Chapter Seven - Governance and Other
Reconstituting Processes
THE
RESOCIALIZING PROGRAM – USING GOVERNANCE THERAPY
This chapter discusses the Fraser
House Re-socializing Program entailing all embracing patient self-governance
and law/rule making via patient-based committees.
Neville pioneered patient
committees in the mental health context within
Fraser House patients and
outpatients progressively took on responsibility for their own democratic
self-government. This is fully consistent with Neville’s exploring of epochal
transition. Neville referred to patient-based rule-making as creating ‘a
community system of law’ (Yeomans,
N. 1965a, Vol. 4). Law
evolved out of evolving Fraser House lore. The Fraser House vehicle for
evolving democratic self-governance initially was a committee that decided the
ground-rules for ward life called appropriately the Ward Committee. Eventually
many committees were established that mirrored the roles of every section of
the Unit’s administration. On every Fraser House committee, each committee
member had one vote. Patients outnumbered staff on all committees. This meant
that patients could always out-vote staff. This often happened. Neville
set the committee ground rules such that he always had a power of veto.
Dissenting people who felt strongly enough about a decision could take it
before Neville and the decision would be held over till he attended the
particular committee where people would present their views.
Neville said (Aug 1998) that he rarely
overturned a decision made by patients where staff dissented, as by Neville’s
reckoning after due consideration, the patients generally held the better
stance. In Neville’s paper, ‘Sociotherapeutic Attitudes to Institutions’ and
consistent with creating ‘cultural locality’ he wrote, ‘Patient committees
formalize the social structure of the patients’ sub-community change’ (Yeomans,
N. 1965a, Vol. 12, p. 46, 60-61). Neville
being ‘dictator’ satisfied the Health Department’s requirements for top-down
control. However, Neville said (July 1998) that he was a ‘benevolent dictator’
and the patients and outpatients effectively ran the place – and by all
accounts, they ran it effectively.
The structures and process of the committees were
being continually fine-tuned. Chapters Eight and Nine of Clark and Yeomans book
(1969) contain a
detailed description of the patient committees at one point in time. Diagram 9
below adapts the top-down traditional organization chart in Clark and Yeoman’s
book (1969, p.
66).
Neville had suggested the following diagram back in December 1993 and reaffirmed
it in Sept 1998; it shows ‘patient controlled’ committees and the staff
devolving their traditional roles to become healers. Neville (Dec 1993) said that his book with
All
of the committees shown in Diagram Nine below were isomorphic with mainstream
administrative cleaving; even following the Federal Government’s Parliamentary Review
Committee (the Fraser House Pilot Committee) and using the term ‘Parliamentary’
Committee’.
Diagram 1. Patient committees and the staff devolving
their traditional roles to become healers
This total self governance of the
total administration is fully consistent with, and understandable in terms of
an epochal transition model. Neville spoke (Dec 1993, Aug 1999) of three levels
of governance at Fraser House – local, regional, and global. Each patient with
their family-friendship network was engaged in their own local self-governance.
The committee for locality-based transport – the Outpatients, Relatives and
Friends Committee (discussed later in this chapter) - was engaged in ‘regional’
self-governance. The parliamentary-pilot committees, in association with the
other sub-committees of the parliamentary committee were engaged in ‘global’
self-governance of the Fraser House ‘global commons’. This is a micro-model of
the ‘local regional global self governance’ model that Neville detailed in his
‘On Global Reform’ paper (1974). This
three-fold governance model involved everybody in a cross linking
network of governance. Everyone was involved at their local level. Everyone was
involved at their regional level. And they were all linked into global
governance level process as a serving committee person, or being engaged by,
and by interfacing with the global governance (by for example being assessed by
the patient-based patient assessment committee). The committee structure was
essentially bottom up with committees reporting to the parliamentary committee
to keep this wider committee of committees informed.
Recall that patients were very dysfunctional fringe
people. In going onto committees they could be moving in and out of their
dysfunction(s) (psychosis or episodes of schizophrenia and the like). Patients
did what they could, depending on the state of their being-in-the-world on the
day. Neville often said (1993, 1998, 1999) that patients and outpatients were
not mad and bad ‘all the way through’.
Imagine
psychiatric patients returning to everyday life with finely honed practical
skills in administering a complex organization having for example, over 3,000
groups a year (Yeomans,
N. 1965a, Vol. 4, 50-54) (with
staff groups to discuss each group) and 13,000 outpatient visits a year. This
is what happened. Neville said (June 1998) that when they were back in their
community and learning to interact with people at say, the counter in their
local Child Endowment office, the patients typically had some understanding
about how bureaucracies work (and in many ways work poorly) through personal
experience of working through the challenges at Fraser House.
Committees
and Balancing Governance
The Ward Committee was the first
of many committees. Patients were voted on to the Ward committee by their peers
and typically, readily participated. The Ward Committee membership was
typically isomorphic with the ward’s mix relating to the merging of opposites.
