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 other patients in it’ (Yeomans,
N. 1965a, Vol. 5, p. 106).
Participating in Domiciliary Care was not time based - ‘so many months prior to
leaving’ - rather ‘psychosocial health and competency’ based. Fraser House, patients were helping
ex-patients settle back into the community before they became ex-patients
themselves.
The little red van was also used for this domiciliary
care with fuel costs again born by the canteen. A group of patients would often
go, without staff, on these domiciliary visits. The Follow-up Committee would
also be continually requesting the visitors, relatives and friends for patients
to be able to use their cars and petrol to conduct domiciliary visits (Yeomans,
N. 1965a, Vol. 5, p. 63).
After a time it was decided to keep activity records and during the first nine
weeks of activity recording (1 July 1963 to 6 Sept 1963) there were 71 group
activities to homes. The average was just under 8 visits per week with a range
of 5 to 12 per week.
Appendix 11 contains a copy of a letter drafted by
resident members of the Parliamentary Committee as an aid to increasing
involvement in Fraser House by family and friends. Neville placed a copy of
this letter in his collected papers in the Mitchell Library (Yeomans,
N. 1965a, Vol. 2, p. 11).
The letter was sent by the patient who was the president of the peak committee.
The inclusiveness of community therapy is conveyed in the fifth paragraph. It
states that support was readily available, ‘by a group of patients’. They would
come and visit friends and relatives in their own red van.
Aspects of this domiciliary care have been adopted into
mental health practice with staff doing the visits. An early example modelled
on Fraser House was the Domiciliary Care Program at Kenmore Mental Hospital in
Goulburn (Mitchell
1964).
Crisis
Support
The
domiciliary care outreach was resonant with and an extension of the Fraser
House practice of providing suicide and other crisis support. From the outset
of Fraser House, a Suicide Clinic was set up as an aspect of the Unit. This may
have been an Australian first. Neville obtained a lot of media attention about
the role of this Clinic (refer Appendix 12).
In evolving support for suicidal people Fraser House
adopted the process of having patients and staff constantly around potential
suiciders as a support and crisis intervention group so that suicidal people
were never left alone. Patients would be co-opted as therapeutic
enablers and patients could and did take on the role of being caring support
for other patients, especially those in danger of self-harm. Any person who was
in a heightened emotional state, disturbed or suicidal would be immediately
‘specialed’. Processes were set up such that a cooperating team of patients,
with or without staff, would take on the responsibility of providing
twenty-four hour support to other patients at risk of suiciding, and in the
process this support team would gain response ability. This meant that two
patients, or a patient and a staff member, would continually stay awake with
that person around the clock (and be replaced by another shift if necessary)
until, on the say of a group, the ‘specialed’ status was removed.
This idea of setting up support processes for suicidals
was subsequently used elsewhere in the wider society and has since become a
standard practice in mental health services. However, outside of Fraser House,
I understand only staff are used in the support process. In Fraser House
‘Special Groups’ could be called at any time whenever a crisis occurred. These
groups would last as long as required to ‘do the job’.
Fraser House became known in
Often
Fraser House would receive a call from residents near The Gap – a place often
used by
Photo 1 Sheer Cliffs at the
Gap – (Lloyd 2005)
Fraser House patients had an
excellent track record in getting potential suiciders to come back with them to
Fraser House. This having patients seeing their Fraser House therapeutic
community having wider community relevance, and seeing their own healing ways
and their peers as significant to themselves and others, was yet another
element of the Fraser House healing process.
Photo 2 Watson’s Bay
Topography - compile made by me from photos taken by tourist and sent to me
October 2005 – used with permission
Neville used locality strategically. Photo 2
reveals Watsons Bay’s topography. The Watsons Bay Festival was in the park (The
green area in the centre right of the photo). The park is located in a primary
valley below the main ridge and between two primary ridges. The festival focal
point was at a Keypoint in the primary valley. The festival’s Keypoint theme was
‘celebrating life”. Neville intentionally placed this celebration of life sixty
metres below where Sydneysiders go to suicide at The Gap. The bus in the photo
is parked where the Fraser House little red bus used to park two years earlier
when the Fraser House patients made crisis calls to stop suiciders.
Neville began speaking at Ted Noff’s Wayside
Chapel at Kings Cross in
The Outpatients, Relatives and
Friends Committee
As a core aspect of regional
governance, shared travel was fostered by a committee called the ‘Outpatients,
Relatives and Friends Committee’, one of the patient-run committees under the
Fraser House Governance Therapy/Re-socialising Program. This Committee would
arrange the matching up of outpatient attendees at Big and Small Groups to
maximize car-pooling and people travelling together for making of friendship
bonds. Often people with very small family friendship networks and poor social
skills would be voted on to the Outpatients, Relatives and Friends Committee to
provide experience in social interaction. This was a major process for extending
functional family-friend networks for patients prior to their leaving Fraser
House.
Neville said (Oct 1998) that as a
consequence, these visitors and their associated Fraser House patient(s) tended
to obtain through their involvement in Fraser House, a completely revised and
extended functional suburban friendship/support network composed
typically, of up to seventy people who they met through Fraser House.
Recall that typically, patients arrived at Fraser house having from two to six dysfunctional
members of their family and ‘friends’ in their lives. Some who had jobs had a
workmate or two that they had some social contact with.
Constituting
Rules and Constitutions
In involving patients and outpatients in self
governance, Neville had them devise their own document entitled, ‘Patient’s
Rules for Committees’ (Yeomans, N. 1965a, Vol. 2, p. 6-12). Neville sent a letter of congratulations to patients
and outpatients on 17 Jan 1963 when they produced this document, giving them
‘100% for effort’ (Yeomans, N. 1965a, Vol. 2, p. 13). I found Neville was superb in giving recognition. A
monograph prepared by patients and outpatients was, ‘The Constitution of the
Fraser House Relatives and Friends Group’ (Yeomans, N. 1965a, Vol. 2, p. 50-60). Patients and outpatients in other committees devised
their own constitution. All of this was, for Neville, part of the community’s
creating a social system of law for the Unit from within the lore of their own
constituting. This is another glimpse of Neville modelling epochal shift
through social re-constituting.
Appendix 13 outlines all the various patient
committees at a particular point in time, and provides a sense of the
comprehensive breadth of committee action. Committees were constantly being
reviewed and/or changed, including which staff function was devolved to which
committee, the roles of each committee, the membership of each committee,
including membership criteria, the split between in-patient and outpatient
membership, and the staff present at each committee meeting.
SUMMARY
This Chapter has discussed the Unit’s milieu
as a therapeutic community. Patient self-governance and law/rule making via
patient committees were outlined. In the Fraser House Governance Therapy,
Neville was evolving praxis towards folk community reconstituting their local
lore and law as a model of this vital aspect of reconstituting collapsed
societies and evolving folk based transitions towards a caring new epoch (Yeomans, N. 1971c; Yeomans 1974; Yeomans and
Spencer 1999). The next chapter explores Neville’s evolving and use of
whole community Big Meetings.