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Time to Listen

Liam Hennessy

Hearing Voices: The History of Psychiatry in Ireland, by Brendan Kelly, Irish Academic Press, 500 pp, €39.99, ISBN: 978-1911024347

Hearing Voices is TCD psychiatry professor, quondam historian and polymath Brendan Kelly’s magnum opus and is likely to supplant the existing histories of the controversial subject of Irish psychiatric practice and experience as the definitive work on this traditionally medical discipline.

As Kelly explains in the introduction, his title is deliberately chosen to reflect the thesis that his history of Irish psychiatry encompasses three dimensions. The first is the traditional notion that hearing voices was the classical symptomatology of possible psychosis. The second is Kelly’s attempt to distil the voices of patients and those who cared, to a greater or lesser degree, for them and who were often, in a sense, almost as institutionalised as those they cared for. Finally, there is the focus on more modern approaches to psychiatry – the recovery model of mental illness and the development of movements in the patient or service-user community such as the Hearing Voices Network, which seeks to validate hearing voices as a common human experience, and such other structures which are being put in place to enable the collective views of patients and their families to be taken into account.

Crucially, Kelly indicates at the outset that he proposes to place particular emphasis on the interactions between psychiatry and society, owing, as he puts it, to “the intrinsically societal basis of the Irish asylums of the 1800s and 1900s, and the social roles commonly foisted (and all too often accepted by) psychiatry, no matter how unsuitable”. Kelly is very clear about his attitudes to this experience and he explicitly states (and pursues throughout his history) that “this regrettable feature is a recurring theme” of his narrative.

But before delving into that narrative, it would be important to identify just what is the “psychiatry” that Kelly sets out to trace the history of in Ireland. Here Kelly adopts the late Irish psychiatrist Anthony Clare’s definition of psychiatry being “that branch of medicine that is concerned with the study and treatment of disorders of mental function”. Now there will be many – particularly those in the so-called anti-psychiatry or survivor-of-psychiatry movements – who will contest this and object strongly to distressful mental circumstances being “medicalised” or “excessively medicalised”, as the jargon has it. This, undoubtedly, can be a valid perspective, given the seemingly inexorable growth of diagnostic categories, for example, as set out in the latest iteration of the psychiatrist’s “bible”, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) of the American Psychiatric Association.

Nevertheless, this review engages with Kelly’s oeuvre on its own terms while acknowledging that what might be termed a different philosophical approach to caring for and treating those experiencing intolerable mental distress is another way the subject can be and, in some quarters, is being evaluated. Moreover, it might be worth hazarding an opinion that the functioning of the brain/mind is immensely complicated and that our understanding of this is still in its relative infancy. After all, William Harvey – arguably one of the founding fathers of modern physical medicine with his documentation of the circulation of the blood in 1628 – coined the term “the divine banquet of the brain”. It may well be the case, then, that the human brain/mind, and not space, is the final frontier.

In his introduction, Kelly sets out the structure around which he wraps his history. The elements of that structure are as follows: the emergence and role of psychiatric professionals; the asylums as social or medical creations; searching for patients’ voices; and patients’ symptoms, letters and belongings. There are two overarching themes to all of this – the growth of asylums and the extraordinary numbers of “patients” who found themselves in such institutions and the role of legislation as a “driver” of developments in the care and the rights (or, more accurately, lack of them) in Irish psychiatry of patients, “lunatics”, “imbeciles”, “idiots”, “fools” or “the mad or insane”, in the common parlance of the nineteenth and early twentieth centuries.

Kelly’s history, although thematic in the senses outlined above, nevertheless follows a largely chronological course. Thus, in the first substantive chapter, we get a brief overview of the birth of psychiatry in Ireland dealing with attitudes towards, and practices adopted in relation to, those in mental distress in medieval and early modern Ireland.

