Albert Kushlick
Albert Kushlick was a psychiatrist best known for his advocacy for greater facilities within mainstream communities for adults and children with a learning disability, including those with severe impairments or difficult behaviour.
Summary
Albert Kushlick was born in South Africa to a Jewish family who had emigrated from Lithuania early in the twentieth century. He was educated at the Benoni High School in Benoni, Transvaal province, before studying medicine at the University of the Witwatersrand in northern Johannesburg. On graduating he worked in the professorial units of the Princess Nursing Home and the Non-European Hospital in Johannesburg, before leaving for London in 1956. He was politically active as a student and young doctor, and had been threatened with arrest by the South African government for his allegiance to communism, his work to resist apartheid, his support for the African National Congress and his contact with Nelson Mandela.He began work in London in 1956 as a locum house surgeon at St Giles' Hospital and later at Fulham Hospital. In 1957 and 1958 he was a registrar at South Ockendon Hospital, a hospital for people with a learning disability, before moving to Salford to study for a Diploma in Public Health.
Albert was known for his work with the Wessex Regional Hospital Board, beginning in 1962, which called for a move from a centralised system of residential care in large-scale institutions to a focus on local community hospitals and community-based care, as well as making sure that therapeutic approaches were used in existing or new hospital provision. The move from a centralised system to local care units was replicated in many countries.
He helped improve care for the elderly and those with disabilities for the Wessex Regional Health Authority and was an honorary senior lecturer at the University of [Southampton School of Medicine]. He later developed individual therapy to help disabled people and their families and carers.
He continued support for the anti-apartheid movement until he was able to revisit South Africa in 1990. He married twice and had a daughter, three sons and a stepson. He died of a heart attack in 1997.
Early life
Albert’s paternal grandparents, Michael and Sarah Kushlick, were a Jewish couple living in the Lithuanian part of the Russian Pale of Settlement. They had seven children, one of whom was Isaac, born in 1893. In the early 1900s, Michael and Sarah emigrated with three of their children to Cape Town in South Africa. Isaac remained behind to complete his education but joined his family in Cape Town later. He married Ethel Zinn, born 1899, also from a Jewish family from the Pale. Isaac and Ethel gave birth in Cape Town in 1928 to a daughter, Edith. Around 1930 they moved to Benoni, a township 20 miles east of Johannesburg. Albert was born there on 2nd March 1932.Albert attended Benoni High School. In 1946 his father Isaac obtained a post as a senior lecturer in physics at the University of the Witwatersrand in Johannesburg. Albert’s sister Edith began a five-year degree in medicine there in 1946, graduating in 1951. Albert was to follow her, beginning his degree in medicine in 1950 and graduating with a Bachelor of Medicine and Bachelor of Surgery degree in 1955. His mother Ethel died in 1964. Isaac retired in 1962 and died in 1966. After his death, Albert and his sister Edith endowed Wits University School of Medicine with an award, the Isaac Kushlick Memorial Prize, given to the first-year medical student who performed best in physics. It is still awarded annually.
Albert was a member of the university Students Representative Council. Many of the members of the SRC were communists and almost all were strongly opposed to apartheid. Albert had shared with his father Isaac an interest in and affiliation to communism, and he was committed to opposing apartheid. As a student he was active on both these fronts. In 1952 the Students Council had voted to become more political. In that year a Defiance Campaign was launched in which the African National Congress and white support groups joined together to resist the apartheid laws.
Visit to Europe
Albert visited the UK and Europe from July to October 1953. His involvement in the trip is an extraordinary story for a 21-year-old student. He played an active role in a scheme to foil the South African government.The World Federation of Democratic Youth, founded in London in 1945, is a socialist, anti-imperialist, anti-fascist organisation for young people whose main activity has been to organize large festivals mainly in Eastern European countries, supported and heavily subsidized by Russia. The fourth World Festival of Youth and Students was held in Bucharest, capital of Romania, from 2nd to 16th August 1953. It involved 30,000 young people from 111 different countries. Romania was a communist country under Russian influence at the time and the festival had a focus on the persecution of communists in other countries. As well as meetings and discussions on this theme there was an extensive programme of sports and cultural events.
