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INTRODUCTION

The history of psychiatry is a history of therapeutic enthusiasm, with all of the triumph and tragedy, hubris and humility that such enthusiasm brings. This book presents this history in the very particular context of Ireland, and tells the story of early psychiatric care, the emergence of Ireland’s remarkable asylum system in the 1800s, its demise in the 1900s, and the development of ‘community care’. It is an extraordinary tale.

What is Psychiatry?

Psychiatry, according to Professor Anthony Clare (1942–2007; Chapter 6), one of the outstanding Irish figures in its history,1 is ‘the branch of medicine that is concerned with the study and treatment of disorders of mental function’.2 More specifically, a medical disorder is a disease or ailment,3 and a mental disorder, according to the World Health Organisation (WHO), is a clinically recognisable group of symptoms or behaviours associated in the majority of cases with distress and with interference with personal functions.4 If personal dysfunction is not present, social deviance or conflict on their own are not sufficient to constitute mental disorder: the person’s mood, thoughts, judgement, relationships or personal function must be disturbed.

Throughout history, the evolution of this concept of ‘mental disorder’ has been, and continues to be, a highly contested process.5 Mental disorders are variously conceptualised as spiritual or religious manifestations, legal conundrums, medical diseases, social issues, or all of the above, with the balance between competing conceptualisations varying over time.6 In recent decades, re-definition and expansion of diagnostic categories within psychiatry have proven especially controversial.7

This book, however, is a history of psychiatry rather than a history of mental disorder, madness, the mentally ill, asylums or even psychiatrists.8 Of necessity, all of these concepts feature strongly in the story, but this book is primarily a history of, to use Clare’s definition, that ‘branch of medicine that is concerned with the study and treatment of disorders of mental function’. It is, quite simply and quite complicatedly, a history of psychiatry in Ireland.

Why Write a History of

Psychiatry in Ireland?

In March 1817, Robert Peel (1788–1850), Chief Secretary, prevailed upon the House of Commons of the United Kingdom of Great Britain and Ireland to set up a Select Committee to look into the need to make greater provision for ‘the lunatic poor in Ireland’.9 The Right Honourable Denis Browne (a Mayo Member of Parliament) gave evidence about the plight of the mentally ill in rural areas of early nineteenth-century Ireland:

There is nothing so shocking as madness in the cabin of the peasant, where the man is out labouring in the fields for his bread, and the care of the woman of the house is scarcely sufficient for the attendance on the children. When a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin not high enough for the person to stand up in, with a crib over it to prevent his getting up, the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies. Of all human calamity, I know of none equal to this, in the country parts of Ireland which I am acquainted with.10

When presented to the Select Committee in 1817, this picture – the mentally ill person kept in a pit until he or she dies – was a searing one and it still retains its power to shock today, some two centuries later. This image and the reaction it evokes highlight the importance of the history of psychiatry in Ireland. Can an examination of this history help us to understand why such a situation was allowed to develop? How did matters change (if at all) following a seemingly endless succession of official reports such as that of the 1817 Select Committee? Did the emergence of psychiatry in the 1800s improve matters? How much of this situation was specific to Ireland and how much was continuous with the broader, international histories of mental disorder, the treatment of the mentally ill by various societies, and the emergence of the profession of psychiatry internationally?

The history of psychiatry in Ireland is located within both the history of Ireland as a country and the broader history of psychiatry internationally. From the international perspective, there are as many versions of the history of psychiatry as there are historians, each presenting varying, often competing narratives about the development of psychiatric practice, psychiatric institutions and psychiatrists. Ireland features in such histories to varying degrees, generally linked with Ireland’s high rates of psychiatric institutionalisation during the 1800s and early 1900s.11 In a dedicated volume, Brennan, in particular, deftly explores Ireland’s high committal rates which substantially outpaced those in England, Wales and Scotland, and by the 1950s resulted in Ireland having the highest rate of psychiatric bed availability internationally.12 Why?

As will become apparent throughout the present book, I am not convinced that core epidemiological rates of mental disorder rose in Ireland during the 1800s or are rising today, or that Ireland has ever had an exceptionally high rate of mental disorder compared to other countries. It is certainly true that there were increased rates of admission to psychiatric institutions throughout the 1800s in various countries, including Ireland, England, France and the United States (US),13 and that Ireland’s rates were especially high at their peak, and particularly slow to decline.14 But Ireland’s increase in committals was influenced by such a broad range of social, political, legal, economic and demographic factors that it is difficult to determine definitively whether or not a true increase in the incidence of mental disorder really occurred. On balance, it is my view that it did not, and this view is explored at various points throughout this book (especially Chapter 3).

