Plate 10: Dormitory arrangement, Therapeutic Community era, Kenmore Hospital 2005 Photo: D Kordes
92 During the Therapeutic Community era, new patterns of asylum admission and discharge evolved. From the late 1950s onwards, in response to the new psychoactive medications and legal instruments, NSW admissions almost doubled while at the same time the long-term resident population began to decline. These trends were similar to asylum admission trends overseas, for example, in England, Wales and the United States (Scull 1984:67). The replacement of ‘lunacy’ with ‘mental health’ in the language of the NSW Mental Health Act 1958, and its greater emphasis on medical treatment rather than on confinement, may have contributed towards destigmatising asylum care, thereby encouraging people to seek psychiatric treatment at an earlier stage.
The Mental Health Act created new categories of residents. Formally recommended patients referred to temporary and continued treatment patients, inebriates, and ‘those admitted for psychiatric examination’ (SPS 1965-66:8). The new category of temporary patient was ordered to reside for a period up to six months, after which he or she was brought before a tribunal, where he or she could be discharged or reclassified as a continued treatment patient. In 1961, for the first time in NSW asylum history, voluntary admissions exceeded involuntary admissions. Of 5,967 admissions to NSW asylums, 3,307 were voluntary patients (SPS 1961:3). This represents a stark contrast to the 0.5-2.0% presence of voluntary patients during the period 1925-59. In 1961, Kenmore admitted 55 temporary patients (37M, 18F), 289 voluntary patients (159M, 130F) and 290 inebriates (245M, 45F). With reference to Kenmore, the increase in voluntary admission numbers was, among other factors, also attributed to the Therapeutic Community approach:
The hospital is stated to be continually growing in status as a therapeutic
community and the prejudices of days gone by are now rapidly being broken down. People are now far more willing to come to hospital for early treatment as
Voluntary Patients than was the case in previous years, and this is reflected in the extremely small number of patients who have been required to be classified as Continued Treatment patients. (SPS 1961:11)
It seemed that more people were willing to consign themselves to the liberal care practices offered by NSW asylums.
The Mental Health Act made provisions for an easier and earlier exit from asylum care, and it was in the Therapeutic Community era that a ‘revolving door’ admissions scenario took off. In his Annual Report for 1962-63, the Director of State Psychiatric Services described this trend in terms of bed utilisation: ‘for every 100 patients resident at the end of the year in 1954 we had admitted 53
93 patients during the year. In 1962-63, for every 100 patients resident at the end of the year, we had admitted 113 patients’ (SPS 1963:4). Table 6.1 provides some insights into NSW admissions and residency trends at five year intervals during a 15 year period:
Table 6.1. Patient Admissions and Residency Figures NSW Asylums 1954-68 Year Admissions % per 1,000 Residents % per 1,000
As at 30 June 1954 6,569 1.91 12,248 3.58
As at 30 June 1959 8,051 2.14 12,668 3.37
As at 30 June 1963 14,380 3.55 12,820 3.16
As at 30 June 1968 20,820 4.81 10,770 2.49
Asylum doctors believed that the new mental health laws and non-medical as well as medical treatments were key factors in admission and residency trends. In his 1963 report, the Director of State Psychiatric Services observed that the increase in admissions was ‘due to a more comprehensive and adequate service being provided. The sharp upward trend from 1958-59 onwards must be partly due to the new mental health legislation introduced in 1958 bringing with it a greater acceptance of psychiatric treatment’. The ‘efficiency’ of NSW asylums, derived from a higher turnover of patients and a slow, unplanned reduction in resident numbers, was attributed to a combination of drugs and ‘skilled professional staff to handle them and to provide a full range of treatment and rehabilitation programmes’ (SPS 1963:5). Those reporting the increase in asylum admissions and the reduction in resident numbers described both trends as progressive. In 1968, Kenmore was reported in the Annual Report as follows:
(p)rogress made at this hospital during the past year is demonstrated by the drop in hospital population.
In this year, Kenmore had experienced a drop in admissions from 1,345 to 913, and a drop in the daily average resident from 1,032 to 981 (SPS 1968:16). After the overcrowded conditions of the 1950s, it is not surprising that progress was measured in this way.
