By Mary Montaut
Professor Ivor Browne was appointed Chief Psychiatrist of the Eastern Health Board in 1966, and Professor of Psychiatry and Head of Department at University College, Dublin in 1967. He retires this month. Here he talks to Mary Montaut about a career which spans almost thirty years.
“How did I come to psychiatry? I wasn’t really interested in medicine as a career, but one day a Professor Abrahamson, who had a great sense of humour, looked at me and said: ‘You’re only fit to be either an obstetrician or a psychiatrist’. Faced with that alternative I thought again about psychiatry and that’s how I half-drifted into it. The tragedy, I think, of a lot of psychiatrists is that although they may question themselves, they never properly address those questions and end up more closed up than ever. At least I can say that I used my psychiatric experience to learn something about myself which is the essential thing in psychotherapy.
My career was not a thought-out consciousness. It was partly because I had been such a mediocre medical student that I couldn’t get a job here when I first qualified. So I went to the Warneford Hospital in Oxford which wasn’t in any way psychotherapeutic and dealt largely with people from the University. It had a profound effect on me. For the first time in my life I met people whose mental health had broken down but who were still questioning and thinking for themselves. I suddenly thought to myself, ‘If they can think, why can’t I?’ I suppose some of this went back to my childhood. I had a very mediocre education in the formal sense but my father was very much a deviant. He created a sort of cocoon environment, perhaps to protect himself from anxiety but it certainly gave me an unusual view of life. I may have learned nothing at school but I certainly learned a lot from my father and his dreams. My mother was Church of Ireland and my father was a sort of rebellious Catholic, so although I was brought up as a Catholic, I didn’t feel part of the dominant culture. It made me think differently and that stayed with me all my life – seeing things from a different angle. I will always tend to ask questions of the current accepted opinion. I see it from a different point of view and that probably led me towards psychotherapy. I remember an old fellow in Oxford who was some sort of psychoanalyst saying to me, ‘Don’t buy any of the current theories, find your own way.’ That advice has always stayed with me. I don’t feel as if I belong to any school. I think most people find it very hard to live with uncertainty, so they tend to join some “ism”.
Later I came back to Dublin and worked in St. John of God’s. Major tranquillisers, psychoactive and anti-psychotic drugs were just being introduced at that time. Young boys were coming up from the country diagnosed with schizophrenia, and the drugs seemed to bring them back to normal. If I had just been there a year I would have left with that impression. But by my second year nearly all of them were coming back in a worse state than before, and that raised a big question in my mind about orthodox psychiatry: that while it was removing symptoms, it wasn’t really changing people. I remember that old psychoanalyst made me sit down with one particular psychotic lady in Oxford. She was mute and it was a very difficult experience. But after about three months of sessions big tears began to roll down her face and again I had this realization that things weren’t as they were supposed to be. I mean, here was supposed to be an organic illness due to biochemistry and genetics and a person whose emotions were blunted because her brain was damaged, and behind it all was emerging this deeper emotion. I was getting a glimpse that people were defended from their real feelings, rather than that the feelings weren’t there.
Then I went to the Marlborough Day Hospital where Joshua Bierer was practising community psychiatry for the first time in Britain. He’s never been given any credit for it, he wasn’t a good publicist on his own behalf, but in fact he, more than anyone, was the father of community psychiatry. As early as 1947 he had very disturbed people out living on their own in a house, long before anyone else thought of it. They were working with LSD in the day hospital, and once I saw people ingesting LSD and regression happening it was a revelation. It made me realise that what was on the surface was very different from deeper feelings and attitudes. I remember one patient – an Irish fellow who was a militant homosexual – who was given just 50 microgrammes, a tiny amount of LSD. Half an hour later he was crying pathetically for his father as a little child. I began to realise that the psychiatry we were told about and read about in the books was largely incorrect. It gave no understanding as to why the symptoms were happening. And that, of course, goes on right up to the present day. In fact, it has intensified and got worse, partly because there is a better understanding of brain physiology, but yet not enough understanding to bring us full circle and make us realise that the brain and the whole human organism works in a holistic way. So the mechanistic view of the human being as some sort of chemical machine has in fact got stronger.
Joshua Bierer was a key influence in my life. He was saying that people are human beings, you can’t understand them in terms of illness. I saw him break through to young schizophrenics in an afternoon. Once you see that, you know that the orthodox view is a very superficial part of the whole. This, I think, gave me my main direction back in 1959.
I then got a scholarship to Harvard. There were several key people there, but particularly Eric Lindemann who wrote the first paper about unresolved grief. He noticed relatives and friends coming in after the Coconut Grove fire (rather like our Stardust fire) who were having all sorts of psychosomatic and sleep problems and visions of their dead relatives. He realised that there was something happening in their way of dealing with the grief that wasn’t fully resolved. Later I went to a protege of his, Gerald Caplan, who was professor in the School of Public Health in Harvard, and did my Masters in Mental Health. His main interest was crisis theory and the handling of life crises.