Reaching firm conclusions on this point is, admittedly, rendered extremely complex by the fact that diagnostic systems in psychiatry are continually changing, principally owing to psychiatry’s dependence on symptom based diagnosis rather than biological testing. There is, in addition, considerable ambiguity of the numbers of persons with mental disorder who resided outside asylums during the 1800s and 1900s (Chapter 4), and the picture is further clouded by continual changes in legislation and institutional practices in Ireland and elsewhere. Notwithstanding these interpretative complexities, this book does not present a history of psychiatry based on the idea that rates of mental disorder were especially high or truly increasing in Ireland, but rather emphasises the roles of other factors in driving up admission rates.

The Emergence and Roles of

Psychiatric Professionals

Another version of the history of psychiatry which seeks to explain institutional expansionism in Ireland and elsewhere places strong emphasis on the emergence of the psychiatric profession and its proposed role in generating increased committal rates. This narrative is supported by the fact that the complex, evolving psychiatric classification system used by medical superintendents during the 1800s undoubtedly reflected, at least in part, their growing desire for specialization and recognition,15 adding the search for professional prestige to the complex of factors affecting practices over this period.16 Links between doctors’ pay and asylum size in the late 1800s further underline the role of the new professionals in the growth of the asylums (Chapter 3).

This book supports this view to the extent that the emergence of clinical professionals, both medical and nursing, throughout the 1800s and 1900s was inevitably a factor in shaping psychiatric practice in Ireland, as it did elsewhere.17 There is, however, little evidence that the search for professional prestige was the main driver of increased committal rates in Ireland, or that it was unconnected with broader societal concerns driving up admission rates.

In the first instance, the medical and nursing professions were by no means the only or even the main stakeholders in the Irish asylums. In 1951, the town of Ballinasloe in the west of Ireland had a population of 5,596, of whom no fewer than 2,078 were patients in the mental hospital.18 As a result, virtually everyone in the area was a stakeholder in the hospital in one way or other, and there is growing evidence that communities and families were powerful users and shapers of the system, acting in complex and often subtle ways, according to community and family needs.19 Most committals were instigated by hard pressed families, rather than governmental agencies or doctors,20 and it was not uncommon for families to remove relatives from the asylums to work in the summer months and then return them in the winter (‘wintering in’).21 The situation was similar in England, where families used asylums strategically and often with considerable thought.22

Indeed, for much of the nineteenth century, medical opinion was not even required for committal in Ireland, as many admissions were certified by justices of the peace, clergymen or others, and decided by hospital boards or courts. As a result, doctors were frequently obliged to admit, ‘treat’ and attempt to discharge people whom they did not believe to be mentally ill in the first instance.23 There is also evidence that asylum board members used their privileges to facilitate admissions from their own localities, adding further to non-medical factors shaping admission practices.24

Second, while asylums sometimes declined to discharge patients despite family requests, it is also the case that the archives of many asylums are replete with letters from asylum doctors urging families and governmental authorities to cooperate with the discharge of patients, often to little avail. Some families were simply too poor to receive home someone with enduring mental illness or intellectual disability, and argued that that person was better off in the asylum. And when a family could not be found to accept a patient home, the patient might well die in the asylum, confirming asylum doctors’ views that confinement after recovery was actively harmful.25 Some of the stories in this book are moving in the extreme.

Finnane quotes a letter sent to Omagh asylum by a family member in the 1800s, declining the asylum’s request that they take their relative, a patient in the asylum, home: the family member outside the asylum explicitly requested that their relative be let die in the asylum, and that the asylum should only contact them again when the relative died.26 Similar cases are presented by Cox27 and yet more are outlined in Chapter 2 of the present book, as archival case notes demonstrate medical officers at the Central Criminal Lunatic Asylum pleading with the Inspector of Lunatics to permit the release of three brothers who showed signs of physical rather than mental illness; not only did these brothers not need to be in the asylum, the asylum environment was clearly unhealthy – and possibly fatal – for them.28

This issue was again highlighted in the Irish Times in June 2016, which recounted the history of a young man admitted to the asylum in Portrane in 1901, who wrote to his father in 1912 noting that the doctors were keen he be discharged, but that his father refused to accept him home.29 The young man begged his father to take him home, as the doctors recommended, but his father did not or could not yield, and suggested instead that his son should remain in the mental hospital indefinitely. That is precisely what occurred: this unfortunate patient died in the hospital in 1949 and was buried in a little wooden coffin, with no relatives at his funeral. There are two key issues here: the family declining to accept the patient home, and the mental hospital, after robustly trying to send him home, eventually acquiescing with the family’s decision. The doctors were progressive to the extent that they recommended and pressed for discharge, but this was not yet enough: the asylum framework still (in 1912) facilitated long term institutionalisation and, too often, that became the default position. Once again, psychiatry acquiesced to the roles pressed upon it by others (families, judges, the police, and the state in various forms), despite highly progressive voices within psychiatry who sought and worked for change but did not always achieve enough.

