Hearing Voices: Lessons from the History of Psychiatry in Ireland
Psychiatry has always attracted the interest of film-makers ^1,2. The results are distinctly mixed, with a general tendency to focus on the dramatic rather than the informative, the custodial rather than the compassionate. Occasionally, however, a film demonstrates an important truth about the nature and history of psychiatry.

Camille Claudel 1915 (3B Productions, 2013) is one such film. Directed by Bruno Dumont and featuring Juliette Binoche, Camille Claudel 1915 focuses on the later life of Camille Claudel (1864-1943), a French sculptor and artist, and close associate of Auguste Rodin (1840-1917), a fellow-sculptor. In the early 1900s, following a tempestuous period in her life, Camille began to behave strangely, destroying some of her work and disappearing for periods. During this time, Camille’s father was her chief support and protector³. Just one week after his death in 1913, Camille’s family arranged to have her admitted to the psychiatric hospital of Ville-Évrard in Neuilly-sur-Marne, France. Doctors tried to convince her family that Camille did not require institutionalisation, but the family insisted and the doctors acquiesced. Her mother, in particular, believed Camille brought intolerable scandal to their lives.

The following year, Camille was transferred the Montdevergues Asylum, near Avignon. There she remained for thirty years until her death in 1943. Camille was buried in a communal asylum grave and asylum staff were the only people at her funeral. Towards the end of Camille Claudel 1915 there is a heart-rending scene during Camille’s time at the Montdevergues Asylum, when her brother, writer Paul Claudel (1868-1955), speaks with Camille’s doctor, who reiterates his view that Camille should be released. Paul strongly disagrees and the asylum doctor again acquiesces, unhappily, to keeping Camille in the asylum. While this particular scene is located in early twentieth-century France, its content has much broader relevance to the story of psychiatry. Throughout its brief history, psychiatry has all too often acquiesced to the roles pressed upon it by others^4,5. This was as true for Ireland over the past two centuries as it was in Camille Claudel’s France, if not more so.
The Irish asylums were a convenient solution for many difficult societal problems, and while there is plentiful evidence that many patients were mentally ill, a significant proportion were not. And, for a great number of those with psychiatric or psychological problems, it is likely that these problems could have been managed without a rush to institutionalisation if viable alternatives had been available: outpatient mental health care, better resources for family care, supported accommodation for the homeless, systematic social welfare for the poor, residential facilities for the intellectually disabled, meaningful supports for single mothers, and so forth. In the absence of such provisions, Ireland’s asylum beds became all-too-convenient options for a society with an apparently insatiable hunger for institutions, incarceration and control.