I had stopped working with LSD when I left Marlborough Hospital in London. It was legitimate at that time, and they were thinking that it gave a sort of model psychosis which was, of course, incorrect. All it does actually is expand consciousness. When I came home to Ireland I worked away with it without any clear understanding of what I was doing, mainly using it with people who were otherwise hopeless. Gradually I began to see where it would have some application and where it would not. For example, regression work has very little relevance to most people we call schizophrenic because essentially they are people who have never developed, who are still developmentally children, so the therapy has to be of a human educational kind. This is misunderstood by psychiatrists. Because the ordinary psychodynamic type of psychotherapy doesn’t have great relevance to them, they say that psychotherapy is not only irrelevant but damaging. But of course it’s a failure to clarify the kind of approach that is necessary. There’s no point in bringing someone who has been treated like a three-year-old up into adult life, back to three. And from the point of view of traumatic environment, many schizophrenics are, if anything, understressed. They may have a certain kind of stress, there may be coldness in the environment and twisted relationships. But it’s not the same kind of syndrome as the person who’s dragged up in an orphanage or who’s abused physically or sexually. So there are different horses for courses.
I think the central point is that most psychotherapy now is happening outside of psychiatry. Psychiatrists, in a sense, have retreated. In many of the American States, the main psychiatric training was based on psychotherapy or psychoanalysis. But because psychoanalysis has let them down, they’ve swung right over and a lot of American medical schools are saying that psychotherapy is irrelevant to psychiatric training. But if you look at psychotherapy, it has gone on developing and out of psychoanalysis all kind of different schools have developed, many of them capable, I think, of giving people the opportunity to change radically. But it’s happening outside of orthodox medicine. For a person to be able to go to therapy, say, once a week, they have to be able to manage their life the rest of the time. If they can’t do that, they won’t be able to avail of that kind of psychotherapy. And, of course, then the psychiatrists say, ‘When they get really sick they have to come to us!’ But in fact it doesn’t mean that the psychotherpay is not relevant to them; it means that they need a supportive context within which they can go on learning about themselves. Psychiatrists offer symptom treatment to people who have a greater need of a more global psychotherapy: perhaps an educational or developmental milieu where they will learn and grow to achieve some measure of adult independence. Almost any orthodox psychiatrist will say that psychotherapy only has a place for the fairly independent neurotic who has some sort of personality twist, but has no relevance to the main depressions or illnesses like schizophrenia. To me psychiatry is simply psychotherapy. I see the giving of a pill which can be relevant, at times temporarily, as one operation in the psychotherapeutic context. I don’t see any psychiatry outside psychotherapy and in using psychotherapy in that sense I’m really talking about education for life, I think it’s as broad as that.
Another failing I see – and this would apply to quite a lot of the psychotherapeutic schools outside of medicine as well as in it – is that we hear a lot about certain kinds of therapists, like a Jungian, a humanistic, a Freudian, a behaviourist or a cognitive therapist. To me psychotherapy starts with a clear definition of the problem. In other words, diagnosis is essential and it’s not that you have a particular technique that you can use on anyone. Thekind of approach then will depend on what the nature of the problem is. It is obviously relevant to see what symptoms and immediate clinical problems the person has, but that’s just describing their current behavioural state. Much more important is the diagnosis of the whole person, because how do you work with someone if you haven’t got a clear view of who they are? To me the first essential is an assessment of the whole personality, and superimposed on that an assessment of the problems they have. Unless that is clear I don’t know how you can start. You can have a set of problems, like an eating disorder, imposed on quite different personality backgrounds, so that any one of the therapies or a series of them may be necessary.
I’ve been aware that I’ve wasted (though some might not agree with that) a great deal of time trying to change the nature of psychiatry and get rid of mental hospitals like this. When I came here there were 2000 patients in St. Brendan’s and another 2000 in St. Ita’s. Now there are just under 300 and half of those are old people who have come in because they’re old. My hope was that a more human kind of psychiatry would happen out in the world where people live. That has become an accepted policy now but, like many other things, it’s turned upside down in the process and now it tends to mean just getting people out of hospital. In many ways psychiatrists are doing the same things outside as they were doing inside the hospitals, so there isn’t any real change. Even if you take the most positive view, just giving out psychoactive drugs is simply controlling symptoms, not bringing about any real human change. The same is true of electric shock therapy.
I would be seen as being against pharmaceuticals and in favour of psychotherapy. In fact I don’t take that position because I think that some of the drugs have been a real help. A lot depends on how you use them. We wouldn’t be able to start to work with quite a number of psychotic people without some initial help. Ultimately you’re working to bring about change in the person. If a drug can help you to start on that road, or control misery even a little then I see nothing wrong with it. A drug like diazapan (Valium), used on a temporary basis, can be very useful and save a certain amount of suffering to enable a person to work. But it’s only an aid to psychotherapeutic work and I see the same with all the pharmaceuticals across the board.
