OPINION: IT WAS very appropriate that the editorial in this newspaper this week on our grim history of detaining large numbers of our citizens in psychiatric institutions was headed "A culture of control". Core to the experience of the 21,000 people who were detained at one time in the 1960s institutions was the fact that control over many aspects, and sometimes all, of their lives was often taken away from them.
The RTÉ documentary series Behind the Wallsdescribed this system unflinchingly but with great empathy for the patients, who in many cases would better be described as victims. It showed poor and manifestly unsuitable buildings and inhuman conditions.
But what made the experience of inpatients so bad in so many cases wasn’t just the state of repair of the premises in which they were housed, but the culture of control that in some cases dictated every aspect of their treatment. In recent decades we have moved steadily away from this old system towards a more enlightened and modern approach. However, this move is not yet complete.
While the number of people detained in psychiatric hospitals has fallen from 21,000 in the 1960s to just 2,800 now this number is still too high.
The inspector of mental health services inspects each institution approved to take inpatients every year. His reports reveal a very mixed service.
Consider the following: “A number of the beds in dormitories in the male admission ward had no curtains . . .
In the male admissions ward one toilet area had low stall-like doors that offered little privacy . . .
The toilets were not in good condition and there was an open drain in one toilet . . . The bedrooms were cell-like and stuffy. The toilets were in very poor state with open drains and the floor was stained and marked. The shower was in poor condition.”
This is not a historical document unearthed by the RTÉ documentary series. It is an extract from one of this year’s inspection reports published just last Friday.
In modern mental health practice each patient should be treated as an individual with their own care plan. Each such plan should be geared towards the recovery of the patient and involve families and carers. Finally, patients should be treated in a community setting and not in an inpatient institution. Of course there will be occasional acute episodes of mental illness requiring a short period of inpatient treatment but these should be very much the exception.
For these basic principles to be applied the reasoning behind them must be accepted by society.
First, we must accept that “the mentally ill” are not a homogenous group to be viewed and treated in the same way, but that each should have a treatment plan tailored for them. Second, we must accept that people with mental illness can and do recover and play a full part in society.
And third, we must accept that people
with mental illness are a full part of the community and should be treated within the community.
There has been considerable progress towards reducing the stigma surrounding mental illness. But the stigma remains. People would still find it easier to tell their employer that they had a life-changing physical illness, rather than reveal they were dealing with a temporary disruption to their lives brought about by an episode of, say, depression or bipolar disorder which could be managed effectively in the long term.
Perhaps the single most significant move towards breaking the “culture of control” has been the introduction, under the 2001 Mental Health Act, of an independent system of review by mental health tribunals.
Under this system every patient who is detained against his or her will is reviewed by a tribunal no later than 21 days after their admission. Prior to the tribunal a consultant psychiatrist who is independent of the detaining hospital prepares an independent report for the tribunal.
A solicitor is appointed to the patient within a few days of admission. A three-person panel makes the decision.
Some argue that 21 days is too long to wait, and other points are made about the operation of tribunals. But their existence is nevertheless a powerful statement that a person detained in a psychiatric hospital against his or her will has rights that must be respected. Patients also have a right of appeal to the Circuit Court.
Today there are many modern and effective treatment facilities but old dilapidated units remain. The Mental Health Commission has played a part in forcing improvements. We have given many institutions the time and opportunity to improve but ultimately we can and do attach conditions to centres obliging them to take particular actions.
So next weekend at our insistence, the admission of patients to the acute units of St Ita’s Hospital Portrane will end and the acute units will close.
At the end of next month, inpatient numbers at St Michael’s Unit in Clonmel will be reduced by 20, and it is intended that the unit will close by the end of the first quarter of 2012. St Luke’s Hospital, also in Clonmel, must reduce its inpatient beds by 40, also
by the end of the first quarter of 2012.
Three wards at St Loman’s Hospital in Mullingar are to be closed by next March, again at our insistence.
But we also insist on improvements in the nature of care and treatment. We need to change our attitudes to mental illness and to those affected by it. Underlying the old approach seems to have been a view of mental illness as being associated with danger and criminality.
The response of society was primarily one of containment and control, rather than treatment with a view to recovery. Patients who found the means of telling their story reported an overwhelming sense of abandonment by their community and society.
The Mental Health Act and the Mental Health Commission established under it represent important steps to ensure patients no longer feel abandoned. The commission has developed standards in relation to all aspects of mental health services and has issued guidance on a number of areas, particularly recovery, team working. We act on the reports of the inspector and they inform our approach to the licensing of approved centres.
However, we are not there yet. Modern mental health services must provide a wide range of psychological and other therapeutic interventions. Our experience is that while many healthcare and administrative staff have made great contributions to improving patient outcomes, systemic change is required and this must be driven from within.
We want to see a directorate of mental health services with the power and energy of the national cancer control programme which has been so effective in driving change in that area.
We want to see the mental health budget protected, we want to enhance patient rights when it comes to making decisions regarding all aspects of care and treatment.
Fundamentally, the State and its citizens must accept mental illness as part of the human condition. Those of us who have
been and will be affected by it are citizens with the same rights as everyone else who are in need of treatment with a view to their recovery.
Edmond O’Dea is chairman of the Mental Health Commission