Facing up to Mental Illness
Bill Toner, SJ
The moral character of a society can best be judged by the way it looks after the weakest and most vulnerable of its members. These include, for instance, the very poor, the homeless, travellers and gypsies, the unborn, children, asylum-seekers, the sick, the elderly, the imprisoned. There is no evidence that Ireland is, in general, significantly worse than many other countries in looking after its most marginalised groups. But neither is it significantly better. Recently it was severely indicted by the United Nations Committee on the Rights of the Child for the lack of policies and the inadequacies of services for vulnerable and at-risk children, as reported in Working Notes (Issue 31).
People suffering from mental illness are among the most vulnerable in our society and we have failed them in two main respects. In the first instance we have failed to protect their fundamental rights and freedoms in our procedures for detaining them against their will. In the second place we have failed to implement and enforce reasonable standards of care for them.
The Long Wait for a Mental Health Bill
Since 1992 the state has publicly acknowledged that, in relation to procedures for detention of people with mental illness, it is currently in breach of the European Convention for the Protection of Human Rights, as well as the relevant United Nations Principles. A Bill is currently in preparation designed:
to redefine the criteria for detaining mentally disordered persons;
to introduce procedures to review the decision to detain a person in a psychiatric hospital;
to give greater safeguards to protect detained persons.
While this measure to at last update the Mental Treatment Act, 1945, is to be welcomed, its progress is agonisingly slow, given that the relevant Green Paper was published in 1992, and a White Paper in 1995 (Note 1). It is doubtful if the Bill will be published in this millennium.
This Bill is very important, as there is a strong suspicion that we are still putting too many people in psychiatric hospitals against their will and keeping them there. On the latest date for which we have figures (31 December 1997) there were about 900 involuntary patients in Irish psychiatric hospitals, a figure which compares badly with other European countries. In relation to patients in psychiatric hospitals as a whole, comparative figures revealed in 1981 gave much cause for concern. In that year, for every 100,000 people in the population, comparative numbers of people in mental hospitals were as follows:
IRELAND 406. (Note 2)
In fact a Commission of Inquiry in 1966 suggested that the number of in-patients in Ireland was the highest in the world! While this Commission raised the possibility that mental illness is more prevalent in Ireland, it also suggested the far more likely conclusion that "the public attitude towards mental illness may not be helpful to the discharge of patients and their reintegration into the community". In fact the detaining of people in psychiatric hospitals may have been part of a more generalised syndrome in Ireland where people who did not fit in were \'put away\', whether in Magdalen Homes, orphanages or whatever. Older readers may recall the custom of some judges of letting petty criminals off on condition that they went to England! In 1940 we had 19,134 in-patients in public psychiatric hospitals compared with about 4,500 at present (Note 3).
Few things could better illustrate the marginalisation of mentally ill people than the delay in implementing the Mental Health Bill. No group in society is in a worse position to "fight its corner". People suffering from depression or schizophrenia, many of them in secure wards in hospitals, are not going to write letters to T.D.s or march on Leinster House. Representations from their friends and relatives and doctors tend, for various reasons, to be only sporadic, and support groups do not command a broad enough base to mount an effective challenge to government inertia.
Mental Health Services: The Slow Pace of Reform
While the reforms of mental health legislation in regard to detention are important, of equal relevance to most people suffering from mental illness is the availability of good treatment and after-care, and again progress in this area is agonisingly slow. In fact the principal concern of the Irish Council for Civil Liberties regarding the new Bill is not the issue of detention, but the absence of any firm proposals on standards of care of the mentally ill (Note 4). The ICCL, quoting the first of the UN Principles that all persons have the right to the best available mental health care, goes on to say:
The White Paper makes no effort to define the standards of care of the mentally ill, nor to ensure adequate monitoring of services by an independent body.
In 1984 a Study Group appointed by the Minister for Health issued its very fine Report The Psychiatric Services - Planning for the Future in which it examined and assessed mental health services and made many proposals (This Report is now out-of-print and virtually unobtainable). In the Foreword, the Minister for Health, Barry Desmond, wrote that "it is the Government\'s intention to implement the recommendations contained in this Report".
