Mental health care in Ireland has improved vastly over the years in terms of quality of care. So why does so much stigma continue to surround the topic?
Entering St Patrick’s University Hospital in Dublin 8, there is no resemblance to anything one would associate with One Flew over the Cuckoo’s Nest, Girl, Interrupted or even The Bell Jar. I see no sterile white corridors or barred windows that are so common in media and artistic portrayals of mental health services. There are no “men in white coats” hiding around corners – in fact, it’s practically impossible to tell the patients from the staff. On the day we visit, an exhibition has just begun of paintings, drawings and pottery by both the staff and the “service users”, as they are known, in the public areas of the hospital.
In short, it’s about as far away from the stereotypical and stigmatised image of mental health care as it is possible to be. We are shown music rooms, art rooms, even games rooms. There’s a gym onsite, a library and a computer room. Every opportunity and privilege of this kind is extended to patients. But this is a private hospital, and most treatment is paid for by patients either through private health insurance or their wallets. It can’t be doubted that St Patrick’s provides extremely well for their patients, but it comes at a price. And despite the therapeutic benefits they may have, the facilities mentioned above that we were given access to do not make a mental health treatment centre on their own – they make a hotel.
Though it’s certainly true that the stigma towards mental health isn’t as harsh as it was in the past, the remnants of a pervading fear of mental health care still lie at the heart of Irish society. It’s hardly surprising given the ways in which we used to treat people with mental health problems. CEO of Mental Health Ireland, Orla Barry, describes mental health services in Ireland in the past, “[Asylums] were places that sat in communities all around Ireland, as these huge, usually grey or red buildings that were feared… if you look back to the 1980s we talked about psychiatry – it wasn’t mental health, it was psychiatry.” However, the stigma is even less surprising given how we talk about mental health care now. The enormous discrepancy between the ways in which mental health care services are spoken of and what they actually do has lead to a distrust of the service that has little to do with historical stigma, and everything to do with current misrepresentations of the challenges that people suffering with mental health problems face in finding acceptable treatment. In many ways, institutional and structural stigma has a bigger role to play than social stigma in the treatment of those suffering with mental illness and looking for help.
Professor Jim Lucey, Medical Director of St Patrick’s University Hospital, is well aware of the issues that lie in the enormous discrepancies between public and private mental health care. “In Ireland, what happens is that you’re told that it [mental health care] will be free at a point of service wherever you go, every clinic that you go to in the country under the HSE is free. But in reality, the patchy nature of the service means that the availability of resources in those clinics is very different depending on your geography. Your postcode geography determines what you’re likely to get. They’re having to ration their resources according to a set of criteria that are largely about geography, and what we’re having to do is divide our service accordingly to the ability to pay something.” As of October 2014, more than 30% of the children and adolescents on the Child and Adolescent Mental Health Services waiting lists were waiting more than three months for an appointment under the HSE. The year-to-date figures in October showed that over a quarter of adults were also waiting for longer than three months for an appointment. There are no costs for treatment available on the website for St Patrick’s University Hospital; however, an appointment in St Patrick’s Dean Clinic in Sandyford, the closest branch of the Dean Clinic to UCD, will cost €150 for one hour. Clearly, if one is suffering with a mental health difficulty, the problems with getting treatment leave patients stuck between a rock and a hard place. There is a major problem in a healthcare system where access to mental health care is not made reasonably and readily available regardless of income levels.
The high cost of private mental health care is not easy to defend, even by those who play a part in it. “By not acknowledging the real cost of [mental health care] we’re not actually assisting people in recognising the real value of it, we’re denying the value of it,” says Professor Lucey in defence of the high cost of treatment at St Patrick’s. This is a difficult point to argue for given the large numbers of callers to organisations and free helplines such as the Samaritans, Childline and Aware, even when we disregard the undeniable classism that is shown by Prof Lucey here. However Professor Lucey went on to say, “We would love to be providing services for free, and what we do increasingly is we provide more and more services for free through our charitable work. In the last year we provided maybe €3 million in free services to various people who were unable to afford our services.” It is this very discrepancy between what is said and the actions that follow that result in the stigma that we attach not to the mentally ill, but to the treatment for those who struggle with mental illness.
