Psychiatrist Brendan Kelly’s latest book takes us back in time and behind the walls of what he calls “Ireland’s awkward institutions”, the nationwide network of large, looming and secular structures that emerged to house “lunatics” in the 19th century and closed in the latter half of the 20th to make way for “mental health units”.
Fascinatingly, this transition was catalysed by an influential 1966 governmental commission, which found Ireland’s asylums unwieldy and unfit for purpose, despite providing the most per capita psychiatric beds in the world. Among other things, the commission called for “adequately staffed and equipped” units. The 21st century mental health commissions – much in the news recently – consistently draw attention to our understaffed and underequipped mental health units, and our paltry number of psychiatric inpatient beds. Will the pendulum swing back? Have we learned nothing? In closing the asylums, have we withheld asylum?
Interesting questions, but not one this book sets out to answer. This is a social history that focuses on Grangegorman asylum, and uses case histories from its archives to centre the narrative around the individuals who worked and resided there.
It doesn’t take long to appreciate the appeal of Kelly’s new approach, whose previous works occasionally laboured under the weight of his academic and archival zeal (flashes of this problem recur in Asylum, but rarely). Early on, we read a letter from Jane in England to her sister Mary in Grangegorman. Mary, 31, is a married mother of a three year old. The letter starts promisingly – “My Dear Sister” – then swerves quickly – “I hear from the doctor that you cannot live long.” A blunter age. Mary, it transpires, having spent 10 years “in poverty” lived the last three years of her short life in Grangegorman. She was admitted with post-partum psychosis and eventually contracted tuberculosis. Jane’s conclusion is grim: “Hoping you will have a happy death, if you are not already reaping the reward of all your suffering here.” The fact that hospital staff withheld the letter, in the prevailing spirit of paternalism, is even grimmer.
The questions Kelly is interested in addressing are simpler: “How did she end up there? Why? What was her life like?” The answers, however, are anything but. . On the one hand, Kelly considers those who “founded, funded and ran the asylums” and concludes they were “fundamentally altruistic”. His admiration for innovative psychiatrists, such as William Hallaran in Cork and Connolly Norman in Grangegorman, is palpable. But on the other hand, he states matter-of-factly that Mary’s fate was not uncommon: “Lengthy institutionalisation, persistent symptoms, and death inside the asylum walls. Once a person was detained in an Irish asylum for more than five years, it was almost inevitable that they would die there.”
He doesn’t just state this fact, he repeats it, using a different case history to make a variation of the same point. The point, in essence, is that for all their fundamental altruism, asylum staff were largely helpless and often hapless in their efforts to treat enduring mental illnesses – be that with “moral management” and padded rooms, or insulin comas and frontal lobotomies.
Grangegorman saw and tried it all, and all this “therapeutic enthusiasm” did little to alleviate the sustained distress. This was evident to practitioners of the era, with Dr Norman conceding, “the pathology of insanity is at present in a very obscure condition”. Moreover, and just as troubling, was the preponderance of admissions for social reasons, often “trans-institutionalised” from prisons, workhouses and general hospitals. (This too will sound familiar to anyone interested in contemporary mental health issues.)
A keen sense of curiosity permeates all of Kelly’s books. It is an infectious and endearing trait, which spurs his research as well as the reader on, and his writing is nimble and confident. In reading Asylum, I felt a growing sense of unease at the catalogue of brief but rather unrelentingly bleak cases: Martin, who “never stood a chance”; Michael, who died after 14 years in the asylum with “no record of ... receiving any treatment”; Eliza, a “good, if disturbing example” of someone forcibly fed. The list goes on.
Perhaps such unease is the point, the lasting answer to the question of our awkward asylum history. Perhaps the repetition is intentional, arriving like waves of nausea, a haunting for a society “toxically obsessed with [institutional] incarceration” and with a peculiar propensity for treating mental health difficulties with a “mix of help and harm, caring and abandonment” that continues to this day.
Those who do not learn history are doomed to repeat it, the aphorism goes. As a psychiatrist working in Child and Adolescent Mental Health Services, I can’t help but wonder: will we ever learn?