Walter Sisulu was a communist and Secretary-General of the ANC at the time. He was invited to the World Festival to speak about the suppression of communism in South Africa and the work of the ANC in opposing apartheid. He set about organizing a South African delegation of young people to the Festival, with the help of Duma Nokwe, a law student at Wits University who was also Secretary of the ANC Youth League. Albert was well-known to both of them and was invited to join the delegation.
The Pass Law in South Africa severely restricted the movements of non-white people and it was almost impossible for them to obtain passports for foreign travel. A strategy therefore had to be developed to enable non-white people to join the delegation to the Festival. The ANC arranged identity documents that immigration authorities in Britain and other European countries were willing to accept for entry by non-white South Africans. Sisulu and Nokwe travelled to England by plane, arriving three days before the rest of the delegation who came by ship. Sisulu and Nokwe had been key instigators of the Defiance Campaign and as a mark of this they proposed a plan to enable non-white members of the delegation to travel first class.
White supporters of the ANC were recruited to take part and were issued with first class tickets for the voyage. Each of them took a non-white delegate on board as a porter for their luggage. The white people who were not delegates themselves would settle their non-white companion in first class with their ticket and would then leave the ship. Those like Albert who were delegates would take the non-white person to first class and then travel on a separate ticket in steerage.
Once the group had successfully landed in England they met up with Sisulu and Nokwe for the next phase of the journey to Bucharest. They flew from London to Prague in Czechoslovakia and then by train to Bucharest in Romania.
After the Festival the South African delegation, led by Duma Nokwe, were invited to visit several other countries. They visited Warsaw in Poland, Prague in Czechoslovakia, Vienna in Austria, Ukraine and Crimea, and Moscow, Leningrad and Stalingrad in Russia, then back to the UK. Albert returned to South Africa from Southampton in October to resume his medical studies.
Development of a medical career
Albert obtained the degrees of Bachelor of Medicine and Bachelor of Surgery at Wits in 1955, his full qualification as a doctor by Membership of the Royal College of Physicians in the UK in 1958, a Diploma in Public Health in 1960, qualification as a psychiatrist by Membership of the Royal College of Psychiatrists in 1971, Fellowship of the Faculty of Community Medicine in 1972, Fellowship of the Royal College of Psychiatrists in 1978, and Fellowship of the Royal College of Physicians in 1979. He also gained expertise in Behavioural Psychology and Cognitive Behavioural Therapy that he applied in his research and work right up until his death. All these required intensive study. Albert managed to combine this with a continuing interest in political action, particularly in arguing for a better deal for disabled people and also in relation to socialist ideals and the defeat of apartheid.After his graduation from Wits Medical School, Albert obtained house officer posts at two health services primarily for black people in Johannesburg. One was the Princess Nursing Home and the other was known as the Non-European Hospital, now part of the huge Chris Hani Baragwanath Hospital. His political activities as a student and his work after graduation brought him into direct contact with ANC leaders including Nelson Mandela and Oliver Tambo. Albert was friends with George Bizos at Wits, a fellow student on the Students Representative Council, and George was a friend of Mandela’s, later becoming Mandela’s lawyer at his trials. Adelaide Frances Tambo, the wife of Oliver, was a nurse at the Non-European Hospital.
During Albert’s time at Wits, all medical students had practical placements at the Alexandra Clinic, a health service in Johannesburg for black people run by Mervyn Susser and his wife Zena Stein. They were well known to Albert and had much in common with him. They were both children of Jewish immigrant families to South Africa, Mervyn’s parents from the Latvian and Zena’s family from the Lithuanian parts of the Pale. They were strongly involved in and committed to communist ideology and they were passionately anti-apartheid. Because of their involvement in support of the ANC they were forced out of their role at the Alexandra Clinic in 1955, and fearing arrest under the Suppression of Communism Act, 1950, they decided to leave for England, arriving in January 1956.
Albert also feared arrest for his involvement in communism and anti-apartheid action, and he followed Mervyn and Zena to England in August 1956. A few years later they would be working closely together in Manchester, as will be described below. Apart from a very brief visit to attend his mother’s funeral in 1964, Albert would not be able to return to South Africa until the release of Nelson Mandela from his long prison sentence and the end of the banning of the ANC in 1990.