There has always been a strong, historiographically neglected progressive tradition within Irish psychiatry, with doctors such as Dr Conolly Norman (1853–1908) at the Richmond Asylum, Dublin in the late 1800s and early 1900s strongly urging alternatives to inpatient care.30 Later analogous figures include Dr Robert McCarthy,31 Dr Dermot Walsh and Professor Ivor Browne, among others.32 The reasons why Norman, for example, did not succeed in his plans for care outside the asylum walls lay not within the medical profession, but within government, which repeatedly frustrated doctors’ efforts to deinstitutionalise, in response to powerful, non-medical vested interests in the asylums. The stigma of mental illness was also relevant: an apparent link between mental illness and danger was indelibly underlined by the Dangerous Lunatic Act 1838 and as long as the asylum stood behind large, grey walls at the edge of the local town, the public felt secure.

Finally, no matter how many doctors, public representatives and other reformers sought to dismantle Ireland’s asylum system, their task was rendered even more difficult by the fact that the asylums also functioned as a vast, unwieldy social welfare system for patients and possibly some staff. In the absence of more extensive, systematic provision for the destitute or working poor, asylums were always going to be full: in 1907, 30 per cent of admissions to the Richmond Asylum came directly from workhouses.33 Exactly a century later, in 2007, the psychiatric service in the Mater Misericordiae University Hospital, just up the road from Grangegorman, reported that 35 per cent of emergency psychiatry assessments were of homeless persons: plus ça change, plus c’est la même chose.34

As a result of these factors, the Irish asylums appeared, for all intents and purposes, immovable, immutable and apparently inevitable features of Irish life for almost 150 years, from the mid-1850s onwards. The only events that produced slight, temporary declines in admission rates were the two world wars, and, once the wars ended, admission rates resumed their seemingly inexorable upward trajectory.35 Much, although by no means all, of this book is concerned with elucidating why this was so.

The Asylums: Social or

Medical Creations?

The history presented in this book leads to the conclusion that the Irish asylum system was a social creation as much as it was a medical one, if not more so. The psychiatric profession was certainly complicit to the extent that asylum doctors permitted and even facilitated the growth of the asylums through their (reluctant) acquiescence to the questionable roles pressed upon them by broader society, and their recurring therapeutic enthusiasms for the broad range of treatments discussed throughout this book, ranging from the moral management of the 1800s to the pharmaceutical innovations of the late 1900s.

Throughout the 1880s and 1900s, determined efforts at reform and moves away from large asylums were continually frustrated by a society with an apparently insatiable hunger for institutionalisation. From the perspective of the early twenty-first century, it is a matter of regret that even greater objections to this state of affairs were not raised by more asylum doctors, attendants or nurses, as legislation such as the Dangerous Lunatic Act 1838 visibly drove up admission rates and the poor conditions within asylums became ever more indefensible. While doctors commonly did indeed object, both publicly and strongly, this book argues that their objections were insufficiently strong and often to no avail.

Ultimately, the end of the institutions, when it finally commenced in the 1960s, was attributable only in part to advances in clinical psychiatry (e.g. antipsychotic medication) and was more substantively shaped by broader changes in Irish society, such as the opening up of Ireland to greater outside sociopolitical influences in the 1960s and 1970s, an increasingly free press, the growth of the language of human rights across Europe, and Ireland’s accession to the European Economic Community (EEC; later European Union (EU)) in 1973. All of these themes are explored throughout this book.

As ever, psychiatry in Ireland came to reflect these broader changes in society as they occurred, as well as advances in psychiatric care in other countries, and so the asylums finally began to empty in earnest in the 1960s. And, as usual, Irish psychiatry was not short of reform-minded doctors enthusiastic for change, as a fresh generation of psychiatrists and other mental health professionals gave shape to a new, post-institutional psychiatry in Ireland. While the pace of reform was slow, the changes were definite and duly reflected in the 1966 Report of the Commission of Inquiry on Mental Illness36 and all subsequent governmental mental health policies (which have, essentially, been re-statements of the 1966 report).37

All of these events are explored in some detail throughout this book. Inevitably, much of the book is devoted to the emergence and ultimate demise of the Irish asylum system owing to both its magnitude and its remarkable, absorbing character. Attention is also given, however, to Irish psychiatry prior to the asylums of the 1800s, and Irish psychiatry since the demise of the large hospitals in the late 1900s, as well as current and future trends.