His story of modern Irish psychiatry – in historical, not medical or psychological terms – begins with the efforts of Sir William Fownes, lord mayor of Dublin who, in 1708, provided for cells for the mentally ill in the workhouse at St James’s Gate. The site of that workhouse is, of course, now the site of St James’s Hospital, in which psychiatric services continue to be provided on both an in-patient and out-patient basis. The claim to be the other founding provider of in-patient care for the mentally ill, of course, resides with Jonathan Swift, hero to Dubliners and long-time governor of the Bedlam Hospital in London, who established St Patrick’s Hospital (now St Patrick’s University Hospital and Mental Health Services) in 1745. Famously, in his Verses on the Death of Doctor Swift, the Dean wrote:

He gave what little wealth he had
To build a house for Fools and Mad
And showed with one satiric touch
That never Nation needed it so much.

It is a curious irony which Swift would probably have relished, and a feature which Kelly explores exhaustively, that there was to be a relentless growth in asylum construction throughout the nineteenth century to a point that Ireland had by the turn of the twentieth century more than 20,000 inpatients in institutional psychiatric “care”. Some – including many who looked into this phenomenon as it developed in the nineteenth century – must have taken the view that the nation did indeed very much need provision of this kind.

But how then to deconstruct Kelly’s structure for the purposes of this review? The approach adopted here is to dip into his big themes and highlight some of their features. Thus, for example, we begin by looking at some of the leading figures – and they were all medical doctors – in Irish psychiatry and Kelly’s take on them.

Kelly identifies the Cork doctor William Saunders Hallaran as the founding father of modern Irish psychiatry, not least because he established the Cork Lunatic Asylum in the late eighteenth century and was, according to Kelly, “an industrious, progressive administrator, clinician and teacher” and “a tireless advocate for a more systematic approach to mental disorder and its treatment”. Moreover, Hallaran published, in 1810, the first Irish textbook on psychiatry with the wonderful title of An Enquiry into the Causes producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons. The “extraordinary addition to the number of insane”, although challenged by Kelly in his analysis of the numbers of mentally ill in Ireland over the years, was to be a recurring concern of politicians and administrators in Ireland throughout the nineteenth century and for much of the first half of the twentieth.

Two doctors associated with the Richmond Lunatic Asylum (subsequently Grangegorman and, finally, St Brendan’s Hospital before its closure in recent times) come next in Kelly’s pantheon. They are Dr John Mollan and his successor, Dr Joseph Lalor, whose involvement with the asylum extended through most of the nineteenth century. Mollan took the view that the Richmond was the first institution in Ireland specifically constructed for the classification of the insane, with a view to the provision of better, more appropriate care, such care to include employing the Richmond patients in gardening, carrying out various trades, mat-making, spinning and needlework among other things. It is curious to note the beginnings of occupational therapy in these approaches and mat making is still a feature of occupational therapy services in some psychiatric institutions. Lalor followed Mollan not only in his role as “physician extraordinary” with the new title of Resident Medical Superintendent (or colloquially, RMS) which was to resonate down the years in Irish psychiatry, but also in his approach, establishing, for example, a school in the Richmond. Both Mollan and Lalor were influenced by the so-called “moral movement” in addressing the needs of the mentally ill. Derived from practices developed by Quakers in England who were concerned about the punitive experiences of the mentally ill and utilised, in particular, in the York retreat of Dr Henry Tuke, the moral movement focused on kindly treatment of those suffering mental illness as distinct from the custodial approach which had been the paradigm for so long. Not only could an early iteration of occupational therapy be seen in the work of Mollan and Lalor, but in the seeds of the moral movement may just be discerned the kernel of today’s psychotherapeutic approaches to care. Sadly, those seeds sown could not and did not flourish in the relentless asylum-building of the nineteenth century with the inevitable, concomitant increases in the numbers of patients placed in, and the overcrowding of, such institutions.

