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GAZETTE
SEPTEMBER 1981
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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