THE SATURDAY INTERVIEW: HARRY KENNEDYA LIGHT EXCHANGE in a shop in Dundrum, in a quintessentially south Dublin middle-class neighbourhood, says it all. Asked for a newspaper and directions to the Central Mental Hospital, the assistant takes a quizzical look at this customer and bursts into laughter. "Ah you're a gas ticket you are," she snorts, handing over the paper. There's an awkward moment or two while it dawns on her that the request for directions is genuine, writes Kathy Sheridan
And the Central Mental Hospital is nothing to laugh about, frankly. Clinical director Prof Harry Kennedy says briskly that "it's a hospital like any other hospital". It's a view that is difficult to square with first impressions.
From a long way off, the towering brick wall encircling its 34 acres broadcasts its status as a high-security institution. Close up, a courteous but painstaking identity check and two soaring prison-style gates - the inner one a fast-acting, electronic model - must be negotiated to gain entrance. The main building, with its Dickensian, three-feet-thick Wicklow granite walls, was constructed as a design test for Broadmoor 158 years ago. It failed the exam even then; Broadmoor was built to a different model. Among the 83 patients on site, the average age is only 40. Almost all have committed serious violence at some point and almost all have schizophrenia, "the most disabling mental illness", according to Kennedy. Patients are drawn disproportionately from the most deprived inner-city areas and are mostly homeless; but seven are members of the "higher professions" and four had breakdowns during degree courses.
There is a poignancy about this place, heightened by well-tended gardens, a deck area used for garden parties, and efforts to soften the edges of buildings never designed for home comforts or modern care. There is a little stand-alone chalet for children who are brought in on strictly supervised visits. Nearby, surrounded by a stand of blue agapanthus, is a memorial stone laid by President Mary McAleese to the hospital's longest-serving patient, who lived here for 60 years. Many others were condemned to spend as many as 40 "completely unnecessary years" here, says Kennedy reflectively.
Apart from the Orwellian-titled Selective Adaptive Behaviour unit, where six of the most challenging patients are housed, we move with relative ease in and out of locked wards.
In a men's area, some attractive art works adorn the walls. Tiny green finches flit around a cage. It's a busy time of day and few people are sitting around. Patients are being escorted to common areas to attend a film club, or literacy classes, cookery lessons or the gym. Men working in the garden, around the fruit and vegetable polytunnels, offer us tea. All of them are on a carefully mapped pathway to recovery, honing long-forgotten skills or ones never learned, for simple day-to-day survival outside.
New admissions occupy the modern, grimly functional, single-storey building across the lawn. With each step towards recovery, patients are moved to gradually more relaxed living areas within the old hospital, still behind locked wards, until finally, when stable and symptom-free, they move to the homely house - called a hostel ward - nearest the gates.
The vast majority will need to continue to manage their chronic illnesses, managing their medicine and lifestyle in the same way as anyone with diabetes or Parkinson's, says Kennedy. "I can think of only two who've left here without medication - and that's because they were very elderly."
The association of schizophrenia with violence is a sensitive issue since the disorder, and mental illness generally, are fraught with stigma. There is a reason, he says, why he prefers not to name the location of the hospital's one community hostel. "And why can I not move my patients, who are well enough, out into the community? Why will I not tell you where I'd like to have a hostel? Stigma. And it's really surprising because mental illnesses are so common. At any one time, maybe two or three people per thousand will be actively ill with schizophrenia, which makes it one of the most common severe illnesses."
And the majority of people with schizophrenia are not violent. "It's a disease of the mind which originates in the abnormal functioning of the brain, and it is the most disabling of mental illnesses because one of the effects of it is that consciousness itself begins to break down in some ways. Thinking becomes very impaired so that people can hold delusional beliefs, can think they are hearing things or seeing things that aren't actually happening. There is very carefully completed research showing that there is a small but real association between schizophrenia and some other mental illnesses, and violence, if those illnesses are not cared for well. For the vast majority, for almost everybody, recovery is a real prospect. But people move at their own pace." Meanwhile, huge amounts of primary research are ongoing in Trinity College Dublin and UCD. "These are world-class, cutting-edge places. We may see the benefits of that, maybe before I retire."
THE ATMOSPHERE OF benign, professional calm speaks of dramatic reform in the 10 years since the EU's Committee for the Prevention of Torture lambasted the state of the hospital. Only then did it change, says Kennedy, who returned from England to take over in 2000.