Early years in the UK
On arrival in England Albert went to London where he spent time as a locum house surgeon at St Giles Hospital, Camberwell, and Fulham General Hospital. He was also studying for his qualification as a Member of the Royal College of Physicians, required for full status as a doctor. In 1957 he obtained a post at South Ockendon Hospital, Essex, 20 miles from London. This introduced him to people with learning disabilities that were to be the major subject of his work for the rest of his life. He was there for two years before applying to study for a Diploma in Public Health with his friends Mervyn Susser and Zena Stein who had obtained posts in the Department of Social and Preventive Medicine at Manchester University. Mervyn was also a Medical Officer for Mental Health for the City of Salford. Albert was appointed assistant lecturer and assistant Medical Officer in both those roles with Mervyn while also studying for his Diploma. The dissertation he wrote for that award was entitled Subnormality in Salford. It was an epidemiological study of the prevalence and characteristics of people with learning disabilities in the city. He also developed an interest in the needs of older people, which was reflected in some of his later work.Albert would have been aware of the work of Neil O’Connor and Jack Tizard at the Maudsley Hospital in London. They published a book The Social Problem of Mental Deficiency in 1956 describing their research demonstrating the potential for work of people living in hospitals which opened up the possibility of them leaving to live in the community. Tizard also organised the 1958 ‘Brooklands Experiment’ in which 16 children were moved from a large London hospital to a house with a more developmental and home-like regime, showing greater progress than similar children who remained in the hospital.
Albert probably met Jack Tizard and his wife Barbara during his time at South Ockendon Hospital, especially as they shared with him an interest in and allegiance to communist ideals. When Albert went to Manchester this interest and commitment were also shared by Mervyn and Zena, Trevor and Jan Griffiths - a couple he became close friends with, and Gillian Olsberg whom he fell in love with and married in July 1959. All of them remained staunch socialists all their lives.
In 1959 and 1960 Mervyn, Zena, Albert and his wife Gill were actively involved in the founding and establishment of the British Anti-Apartheid Movement and gave strong support to the movement until the ending of apartheid in the early 1990s.
In the 1960s, Albert and Gill had four children: Anna in 1961, Danny in 1962, and they later adopted Ivan, born 1964, and Andy, born 1966.
The Wessex research project
Jack Tizard had developed a model that proposed that provision of comprehensive services, including residential care, within population areas of 100,000 people would enable all people with learning disabilities to be served in their local community close to their families. Hostels of around 20 places – one for children and four for adults – could cater for all residential care needs within that size of community. In 1962 he successfully negotiated funding from the Medical Research Council and the Department of Health for such a residential care project to be researched in the region served by the Wessex Regional Hospital Board covering the population area of 2 million people in Hampshire, Dorset, the Isle of Wight and part of Wiltshire.The first stage of the project, a survey of need, would require expertise in epidemiology. Further stages would require someone familiar with residential services and with the ability to plan a complex research project and lead a team of researchers. The obvious person already well known to Jack was Albert and he was appointed in 1962, first under the auspices of London University and later Southampton University. Albert’s post was based at the headquarters of the Wessex Hospital Board in Winchester. The family lived first in the Hampshire town of Chandlers Ford, moving to Southampton around 1968 where Albert lived for the rest of his life.
Albert recruited a fellow researcher, Gill Cox, and secretarial staff to carry out an extensive epidemiological survey. It involved designing data collection forms for all the residential accommodation and local authorities in the region, to identify the numbers and characteristics of all the people with learning disabilities being served. The survey related to a specific date, 1st July 1963. It produced two kinds of data: figures for the overall prevalence of known learning disability at different ages, and the identity of people in residential care from particular communities in the region. Because it was realised that people were sometimes in hospital care outside the region, the survey had to be extended to seek data about residents from Wessex from all the learning disability hospital accommodation in the whole of the UK. The survey was a mammoth task.
It was decided that the research would start with the relocation of all the children from two population areas of 100,000 who were in dispersed hospital care, moving them into two locally situated hostels of up to 20 places. This would provide a more homely environment close to the children’s families. To evaluate the service the progress of the children and the satisfaction of their families would be assessed in comparison with the same data on children remaining in hospital. Two cities in Wessex had populations of about 200,000 each: Southampton and Portsmouth. Demographic data were collected to enable each city to be divided into two comparable halves. The children from one half would be moved to the new hostel while the children from the other half would act as controls for the evaluation research. The research team was expanded and named the Health Care Evaluation Research Team. Several years were spent in the 1960s working with the Hospital Board to plan the hostels and collecting data about the children and their families. The research team developed extensive questionnaires about the abilities and behaviours of the children and about the views and experiences of their families. Key members of the team were Gill Cox, Paul Williams, Ron Whatmore, Roger Blunden, David Felce, Judith Jenkins, Ursula de Kock, John Smith and Jim Mansell. Jack Tizard kept in close touch with Albert and the research team until his death in 1979.
