It feels sometimes as if he wasn't there at all. It's as if he was a spectator watching scenes in a movie of his life, played by an actor. Here's one: Rory Doody in the kitchen of his home. His eyes are tormented. He has a knife and he's cutting himself to let the pain escape. Now, five gardaí have arrived in stab vests, to take him away to the locked ward of the psychiatric hospital.
“I could hear voices in my head,” he says. “But I couldn’t differentiate them with the reality around me. They were exceptionally overpowering . . . I was feeling enormous pressure from events that didn’t exist. I wanted to escape. I didn’t want to feel like that anymore.”
Looking back, he says he tried to cope in different ways. He recalls getting up at about 4.30am one morning, going downstairs and making tea for six people.
“There weren’t six people coming for tea,” he says. “There were six voices in my head.” Another time the din of conversation was so loud in the back of the car that he pulled over and ordered the voices to leave.
“When I look back to those days, I see that I couldn’t cope,” he says. “I couldn’t differentiate what was going on in my head with the reality around me.”
Doody lost count of the number of times he was admitted to various institutions or hospitals over a 20-year period. But what he remembers with startling clarity is the sense of fear, shame and loss of dignity that followed being hospitalised.
It felt as if the system had given him a life sentence. He was told he would never have a full-time job, that he shouldn’t get married or ever have children.
“When I cut myself, it was a way of letting the pain out, but no one seemed to ask me that. I was sick, undoubtedly. But there was a lack of a connect between what I was doing and the response to it . . .
“A lot of things got lost during those admissions. There was a loss of self-confidence, trust and dignity . . . I felt isolated and alone, never knowing if I’d get through what I felt I was going through . . . it was just an incredible feeling of not knowing.”
There are many people who carry hurt and suffering from past experiences in asylums or psychiatric hospitals
The old granite and red-brick buildings are closing. But shutting the door on a culture which often ignored the voice of patients isn't necessarily as easy.
"While many improvements have been made in recent years, the need for a more humane, person-focused service is still the consistent message from the many people we consult across the country," says Orla Barry, director of the campaign group Mental Health Reform.
“Although many people have positive experiences of mental healthcare, we regularly hear about those who feel they cannot get their voice heard within mental health services and are not given the choices they should have over their treatment.”
Groups such as the Critical Voices Network and Mind Freedom – which includes many service users – say many people still feel marginalised and have little meaningful say in their own care.
Surveys by the National Service Users’ Executive – a group established by the HSE to give patients a stronger voice – indicates that an increasing number of patients are happy with services. But significant numbers feel they don’t receive sufficient information about the medication they’re given, while there is also frustration that communication with doctors is too often “one-way”.
The government's mental health policy, A Vision for Change, published in 2006, was to be implemented by 2016. It envisaged a departure from overly-medicalised, hospital-based services to modern, multidisciplinary, recovery-focused and community-based mental health services.
Now, seven years into the policy, it remains an unfulfilled promise. Staff are being recruited and progressive projects are flourishing in parts of the country. But mental health services are still staffed at at least a quarter below the level recommended in the policy.
There is a gnawing frustration among psychiatrists and other professionals who want to play a greater role in promoting recovery and working with patients in the community.
“There has been an active dismantling of community mental health services and specialist rehabilitation and recovery services,” says a spokeswoman for the College of Psychiatrists of Ireland.
“Last year we saw mental health professionals taken back into acute services from the community and rehabilitation and recovery specialists posts just terminated. Teams are under constant pressure due to cuts, which ultimately affect the quality of support and care patients and their families receive.”
The HSE, however, says it is appointing hundreds of staff this year to staff up community mental teams as part of a €35 million investment. Officials say this reorientation of services faces the challenges of a dwindling in overall staff numbers in the health services and cuts to annual budgets.
'You can chalk it down to an imaginary friend'
Doody first recalls hearing voices as a youngster. "When I think about it, my parents are mystified over how I could be laughing on my own or talking on my own in the room – you can chalk it down to an imaginary friend, or whatever. It was certainly something that registers in my own mind as more than a little bit odd."
As he grew older, the pressure inside his head would build up and up. Unable to talk to anyone about it, he’d end up burying himself in drink to numb the pain.
Other times he would bang the wall so hard he cracked bones in his hand. “I know it sounds a bit much, but it was that severe physical pain,” he says. “I loved it. It was better than the mental pain, and I would feel good for a short while. It’s terrible, really.”
He doesn’t remember all that much about the hospitalisations. He recalls more about the struggle to return to community and society. He calls the process “re-entry”.
“Anytime I’ve ever left a hospital or had a breakdown, there’s a point where I’ve come to; where I’ve come back and felt my two feet underneath me again. I come back to the world we live in . . .
“It was something that was always slow for me. I’d struggle with simple things like wanting to shower, wanting to put on fresh socks, wanting to clean my teeth . . . and then trying to answer the phone and hearing the voice on it, knowing it’s a real voice; or getting into the car and driving to town.
