Michelle doesn’t remember when she first heard them.
Even as a child the voices always seemed to be in the background. They felt comforting. Reassuring. They were more like imaginary friends, telling her stories or helping to direct her through life.
"I saw them as a childhood thing. In a lot of ways, they kind of protected me," Michelle Dalton says. They could be be funny, making her laugh out loud, or give a helping hand by alerting her to danger.
But by her early teens the voices had changed. They were turning angry. They seemed to take a hatchet to almost everything she did, criticising her decisions and wrecking her self-esteem. The most destructive of all them all was the voice she called “the butcher”.
“It tried to butcher anything I’ve ever tried to do,” she says. “It would say the most awful things imaginable . . . it would speak very clearly, very directly. This wasn’t my own thoughts or inner voice – this was a distinctly different voice.”
Sometimes the voices were so loud and venomous it felt like being in a room full of angry people roaring abuse from all sides. It led to her first breakdown at the age of about 14.
“I was in a cafe in Bandon. I was with friends, but it was like I couldn’t see or hear anybody outside of me. All I could feel was what was inside me. I was like a volcano erupting,” she says.
“I stormed out, practically lifted the table and threw it on the ground. People were chasing me, trying to calm me down, but my perception was completely abnormal. It was like the most chaotic form of self-destructive energy a person could feel – it drove me to want to smash my head off concrete,” she says.
Gardaí arrived on the scene. Her friend made up a story, saying she had just broken up with her boyfriend. No one knew what had happened.
Michelle felt too ashamed to say anything about voices in her head. "I didn't want to be called crazy," she says. "I didn't want that."
Establishing your independence, navigating your way through adulthood and making critical life decisions is no easy feat. Almost a third of young people say they have experienced mental distress in one form or another, according to research by the youth mental health group Headstrong.
For some, it's tougher still: more than a fifth of young adults have engaged in self-harm and 7 per cent reported a suicide attempt. Dr Barbara Dooley, Headstrong's director of research and senior lecturer at UCD school of psychology, says the figures underline the urgency of providing services to these young people.
“We must see youth mental health as a national priority. There is no health without mental health,” she said at the launch of a recent report.
With mental health and education budgets under strain there is increasing concern at the consequences for child and adolescent support services. The campaign group Mental Heath Reform points to a number of worrying indicators.
Despite significant progress in recent years – such as the development of adolescent inpatient units – waiting times for adolescent mental health services are on the rise.
At the end of 2012, there were 338 children and adolescents waiting for more than a year for their first appointment. The HSE’s target for 2012 had been to bring this waiting list down to zero.
For young people with more severe mental health problems, services are still far from ideal. Last year 106 children and adolescents were admitted to adult psychiatric units, despite concerns expressed by the Mental Health Commission that the practice is "inexcusable and counter-therapeutic".
Staffing shortfalls also exist within child and adolescent mental health services and are about half the levels recommended in the Government’s official policy. For professionals such as Dr Dooley, there should be no excuse for substandard services given what we know about the importance and effectiveness of early intervention in the lives of children with mental health problems.
“We have never had access to such rich information that enables us to identify critical protective factors that help young people to resolve the challenges they face, and also the risk factors that compound their distress,” she said.
Growing up, Michelle lived much of life in her own head.
"I grew up in Ballincollig and there was drugs, crime, people you couldn't trust. I was extremely introverted as a kid. I remember I didn't want to play with other kids . . . I was living in my imagination. My reality was nearly an unreality. I created this inner reality because my reality wasn't so good."
The voices, she feels, were part of that. She lived with them for years, but it was only in her late teens – as they grew increasingly aggressive – that she realised she needed help.
“I didn’t tell anyone about them. I felt guilty . . . I didn’t want to cause my parents trouble or cause upset.”
At the age of 17 she met a consultant psychiatrist attached to Cork’s South Lee mental heath services who listened to her. It was this psychiatrist’s intervention that helped her finally understand what she was experiencing.
After the summer of her Leaving Cert, Michelle was making great strides. The voices had disappeared. She was looking forward to the next chapter of her life.
