The Central Mental Hospital was already out of date when it was built in 1850 - so how does it cope in the 21st century, asks Carl O'Brien, Social Affairs Correspondent.
Hidden away from the main street, beyond the high granite walls, through the security barrier and past the 12ft-high electronically-controlled gate, the first glimpse of the grey institution of the Central Mental Hospital comes into view. The Victorian-era building feels incongruous, just a short distance away from the glitzy, chrome-and-glass monument to consumerism that is the Dundrum Town Centre.
The building's grim design, with its small bedrooms and long corridors, was loosely based on the old Bethlem Royal Hospital in London - popularly known as "Bedlam". By the time the Dundrum institution was built in 1850, say senior staff, it was already out of date. It feels more like a museum dedicated to a less enlightened time of "lunatics" and "the insane".
The small, bare bedrooms in the old building feel like prison cells, with thick metal doors and a narrow hole above the doorway where wardens used to hold up a lantern to check on individual patients. There are also marks where a second metal door was positioned outside each individual room - aimed at drowning out the noise of individual patients.
Despite cramped living conditions, poor ventilation and peeling walls, the building is very much still in use. Newer single-storey buildings on the campus provide better conditions, bigger bedrooms with toilets and facilities such as a swimming pool and gym. Investment in multi-disciplinary teams is also improving the standard of care for patients. But there is no escaping the grey, spectral institution that dominates the 34-acre site.
"It's gloomy, it's stuffy, the paint is peeling off the walls," says the hospital's director, Prof Harry Kennedy, as he walks its corridors. "In the winter it's too hot, because we can't regulate the temperature. In the summer it's dark and there's not enough air circulation. It's an extremely inflexible building." He has been campaigning for improved standards of care for many years.
The Government is planning to sell off the site and relocate the complex to a new prison site at Thornton Hall in north Co Dublin in a few years' time. However, that plan has ignited an ongoing controversy over claims it will criminalise the hospital and stigmatise the service.
About 100 patients a year pass through the Central Mental Hospital (CMH), the State's most secure therapeutic facility for psychiatric patients. It provides care in conditions of high, medium and low security for those transferred from prison, those found not guilty by reason of insanity and those transferred from local psychiatric hospitals who are in need of treatment in special conditions of security.
Some of the State's most notorious prisoners have been held here including the late triple murderer, Brendan O'Donnell, and John Gallagher, who, in 1989, was found guilty but insane of the murder of his former girlfriend and her mother.
A few disturbed individuals involved in murders in the 1960s and 1970s, but now long forgotten by the public, are still accommodated in the hospital and might never be released. But for the most part, those who flow through the CMH each year do not fit the profile of notorious offenders.
Most patients tend to stay a few weeks or months, typically after being arrested for a petty crime linked to their condition, and return to the community when they are deemed well enough. Only a small number - about 10 a year - are transferred here because they are unfit to plead in a case or are found not guilty of a serious crime by reason of insanity.
"We regard ourselves as a modern forensic mental health service. We're dealing with people who are seen to be a high risk and we provide a high standard of risk management," says Prof Kennedy. "We have a high quality of staff-to-patient relationships and we're very proud of that. We also have more staff than many other psychiatric service." Yet the description of the institution as a modern service is at odds with the gloomy picture painted in successive reports by mental health inspectors and campaign groups such as the Irish Penal Reform Trust about services in the hospital.
It is clear during a visit to the facility that there has been progress. Some of the most distasteful practices at Dundrum have been discontinued, such as patients having to slop out their rooms, which ceased a year and a half ago. The practice of locking up patients for extended periods has diminished in recent years.
However, deep-seated problems remain. Earlier this year, the Mental Health Commission, the State's watchdog for the mental health sector, conducted a special report into conditions at the hospital. It criticised the blanket policy of locking patients in their rooms at night, irrespective of levels of risk, and for delays in allowing them out to use the toilet. For women, inspectors reported that their underwear was routinely removed during seclusion and they were not allowed a choice of sanitary protection. Patients also have their mail monitored, despite legal advice that the practice is illegal.
It is clear from the report that practices within the hospital are in need of reform in order to respect the dignity of individuals and to provide focused, individual care for patients. Prof Kennedy says many of these issues are actively being worked on, although some are related to staffing levels and the design of the old building. The most significant change is that the hospital now has six multi-disciplinary teams, which can provide a much greater range of care to patients.
"For patients, this means the difference between custody and therapy. There are lots of different therapies delivered to patients, according to their need. Their individual treatment plans vary according to their stage of recovery," he says. "Our multi-disciplinary teams have, for example, a consultant, social worker, community nurse, and a range of other therapists. Right now we're recruiting for an occupational therapist for one of our teams."