Progress was also equated with the fall of the inebriate presence in the asylum. Initially, inebriate admissions for NSW rose, from 217 in 1954, to 487 in 1959, to 1,009 in 1963. The rise in numbers was attributed to a rise in the incidence in alcoholism and to ‘social and even administrative influences which are bringing a higher proportion of alcoholics under the psychiatric hospital control’ (SPS 1963:7). By the mid 1960s, though, administrative changes brought about the decline of inebriate numbers, at least in Kenmore:
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in the latter half of the year, there has been a diminution in the number of patients admitted to this hospital under the Inebriate Act as a result of a new policy whereby many early alcoholics are now treated in metropolitan hospitals. (SPS 1964-66:31)
By 1970, the Director noted that for Kenmore:
(t)he hospital has averaged approximately 80 inebriate patients, which is in marked contrast to the large number of inebriate patients previously accommodated. This reduction in the number of inebriates has been brought about by admitting many patients suffering from alcoholism, on a voluntary basis, and also because the metropolitan hospitals are assuming responsibility to treat the patients who suffer from alcoholism in their individual admission centres. (SPS 1970:39)
The change in policy, favouring voluntary admissions over the legal paperwork generated by the 1912 Inebriates Act may have been reflective of a wide-scale liberal approach towards persons under asylum care and treatment. The custodial emphasis of the Inebriates Act was out of step with the Therapeutic Community approach. Although the powers vested in the Inebriates Act have not to this day been repealed, psychiatry was able to use its discretion in how it would classify persons presenting with alcohol-related problems. The reclassification of the inebriate to the ambiguous, catch-all category of voluntary patient also avoided an embarrassment for the psychiatric profession, of the asylum typecast as a human warehousing facility for the alcoholic.
The drop in resident numbers encouraged the better separating out of patients. Wards were reclassified in ways which divided up and separated inmates as well as reintegrated them in novel ways. In the context of a declining asylum population, it became possible to divide the inebriates, retards, geriatrics and the psychiatrically dis-ordered, as well as segregate according to psychiatric diagnosis. For example:
An attempt has been made to separate the inebriate patients from the newly admitted psychiatrically ill. ... Those who are physically ill go to the Admissions Centre Wards and those who have a potential for early rehabilitation are sent to Male 8 Ward and integrated into the Fairlight Hall Group Therapy Unit. (SPS 1964-66:31)
For a short period in the late 1960s, ward classifications also reflected residents’ eligibility for the disability pension.62
The shift to a Therapeutic Community approach involved the modification of the asylum’s physical and human geography. Reflecting the new training programs for nurses and programs for training inmates for freedom and responsibility in the community, the asylum’s buildings and grounds were
95 refurbished and new buildings were constructed. A former operating theatre at Kenmore was turned into a centre for group therapy and occupational therapy workshops were constructed, reflecting the rehabilitative focus of Therapeutic Community. Similarly, cottages – half-way homes - were constructed on the periphery of Kenmore, thereby physically marking residents’ progress towards rehabilitation and recovery.
At the same time as Kenmore was implementing new dividing practices, there was a gradual reintegration of the genders commencing with supervised interactions between Male 3 and Female 3 Intermediate wards. In 1963, these wards became the loci for the implementation of therapeutic community techniques. In addition to providing the spatial settings for early experiments in male/female social interactions, these wards were also renovated with a view to giving each inmate more privacy.