“I had the best summer. I was partying, I’d just turned 18. It was Jäger-bombs all the way, like. Everything was great. I felt, ‘Wow, I’ve been misdiagnosed’. I even bought the psychiatrist a present as if to say, ‘Nice to know you, I won’t be seeing you again.’ ”
Then came a fall. A week later the voices returned. This time, they were more intense than ever, giving her direct instructions on how to take her own life. "They were saying, 'Pack your bags, don't tell your parents, go to Galway, don't take your phone with you.' "
The psychiatrist advised that an inpatient admission to the psychiatric hospital was necessary for her own safety. Michelle felt struck with terror as she was shown to her room. “I had finished my Leaving Cert. I remember thinking, ‘I’m 18, my friends are in college and I’m in a room with a woman who stares out the window all day,’ ” she says.
Though the inpatient unit was terrifying initially, her road to recovery began there. Getting to know other psychiatric patients changed her view of mental ill-health forever and made her reassess her own condition.
“I went in with the Hollywood idea: these are people with shaved heads, faeces, all those horrific things the media portrays . . . then I found out that some of those patients were the most beautiful, honest, brave people.”
“In the outside world, people hide their emotions. They try to put on a party face. But in there it was honest. There was a real empathy there between people. You didn’t have to apologise for not talking or for feeling depressed. There was a normality of madness.” She ended up being hospitalised on more than a dozen occasions.
What helped spark her recovery, she says, was learning more about herself, making connections between the voices and her life, and not being so hard on herself. “I could see that some great artists were considered ‘mad’ and that was a real turning point. My idea of what crazy people were like was all wrong.”
Michelle also says she gained insight into the role of medication, and how real long-term recovery – in her experience – lay within herself. “The drugs seemed like a band-aid to cover the distress. At the end of the day, anxiety or extreme states of emotion have deep roots, and medication can’t get to the core of the problem.
“Drugs have a role, I think. But recovery depends on community support: having a network of friends and family. Psychotherapy also has a big role for me, looking at your self and drawing on your inner resources . . . but many people don’t have those choices.”
The field of mental health is facing growing questions over the use of medication and the manner is which mental disorders are diagnosed.
Over the past five years, prescriptions for antidepressants, benzodiazepines and sleeping pills on the medical-card scheme increased by more than 25 per cent.
Critics – including patients’ groups and some high-profile psychiatrists – say fresh scrutiny of scientific literature suggests the benefits of many medications have been exaggerated and that in the long term they might even exacerbate a person’s illness.
Further, they say, the medicalisation of “common distress” is serving only the interests of drug companies, which don’t care who is prescribed antidepressants as long as they are prescribed in great quantities.
It’s a challenge hotly disputed by representative groups for the psychiatric profession, who see mental disorders mostly as diseases of the brain that can be treated effectively with medication, along with other therapy. They argue that critics make too much out of often minor technical matters and then ignore an overwhelming body of data supporting the effectiveness of medication.
This debate over medication and how best to treat mental health problems comes at a time when the voices of patients and advocates, especially those critical of the system, are growing louder.
Groups such as Mind Freedom Ireland, Mad Pride and many others are rejecting the labels and language of psychiatry, which views mental ill-health as a biomedical problem.
Instead, these organisations tend to see mental health problems as forms of emotional distress or an underlying vulnerability, and are demanding a much greater emphasis on choice and on being involved in their route to recovery.
For people such as Dr Terry Lynch, a Limerick-based GP and psychotherapist, the debate on how best to treat mental health problems needs to focus more on developing a genuinely recovery-orientated approach.
While he says he is not “anti-medication or anti-psychiatry”, he says the process of recovery requires therapy and time.
“The mental health system doesn’t sufficiently understand the emotional and psychological aspects of mental health problems, nor the importance of exploring in detail the individual’s experiences, whatever they may be.”
Today Michelle is 24. She's an accomplished artist and concert curator.
She rents her own home on the outskirts of Bandon, in Co Cork, along with Hendrix, her dog, and cat, Lizbeth. The walls of the house are adorned with her paintings. Michelle still has a fantasy world. She hears voices from time to time. They're not bad or critical. They can, instead, be teachers for dealing with issues in her life.
Until very recently she was using her experiences to help others in the Hearing Voices Network, a support group for people who hear "auditory hallucinations".
She feels proud that she has turned some very negative experiences into something very positive.
The other day she wrote the following in her journal:
Today, I am thankful to myself for building such a great life. I have more wealth than most people do and it had nothing to do with printed paper.
It captures, Michelle says, how she feels these days.
“It’s not sappy, it’s quite fierce . . . I like my reality now. And I’m quite proud that I’ve managed to create this great life for myself.”