The impact of that external criticism is a prime example of why Kennedy fervently talks of Ireland's need for an "international dimension" and why he was "massively disappointed" by the rejection of the Lisbon Treaty. Nineteen years in England gave him a perspective he believes is sorely needed by politicians and those in charge of running the health service. "Ireland is really too small to independently inspect itself, to independently judge itself. I think Europe is our best way of being genuinely independent and of keeping a grip on external reality. Basically the alternative is to become the really insular, narrow, unimaginative place that Ireland used to be when I was at school in the 1960s and 1970s."
Kennedy's language can be terse and cockily confident to the point of being dismissive, an impression not softened by his reluctance to give away even the most innocuous personal details about himself or family life. "All psychiatrists have to be careful to some extent. But yes, I would be more careful. In my work as a forensic psychiatrist, there are realities of what I do. I do come in contact with a tiny minority of people with mental illnesses who are at risk of violence and who at times develop unhealthy interactions or relationships with other people."
DOES HE BELIEVE that psychiatrists can be fooled into believing that a murder suspect is mentally ill? "Of course," he says, but adds that since people remanded to the Central Mental Hospital for up to a year preceding a trial are assessed so intensively, "it's not really possible to sustain a deception 24-7 for a year".
He understands why people prefer to believe that the perpetrators of unimaginably brutal acts, such as child sex abuse, are mentally ill. In reply, he quotes magistrate and social scientist Baroness Barbara Wootton: "She referred to the common assumption that if someone does something really unusual, they must be unbalanced. She was talking about murder but it's a common fallacy. There is little or no link between sex offences and mental illness. You may hope such people are mad, but it doesn't follow."
His route into forensic psychiatry was random but ultimately chosen with deliberation. This was the bright boy who excelled in both English and physics at Terenure College, the UCD scholarship student who studied medicine, won places at London's most prestigious training hospitals, then baulked at the narrow intellectual focus of mentors and colleagues. "They were great places for laboratory science but not for discussing Japanese films," says the man who names Japanese director Akira Kurosawa's movie Kagemusha as his all-time favourite, likes to relax with the Sex Pistols, the Clash and the Undertones played at full volume, and in another life might well have been a portrait painter.
His wife, with whom he qualified, had switched from paediatrics to psychiatry "and was plainly doing much more interesting things", he noticed. He had already switched to the Maudsley psychiatric hospital in south London when, on a random training attachment, he accompanied a psychiatrist to interview a man in prison.
"I had been in prisons before . . . but sitting down for two hours, listening to this very experienced consultant interview a man who had done something spectacularly strange - he'd kidnapped a woman who he had driven the wrong way up the M1 - was hugely interesting. After that I asked for my next six-month placement to be in a forensic unit."
There was a year in Broadmoor - "a hospital like any other", he says - then a rapid climb up the career ladder, at 35, to a forensic psychiatry consultant's post in north London, before becoming its clinical director.
He says he emigrated twice - the second time on arriving back to "an utterly transformed Ireland" in 2000. A south Co Dublin boy, he remembers how age defined one's social life - first, lots of engagement parties then lots of weddings in your 20s, then lots of christenings in your 30s. "I'm now 51, and when you go past 50 you get another of those funny phases where you look around and all the people you went to school and college with are now running things. They're actually in charge of really big, really important things. And to a surprising extent, I have grown up with people who are running half the country."
It may sound like a smug boast. On the contrary, it's a reflection on the inbred, inward-looking nature of the country's ruling classes. Politicians and health service managers "should be forced off the island at regular intervals to look at how things are done elsewhere. Go to Melbourne , or to Sydney or British Columbia. The interesting thing is that we have an entirely internationally trained group of consultants who, in management terms, are the factory hands of the health service. We are the ones who do the work. And in management terms, the people who run the health service, uniquely in Ireland, are not clinicians and have not seen service abroad. It's a pity I had to spend 19 years abroad to come back and explain a psychiatric court liaison scheme, where you provide advice and support to the courts, for example. Such schemes had been operating successfully for decades in England, in Canada, Australia and parts of the US. When I came back in 2000, I was told it was a really interesting idea but it couldn't happen because we'd have to have special legislation, special facilities, special courts. Now, informally, we have started doing it [at Cloverhill remand prison] and it is massively successful. But had we waited for permission from everybody, it would never have happened."
