Custody, Care and Criminality (eBook)

Foreword

It is a pleasure to welcome the reader to this treasure trove of material assembled and analysed by Professor Brendan Kelly from primary sources in Irish hospital archives. Professor Kelly has gone beyond the nineteenth century, delving back into the 1700s and forwards into the twentieth century. Professor Kelly has drawn together the archives of the Irish asylums, case notes and committee minutes, to allow the reader to understand how this extraordinary mass confinement grew and declined. This is an important book for anyone interested in the real history of asylums, the management of mental health services and the care of the severely mentally ill and incapacitated. Those preparing syllabuses at undergraduate or postgraduate level will find this book valuable as a starting point for seminars on care, culture and compassion in mental health services, on mental health law and human rights.

What can the non-historian learn from this review? Professor Kelly raises a number of questions that are familiar, and some that are not.

WERE THE CALCULATIONS WRONG?

Was there a real increase in the number of new cases of severe mental illness in Ireland between the beginning of the eighteenth and end of the nineteenth centuries? Professor Kelly identifies distinguished writers such as Tuke (1894) and Conolly Norman, the forerunners of modern psychiatric epidemiology, who carefully calculated the increasing number of persons detained on the grounds of (legal) insanity in Ireland and concluded that there was a real increase in such disorders in Ireland over the course of the eighteenth and nineteenth centuries. They can be forgiven for confusing legal categories with clinical reality. The means of making such calculations were still being developed. National census data had been compiled from about 1821 onwards and Durkheim in France began calculating population-based suicide rates and the related confounding factors only from the 1890s. Hacking has reviewed the emergence of our modern understanding of probability and risk at about that time.1

THE FAMINE 1845–1852

Did the asylums increase in size so dramatically in Ireland because of the famine? They also increased in England, though not to the same extent. Was the growth of asylum care due to urbanisation and the loss of family cohesion and supports? Not in Ballinasloe or the other west of Ireland asylums.2 Was it due to emigration, leaving the mentally incapacitated behind? This at least is a possible explanation for some of the growth in the numbers dependent on asylums, but as Professor Kelly shows in this excellent book, there are many other factors that may be relevant also.

How would a modern epidemiologist think about the famine and its consequences? The famine in Ireland might have created a dispossessed generation of physically impaired and mentally traumatised survivors.

Biological factors may have contributed to a real increase in severe mental illness. Starvation in utero would produce a generation reaching adulthood in the decades after the famine with impaired intellectual function and vulnerabilities to schizophrenia and other mental illnesses. Pelvic disproportion due to childhood malnutrition might have caused a second generation burdened with birth injury presenting four or five decades after the famine. Even in modern times, birth injury has been described as part of the diathesis for schizophrenia.3 However, these are only speculations.

CULTURE AND WELFARE

It would be no surprise that the famine and the evictions around the same time should lead to transgenerational welfare dependence. In Ireland two factors may have limited this – the ease of emigration for those who were capable, and the lack of any welfare system on which the incapable could depend, other than the work houses and asylums. This was acknowledged in what may have been a satirical sketch by John Millington Synge who recounts a conversation with a woman in Wicklow, sometime around the end of the nineteenth century –

In Wicklow, as in the rest of Ireland, the union, though it is a home of refuge for the tramps and tinkers, is looked on with supreme horror by the peasants. The madhouse, which they know better, is less dreaded …

‘My brother Michael has come back to his own place after being seven years in the Richmond Asylum; but what can you ask of him, and he with a long family of his own? And, indeed, it’s a wonder he ever came back when it was a fine time he had in the asylum.’