The next major figure in Irish psychiatry identified by Kelly is Dr Connolly Norman (Connolly was his first name) whom he describes as the leading psychiatrist of his generation. A measure of Norman’s impact on Irish psychiatry is the labelling today of the psychiatry of later life unit in St James’s Hospital and a day hospital on Dublin’s North Circular Road as the Connolly Norman Ward and Connolly Norman House respectively.

In 1886, Norman was appointed RMS in the Richmond District Asylum – a notably powerful and prominent position in Irish medicine according to Kelly – having had a succession of leading appointments in other Irish asylums. It would be useful to let Kelly’s citation from The Irish Times after Norman had died suddenly in 1908 capture the crusading and innovative nature of the man:

To him (Norman) must ... be attributed the initiation of a campaign against restraints in asylums. On his advice the “straight jacket” was abolished in the institution, and his influence in this respect penetrated into all the asylums in Ireland and very many institutions in England and Scotland.

Norman also proposed the “boarding out” of patients at the Richmond so that such patients could be cared for in their own homes. This was an early manifestation of modern community mental health care, which sadly was not pursued at that time because of the widespread political and social view that care for the mentally ill should take place exclusively as in-patients in the large asylums.

Kelly devotes considerable coverage to the pioneering female psychiatrists in the Irish asylum system. In fact, the first ever female psychiatrist in Ireland or the United Kingdom was Dr Eleonora Fleury, who might be described as a protégée of Norman. She also shared with another pioneering woman psychiatrist, Dr Ada English, as well as a number of other women doctors in other disciplines, an abiding commitment to republican politics. In fact, in English’s case when she was working in Ballinasloe Asylum, where she was an early proponent of occupational therapy, she had to be replaced by a locum following her arrest in 1921. Her boss, RMS Dr Mills, informed his governing committee that he had had to employ a locum as “Dr English (was) under detention in a government institution”. These pioneering women doctors, by and large, took the anti-treaty side in the Irish Civil War.

In his chronology of influential figures in Irish psychiatry, Kelly then moves on to what might be termed doctors who practised as major figures in Irish psychiatry within living memory. These included Professor John Dunne, Professor Ivor Browne (Dunne’s successor as RMS in the Richmond – by this time, it had morphed through being Grangegorman to its final nomenclature of St Brendan’s Hospital – and Browne himself would not have used what had become an oppressive title for the clinical director), Dr Dermot Walsh and Professor Anthony Clare. Sadly, only Browne among these figures is still with us.

In Kelly’s words, Dunne was a highly influential figure in Irish psychiatry over many decades – from the mid-1920s to the mid-1960s. In fact, he goes further than that, describing him as “one of the key iconic figures in twentieth century Irish psychiatry”. A measure of Dunne’s influence is the fact that in 1989 the Irish Journal of Psychological Medicine awarded the inaugural John Dunne Medal, established in his honour, not least because he was the first professor of psychiatry in Ireland and believed in the “contribution of the physical sciences to psychological medicine” and endorsed a rigorous, broad-based approach to psychiatry. The medal is now awarded annually for a contribution to an original paper and the prize is open to all postgraduate psychiatry trainees from Ireland, Northern Ireland and Britain.

Because of the longevity of his “leadership role” in Irish psychiatry, Dunne was associated with many treatments which at the time were thought to be novel and which seemed to offer hope of amelioration of some of the more intractable psychiatric conditions. We would look askance at some of these today and Kelly is insistent in the refrain that, although such treatments seem barbaric and unscientific now, resorting to them was a desperate effort by a profession trying to find ways to help their patients and, not incidentally, create a distinct medical discipline for themselves.

Dunne, for example, introduced malarial – yes, malarial – treatment for general paralysis of the insane (GPI) in Ireland. GPI is a neuropsychiatric disorder caused by late-stage syphilis. The treatment involved deliberately infecting patients with the condition with malaria by inoculation. In one of those humorous asides which Kelly uses deftly in his text, he states that “Dunne initially collected mosquitoes from Customs men in Dublin, but when the mosquitoes wouldn’t bite in Ireland’s chilly climate, switched to malarial serum from London”. Strange and even cruel as this treatment seems to be, it might be worth noting that the German doctor who initiated it went on to win the Nobel Prize for medicine in 1927 and Kelly notes that the death rate from GPI had been reduced to five per year, having been thirty-five per year prior to malarial treatment.

