IN THE 1800S and 1900s, there was an epidemic of asylums in Ireland – at one point, 20,000 people were in the institutions being treated for mental illness.
But according to the first published history of psychiatry in Ireland, there was not an epidemic of mental illness in the country during that time. Instead, a number of social, political and other factors combined to lead to such a high number of people being admitted.
The sheer number of people in the institutions meant that ill-treatment was rife, and their roots in the prison system meant that some patients were left chained up for months on end.
The author of the book on the topic, Hearing Voices: The History of Psychiatry in Ireland, is Brendan Kelly, Professor of Psychiatry at Trinity College Dublin. He looks back at psychiatry in Ireland from the earliest times to the present day, showing how it reflected the social changes in the country – and busting the myth that Irish people are more prone to mental illness than other people.
“This is a very popular myth,” Kelly told TheJournal.ie, adding that he is contacted regularly by journalists – particularly American journalists – about this topic.
His book details how there was a vast web of large asylums in Ireland, in locations like Enniscorthy, Letterkenny, Mullingar, and Dublin, which provided employment for these areas – and places for families to send relations. It also shows how the psychiatric profession has evolved in the past century, and how legislation has changed to benefit the patient.
“Recent years have seen great exploration of Irish institutions of various sorts, for example Magdalene laundries and industrial schools, but I felt less attention had been devoted to the mental hospitals or asylums,” said Kelly of his motivation behind writing the book.
They were very big and they were very interesting – one of the most interesting aspects of it was the Roman Catholic Church was not involved. All it did was it supplied chaplains, but so did the Church of Ireland.
Despite what people might assume, the Catholic Church never really got into mental healthcare, discovered Kelly. “The church is far from blameless in many other areas but in this area these were entirely secular government-run institutions. So it challenges some of the received narrative of Irish history.”
Early asylums developed from prisons, explained Kelly. “Prison workhouses would have lunatic wards or rooms or areas and then they eventually became free-standing asylums,” he explained. “Some of the practices in the asylums came from prisons rather than coming from a healthcare starting point.”
This meant that some patients were chained up, while others were restrained in straitjackets. “The asylum in Limerick was especially bad, where the inmates were chained with their hands under their knees and they weren’t allowed to stand up, so when the inspectors came they found these people were no longer able to stand up and likely would no longer be able to.”
Difficult lives
The first major asylum – the Richmond Asylum, or Grangegorman – opened in 1814. But before this, people with mental illnesses were treated at home, often in quite shocking ways due to a lack of community or government support. People with mental illness could end up living quite difficult and short lives.
Kelly details how mental illness in early Ireland- pre the 1800s – involved myths and folk cures.
This included that the mentally ill could be cured by drinking water from the well at Gleann na nGealt in County Kerry – it was said to contain high levels of lithium, a suggestion which Kelly debunks. However, he notes that biochemical analysis isn’t the best way to examine the therapeutic value of folk cures for mental illness.
“Towards end of 1700s it was very clear there were mentally ill people wandering the streets, sleeping in fields and worst of all getting locked up in various ways,” explained Kelly of the impetus to open asylums.
An inquiry in 1817 revealed that the most common way of treating people that family members had “was they would dig a pit in the ground of the hut or home, put the mentally ill person in there, put grid or grill across the top and simply feed person in this pit”, said Kelly.
Before we built these asylums there is sometimes a romantic notion the mentally ill were cared for by the community – the butcher gave them meat, the baker gave them bread and a farmer gave them a field to sleep in. That never happened. We have always found ways to lock up mentally ill people and the asylums were an effort to do that according to law.
The asylum approach fitted with the newly emerging philanthropic mindset of the 1800s, the belief that those in need could be helped by charity and support.
This impulse was in many ways a good one, said Kelly – but “within decades the asylums were too full, too big and grossly anti-therapeutic”. What had started as a way to help people ended up damaging some of them.
The level of poverty and the impact of the Famine in Ireland meant that in the 1800s the pressure on asylum beds was “extraordinary from the word ‘go’”, said Kelly.
The Dangerous Lunatic Act of 1838 also meant that someone could be committed to an asylum without medical opinion. It wasn’t necessary to have a medical certificate in order for magistrates to commit someone to an asylum. All that was needed was their opinon that someone was likely to commit an offence.
This led to families and communities beginning to use asylums in very specific ways, explained Kelly – “to remove mentally ill [people] or [people with an] intellectually disability or generally unwanted people from the family home”.
Some families even took part in ‘wintering in’, where they would drop a person into the asylum at the start of the winter and leave them there until they needed them back on the farm during the summer.
You had families and communities using asylums in really quite subtle ways according to their family needs – this wasn’t right obviously.
In his research, Kelly came across archived letters from asylum doctors asking people to bring family members home.
“I am really not blaming families,” said Kelly, given that many were poor and dealing with emigration and disease.
“The State offered them no solution or support other than the asylum.”
Reflecting society
The changes within asylums were also reflections of changes in wider Irish society.
“Psychiatry has always reflected changes in society far more than any area of medicine or indeed any other area of social care,” said Kelly.
In 1907 at the Richmond asylum, one third of all admissions were directly from the workhouse across the road.
“Then in 2007 up in the Mater: I was working there at the time, and one third of psychiatric assessments in the emergency department were homeless people,” pointed out Kelly.
There are enormous similarities in the way society seeks to use psychiatry and asylums for dealing with the problem of homelessness.
The size of the asylums grew to be a problem by the early 1900s. In an effort to deal with this, and try and improve people’s situations so they could leave, doctors seized on new treatments in psychiatry.
