Ellipse
Despite St Brendan’s bleak reputation, the hospital was established on foot of a wave of sensitivity towards the needs of the mentally ill. In postrevolutionary France, Philippe Pinel struck the chains off his patients at an asylum, convinced a more humanitarian approach would be more effective than restraint and control. This “moral management” philosophy had much in common with what we now consider key aspects of mental-health treatment: a good doctor-patient relationship, a therapeutic environment, good diet, exercise and an occupation.
Richmond Asylum, as St Brendan’s was formerly known, was established on these principles. It was the beginning of a frenzied period of asylum-building that resulted in large-scale institutions being established in towns and cities around the country. In reality, most asylums quickly became overcrowded, dirty and unmanageable.
“When you look back you find that many physicians had progressive plans, and they implemented many of them to do with education or living outside the asylum,” says Dr Brendan Kelly, a consultant psychiatrist with the Health Service Executive, who has researched the history of psychiatry in Ireland. “However, the asylums became too large. Once an institution becomes sufficiently large, attention shifts from caring for the individual to managing the institution. Once that happens, problems emerge.”
Asylums, which were run initially by lay people, were gradually were taken over by the medical establishment. Medical superintendents – the equivalent of psychiatrists – introduced a medical approach to treating mental ill health, and moral management, with its focus on the individual, began to fade. This was a time of discredited and experimental approaches to treating people with mental-health problems. They included “Dr Cox’s circulating swing”, which involved spinning a patient at high speed; the “bath of surprise”, a gallows-style platform that dumped a patient into icy water; and enforced “purging”, or vomiting.
Much later, other forms of brutal treatment came and went, including insulin-coma therapy, where patients were repeatedly injected with the hormone to induce a coma, and lobotomies, which involved removing parts of the brain. These procedures continued in some Irish psychiatric hospitals until the 1960s and 1970s.
The sheer number of people admitted to mental institutions in the years after the Famine was striking. The number of “certified lunatics” increased by 60 per cent in two decades in the late 1800s. Little of this had anything to do with an increase in mental ill health.
“The population had halved, but the number of beds remained the same,” says Dr Ivor Browne, former chief psychiatrist with the Eastern Health Board, who began working at St Brendan’s in 1962. “Conditions for many were desperate, so the asylums were like a suction [drawing people in]. People could get three meals a day.”
Overcrowding and unsanitary conditions remained major problems for decades afterwards. As a result, there was no meaningful relationship between doctor and patient. Browne recalls visiting the women’s section of St Brendan’s in the 1950s, not long after qualifying as a doctor. Even though he had worked in other areas of psychiatry, he was shocked by what he saw. “Many of the wards had more than 100 people in them. There were crowds of patients, jostling each other, some of the women with their dresses pulled over their heads, and here and there a nurse, struggling amid the chaos,” he says.
“There was a cacophony of sound, and I felt as though I was lost in some kind of hell . . . I remember passing a little old lady, quite sane and conscious, sitting in bed and shaking with terror.”
Anyone who fell through society’s cracks tended to end up in an asylum. He recalls seeing patients being admitted for spurious reasons – alcoholism, disruptive behaviour, promiscuity – who often never left. They aged inside and became hopelessly institutionalised.
But the perception of the asylum as a simply brutal environment is too simplistic and doesn’t credit the efforts of staff and doctors, according to Dick Bennett, a former staff nurse who worked at St Brendan’s from the 1970s to the 1990s.
“It was like an asylum in the old meaning of the word: it was a refuge from the outside world,” he says. “There was a sense of community there. The standard of care was excellent. There were older people who lived to their 80s or 90s, which says something about the care.”
Browne adds: “In many ways, there was a great humanity about the place because they couldn’t refuse anyone. There was a kind of acceptance of suffering. There were some nurses who could be quite brutal, but most were quite benign.”