The year 1927 was not the only year that the Nobel Prize for medicine was conferred on the discoverer of a novel “treatment” for challenging psychiatric conditions. In 1949, the prize went to Portuguese neurologist Egas Moniz for developing frontal lobotomy for mental disorder. The procedure, which has always been controversial and was so even from its outset, involves cutting nerve connections to and from the prefrontal part of the brain. The procedure was introduced for patients at Grangegorman in the mid-1940s and was carried out in the old Richmond (physical and surgical) Hospital by the “father of Irish neurosurgery”, Adams Andrew McConnell, or under his direction. While hundreds of such lobotomies were performed, Kelly insists that Dunne was keenly aware of the seriousness of the operation and limited the surgery to patients with schizophrenia who had not improved with other controversial treatments such as insulin therapy and electroconvulsive therapy (ECT) and had ongoing symptoms of a very impulsive, negative, suicidal or homicidal nature. It is worth recording here that lobotomy went into decline during the 1950s not least due to its adverse effects – Brendan Behan is reputed to have said: “I’d rather a bottle in front of me than a frontal lobotomy” – and lack of efficacy as well as the fact that (relatively) safer alternatives for the treatment of schizophrenia in the form of antipsychotic medications had begun to come on stream. Lobotomy or, in its modern incarnation, psychosurgery, is still performed very rarely for extreme cases to address, for example, otherwise untreatable obsessive compulsive disorder (OCD) and only when very rigid protocols are adhered to.

Dunne’s successor in 1962 as clinical director at St Brendan’s and as professor of psychiatry at UCD was Ivor Browne. Browne brought new insights and approaches to the treatment of the mentally ill in his care, including some unorthodox forms of psychological therapy involving ketamine and music amongst other things. (It is not surprising, perhaps, that Browne called his memoir Music and Madness). At the same time, he systematically (in Kelly’s words) dismantled this old institution and sought to replace it with community-based facilities. Kelly references the large volume of Browne’s published papers which he suggests are “notable for both their breadth and depth” and, perhaps more importantly, for “their continuous empathic awareness of individual suffering”. Kelly makes the critical point about Browne’s tenure that he, in conjunction with other progressives, almost halved the annual admission rates to Grangegorman from almost three thousand each year to just over one thousand five hundred “simply by diverting less ill patients to community-based sector mental health services”. Browne was rightly honoured at its recent fiftieth anniversary conference as the last surviving member of the founding committee of Mental Health Ireland (formerly the Mental Health Association of Ireland), the first mainstream advocacy body in the field in Ireland when it was founded in 1966.

Another psychiatrist who played a leading role in the decongregation of the large Victorian institutions was Dr Dermot Walsh, in a variety of ways. The first was as clinical director of St Loman’s Hospital in Liffey Valley in Dublin (curiously, there were two St Loman’s mental hospitals in the Irish mental health services – the other was in Mullingar). His other two major roles were as Inspector of Mental Hospitals from 1987 to 2003, when he wrote some truly shocking reports about the conditions in many of the hospitals (an insight that Kelly, for once, does not appear to pick up on) and as an indefatigable researcher in the field. Sadly just as this review was being written came news of Walsh’s death in his late eighties.