The precise roles of psychiatry and psychiatrists in all of this are interesting, engaging and occasionally alarming. Rather than psychiatry shaping its own history as a distinct discipline within medicine, it often seems as if psychiatry in Ireland was, for the most part, shaped by broader social and historical trends, as opposed to developing as an autonomous, readily identifiable entity on its own terms. As a result, it is difficult, although by no means impossible, to trace out a clear identity for Irish psychiatry over past centuries.

Notwithstanding these challenges, I hope that the historical events explored throughout the book set out the parameters for establishing such an identity, and that the analyses presented provide perspectives on both how psychiatry has evolved in Ireland and how the path to today’s psychiatry is likely to influence its future.

Gaps in the Story

While a growing quantity of research has focused on various aspects of the history of psychiatry in Ireland, substantial lacunae remain.38 Walsh, in his positive review of Reynolds’s invaluable book, Grangegorman: Psychiatric Care in Dublin since 1815, noted that Reynolds’s ‘worthwhile’ and ‘meticulous contribution’ did not ‘pretend to be a scholarly analytical academic work analysing the various forces shaping the intellectual and emotional attitudes to lunacy policy and its administration in Ireland in the 19th and 20th centuries’.39 Clearly, further work, likely by a range of researchers, was needed to build on the accounts of Reynolds and others and provide a clearer picture of the history of psychiatry in Ireland.

Looking more broadly, there are, in fact, very many gaps in the historiography of Irish psychiatry. One of the key features of the literature to date is that it demonstrates a remarkably strong focus on the history of institutions, understandably echoing the emphasis that government traditionally placed on asylums as a key element in resolving the social problems presented by people with apparent mental disorder or intellectual disability. There has been particular engagement with the histories of earlier, larger institutions such as St Brendan’s Hospital, Dublin;40 St Patrick’s Hospital, Dublin;41 St Vincent’s Hospital, Fairview;42 St Davnet’s Hospital, Monaghan;43 Our Lady’s Hospital, Cork;44 St. Mary’s Hospital, Castlebar;45 Holywell Hospital, Belfast;46 St Fintan’s Hospital, Portlaoise;47 St Luke’s Hospital, Clonmel;48 and Bloomfield Hospital, Dublin,49 among others. There is also a growing literature relating to the Central Criminal Lunatic Asylum (later Central Mental Hospital [CMH]) in Dundrum, Dublin.50

In addition to this focus on institutions, the historiography of Irish psychiatry also shows a strong focus on the evolution of mental health legislation. This, again, is entirely understandable and largely attributable to both the existence of laws permitting criminal and civil detention on the grounds of mental disorder,51 and the fact that the development of Ireland’s psychiatric institutions throughout the 1800s and 1900s52 was rooted in endless, obsessional revisions of legislation, including committal laws.53

There are, however, other stories to be told and other perspectives to be explored, many of which are challenging to uncover. St Patrick’s Hospital in Dublin, for example, was founded following the benevolent bequest of Jonathan Swift (1667–1745), as a private, charitable institution aiming to provide high quality care to a finite number of the afflicted, without the broader, population level responsibilities of government run institutions.54 Malcolm, in her excellent, detailed history of St Patrick’s, however, found that it was noticeably difficult to reconstruct the living conditions of the patients there.55 There was a wealth of information regarding details of the building, the provision of food and so forth, but, from a clinical and historical perspective, the patients themselves proved remarkably elusive.56

This elusiveness may reflect a lack of governmental interest in individual patients and an exuberance of interest in psychiatric hospitals as institutions. Dr William J. Coyne, chief psychiatrist and resident governor at the CMH in Dundrum, who resided at the hospital from 1949 to 1965, was, every year, in the words of his grandson, Dr Maurice Guéret, ‘hauled before politicians on the public accounts committee to explain matters like failures of the carrot crop on the hospital farm, low prices from sales of hospital sheep, victualling rations for staff and the late delivery of spring seeds. Never once was he asked a single question about his patients’.57

As a result of these factors, the historiography of psychiatry in Ireland, as elsewhere, focuses largely on the histories of institutions and legislation, and the patients themselves remain ephemeral, elusive and largely unknown. Despite their vast numbers, patients’ voices are astonishingly distant and frequently inaudible to today’s historians. How can this be remedied?

Searching for Patients’ Voices

Recent decades have seen some progress towards seeking out the patients’ voices in the history of Irish psychiatry, commonly through analysis of official clinical records in certain establishments, including St Brigid’s Hospital, Ballinasloe,58 the Central Criminal Lunatic Asylum,59 St Brendan’s Hospital,60 and Enniscorthy Lunatic Asylum, County Wexford,61 among others. These are, however, analyses of official medical records, with all of their associated narrative and interpretative ambiguities.

