Neville Yeomans
An Australian
Psychiatric and Social Pioneer
Last updated Feb 2007.
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Abstract
Dr Neville Yeomans’
pioneering of community psychiatry, psychiatric nursing, psychiatric
therapeutic community, community mental health and other related practice in
Australia is outlined. Yeomans’ role as the founding director of Fraser House,
a therapeutic community based psychiatric unit in 1959 in North Ryde
Psychiatric Hospital in Sydney, Australia is detailed, along with his Fraser
House outreach in pioneering the application of psychiatry as an integral
public resource that nurtures humanities perennial social transformation
towards a more caring and humane local regional and global society.
Keywords:
‘Community, Fraser, House, Therapeutic, Yeomans
Photo - Neville and nurse at Fraser House in 1960
(Yeomans 1965a).
An Overview
This
paper outlines psychiatrist Dr Neville Yeomans’ (1928–2000) pioneering of
psychiatric approaches in Australia. Qualifying as a
psychiatrist in the mid 1950s, Yeomans was the founding
director of Fraser House, a psychiatric therapeutic community unit in North
Ryde Psychiatric Hospital in Sydney, Australia. In the 1960s and 1970s Yeomans
pioneered community psychiatry, psychiatric nursing, community mental health,
suicide/crisis telephone services, psychosocial domiciliary care, small
residential therapeutic communities and dispersed non-residential therapeutic
communities, as well as professional and peer-lead psychosocial self-help
groups. This paper has been written as part of research towards a PhD on
Yeomans’ life work[1] and draws
upon research by Yeomans and others relating to Fraser House.[2]
While few people in Australia and elsewhere have
heard of Dr Neville Yeomans, the Sydney Sun newspaper in 1963 included Yeomans’
groundbreaking work in psychiatry with six other Australians under the heading,
‘The Big Seven Secrets Australians were first to solve’ (1963). Yeomans was included with people like Sir John
Eccles who won t Sir Norman Greg who in December 1957 received an invitation
from an Italian pathologist Professor Alfonso Giordano to be nominated for the
Nobel Prize in physiology and medicine for 1958. Yeomans’ work was also recognised by anthropologist
Dr Margaret Mead who is reported[3] as saying when she visited Fraser House in
the 1960s that she considered ‘Fraser House the most advanced unit she had
visited anywhere in the world.’ Mead’s interest in Fraser House followed from
her role as the Co-Founder (1948) and ex-President (1956/7) of the World
Federation for Mental Health.[4]
UK Therapeutic Community pioneer Maxwell Jones wrote the following about
Yeomans’ Fraser House structure:
Given such a carefully worked-out structure, evolution is an
inevitable consequence[5].
Yeomans pioneering work in
evolving Therapeutic Community practice in Australia (1959-68) places him among
other pioneers like Tom Main and Maxwell Jones in the UK and Harry Wilmer in
the USA[6].
As further evidence of Yeomans’ recognition he served on a number government
and non-government peak advisory bodies[7].
Evolving Community Psychiatry at Fraser House
Following
formative experiences[8]
Yeomans’ first degree was in biology. Yeomans became a psychiatrist in the mid
1950’s and completed other studies to become a sociologist and psychologist in
the early 1960s and a barrister in the early 1970s.
Yeomans
recognized that in 1957, with considerable upheaval and questioning in the area
of mental health in New South Wales and a Royal Commission being mooted into
past practices, there was a small window of opportunity for innovation in the
mental health area.
Fraser
House was purpose built for Yeomans during 1958-1959 by the New South Wales
Health Department as an 80-bed residential unit on the grounds of North Ryde
Psychiatric Hospital. Yeomans was aged thirty-one when he obtained the go-ahead
from the Health Department to take in male patients at Fraser House in
September 1959. The female ward opened in October 1960.
Yeomans evolved Fraser House as a short-term residential unit addressing the social basis of mental illness. Fraser House intervention was sociologically oriented. It was based upon a social model of mental dis-ease and a social model of change to ease and wellbeing. Yeomans observed social dysfunction as a consistent predicative indicator of diagnosable psychopathology; he was at the time a government advisor on psychiatric diagnosis as a member of the Committee of Classification of Psychiatric Patterns of the National Health and Medical Research Council of Australia[9]. This networked dysfunctionality among prospective patient networks was the focus of change at Fraser House. Consistent with this, before admittance was considered, a prospective Fraser House patient was required to attend Fraser House Big and Small groups twelve times along with members of his or her family/friend network (typically under six), with all network members attending groups signing in as outpatients.
