In his foreword to Mental Health in Ireland: Policy, Practice and Law, Ivor Browne surmises that the psychiatric profession, ‘seeking to distinguish contemporary practice from the barbarism of the past … found refuge in a reductionist, mechanistic conception of the human being’. The shortcomings of psychiatrists and the mental health system they control are critically scrutinised throughout this searching new collection of essays edited by Agnes Higgins and Shari McDaid. Indeed, many of the essays question the fundamental beliefs that underpin the delivery of mental health care in Ireland today.
The book is divided into three sections, the first of which deals primarily with historical aspects of mental health care delivery in Ireland. Damien Brennan in his treatise on institutionalisation and deinstitutionalisation argues that psychiatric hospitals became a dumping ground for social misfits and that their economic importance to communities sustained them long after it was obvious that they were not fit for purpose. Similarly, Brennan sees deinstitutionalisation as having been driven by social, political and economic factors. He discounts the severe mental illnesses that many of those who were institutionalised suffered and gives little credit to advances in treatment, tightening of diagnostic standards and more enlightened mental health legislation in their subsequent release. In the subsequent chapter, Liam Mac Gabhann rails against psychiatric hegemony and looks forward to empowered service user movements pushing back the professions. Shari McDaid follows this with an essay highlighting the degree to which those with ‘mental health conditions’ continue to be excluded from full participation in society and criticises mental health services for engineering the reinstitutionalisation, segregation and marginalisation of these people.
The second section that examines developments in the field, starts off with Agnes Higgins and Paddy McGowan describing the many challenges in reorienting mental health service delivery towards recovery. They recognise the risk that the language of recovery will be assimilated without accompanying meaningful changes in the delivery of care. They rightly draw attention to the tightrope that psychiatrists walk between a government policy that espouses recovery and a legal framework and public discourse that holds them responsible for preventing adverse outcomes. Liz Brosnan then traces the interesting history of Irish mental health service use/survivor movement and looks forward to a day when professionals are on tap rather than on top. Mike Watts in his piece on mutual help seeks a similar change, to a system in which non-professionals have a much larger role.
The editors combine forces for an interesting essay entitled ‘The paradoxical role of families in mental health’. In their view the burden on families and carers arises from ‘their relative’s engagement with mental health services’ rather than directly resulting from their mental health condition. An extremely informative chapter on the mental health needs of minority ethnic communities in Ireland follows. Shane Butler then recounts the historical flip-flopping and continued disparities in Irish approaches to the treatment of alcohol disorders. The second section is rounded off by a useful chapter on the Irish criminal justice system’s many interfaces with people experiencing mental health problems.
The final section looks at future of mental health care delivery in Ireland. Brendan Kennelly valiantly explores the question of how to redress the current inequities in mental health service provision. Mary Keys examines current Irish mental health policy and law in relation to human rights provisions and finds a need to move away from medically determined best interests towards individual choice and autonomy. This is followed by a thoughtful chapter on risk that points out the inherent contradiction between society’s pre-occupation with risk reduction and the concept of recovery. David Healy then details the profit-driven practices of the pharmaceutical industry as new drugs are promoted despite minimal added value and without due regard to their adverse effects. He argues that the RCT and the prescription pad, although originally conceived of as safety measures, have been subverted to facilitate pharmaceutical sales. The editors conclude that ‘real collaboration, partnership and recovery orientation will only happen when the institution of psychiatry is ready to recognise the damaging effect of current models of care on service users, family supporters and indeed practitioners’.
There is much to be recommended in this handsomely produced collection of essays. Each chapter is followed by provocative questions for discussion and debate and I certainly found the book’s critical stance to be intellectually stimulating. To my mind, the book’s title should have been chosen to give some suggestion as to the uniformly censorious nature of the material therein. Many of the pieces included are excellent and contain important new material. However, some important topics such as drug addiction, psychological treatments, or child and adolescent mental health are not covered. The book would have been stronger in my view if the editors had included a broader church of opinion. Sociologically oriented academics dominate the discourse and there is very little room for psychiatrists, psychologists or others working at the coalface. Notwithstanding these criticisms, this book is an extremely valuable addition to the mental health literature.