One of the key merits of historical research based on clinical records is that such records are uniquely useful for identifying shifts in clinical practice over time and conveying the complexity of hospital life.62 Compared to approaches framed by institutional or legislative perspectives, which are so common in the historiography of Irish psychiatry, approaches based on clinical notes move somewhat towards Porter’s conceptualisation of ‘medical history from below’,63 although they still rely on official records written by medical superintendents and others, rather than direct patient accounts, such as patients’ own correspondence or memoirs.64 Official medical records can be manipulated, consciously and unconsciously, by the individuals writing the records, to demonstrate, for example, that staff always behaved in a fashion appropriate to the doctor-patient relationship (even if they did not).65 But such accounts do, at least, seek to tell that patient’s story at the individual level, as it was experienced.

Given these methodological issues, it is apparent that constructing an ‘authentic’ account of patient experience is a complex, challenging and possibly impossible task.66 Be that as it may, the case record still reflects both the patient’s behaviour and the interpretation of such behaviour by hospital authorities and, as such, presents a unique and crucial account of the patient’s experience – an account which generally played an important role in determining how the patient was treated in and by the institution. Archival case records are used to present patient histories throughout this book (e.g. the cases of three brothers committed to the Central Criminal Lunatic Asylum in the 1890s in Chapter 2, and that of Mary in Chapter 3).

Other limitations with approaches based on archival case notes include unclearness about how systematic medical notetaking was in the nineteenth century; potentially inconsistent use of medical terms; and inclusion of clinical descriptions which may be challenging or impossible to interpret today.67 These issues, however, present both challenges and opportunities. In relation to individuals with apparent intellectual disability, for example, an enquirer with experience of both historical and clinical work can at least attempt to move beyond the diagnostic labels used loosely throughout historical case records and focus on more objective descriptions of clinical symptoms (many of which are readily recognisable today), in order to provide a clinical analysis of the extent to which such patients in nineteenth- and early twentieth-century Ireland were truly intellectually disabled by today’s standards.68

Therefore, while extreme caution must be exercised when associating archival clinical descriptions with contemporary diagnoses (‘presentism’),69 this approach can nonetheless prove fruitful if archival accounts of patients’ experiences can meet the careful ‘clinical gaze’,70 with an emphasis on descriptive pathology rather than loosely applied diagnoses, and a focus on the clinical rather than institutional or legislative dimensions of patients’ histories. The case study of Michael in Chapter 4 presents an example of this approach from the 1890s.

Patients’ Symptoms, Letters

and Belongings

Even with careful interpretation and analysis, however, official clinical records are still at least one step removed from the voices and thoughts of patients themselves. In order to move closer to the patient’s voice, recent international attention has focused on other materials such as patients’ letters, journals and first-person accounts of incarceration and treatment.71 Beveridge, for example, studied letters written by patients admitted to the Royal Edinburgh Asylum and found evidence of commonality between symptoms in the letters and symptoms commonly seen in clinical practice today.72 Similarly, Smith studied letters from families and some patients at Gloucester Asylum between 1827 and 1843.73 While some admissions and discharges were undoubtedly problematic, there was also evidence of dialogue between asylum staff, families and patients, and by no means were all interactions conflictual, with certain patients very grateful for their care. There have also been studies of correspondence related to the York Retreat in England74 and the colonial asylums of New Zealand and Australia.75

Not all discharged patients described positive experiences, of course, and patient accounts of treatment in England and the US during the 1800s and 1900s were often highly critical.76 In Ireland, the past few decades have seen interesting initiatives seeking out patients’ voices in different ways, including through the reminiscences that accompanied the closure of St Senan’s Hospital in Enniscorthy.77 Other patient voices from recent decades were presented by Prior78 and McClelland,79 with the latter providing a fascinating account of Speedwell magazine, and its ‘insider view’ of Holywell Psychiatric Hospital, Antrim, from 1959 to 1973. Another mental hospital magazine, The Corridor Echo, of St Mary’s Hospital, Castlebar, provides further insights from 1966 onwards.80

Notwithstanding these records, accounts and publications, however, there remains a real paucity of detailed patients’ accounts of psychiatric admission and treatment in Ireland in the 1800s and early 1900s. Despite the general dearth of such literature in Ireland, this book includes, where possible, patients’ voices, with particular consideration of patient accounts of treatment in Irish psychiatric hospitals, such as those provided by the Reverend Clarence Duffy (1944)81 and Hanna Greally (1971)82 (Chapter 6).

In the absence of a plentiful supply of such accounts, however, it is worth speculating if there are other routes to the patient’s voice from past decades and centuries that merit exploration. What about delusions or hallucinations, which are often recorded in some detail in archival case notes? Delusions are convictions which are strongly held despite evidence to the contrary and hallucinations are perceptions without appropriate external stimuli (e.g. hearing voices).83 Can such phenomena be gainfully understood or decoded by the historian or clinician today, up to two centuries after they were recorded?

