05 May, 2016

A Century of Irish Mental Health Care: From moonstruck to the healing of the psyche...

On the 25th April 2016 a free interactive exhibition entitled “Saoirse - A Time for Freedom?” opened to the public at St. Patrick’s University Hospital. The artefacts and paintings on display illustrate the experience of our patients during the Easter Rising of 1916. The anniversary of our nation’s proclamation provides an opportunity to reconsider the changing attitudes to mental healthcare in Ireland over the past century.

The exhibition was curated by our chief biochemist Ms. Mary Anderson and many of her colleagues on the staff of the hospital assisted by our resident archivist and historian Mr. Andrew Whiteside. The impressions taken from such an exhibit, given its emphasis on mental health over the past century, may be very personal and private, but some objective observations are also important. “Saoirse- A Time for Freedom” allows us reconsider our recent history comprising the past century of mental healthcare at St Patrick’s and throughout Ireland.

The exhibit reminds us that in 1916 the concept of lunacy was still the prevailing understanding of mental illness, illustrated by the archaic language used to describe the patients of St. Patrick’s Hospital at the time. In 1916 the inspector of mental health services was still titled the Registrar of Lunatics.

In June 1916 on the occasion of his visit to St Patrick's the Inspector of Lunatics made a very small but important note in his report. He reported that there was one voluntary patient out of the 137 people there at the time. Up until this time all admissions to asylums in Ireland were involuntary, that is to say they were committed to asylums by the Lord Chancellor and two examining doctors. Today in St Patrick's that figure is exactly reversed with less than 1% of people in our hospital admitted on an involuntary basis.”

The language used to describe mental illness in 1916 is also very different to the language of today. The word lunatic is an ancient concept that literally means 'moonstruck'. While the rising in Dublin marked the birth of modern Ireland, in 1916 the birth of modern psychiatry was under way elsewhere in Europe with the emerging work by Jung, Freud and others paving the way for the exploration of the conscious and subconscious parts of the human psyche.

Since the beginning of the 20th century advances in the understanding of brain structure and disease were contributing to a deeper understanding. In 1913 the bacterial spirochete was first identified in the brains of patients with General Paralysis of the Insane, the venereal infection underlying the illness of between 10% and 20% of detained patients in asylums at the time. This discovery lead the way to the successful treatment of venereal disease and the eradication of this form of insanity. 

This new therapeutic era lead to a changed expectation regarding mental health. This is illustrated by the growing reference to the word “Psychiatry” derived from Psyche (meaning psyche, spirit, essence, soul, butterfly) and Iatros ( meaning healer).

The Medical Superintendent of St Patrick's in 1916 Dr Richard Leeper along with Matron Marie Einthoven and their staff were keen to bring St Patrick's into this new era of therapeutic care. In reality in 1916 there was little option or them but to hark back to their founders noble ideals, so one of the first things Dr Leeper did was to purchase the first clocks for the hospital. He bought three of them. By doing so he introduced time, structure and hope for the patients.

Between 1916 and the late 1950's many new medical treatments were enthusiastically embraced without a modern evidence base, only to be abandoned later as the scientific basis for these treatments was called into question. Insulin comas, psychosurgery and other methods now deemed wholly inappropriate and ineffective were used in a desperate attempt to alleviate many severe symptoms of mental illness.

A more emancipated, hopeful, effective and evidence based approach to mental illness was introduced later by Dr Leeper’s successor Professor Norman Moore, Medical Director, St. Patrick's (1947 -1977). In his address to the Hospital in 1959 Moore said, “…for too long we have lived in isolation behind the same high walls and locked doors which sheltered our patients. We are only beginning to realise that our responsibilities to our patients do not begin when they enter hospital, or end when they have been discharged: prophylaxis, after-care and rehabilitation must play an increasing part in the psychiatry of the future. ... Emotional problems are so universal and affect so intimately every branch of life that we need, not so much more specialists and certainly not more hospital beds, but more out-patient facilities, more expert treatment of patients in their own homes more schemes for training .. And more universal recognition that the mentally ill are not a race apart but ourselves in a different set of circumstances”.

The post war years of the 20th century were noted for the growth of hostility to institutional psychiatry and the emergence of new talking treatments ranging from psychoanalysis to cognitive behavioural therapy. At the same time the closure of the asylums occurred throughout the western world and this coincided with the expansion of biological psychiatry and psychopharmacology.

The second half of the century continued these trends. Hopefully much has been learned. While some treatments are helpful for some people some of the time, not all treatments work for all of the people all of the time.  Understanding mental health and mental illness turns out to be more about the combination of nature and nurture than many purists would like to acknowledge. Combined advances in the areas of neuroscience, neuro-imaging, molecular biology, psychology and mindfulness have shown us that each person is  unique. There is no 'one size fits all' mental health solution. 

Many years ago our founder Jonathan Swift identified the best doctors in this land as.. “Dr Diet, Dr Quiet and Dr Merryman'... Today the importance of a holistic and humane perspective on our mental health has been re-discovered. Chronic stresses remains a breeding ground for many of the illnesses in the 21st century, and one of the biggest causes of stress is the feeling of not being listened to, the feeling of not being heard.

Modern 21st century mental health care is at its best when it is just, holistic, and therapeutic. Mental health care can be a positive restorative force in the community, supporting people where they live work and love. In the 21st century we have the potential to heal the despair and division that characterised the fragmented and ineffective mental health care of the past.

The search for mental health and wholeness is universal and timeless. Our shared history reminds us that we are united by the same search for mental and emotional wellbeing. It is appropriate that we look back on the past 100 years, to check where we are at present, and look forward together to the future of mental healthcare in Ireland.

In June 1916 the Medical Superintendent of St Patrick’s Hospital Dr. Richard Leeper wrote to the hospital Governors describing the part played by the hospital in the Rising by saying “We have been at the centre of a battlefield surrounded by the armies and this is an experience that few people have had”. He went on to praise the bravery of the hospital staff and its patients during 10 days caught in the crossfire between the insurgents in the South Dublin Union and the British forces firing from the river Liffey at Kings Bridge. A reading of his actual account is available on YouTube.