encouraged me to design a screening questionnaire for use in general practice. My psychology training came in handy, and I worked in his ‘General Practice Research Unit’ (1957–1969), while I did so
I became fascinated with the psychological work of a general practitioner, and combined this with an interest in what it was that had made some of my previous teachers in internal medicine such excellent detectors of emotional distress, and some so lousy. We soon showed that GPs were no different. I was determined to find out not only why this was, but what could be done about it. Michael Shepherd had a formidable intellect – but he could also reduce his research team to helpless laughter, by imitating the colleagues (and there were many) whom he especially disliked. He advised me to seek the advice of George Brown – at that time working with John Wing in the Institute. George has been an enormous influence on me, and I have followed his research on depression with keen interest. It was from him that I learned to interest myself in long-term developmental factors that determine vulnerability to distress.
Part of my work with the ‘General Health Questionnaire’ (GHQ) took me back to St Thomas’, where I was allowed to carry out a validation survey in the gastroenterology clinic. To amuse the consultant, I would tell him things during our tea break that I had learned about his patients. ‘How do you learn such fascinating things about patients I have been treating for years?’, he asked. This stopped me dead in my tracks. It would have been good to claim that psychiatry had taught me recondite interviewing skills – but, in truth, it had not. What I had learned was to allow patients to speak to me, and listen to them – while in internal medicine, I had learned to interrupt the patient with brilliant, probing questions aimed at discovering the diagnosis.
My main research involved me in interviewing a stratified sample of patients in primary care, and my next revelation was at hand. Where were the distinct groups of patients I had learned about during my basic psychiatry, with anxiety disorders, affective disorders and somatoform disorders? These neat concepts turned out not to exist. The patients I saw had untidy combinations of anxious and depressive symptoms, typically with somatic symptoms that were not part of any physical disease they had. They varied mainly in the severity of their distress, although it was true that some had more of one type of symptom than another. It seemed to me that the diagnostic system that I had been taught was ‘top down’, derived by groups of senior psychiatrists (many of whom had never interviewed patients in general medical practice) getting together in Geneva and Washington and pontificating about ‘typical’ cases of various disorders. From then on, I was determined to be ‘bottom up’, and my final years with Michael were spent considering the relationships between various groups of symptoms.
I took a post as a Consultant/Senior Lecturer in Manchester in 1969, and become a Professor and Head of Department in 1973 – having had the first year of my ‘BTA’ (Been to America) degree in between times. In Philadelphia, I completed my research on the GHQ, and continued to interview consecutive attenders in general practice. I expected that there would be ‘cultural differences’ in the expression of distress – but there were very few. Later I was to interview patients in India and Myanmar, and found them to be impressively similar to patients I had previously seen.
In Manchester, I was responsible for teaching about 300 medical students basic psychiatry, and around 50 junior psychiatrists each year. Fortunately, I was part of a large team of keen teachers, but I began to think what I would have liked to be taught had I had my time over again. We began to use television as a teaching aide, and this led to the research uses of television to observe medical encounters, and comparing each doctor’s interview style with how good he or she was in identifying patients with high scores on the GHQ. At last, it was possible to describe exactly how a doctor who detected distress accurately differed from a colleague who missed most of the patients with high scores in the questionnaire.
At this time, Peter Maguire joined the Department from Oxford, where he had been teaching interviewing skills to the medical students. We adapted his methods to the much larger numbers, and began to teach the methods of the sensitive doctors to our students. It turned out to be quite easy – so, we next turned to GPs, and found that they could also be taught the necessary skills.
Norman Sartorius had been a fellow student at the Maudsley who became a life-long friend. He has enriched my life in many ways. By the time I became Head of Department in Manchester, Norman was in charge of the Division of Mental Health at WHO, and was pursuing his wholly exceptional international programme of research into both schizophrenia and depression. Over the next 25 years, he provided me with opportunities to visit China, Burma and India as a WHO Consultant, as well as opportunities to design and participate in the international projects which he is so skilled at organizing. My work with the ‘Psychological Problems in General Health Care’ study involved me in working with gifted colleagues from the USA, Holland and West Germany, and afterwards participating in data analysis. We also designed the ‘Pathways to Care’ study which has now been carried out in many parts of the world. After we both retired, Norman and I have taught professional skills to young psychiatrists in most East European countries, as well as in Africa, Japan and China.
While visiting India, I became friendly with Naren Wig, at that time in charge of the Department of Psychiatry in Chandigarh. Naren is a man of self-effacing excellence, and I learned many things about the provision of village health care from him. I would like to say that I could emulate the fierce loyalty that Naren achieved from both staff and patients, as well as the unfailing kindness and care that he provided to all who worked with him. After his retirement from academic life in India he worked as Regional Representative for the East Mediterranean Region of WHO, and it was now his turn to invite me to become a WHO consultant to demonstrate teaching methods in Rawalpindi, Pakistan.