The final Irish psychiatrist, and probably the most well known internationally is the sometime enfant terrible of Irish and British psychiatry, Anthony Clare, who died suddenly in 2007. Significantly – just as he does with Hallaran, Norman and Dunne – Kelly devotes a single named section of his narrative to Clare’s multifaceted career. That career emerged into the limelight with the publication, in 1976, only ten years after his graduation, of his Psychiatry in Dissent: Controversial Issues in Thought and Practice. Kelly asserts that “Clare’s text, lucid, incisive and endlessly compassionate, has become a classic of twentieth century psychiatry.” Clare is probably more widely known for his BBC Radio 4 series In the Psychiatrist’s Chair, which ran for twenty years from 1982. After successful spells as a leading psychiatrist at the Institute of Psychiatry and Barts in London, Clare returned to Dublin to take up the post of medical director of St Patrick’s – Swift’s Hospital – and clinical professor of psychiatry at TCD, also working as a consultant in St Edmundsbury – a sister hospital of St Edmundsbury.

While much of the foregoing account of the luminaries of modern Irish psychiatry presents them in a largely positive light, it would be wrong not to recognise that they had their critics in both the service-user and service-provider communities. As is often the case, our heroes can have feet of clay.

There is hardly a major town in Ireland that does not still have a hulking institution looming over it – the ubiquitous and monumental old mental hospitals. While these have all been effectively decommissioned now, Kelly rightly devotes a considerable part of his narrative to their extraordinary growth in Ireland in the nineteenth and early twentieth centuries. At the outset, he poses the rhetorical question whether asylums for the mentally ill were inevitable, inexorable and unstoppable? This is loaded language indeed and Kelly answers his own question with the contention that, driven by legislative and social imperatives, they were, in practice, in the nineteenth and early twentieth centuries, unstoppable. Moreover, with the exception of the moral movement described earlier, Kelly makes the case against his fellow professionals of that era that, while not exactly conspiring in the creation and construction of these characteristic Victorian institutions, they nevertheless consented, not least because they facilitated the medicalisation of mental distress and, thereby, the creation of a respected and distinct medical discipline. That “new medical discipline” not only conferred professional prestige but, probably more importantly from the perspective of the patients they cared for in the asylums, the power and authority to invoke some very dubious treatment practices and care in desperate attempts to alleviate the suffering of the very seriously mentally ill. While some of these treatments have been touched on already, it might be useful to describe one example of treatment and one example of care in the early nineteenth century to give an insight into the challenges (a considerable understatement) facing patients. Thus, founding father Hallaran, according to Kelly, noted that patients occasionally exhibited “excessive obstinacy” and, in such circumstances, he recommended the use of the “circulating swing”. This involved suspending a chair from the ceiling by means of ropes; seating a patient securely in the chair; and instructing an asylum attendant to rotate the chair at a given speed and for a certain length of time, spinning the patient around a vertical axis. This “treatment” was common practice in psychiatric institutions across Europe at the time. It is difficult not to speculate that this approach might have not been out of place in Gulliver’s Laputa.

If the treatment could at best be described as idiosyncratic, physical care could, in some institutions, be considerably worse. Thus, the Committee of Inquiry on the Lunatic Poor in Ireland of 1817 – in fact, the first in a long line of such committees and commissions which examined the treatment and care of lunatics, the insane, the mad and the mentally ill in Ireland right up to the seminal Vision for Change in 2006, which is currently under review – noted that the “accommodation for the insane” in Limerick Lunatic Asylum was “such as we should not appropriate for our dog-kennels”. That committee went on to note that

three of the insane have been condemned to lie together in one of those cells, the dimensions of which are six feet by ten feet seven inches; some of them in a state of furious insanity. In order to protect them from the obvious results, the usual mode of restraint was by passing their hands under their knees, fastening them with manacles, fastening bolts about their ankles, and passing a chain over all and then fastening them to a bed.

Some may be surprised to know that physical and mechanical restraint can still be used in modern acute psychiatric units. However, this can only be done in very exceptional circumstances where there is a danger to the patient or to others and only in very carefully prescribed and monitored minimalist ways. It has to be carried out by clinical staff who have formal training in the prevention and management of physical violence and aggression or PMAV, where the emphasis is on prevention.