One of the guiding recommendations of the 1984 Report was that the psychiatric services should be community oriented, that is, that they should be located close to where people live and work. This was to be a departure from the centralised and largely institutionalised services of the time. As one way of achieving this, a second recommendation stated that the service should be sectorised, with a population of about 25,000 in each sector. A multi-disciplinary team was to be based in each sector. On the following page is a diagrammatic summary of the overall shape of the psychiatric service envisaged in the Report. It is somewhat simplified. For instance not all possible lines of referral are drawn, psychiatrists also work out of out-patient clinics, and so on.
Fifteen years on, the 1984 Report still represents the standard for the psychiatric services to aim at. But the implementation of the Report has not been uniform. In this regard it is instructive to compare some of the recommendations of the 1984 Report with the current situation, as described most recently in the Report of the Inspector of Mental Hospitals for 1997 (see pp.4-7). It can be seen from this that many of the hopes of the 1984 report have not yet been fulfilled. (Note 5).
Shortcomings of the Psychiatric Services
It would be wrong to launch into an analysis of the shortcomings of the psychiatric services without paying tribute to the dedication and hard work of the many thousands of people who help others, in different ways, to cope with the crippling effects of mental illness. These include members of families, carers, GPs, psychiatrists, psychologists and other specialists, psychiatric nurses, members of religious orders, academics and commentators, health board workers, hospital administrators, voluntary helpers, civil servants, local authority workers and many others.
Yet in spite of the efforts of all these people, there are many deficiencies in the system. Most are due ultimately to a failure of public opinion to galvanise politicians sufficiently to put the necessary resources into mental healthcare.
One of the most important critiques of the psychiatric services is provided by the annual Report of the Inspector of Mental Hospitals, currently Dr Dermot Walsh. Carers, representative organisations, and community workers interviewed by Working Notes staff have identified other problems of well. Matters which seem to call for attention include the following:
The crisis intervention service has never been put into place. Regrettably people do not always succumb to mental illness between 9 and 5 on week-days, but often at week-ends and late at night It is not always feasible to bring mentally ill people into emergency departments of general hospitals. Ideally a psychiatric team, working in conjunction with the gardai where necessary, would be available to deal with local emergencies, especially in major cities and towns.
There is a shortage of suitable accommodation. This runs right through the service, from acute units to high-support residential facilities. In fact there is not strictly a shortage of beds in acute units, but almost half of them are occupied by non-acute patients (Note 6). This makes it very difficult for someone, except in an extreme emergency, to access a bed. Assessment of patients is coloured by the shortage of beds, and patients who really need residential treatment are assessed as capable of being treated in out-patient clinics.
The \'inappropriate occupancy\' of acute wards is in fact caused by a shortage of suitable high-support residential facilities, particularly ones which are able to deal with \'difficult\' patients or those with very low coping skills. This appears to be the \'Achilles Heel\' in the plan to replace psychiatric hospitals by high-support facilities. It leads to patients being retained in admission wards for long periods, leading in turn to a shortage of emergency beds.
People who suffer from mental illness but who are well enough to live \'in the community\', have major problems finding suitable accommodation. Waiting lists for the better hostels are huge. Few of those living outside a family setting are happy with their living conditions or feel they have a place they can call \'home\'. Many live in flats or lodgings where they experience loneliness. Others live in low-support residences where they may be four to a room, sometimes without any privacy. It cannot be easy to recover from illness in this situation.
In 1993 there were 11,000 beds in psychiatric hospitals and units, and there are now about 7,000. While the official \'belief\' is that 4,000 who would have been in psychiatric hospitals are now living \'in the community\', many people, including many health workers, are concerned that many of these people are homeless, or are \'walking wounded\' living lonely existences, or are living inappropriately with family members and sometimes causing them considerable stress or are in prison. There is considerable scepticism as to whether all these people are better off than they would have been in the traditional institutions.
It should be noted that the current inflation of house prices and building land is seriously affecting the ability of the psychiatric services to provide additional residential accommodation in communities. Rapidly increasing rents are also causing problems for mentally ill people living in a flat or trying to move into one.
There is still not sufficient support for carers. As the 1984 Report pointed out, the main burden of caring for a mentally ill person in the community, particularly a chronic psychotic patient living at home, may fall on the patient\'s family, and the cost to the family, in terms of emotional stress, can be considerable. The psychiatric team (where it exists locally) must have a commitment to supporting the relatives of patients who live at home and arrangements should be made so that they can take holidays from time to time. The care of people with mental illness is the responsibility of the whole community, not just the patient\'s family.