The emergence of clinical professionals, both medical and nursing, was inevitably a factor in this complex mix, but the effects of any search for professional prestige were dwarfed by asylum doctors’ clear outrage at what the asylum system became. There were powerful, non-medical, vested interests in keeping large asylums open. In 1951, the town of Ballinasloe had a population of 5,596 people, and, of these, 2,078 were patients in the mental hospital6. As a result, virtually everyone in the locality was a stakeholder in the mental hospital in one way or other, as a relative of patient, worker, or supplier.
Communities and families used mental hospitals in complex and often subtle ways, according to their needs: e.g. removing relatives from asylums to work at home in the summer and then returning them for the winter (‘wintering in’). Medical opinion was not required for committal much of the time, and Ireland’s asylum archives are replete with letters from doctors urging families and governmental authorities to cooperate with discharge of patients⁷. As occurred with Camille Claudel’s doctors in France, Irish doctors’ entreaties often fell on deaf ears, or families were genuinely too poor or ill-equipped to accept home a person with mental illness or intellectual disability.
There was strong medical support for alternatives to inpatient care and the reasons why Dr Conolly Norman of the Richmond did not succeed in his plans for care outside the asylum in the late 1800s and early 1900s lay not within the medical profession, but within government, which repeatedly frustrated efforts to de-institutionalise. Reformist impulses were further stymied by the stigma of mental illness (as reflected in the Dangerous Lunatic Act 1838) and the fact that Ireland’s asylums functioned as a large, unwieldy social welfare system for many patients and some staff.
As a result, Ireland’s remarkable asylum system was primarily a social creation rather than a medical one, albeit that asylum doctors were involved in the growth of the system or, at very least, their objections were insufficiently effective to control it. But that was just one part of a broader, more complicated story: the much larger failing lies outside the field of psychiatry entirely, in a society that failed to generate solutions to real human suffering (mental illness, disability, disease, poverty, ill fortune) other than the extraordinary network of institutions that characterised so much of Irish history: orphanages, industrial schools, reformatories, workhouses, laundries, borstals, prisons and, of course, asylums.
Many of these problems persist today. In 1907, for example, 30% of admissions to the Richmond Asylum at Grangegorman came directly from workhouses⁸. In 2007 - exactly a century later - 35% of emergency psychiatry assessments at the Mater Misericoridae University Hospital (just up the road from Grangegorman) were for homeless persons⁹.
Ultimately, taking both historical and current clinical perspectives into account, one of the clearest features of the history of psychiatry is that the pendulum in Irish psychiatry has now swung strongly away from institution-based care, as the number of inpatients has diminished greatly in recent decades and the rate of involuntary admission is now comparatively low by international standards. Indeed, it is arguable that his process has reached its limit, and that the pendulum might swing back towards inpatient care. And that might well be a necessary corrective, in order to improve all forms of care and support required by the mentally ill and their families.
There is also strong evidence of powerful re-interpretations of certain experiences (such as hearing voices) which used to be invariably associated with mental disorder but are now subject to more nuanced interpretations, formulated chiefly by those having such experiences themselves (www.voicesireland.com). The ‘Open Dialogue’ approach presents another innovative and inclusive approach to mental health¹⁰, and the EOLAS project is another progressive, collaborative development in this area11. There are now myriad voices of change within Irish mental health services and communities: one size does not fit all.
There are also powerful movements to promote the human rights of the mentally ill, as reflected in Ireland’s ongoing revisions of mental health legislation. These initiatives need to be matched by continued developments in services and ongoing improvements in social care, in line with national mental health policy. Much has changed, but there is still much to do, especially in the areas of economic and social rights.
Too often in the past, the mentally ill were shamefully neglected by systems of health care and, especially, social care, to the point of the mentally ill dying alone, paradoxically abandoned within a custodial asylum system which, despite considerable effort, could not find a way to persuade broader society to accept them back.
And, as with Camille Claudel, members of asylum staff were often the only ones at the funerals of the forgotten patients of the Irish asylums – a small measure of humanity afforded by a society that has always excluded the mentally ill.
But it was far too little humanity, far, far too late.
We must do better.

Correspondence:
Brendan D Kelly
Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin 24, Ireland
[email protected]

Conflict of interest:
None to declare

References
1 Gabbard GO, Gabbard K. Psychiatry and the Cinema (Second Edition). Washington, DC and London: American Psychiatric Publishing, 1999.
2 Kelly BD. Psychiatry in contemporary Irish cinema: a qualitative study. Ir J Psychol Med 2006;23:74-9.
3 Mahon EK. Scandalous Women: The Lives and Loves of History's Most Notorious Women. New York: Perigree/Penguin Books, 2011.
4 Kelly BD. Hearing Voices: The History of Psychiatry in Ireland. Dublin: Irish Academic Press, 2016.
5 Walsh D. Brief historical review. Ir J Psychiatry 1992;13:3-20.
6 Walsh D. Mental illness in Ireland and its management. In McCluskey D (ed.), Health Policy and Practice in Ireland (pp.29-43). Dublin: University College Dublin Press, 2006.
7 Kelly BD. Folie à plusieurs: forensic cases from nineteenth-century Ireland. Hist Psychiatry 2009;20: 47-60.
8 Kelly BD. One hundred years ago: the Richmond Asylum, Dublin in 1907. Ir J Psychol Med 2007;24:108-14.
9 O’Neill A, Casey P, Minton R. The homeless mentally ill: an audit from an inner city hospital. Ir J Psychol Med 2007;24:62-6.
10 Kłapciński MM, Rymaszewska J. Open Dialogue approach - about the phenomenon of Scandinavian psychiatry. Psychiatr Pol 2015;49:1179-90.

11 Higgins A, Hevey D, Gibbons P, O’Connor C, Boyd F, McBennett P, Monahan M. A participatory approach to the development of a co-produced and co-delivered information programme for users of services and family members: the EOLAS programme (paper 1). Ir J Psychol Med 2016 [published online ahead of print].

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