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.
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.