Introduction

The office of the President has kindly agreed that this journal can publish in full the talk he gave to the college at our recent Winter Conference in Dun Laoghaire. He had been invited to speak at the conference in his capacity as Patron of the College and President of Ireland and we were delighted and honoured when he agreed to speak to us.

When the structure and governance of the new college was being planned before its formal commencement in January 2009, it was agreed that an Advisory Board would be part of that structure. The invited members of that board were to represent a broad section of wise and experienced people in society who had an interest in and knowledge of mental health issues and the importance of these issues for individuals, families and society. Michael D. Higgins was invited to be a member of our first advisory group because of his experience in sociology and other disciplines and subsequently became President.

At the first Advisory Board meeting that he attended he was very disappointed when a quite divisive debate took place between some members of the board about the relevant balance to be given to psychological versus biological theories and treatments of mental health problems. He was not alone in being disappointed and clearly expressed his views about how such polarised positions should be a thing of the past. He spoke then of how, during his time in public life, he had witnessed so much mental distress and illness and how simplistic and singular explanations about the nature of human suffering were outdated and wrong and a hindrance to progress.

Therefore, when invited to speak at our Conference, now as President of Ireland and Patron of the College, he clearly spoke from the heart and decided that he was not going to utter platitudes and empty praise, nor was he going to engage in a hollow exercise. Instead, he was going to challenge his listeners by reminding them of all the suffering he witnesses, and bears witness to, in his office as President and invited them to move beyond these old and sterile divisions. He welcomed Innovation and Research, the theme of our Conference, but challenged us to think more deeply about our practice and our society. A Patron is one who ‘gives benefits to his clients’. Our Patron gave us the benefit of this speech and his vision. Our college was honoured by his presence and sincerity.

Dr Anthony McCarthy

President

The College of Psychiatry of Ireland

Remarks by President Michael D. Higgins

The College of Psychiatry of Ireland

Research and Innovation Winter Conference 2012

Thursday, 15 November 2012

Good morning ladies, gentlemen and distinguished guests.

I wish to express my thanks to the College President Doctor Anthony McCarthy for the invitation to officially open your Winter Conference for 2012, with its focus on ‘Research and Innovation’. From reading the titles of the open sessions and the workshops I am sure that your conference will prove to be both informative and interesting.

Your meeting also provides an ideal forum for the sharing of your professional experience and information on improving and strengthening mental health care and services for our citizens, and appreciate too how you will want to respond to the challenges that arise in matching performance to your own standards, to legislative requirements, to new developments in difficult conditions and circumstances of care of which the legislative requirements are but one part, with all the affective care to which professionals at every level aspire and which constitute only the best of care practices that citizens might hope and expect from their professionals in a shared republic of citizenship, coming from the experience and encounters of patients with those who are now caring for them.

The promotion and undertaking of research must always be a central aim rather than an optional extra in mental health. It remains vital in contributing to new knowledge needed to improve health outcomes.

Research too, if sufficiently broadly structured, helps recognise and reduce the impact of inequalities on so many lives. It is all the more important to maintain a strong focus on research when resources are under pressure. Developing new ways of preventing, diagnosing and treating illness must continue, even while acknowledging the need to be more efficient and using resources more effectively.

Tapaím an deis seo freisin le rá go ndearna mé, an tráth ar iarradh orm glacadh le ról an phatrúin ar an gColáiste níos luaithe sa bhliain, an cheist a chur orm féin cén beart fiúntach a d'fhéadfadh patrún d'eagraíocht dá leithéid a dhéanamh. Tagann an focal ‘patrún’ ón bhfocal ‘patrónas’ na Laidine, as a mbaintear ciall an duine a thugann sochair dá cliaint. Is beag an sochar atá agamsa ar ndóigh, taobh amuigh de thaithí an tsocheolaí theoiriciúil arna aimpliú le daichead bliain a chaitheamh sa saol poiblí, is saol a chuir mé i dteagmháil leis na hearnálacha is soghonta den phobal, agus sin in am an ghátair go minic. Mar phatrún, rith sé liom go bhféadfadh sé a bheith úsáideach cúpla ceist a chur, agus cúpla cás a dhúiseacht, mar a bheadh ó thaobh an tsaoránaigh.

