After the Asylum
People with mental-health problems were once locked away in asylums. Now most live in the community, like Mags Kelly, whose story is told here. But they can easily fall through the cracks of an underfunded service.
Mags wakes up and waits for her heart to slow down. She feels like a woman pulled from a burning building: still not quite able to believe she’s safe.
At 6.30am she slides out of bed, sits at her dressing table and rolls a cigarette. Today, like lots of days, her anxiety is sky-high. In a few minutes she’ll take her anti-depressants and mood stabilisers. They numb the distress and ease the panic – but they don’t take away the pain.
Shards of memories tumble around her head. They are of rough-and-tumble years spent living on the streets: unprovoked assaults, bloodied noses, crack-houses and pimping. It all seems part of one chaotic mess.
Then the faces of her children. The girls she never knew, taken into care because she couldn’t cope.
And the fear that courses through her. What if the psychiatrist she saw thinks she can’t cope living in the community? Maybe she’ll get sectioned again and end up in a locked ward? Or maybe she’ll slip through the cracks of the system and end up back on the street?
“Fear is an awful thing,” Mags says. “If you have a lot of fear in your body, it just doesn’t go away . . . I can put on a false front. Put on a bit of make-up and act like I’m well. People say, ‘She’s better,’ but I can’t seem to relax or anything.
There are days when it feels like she’s making progress. Like the other week, when she discovered a bunch of newborn ducklings in a corner of the garden, all open beaks and yellow and black fur. She was the first to find them. It made her feel elated for days afterwards.
Or recently, when she got a letter to say one of her daughters in foster care wanted to make contact with her. She’ll dress up nicely and send on some photos of herself. Maybe one day they’ll be able to strike up a relationship.
But the bad days still come. And when they do, it can be overwhelming. “Depression is terrible. It’s rotten. Look what it’s done to me,” she says, baring her arms. “I’m destroyed. I’ve used myself like a human ashtray, stubbing cigarettes into myself.
“There are sometimes all these thoughts of self-harm in my head . . . I talk to someone, and I feel okay. Then, an hour later, it’s back. It’s like I’m slipping back into the past, and I can’t see a road ahead.”
Until recently, Ireland’s mental health system dealt with people such as Mags through institutionalisation and drug treatment. It was a model with a long history. For hundreds of years, people with psychiatric health problems were locked away in asylums, behind high walls. We led the world locking people up in institutions, with inpatient admission rates that were multiples of other countries.
Today, most of these institutions have closed or ceased admissions. Only 300 patients remain, down from 25,000 about 20 years ago. The last remaining asylum is due to close within the next 12 months or so. The State’s policy now is to provide care in the community. To do this, it is funding the development of teams of professionals – psychiatrists, therapists, nurses and social workers – who support those with mental-health difficulties in a home environment.
Everyone agrees A Vision for Change, the policy launched in 2006, is a more enlightened and progressive approach. Research shows that a wider range of support is much more effective at helping patients recover than the narrower “medical model” associated with institutional care.
But our community mental-health services are under real strain. Dr Patrick Devitt, the Inspector for Mental Health Services, found the system of support was “stagnant and perhaps slipped backwards” last year as a result of dwindling staff numbers and poor governance.
The concerns were echoed by John Saunders, chair of the Mental Health Commission, the State’s watchdog for psychiatric services. “We have incomplete mental-health teams trying to provide multidisciplinary care,” says Saunders.
Last year, millions of euro ring-fenced by the Government to hire more than 400 staff to modernise mental-health services disappeared. It ended up being used to tackle cost overruns in other parts of the health services.
The Health Service Executive says all these posts are being filled this year. But staff have been retiring in even greater numbers, so the extra recruitment is like pouring water into a fast-leaking bucket.
New figures show more than 1,000 fewer full-time posts exist in mental-health services today than in 2009. Staffing levels in some sectors are now at about 50 per cent of those recommended in the Vision for Change policy as being needed to run an effective service.
