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)
