Psychiatry’s Third Way

In the lead-up to World Mental Health Day, Matt Gregg investigates Ireland’s conflicted approach to a global debateThere can be normality in madness. At first glance, perhaps, this may seem a contradictory turn of phrase, yet it encompasses an idea that is fast becoming the new way of approaching mental health. For so long, the concept of mental health and mental health disorders were confined to a select few amongst the general population. These people, not only cut off from society by the walls of mental institutions, were further imprisoned by social stigma. Though not complete, much progress has been made in tearing down the physical walls of these outdated institutions. It is now time to finish tackling the figurative barriers.“A huge amount of people delay seeking help due to the fact that they take the view that other people will view them negatively. People still see having a mental health issue as a mark of shame,” explains JP Swaine, managing director of the mental awareness group First Fortnight. “I suppose it’s just a very common Irish social phenomenon of not accepting vulnerability and a failure to counteract mental health disorders when they occur, which leads them to worsen due to the time lapse to respond to them.”Founded in 2010, First Fortnight uses arts events preceded by discussions concerning mental health in an attempt to bring greater awareness to the general public and break down the prevailing stigma. JP believes that music events or plays can be used to engage people who would not normally give much thought to the conditions of mental health. “What we want to do is to draw them into the issue, the debate and to draw them into the centre of the debate that really this is about life and living,” JP reasons. “For too long we’ve talked about mental health in terms of life and death - it’s really in terms of life and living.”This is a point echoed by Dr. Patricia Casey, a Professor of Psychiatry at UCD and the Mater Misericordiae Hospital. “It’s improving, but I certainly agree that there is a stigma attached to receiving psychiatric treatment. Of course I believe it should be broken down because it deters people from coming forward for help and treatment. I think simply talking about it, giving people insight into what modern psychiatry is like [...] not still talking about institutions.”Dr. Casey emphasises that there has been a shift in Ireland’s psychiatric approach, which now focuses increasingly on the outpatient procedure and talking therapies. However, she maintains that there is still a long way to go, as current waiting lists are still extremely long; for example, Dr. Casey’s currently stands at three months.“Politicians should be encouraged to listen. I would like during the elections, on the doorsteps, if politicians were asked about their commitments to mental health. The proportion of the health budget being spent on psychiatry has reduced from twenty-three per cent in 1968 down to six or seven per cent in 2010. That shouldn’t have happened because sale of the lands and old institutions should have allowed this to remain the same if there were no increases. So it means that the money from all this has been siphoned off by successive health boards, the HSE and governments for other things.”The legacy of these institutions continues to shape other aspects of the mental health debate. Mad Pride Ireland, founded by John McCarthy, is a group that campaigns vigorously against the psychiatric establishment in Ireland. He contends that the ‘medical model’ of psychiatry does not really understand the concept of ‘madness’, and is over-reliant on the use of drugs.“What I am saying is that there is no record of people being diagnosed. You cannot diagnose a mental illness. You cannot,” argues John, a former patient of St. Patrick’s Hospital in Dublin. “We have all bought into this diagnostic box. We have all bought into the fact that psychiatrists can somehow [diagnose]. I got four different diagnoses but I’ve never had a psychiatrist take my pulse. And yet he can state, within twenty minutes of talking to me, that I have a chemical imbalance in my brain.”John instead argues that “madness” needs to be embraced as a part of the human condition and a sign of individuality rather than labelled as a disease. “I have lots of friends who hear voices. They have no problem with hearing voices; they lead very productive lives. But they can’t talk about it so they have to carry the burden and the secrecy of hearing voices in their head and in their hearts,” bemoans John. “And that’s where it hurts the most. Stigma hits not in the head but in the heart. We need to show a bit of love and compassion around that community, around the great normality of madness. There’s nothing wrong with madness. We’ve made it something to be afraid of – my priority is trying to show that madness is a gift.” John compares the social struggle of the abjected mentally ill with that of other civil rights movements; “If black is beautiful, madness is a gift.”Dr. Casey confirms that there is no ‘test’ in the conventional sense, and that diagnosis is instead reached by assessing the symptoms of patients. However, she disagrees that this undermines the usefulness of psychiatry and feels that Mad Pride Ireland’s claims increase the risk of stigmatisation.