Over time, wards were renumbered and renamed to reflect the changing human geography and by the 1980s, most wards had become integrated spaces, with male and female patients and staff living or working under the same roof. The new names such as, for example, ‘Oasis’, ‘Lobelia, and ‘Dinderra’, were not meaningful names to the newly arrived or to visitors regarding the categories of patients the asylum catered for. The new names were rather an expression of the asylum’s effort to disassociate itself from custodialism and to strive for the Therapeutic Community aims of normalisation and integration, to the degree that ‘(m)any members of the public have been surprised to discover the pleasant and normal atmosphere prevailing in our institutions …’ (SPS 1963:7)
Lower resident numbers provided more opportunities for Therapeutic Community interventions. By 1970, NSW asylum resident numbers had declined from 12,539 in 1960 to 9,430. In his Annual Report for 1971, the Director of Psychiatric Services notes that the ‘reduction in patient numbers has enabled substandard accommodation to be abandoned or renovated with a substantial reduction in standard bed numbers’ (p.4). Standard ward patient numbers could now be reduced, from 60 to 40, providing space for ‘individual clothing locker’ and ‘leisure and therapeutic activities’ (p.4). In its overcrowded eras, these wards had accommodated up to and over 100 patients.
Asylums were no longer the overcrowded and substandard accommodation facilities of previous decades. Creating an aesthetically pleasing environment for their patients became part of nurses’ daily routine:
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When Dr C came, he really … supported us in improving the physical … décor of your wards and things, to make it more attractive. He would always say, “what are you doing now? What are you doing this week?” And I’d say, “Oh, I’m buggered, I’m having a break.” “Oh no”, he’d say, “you better keep going”. I’d say “Yeah, but look, we’ve just got all those lovely photos and pictures around, and so and so has gone and smashed all the glass.” “Oh”, he’d say, “well give it another go”. You’d do all these things to try and make their environment better for them, get nice pictures or rearrange the place different to make it look nice. Even get … nice tablecloths … (Linda)63
By the 1970s, the Therapeutic Community approach had been introduced to all Australian asylums (Savy 2005:207).
The locked door spaces of Therapeutic Community
Wards reflected the amount of freedom, responsibility and choice available to their inhabitants. Custodial and disciplinary techniques of the locked door era had not been abandoned but continued to form part of the asylum’s repertoire of treatment and care. The disciplinary mechanisms of the asylum were slowly relaxed for some but not for all. Destructive and violent patients, escapees, low- functioning retardation patients, the senile and the demented, and newly admitted patients still required a level of surveillance that involved maintaining restrictions on their freedom of movement. For alongside its objective of ‘civil restitution’ of the patient was the asylum’s overarching and enduring responsibility to ensure the safety of staff and patients and to maintain its project of upholding the ‘norms of order and conduct’ (Gordon 1988:278).
Not all spaces of Kenmore’s physical geography were exposed to environmental improvements. Ward conditions reflected staff assessments of residents’ capacities to appreciate them. For example, wards for the severely institutionalised or the violent were unlikely to be renovated: the inmates of these wards were regarded as having no capacity to appreciate ward refurbishments, and it was believed that improvements to the environment would have little or no effect on their behaviour. Indeed, it was believed that these inmates would more than likely destroy any efforts at making their living surroundings more comfortable and aesthetically pleasing.
Alison recollected how the refractory ward with the exception of its bathrooms was a ward that had very little renovations done to it. The
63 Reminding us of the discrepancies within and overlaps across the care regimes, the Evacuation
Officer reported to the Inspector-General on 29 May 1942 that: ‘The practice of allowing patients to have their own private furniture had grown up at Kenmore, the whole of this furniture being of good quality and valuable.’
97 appreciation of an aesthetically pleasing environment was supposedly lacking in the refractory inmate. This category of resident was therefore regarded as potentially destructive of any improvements to the ward environment. The wet end of the male refractory ward, a series of seclusion rooms tiled from ceiling to floor, each room fitted with a run-off hole to enable staff to hose off faeces and urine from its walls, remained an environmental feature of Therapeutic Community.64 At least until their condition had stabilised and they had become psychologically accessible, residents of the wet end were not exposed to the freedoms and responsibilities offered by this care regime.
Accordingly, the open door policy of Therapeutic Community was modified by nurses in correspondence with their understandings of patients’ capacities for responsible and rational behaviour. Linda described how the ward spaces were kept safe and orderly for low-functioning retardation patients:
Linda: (V)ery few of them were ever allowed freedom of the, ah, sleeping areas, for many different reasons, some because of their destructive behaviour, others
because of their feeding behaviour, or, and I mean you just couldn’t have them all walking through the door …
Doris: What do you mean, freedom of the sleeping areas?