HIS EXASPERATION WITH such bureaucratic foot-dragging is barely veiled, but it is veiled nonetheless. For those dependent on the budgetary goodwill of HSE management, diplomacy is the first rule. Is he satisfied with resources? "For the beds that we have, we are adequately resourced. Like every other part of the HSE, we have had cuts in our staffing," he says in a monotone. Are you being diplomatic? "Yeah," he says instantly, with a wintry smile. So what percentage has been cut? "The unfortunate thing is if you were given a percentage by which things had to be cut, you could try to make rational choices with it. What happens instead is that you get a blanket ban on recruitment, which means that when people leave you cannot replace them. It may be that the person who leaves is not very critical to the way the service runs or they may be highly critical. For instance, we have five psychologists; we lost two of them in the last year. That's a massive loss."
What he doesn't say is that despite a four-fold increase in per-capita spending on mental health in real terms in the past 20 years, the share of total public health expenditure fell from just under 14 per cent in 1984 to 7.76 per cent in 2007.
"In our health service, doctors do not control any budgets or manpower. We have a manager who is an excellent colleague and has a whole chain of managers above him - all the way up as far as Brendan Drumm somewhere," he says with - is that an arched eyebrow? "I never arch an eyebrow. This, however, is one of the ways in which the Irish health service is different to health services in other places. I have no control over resources. If tomorrow all my staff were taken away, I would have no influence over that. So yes, I'm often very diplomatic. That's how it is in all parts of the health service."
A reason to hope, in his view, lies in Brendan Drumm's proposal for a system of clinical directors, "so that clinicians would have some say in the management of the HSE. That's how the health services are run in Canada, Australia, America, anywhere you can think of."
Meanwhile, the Central Mental Hospital is full, with 28 on the prison waiting list and five waiting in other hospitals around the country. Such numbers may sound piffling compared with the regular AE trolley war, but placements in the hospital are often long-term, so turnover is much slower. The pressure could be alleviated by the moving on of least 12 patients, but the community facility to accommodate them doesn't exist. "We have quite advanced plans to increase those facilities but the resources are now gone."
MEANWHILE, PAINED DISTRICT COURT judges every fortnight face the same people from Cloverhill remand prison shuffling back before them, people who are "clearly seriously ill, and clearly not progressing up the waiting list because your waiting list is not progressing very much". This is compounded by the fact that district judges - as they are entitled to do - may find people have mental disorders and are unfit to stand trial. But they do this, says Kennedy, "without any psychiatric evidence whatsoever, and this has been misused at times". Then again, he notes, " McDowell famously said in the Senate that he believed judges knew better than psychiatrists". The minister himself may have moved on, but his legacy - a plan to site the Central Mental Hospital beside a titan prison at Thornton Hall, 10 miles from the city - is being carried on by his successors.
Prof Kennedy recently toured the new forensic hospital in Sydney, which was built beside a prison - "the only place in the world that I know of that has done that". He tries to find diplomatic words for it: "It's just custodial instead of being therapeutic, and that's a problem. It is overlooked by a sort of observation tower from the prison. The windows inside are riveted into the walls rather than framed. In Thornton Hall, it would be almost impossible if you are cheek by jowl with a prison, in the middle of nowhere, isolated together, surrounded only by fields, not to be perceived by everyone, including the people who work in it, as a prison, not a hospital. Obviously the stigma will be worse for the patients."
And there are practical reasons why Thornton Hall is wrong, he says. "How can you work at rehabilitation, have patients going out with nurses to do their shopping, for example? How could you do that if you're in the middle of a farm in the middle of nowhere in north Co Dublin?"
When Prof Kennedy is otherwise engaged, a male nurse quietly points out that, long ago, Queen Victoria set out to separate the criminally insane from the general prison population and what were termed "the gawking minds". Now, he protests softly, "we're going to do it all in reverse".
Kennedy's own preference is for a "health park" that would accommodate several hospitals. "There are 300 acres out there in Abbotstown, doing nothing." As we finish, "apropos of nothing", as he puts it, he refers to David Owen's The Hubris Syndrome - "which is something that happens to politicians who've been in power for slightly too long. He makes a good case for it. And also for CEOs." The latter, he also muses, are often in the "creative psychopaths" mould. No names are mentioned.