This involved me in, first of all, spending time in Alexandria with my opposite number from Rawalpindi, Professor Moby Mubbasshar. Moby and I took to one another immediately, and the first of a succession of visits to Pakistan followed – during which I was able to observe the development of what must be one of the finest village mental health service I have seen anywhere. Moby is a man of limitless energy who is only satisfied if he goes to the very top of the power hierarchy in order to procure better resources for community mental health services and psychiatric education.
Our second year in the USA followed from my friendship with Layton MacCurdy, and grew out of our common interest in uses of television in teaching psychiatry. I met Layton during the year he spent with Malcolm Lader in London, and before long I found my whole family in Charleston, South Carolina. I carried out research for NIMH on how to improve the interviewing skills of residents in family practice. This research involved me in identifying the five residents in each year of training who were least able to identify distressed patients, and then to provide them with video feedback of their interviews with real patients. This turned out to be a straightforward procedure; so, on my return to Manchester we adapted the technique to UK conditions by training GP trainees in groups rather than individually. We also began to collaborate with established GP Clinical tutors and so provide joint teaching at our GP Case Conferences.
My visits to Australia began when I was invited to deliver a series of seminars in Sydney, and so began a very long, warm friendship with Gavin Andrews and Scott Henderson. Gavin’s iconoclastic tendency finds an echo in me, although I cannot claim to be his equal in upsetting the apple cart. But I admire what he achieves, and, following his lead, hope to dent the complacency of ICD mental illness diagnoses. Scott is a fellow epidemiologist who has befriended me over many years, and introduced me to Pat Moran – a most formidable statistician who helped me make sense of what I had observed when I surveyed populations of primary care attenders, and had tried many ways of making sense of their untidy collections of symptoms.
During a later visit to Australia I met Ken Burnett quite by chance. Ken was Chief Executive at a community mental illness service in a distant seaside town called Warrnambool. It was difficult to get sufficient trained nurses and psychiatrists to leave the safety of the Melbourne area and make the 300-mile journey to the town, but Ken had adopted a highly original solution to this problem. His service recruited unemployed graduates – many of them in psychology, but some in social work or nursing – and trained them intensively for 6 months in treatments with demonstrated cost effectiveness. They learned 17 different therapeutic skills, and worked under the supervision of an experienced nurse practitioner. His psychiatrists were all encouraged to send patients back to the care of their general practitioners at the earliest opportunity, and were only allowed to prescribe for those on the small in-patient unit. The patients on this unit each had a nurse who had special responsibility for the therapeutic plans formed for them, and had clearly stated therapeutic objectives, while the far more numerous out-patients also had clearly stated aims, and were encouraged to become autonomous as soon as possible. Ken argued that if one needs a cardiological opinion you are investigated by the cardiac department, but they lose no time in returning you to your GP, and they expect the GP to prescribe. Why should mental illness be any different? Well, different it usually is, both elsewhere in Australia and in England, where we are far more likely to tolerate dependence on our services.
For the past 25 years, my research interests have moved away from doctors, and back to the people who are in states of distress – with particular attention to the factors that make some people vulnerable to stressful life events. Research in social psychiatry in the last part of the 20th century had tended to concentrate on proximate causes of episodes of distress, as well as on their current social conditions. My first book on this subject dealt with both GPs and their patients (‘Mental Illness in the Community, the Pathway to Psychiatric care’ with Peter Huxley), but my most recent book takes a thorough, developmental look at the determinants of the vulnerability that puts some people at much greater risk of an episode of disorder following a stressful life event (‘The Course and Origin of Common Mental Disorders’ with Ian Goodyer).
In 1993, I returned to the Maudsley as Professor of Psychiatry and Director of Research and Development. Returning to the Maudsley was like coming home, and the previous 16 years had been very pleasant. In 1997, I was given a knighthood by the Queen, who surprised me by asking me what she was giving me a knighthood for.
I said that I hoped it was being given for teaching a generation of doctors in Manchester how they should talk to patients. At the time I thought she looked bad tempered – but this shows just how unreliable memory can be. The videotape shows her smiling most graciously at me, throughout the 20 seconds I was granted with her. The citation did not help much – it said ‘for contributions to Medicine’.
The last few years have seen the gradual destruction of the National Health Service in the UK – which I have been proud to serve all my life – by an allegedly left-wing government, and this has been very distressing. The missed opportunities to improve the basic community mental health services, and the hospital units that should support them, have been my only sour professional experience.
After I retired I was delighted when the Institute opened a new centre for Health Services and Population Research, under the direction of Graham Thornicroft, and called it the ‘David Goldberg Centre’.
My views about the nature of common mental disorders have not changed, and I am happy to report that I have been listened to politely in Washington and Geneva as a new classification is prepared. In summary, I think mental disorders are far too complicated to have order imposed from above, based on highly skewed samples of the patients referred to us as psychiatrists. We have to discover natural relationships between disorders from studying normal populations – although it is permissible to study consulting populations, as this excludes many people with few symptoms. We may not win the battle over classification – but it has been stimulating to state our views.