“Or calling your parents and telling them how you are. They felt like massive events which were hugely difficult.”
The road to recovery only came into view after a number of crucial turning points.
One of them was when his consultant psychiatrist admitted he didn’t have all the answers. Instead, the consultant admitted, they would need to work together to figure a way out of his distress.
Another was a close friend who would ask Doody: what are you going to do? Through a combination of dealing with issues in his own life and working on his own mental health, he began to make real strides towards recovery.
“My wife Martina likens it to a light-bulb. After five years, she says, someone turned on a light switch; five years later, someone turned up the dimmer,” Doody says. “It was the start of a journey of empowerment . . . I had handed over my life and will to the institutions of doctors, psychiatrists, nurses. I did it willingly . . . But I began to realise there were choices I could make. I didn’t have to leave it up to others.”
'The concept of recovery is well understood but implementation remains uneven'
Traditionally, Ireland's response to mental health needs has been almost exclusively medical, with decision-making power focused in the hands of psychiatrists.
The recovery ethos – the idea that mental health services are designed to assist in a person's recovery rather than simply to "manage" their illness – is central to A Vision for Change. It involves rebalancing decision-making power and ensuring patients play a much greater role in their care.
However, the Mental Health Commission says there are "serious deficiencies" in the development and provision of recovery-oriented mental health services.
“The concept of recovery is now well understood but implementation of it remains uneven,” it found in a recent report. “Such a service requires an additional multi-disciplinary approach involving psychologists, social workers, occupational therapists and others.
“However, service delivery is still largely provided by medical, psychiatric and mental health nursing staff.”
Although individual care plans for patients are now a legal requirement, the Inspector for Mental Health Services, Dr Patrick Devitt, recently found that only half of services were complying with their obligations.
“Safe, high-quality care can only be given if there is a clear, individual care plan for each service user, recognising and addressing their individual needs,” according to Devitt.
“It is disappointing that the level of compliance with this requirement fell from 62 per cent in 2011 to 52 per cent in 2012.”
Consultant psychiatrist Dr Pat Bracken says his profession needs to change. He says psychiatrists still have huge powers – and responsibilities – under the terms of the Mental Health Act. A psychiatrist has the power to determine what treatment will be used, how it will be used and its duration.
It is also within the psychiatrist’s power to decide what risks to the patient’s health will be tolerated. They can even order electroconvulsive therapy if the patient or their family refuses it.
“The powers invested in psychiatry are a legacy of the asylum era and can no longer be justified on scientific or moral grounds,” he wrote, recently.
He argues that the ongoing review of the Mental Health Act offers an opportunity to rethink the ways the profession deals with risk.
More and more research points to the fact that people who recover from serious mental health problems place a major emphasis on things such as relationships, meaning, purpose in life – issues that were often forgotten about in our medical model.
Much of the profession is embracing change. Service users are now routinely consulted by authorities.
There are encouraging developments in the form of HSE initiatives aimed at embedding the recovery ethos across mental health services. But patient groups still, by and large, feel frustrated at what they see as a slow pace of change.
'I have bad days, like anyone else. But it doesn't have to turn into a psychotic breakdown'
Today Rory Doody is happily married with four children, aged between four and 10, and has a bright, airy home on the outskirts of Bantry in west Cork.
“I’m very comfortable with myself, with my person,” he says. “I can still hear voices. I still have crises with my mental health. I have bad days, like anyone else. But it doesn’t have to turn into a psychotic breakdown . . . Now, I can engage with my mental health as part of the jigsaw that makes up all of me.”
Looking back, he feels some of his issues stem from handing over too much of himself to others.
“I always wanted to be cared for. That need to be wanted . . . that all stemmed from other stuff.
“Now, I’ve learned to love myself. To respect all of me . . . Like that late 20th-century philosopher L’Oreal puts it, ‘because I’m worth it’,” Doody smiles.
He’s also using his experiences to help others. Doody forms part of what’s known as the “home focus team”, an innovative initiative of the National Learning Network and West Cork Mental Health Services. It involves visiting and supporting people with mental health problems in their own homes.
“Traditional services see the need to fix someone, to get them better and back into their lives,” Doody says. “But recovery work is about being there until a person wants to get better, and facilitating that want.”
The project is being reviewed by academics who say it has significant potential as a way of empowering people in recovery and, ultimately, guiding them into training, education or employment.
“Over the last year and a half I have seen people having an awakening,” he says. “This kind of work is genuinely recovery-oriented. In my own case, I found that nothing really mattered until I wanted to get better myself.”
Doody says the trauma he experienced earlier in his life has changed his perspective on the world.
“I have four children. And I just think there’s nothing wrong with any of them, or any aspect of them. If they’re angry, that’s alright. If they’re quirky and do things in odd ways, that’s alright too. That idea of becoming okay with yourself is every important. I’ve accepted myself. I wouldn’t change anything about me.”