During the 1960s and beyond, Albert continued his political involvement in anti-apartheid and anti-racism. He was strongly involved in protest against the racist Rivers of Blood speech by Enoch Powell in 1968. He maintained contact and friendship with several black South African activists living in exile in the UK, including Oliver Tambo, his wife Adelaide Frances Tambo, Paul Joseph who Albert had helped to attend the 1953 World Festival of Youth, Albie Sachs a colleague at Southampton University, and Desmond Francis a mutual friend of Paul Joseph.
The evaluation research finally took off in 1969 when the first Wessex hostel, Westwood House, was opened in Southampton. It took 16 children from a number of different hospitals to live in the half of the city where their families were. Children from the other half were identified as controls for the evaluation. The hostel was created from two large houses in an ordinary street which had been knocked into one. It was thus large enough but fitted in well with neighbouring buildings and had the look of an ordinary home. In 1970 the second hostel, Locksway House, was opened in Portsmouth serving the children from half of that city. It was less successfully designed, having a large chimney from a boiler room and had the look of a group residence rather than an ordinary house, and the site chosen for it was on the edge of a large psychiatric hospital. The first hostel for adults, Fairmile House in Christchurch, Dorset, was opened in 1972. It had a pioneering nature in that it took the most severely disabled people from the town out of hospitals into smaller accommodation close to their families.
In the late 1960s, Richard Crossman, the Minister of Health, met with Albert to learn about the Wessex research and Albert was involved in giving advice on the content of the White Paper initiated by Crossman, published in 1971 under the title Better Services for the Mentally Handicapped.
In 1971 a clearer academic base for the research team was established by a move to the auspices of the newly established University of Southampton School of Medicine. Albert was appointed as Director of Research into mental handicap and care of the elderly for the Wessex Regional Health Authority and honorary senior lecturer in clinical epidemiology at the Southampton School of Medicine.
Albert had become interested and well informed about methods of teaching derived from behavioural psychology and often called ‘behaviour modification’. There were two aspects to this. First it opened up an educational approach to the care of people in any sort of residence. Albert was keen to provide information to those involved in this care, whether in old-style hospitals or in the new smaller services. He began to advocate strongly for the adoption of teaching methods in all the settings based on behavioural psychology. The other aspect of this interest was identification of a need to make direct observations of people’s behaviour and their contacts with their carers, involving assessment of the extent of engagement in activities and the quality of interactions.
Albert had recognised that the research programme and advice he was able to give on services for people with learning disabilities were also relevant to services for other groups and he revived his interest in services for older people. Members of the research team began studying residential services for older people as well as those for people with learning disabilities, in particular applying the methods of observation of activities and interactions.
The Medical Research Council was impatient for results of the hostel evaluation and it was initially agreed that they would be available by 1975. Some of the data collected proved to be too complicated to analyse, but data on children’s progress, the activity of residents and staff, professional contact and resident morbidity, staff continuity, family contact, and capital and revenue costs were reported. At first this was in a series of internal reports rather than being published in a scientific journal. Funding for the research team was renewed for further work, and much of the results were eventually published in 1980 in a special issue of the journal Advances in Behaviour Research and Therapy.
Widely recognised as an authority on services for people with learning disabilities, Albert was much in demand to attend conferences or to advise relevant organisations. For example, in June 1975 Albert visited Australia at the invitation of the Australian Council for the Rehabilitation of the Disabled, based in Sydney, to share his ideas and experience in that country. In 1977 he was a consultant to the Warnock Committee on the education of children with special needs, the report of which was the basis of the 1981 Education Act.
