The Gazette 1981

SEPTEMBER 1981

GAZETTE

based approach, the range of treatment functions which previously were practised in the restricted setting of a mental hospital are reorganised around population sectors of 1 0 0 , 0 00 people. Each such area is served by a multi- disciplinary psychiatric team operating from a comprehensive range of facilities in their area which, in their totality, provide a more effective range of treatment services. These include small in-patient units to cater for acute, medium and longer-stay patients, together with a full range of residential and day-care facilities such as day-hospital, day-treatment centres, group homes, sheltered workshops and rehabilitation services. And here perhaps the truth of Donne's insight is relevant. The kind of society that it would have taken voluntarily, by political and social will, to meet the entitlements and rights of the mentally disabled would, by definition, have been a more open minded and truly liberal society which, whilst pursuing economic prosperity, would at the same time have promoted and fostered the development of other humanitarian values to enhance personal worth, happiness and fulfilment. It will be evident that all I have described up to now is the ideal that ought to exist where the rights of the mentally disabled are met by a State which is willing to recognise and undertake its responsibilities on behalf of a society whose value systems encourage it to do so. A s such, it constitutes an ultimate objective to be obtained in the development of a psychiatric service, in the promotion of the rights of the mentally disabled and in the development of a better society. It also constitutes a yardstick against which to measure the existing position for the mentally disabled; to realise the inadequacy of the treatment services currently available to them; to appreciate the refusal by the State either to recognise or honour its obligations to the mentally disabled and to appreciate the apparent indifference with which society excludes them from its conscious awareness. The reality of the position in which the mentally disabled find themselves is quite at variance with their rights; it is disturbing and damaging, not just to them, but to the very structures of society itself. The Mental Hospital Scandal There are between thirteen and fourteen thousand people who are inmates of our mental hospitals. The magnitude of this can be understood better when it is realised that this is the population equivalent of a good-sized Irish town and comprises several times the total prison population in the country. By international standards, it represents an exceptionally high proportion of people hospitalised for mental illness. Usually taken to indicate a high national rate of mental illness, in fact this figure represents the result of a total reliance on, and overuse of, mental hospital beds because of the lack of alternative community-based residential and treatment facilities outside the mental hospital. The thirty six mental hospitals scattered throughout the country are, for the most part, grim, forbidding institutions which have a profoundly depressing effect on the casual visitor. It is in such prison-like institutions that we, as a society, have locked away and forgotten people whole sole transgression is that they suffer from an illness which is better dealt with in alternative facilities. Many

are mentally handicapped. Many more are infirm, elderly persons, guilty of little more than reaching old age in a social order in which, because there are not adequate support services available and because their families lack the resources to help them endure a natural condition with dignity, they are incarcerated in the only space available and in conditions never designed for them. With such a policy of disposal and containment in operation, the radical criticism both within and without psychiatry that society in this country is using the mental hospital as a "human garbage pail" has an inescapable ring of truth. T o make matters worse and in rebuttal of any claim that this policy is at least humanitarian, the institutions which are incorrectly used to contain these people are, with few exceptions, grossly substandard. The physical conditions of the hospitals in which we treat our ment- ally ill are largely those of neglect, deterioration, overcrowding and squalor. Consequently they induce widespread secondary demoralisation and apathy, despite the best endeavours of a caring staff. The very existence of such appalling conditions is a major public scandal. Their quiet acceptance by society and their perpetuation for years by the institutions of central government represents a damning indictment of our failure, in sixty years of national independence, to use our available resources of wealth and manpower to create an equitable social order. The alternative to this, the development of a community-based approach, has already been identified. The reorganisation of treatment services on such a community basis has considerable practical advantages over the institutional approach. It enables earlier and more therapeutically effective diagnosis of mental illness and related disorders to take place, producing better rehabilitation and reintegration into family, work and community life. It can deal just as effectively with the serious psychiatric disorders which formerly had to be dealt with in the traditional mental hospitals. By its integration and interaction with the community, it is better equipped to respond to the problems generated by the stresses and strains of modern life. These produce a wide range of conditions, such as personal and family stress or breakdown, which show themselves in various indices of social pathology, including high rates of alcoholism and absenteeism, at considerable cost to industry and the exchequer. Ten years ago the estimated cost of implementing a community psychiatric service in the Eastern Region, covering about one third of the national population, was in the region of £ 2 million. The plan was turned down and, in the meantime, little has been done other than to spend the cost of the alternative community service many times over in trying, un s u c c e s s f u l l y, to maintain antiquated and decaying institutions whilst the cost and need for the alternative service continues to grow. Nevertheless, the development of a modern community psychiatric service is not particularly expensive in the context of present day health services. A once-off capital investment of s ome £ 3 0 million, spread over three years, would provide such a comprehensive service in the Eastern Region. This compares favourably with an estimated expenditure in the same Region over a like period of some £ 1 5 0 million for four new general hospitals and a third new medical school. In other words, the cost of providing a total comprehensive psychiatric

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