Sarah Harte: Mental health is still stigmatised in Ireland — we need to normalise it
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Historically, we locked people up in this country for all sorts of reasons, many of them spurious. At one point during the 1950s our ‘inpatient’ admission rates for so-called mental health problems were so high we outstripped the Soviet Union for detaining people, followed by the US.
Coercive confinement became a socially expedient way of ‘disposing’ of people who were perceived to have transgressed in some way or quite simply whose families wanted them out of the way. It was a backdoor way of managing social problems with ‘asylums’ often acting as repositories for ‘problem’ people.
Mental hospitals were controlled by the State so problematic admissions cannot be laid solely at the door of the Church but rather at broader societal attitudes within which diagnostic criteria for admissions were made and family decisions were made.
Sebastian Barry’s novel which won the Costa award and was shortlisted for the Booker prize tells the story of Roseanne McNulty who spent 50 years in Roscommon Regional Mental Hospital having been put there by her family. It was inspired by a story Barry’s mother told him of an old relative whom his grandfather once called ‘no good’. It questions the validity of those who judged Roseanne and put her away and women like her who didn’t conform to strict Catholic rules.
These asylums could resemble prison-like institutions for people who hadn’t broken the law.
Locked doors, high walls, and barbed wire were part and parcel of the experience.
Hidden away, these institutions were often located in isolated geographical settings. Mortality rates were high partially through diseases such as TB or old age due to long stays, but treatment was sometimes said to be barbaric and discredited medical procedures were not uncommon.
Although we were world leaders in institutionalising people, Ireland was not alone in having institutions of this nature.
The large psychiatric institution model evolved, and many patients received good care with some psychiatric hospitals being integrated into the towns in which they were based but this form of care still resulted in patients lacking agency over what they ate, when they went to sleep, and they were cut off from family and community.
Advances in drugs and a changed philosophy that mentally ill people could be socially included in mainstream society meant that we effectively began to deinstitutionalise mental health patients.
It was recognised that institutions dehumanised and damaged mentally ill people by socially isolating them and so from the late 1980s onwards, it became government policy that large psychiatric hospitals or congregated settings would be closed or downsized. Depending on a patient’s needs they could be treated with outreach services or accommodated in supervised supported housing.
Relatively speaking, we became more comfortable talking about our mental health. Culturally, we got past telling children that “Auntie Mary has gone away on a little holiday”. And yet, a certain stigma remains around mental health disorders. Stigma usually comes from a lack of understanding and fear. Institutional stigma involves governmental policies including lower funding for mental health issues or fewer or qualitatively poorer mental health services relative to other health care.
Last Friday, it was reported in this newspaper that the Inspector of Mental Health Services Dr Susan Finnerty concluded that disability services had moved on more quickly than psychiatric services. She expressed concern about finding almost 2,000 people still living in large mental health institutions including elderly people who have lived like that for decades unable to make decisions for themselves.
“When you... think of the individual people living in those congregated settings, I suppose the basic question is, ‘would we like to live there?” she said.
The HSE in Cork is reputedly planning to invest heavily in a large-scale unit for people with the highest level of mental health needs on the relatively isolated grounds of St Stephen’s Hospital in Glanmire, replacing existing long-stay wards. Ironically, in the 1990s and early 2000s, long-stay patients of St Stephen’s were helped to move by the HSE to newly developed 24-hour staffed community residences in Mallow, Fermoy, and Kanturk as part of a phased process.
The North Cork HSE catchment consisting of these three towns is considered to be a model of rehabilitation mental health services. Each residence has 14 single, ensuite rooms and there is a multi-disciplinary team who have helped many people over the years transition back into their communities.
Outside of North Cork, there is no such clear pattern to the provision of services in the Cork/Kerry areas. There are, for instance, two community mental health residences in Skibbereen but none in the towns of Bantry, Clonakilty, and Kinsale within the same HSE West Cork catchment.
Any such investment in St Stephens has clear implications for community service funding. Why is this money not being invested in community residencies in big towns locating those with mental health challenges at the core of the community?
published in 2006 details the HSE’s comprehensive model of mental health for “building and fostering positive mental health across the entire community and for providing accessible, community-based, specialist services for people with mental illness”. This is the stated official HSE policy.
This community model of care also dovetails with the UN Convention on the Rights of Persons with Disabilities. What has happened to this vision?
On the face of it, this would certainly seem to be the case. Owenacurra, located in the centre of Midleton, Co Cork, is a community-based facility long regarded as transformative for the people who moved there in 1988 from Our Lady’s Hospital as part of a phased process to integrate these residents into the community. Residents who successfully made this transition learned the benefits of independent living and became part of the fabric of the town.