Linda: Well, just able to go through to their bedroom any time of the day or night. Some of them of course, um, were still destructive, were physically destructive of the furniture and other people’s belongings and things like that. ... It was the type of people we had. Other wards, you know, they could [go] ... everywhere, every area of the ward all the time.
As well as the residents of low-functioning retardation wards, refractory patients were subjected to similar surveillance and control measures. While it was not unusual for a ward of male patients to invite the equivalent ward of female patients, and vice versa, to listen to music on the gramophone and have dances,
one never put the refractory wards together.
The emergence of new communities across asylum boundaries
The declining resident patient numbers as annually reported by the Director of State Psychiatric Services indicate that an informal process of deinsitutionalisation, the prerequisite for Community Care, had commenced in the 1960s. This trend was generally supported by psychiatrists. In a conference on community mental health held in NSW in 1966, the Medical Superintendent of Gladesville Hospital noted that:
64 There was no equivalent to the wet end in the female refractory ward. This was explained by
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Treatment of new patients in their own milieu has superior results to those gained when the patient is isolated from his community. ... Gaining re-admission to his community and attempting to re-establish himself in his former role, is often a task of such magnitude that failure to achieve this aim is almost guaranteed. ... Also, treatment in the community of new patients as far as possible would obviate the very definite stigma which becomes associated with this person ... (Frame 1966:18)
During the 1960s, the shift from asylum to community care solutions was increasingly regarded as a humane and enlightened answer to the problem of psychiatric dis-order:
Now we are on the edge of a more fundamental change. Even in our lifetime we shall see psychiatry move into the community and a new attitude emerge to mental illness, its prevention and its treatment. Perhaps this is the most exciting phase of all, for with support, tolerance and group understanding we may together learn to carry more of the stresses of civilisation within our new community structure. (Dax 1961: 205)
At the same time as care in the community was described as a progressive move into the future, the asylum became increasingly associated with the past, as an anachronistic, stigmatised and stigmatising total institution productive of and contributing to inmates’ psychopathologies (Barton 1959; Berks 2003; Goffman 1961).
The move to care in the community liberated the profession Psychiatry from the asylum as much as it did the patient. Not surprisingly, this liberation was also framed in terms of progress, of embracing the new stage of knowledge and practice for a ‘modern’ psychiatry. In 1963, the Director of State Psychiatric Services provided a rationale for the expansion and extension of the terrains for psychiatric practice:
We must look more searchingly at the need for adequate community psychiatric services. Physical treatments are only partial treatments. Patients must be treated at the earliest possible moment even before admission is required and, once
treatment is initiated, there must be frequent follow up interviews with provision of psychotherapy, occupational therapy, social rehabilitation, family therapy and review of treatment. ... modern psychiatric services place maximum emphasis on early treatment of patients as outpatients, in their own homes or in the outpatients departments close to their homes. As a second step, day hospitals provide more comprehensive supervised treatment in the community in which the patient lives. ... Psychiatric patients and their relatives are often poorly motivated to seek treatment ... psychiatric services cannot wait for people to seek them out. Services must be taken to the people. (SPS 1963:5-6)
NSW psychiatry provided additional justification in terms of the growing market demand for its services:
The rapid growth in population of this State and the increasing demand for mental health services from all sections of the community make it essential that our activities extend well beyond the walls of the psychiatric hospital into the community which surrounds that hospital. (SPS 1964-66:5)
99 The extension of the psychiatric enterprise implies that the emerging regime of care in the community did not develop in the dispersed geography of the community but borrowed from existing knowledge developed in the asylum and techniques mobilised by asylum staff. The melting away of the boundaries between asylum and community provided a pathway for psychiatry to extend its influence ‘into areas from which it remained excluded so long as its practice was confined along with its patients to impregnable institutions’ (Castel et al
1982:172). Perhaps just as important to understanding the impetus for emptying the asylum, then, is the reconfiguration of the psychiatric profession itself:
At the professional level, … what was at stake was not a desegregation of the