When he took over as chief psychiatrist, in the mid 1960s, one of the first things he did was arrange for some of the high perimeter walls to be knocked down, a symbolic demolition of the barrier between the patients and the community. “Ironically, we ended up having to put up railings instead. Not to keep people in but to prevent antisocial behaviour from outside.” He also set up an assessment unit to try to prevent unnecessary admissions and set about transferring some patients back into the community. Sometimes people were so institutionalised that the prospect of leaving was terrifying.
“I remember one fellow who was keen on gardening and growing things. He had a little hut. I thought he would be a prospect for living in the community. We got a place for him in the community. But he walled himself up in his hut and suffocated himself, because he couldn’t face leaving.”
By the time Browne left, in the late 1990s, the population of St Brendan’s, which had peaked at 2,500, had fallen to about 400.
He says moving patients into the community made sense, but he acknowledges that it didn’t fully work. “What I didn’t realise early on was that any real community in a city like Dublin had ceased to exist. So the only place they could go to was either some offshoot of a mental hospital, like a day hostel, or a rehabilitation centre, which were often like mini-institutions.”
In a few days the old asylum will close and the care centre, which looks more like a corporate headquarters, will take its place. Much has changed in our approach to mental ill health in the past two centuries, and nowadays the vast majority of people are cared for and supported in the community.
Some aspects of the system are still considered antiquated – the admission of teenagers into adult units or the housing of intellectually disabled in “de-designated” wings of old psychiatric hospitals – and concern remains about patchy community-based care and an overreliance on medicine rather than talk therapy. But most agree that we are on the right road to a service that involves patients in their own care and respects their human rights.
“What’s very positive about the future is that the size of the in-patient unit is much smaller,” Kelly says. “The Phoenix Care Centre has a maximum of 54 beds, compared to 2,500 beds at the start of the 1900s. That’s a huge change. It allows more focus on the individual. Sometimes, in the history of the asylums, that’s what was lost, quite simply.”
Source : Irish Times Health Supplement, February 2013
Ellipse
Despite St Brendan’s bleak reputation, the hospital was established on foot of a wave of sensitivity towards the needs of the mentally ill. In postrevolutionary France, Philippe Pinel struck the chains off his patients at an asylum, convinced a more humanitarian approach would be more effective than restraint and control. This “moral management” philosophy had much in common with what we now consider key aspects of mental-health treatment: a good doctor-patient relationship, a therapeutic environment, good diet, exercise and an occupation.
Richmond Asylum, as St Brendan’s was formerly known, was established on these principles. It was the beginning of a frenzied period of asylum-building that resulted in large-scale institutions being established in towns and cities around the country. In reality, most asylums quickly became overcrowded, dirty and unmanageable.
“When you look back you find that many physicians had progressive plans, and they implemented many of them to do with education or living outside the asylum,” says Dr Brendan Kelly, a consultant psychiatrist with the Health Service Executive, who has researched the history of psychiatry in Ireland. “However, the asylums became too large. Once an institution becomes sufficiently large, attention shifts from caring for the individual to managing the institution. Once that happens, problems emerge.”
Asylums, which were run initially by lay people, were gradually were taken over by the medical establishment. Medical superintendents – the equivalent of psychiatrists – introduced a medical approach to treating mental ill health, and moral management, with its focus on the individual, began to fade. This was a time of discredited and experimental approaches to treating people with mental-health problems. They included “Dr Cox’s circulating swing”, which involved spinning a patient at high speed; the “bath of surprise”, a gallows-style platform that dumped a patient into icy water; and enforced “purging”, or vomiting.
Much later, other forms of brutal treatment came and went, including insulin-coma therapy, where patients were repeatedly injected with the hormone to induce a coma, and lobotomies, which involved removing parts of the brain. These procedures continued in some Irish psychiatric hospitals until the 1960s and 1970s.