Admittance
was also dependent on the network members undertaking to continue attending
Fraser House groups as outpatients throughout a patient’s stay. During the
1960s, Fraser House had around 13,000 outpatient visits per annum. Fraser House
patients arrived at Fraser House typically with a small (less than six)
dysfunctional family friendship network and left in twelve weeks (the maximum
stay) with a functional network of around seventy people, most of whom lived in
the same locality as the patient. Ex-patients could, by arrangement, return
three times for further stays at Fraser House. Fraser House processes ensured these
seventy-people networks were being linked into other Fraser House based
networks in an extended network of networks.
Sourcing Patients and the Fraser House Milieu
Yeomans
sustained Fraser House as a balanced community in a number of respects. Half the
patients at any one time were from asylum back wards and half were from
prisons. Half were male and half were female. Half were under-active and half
were over-active. Half were under-controlled and half were over-controlled.
Half were under-anxious and half were over-anxious. Having opposites sharing
the same dorm was based on the principle that the presence of opposites creates
a metaphorical normal position in the middle. Fraser house research showed that
there was a tendency towards the mean, with the under-controlled becoming more
controlled, and less active, the over-controlled becoming less controlled and
more active.
Yeomans
was quoted as saying, ‘We have a plan to transfer to the Centre over a period
of time all fifty Aborigines who are now patients in NSW mental hospitals.’[10]
This happened and apart from a few that needed full time care because of
associated medical conditions, all of these people passed through Fraser House
and returned to their respective communities.
Like Maxwell Jones in the UK,[11]
Yeomans evolved Fraser House as a transitional community. In Fraser House
everything was in constant change and flow – staff, patients, outpatients,
processes, policies, and procedures. Like the water in motion in the whirlpool,
in Fraser House, structure was process in action. Every aspect of Fraser House
process supported the emergence and growth of functional nested networks of
around seventy people.
Big and Small Group
Process
The Fraser House Handbook[12]
refers to audience and crowd behaviour, especially contagion, being a central
aspect of Big Group[13].
In Yeomans’ paper, ‘Collective Therapy – Audience and Crowd’[14]
he wrote, ‘the skilled use of collective forces is one of the paramount
functions of the socio-therapist and such skills are defined by the team as
‘Collective Therapy’. In Yeomans’ paper, ‘Sociotherapeutic Attitudes to
Institutions’ he wrote, ‘Collective therapy, both audience and crowd, utilizes
social forces in the patients’ primary group.’[15]
Yeomans engaged all involved in Fraser House (staff, patients and outpatients)
in recognizing, understanding and utilizing these social forces.
A half hour break followed Big Group where staff
reviewed the Big Group. After the half hour break, staff and attendees were
split up into many small groups where group membership was based on a revolving
set of sociological categories. The composition of small
groups varied daily. All the small groups at any one time were based on the
same category. The social categories were:
- Age
- Age and sex
- Kinship
- Locality
- Married/single status,
and
- Social order (manual,
clerical, or semi-professional/professional).
People in pathological
social networks would be all together with everyone else in Big Group. However,
because of the continual changing composition in small groups, the members of
these pathological networks were regularly split up for the small group
sessions.
For the small groups based
on locality, Sydney was divided into a number of regions. In most cases, groups
of people came regularly on the same trains, buses and each other’s cars so
they all got to know each other. Patients and outpatients would attend the
small groups allocated by locality for their region of normal domicile.
The Unit’s aim was to
increase the patients’ role-taking functionality and psychological comfort
towards their returning to functional life in their local community with an
extended and functional family/friendship/workmate network. This meant that
people who may have previously had a social network that was smaller than
typical in society, ended up having one that was typically larger in terms of
the number of people in the ‘closely known and regularly interacting’ part of
their social network.
After a time at Fraser
House these individual patient family/friendship networks would expand to have
members with cross-links to other patient’s networks, and with a continual
changing Unit population, with overlap in stays, these nested patient-networks
became very extensive. As well, all these people had Fraser House experience in
common, and a common set of mutual support skills.
