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