[Let me also take this opportunity to say that when I was asked to accept the role of Patron of the College earlier this year I asked myself the question as to what a patron of such an organisation might usefully do. The word ‘patron’ derives from the Latin ‘patronus’, translated as one who gives benefits to his clients.

I have little benefit to confer, other than the experience of a theoretical sociologist amplified by 40 years of public life that brought me into contact with the most vulnerable sections of the community, often in times of crisis. As Patron, I decided it might be useful to look at the Reports of the Inspector of Mental Health Services of 2011 and 2012 and to pose some questions and raise some concerns from such experience and from a citizen's perspective as it were.]

Much has changed, but then, sadly, so much that needed to change has not changed. More than 40 years ago as a sociologist lecturing on the sociology of deviant behaviour, which include, to a certain degree, the sociology of mental health, as it was at that time I recall that what was a very polarised discourse in the area of mental health between what was crudely summarised as a clash between talking therapies of the formation of the mind and what influenced it that invoked a humanistic discourse, and on the other side what was asserted as a real science of the brain that was heavily supported by the pharmacological industry in its suggestions for such treatment as would make life possible or, in the difficult cases bearable. These separate approaches differed not only in assumptions and concept but also in tone.

At about the same time, as a citizen and a public representative, I saw the merit and indeed the necessity of accepting that the circumstances of making a response to mental illness do differ and must define, to a degree, the approach of practitioners at every level and that good judgement is called for in indicating the choices to be made between the broad approaches to which I have referred, be they transactional or pharmacological.

As a sociologist looking in, I had hoped then for a coming together in future years of a parity of esteem between the advocates of such perspectives. I was to be disappointed. The discourse, I found years later, had become more personalised and frequently petulant.

This became very clear to me when, just a few years ago, I was asked to become a member of the College's Advisory Council. As late as 4 years ago, it was very clear that the polarised discourse was still there.

This is a matter of the greatest disappointment to me. Much more than that, the claim often made with broad brush strokes that there have been significant or deep changes in this area, including commitment to interdisciplinary approaches, may be correct in some areas and may have some validity, and I welcome it, but it concerns me that such interdisciplinary service provision as is recognised as valuable by all on paper is quite frankly not being delivered in so many places, is not part of the experience of patients and their families as the Mental Health Inspectors’ Report clearly shows. The picture is a very uneven one and it should be a cause for concern.

Yes, of course, the issue is one of resources, but I suggest it is much more than that. Yes, there have been some improvements, but there are neither fully interdisciplinary supports in place nor are such generally available. It raises for me the question as to whether it is not only the scarcity of resources, which is a problem, and indeed taking into account the necessary delay in professional formation that would give us new, skilled, professionals to fill the gaps, but perhaps the commitment to an interdisciplinary approach has simply become a rhetorical accommodation, tolerated as something of interest, not an essential to be demanded as part of adequate professional performance.

I said earlier that my experience was as a sociologist; as a former lecturer in humanistic sociology I have been struck by the near total neglect of the discourse issues – in the formation of medical students, issues of the construction of language, issues as to the use of language and the protocols for such in the citizen's interaction with services, the interaction of professionals with families, of fellow professionals with each other and with members of communities. These interactions raise issues that go far beyond the problems of language itself. They ask us to consider, for example, the forms of authoritarianism that we may have imported into our daily and professional practice and discourse with each other. I was very moved by Professor Kathleen Lynch, John Beker and Maureen Lyons’ recent book Affective Equality – Love, Care and Justice.

As a sociologist and a citizen, I have been concerned too as to how many of our citizen encounters in what we claim as a Republic are constructed in terms of asserting hierarchy and status – an unedifying debate as to who can affect the most certainty in circumstances that are full of uncertainty that modernists would suggest as of the past still prevails in places and at times, and indeed in a fashion that suggests a parallel with the dogmatic theology of the early middle ages.

In a lán áiteanna fán tír, is oth liom a thabhairt chun suntais nach ann d'fhoirne idirdhisiplíneacha ar chor ar bith dháiríre. In a lán áiteanna eile is faoi bhagairt atá siad. In áiteanna ina bhfuil siad ag feidhmiú, agus inarb iontach an obair idirghabhála, an obair freagartha agus an obair slánaithe ata á déanamh acu – tá siad anois i ndálaí deacra.