Records obtained by The Irish Times show unfilled posts are resulting in professionals being pulled out of community services to plug gaps in inpatient care, a move that flies in the face of Government policy. “With the huge exodus of nurses who are retiring, coupled with the recruitment embargo, the community services of which we are so proud are being decimated,” reads an internal email from the clinical director of one HSE service.
The result is an understaffed community mental-health service that patients say is leaving them isolated, disempowered and starved of meaningful treatment options. Concerns are growing that patients in the community may fall through the cracks of an underfunded and understaffed service into homelessness, prison or back in acute in-patient units.
All of this is happening at a time when indicators show an increase in demand for mental-health assistance. Latest figures show the number of suicides and people self-harming is up, while mental-health groups such as Pieta House and others say they are struggling to meet demand for assistance. Just when mental-health services are needed most, they are fraying at the seams.
How Mags dresses depends on her mood. Today, she’s wearing black, splashed with a riot of primary colours. Morning begins in the kitchen, helping to bake scones, and feeding some of the animals. Later, other residents will come back from the bakery and they’ll sit down and catch up on the events of the day.
Her days now are measured in structure and routine – a world away from the chaos of her life before. Looking back, it’s hard to see when things began to unravel. Maybe it was abuse she suffered, or maybe it was anger. She would steal tablets and take overdoses, go on drinking binges that left her in hospital, or lash out at people around her.
“I was seen as a wild child,” she says. “I remember cutting all my hair off. That’s when I began stubbing myself with cigarettes.”
Now that she looks back, she feels that abuse and other troubling experiences earlier in life were at the root of it all. In her mid-teens she ran away from home. It was the beginning of two decades of tumult: sleeping on pavements or in crowded homeless shelters, or getting through the day in a haze of drugs or alcohol.
There were times when she held down jobs or had a flat. But her mental-health problems were always lurking around the corner, waiting to trip her up. The response of authorities seemed to make things worse.
“The psychiatric system that I went to for help just kept pumping me up with tablet after tablet – up to 50 or 60 a day at one point,” Mags says. “. . . I was getting injections as well – I never knew what they were – and couldn’t get out of bed for days afterwards . . . I’d be asking people what day of the week it was. I didn’t know. I’d be drooling from the mouth.”
There were inpatient stays in mental hospitals, too. So many now that she can’t remember. Back on the street, she used crack, heroin or alcohol to ease the pain. Many of those she met on the streets died through overdoses, medical complications, suicide or other reasons.
Just over a year ago, Mags suffered a brutal assault. She could feel her life slipping through her fingers as she lost several pints of blood. She recovered, but she wasn’t sure if she could survive another setback. By now she was living in a homeless shelter in Cork.
When she was told about Slí Eile, a community therapeutic centre in the countryside, she was skeptical at first. “It sounded like the kind of place that was full of nuns,” she says. “But another girl – a previous tenant here – told me, ‘My neighbours were the bird; you’ll be safe and get your life sorted out’.”
It was a big readjustment. Empty days were replaced with support and routine; a bakery to get involved in, as well as gardens and farmyard animals. The other residents seemed nice. Counsellors visited and a step-by-step programme was provided, designed to give Mags the chance to live either independently or with support. She left after two weeks, unable to cope. She couldn’t settle. It was too much, too soon.
Care in the community is complicated. If there are lessons to be learned about how to close Ireland’s asylums, the UK is a good place to start. Its policy to close down institutions and provide care in the community took place mainly during the late 1970s and 1980s.
While also seen as a progressive move, It ended up being criticised for not providing the kind of rehabilitation services needed to help people with psychiatric problems live successfully in the community.
The numbers of mentally ill people in jail or on the streets climbed significantly during this period. Some refer to it as Penrose’s Law, after the British psychiatrist Lionel Penrose who found that the prison population rose as the population in psychiatric institutions fell.
Professionals here worry that we are seeing the same troubling indicators in Ireland: our prison population has been growing over recent years – along with the numbers of homeless – at a time when we are closing down old institutions.
