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.