Governance Therapy – The Fraser House Committee Process
Within Fraser House Yeomans pioneered psychiatric
patient committees in Australia. He set up a process whereby patients, and
their family-friendship networks as outpatients, were massively involved in
meetings and committee work. Members of patients’ family friendship networks
were required to offer themselves for election to serve on committees. Fraser
House patients and outpatients progressively took on responsibility for their
own democratic self-governance. While other professionals in the UK had used
patient committees, in Fraser House the committee process was extended such
that patients and outpatients effectively became responsible for the total
administration of Fraser House.
Yeomans spoke[16] of three levels of
governance at Fraser House – local, regional, and global. Every patient along
with their respective family-friendship network was engaged in their own local
self-governance. The committee for locality-based transport called the
Outpatients, Relatives and Friends Committee (one of the Fraser House
Committees) 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’. The committee structure was essentially bottom-up with committees
reporting to the parliamentary committee to keep this wider committee of
committees informed. This three-fold governance model involved everybody in a
cross linking network of governance. All were involved at their local level.
All were 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).
This three level (local, regional, and global) governance at Fraser
House is a micro-model of the ‘local regional global self-governance’ model
that Yeomans detailed in his paper called ‘On Global Reform’[17] setting out how community
psychiatry may contribute towards societal transition to a more caring and
humane world – Epochal Shift. Yeomans was not alone in this; other people in
the Therapeutic Community in the UK evolved models for social reform.[18] However, Yeomans took the
pioneering step of applying his model in systematic sustained and prolonged
action research and making this action research very public and accessible.
Work as Therapy
It
was commonly acknowledged by my interviewees and within archival records that
psychiatric patients and outpatients became the most skilled in the emerging
new field of community psychiatry – even ahead of the Fraser House psychiatric
staff whose prior education and training had not prepared them for the Fraser
House evolving milieu. Patients who became experienced in community psychiatry
were elected as members of the patient assessment committee. The archival material,
especially the Fraser House Handbook written by patients to train new staff[19],
and the research interviews all support the view that patients became highly
skilled in carrying out their committee and other work. 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.[20]
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.
According to Yeomans and the ex-staff members Warwick Bruen, and Phil Chilmaid,
none of the professional training of the Unit’s staff had in any way prepared
them for engaging in community therapy. Patients had the advantage that they
lived therapeutic community every day in the Fraser House milieu. They were
emersed in it.
As
an indication of the staff, patient and outpatient competence, they effectively
self-organised and ran the Unit during Yeomans’ absence overseas for nine
months in 1963. For a numbers of weeks after Yeomans left there was no
replacement psychiatrist (because of no replacement being found in time by the
Health Department) and things went smoothly in the Unit.
Fraser House became the centre for training
psychiatrists in community psychiatry, with the patients as the primary source
of training. Three years after the Unit started
the Australian and New Zealand College of Psychiatry co-opted Fraser House
patients as trainers of trainee psychiatrists in the new area of community
psychiatry.[21]
Linked
to this patient/outpatient ‘work’ in Fraser House governance, assessment and
therapy was the use of ‘work’ as therapy. Progressively, patients with support,
took on all staff roles. The principle was ‘give the job to those who can’t do
it, with support so they learn to do it through experience’. To provide
refreshments during the break between Big and Small Groups the patients sought
and got permission from the North Ryde Hospital Director to set up, own and
operate their own canteen. As another example of work as therapy, Fraser House
patients tendered for a public contract to build an outdoor bowling green in
the grounds of Fraser House. They won the tender and built the bowling green.
It is still functional to this day. Work as therapy was also evolving in the UK
Therapeutic Community movement.[22]
Photo Two - Patients Building the Fraser House
Bowling Green in the Sixties with a Dormitory in the Background
A Photo
from the Sydney Morning Herald[23]
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[24].
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[25].
Fraser House, patients were helping ex-patients settle back into the community
before they became ex-patients themselves. Patient members of the Domiciliary
Care Committee started to go on suicide crisis calls into the community often
late at night[26]. This
service was the precursor to today’s crisis telephone line services. The
patients used the canteen’s profits to purchase and run a little red van that
the patients used for domiciliary care and suicide crisis calls. A group of
patients would often go, without staff, on these domiciliary visits. Yeomans
wrote that these patients involved in domiciliary care and crisis support were
very skilled[27].