In other words, even though delusions and hallucinations are, in most conventional senses, ‘false’, might they also reflect truths, possibly unspeakable truths, in disguised or metaphorical form? Certainly, in contemporary clinical practice, both delusions and hallucinations are rarely random in their content and are commonly, demonstrably shaped by context. This is surely equally true when they are sourced from archival case notes.

Finnane, for example, recounts the case of a young woman in the Richmond Asylum in the early 1890s, who was brought up as an orphan in the workhouse but then went to prison and was later admitted to the asylum.84 According to the asylum case book, she was frightened when she believed she saw three nuns on a ladder beating their own foreheads with stones, and when distressed she believed herself to be dead. Might not this young woman have had good reason to fear nuns, or at least view them as difficult to understand and somewhat strange? And, following a difficult childhood, imprisonment and, now, incarceration in an asylum, was she entirely incorrect to consider herself, in a certain sense, ‘dead’?

At the Central Criminal Lunatic Asylum in 1892, a 34-year-old servant from Dublin was admitted after being charged with the murder of her 8-month-old child. Her previous five children had all died young.85 The asylum’s case book records that, ‘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’. A distressed young mother in late nineteenth-century Ireland, mourning the loss of her five children, feels persecuted and alone? True, there were no soldiers following her that morning, but surely there is still a very compelling truth in her delusions of persecution? Her feelings of being lost? Her hopelessness?

The ultimate truth about what this or other patients thought about their committal and treatment may lie hidden somewhere in these evolving delusions and hallucinations, or in the patients’ own stories (wherever they may be), or even in the physical objects and personal effects that patients left behind when they died or finally left Ireland’s asylums behind them.86 Some of these objects and possessions are explored with particular power and poignancy in ‘Personal Effects: A History of Possession’ by Irish artist Alan Counihan, focusing on patients’ personal effects found in the attic of a disused hospital building at Grangegorman Mental Hospital in Dublin (later St Brendan’s).87 A profound sense of tragedy is palpable in many of these found objects and images, as is a sense of loss and, more often than one might expect, a real sense of survival, hope and life.

For the historian, the methodological challenges inherent in hearing patients’ voices from the asylums of the past are all opportunities, complicated to navigate but by no means impervious to exploration, and certainly not impossible to understand. As a result, while the voices of patients from the 1800s and early 1900s might presently remain largely unknown, they are certainly not unknowable. Maybe we just need to listen harder and, perhaps, listen better. This book sets out to do so, insofar as possible, with particular focus on case histories and various other accounts and analyses of patients’ experiences inside and outside the asylums.

The Title, Approach and

Structure of this Book

This book is titled ‘Hearing Voices: The History of Psychiatry in Ireland’. There are three reasons for this choice of title. First, ‘hearing voices’ (auditory hallucination) is one of the classic symptoms traditionally associated with mental disorder, so it inevitably features in any history of psychiatry. Second, as I’ve just discussed, this book is an attempt to hear voices that have not often been heard: not only the voices of patients in the asylums, but also those of clinical staff88 who lived their lives behind asylum walls, in circumstances that differed significantly, although by no means completely, from those of their patients.

Third, evolving attitudes towards the experience of ‘hearing voices’ reflect important, iconic changes in psychiatry in recent decades, which I am very keen to highlight. In Chapter 8, I explore the international ‘hearing voices’ movement, which is based on an exceptionally powerful reinterpretation of the experience of hearing voices which used to be routinely associated with major mental disorder but is now subject to more nuanced interpretations, formulated chiefly by those having such experiences themselves (rather than mental health professionals).89 This is an important and arguably iconic shift in the societal approach to such symptoms, and this is an important element of the story that I seek to tell in this book.

From a methodological perspective, there are many possible approaches to my task and to the history of medicine in general, ranging from exclusively medical perspectives, charting the evolution of treatments over time, to exclusively sociological approaches, which prioritise the social and political contexts in which medicine and healthcare develop and are practiced. Like most historical texts, this book lies somewhere between these extremes.

From a thematic perspective, Burnham identified five key ‘dramas’ in the history of medicine, relating to the histories of (a) the healer; (b) the sick person; (c) various diseases; (d) discovery and communication of knowledge; and (e) interactions between medicine and health on the one hand, and society on the other.90 All of these ‘dramas’ are reflected in a variety of ways throughout this book, with particular emphasis on interactions between psychiatry and society, owing to the intrinsically societal basis of the Irish asylums of the 1800s and 1900s, and the social roles commonly foisted upon (and all too often accepted by) psychiatry, no matter how unsuitable those roles are. This regrettable feature of the history of psychiatry is a recurring theme in my story.

