On Re-Minding
Matina Pentes
Matina Pentes
It was the mid-1960s, and we were having morning tea in Ward 4 at the Broughton Hall Psychiatric Clinic in Rozelle, Sydney. Among us was a young doctor who was completing her Diploma of Psychiatric Medicine. She commented that she had a teenage patient who was fourteen years old and pregnant. She said: ‘She shouldn’t be here; she should be in school’. The young doctor had young children of her own. Her husband was a footballer—he wasn’t Lord Mayor, yet. At the time, what seemed like a random comment was in fact a prophetic observation that began the journey that would lead to the Rivendell Adolescent Unit located at what was the Thomas Walker Convalescent Hospital at Concord. Sometimes we catch these moments and sometimes we don’t even notice them.
On his return from the USA in the mid-1960s, where he spent some time with Professor Gerald Caplan (a pioneer in community mental health then associated with Harvard University), David Maddison (professor of Psychiatry at the University of Sydney) set up a pilot project at Broughton Hall which was aimed to explore the feasibility of delivering mental health care to people in their homes to prevent future hospitalisations. Canterbury Municipality was selected as the catchment for this project because it had the most ‘average’ demographics in Sydney at the time. This project was well-staffed and well-resourced. Elizabeth Tow, a social worker was a member of the team. She had links with Elly Jensen, who had established an organisation to set up ‘halfway houses’, known as the Richmond Fellowship, under the auspices of the Archbishop of Canterbury. One very ordinary and practical initiative undertaken by Elizabeth was starting a group of single mothers who were living in public housing in Punchbowl. She supported them to organise a School Uniform Exchange. During their meetings, the women found themselves chatting about many things while sharing the vicissitudes of their daily struggle. Eventually, a small network of support grew from this which called itself the ‘Endeavour Club’. I can remember wondering: These women aren’t sick. They are not on medication. Is this stuff the responsibility of a mental health team?
In 1971 I was studying at the Cassell Hospital, a therapeutic community, at Ham Common in London. Thomas Main was the medical director. He was one of the Tavistock group of psychoanalysts who felt strongly that psychiatry needed a stronger social dimension. It was morning teatime, again—isn’t that the time when we can have those off-the-cuff discussions that can take us to amazing places when no-one is watching. I asked him why we didn’t provide general practitioner–style medical care for patients as part of their admission to the Cassell. He answered that he believed that it was important for patients to maintain their relationship with the community and that hospitals shouldn’t create artificial environments that disengaged people from their social contexts.
In 1974 I was back in Australia. I had taken a position with the Crisis Team in Crown Street, an early Australian foray into delivering mental health services in the community. We dispensed and administered a lot of psychotropic medications. It was late autumn when a young man presented himself complaining about ‘the voices’. He had long hair and needed some dental work. He looked well enough fed. We spoke for a while: he told me he was travelling from Tasmania to Queensland. I recognised immediately that he was part of a seasonal migration of people who were referred to as the ’Eastern Seaboard Transients’. I asked him: ‘If you didn’t have to be mad to get assistance, what would we be doing for you?’ He replied that what he really needed was something to eat and somewhere to sleep. That was a career-changing moment for me.
In the mid-1970s I fronted up to Tony Adams, director of Health Services Research, Planning and Development of the Health Commission of NSW. Bill Barclay was commissioner for Personal Health Services at that time. I asked for an interview with Tony and told him that I had heard that a huge amount of funding had been made available for reforming psychiatric services. I also told him that I was concerned that nurses constituted the largest workforce in health and that he didn’t have a single nurse in his department. We took it from there. One of the first projects I was involved with was conducted with Laurie Young. Bill Barclay had asked us to look at ‘unnecessary psychiatric hospital admissions’. Laurie and I agreed what was deemed ‘unnecessary’ involved value judgements. We went back to Bill and told him that we could ascertain the predominating criteria for admission, but that it would be difficult to determine unnecessary admissions. During our investigation, which was state-wide and involved nursing staff, administrators, and psychiatrists, I thought that we should be interviewing patients as well. Laurie disagreed and claimed that their opinions were unreliable and would ‘skew’ the results. Even though I was very pregnant at the time I refused to budge. He agreed to let me interview patients but that the patient results would be published as a separate document. That was better than nothing.1
Soon after I was lucky enough to be included in the team that designed Community Health Programs for NSW, under the leadership of Howard Gwynne. This team produced what came to be known as The Rainbow Books, which detailed a radical and new approach to delivering care.2 The model constituted a community-based approach that horizontally integrated services for individuals with a mental illness, home nursing, drug and alcohol issues, adolescent health issues, and included baby health centres, health promotion, and community development. Those names may have changed over time, but the thrust was taking services to the people, keeping people out of hospital, and strengthening communities, with an ethos of democratic process (prevention, participation, and catchment-focused services). Radical stuff for those days.