The way social welfare regulations are enforced can cause considerable distress to people who are mentally ill. For instance if a person on invalidity pension of £68 a week goes into hospital, between £40 and £60 of their payment can be stopped to contribute to hospital costs, depending on length of stay. A long-term patient in hospital receives only £8 a week to spend on such things as toiletries, cigarettes, newspapers and so only. But more significantly, the bills back home do not stop. People frequently lose their flats because they cannot afford to keep up payments. When they come out of hospital people can be faced with old bills for gas and electricity, phones or phone rental, and other items, but they are unlikely to receive any help with these. Obviously the last thing person struggling to recover from mental illness is to be burdened by financial anxieties.
There is a severe shortage of suitable employment opportunities for people suffering from mental illness, or with a history of it. In general the labour market is allowed to dictate the availability of jobs. While sheltered employment schemes do exist, the allowances paid are small, and many people suffering from mental illness find it insulting to be asked to work long hours for the money offered. It is an enormous boost to the self-esteem and morale of people with mental illness if they are able to hold down a job. The biggest challenge is to change the attitudes of employers, who would need not only to create appropriate structures for employing vulnerable people, but also be more open to the idea of taking them on. The problem is not peculiar to Ireland. One U.S. study showed that 54% of personnel directors of companies quoted on the New York Stock Exchange would never, or only occasionally, employ somebody who was currently depressed (Note 7).
Treatment within the community is poor. It is difficult to get a GP to take on a mental patient, which puts a lot of pressure on the local clinic. Typical of the poor quality of delivery is the situation in one Dublin suburb where the out-patient clinic is in the local community centre. Even with an appointment a person might have to queue for two hours in full view of everyone who knows that they are queuing for psychiatric treatment. Given the stigma attached to psychiatric illness, this can put additional stress on ill persons and their carers.
Patients who attend clinics are likely to see registrars-in-training. These change every six months, so there is a lack of continuity in the doctor-patient relationship. This is more serious than in the case of physical illness where for instance any doctor can inspect x-rays. In this regard, the training plans of the Health Boards seem to have priority over the well-being of public patients.
In most cases there is no home follow-up by a community nurse after coming out of hospital. The nurse can only be seen at the clinic.
There appears to be is a reliance on medication over other forms of treatment. Part of the reason for this is that services are understaffed and doctors are under too much pressure. Frequently patients find it difficult to have a chat with the doctor, as the doctor is too busy, and the outcome may be to receive a month\'s supply of medication with an appointment to return when the medication is finished. In some cases the month\'s supply may be gone the same day. Doctors sometimes do not find the time to explain the effects, and side-effects, of medication. Some medicines do not \'kick in\' for some time, and patients who take them continue to get worse before they get better. Because this has not been explained to patients or their carers, there have been cases where they have given up the medicine before it has had time to take effect.
Some doctors do not see themselves as having any responsibility for after-care, with the result that issues like accommodation and occupational therapy are not properly integrated into the treatment programme. It was reported that one psychiatrist who was asked by a carer about accommodation replied that this was like asking the Taoiseach to fix the traffic lights. Subsidiary and support services might be of a higher standard if more doctors brought their considerable moral influence to bear in these areas.
This last point relates to the wider critique that psychiatric services work in isolation from the social and other problems which patients present. Thus homelessness may be the cause of major stress. The psychiatric services tend to wash their hands of such patients on the grounds that their problem is primarily social. Similarly, someone who had difficulties in relationships, or with drug misuse, will get short shrift. This \'isolationism\' of the psychiatric services fails to face up to the fact that for many people their problem is both a mental health problem and a social or personal problem. Dealing with one, without addressing the other, is futile.
Thus, rather than focusing on the overall problem, the psychiatric services tend to focus on the part of the problem that is specific to their expertise. Better coordination with social and other services seems essential.
A report by two researchers in Northern Ireland highlighted the extent to which homelessness coincided with mental illness in Belfast (Note 8). Thirty seven per cent of all homeless people resident in hostels and B&B residences were reported to have a mental health problem, and many more suffered from psychological distress. Of single homeless people, almost half had been homeless for more than a year owing mainly to alcohol/drug related problems, parental/marital dispute, or intimidation. One third of the group had received psychiatric inpatient care at some stage, though discharge from psychiatric hospital rarely featured as the immediate reason for homelessness. The report shows that it is difficult to disentangle mental illness from other social problems.
