Review

Katriona O’Sullivan, an Associate Professor in the Department of Psychology at Maynooth University whose research focuses on digital inclusion and educational disadvantage, offers in Poor a memoir that is more than a narrative of personal resilience. The book traces her journey from a childhood marked by poverty and parental addiction in the UK and Ireland to her eventual academic achievement (O’Sullivan Reference O’Sullivan2023). For the Irish psychiatric clinician, it functions as a visceral map of what might be called the “secondary care reality.” While many readers may focus on the author’s eventual academic success, a clinical reading reveals a profound account of how social deprivation, childhood adversity, and systemic neglect converge to shape complex psychiatric presentations.

One of the strengths of O’Sullivan’s account lies in its depiction of what might be described as sub-threshold psychiatric illness. Within diagnostic systems governed by the categorical frameworks of DSM-5 and ICD-11, clinicians often struggle to classify patients whose symptoms such as anxiety, emotional dysregulation, and hypervigilance are not discrete disorders but are embedded in conditions of chronic instability. O’Sullivan describes an environment in which the nervous system remains permanently calibrated for threat. This is illustrated through her accounts of unstable housing and parental substance misuse, where unpredictability becomes the organising principle of daily life.

As a trainee, I have often encountered “adult versions” of the children she describes: individuals presenting repeatedly in crisis, frequently driven by substance misuse or acute social stressors, yet not meeting criteria for a primary psychotic or affective disorder. The memoir captures how poverty can shape psychological development long before patients appear in psychiatric services. Of particular clinical relevance is O’Sullivan’s reflection that her mother may have experienced sub-threshold mental illness, which in the context of substance misuse, was never formally recognised or explored by services. This highlights the extent to which diagnostic overshadowing and social complexity can obscure underlying psychopathology in real-world settings.

The book also highlights the limits of acute psychiatric intervention when it is separated from social context. One of the persistent realities of clinical work in socially deprived urban areas is the “revolving door” of systemic involvement between emergency departments, addiction services, social care, and mental health teams. O’Sullivan’s recovery did not arise from a single medical intervention but from sustained relational support and access to educational opportunity. Her account illustrates the importance of what she describes as “relational poverty,” the absence of stable interpersonal connections that support psychological resilience. Medication may stabilise acute crises; however, the long-term recovery in the memoir depends heavily on relationships, social capital, and structural opportunity, factors often beyond the immediate scope of a psychiatric consultation. Although the memoir is compelling, readers may wish for a more explicit engagement with the structural barriers that continue to constrain similar trajectories for many individuals. This clinical reading foregrounds adversity and patterns of service interaction, the memoir also powerfully illustrates the role of education, relational support and structural opportunity in enabling social mobility.

The narrative also invites reflection on how clinicians interpret concepts such as “non-compliance” or “difficult engagement.” In clinical documentation, patients from disadvantaged backgrounds are frequently described as hostile or resistant to treatment. O’Sullivan’s account suggests that distrust of institutions, including medical and psychiatric authority, may represent an intelligible adaptation to environments characterised by neglect and instability. A trauma-informed approach that prioritises listening before labelling may help mitigate the epistemic injustice that vulnerable patients sometimes experience within medical systems.

Another important theme within the memoir is the intergenerational transmission of adversity. O’Sullivan describes the legacy of parental addiction and poverty within a specifically Irish social context. Her experiences highlight the cumulative nature of disadvantage and reinforce the relevance of the Adverse Childhood Experiences framework in contemporary psychiatry (Felitti et al. Reference Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss and Marks1998). When clinicians encounter a patient in crisis in an emergency department in Dublin’s North Inner City, they are often witnessing the outcome of decades of environmental stressors that have shaped both neurodevelopment and identity.

For psychiatry trainees working within the Irish Health Service Executive, Poor offers an important complement to formal clinical training. The memoir provides narrative context for the social determinants of mental health frequently discussed in academic literature (World Health Organization 2014). It reminds clinicians that the experiences appearing in case notes often represent only a brief snapshot of complex life histories shaped by poverty, trauma, and structural inequality.

Ultimately, Poor functions as a quiet call for a more socially informed psychiatry. The memoir highlights the importance of integrated care pathways that connect mental health services with addiction treatment, education, housing, and community supports. In doing so, it reinforces the need for a model of psychiatric care that recognises the structural barriers to mental well-being and that effective clinical care must extend beyond diagnosis to engage meaningfully with the structural conditions shaping patients’ lives.