In 1976 I went looking for a position in community development. I met Max Frame, then Regional Director of Southern Metropolitan Regional Health Service. He said he didn’t have any positions called ‘community development’, but he had a new group of health workers at Bondi Junction. If I could turn them into a team, he said, that would be the same as being a community development officer. I was still young enough to think I was bulletproof and agreed to check it out. I thought it could be an opportunity to test whether the model of community health services developed in the Rainbow Books could ‘float’.
We took the concept of participation and its underpinning requirement of democratic decision making to inform how we would create a structure for managing this service. We found ourselves with sixty-four staff across a range of services: mental health, home nursing, drug and alcohol, adolescent health, school health, and health promotion. The school counselling team was co-located with us. Because we were convinced that the mechanistic style of management that we had inherited from the institution-based model would only result in an authoritarian service, we decided to establish our own structure and articulate our core values as a service first. We agreed that we needed a management structure based on democraticand participatory principles to be able to deliver a service that was democratic and participatory. A key mechanism established to achieve this was a management committee. Representatives were elected from each of the service focused sub-teams; we met weekly. These representatives were not appointed by the team leader but by the whole team that they would represent.
Not long after, we were approached by Michael Cox from PALA (Positive Alternatives to Psychiatry) who wanted to set up an ‘alternative to psychiatric hospitalisation’.3 They needed a physical space and some funding support to set up their program. Once again, Max Frame, the regional director at the time, ‘stepped up to the plate’, after he was satisfied that the proposal was rigorously articulated, evidence-based, and had the capacity to establish a dialectic between the conventional and the innovative from which we could expect to learn something. The Doomsayers predicted that this ‘Council Street, Special Project No: 1’ would inevitably go the way of Marcusean repressive tolerance. Only history will tell.
During the first year of operations, we had a veritable tsunami of doubt and anxiety from our staff. An example was the cries from the generalist nurses stating: ‘We want to go back into the hospitals to work, we want to do “real” nursing, we don’t want to waste time sitting around discussing services, we want to deliver services’. After discussing their concerns, it seemed that some of them were struggling with the responsibility and having the authority to make their own clinical decisions, albeit within their scope of practice. They were also feeling abandoned by the local GPs (general practitioners) who had formally refused to cooperate or collaborate with this new community health program. The local branch of the AMA (Australian Medical Association) formally declined collaboration, seeing community health programs as a threat to their livelihood, for starters.
There was a growing resistance from inpatient mental health services to collaborate with community mental health unless management of community based services were vertically integrated with existing hospital based services. Professor Leslie Gordon Kiloh (University of New South Wales) explicitly and unambiguously expressed across the meeting room table that he would under no circumstances support this model of mental health service delivery.
Regardless of how innovatively, cleverly, wisely, democratically, or inspirationally we developed a structure for managing and providing services that operationalised and embedded our objectives, regardless of the core values that enabled change making and community strengthening outcomes, that integrated services across service specialties, that supported and promoted team work, and that would reduce the numbers of people needing to be institutionalised to receive care, we were hamstrung in the end. There had been inadequate preparation of the health care system to support these far-reaching changes. There had been no real work done to bring all important stakeholders on board. When we met with the NSW Nurses Association to discuss how nursing could respond to innovations in the delivery of mental health services—including deinstitutionalisation—the response was that there would be no support because nurses’ jobs were at risk, since there were no guarantees that they wouldn’t be made redundant. In fact, only few benefits were realised from the funding opportunities generated by deinstitutionalisation. The moneys generated by selling off the real estate and land of the mental hospitals didn’t follow the inpatient population into the community.