Further developments in work and family
By the late 1960s the concept of the large institution for care of people with learning disabilities was being challenged on many fronts. During the 1970s the concept of hostels as alternative accommodation to large institutional hospitals also came increasingly under question. During the decade, several examples emerged in the UK, the USA and Scandinavia of the use of ordinary housing for smaller groups of people, providing more homely environments and better opportunities for community participation. Albert’s research team came to recognise the limitations of the hostel concept and urged the Wessex Health Authority to begin to provide much smaller homes in ordinary housing. This they did, and smaller homes were opened in the late 1970s for both children and adults.Albert was always keen to provide practical help and advice to the families and carers of people with learning disabilities. He came to hear of a scheme in America that was highly thought of and effective in helping families to teach their children. It was called ‘Portage’ after the town in Wisconsin where it had first been developed as part of President Johnson’s Head Start program to help low-income families prepare their children for school. Albert saw the potential for helping families of disabled children and he applied for a grant to establish a pilot scheme in Britain. This was started in Winchester in 1976 by Albert with members of the research team and other colleagues. Soon many others were established in the UK. A conference of schemes was held in 1980 and a second in Cambridge in 1981 at which a steering group was set up to consider the feasibility of a national organisation. The National Portage Association was duly formed in 1983 and Albert was elected President, a role he remained in for many years.
In 1977 tragedy struck. Albert's wife Gill and her close friend Jan Griffiths had remained interested in communist ideology and they had an ambition to visit Cuba one day to see communism in action in what they regarded as a more humane way than in Russia. The opportunity arose and they decided to go without their husbands. They boarded a Russian plane, Aeroflot Flight 331, on 27th May 1977 which crashed in bad weather approaching Havana airport. Two passengers survived but Gill and Jan were amongst those killed. For the next four or five years Albert had the role of single parent to four teenage children. Jan’s husband Trevor Griffiths, a much respected tv and stage playwright, continued a close friendship with Albert and wrote a moving tribute as part of an obituary in The Guardian newspaper after Albert’s death in 1997.
During the late 1970s and early 80s Albert had become increasingly interested in direct contact to help people and rather less committed to research and service evaluation, though he did continue writing about service evaluation as late as 1983. Albert concentrated on teaching at Southampton University, giving advice on the development of services, supporting the Portage Association and helping to develop the Southampton Centre for Independent Living.
At the 1981 Cambridge conference which led to the founding of the Portage Association, Albert met Dee Williams, a teacher and school inspector involved in Portage programmes. She was elected Chair of the new Association. They began a relationship and Dee moved to live with Albert in Southampton. They married in 1989. Dee already had a son, Barney, who became Albert’s stepson.
As a senior lecturer at Southampton University, Albert gave lectures to students, not only on medical courses but for those studying other subjects including philosophy. One philosophy student was a young man with physical impairments, Simon Brisenden. He and Albert became friends and when Simon needed accommodation Albert invited him to live at the house he shared with Dee. Simon lived there for several years. Around that time the concept of Centres for Independent Living was developing. These supported disabled people in asserting and protecting their rights and achieving independence in housing and activities. Simon was keen for such a Centre to be established in Southampton and Albert assisted him in pursuing that goal. Simon organised a meeting of disabled people in December 1984 at which the Southampton Centre for Independent Living was founded.
In 1987 the group acquired premises in Southampton as offices and training facilities. Albert was a Director on the Board of Spectrum for ten years and appreciation of his contribution to the organisation features prominently in the group’s account of their history. A room in the group’s current offices is named ‘The Albert Kushlick Room’.
In the mid-1980s the Medical Research Council and the Department of Health which had funded the research team for twenty years decided that further work by the team was not needed. The funding stopped, the research team was disbanded, and Albert took retirement from his posts at the Wessex Hospital Board and Southampton University.
Since visiting the Soviet Union as a student Albert had always wanted to visit again, but conditions there were not conducive to tourism. However, when Mikhail Gorbachev came to power Albert and Dee felt able to join a trades union visit to Russia in 1986. As well as touring with the delegation Albert was able to make contact with some professional colleagues and he and Dee spent a few days of visits on their own.