[In so many parts of the country I regret to note that interdisciplinary teams simply do not exist. In many others they are under threat. But of course where they are working, they do wonderful work of intervention, response and healing and they are now doing so in difficult circumstances. I thank them and salute them.]

But beyond the issues of even an equality that included affective equality, one might also ask as to whether an ethos of equality of skill, professional practice and even compassion within such teams exists? The patient in a hospital setting meets many staff. I have heard wonderful memories from patients of sensitive and compassionate staff at all levels, including the cleaning staff.

Understanding the issue of behaviour and its connection to language involves accepting that behaviour is mediated through culture, ancient and contemporary. Some professions indeed solve the problem by inventing a subculture of the place or of the profession – the way it's done here, or, more radically, the way ‘we’ do it. That there is a serious burden of authoritarianism in Irish culture and that it constitutes a real obstacle to compassionate engagement with each other and between classes I am convinced.

If we are to take account of our behaviours and assumptions, we must critique our culture for its failures, as well as drawing on its strengths. Why, for example, I ask do we not research, study or investigate the factors that inhibit, damage or block the working of intimacies and friendship as aspects of health research in a multidisciplinary way? All treatment strategies are, after all, affected by the cultural context in which they are offered. Can there be a science of mental treatment? And if there might be, is it not delivered through a craft of humanistic response? Is it not a more accurate suggestion, if more humble, and avoiding hubris, to say the findings of science can be applied in mental care?

All of these questions are ones that might rise from the consideration of her or his role by a patron in speaking to a conference like this, and I hope you will understand why I believe these questions I have mentioned must sit side by side with questions of quantitative research, valuable and indeed as essential as it is.

As to the legal environment which is part, but not all, of the choices to be made in care. The circumstances of mental illness will inevitably generate choices even for the application of the human rights clauses to which the college is committed and these clauses are welcome. But there are questions that occur to one as a former human rights participant in university. Are these human rights clauses derived from the rights of a community, from rights that constitute a social basis, or are they an assertion of personal rights from a theory of individualism?

If freedom is to be respected, personal rights are of course fundamental; but can a legally defined freedom be asserted in such an assertive manner as abandons an ill person to the risks of significant harm to himself, herself or others? These are fundamental rights questions with policy implications.

Again, if a prior assumption of disability or illness precedes the acknowledgement or recognition of a right and the imputation is made that the right of the citizen/patient only commences after such a designation, then such a serious limitation occurs as to make the rights involved, without real substance.

Such a version of rights is very different from the right to a full, healthy and participative right of a citizen. Thankfully, the current human rights debate has now moved on to the right to health and beyond the limited defensive notion of treatment, with a human rights rhetoric available for reference.

The institutions of professional practice and the protection of the State must surely meet in such a way as delivers the best outcome to the citizen and the community. All of these issues are, I believe, part of a full and sufficient discourse on citizens and their right to health.

As President, I have had the opportunity to visit communities who are engaging with mental health issues throughout the length and breadth of Ireland, and this has given me, I think, some insight into the issues facing our citizens in the Ireland of today – economic hardship, unemployment, social exclusion, age-related vulnerabilities and mental health issues. I see the destructive consequences of hopes dashed, lives devalued and its multiplier effect in misery and despair, through families and communities.

Experts say that one in four of us will experience a mental health problem in our lifetime, an increase linked, it seems, to how we live our lives in the 21st century. But numbers alone do not measure the suffering, the isolation, the exclusion and the stifling of human potential that mental health problems can cause. Too many families every day are forced to confront the sheer initial helplessness, and grief too, when a loved one at any age becomes mentally ill.

For those families and those individuals it is critical that the appropriate range of multidisciplinary community-based services be available and responsive to the holistic needs of those seeking support, and those too, who, while not seeking support, need it to be made available.

Our approach to mental health care has changed fundamentally over the past 25 years or so, but from a low base of public consciousness and in some cases institutional behaviour. The move from treating people with serious mental illness in long-stay psychiatric institutions, something that often hid a problem for relatives or communities, was a long time coming, but thankfully, now in more enlightened times, the accepted policy is that the vast majority of people should receive support in the community. Turning that policy into a reality with adequate provision is our current challenge.