While the experience described in Limerick Asylum in 1817 was extreme, it was not unique and a recurring feature of Kelly’s book is the recounting of similar, if not always quite so bad, physical “care”. And let us not forget the huge rise in numbers of patients “held” in asylums by the turn of the twentieth century. Nor did dubious treatments stop at that point. The desperate search for reliable methods to ameliorate serious mental illnesses such as schizophrenia, psychosis and extreme manic depression (now bipolar affective disorder), the condition Van Gogh suffered from, led to the use of insulin coma therapy and an inappropriate and widespread use of ECT. (It is worth noting here that ECT is still used to address catatonic and life-threatening depression under certain very strict protocols and methodologies and is endorsed as a safe and effective treatment for such by the Royal College of Psychiatrists and the National Institute for Clinical Excellence (NICE) in the United Kingdom. However, it would be unfair not to record that this treatment, no matter how strictly regulated, still has its very vocal critics both within the psychiatric profession and elsewhere.)

Insulin coma therapy, Kelly tells us, generally involved inducing comas five or six mornings a week until such time as either a satisfactory therapeutic response was produced or fifty or sixty comas had been induced. The patient spent up to fifteen minutes under a deep coma on each occasion, although some patients were liable to develop convulsions. Each coma was terminated by the administration of glucose intravenously or through a nasal tube. Most patients became obese during the course of treatment; and there was a mortality rate of two to five per cent. Curiously – at least to the layman – as regards the treatment which displaced coma insulin therapy as an approach to the challenge of schizophrenia, the various antipsychotic medications developed in the late 1950s and subsequently, some of these too have the side-effect of inducing significant weight gain as well other sometimes unpleasant side-effects.

The astute reader at this point might wonder where in the history of Irish psychiatry was there a role for the non-medical approach of psychotherapy and, particularly, its dominant format for much of the twentieth century – psychoanalysis. In fact, there is little room in Hearing Voices for psychoanalysis, Janet Malcolm’s “Impossible Profession” and the dominant approach to psychiatry in the USA for much of the twentieth century (although some psychoanalysts would contest the linkage). In fact, Kelly mentions the work of another one of his luminaries, Dr Thomas Drapes, who, as co-editor of the Journal of Mental Science, published his own translation of French psychiatrist Yves Delage’s Une psychose nouvelle: la psychoanalyse in 1917. It is a curious irony that the jurisdiction in which psychoanalysis is still practised to a great extent is France and the acute observer on any street in any middle class district of Paris can’t help but notice the abundance of brass plates containing the legend psychoanalyse.

According to Kelly, “both the breadth of Drapes’s learning and his myriad intellectual gifts were clear in his deft rendering of Delage’s coruscating critique of psychoanalysis”. And let us not forget the canard that Freud suggested that the Irish were the one race of people for whom psychoanalysis was of no use whatsoever. Nevertheless, Kelly recognises that psychoanalysis did (and does) play a modest role in Irish psychiatry and related disciplines. He does mention the work of Jonty Hanaghan, poet, writer and psychoanalyst, who founded the Irish Psycho-Analytical Association in 1942. However, by 1963, Kelly informs us that the association had just five practising psychoanalysts, presumably gathered round the Hanaghan/Rupert Strong dyad.

On a more positive note apropos the psychoanalytical therapies, Kelly notes the establishment (and current functioning) of the School of Psychotherapy at St Vincent’s University Hospital by Professor Noel Walsh and psychoanalysts Michael Fitzgerald and Cormac Gallagher.

Kelly devotes a substantial part of his narrative – so substantial and critical in fact that this aspect of his history deserves a review in its own right – to the role of legislation in driving the characteristics of Irish psychiatry right up to the present day, with the Mental Health Act 2001 and its associated regulations, which took a further five years to promulgate. (That act itself is currently under review.) Those characteristics have already been touched on but are worth repeating and highlighting here. They are the asylum paradigm, the professionalisation of medical care of mental illness, the use of extraordinary – to the modern mind – treatment practices and, most importantly, the custodial nature of Irish psychiatric care up until 1945 and, arguably, up to the enactment of the Mental Health Act 2001, which finally provided for extensive and state-supported mechanisms of case review for patients involuntarily detained.

