‘It’s an ethical challenge, choosing which prisoners we can take’

I always wanted to be a doctor, and after medical school at University College Dublin and the Mater hospital, I went to London to do postgraduate studies in respiratory medicine. Following careers advice from the psychiatrist Robin Murray at the Institute of Psychiatry and the Maudsley Hospital, I switched to psychiatry.

I have been the clinical director of the forensic mental health services at the Central Mental Hospital since 2000. I have always been interested in medicine as an art, as well as a science. There is a neglected scientific side to psychiatry and in all areas of medicine, particularly psychiatry, the humanities can inform and embellish the picture. Many of our patients struggle to do the basics in terms of looking after themselves, yet they can get huge satisfaction from artistic expression and other forms of self-expression. My work is also informed by fiction because novelists are better able to say things about how the mind works.

The patients

The patients we have at the Central Mental Hospital suffer from severe, enduring and disabling mental illness and have come to us because they have had contact with the criminal justice system. They are here instead of in prison because they have carried out serious acts of violence. Most of them have schizophrenia and similar diseases such as bipolar disorder. Some of them have an intellectual disability as well. There is an alarmingly high likelihood that a young man with schizophrenia will spend some time in prison.

The typical patient is male, in his late 20s or early 30s, has had schizophrenia for about eight years, and stopped taking medication. He has become lost to follow-up in the community mental health teams and he has killed one of his parents.

There are two forms of violence: expressive violence, which is impulsive, explosive or a product of confusion, delusions or hallucinations; and deliberative or instrumental violence, which is carried out to achieve a goal. The majority of people with expressive violence are unwell, and a small percentage are well but choose not to moderate their behaviour. Most people with deliberative violence are perfectly well.

We have a very high staff-to-patient ratio: two nurses for every patient over a 24-hour period, 365 days a year. I am one of eight consultant psychiatrists working in this hospital and in the equivalent of community clinics in all prisons except Limerick and Cork. The number of people with schizophrenia is rising all the time. Ten years ago, 3 per cent of the prison population had a severe, enduring and disabling mental illness such as schizophrenia; now it’s 7 to 8 per cent of the prison population.

There is no simple answer to why this is happening but one reason is due to the rise in voluntarism in that people choose not to take their medication and they lack the ability to understand their illness and their own needs.

There is also an unanticipated consequence of reforms such as the move to the community model and individual rights: these were good in principle, but fail to respond to people who lack capacity to make decisions in their own best interests. The people with severe mental illnesses are the losers in the move away from asylums towards the concept of mental health. What we’ve got instead is a lot of counselling – and quality of life interventions – for people who are not seriously mentally ill. There is a cultural denial of mental illness as a result.

Serious violence

One-fifth of our patients come from an acute psychiatry unit: they are admitted under the Mental Health Act because they have done something seriously violent but have not been charged for it. We have 94 beds for men and 10 for women.

There is a huge list of prisoners waiting to come into the Central Mental Hospital. It’s an ethical challenge, choosing who we can take. We must choose based on who is at risk of harming themselves or others above those who are so tormented by voices telling them to do things that they would require involuntary treatment to relieve their suffering.

As medical director, I spend most of my time supporting my colleagues in their work – both formally and on an ad hoc basis, which is the most important part. In forensic psychiatry, we have the time to get to know our patients very well.

Our job is to provide a safe, caring, therapeutic environment for people who are such a danger to those in their immediate environment. Every day, that’s what is done here. It’s quite exacting and quite special. Safe, therapeutic and humane hospital care followed by structured community care will always be needed for the most severely disturbed and challenging who are mentally incapacitated and mentally disabled. We have a six-bed intensive care unit for high-risk patients. If they are found to be not guilty by reason of insanity, they will spend a very long time with us. Patients move from the highly intensive admission unit to a medium secure unit where they receive psychological and psycho-educational interventions, occupational therapy and rehabilitation. It can take seven to nine years to proceed through our five pillars of care. These address their physical health needs, mental health needs (understanding health and how to stay well), drugs and alcohol problems, problematic behaviours (anger management, how to build healthy relationships) and activities of daily living (social, occupational and educational).

By the time they have worked through these programmes – with six-monthly assessments – they enter a pre-discharge programme and are then conditionally discharged back into the community. The conditions are that they stay well, stay safe, stay on their medication and abstain from substances. The safest way to manage forensic patients in the community is to attach conditions to their discharge, and the biggest obstacle to conditional discharge is legal challenges. It would be really helpful if psychiatrists had more input into the training of judges at all levels.

Growth of trust

The most important measure of progress is the growth of trust between the clinician and the patient. Apart from supporting my colleagues, I spend one day a week seeing outpatients in the community. This can mean travelling to any part of Ireland and sometimes to the UK. I also chair meetings about admissions, risk management, transfers and discharge, and research and ethics.

I spend time with our trainees who are reflective about their practice and choose to do research. And, as a clinical professor in forensic psychiatry at Trinity College Dublin, I give postgraduate tutorials about the work we do here. I love my work and I have a team of psychologists, social workers and nurses who are all highly committed and who view their work as a vocation. I do feel a sense of responsibility for all those who work in the service.

There are real risks to the safety of patients and their carers and we have physical injuries every year.

Over the past two years, I also spend two days a week working with the design team for the new hospital, which will be built in Portrane by 2018.

This building we are in has been condemned repeatedly since the 1990s as unsuitable for modern practice and impossible to maintain. This new hospital will represent the single greatest advance in living conditions for our patients that can be imagined.

Next to it will be the first forensic child and adolescent mental health secure unit in Ireland.