Participating in Domiciliary Care was not time based - ‘so many months prior to
leaving’ - rather ‘psychosocial health and competency’ based. After a time it
was decided to keep activity records.[28]
Fraser House’s
transforming of the dysfunctional people at the margin of the dominant society
was in the context of Yeomans sensing that these people were the very best
people to explore how to reconstitute societies and evolve humane caring global
futures[29]. Everything
Neville did in and following Fraser House was designed to fit with everything
else naturally, what Yeomans called ‘the survival of the fitting’. Everything
complemented and supported other aspects. Things that did not work were
fine-tuned or discarded. Issues that arose in one context were resolved, or
passed on to other contexts. In Fraser House, what worked (as well as
problematic aspects) was discussed with everyone in Big Group. Issues not
resolved in Big Group were passed on to Small Groups and vice versa. Issues
within Committees were resolved, or passed on to the Parliamentary Committee.
The Pilot Committee reviewed issues within the Parliamentary Committee. This
pervasive inter-connected weaving of everything with everything contributed to
Margaret Mead describing it as the most complete and most total therapeutic
community she had ever seen, and why Maxwell Jones said that evolution was
inevitable (1969).
Yeomans opened up his work and the
Unit to public gaze and scrutiny in maintaining a very public profile for
himself and Fraser House. Yeomans regularly gave public addresses about Fraser
House and wrote many press releases and had the media attend groups at the
Unit. People from religious, business, academic, non-government and government
organizations including the Federal Government Foreign Affairs Department
attended Fraser House groups. Requests to attend were typically granted and
Fraser House became a major centre for learning group skills. Yeomans was
immensely confident born of his experience of the Unit’s functioning. When
asked about ‘miracles’ at Fraser House[30] Yeomans replied:
Of course it was miraculous. We were the best in the planet,
and we all believed this, so we would acknowledge our failings, as we were
streets ahead of everyone else. I was accused of being an impossible optimist.
I sense I was more of a fatalistic optimist. I was context driven - if I go to
‘creative context’ then ‘everything is creative’ - it worked like that. As for
the miraculous - well that was a calm night.....peaceful.... remember we were
filled with the very bad and the very mad - the under controlled and the over
controlled.
Extending Fraser House Processes into Civil Society
Yeomans left Fraser House in 1968 and devoted himself to extending the
transformative ways evolved at Fraser House into wider society. While still at Fraser House, Neville wrote a detailed
monograph entitled, ‘The Role of a Director of Community Mental Health[31]. This was a proposal, a ‘job description’ and a ‘CV’ all
rolled into one. His suggestion was adopted and upon leaving Fraser House he
became the coordinator of the New South Wales Community Mental Health Services. He started Australia’s first
Community Mental Health Centre at Paddington in Sydney. Yeomans also started
Paddington Bazaar, Sydney’s iconic Saturday community market to surround his
first community mental health centre with a small village atmosphere.
Paddington Bazaar continues to this day as a Sydney icon[32].
In the ensuing years Yeomans pioneered family therapy, suicide-crisis
telephone services as well as counselling and family therapy within family law.
Other processes Yeomans pioneered in Australia were mediation and what he
called ‘mediation therapy[33]’. Yeomans also evolved a
number of psychosocial self-help groups. Another focus was multicultural and
Alternative festivals as contexts for action researching the self organising
emergence and strengthening of social networks among people of the fringe[34]. One of these Alternative
Lifestyle festivals called ConFest[35] continues to be held twice
yearly. The preparation of the festivals and gatherings created rich contexts
laden with possibilities for community to emerge, and opportunities for
integrated and dispersed social networking to occur.
In 1972 Yeomans shifted to Northern Australia to action research his
ideas in places away from the power structures of Capital cities. An outcome of
Yeomans’ action research has been the emergence of an informal network of
networks amongst Indigenous and other marginalized healers in Northern
Australia and in the East Asia-Oceania-Australasia Region[36]. These networks, as self-organising
dispersed therapeutic communities are evolving and supporting self-help and
mutual-help amongst Indigenous/Oppressed trauma survivors in the Region.
Dr Neville Yeomans
contributions to psychiatry, the social sciences and the History of Ideas
continue to touch and transform people’s lives.
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