By 1986 the dream collapsed, and community health services returned to a silo-style of vertically-integrated services with the large institutions once more taking control of all mental health services. When the architecture supported it, multiple teams became polyclinics co-residing in the same building.
The easy explanation for the demise of the Bondi Junction Community Health Centre might be that we didn’t try hard enough or were incompetent. The truth, I suspect, is complex and may lie under several rocks, like the policy to do nothing until all the ‘hollow logs’ were depleted before rebuilding the system. It might have been that there was a demand for more acute beds in general, as we faced a rapidly increasing population. In the wash up the Bondi Junction Community Health Centre was a good piece of social reform that was not supported as vigorously as it could have been by the health system.
In 1984 I co-authored a book entitled Travelling with Children to Indonesia and South-East Asia (an anthropological approach).4 In 1986 I reinvented myself as a director of Asian Field Study Centres Pty Ltd and worked with Australian primary and secondary school groups operationalising the theory of their school-based curriculum in subjects such as Wet Rice Agriculture, Bahasa Indonesia, Use and Misuse of Resources, Dance, Art and Crafts. After the Indian Ocean tsunami I worked as regional director for USAID’s Health Services Program that, among other things, trained mental health nurses and midwives in Aceh, Indonesia. I now teach mental health to nurses in Sydney.
What have I learned over all those years? One thing that I have learned is that in one place on this earth (Aceh), it took 80 years of conflict followed by a 9.4 earthquake and a tsunami that flattened the whole province, razing it to the ground and killing up to 30% of the population, before meaningful change could take place. Another thing I have learned is that when change is at the mercy of a process of reform, other imperatives often impose themselves, including political constraints and vested interests, which tend to derail change.
But thanks for the journey, and thanks for the memories.
Matina Pentese was trained as a psychiatric nurse at Broughton Hall in the 1960s. She was involved in a pioneering community health initiative in Waverley-Woollahra, as part of the Health Commission of NSW from 1976 to 1986 when she was the director of the Bondi Junction Community Health Centre. She has enjoyed a career spanning decades, continents, situations, and roles. She confesses she has been ambushed by real resistance fighters once only.
This reflection first appeared in Health and History 24, no 2 (2022): 111-116.
1. The results were published as: Laurie Young and Tina Ermoll [Matina Pentes], Admissions to Psychiatric Hospitals: An Evaluation Based on Interviews with Hospital Staff (Sydney: Health Commission of New South Wales, Division of Health Services Research, 1975). The results of the research that involved interviewing patients was published as: Laurie Young and Tina Ermoll, The Experience of Psychiatric Hospitalization: An Evaluation Based on Interviews with Inpatients (Sydney, NSW: Health Commission of New South Wales, Division of Health Services Research, 1975).
2 The series Community Health (Sydney, NSW: Health Commission of NSW, 1977), nicknamed the ‘Rainbow books’ because of the bright colours of their covers, had six volumes: 1. General Concepts; 2. Goals for Community Health Services; 3. Organizational Objectives for Generalist Services; 4. Organizational Objectives for Community Health Services for Emotional, Social and Health Related Problems; 5. Organizational Objectives for Services for Mothers, Babies, Children and Adolescents; 6. Organizational Objectives for Services for the Aged and Chronically Ill.
3 PALA was founded by several students of Robin Winkler, a critical psychologist who taught at the University of New South Wales at the time. Winkler famously conducted research with pseudo-patients in several mental hospitals. Alan Owen was the most prominent member of PALA. For more on PALA see Gemma Lucy Smart, “PALA: A 1970s Radical Alternative to Psychiatry”
4 Tina Pentes and Adrienne Truelove, Travelling with Children to Indonesia and South-East Asia (An Anthropological Approach) (Sydney: Hale & Iremonger, 1984).