Neville said (July 1998) that typically, diabolically autocratic people served
along side people who displayed extreme tolerance and passivity. Criminals
often with a tough ‘no mercy’ attitude would serve with the anxious
over-controlled. This was another social context for working out how to work
together, and working this through created potential for all involved to catch
glimpses of a metaphoric normal person somewhere in the middle.
In maintaining balance, the aim
was to have equal numbers of females and males on each committee. Endeavour was
made to maintain an inter-generational mix. Endeavour was also made firstly, to
maintain a balance on committees between under-controlled/over-active people
and over-controlled/under-active people, and secondly, to include outpatients
within the various committees. At one stage their were eight patients and four
outpatients on committees, that is, twice as many patients (Yeomans,
N. 1965a, Vol. 2, p. 12). Also,
patients were encouraged to have balance between committee work and
self-healing.
Isolates were learning to
re-socialize and form relationships with other patients and outpatients. The
Committee work required acquiring and using a wide range of personal and
interpersonal communicating skills. Participants were encouraged to recognize
and respect their own needs and those of others. This is a reason why the
committee work was called the ‘Re-socializing Program’.
Any person ‘hiding’ from their own
change-work by being too busy in committee work soon had other patients pointing
this out to them. If patients put themselves forward for elections too earlier
in their stay, patients and staff alike would be suspicious of them being on a
power trip or avoiding personal change work and would challenge them about
this, or raise the issue in Big or Small Groups. The same thing would apply to
a person seeking to serve on many committees.
Patient Administration
The other early committee was a
Parliamentary Committee that grew to be a committee that governed the work of
all other committees. Every member in every other committee was automatically a
member of the Parliamentary Committee. The Pilot Committee was a ‘Committee of
Review’ of the Parliament Committee. Within a very short time, a number of
patient-run committees and work groups were set up that involved the patients
themselves being actively involved in making decisions and taking actions on
every aspect that normally would be the role of Fraser House administration
people. Neville evolved the Fraser House committee process so that eventually
the committees were taking on aspects of all of the roles normally undertaken
by staff.
The
New Role for all Staff
In this devolving, staff took on
the enabling/mentoring roles in respect of the patients taking over the staff’s
administrative duties. This freed up all the staff including the cleaners to be
also enablers and supporters of self-healing and mutual-healing by the patients
and outpatients. The patients did the cleaning, with cleaners in mentoring
roles. Because the cleaners were constantly present in the community during day
work hours, they saw most of what was going on. Aided by this and by common
agreement of patients and staff, the cleaners were the most insightful
community therapists after the patients (refer the case study on an insightful
cleaner in Appendix 9). This skilled therapeutic role of the patients and
cleaning staff was reported in the research, writing, and other material in
Neville’s collected papers (Yeomans,
N. 1965a),
and collaborated by interviewees.
Neville and all of the staff were
entering into new territory at Fraser House. There was a climate of continual
experimentation. No one outside of Fraser House had experience in the processes
they were evolving either.
Flexible
Rigidity
Paradoxically, through the patient
and outpatient Governance Programme the Unit became increasingly flexible,
although simultaneously, there was the making of tightly detailed microscopic
rules. In a conversation with Neville, (13 July 1999) he stated that rules kept
changing by refinement as necessary, although often a set of rules would be
collectively dumped if they turned out to be non-functional. This paradoxical
‘increasing flexibility within tightly detailed microscopic rules’ mirrored
Neville’s ‘non-interventionist/interventionist and uninvolved-passive/ totally
involved’ leader stance. Action was a function of context. This mirrors
Aboriginal way. When things flowed, the people involved engaged in the flow.
When there were upsets or strife, rules would be swiftly invoked. As on the
Yeomans’ farms, all action was context driven, and what aspect, of what were
often polar opposites came into play, was a function of the unfolding moment.
Detailed rules were there constantly as a guide to action.
Patient Treatment and Training
In a Fraser House staff handbook it was reported that
patients were engaged in doing the following work:
Perhaps
the most immediate observation made by a nurse coming to work in this
therapeutic community for the first time, is that the patients themselves have
had a great deal of authority delegated to them. Indeed, in some matters they
are virtually the sole authority. At first glance it will seem fantastic that
patients assess and admit new patients; review progress and institute treatment
procedures; make new rules and alter old ones; mete out discipline, etc. (Yeomans,
N. 1965a, Vol.4, p. 17).
Committees of patients prescribed
community non-drug based treatment. At first this may sound a bizarre and
dangerous notion. And yet all the reports in archival material and from
interviews with the psychiatrist, psychologists and a senior charge nurse said
the same thing - the patients quickly emerged as the most skilful in
community therapy. Collectively they were way ahead of the professionally
trained psychiatrist, the trainee psychiatrists, the psychologists, and ahead
of the nurse therapists. According Neville, Bruen and Chilmaid none of
the professional training of these groups had in any way prepared them
for community therapy enabling; Fraser House became the centre for training
psychiatrists in community psychiatry, with the patients as the primary source
of training (Yeomans, 1989, 1992, 1993, 1997, 1998; Bruen, April 1999; Chilmaid,
April 1999).