Chapter 1 of the book commences by exploring the ‘birth of psychiatry in Ireland’ and covers the Middle Ages and early modern era, Gleann na nGealt and Mad Sweeney (in the twelfth century), and Brehon Law (up to the seventeenth century). The emergence of new forms of institutional care is explored, as are the lives and work of Sir William Fownes and Jonathan Swift, especially in the context of St Patrick’s Hospital, Dublin (1746). Burnham’s ‘drama’ of the healer features strongly in the form of Dr William Saunders Hallaran and the succession of therapeutic enthusiasms for new treatments that emerged in the late 1700s and early 1800s in Ireland, as was also the case elsewhere.

Chapter 2 moves on to examine the growth of the asylums in nineteenth-century Ireland, commencing with the Richmond Asylum (1814) and examining the work of pivotal figures such as Dr Alexander Jackson, Robert Peel (Chief Secretary, 1812–17) and Dr John Mollan at the Richmond. Other notable developments included the Select Committee on the Lunatic Poor in Ireland (1817), the Dangerous Lunatic Act 1838, the Private Lunatic Asylums (Ireland) Act 1842, the 1843 report on the ‘State of the Lunatic Poor in Ireland’, the 1851 census and the 1858 Commission of Inquiry on the State of Lunatic Asylums in Ireland. The ‘drama’ of the patient is explored through the use of archival case records and case studies of restraint, ‘neglect and cruelty’, as well as folie à plusieurs, an unusual psychiatric syndrome which, in these cases, was associated with the killing of family members. This chapter also examines treatments for mental disorder, life and death in the institutions, and the experiences of women in nineteenth-century asylums.

Chapter 3 moves explicitly to the ‘drama’ of the interactions between psychiatry and society, looking at the effects, if any, of the Great Irish Famine (1845–52) on admission rates, workhouses, treatment of the intellectually disabled, and widespread alarm about the alleged ‘increase of insanity in Ireland’ during the late 1800s and early 1900s. This chapter also reflects on why the Irish asylums grew so large; outlines (in detail) psychiatric diagnoses from the archives of Carlow Lunatic Asylum in the late 1800s; explores the histories of Bloomfield (1812) and Hampstead Hospitals (1825); and examines Burnham’s ‘drama’ of the healer by looking at the contributions of Dr Thomas Drapes, Dr Conolly Norman and Dr Eleonora Fleury, a remarkable republican doctor and first woman member of the Medico-Psychological Association (MPA, 1894).

Chapter 3 also presents the case of Mary, a 40-year-old ‘housekeeper’ with seven children who was charged with the manslaughter of her 4-year-old child in the mid-1890s. Mary was ‘acquitted on the grounds of insanity’ and detained at the Central Criminal Lunatic Asylum (later Central Mental Hospital, Dundrum) ‘at Her Majesty’s Pleasure’ (i.e. indefinitely). Mary’s admission diagnosis was ‘chronic melancholia’, and examination of her archival case records in this chapter questions the nature of this diagnosis and uses Mary’s story to illustrate diagnostic challenges in the late 1800s, along with difficulties separating mental disorder from social and economic problems, especially among women, during this difficult period in Irish psychiatric history.

Chapter 4 explores ‘early twentieth-century psychiatry’, setting the scene with consideration of the remarkably insightful (but sadly ignored) Reports of the Committee Appointed by the Lord Lieutenant of Ireland on Lunacy Administration (1891).91 Chapter 4 then outlines the fate of the mentally ill outside the asylums in the early 1900s, the Conference of the Irish Asylum Committees (1903) and key issues at the Richmond District Asylum (Grangegorman) in 1907. In terms of the links between psychiatry and broader sociohistorical events, this chapter outlines the effects of the 1916 Easter Rising on Dublin’s asylums; the story of the Richmond War Hospital (1916–19); the remarkable life and career of Dr Ada English, patriot and psychiatrist in Ballinasloe; and the broader relevance of nationalist sentiment throughout the asylum system during Ireland’s revolutionary years.

Again, Burnham’s ‘drama’ of the sick person is explored throughout this material, especially through the case study of Michael, a 35-year-old man committed to the Central Criminal Lunatic Asylum in the 1890s, charged with ‘assault’; declared ‘insane on arraignment’; and diagnosed as a ‘congenital imbecile’. Michael’s story, based on archival clinical records, demonstrates many important features of Irish asylum life in the late 1800s and early 1900s, especially as they relate to persons with apparent intellectual disability. The experiences of the intellectually disabled feature repeatedly (and disturbingly) throughout the story told in this book.