“Mad Pride are a problem because they don’t believe in psychiatric illness, they don’t believe in the role of psychiatrists and I think they actually contribute to stigmatising psychiatry,” she argues. “I mean one of the ways you get over stigma is not to pretend that something doesn’t exist, but to acknowledge that it is a reality. I think Mad Pride want to ignore the reality of psychiatric illness and that some people do need medication and that some people do sometimes kill themselves because they haven’t been adequately treated.”This polarisation of views is hardly surprising. Recent documentaries, such as RTÉ’s ‘Behind the Walls’, have painted an accurate and frightening picture of how poor the conditions in Irish psychiatric institutions were for a long time. Heavy dependency on dangerous cocktails of drugs to keep patients sedated and instances of abuse were far too regular to be dismissed as the actions of a select few. It was really only with increased debate concerning mental health and the continual thrusting of institutions’ reports into the public domain that Ireland’s mental health establishment began to shift towards the less custodian version in place today.This idea of dialogue as the best way to improve Ireland’s approach to mental health is one area in which both Dr. Casey and Mad Pride Ireland are in firm agreement. “There are all kinds of misinformation and ignorance out there. I think if we can get out the message through various media outlets that psychiatry has changed, I think that will help break down the stigma. The public will see that these conditions are treatable, people get over them and people can live fully productive lives, which would be wonderful. I mean that the number of people that I treat that are doctors, lawyers, teachers [...] all walks of life you know; from the highest echelons to the humblest of the humblest is quite heartening,” explains Dr. Casey. “People are able to come through these spells and live very productive lives to the extent that you would not know that they had just walked out of my office.”Similarly, John describes Mad Pride Ireland’s main objective as creating “a space to have a debate. The function of Mad Pride Ireland is to open a debate [...] Our other function is to dispel the senseless fear created on purpose for an agenda of what I like to call the ‘medical model’. All we are trying to do is to open up a conversation around whether I am correct or incorrect about whether there is an agenda or not. I think that fear is coming from voluntary agencies and certain members of the medical community, certain members of the HSE, certain members of the judiciary [...] we need to open up. And if I’m wrong? Well, at least we will have had the conversation.”However, dialogue will require compromises on both sides as currently both maintain that the other is too set in their ways to engage in a meaningful manner. “Mad Pride Ireland are un-engageable,” declares Dr. Casey. “I have tried on several occasions and attempts to engage with them don’t really get very far because they have a very set view. I think the best thing is to ignore them.” Likewise, John states that “Mad Pride Ireland has never received any invitation or encouragement in private or in public from Dr Patricia Casey to engage in any way. We would welcome such an invitation. Mad Pride Ireland has always stated we can only progress through debate. This is not anti-psychiatry - this is about human rights and power”.Assessments of mental health and appropriate care remain heavily disputed. For example, people with personality disorders present a problem because they demonstrate both symptoms of psychological distress and social rule-breaking behaviour. This behaviour invites punishment as well as therapeutic responses. This is a reason why care can be challenging and sometimes evokes strong resistance, which can lead to confusion and negativity. However, this cannot become a reason to hide, deny or shame.To quote JP of First Fortnight, “it’s actually taking the ‘them’ away and accepting that there’s only a ‘we’ in all of this. The distance between a bad day and a mental health crisis is something we can only explain for ourselves; no-one can say particularly there was anything special or unique about them. That their bad days turn into a series of bad days and, ultimately, into a crisis that they felt they lost control of. Sometimes our bad days are just bad days and get better the next and we have to count ourselves lucky for that, and understand that we actually have walked a little of this road, even though we pretend we can’t imagine it.”