“The danger is that, in many cases, we’re just swapping one institution for another,” says one HSE consultant psychiatrist. It’s a reminder that community care means much more than simply providing housing: it also requires support, rehabilitation and a strong focus on recovering people’s shattered sense of self.
About 3,000 former long-stay inpatients now live in State-funded group homes, of which there are about 300 in Ireland. A report for the Mental Health Commission found the climate and culture of many of these residences “reflected those of a ‘mini-institution’ rather than a home-like environment, especially in the high-support residences”.
As a result, it found many didn’t work towards independent living in the community in any real sense. In addition, community mental-health services are supposed to offer patients – or service users – access to a broad range of treatment to give them the best chance of recovery.
But the Inspector for Mental Health Services has found that most people are still offered a more traditional, medicalised version of mental-health treatment rather than the holistic service envisaged in our policies.
Minister of State for Mental Health Kathleen Lynch says services are still being developed, but insists the jigsaw pieces for effective community-based services are being put in place. “We hope to have all the [multidisciplinary] teams in place soon. We’re hiring hundreds of additional posts . . . We’re going to focus more on enhanced rehabilitation and different types of services. We don’t have everything we want, but we’re a long way down the road.”
Pilot “deinstitutionalisation” projects are under way across number of HSE regions which are trying new ways of supporting patients in the community. In addition, local and regional bottom-up initiatives are providing high-quality community services, driven by local leadership.
Slí Eile, near Charleville, in Co Cork, is one of them. Once a stately mansion, it is now the setting for a therapeutic community residence for up to eight former psychiatric patients.
“We are not caring for people here, but we care about them,” says Joan Hamilton, who founded the centre. “It’s supported living, so it’s a stepping stone to something more permanent.”
Her search for an alternative model of recovery came from seeing the lack of support available for her daughter. Slí Eile’s aims are simple: help residents to believe in their own potential, develop the skills to manage their mental illness and, in time, create a transition to a more independent form of living.
All the residents play a role in running the house, such as cooking, cleaning and managing household budgets, as well as running a bakery, which sells bread and scones to local shops. It has had remarkable successes over the past few years, with residents who once seemed destined to languish in the psychiatric services progressing to living on their own in social housing.
“This isn’t rocket science,” says Hamilton. “It’s what people want. It gives people a sense of structure and purpose, a reason to get up in the morning, in an atmosphere where they feel safe and accepted. It’s all about making choices.”
Mags returned to give the community residence another go.
“I couldn’t settle down at first. I was going around at the start, bringing my handbag everywhere. I was afraid my cigarettes or money would be stolen,” she says.
“I found it hard: I was going to bed during the day, I’d sleep anywhere because I’m so used to it . . . I’d sleep on the chair here. I just felt mentally drained and exhausted . . . But that went. I began to like it here.”
She started seeing a counsellor. She began to steadily lower her levels of medication, with the advice of a psychiatrist.
She discovered health problems she wasn’t aware she had: diabetes, emphysema and liver problems, linked to her life on the streets. There were also internal injuries she had suffered from assaults.
Recovery is still a step-by-step process. There have been slip-ups along the way. But, for the first time in a long time, Mags feels she’s heading in the right direction and is hopeful about the future.
“I cry a lot in my room. I think of the past. I lost a lot of friends. I had sixteen friends – only two of us are alive. Overdoses, suicides. I was only young. I’ve seen too much. I grew up too fast,” she says.
Studies suggest that between a third and half of homeless people in Ireland have a diagnosed mental health condition. But a lack of specialised community-based services means many end up ricocheting in and out of homeless shelters, emergency accommodation and the street.
Mags is fortunate to be able access to the kind of community support she needs.
“I never thought I’d last this long . . . I still feel panic over the smallest things. I was so used to being beaten, mugged, or sleeping in a homeless shelter with 50 others. But these days. I can turn off the light and be safe.”
For an interactive narrative version of this story see aftertheasylum.com
Photographs by Bryan O’Brien