Such detention down the years Kelly rightly recognises as a deprivation of liberty largely without recourse to appeal. At least prisoners in the penal system had a certainty about the duration of their incarceration. Even this limited comfort was not available to involuntarily detained patients in the psychiatric system throughout the nineteenth and much of the twentieth centuries. Kelly – a formidable advocate of the human rights of patients – is incensed by this.

And what of those patients who did experience long incarceration in the so-called “back wards” over the years? Kelly records with regret that this is the one area of his history that is incomplete and perhaps it can never be completed, at least in relation to the history of Irish psychiatry up to now. He can find only two published accounts of such experiences: It Happened in Ireland, written by maverick priest, Clarence Duffy, about his detention in Monaghan Mental Asylum in the 1930s and published in New York in 1944, and Hannah Greally’s Bird’s Nest Soup, published in 1971 and happily still in print. Kelly acknowledges that he has had limited access to old patient files in a number of the former institutions but concedes that these provide largely medical descriptions and classifications of illnesses of the patients to which they relate. They cannot provide an insight in the way that Duffy and Greally do into the “lived experience”, as the current jargon has it, of the patients concerned.

However, some progress is now beginning to be made in this area, for example with the publication (by agreement, of course) of a number of books by the current medical director of Swift’s Hospital, Jim Lucey, on the experiences of his patients in their engagement with the services in St Patrick’s. Then there are the wider engagement processes set up by the College of Psychiatrists in Ireland and in the Health Service Executive to ensure that the views and experiences of patients and their families can be tapped into to inform the training of young psychiatrists – who now must be trained in psychotherapy as part of their syllabus – and to improve policy-making in relation to mental health and the delivery of services, which is what counts most after all. Kelly, in his examination of the role of these and other developments in the current and future practice of Irish psychiatry, recognises the importance of Mad Pride Ireland founded by the late John McCarthy in Cork, the development of the Mental Health Trialogue Network as a community development initiative in Irish mental health and, perhaps, not surprisingly given the title of his book, the Hearing Voices Network set up in Limerick in 2006 by the redoubtable Brian Hartnett.

This, in a way, takes us full circle. It might be appropriate to finish this review of what will become a vade mecum for anyone with an interest in the history of Irish psychiatry and the care of the mentally ill by quoting in full from the final three paragraphs of Kelly’s substantive text:

This ongoing task of historical exploration is complex, compelling and utterly critical if Ireland is to come to terms with its troubled institutional past and to provide a meaningful voice for those who were denied a voice for so long.

The first and most immediate step in achieving justice and resolution, however, is to address the social exclusion experienced by the mentally ill today, especially those detained in Irish prisons and homeless on Irish streets. Solutions are to hand: enhancing general psychiatric services (community services and inpatient care) to prevent these problems in the first instance, strengthening forensic mental health care (including secure inpatient care), and creating genuine functional links between social services and mental health teams to address homelessness and other social problems among the mentally ill and their families.

These goals are readily achievable in partnership with patients, families and community groups. Taking these pragmatic steps is the best way to remember the forgotten multitudes that crowded the Irish asylums of the 1800s and 1900s and the even greater numbers who languished in prisons and died in squalor prior to the era of the asylums. Addressing these contemporary issues is the most effective, compassionate and transformative way to use the lessons of Ireland’s psychiatric past to bring justice and healing to the mentally ill today.

For this reviewer, these words are a ringing and humane call to arms to the psychiatric and wider communities. Let us hope that call is heard.

Liam Hennessy is head of Mental Health Engagement (MHE) at the Irish Health Service Executive (HSE).

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