A powerful letter in this paper from a clinical nurse manager who worked in Owenaccura for 10 years attested to the “high esteem these residents [were] held in by the townspeople of Midleton". Monica Doyle outlined how many of the residents undertook Fás schemes, National Learning Network programmes, and community college courses. She cited how residents had family and friends nearby and “townsfolk who [had] their best interests at heart”, referring to Owenacurra as being “the jewel in the crown of the Southern Health Board”.
Owenacurra is due to be shut down, although patients and their families don’t know why or even when. There were originally 20 residents in Owenacurra when, in 2021, the facility was earmarked for closure; there are now six residents left.
Of course, it’s more cost-effective to admit people who need support to large, centralised centres. The high cost of inpatient mental health care is clearly one driver behind what appears to be a change in policy but as our budgetary surplus attests to we have resources.
Local Independent councillor Liam Quaide, a HSE psychologist (he resigned from the Green Party due to a lack of support from ministerial colleagues on the Owenacurra facility), cites “decisions made without due consideration or consultation by local managers”, out of sync with official policy, as being another driver.
Who is making these decisions, and on what basis is of particular interest? Because there seems to be a broad consensus among many mental health professionals that out-of-area placements for people with severe and enduring mental health difficulties to facilities cut off from their communities have multiple adverse consequences for patients.
Psychiatric studies show that patients with the least social interaction, fewer activities to take part in, and less access to the community or outside world are more unwell. Patients benefit from richer social environments and opportunities. Social dislocation leads to discontinuity of care and functional regression.
We retain stereotypes about people with enduring mental health difficulties that they are dangerous when in fact some mentally ill people are more of a risk to themselves and of being attacked. The strongest evidence for combating stigma involves community contact with people suffering from mental health issues. We normalise what we know.
There are minimum standards we need to meet for the provision of mental health services to vulnerable citizens. The Mental Health Commission’s (MHC) report published last week pointed to low standards in care planning and premises in several HSE facilities and particularly highlighted concerns around St Catherine’s Ward in St Finbarr’s Hospital in Cork.
No doubt, there are plenty of dedicated, creative, and hard-working staff working in these facilities doing their best. However, MHC chief executive John Farrelly said, in the wake of the MHC’s report being published, that “a targeted, funded strategic capital investment programme is urgently required now in our public [mental health] system”.
More generally, the provision of rehabilitation services for mental health patients is accepted to have been severely underfunded. Persistent and chronic underfunding of mental health services must mean that at some level a political decision has been taken that mental health services come way down the list of priorities. Could it be that it’s not a vote-catcher?
Postgraduate training in psychiatry is comparatively underfunded by the State in comparison to other specialists. Last year, a publication highlighted that hundreds more consultant posts are needed in psychiatry for the HSE to run a safe and effective service for mentally ill patients.
We saw what happened with the South Kerry Child and Adolescent Mental Health Services (Camhs) scandal where hundreds of children received inappropriate, risky medication, with significant harm being done to 46 of them. The failure of Camhs to deliver a safe mental health service cannot be attributed to one unsupervised junior doctor but rather to a much wider and continuing political failure.
It’s doubtful we will ever have an inquiry into the excessive use of mental hospitals in Ireland, because it would involve shining a light on doctors, families, and communities that colluded in the incarceration of family members and neighbours in an extensive programme of institutionalisation. Somewhat understandably, there wouldn’t be a public appetite for that.
But, as Mick Clifford wrote in this paper, prisons are currently being used as dumping grounds for people with mental health difficulties. “Judges,” he wrote, “should be able to refer mentally ill offenders to an appropriate setting. In reality, that option does exist in this State.”
The reality is that many homeless people in prisons could be bailed by the courts into the care of community psychiatric facilities if the HSE would take them. The HSE won’t because mental health services are based on people having an address in the catchment area.
This is an extraordinarily callous gap and could be said to be a variation on an old theme of using mental health facilities to deal with social problems.
A pressing question, in the wake of the publication of the MHC’s report, is whether we are reinstitutionalising mentally ill or vulnerable people who don’t meet societal expectations, reverting to a debunked model of providing psychiatric services through centralised long-stay mental health care.
The more overarching question is whether we in fact have any coherent, long-term strategy in place to reform mental health services. What seems patently clear is that the HSE and the Government have questions to answer. Will we get those answers? I wouldn’t hold your breath.