19th September 2005
The Mental Health Commission's Annual Report for 2004, which includes the report of the Inspector of Mental Health Services, weighs 3 kilos. Having carried it home to read it I was in such a state of collapse I felt obliged to weigh it. It had an impact in the press to match its size when produced a couple of months ago - "shock and awe" would be a good way to describe the reaction of many who wrote about it in the lay and medical press.
It is a fine report and a great deal of hard work has gone into producing it, but from past experience I feel sure that little will happen to ensure the recommendations therein are implemented or the criticisms responded to. The reports of the Inspector of Mental Hospitals which preceded this report were lighter but pointed out serious deficiencies, too, and it was a war of attrition to have even such basic recommendations as that patients should have their own clothes implemented. Let's face it - there are no votes in mental health.
At some stage in our lives a quarter of us will suffer from a mental illness. Maybe it won't last long but maybe it will be enduring. Maybe outpatient treatment will suffice - but perhaps, especially at the acute stage, we may need a spell in hospital. If I was writing the same about broken legs, and a quarter of us were to suffer from them, I know that the groundswell of support for proper orthopaedic units would be intense, but this is not so with mental illness.
It is very disappointing that agreement has not been reached with the consultant psychiatrists regarding the establishment of the Tribunals to examine those who are held involuntarily in mental hospitals. Lack of resources to implement legislation is all too frequent. In the explanatory memorandum to the Criminal Law (Insanity) Bill 2002, to which I will refer below, it was said there were no financial implications!
Because early treatment is so important for a satisfactory outcome in all kinds of illness, and prevention even better, I have great sympathy with the pleas for better child and adolescent facilities, but it is the section on Forensic Health Services that touched my heart most. Every report on prisoners emphasises that many people get involved in petty and serious crime because they are mentally ill and get very little treatment after they are apprehended.
In the Mental Health Commission Report 2003 Teresa Carey, who had just begun as the first Inspector of Mental Health Services wrote:
"The forensic mental health services nationally are seriously underdeveloped. While the staffing of the service has expanded somewhat in recent years, services remain inadequate at both hospital and community level. The Central Mental Hospital (CMH), a facility providing medium and high security beds, is the only designated forensic unit available nationally but has long been recognised as providing accommodation that is of a totally unacceptable standard."
The Inspector goes on to point out that in the CMH, because it is the only forensic unit, there are persons who may require a lower level of security and the lack of community follow-up for these patents outside the city area hinders their discharge.
When persons become mentally ill, or are found to be mentally ill when they come before the courts having been accused of committing a crime, they become patients. At any time there are patients in the CMH who have not been accused of committing any crime, too. In 1991 the General Assembly of the United Nations adopted Resolution 46/119 on the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, "These Principles" the preamble states "shall be applied without discrimination of any kind such as on grounds of disability, race, colour, sex, language, religion, political or other opinion, national ethnic or social origin, legal or social status, age, property or birth".
May I draw your attention to "legal status"? In the 2003 report the Inspector goes on to say that "developments in the forensic mental health science are dependent not only on adequate resourcing, but also on developments in the legal framework for mentally disordered offenders".
The Criminal Law (Insanity) Bill 2002 left the Seanad for the Dáil in a state which I felt, despite my best efforts, was worse than in which it came in. When discussing this Bill in her 2004 report the Inspector writes "The current Bill stigmatises those who have a mental illness who offend by using the term 'insanity' in its title. The term has no meaning in the discipline of psychiatry. If it still has meaning within the legal profession it is perhaps time to find a less stigmatising word to describe the concept of incapacity due to mental illness." Well, when I tried to get the words "Mental Disorder" inserted to replace "Insanity" my legal friend, the Minister for Justice, Law Reform and Equality said: "We do not want a situation in which juries would arrive at the view that any mental disorder, regardless of how trivial, would provide grounds for acquittal. The Bill creates a high threshold. Whatever the term 'insanity' might convey and connote to psychiatrists and sociologists, to the ordinary man and woman in the street it suggests that the person in question was insane when the offence was committed." (Criminal Law (Insanity) Bill, Committee Stage, 7 April 2004, Col. 261)
Worse was to come. In the Mental Health Act 2001 patients are to be given "care and treatment". The Criminal Law (Insanity) Bill 2002 unkindly varied "care and treatment" with "care or treatment". While the minister had told me he did not see consistency between the Bills as being of importance, he said at Committee Stage "I appreciate the reasoning behind Senator Henry's amendment which proposes the alignment of mental disorder for the purpose of this Bill and that of the Mental Health Act 2001. Although this issue has been the subject of much public debate, I profoundly disagree with the proposition that there should be an alignment". (Criminal Law (Insanity) Bill, Committee Stage, 7 April 2004, Col. 255)
I was dismayed when all my amendments to ensure the patient always got care and treatment were dismissed and where those words had existed "care or treatment" replaced them. Note the reply Minister Brian Lenihan gave me: "To use 'care and treatment' throughout the Bill would suggest that in all circumstances, both care and treatment must be provided, whereas only one might be possible. An example might be where a person's condition is not treatable where, for example, he or she suffered from Alzheimer's disease, but the person would still require a great deal of care." (Criminal Law (Insanity) Bill, Report Stage, 19 April 2005, Col. 27-28)
How many grey heads do we see in prisons? I can only hope someone in the Dáil succeeds in getting the Minister to change his mind.
Senator Mary Henry, MD