She saw my movement of surprise and went on:

‘There was a son of my own, as fine a lad as you’d see in the county – though I’m his mother that says it, and you’d never think it to look at me. Well, he was a keeper in a kind of private asylum, I think they call it, and when Michael was taken bad, he went to see him, and didn’t he know the keepers that were in charge of him, and they promised to take the best of care of him, and, indeed, he was always a quiet man that would give no trouble. After the first three years he was free in the place, and he walking about like a gentleman, doing any light work he’d find agreeable. Then my son went to see him a second time, and ‘You’ll never see Michael again,’ says he when he comes back, ‘for he’s too well off where he is.’ And, indeed, it was well for him, but now he’s come home.4

RURAL DEPOPULATION, URBAN DRIFT

The subdivision of small holdings by the law of inheritance up to the time of the famine and the evictions that followed it forced the numerous offspring of Irish families to leave the land. Elsewhere in Europe a drift from rural areas to cities was actively facilitated by urban growth and the need for labour in industrial centres. Since there was no industrialisation and little urban growth in Ireland, the young and fit went to industrial centres abroad. Those not fit for emigration gravitated towards the workhouses and asylums. In industrialised countries such as England the urbanised poor had subsistence work and access to a market in rented or social accommodation of a decent standard – they did not have the same expectation of inheritance, of property rights and of a living. The urban disabled could share in what was available without threatening any right of succession, where none was expected. Emigration, for the Irish brought up on a small holding, was a liberation. In Ireland, the only market in rented accommodation was the crowded tenements of Dublin.5 Paradoxically, family cohesion may have been easier in urban centres abroad than in rural Ireland.

CYCLES OF ASYLUM REFORM AND REGRESSION

The asylums described by Professor Kelly appear to veer cyclically from enlightened and humane ‘moral’ regimes to custodial and impoverished, and were often inherently lacking in relational care. Asylums were at times designed as places of utopian idealism.6 The early asylum doctors regarded the design and management of their hospitals as a scientific project,7,8 as science was understood in their day. The careful description of the roles and duties of all those working in an asylum accords with modern interests in the distinction between care and custody.9 Relational care is that therapeutic alliance between clinicians and patients that is now recognised as central to recovery. It is the antithesis of custodial control. Why are asylums characterised by cycles of idealism and enlightenment, followed by custodial repression, followed by further cycles of reform and regression? Professor Kelly records the ‘moral’ humanitarian hospital regime of Dr William Saunders Hallaran in the early years of the nineteenth century in Cork, where he was medical superintendent from 1789 to 1825, as was prevalent also in England, the USA and elsewhere. This was followed by unrestrained growth and regressive, custodial care in the aftermath of the famine. By the 1930s the Inspector’s reports on conditions in the Cork asylum described oppressive, unhygienic and impoverished facilities and custodial practices. Dr Robert MacCarthy10 was medical superintendent at Our Ladies Hospital, Cork from 1961 where he had to reform the ‘existing regime of institutional care … abolishing padded cells and straitjackets … injected a dose of humanity into what was a harsh environment inherited from Victorian times.’

In Dublin, reform took hold again around the turn of the nineteenth and twentieth centuries with Conolly Norman in Dublin (medical superintendent of the Richmond Asylum Grangegorman 1886–1908), followed by Dunne’s reforms (1937–1966) at the same hospital after a further period of regression during the Second World War or ‘emergency’. To these reformers could be added Blake in Carlow.11 Yet by the late 1970s when I first visited Grangegorman as a medical student it was in such a state of decay that closure seemed the only possible course. Closure eventually occurred – in 2013.

Clearly Hallaran’s work in Cork had not taken hold, any more than the work of Conolly Norman or Dunne had in Grangegorman. The prolonged recession of the 1970s and ’80s led to further set-backs. Why did the asylums grow, and even more to the point, why did they regress from the idealistic havens of moral therapy and humanitarian care, to custodial and neglected places in what appear to have been regular cycles? Simple economic strictures, cycles of public expenditure and austerity, are probably the most obvious explanation.

Table 1 in chapter 2 shows the very low ratio of doctors to patients across all asylums in 1906, and the ratio of ward-based staff was likely to be as low in modern terms. The asylums therefore had to rely on security procedures and physical structures – walls, locked...