The sheer number of people admitted to mental institutions in the years after the Famine was striking. The number of “certified lunatics” increased by 60 per cent in two decades in the late 1800s. Little of this had anything to do with an increase in mental ill health.
“The population had halved, but the number of beds remained the same,” says Dr Ivor Browne, former chief psychiatrist with the Eastern Health Board, who began working at St Brendan’s in 1962. “Conditions for many were desperate, so the asylums were like a suction [drawing people in]. People could get three meals a day.”
Overcrowding and unsanitary conditions remained major problems for decades afterwards. As a result, there was no meaningful relationship between doctor and patient. Browne recalls visiting the women’s section of St Brendan’s in the 1950s, not long after qualifying as a doctor. Even though he had worked in other areas of psychiatry, he was shocked by what he saw. “Many of the wards had more than 100 people in them. There were crowds of patients, jostling each other, some of the women with their dresses pulled over their heads, and here and there a nurse, struggling amid the chaos,” he says.
“There was a cacophony of sound, and I felt as though I was lost in some kind of hell . . . I remember passing a little old lady, quite sane and conscious, sitting in bed and shaking with terror.”
Anyone who fell through society’s cracks tended to end up in an asylum. He recalls seeing patients being admitted for spurious reasons – alcoholism, disruptive behaviour, promiscuity – who often never left. They aged inside and became hopelessly institutionalised.
But the perception of the asylum as a simply brutal environment is too simplistic and doesn’t credit the efforts of staff and doctors, according to Dick Bennett, a former staff nurse who worked at St Brendan’s from the 1970s to the 1990s.
“It was like an asylum in the old meaning of the word: it was a refuge from the outside world,” he says. “There was a sense of community there. The standard of care was excellent. There were older people who lived to their 80s or 90s, which says something about the care.”
Browne adds: “In many ways, there was a great humanity about the place because they couldn’t refuse anyone. There was a kind of acceptance of suffering. There were some nurses who could be quite brutal, but most were quite benign.”
When he took over as chief psychiatrist, in the mid 1960s, one of the first things he did was arrange for some of the high perimeter walls to be knocked down, a symbolic demolition of the barrier between the patients and the community. “Ironically, we ended up having to put up railings instead. Not to keep people in but to prevent antisocial behaviour from outside.” He also set up an assessment unit to try to prevent unnecessary admissions and set about transferring some patients back into the community. Sometimes people were so institutionalised that the prospect of leaving was terrifying.
“I remember one fellow who was keen on gardening and growing things. He had a little hut. I thought he would be a prospect for living in the community. We got a place for him in the community. But he walled himself up in his hut and suffocated himself, because he couldn’t face leaving.”
By the time Browne left, in the late 1990s, the population of St Brendan’s, which had peaked at 2,500, had fallen to about 400.
He says moving patients into the community made sense, but he acknowledges that it didn’t fully work. “What I didn’t realise early on was that any real community in a city like Dublin had ceased to exist. So the only place they could go to was either some offshoot of a mental hospital, like a day hostel, or a rehabilitation centre, which were often like mini-institutions.”
In a few days the old asylum will close and the care centre, which looks more like a corporate headquarters, will take its place. Much has changed in our approach to mental ill health in the past two centuries, and nowadays the vast majority of people are cared for and supported in the community.
Some aspects of the system are still considered antiquated – the admission of teenagers into adult units or the housing of intellectually disabled in “de-designated” wings of old psychiatric hospitals – and concern remains about patchy community-based care and an overreliance on medicine rather than talk therapy. But most agree that we are on the right road to a service that involves patients in their own care and respects their human rights.
“What’s very positive about the future is that the size of the in-patient unit is much smaller,” Kelly says. “The Phoenix Care Centre has a maximum of 54 beds, compared to 2,500 beds at the start of the 1900s. That’s a huge change. It allows more focus on the individual. Sometimes, in the history of the asylums, that’s what was lost, quite simply.”
Source : Irish Times Health Supplement, February 2013