Mental illness needs to be dealt with in the community, not in Victorian-era hospitals, says PAT DEVITT
PAT DEVITT doesn’t have the most enviable of jobs. As Inspector of Mental Health Services, he spends much of the year travelling around the country, examining the state of psychiatric facilities. All too often, the results are deeply disturbing.
Take his latest report, due to be published shortly. It says two wards at St Loman’s in Mullingar were in “poor condition and unfit for human habitation”, while others were “dilapidated, desolate and depressing”.
At St Ita’s in Dublin, many were living in appalling conditions where it was “difficult to convey the extent of dilapidation”, with cramped dormitories, rooms smelling of urine and a bare, drab environment. At St Brendan’s in Dublin’s north inner city, patients were wandering around “apparently aimlessly” in one ward, while overall the centre was found to be in breach of more than half of the care regulations.
Some ask how are professionals entrusted with their care – and society in general – able to tolerate such inhuman and outdated conditions.
“You have to remember that these old Victorian-era institutions were the main employment centres – they were the Dell of our times. It’s been that way for the past 100 years or so,” says Devitt.
“There are a lot of old attitudes and comfortable practices. Also, there’s a lack of investment in infrastructure, which has hindered plans to close down these old asylums . . .
“In addition, people with serious psychotic illnesses are marginalised by society. When what was known as the ‘great confinement’ took place in the 19th century, it was because the people seen as mad were frightening. They were wandering the streets and frightening the horses. You’d have to say that some of those attitudes still persist.”
The kind of changes needed to modernise our mental health services are hardly a secret. They were laid out in a major policy document in the 1980s known as Planning for the Future.
And they were restated in its latest incarnation, A Vision for Change, adopted as official government policy four years ago. Yet progress, by any objective assessment, has been abysmally slow.
Against a backdrop of shrinking resources for mental health and glacial change, Devitt remains upbeat about the prospects for modernising the sector.
“It can be hard to see progress on a year-on-year basis. You could describe mental health services as a big vessel – it’s hard to see it turn,” says Devitt. “But over the decades there have been changes.
“There are more acute hospital units, more community services. I was lucky enough to be involved in one of the first home-based mental health services, which started in Clondalkin 20 years ago . . . there has been movement, let’s not be too pessimistic.”
The key to change in this instance is a mental health directorate within the Health Service Executive. It may sound like a dull, administrative point but, he insists, it is crucial to introducing the concept of change management.
“This would be a directorate with budgetary powers . . . It would operate in much the same way as the so-called ‘cancer tsar’, establishing a focused team with significant power which can effect change in the right direction.”
Any change will need to include winning over nurses and consultants on the ground, who have proved obstacles to modernisation in the past.
He’s confident health professionals can be won over – because the changes are in their interests as well as the patients’. “There are professionals, be they nurses or consultants, who say, ‘Well, it was good enough in my father’s day. And isn’t it good enough now?’ These groupings need to be moved on in an educational and training way, towards where modern services should be: in the community without much recourse to hospitalisation. We know that because it has worked in places like Clondalkin in Dublin, Cavan-Monaghan and Loughrea. There are very low hospitalisation rates there.
“If you’re a parent, and your child develops a mental illness, you don’t want them going into any hospital – especially not a Victorian-era one – on their first admission.
“The essence of the concept of recovery is that they have hope and will go on to live a fulfilled life despite their illness, have friends, enjoy recreational activities and enjoy life. You can see how going into those places can really suck the life out of you.”
And this is the key to A Vision for Change. It envisages closing down the old institutions, providing more care in the community, setting up multidisciplinary teams on the ground, ensuring there is a recovery-based approach to mental illness.
But if the future lies in the community, many communities aren’t ready. There have been numerous cases of local protests against planned mental health facilities or community residences.
Devitt says the public needs to be educated about mental illness and a major project is needed to de-stigmatise attitudes.
Alcohol, for example, causes infinitely more violence than mental illness. Yet, he also accepts placing more patients – especially psychotic ones – in the community carries risks as well.
“You could say that societies love to be frightened. When it’s not Jack the Ripper, then it’s the nuclear scares . . . Studies in the US show people with mental illnesses who are treated are no more violent than anyone else – in fact, they are more susceptible to having violence perpetrated against them,” says Devitt.
“What you don’t understand is frightening. If your child is ill and has a temperature, that can be frightening. So, if a child has bizarre thoughts, behaviours or perceptions, that can very frightening.”
Devitt says placing people with mental illnesses in the community can involve a degree of risk – but if done properly, it can strike the right balance.
“My own view is that we have to take account of risk and manage it properly – we shouldn’t be paralysed by it.
“Giving individual autonomy does carry risk. We could avoid all risk with mental illness if we locked up everyone who ever had a history of it and place guard on them day and night. But that’s not the kind of society we want.”