The Health Service Executive (HSE), which funds Dundrum, points out that it has been increasing resources for the facility. A significant increase in nurse staffing levels has helped provide a proper continuity of care, it says, while services now comply with new guidelines on seclusion, introduced late last year. Meanwhile, a HSE advisory group is being established to help monitor and guide the development of services in this area.
MALE PATIENTS ARE cared for in a range of units, from the most secure (known as the selective adaptive behaviour unit) to the least secure (the hostel unit), where patients may leave the grounds during the day to attend courses. All the female patients, however, are kept in a single unit regardless of their level of need.
Each patient gets a care plan following an assessment and a case conference, involving the patients, their families and health professionals.
Life inside is highly structured and tightly controlled. No patient is allowed to walk around the grounds of the hospital unaccompanied, except those who are almost ready to be discharged. Patients have access to secure courtyards, although they tend to be drab and grey. Almost all bedrooms are locked at night, from 9pm until 8.30am. Therapies take place in the morning; activities such as gym, bingo and education take place in the afternoon; while visits take place in the early evening. Telephone calls are supervised and listened to by staff. In the evening, patients may watch television or play with a PlayStation.
Patients themselves have mixed views about the quality of care and treatment. Eimear (see panel) acknowledges the dedication of many staff, but says practices such as seclusion are overused and undignified.
Others complain about the boredom and lack of access to activities. While activities such as VEC education programmes, music and gardening are available to many patients, some say most of the day is taken up with television or being stuck in a bedroom.
"You end up watching a lot of TV, but it's in a communal area, so you don't get a choice of what you watch," says one patient, who declined to give his name. "You can get outside some of the time, but not enough."
Many former patients are highly complimentary about the recent introduction of an independent advocacy service, in which former patients and volunteers help give a greater voice to individual patients. A graduation ceremony, in which patients' relatives are invited when individuals are ready to leave the hospital, also attracts many positive comments.
PATIENTS IN DUNDRUM need all the help they can get. In many ways they are doubly stigmatised, regarded both as prisoners and as people who are mentally ill. Once discharged, they face many difficulties, such as being accepted by their families, accessing local mental health services, getting housing, and adjusting to life in the community.
"The loneliness of being discharged on your own, into a grim bedsit is very difficult," says one patient. "You feel very much like you're on your own with no one to help."
Pauline Gill, a social worker at the CMH, says many patients face a daunting cliff-face drop once they leave the hospital. She estimates that about half have nowhere to go once they leave, while a large proportion are in need of supported accommodation, as they cannot cope on their own.
"Homelessness is a real risk. For example, if you have a council house and you go into the CMH, you lose your house. It's incredible, but it's true. That kind of institutional stigma is still significant," she says. "I'm seeing people ending up on the streets as a result. No services out there want to deal with patients or try to meet their individual needs. It's a matter of huge frustration, given the amount of support they get in here, and how easy it is to undo all that once they're outside."
The lack of specialised community services for patients leaving Dundrum is an obvious and urgent priority. The Government's blueprint for the development of the mental health service, A Vision for Change, tackles some of these issues. It pledges to appoint community-based multi-disciplinary teams, which would specialise in caring for at-risk psychiatric patients in each HSE region, although it is less specific about when this will happen.
The need for such services is all too obvious to Prof Kennedy. "In the community there is really nothing at all for these patients. Our top priority needs to be to develop good locally-based aftercare for those who are discharged into the community," he says.
On top of this, he estimates there are about 200 patients in prison at any one time who need expert psychiatric help, but can't get it because there are no free beds in Dundrum. The rate of mental illness among prisoners on remand is 40 times higher than in the general community.
This category of patient could also be intensively cared for in special community facilities.
WHILE THIS ALL looks good on paper, most professionals are sceptical about whether it will happen soon. It will take political leadership to develop a service that has long been considered the Cinderella of the health system, they say. There are few votes to be won in developing the mental health sector, while many communities have a track record of loudly campaigning against locally-based psychiatric services. Only time will tell if these principled ideas survive the pragmatism of the political process.
As you leave the hospital in Dundrum, past the electronic gates, through the barrier and past the tall granite walls, the vibrant array of flowers and shrubs in the gardens, maintained by staff and patients, is striking - the violet lavender bushes, the pink geraniums, the pale red roses.
Images of some of the patients remain with you long after the visit.There's the old man sitting quietly in the corridor of the high security ward who greets the doctors and staff by name. He was calm on this occasion, although during psychotic episodes he lashes out around him and is convinced that others are trying to steal his oxygen.
In the medium-secure unit there's the haunting face of a middle-aged man in the seclusion unit, sitting motionless on a mattress, staring out the window.
And there are the other patients working quietly in the attractive and colourful gardens. All on their own road to recovery, all trying to come to terms with their own condition, and all facing the most uncertain of futures.