There are few, if any, Irish junior doctors in psychiatric services. Some hospitals have non-Irish staff only. This can give rise to communication and other difficulties. A better mix of doctors would give patients greater reassurance. The fact that few Irish doctors want to get into psychiatric services also says a lot about the general state of the services here, and the way they are seriously under-funded.
Children over 16 are classified as adults under the Mental Health Act. In all other respects, young people are considered to be children in law until they are 18. Adult services are usually totally unsuitable for 16 and 17 year olds. Promises to amend this anomaly have been made for several years, but to date it has not been remedied.
Services for children under 16 are excellent, but difficult to access. Long waiting lists are the norm.
Residential psychiatric services are sometimes in dilapidated buildings which are gloomy, depressing and in poor repair. The Inspector\'s Report makes sad reading in this regard. The conditions in some hospitals, detailed on p.4, would never be tolerated in an ordinary general hospital Such neglect betrays a failure in our society to value mentally ill people as much as physically ill people.
In fact there seems to be a lack of clear policy with regard to psychiatric hospitals, and the 1984 Report seems to contain contradictory comments and recommendations In general the Report sets its face against any attempt to perpetuate the hospitals:
"If they are to provide tolerable living accommodation for patients, an extensive programme to restructure and replace the existing stock of buildings must be undertaken....Apart from the question of cost, we consider that investing on such a scale in psychiatric hospitals would be a disastrous path for this country to follow. It would perpetuate a pattern of care and treatment which is increasingly irrelevant... (15.10,11)
The danger is, that, as hospitals are improved, admissions of certain categories of patients may increase and the dilemma is how to bring about these improvements without perpetuating the form of care which has become associated with the hospitals (1.28).
On the other hand, in the section of the Report discussing the hospitals themselves, a different emphasis is to be found:
The improvement schemes of the last three years have already made a significant contribution to upgrading the physical condition of many psychiatric hospitals... (7.23). The psychiatric hospitals will have an essential function in this (psychiatric) service for many years to come and it should be made quite clear that the phasing-out of these hospitals is a gradual process which is dependent on the build-up of a range of alternative services (7.43.2).
At the end of 1997 there were still 4,698 patients in public psychiatric units. Numbers are currently declining at the rate of about 300 per year, which suggests that these hospitals are unlikely to be phased out before 2013. The difficulties in providing high-support residential units in the community which can adequately cater for the needs of many chronically ill patients (many of them currently filling acute beds) may yet force a re-think regarding the total closure of psychiatric hospitals (Note 9). As the report by Keogh et al.(1999) found "there (is) in general, a lack of a systematised spectrum of provision through the rehabilitation...across the continuum of support". The gap between the large or medium-size psychiatric hospital and the 15-20 bed high-support unit may involve too great a discontinuity in this spectrum.
It is to be noted that there is no great pressure to close the large private psychiatric hospitals such as St.Patrick\'s in Dublin, or St. John of God\'s in Stillorgan, which have 503 beds between them. It is not necessarily the size of the hospitals which causes the problems, but the way they are run. The most important consideration must be that patients get the best possible standard of care appropriate to their condition and prospects of recovery.
Residential services can be very boring. In some hospitals there seems to be nothing to do all day long. It is common for the TV room not to open till the evening. Many leisure facilities are shut down at week-ends. Patients walk around all day, bored to tears. It is difficult to understand how a person\'s mental state can be improved in these surroundings. The shortage of occupational therapists does not seem to be regarded with sufficient seriousness.
The psychiatric services understand their role as treating definable psychiatric illnesses, mainly by medication. However there is a grey area where people, though they do not have a definable illness, are stressed out, unable to cope, and often suicidal. Perhaps it is unfair to ask the psychiatric services, already over-stretched, to meet the needs of these people. Yet in the absence of any other services, it is to the psychiatric services that these people turn. People in these situations need someone to talk to, perhaps for a lengthy period of time, and perhaps some medication on a temporary basis.