I would like to mention an aspect of psychotherapy which is not understood clearly across medicine as a whole and that is the role of the therapist. Because of the tradition of medicine and the way it developed around bacteriology, the view is that the doctor carries out the action or “treats”. Most psychotherapists would realise that this is not so. But I think it is important to state clearly that even in medicine the role of the doctor is seldom other than supporting the natural health-preserving qualities of the person. A doctor doesn’t heal a fracture, the person does. A doctor may appear to be active but he or she is actually playing a supportive role to the natural healing process. This is emphasised starkly by the advent of AIDS where once the immunity is attacked, medicine is largely ineffective. So our role as psychotherapists is never more than that of a guide or an aid to the person in working on their problems. They have to do the work, they have to experience the suffering. There is, therefore, a natural limitation in the effectiveness of any psychotherapy. It means that no matter how wonderful your psychotherapeutic method is, it is only as good as the motivation and the work that the person is prepared to undertake in effecting change. If they are not prepared to go through that, the role of the psychotherapist will be limited and psychotherapy can never be 100% effective. The same is true of medicine. The human being is a self-managing, self-organising system and it is only healthy when it’s running itself. So that any interference, if it is to be positive, can only be a support in that. Otherwise it becomes invasive or even precipitates illness. And medicine is full of examples of that mistake.
In the last few years I’ve been able to return to what I should have been doing at first. I worked up to the 1970s with LSD but then, because of all the bad publicity, it wasn’t possible to obtain it. I owe a debt of gratitude to Stan Grof because he came up in the early 1980s with the Holotropic Method, which was an alternative way of achieving altered consciousness. I don’t regard what I do now as holotropic – I mean he’s patented that particular aspect. We’re using a number of modalities to bring about or assist change, but it made me return to that way of working. Since then we’ve developed a form of experiential work using a number of channels to assist the person to break down the blocks, to open up what is hidden from them so that they can change and let the past go. In the last ten years, and particularly the last five, we’ve been mainly working with people who have suffered trauma.
If you look at a lot of the writing on Post-Traumatic Stress Disorder the interest is in the external event which is supposed to have caused it. But the external event is only of significance to the degree to which the person is not able to resolve it. So the real work is internal. Out of that we’ve been developing a theory that, faced with a severe external threat, we have a quite primitive ancient biological capacity to block the processing of experience or the integration of it, so that we, in fact, stop it happening. Now this sounds similar to Freud’s term of ‘repression’ but is actually quite starkly different because, given what was known at that time of neurophysiology, it was assumed that when something happened it was automatically integrated fully into the person and became a memory. But it’s quite clear now from a lot of the recent neurophysiological work that taking something from the external happening and the perception of it, into long-term memory, is a whole difficult process that particularly involves the primitive brain. So we can’t take anything from the point of perception and the point of it happening, into our long-term memory system, without it going through the limbic system, the primitive mammalian brain and including the brain stem which is our reptilian brain – that whole primitive system is our survival mechanism, not simply the brain, but the brain totally integrated with the endocrine and non-conscious or autonomic nervous system. So it’s a totally integrated mind-body system which still constitutes our main adaptation to the outside world. And the reason, it seems to me, that any perception has to go through that is because that’s how we tell the significance of things, by firing the whole emotional system. We know the significance by changes in our bodies, not by some intellectual operation. So, in order for something to be integrated fully, it has to go through that system.
That has become quite clear from work in neurophysiology in the last twenty or thirty years but all I’m adding to it is that, given sufficient stress, or some threatening or horrendous event, then that system can be blocked. But we have to be quite clear that it’s already started to process. If it was blocked completely at the point of perception, then the perception would be wiped away by the next input, as many perceptions are, we don’t store everything. But it means that there must have been some kind of immediate recording or representation of this before it then goes on to be processed into full memory or long-term memory. To put it in ordinary language, you’ve something like a video of the raw experience and that’s what’s there. Now that’s something which is rather unstable, which is trying to move on, but nevertheless we have this capacity to block it. I think many psychotherapists are inclined to think they are working on the past. The past is gone, we are always working on the present and what’s there now. The question for me about this kind of experience is that it’s something which has intruded into us, which is then blocked so that it’s in us but not fully part of us, and we’re stuck then with a sort of psychological time-bomb. When something happens in life that activates it, experiences from many years ago can suddenly come, and what comes is not memory in the sense that we ordinarily use it and something that we recognise as past, but the raw experience starts to happen: what we call flash-backs.
People describe this, they describe the numbing and then the grief, but they don’t seem to say clearly what they’re actually talking about, so it’s a very different idea from the notion of repressed memory. In one sense you could say this is a kind of memory, it’s stored experience, but it’s stored at a point that’s totally different from long-term memory and makes sense therefore of some of the psychotherapeutic work. Why should just making a memory conscious change anything? But moving an experience on into fully assimilated form, you can see the work that has to be done, and once that’s done then you have a memory that you can recall. So that’s some understanding that’s come out of the last five years of our work, although I don’t feel it’s really being heard.
This brings us once again to the wisdom of the East which says that the heart is a part of the mind and has its intelligence. The old language knew this, all the emotional language is to do with the heart. If we talk of mind, we are inclined in the West to think of it as a representation of the brain. It is a representation of the entire being and so is consciousness, so you can’t say consciousness is located in any part. That whole system is what we have to work through in order to make experience – and we are our experience, we are our memories. We can only use ourselves to the extent that we are integrated.”