It is entirely possible that access to mental health care and the type of mental health care that one receives as a result is a class issue. Orla Barry of Mental Health Ireland says “This is down to who has access to what… The likelihood is that if somebody goes into their GP and they’re feeling depressed, the GP may refer them to a support group or they may suggest that they go to see a therapist. But it is also quite likely that a GP as a medical doctor will take the approach of prescribing medication.” A GP may be most inclined to prescribe antidepressants or some form of medication for a mental health issue where a psychologist may be more likely to prescribe a form of therapy, whether this is psychotherapy or a form of creative therapy. Barry goes on to say, “I would certainly be of the view that there would be huge benefit in having a wider range of therapeutic approaches available to people rather than simply medication. Some people find medication very helpful, other people don’t but it’s actually about choice…The difference between those services [private hospitals] is that they’re hospital based in the main – the primary focus of their service is the hospital and what goes on there. In the public service the primary focus is the community service, so they’re very different in terms of their orientation. Within the community services it’s much more likely that if there was somebody who was attending a community mental health team and it’s judged that mindfulness might be very helpful for them, their community mental health nurse or their occupational therapist is quite likely to advise them to go to something in their community… so there’s different priorities and it’s a different orientation.” However the same thing cannot be said for patients; presumably, they only have one main priority in seeking mental health care, and that is recovery. Unfortunately it is impossible to adequately examine the affects of these different priorities on patient care.
But stigma surrounding mental health treatment may also arise directly from the treatment itself. A current trend in recovery from mental health difficulties is the notion of “self-directed care”, which empowers a patient to take charge of their own recovery. Barry says, “The essential thing in recovery is that the power is with the person, not with the professional. A very big push within our whole mental health system now is to actually see the person as their own expert, and to see the role of the professional as bringing an expertise to the aid of the person to help them in terms of their recovery.” Again, we see inconsistencies between what we are told and what actually happens. Time and time again we have heard that mental illnesses are often biological or physical in nature, but patients suffering with pneumonia or any other physical illness are not told to take charge of their own recovery. Why should the onus be put on patients of mental health issues, some of whom can be some of the most vulnerable in society, to be well? Is it therefore our own fault if we cannot recover from mental illness alone? The answer is of course a resounding no, but when mental health treatment centres themselves come so perilously close to blaming those struggling with mental illnesses for being ill, how can there be any hope of reducing the stigma of mental illness in the eyes of the general public?
“Self-directed care” comes to a grinding halt when it meets the Mental Health Act. Unlike most other areas of healthcare, mental health can in extreme cases impinge on the liberty of the patient. Under the Mental Health Act, a patient can receive electro-convulsive therapy (ECT) when they are unable or unwilling to receive it, if it is deemed to be in the patient’s best interests. Although modern ECT is not the archaic and barbaric treatment it was when it was first administered without anaesthesia in the earlier half of the twentieth century, the potential side effects of memory loss can be very severe and it remains a controversial treatment. St Patrick’s University Hospital doesn’t administer ECT to those who are unwilling to receive it, but the same may not be said for other mental health centres around the country. Professor Lucey says, “ECT is a regulated treatment provided under rules set by the Mental Health Commission, which is the national regulator for mental health. It’s provided in St Patrick’s and a number of designated centres for mental health throughout the country and we provide it for a very small number of people, but a number of people who do need it as part of their treatment plan. It’s a treatment like any other in mental health in the sense that it’s prescribed and is regulated by law… We don’t give ECT to people who are unwilling to take it under the [Mental Health] Act. Even though the Act hasn’t been reformed in that way yet, we’re operating as though it has.” There is no room for self-directed care when it comes to unwilling ECT performed on a patient – and yet, many mental health practitioners seem to forget that while self-empowered recovery may work for some, for others it merely increases the stigma that surrounds getting help.
See Change is the national stigma reduction programme for mental health. Sorcha Lowry, campaign manager for the Green Ribbon campaign, says “Yes, our history has a role to play, but more importantly let’s look at the sources of stigma that allow this silence and shame to exist. Stigma is cultural, social and also structural. Culturally for instance, we have a million different euphemisms for mental health to avoid actually talking about it. Socially, there is still a huge reluctance to be open about what’s really going on for you with friends and even family. Structurally, it’s a regrettable fact that people who are open about their mental health still often experience prejudice and discrimination in the workplace, applying for insurance and mortgages etc.” Making mental health care and recovery seem like an easy task that can be accomplished through fancy facilities and “self-empowered recovery” undermines the difficulties that one can go through when they have a mental health problem, and the affects of class on the type of treatment that one will receive destabilises our perception of it. Cancer is widely spoken of and little stigma surrounds it nowadays- but it is a well known fact that cancer treatments such as chemotherapy and radiotherapy are very difficult on the patient. There is no reason why mental health problems should not be treated in the same way, by mental health practitioners and the general public alike. We must fully encourage those who are suffering to seek help – recovery is always possible – but we also must be truthful about the disenchanting nature of the public and private mental health services. In order to overcome the stigma of mental health, all we have to do is be honest about it.
Ireland is fortunate in the numbers of voluntary and charitable organisations that provide services for free. The Samaritans can be reached free in the ROI by calling 116 123. The Aware support line can be called on 1890 303 302 and charges local rates. The Green Ribbon campaign by See Change works to overcome the stigma of mental health- more information can be found at www.greenribbon.ie