Chapter 5 moves on to examine efforts at reform of Ireland’s mental health services in the early 1900s, looking at multiple sources of evidence including media articles, developments relating to the intellectually disabled, and accounts of industrial unrest (e.g. the Monaghan Asylum Soviet, 1919). Burnham’s ‘drama’ of the healer is explored through the work of Professor John Dunne in Grangegorman and, in relation to occupational therapy, Drs Eamonn O’Sullivan in Killarney and Ada English in Ballinasloe. This chapter also explores therapeutic enthusiasms for some of the most controversial treatments in the history of psychiatry (psychotherapy, malarial treatment, insulin coma, convulsive therapy, lobotomy); the reforming efforts of the Mental Treatment Act 1945 and the Commission of Inquiry on Mental Illness (1966); and, in the independent sector, the development of St Patrick’s Hospital, Dublin during the twentieth century.

Chapter 6 documents the ‘decline of the institutions’ in the late 1900s and explores various factors that contributed to this, including the advent of effective antipsychotic medication, and changing public and press perceptions of psychiatry. The patient’s voice is heard through first-person accounts of psychiatric hospitalisation provided by the Reverend Clarence Duffy (1944) and Hanna Greally (1971).

This chapter also examines Irish psychiatry in relation to homosexuality, explores the remarkably persistent idea that mental illness was more common in certain parts of Ireland than elsewhere, and looks at the figures who led various reforms within Ireland’s mental health services, including, but by no means limited to, Dr Dermot Walsh, Professor Ivor Browne, Dr Des McGrath, Professor Thomas Lynch, Professor Thomas Fahy, Dr Robert McCarthy, Professor Robert Daly, Dr Brian O’Shea, Professor John P. (Seán) Malone, Professor Noel Walsh, Professor Marcus Webb and Professor Eadbhard O’Callaghan. These figures speak not only to Burnham’s ‘drama’ of the healer, but also the emphasis Burnham places on the discovery and communication of knowledge as a key factor in the history of medicine, as well as interactions between psychiatry and broader society.

Attention is also devoted in Chapter 6 to the emergence of military psychiatry in Ireland, the ill-fated Health (Mental Services) Act 1981, the opening of new acute psychiatric units in general hospitals, issues relating to mental health nursing, the 1984 policy, Planning for the Future, and the outstanding contribution of Professor Anthony Clare to psychiatry in Ireland and beyond. Chapter 6 incorporates considerations of the emergent emphasis on human rights in mental health in Ireland and the role of international human rights movements in creating a context for changes in policy, law and social perceptions of mental illness and psychiatry.

Chapter 7 explores the recent history of psychiatry in Ireland in the early twenty-first century, looking at the Mental Health Act 2001; the 2006 policy, A Vision for Change; the development of child and adolescent psychiatry; the Irish Journal of Psychiatry (1982), the Irish Journal of Psychological Medicine (1982) and other professional journals in Irish psychiatry; the emergence of the College of Psychiatrists of Ireland (2009); and the 2015 review of the Mental Health Act 2001. Important service developments are explored, including the ongoing move to community care, the evolution of the National Forensic Mental Health Service and mental health services for the deaf.

The final chapter, Chapter 8, focuses on the future of psychiatry in Ireland in light of the historical analyses presented in earlier chapters, as well as recent data. This concluding section focuses particularly on interactions between psychiatry and society; societal ‘structural violence’ and social exclusion of the mentally ill; postpsychiatry and other reformist movements; suicide; ongoing issues relating to human rights; and likely future developments in clinical, academic and historical psychiatry. The book concludes with a consideration of the overall future of psychiatry in Ireland, based on events and trends over past centuries and informed by the state of psychiatry in early twenty-first century Ireland.

Throughout the book, extensive details of primary and secondary sources are provided for readers who seek further information on any topic. I have devoted particular attention to citing and quoting primary material and cross referencing to the secondary literature, with an especially strong emphasis on publications relating directly to psychiatry in Ireland. It is hoped that this extensive quotation, citation and referencing will assist future researchers.

For the most part, practicing psychiatrists are not discussed in depth, although some are mentioned. For recently retired or recently deceased psychiatrists who are discussed (especially in Chapter 6), it is too soon to present a historically informed, critical appraisal of their contributions. As a result, my accounts of recent figures should not be read as critical, historical analyses of their lives and work, which would be premature at this short remove, but as summaries of their careers and achievements (with some brief comments). Future historians will be better placed to comment critically on the enduring effects of their work, and hopefully the brief accounts presented here will assist in informing such assessments.

Finally, throughout this book, original language and terminology from the past and from various archives and reports have been maintained, except where explicitly indicated otherwise. This represents an attempt to optimise fidelity to historical sources and does not represent an endorsement of the broader use of such terminology in contemporary settings.