Individual and group therapy
Despite his usual presentation of a happy cheerful disposition, throughout his adult life Albert suffered from bouts of depression. He spent several weeks in hospital after one episode in the late 1960s and he received treatment at regular intervals in later years. Alongside his general interest in behavioural psychology he found Cognitive Behavioural Therapy and Rational Emotive Behaviour Therapy particularly helpful. On retirement Albert decided to explore the application of these therapies directly with people with learning disabilities and especially to help their families and carers. To offer this help, he began to run therapy sessions within the NHS at Lymington Day Hospital in Hampshire and later at St Ebba's Hospital at Epsom and a Health Centre in Guildford. A large part of his success in this was that he was able to share his own experience with those who came to him. A particularly useful concept he developed was that of the ‘fallible human being’. He used this to help people manage conflict and difficult care tasks. We are all fallible. We make mistakes and are often unsure how to act, but there is no point in beating ourselves up about this; we share our situation with each other and should behave with tolerance and humility. That way we will show solidarity and equality with other people in a search for solutions to problems. A quote that Albert sometimes used was ‘A sign of maturity is the ability to live with uncertainty’.Albert was particularly concerned with the issue of so-called ‘challenging behaviour’. People with learning disabilities sometimes exhibit behaviour which others find very difficult to accept or manage. This is frustrating and unpleasant for their carers, and for service policy the people were the hardest to envisage being able to leave the restrictive environment of the large hospital to small community-based homes. As already mentioned, Albert became enthusiastic as far back as the 1960s with the concept of ‘behaviour modification’. This involves manipulating the antecedents that trigger behaviour and the consequences of behaviour for the person. During the 1970s and 80s it came to be realized that this model omitted consideration of two vital elements of human make-up: thoughts and emotions. Following his own direct experience of therapy, Albert became interested in particular in the work in America of Gary LaVigna, who promoted the concept of behaviour analysis which views behaviour as communication, and Albert Ellis who developed exploration of thoughts and emotions in relation to behaviour in the treatment called Rational Emotive Behavioural Therapy. Albert was particularly interested in how he might integrate Rational Emotive Behavioural Therapy into behaviour analytic approaches.
Albert visited America in the early 1980s to learn more about these approaches, and he met with both LaVigna and Ellis. He was also influenced by a Professor at Goldsmiths College at London University, Windy Dryden, one of the UK’s foremost experts on Cognitive and Rational Emotive Therapy. Albert adapted these ideas and therapies for direct work with people with learning disabilities who exhibited ‘challenging behaviour’. He also developed extensive work with the families and carers of people, helping them to develop strategies of understanding and managing the behaviours of those they cared for. He cooperated with others who were developing similar ideas, particularly Peter Trower and Dave Dagnan with whom he wrote some papers describing this work and who wrote the main obituaries of Albert in The Guardian and the journal Clinical Psychology Forum. Albert was widely regarded as a pioneer of new effective approaches to helping people with learning disabilities and their carers.
In 1989 Albert attended a two-week Summer Institute in Los Angeles, by the Institute for Applied Behavior Analysis, where he was able to share his ideas and experience in an international context.
Final years
When Nelson Mandela was released from prison in 1990 and the ban on the ANC was lifted, Albert was able to return to the country of his birth and early years. He and Dee visited South Africa in that year to meet family members and friends from the ANC. Albert was obviously delighted to see the end of apartheid. They went again in 1994 when Albert gave some workshops, free of charge, on working with people with ‘challenging behaviour’ and helping their carers. He was thus able to share his expertise in the country where his career and commitment to disadvantaged people had first been nourished.Albert had begun to suffer heart problems in the 1970s and he had several heart attacks then and in the 80s. In the early 90s he had a triple bypass operation but continued to have an increasing degree of heart failure. Typically of Albert, if anyone spoke to him of his ‘bad heart’ he would say ‘My heart is not bad, it’s a very good heart; it’s kind and generous, it’s just not working properly.’ He had another heart attack in August 1997, was admitted to Southampton General Hospital and died there on 23rd August, aged just 65. Dee received many letters and messages of appreciation of Albert’s work, especially from those who had been greatly helped by his therapy. A memorial event was held later in the year to which a large number of friends and colleagues came.
Albert had lived to see the complete closure in the early 1990s of the three main large hospitals for people with learning disabilities in the Wessex region: Coldharbour Hospital at Sherborne in Dorset, Tatchbury Mount Hospital near Southampton, and Coldeast Hospital near Fareham.
Albert’s legacy lies in the achievements of his children, the abandonment of the concept of the large institution to serve people with learning disabilities, the development of work with people with difficult behavior so that they can be included in ‘ordinary life’ options, the establishment of the nationwide Portage home teaching program, the success of the Southampton Centre for Independent Living, the development of measures for evaluating the quality of services, the support and therapy he pioneered for family members and carers, the advice he gave on development of services to politicians, service planners and providers, and the future work of the people he taught in his role as lecturer and employed in his research team. He also played a distinctive role in the eventual abolition of apartheid in South Africa.