Hearing Voices - Brendan Kelly

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drawn by a horse with a sly and regular trot as if he felt and feared anything else might entitle him for companionship with the dread life of the still-twitching dead. Dotted here and there in the grounds were the dismal brothers of disorders grey, their red mufflers making them look as if their tormented heads had been cut off, and pushed crookedly back on to their necks again. The cab stopped slowly before the building, wide and long, built like a bully that had suddenly died shrugging his shoulders. Long rows of lifeless windows mirrored long rows of lifeless faces, their silence hymning a fading resurrection of Velazquez’s idiots5, a whole stonily-grinning gallery of God’s images turned to dull grey clay, the emptiness of a future age in every face. Now and again, some of them would vent a laugh that rippled a shudder along the walls of the asylum. The grass everywhere grew brown and long, and fell to dust whenever it was touched; the trees twisted their branches like limbs in pain, and grew grey leaves that never seemed to move, a cold immortal grey, as if under the blight of the fig tree Christ had cursed. Flowers that tried to grow beneath the windows were slimy stalks, crawling along the grey ground like slugs tantalizing the rim of a festering lily, lost amid the quiet storm of lunacy distilling a sour air everywhere. In a corner a chestnut tree dropped worm-worn fruit like leaden balls, and riven church bells rang out a raucous angelus three times a day, carolling rakishly mid the mindless chatter and the rasping laugh. Only ghosts of things and men were here …

Symbol

      INTRODUCTION

      The history of psychiatry is a history of therapeutic enthusiasm, with all of the triumph and tragedy, hubris and humility that such enthusiasm brings. This book presents this history in the very particular context of Ireland, and tells the story of early psychiatric care, the emergence of Ireland’s remarkable asylum system in the 1800s, its demise in the 1900s, and the development of ‘community care’. It is an extraordinary tale.

      What is Psychiatry?

      Psychiatry, according to Professor Anthony Clare (1942–2007; Chapter 6), one of the outstanding Irish figures in its history,1 is ‘the branch of medicine that is concerned with the study and treatment of disorders of mental function’.2 More specifically, a medical disorder is a disease or ailment,3 and a mental disorder, according to the World Health Organisation (WHO), is a clinically recognisable group of symptoms or behaviours associated in the majority of cases with distress and with interference with personal functions.4 If personal dysfunction is not present, social deviance or conflict on their own are not sufficient to constitute mental disorder: the person’s mood, thoughts, judgement, relationships or personal function must be disturbed.

      Throughout history, the evolution of this concept of ‘mental disorder’ has been, and continues to be, a highly contested process.5 Mental disorders are variously conceptualised as spiritual or religious manifestations, legal conundrums, medical diseases, social issues, or all of the above, with the balance between competing conceptualisations varying over time.6 In recent decades, re-definition and expansion of diagnostic categories within psychiatry have proven especially controversial.7

      This book, however, is a history of psychiatry rather than a history of mental disorder, madness, the mentally ill, asylums or even psychiatrists.8 Of necessity, all of these concepts feature strongly in the story, but this book is primarily a history of, to use Clare’s definition, that ‘branch of medicine that is concerned with the study and treatment of disorders of mental function’. It is, quite simply and quite complicatedly, a history of psychiatry in Ireland.

      Why Write a History of

      Psychiatry in Ireland?

      In March 1817, Robert Peel (1788–1850), Chief Secretary, prevailed upon the House of Commons of the United Kingdom of Great Britain and Ireland to set up a Select Committee to look into the need to make greater provision for ‘the lunatic poor in Ireland’.9 The Right Honourable Denis Browne (a Mayo Member of Parliament) gave evidence about the plight of the mentally ill in rural areas of early nineteenth-century Ireland:

      There is nothing so shocking as madness in the cabin of the peasant, where the man is out labouring in the fields for his bread, and the care of the woman of the house is scarcely sufficient for the attendance on the children. When a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin not high enough for the person to stand up in, with a crib over it to prevent his getting up, the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies. Of all human calamity, I know of none equal to this, in the country parts of Ireland which I am acquainted with.10

      When presented to the Select Committee in 1817, this picture – the mentally ill person kept in a pit until he or she dies – was a searing one and it still retains its power to shock today, some two centuries later. This image and the reaction it evokes highlight the importance of the history of psychiatry in Ireland. Can an examination of this history help us to understand why such a situation was allowed to develop? How did matters change (if at all) following a seemingly endless succession of official reports such as that of the 1817 Select Committee? Did the emergence of psychiatry in the 1800s improve matters? How much of this situation was specific to Ireland and how much was continuous with the broader, international histories of mental disorder, the treatment of the mentally ill by various societies, and the emergence of the profession of psychiatry internationally?

      The history of psychiatry in Ireland is located within both the history of Ireland as a country and the broader history of psychiatry internationally. From the international perspective, there are as many versions of the history of psychiatry as there are historians, each presenting varying, often competing narratives about the development of psychiatric practice, psychiatric institutions and psychiatrists. Ireland features in such histories to varying degrees, generally linked with Ireland’s high rates of psychiatric institutionalisation during the 1800s and early 1900s.11 In a dedicated volume, Brennan, in particular, deftly explores Ireland’s high committal rates which substantially outpaced those in England, Wales and Scotland, and by the 1950s resulted in Ireland having the highest rate of psychiatric bed availability internationally.12 Why?

      As will become apparent throughout the present book, I am not convinced that core epidemiological rates of mental disorder rose in Ireland during the 1800s or are rising today, or that Ireland has ever had an exceptionally high rate of mental disorder compared to other countries. It is certainly true that there were increased rates of admission to psychiatric institutions throughout the 1800s in various countries, including Ireland, England, France and the United States (US),13 and that Ireland’s rates were especially high at their peak, and particularly slow to decline.14 But Ireland’s increase in committals was influenced by such a broad range of social, political, legal, economic and demographic factors that it is difficult to determine definitively whether or not a true increase in the incidence of mental disorder really occurred. On balance, it is my view that it did not, and this view is explored at various points throughout this book (especially Chapter 3).

      Reaching firm conclusions on this point is, admittedly, rendered extremely complex by the fact that diagnostic systems in psychiatry are continually changing, principally owing to psychiatry’s dependence on symptom based diagnosis rather than biological testing. There is, in addition, considerable ambiguity of the numbers of persons with mental disorder who resided outside asylums during the 1800s and 1900s (Chapter 4), and the picture is further clouded by continual changes in legislation and institutional practices in Ireland and elsewhere. Notwithstanding these interpretative complexities, this book does not present a history of psychiatry based on the idea that rates of mental disorder were especially high or truly increasing in Ireland, but rather emphasises the roles of other factors in driving up admission rates.

      The Emergence and Roles of

      Psychiatric Professionals

      Another version of the history of psychiatry which seeks to explain institutional expansionism in Ireland

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