The new policy is directed towards a shift in thinking, which recognises that people who experience mental ill health can, and with the right support, be able to live independently, be in work or education and have an active social and family life. But it is becoming increasingly recognised that these multidisciplinary supports are essential to recovery.

However, for too many people, the experience of mental health difficulties and the challenges faced in recovery are compounded by the absence of social and economic supports such as access to housing, job opportunities and adequate income.

I have met many people who have told me that they could never reveal to their employer any knowledge of their illness or its treatment.

The Ireland of the past never spoke openly about mental health illness, but a new, more enlightened, vocabulary and a growing awareness about the widespread impact of mental ill health on each of our lives has gone some way to changing that, even if the excluding forms of stigma still exist and often now lurk behind more sophisticated masks.

One of the most welcome developments about this new, more open, approach is that it has increased not just our ability to protect our mental health but also for many, though not enough, to recover it when it has been lost.

Our approach to mental health in the 21st century means that Irish people have an opportunity to understand, to some greater extent, what it means to be mentally healthy and are able to recognise, as they do with heart disease or cancer or any other serious illness, the earliest signs of mental ill health. But we are some distance from this as a general position.

We all want to see an Ireland where Irish people feel comfortable to share their experiences of mental ill health with those close to them and be able to ask for help if they need it.

However, far too many people with mental health problems suffer in silence, and report that negative attitudes, stigma and discrimination remain very serious impediments to their inclusion and meaningful participation in society.

I wish to turn briefly to the matter of mental health for our young people. Teenage years should be happy ones – it should be a fun and carefree time when personality develops and individuality blossoms. However, we know all too well that the reality for some young people can be quite different, and that adolescence for them can be a very difficult time. Physical and emotional development during adolescence can bring great stress, and many of our young people dwell in silent suffering, pretending all is well.

In advance of my recent Presidential Seminar on Being Young and Irish, I held a consultation with young people, and young people are asking for a holistic discourse and they are more than well aware of the risks of sounding too sensitive that all those words ending in ‘ss’ – goodness, kindness, gentleness – are no longer in general use or are seen as ‘soft’, when they encounter mental health problems or in the institutional response to it. Some practitioners too have given an impression, the young people told us, that efficiency must be delivered in such a way as excludes a vocabulary with ‘soft’ language.

It is critical therefore that we provide both in our health services and in our communities supports that are appropriate and accessible to children and young people. Early intervention for any young person experiencing mental health difficulties is what is needed. This provision will depend on the public requiring it to be delivered. We know that early intervention leads to the best health outcomes and reduces the likelihood and often the exclusions in many senses of long-term disability.

So let us welcome research and innovation, and let us agree that it is past time to abandon useless polarised divisions, old authoritarian certainties and the keeping of a professional silence on such inadequate provision as threatens professional integrity. Above all else, we need not only interdisciplinary work but the generosity of mind which can draw on it.

Let us welcome such improvements as have been made possible over these past decades, and salute too those who agitated for them and even more so those who are struggling to provide services in times of austerity.

Mar phatrún, ní mór dom chríochnú le hinsint daoibh go raibh mé corraithe chun labhairt libh mar a rinne mé arae gur mhothaigh mé nach fiú tráinín gníomh de mheon mímhacánta nó moladh bréagach agus dairíre píre mhothaím go mbeadh sé ag teacht salach ní amháin ar a bhfuil i mo chloigeann ach ar na mothúcháin is doimhne i mo chroí sin a dhéanamh, is croí a briseadh an iomad uair ar son comhshaoránach a bhí caite suas ar thrá an tsaoil, iad tréigthe briste gan caradas gan dlúthpháirtíocht.

[As patron, I must end by saying that I was moved to speak as I have because I felt that an exercise in bad faith, or hollow praise, would be worthless, and, frankly, I would find that it contradicted not only my head but the instincts of my heart, which has broken many times for fellow citizens who have been left broken and without friendship and solidarity in their vulnerabilities, vulnerabilities which should be ours too and shared.]

I do wish you well. As President of Ireland, I suggest it is not just your profession, but it is the people of Ireland, all of them, young and old who will benefit from your proceedings and maybe too in the future there may be occasions for the adequate discourse I suggest. May it happen.

Thank you. Go raibh maith agaibh as ucht éisteacht liom.