But some of these treatments were very questionable when looked back on.
“Therapeutic enthusiasm is one of the themes of the book – it led to progress and some of the great tragedies in the history of psychiatry,” acknowledged Kelly.
Malaria therapy, for example, involved giving people malaria to cure their mental illness.
It was used for people with advanced syphilis, where syphilis had gotten to their brain (modern treatments mean that today this rarely occurs). Its inventor won the Nobel Prize.
In Ireland, blood had to be brought over from malaria patients in London after mosquitoes shipped here kept dying due to the cold. The patients were then treated with quinine and their mental health symptoms improved.
Insulin coma therapy involved putting people into a coma with insulin a few times in a week, then waking them up again. “Some people died with this treatment,” said Kelly. “Everyone who did it gained enormous amounts of weight, and it was not effective and it was abandoned.”
Lobotomies – where the connections between the two hemispheres of the brain are cut -were also carried out in Ireland
“This is the biggest mistake in the entire history of psychiatry,because it just didn’t work,” said Kelly of lobotomisation.
It is a really disturbing example of how people with really good intentions about clearing out asylums and helping people, how that can go wrong. And how it wasn’t stopped sooner is the frightening thing about lobotomy.
Psychiatry today
Kelly describes asylums as part of the much broader programme of institutionalisation in Ireland, including prisons, laundries and industrial schools. What happened with them has gone on to affect the psychiatric approach in Ireland today.
“The asylums ingrained the idea of institutional psychiatry as in opposed to outpatient care,” he explained. “And this is very interesting because in the 1960s as numbers in asylums fell there was a big reaction against in-patient care, so now today we are in a situation where Ireland’s rate of involuntary psychiatric admission is only half the rate it is in England.”
The pendulum, said Kelly, has swung in the other direction.
At the same time, he noted that families have spoken out about difficulties accessing psychiatric care. However, legislation has improved in this area.
“It should be difficult to get someone deprived of their liberty,” he points out.
“One of the legacies of the history of psychiatry is it has really struggled to shake off this custodial atmosphere or feeling that has been associated with it since the asylums in Ireland,” said Kelly.
There were “endless inquiries” into asylums in the 1800s, but little happened other than prompting another inquiry. This is despite the fact that their findings were usually grim.
The reports eventually led to public reaction to what was going on in the asylums.
“They were grossly unhealthy, having thousands of people in a single building,” said Kelly. Around 12% of all asylum patients died every year in the asylums mainly from infections disease.
“Obviously it’s a very disturbing history in many respects but what struck me most forcefully is how the asylum doctors and psychiatrists so often objected to the size of the asylum, the bad legislation governing them, the ineffective legislation, [but] how they did not produce change.”
In the early 1900s a Dublin psychiatrist named Dr Conolly Norman set up a boarding out scheme in an attempt to help asylum patients leave, but this was blocked by Dublin Castle, said Kelly.
In 1951, Ballinasloe town had a population of 5,600 – of those 2,100 were patients in the asylum.
“Everyone else, they were all either working in the asylum, supplying the asylum or had a family member in the asylum. So when doctors tried to reduce the size of the asylum then local and national politicians blocked it immediately because these were economic powerhouses for towns,” said Kelly.
By the end of the 1950s, the asylum system in Ireland had reached its peak. Irish society was changing, as was the medical approach to mental illness. A “general opening of Irish society and diminished tolerance for institutional solutions” developed, along with a gradual decline of the Catholic Church.
These all contributed to the diminished role of asylums.
Since that time, Kelly says there has been “good progress” in Irish psychiatry, but issues do remain. “We have too many homeless mentally ill people, too many mentally ill people in prison,” he said.
While Irish legislation is focused on the right of the individual to liberty, said Kelly, “families at the moment don’t have hard rights, actual rights in court about reasonable involvement in care and that’s an area we need to work on”.
“It’s very clear we needed to get the person’s right to liberty protected better and we’ve done that,” he said. “We do need to move on to the next thing which is recognising the key role that families and carers play and giving them rights with regards to having more of a say in maybe not the details of treatment, but the overall treatment approach.”
He would be happy to see the use of mental health tribunals by families over decisions not to admit someone to a psychiatric institution or service, and to see “the service being held to account for what it did or what it didn’t do”.
“I would like to see some mechanism whereby family concerns could be taken on board to great degree.”
Overall, though there is work to be done, Kelly’s delving into the history of Irish psychiatry has shown him one major thing: “Mental health services have moved on from past.”
Case study
In 1892, Dora, a 34-year-old single servant from Dublin, was admitted to the Central Criminal Lunatic Asylum (later Central Mental Hospital, Dundrum) charged with the murder of her 8-month-old child. Dora’s previous five children had all died young. The asylum’s case book records that, “some days before the crime, [Dora] suffered from a violent pain in the head.
She felt as if the top of her head was splitting open… On the morning of the crime, she took the child in her arms and left the house. She wandered off some distance from home, did not know where she was or what she was doing. She imagined that she was followed by a large crowd of soldiers and people”.
Diagnosed with “melancholia” and “delusions of infestations”, Dora actually had a brain tumour.
Dora spent 14 years in the Dundrum, before being sent (for the rest of her life) to the Richmond Asylum in Grangegorman, at which point she was “miserable and demented, never speaks, takes no interest in anything and stands about in a semi-dazed condition.”
Hearing Voices: The History of Psychiatry in Ireland is published by Irish Academic Press.
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