The archival material, especially
the Fraser House Handbook written by patients to train new staff (Yeomans,
N. 1965a, Vol. 4, p. 17-20, 50-54), and the
research interviews all support the view that patients became highly skilled in
carrying out their committee and other work. I have access to embargoed Fraser
House records that include some of the reports of the Initial Assessment
Committee. I read restricted material including case records and the patient-run
Assessment Committee’s initial assessment on the same patients. It was apparent
that the insights in the initial assessment were congruent with the dynamics
that unfolded for particular patients. The assessments by patients read like
they were written by an extremely skilled, insightful and
psychosocially-emotionally wise and discerning community psychiatrist. This is
consistent with the expression, ‘It takes one to know one’.
Fraser
House Training
Such
was Fraser House’s growing reputation in the new field of ‘community
psychiatry’ that Fraser House became the place providing community mental
health training in community psychiatry for students preparing to become
members of the Royal Australian and New Zealand College of Psychiatry. Students
were allocated to Fraser House for six-month periods. Social worker students
from both the University of Sydney and the University of NSW were also trained (Yeomans, N. 1965a, Vol. 12, p.
73). Dr William (Bill) McLeod, head of Royal Park Psychiatric
Centre in
Neville
and Margaret Cockett both confirmed that they and Harry Oxley prepared a course
introducing psychiatrists and also medical students to the sociology of
medicine, socio-medicine and anthropology. They then began lecturing in this
course through Callan House in the Leichhardt municipality. This was the first
course of this type. I have been unable to track down any records of this
course.
The
Canteen and the Little Red Van
The
idea of having a patient run canteen was first discussed by the Ward Welfare
Committee in July 1960. This was reported in a Unit File Note now contained in
Neville’s Collected papers (Yeomans, N. 1965a, Vol. 5, p. 30). The possibility of a canteen was raised because of the
news that the Female Ward was about to open. This meant that extra funds would
be needed to meet the expanding welfare needs of patients. As well, the canteen
could provide snacks for the breaks between Big Groups and Small Groups.
The
canteen was fully owned and controlled by the patients and the profits could be
used at their discretion and by their deciding. Patients involved in running
and administrating the canteen learned valuable life and social skills and
response abilities/responsibilities. It provided a number of opportunities for
‘work as therapy’. It meant that patients learned responsible financial and
other management skills. None of the administration money of the hospital was
used. The canteen was totally set up and funded by the patients. Appendix 10 is
a Case Study relating to the Canteen as work therapy.
Profits
of the canteen funded the purchase of a little red van and money for related
fuel and maintenance. With between 10,000 and 13,000 outpatient visits and many
hundreds of guests a year, the canteen had a steady stream of customers. The
van was used by the patients in their suicide and crisis call-out actions.
Additionally, the patients used this van to go on domiciliary visits to
ex-patients and outpatients.
In
the devolving of administration to the patients in Fraser House, Neville used
the patients’ involvement in administrating and organizing the Unit (and all
the work that this entailed) as an opportunity for them to learn by living and
surviving. Fraser House ‘Administration
Therapy’ as the name implies used ‘learning how to administer a major hospital’
as a therapeutic process. Patients and outpatients also had opportunity to
learn that fault, if it be called that, was not theirs, but a part of a
‘disorganized’ and ‘conflicted’ Fraser House system. For example, the canteen
was ‘delegated’ - through voting by patient and staff, and by common
understanding - to those who were least able to do it (a standard Fraser
House practice), though capable of learning - so everyone could support them
until they could learn to do it. The canteen was a continual source of
claims and counter-claims about theft and mismanagement. The mess was
therapeutically valuable and this was commonly understood by all involved in
Fraser House – the functional value of ‘dysfunction’. It is another example of
Neville following his father’s use of opposites and reversals.
The
Domiciliary Care Committee
and Domiciliary Care
Fraser House pioneered home visits and domiciliary
care by psychiatric nurses and patients. A Fraser House monograph reports that
follow-up groups to homes became routine in 1962 (Yeomans,
N. 1965a, Vol. 4, p. 2-4).
Patients, who had substantially changed to being psychosocially functional, and
had been assessed as being proficient as co-therapists, and were anticipating
leaving the hospital themselves, would call on ex-patients and their families
and friends to assist and resolve difficulties (Yeomans,
N. 1965a, Vol. 5, p. 63). Members
of the Domiciliary Care Committee started to do domiciliary visits on
ex-patients and outpatients, and to go on suicide crisis calls into the
community often late at night (Clark
1969, p. 69-70).
Neville wrote that these patients involved in domiciliary care work and crisis support were very skilled and helped ‘to destroy the lunatic image that often some of these disturbed relatives have of the hospital and othe