Most people interviewed by Working Notes staff mentioned the problems caused by shortage of nursing staff in hospitals and residential units, and the difficulties of recruitment. In the past few years the number of psychiatric nurses has fallen from 7,000 to 5,000. At a time of so many job opportunities for young people, psychiatric nursing is not one of the more popular options.. Although the requirement of a third level qualification for psychiatric nurses is to be welcomed, the lengthy training requirement, while living on a small allowance, has made this career unattractive. The Department of Health recently approved an intake of 201 trainee nurses, but only 91 places could be filled. There is an urgent need to introduce bursaries to encourage entry into the profession, as is the case in Great Britain.
Shortages of staff in other areas, such as occupational therapy, seem to be due more to inadequate funding of the psychiatric services than any other reasons.
The forthcoming Mental Health Act proposes a Commissioner for Mental Health, linked to the Department of Health, who would be a consultant psychiatrist. It has been pointed out that this represents a continuation of the current post of Inspector of Mental Hospitals and thus carries conflicts of interest. As it happens, the current holder of the post has been trenchant in his criticisms of the psychiatric services, but that is not to say that every future incumbent of this or a similar post would be so outspoken.
There is a strong case for an independent Mental Health Commission on the same lines as exists in Northern Ireland. In fact many aspects of the psychiatric services in Northern Ireland, such as the deployment of psychiatric social workers, are better organised and resourced than in the Republic. This area is likely to be a source of embarrassment in the context of greater cross-border dialogue and influence.
Public Attitude to Mental Illness
In a liberal democracy like Ireland, the most powerful factor in bringing about change of any kind is public opinion. People may choose to blame politicians for various shortcomings of our society, but politicians have a vested interest in keeping their ears fairly closely to the ground and are unlikely to completely misread the public mood.
Thus, the reason why psychiatric services in Ireland are not better is because the public do not care enough. Society is prejudiced against sufferers of mental illness and tends to set them apart from the rest of the community. Over the past four decades surveys of public attitudes on mental illness indicate that it is perceived as something to be feared, and that its sufferers tend to be mistreated and shunned. Even recent change show that change in public attitude is minimal (Note 10). As Professor Anthony Clare stated, "The mentally ill are now the most systematically stigmatised group in our society. They...are the true lepers of today" (Note 11). Many of the shortcomings of the system of treatment betray a lack of belief that people with mental illness have the same rights as everybody else, and have done nothing to forfeit them.
Our treatment of our people who suffer mental illness is as unworthy of us as it is of them. It reveals traces of a primitive mind-set which has no place at the end of the second millennium. Hopefully we can begin the new one by accepting our responsibilities under the constitution to defend and protect all our people.
Our thanks are due to the many people who gave gladly of their time to discuss the many issues raised in this article, and who provided us with valuable information.. These people include representatives of support organisations, patients and former patients, professionals, representatives of nursing organisations, civil servants, and relatives of people suffering from mental illness.
Bill Toner S.J. (Editor, Working Notes).
1. Green Paper on Mental Health. Stationery Office. 1992.
White Paper: A New Mental Health Act. Stationery Office. 1995.
2. The Psychiatric Services: Planning for the Future. Stationery Office. 1984, p.143.
3. Ibid. p.164.
4. \'Response of the Irish Council for Civil Liberties to the Government White Paper on Mental Health (1995)\'. March 16 1998.
5. Report of the Inspector of Mental Hospitals for the year ending 31st December 1997.
Department of Health and Children. Stationery Office. 1998.
6. Keogh, Fiona et al. \'We Have No Beds\'. Health Research Board. 1999.
7. McKeon, Patrick et al. \'Employees\' Attitude to Depression: What They Tell the Boss\'.
mimeographed report (undated).
8. McGilloway, Sinead and Michael Donnelly, \'The Impact of Environmental Factors on Mental Health\'. Health and Health Care Research Unit, the Queen\'s University, Belfast.
9. See Marcus G.T. Webb "Closing Mental Hospital Beds: A Re-Appraisal".
Psychiatric Nursing. Issue 1 - May 1993.
10. McKeon, Patrick and Siobhan Carrick. \'Public Attitudes to Depression: a National Survey\'.
Irish Journal of Psychological Medicine 1991; 8: 116-121.
11. In an address to the Royal College of Psychiatrists in U.C.C. Quoted by Archbishop Dermot Clifford in The Care of the Mentally Ill in our Community. Messenger Publications. 1995.