Introduction

The Central Mental Hospital in Dundrum probably evokes a cold shiver in people as they pass by – that is, if they think about it at all. The perception of the hospital is influenced visually by the high walls, the imposing metal gates leading up a long avenue to another electronic gate, and the glimpse of a huge grey granite building. It is fuelled, no doubt, by stories and myths about mental illness, criminal lunatics and madness. People may read in the newspapers about the crimes of some patients but do they realise: ‘There but for the grace of God go I’? None of us knows when or where mental health problems will occur or with what severity. Certainly none of us who are parents or relatives of patients in the Central Mental Hospital ever expected serious mental illness to visit our families.

The Central Mental Hospital Carers Group is a voluntary group of relatives – mostly parents – and carers of patients in the hospital in Dundrum. We meet monthly at the hospital. We liaise with hospital management and staff on a regular basis on matters relating to the care of patients and the conditions in which they live. Our goal is to improve the lot of the patients and their families and to campaign for improved facilities and care for patients and respect for their human rights. We also provide a supportive environment for families and carers who have been affected by severe and enduring mental illness in their family.

People may be surprised by our experiencing the Central Mental Hospital as a peaceful place, a refuge for our children who became seriously mentally ill, a place where, at last, having done the rounds of GPs, local psychiatric health care services, and often the courts and prisons, their illness is finally being understood and treated.

The Government has decided to sell off the site in Dundrum and to relocate the Central Mental Hospital to Thornton Hall at St. Margaret’s in north County Dublin, near the Meath border. It intends to site the hospital beside the relocated Mountjoy Prison in one large new complex. We, as the families of patients, are deeply opposed to this decision. The reasons for our opposition are outlined in this article. There is an alternative, which we also detail and which we are urging the Government to consider.

Origins
The Central Mental Hospital was established in 1850 as a result of recommendations of a parliamentary committee set up in 1843 under Sir Edward Sugden, the then Lord Chancellor of Ireland. The hospital was built on a thirty-four acre site, four miles from Dublin city centre. It was located on a large parkland site because the Victorians realised that people who were seriously mentally ill needed such space and seclusion in order for their condition to improve.

At that time, and following much discussion, it was decided not to co-locate the hospital with a prison, in recognition of the distinction between illness and criminality.¹ It is ironic that the Victorians could make such an enlightened decision when, one hundred and fifty years later, modern Irish politicians can decide to co-locate the proposed new hospital with new prison facilities.

The Central Mental Hospital was the first secure hospital in Europe and provided care and treatment for mentally disordered offenders for the entire thirty-two counties up until partition in 1922. It has always been administered by the health authorities.

The hospital provides treatment in conditions of high, medium and low security. Patients come from either the prisons, the courts (either having been referred for assessment or having been found unfit to be tried or not guilty by reason of insanity) or from local psychiatric hospitals. Intensive psychiatric treatment and rehabilitation are provided in a structured therapeutic environment by five consultant-led multidisciplinary teams. The hospital is fully accredited for training purposes by the Royal College of Psychiatrists. It functions very much as a hospital which provides asylum for its patients, many of whom, for one reason or another, have lost contact with their local psychiatric services. Today, the Central Mental Hospital accommodates eighty-two patients, although there is need for a facility able to provide for a much larger number.

Need for a New Facility

We agree with the position taken by the Expert Group on Mental Health Policy in its report, A Vision for Change:

The Central Mental Hospital should be replaced or remodelled to allow it to provide care and treatment in a modern, up-to-date humane setting, and the capacity of the Central Mental Hospital should be maximised.²

The Group’s Report, which was published in January 2006, was accepted by the Government as a template for future policy in relation to mental health care.³

Despite many improvements to the Central Mental Hospital, the fact remains that the design and layout of its buildings still strongly reflect their origins in the Victorian era. Not only are they out of date but they are in need of repair and renovation. These buildings are not suitable for the provision of modern twenty-first century forensic psychiatric care. Investment in modernisation is long overdue. The inadequacies in the physical conditions of Dundrum were highlighted in reports on inspections carried out by the Council of Europe Committee for the Prevention of Cruel and Inhuman Treatment and Torture (Committee for the Prevention of Torture), in 1998, 2002, and 2006.⁴

A National Tertiary Centre

The provision of psychiatric mental health care can be viewed as tiered into three levels, just like the provision of physical health care. In the case of physical illness, the GP, as the first contact, represents the primary tier; consultants based in hospitals the second tier, and national specialist treatment centres the tertiary level. The degree of specialisation and expertise increases with each tier and the numbers requiring treatment should reduce at each level of specialisation. The same model applies to the provision of mental health care: the GP is usually the first tier, the local psychiatric hospital the secondary tier and the Central Mental Hospital the tertiary level, catering for the seriously mentally ill in need of secure accommodation and specialised treatment.

Patients not Prisoners

The Government has argued that the Central Mental Hospital should be located beside a prison because many of the patients come from the prisons or through the court system. This thinking is, at best, based on administrative convenience. It fails to acknowledge the fact that it is as a result  of their mental illness that such patients come into the criminal justice system. They are patients first: it is their illness which has caused them to transgress or which prevents them from understanding the charges put to them, leaving them unfit to be tried.

We know this is fact because it has happened to our children. We have watched as a mental illness, such as schizophrenia – the illness the majority of patients in Dundrum suffer from – took control and altered their reality to such an extent that many committed a crime or harmed themselves. We have experienced the lack of understanding of serious mental illness and the lack of secure units in both general and psychiatric hospitals. We have experienced the lack of community support services and social workers for the psychiatrically ill.

Violent incidents involving seriously disturbed mentally ill persons are frequently reported in the national media. We, as relatives and carers, understand in a very personal way the grief, the fear and the suffering of the victims but also that of the perpetrators suffering from severe mental illness. We are all victims of an inadequate mental health system and also victims of mental illness and its consequences for our families. We have lost family members to mental illness.

It is our experience that our children did not receive the help they needed when we knew they needed it. Our health system did not respond as it should have. Sadly, the ‘normal’ pattern is that families cannot get appropriate services for their relative and the illness escalates to the extent that serious and sometimes fatal incidents occur and the patient falls into the penal system. For our children, the Central Mental Hospital is their last chance and their best chance. They need therapeutic intervention and treatment in secure accommodation because of their illness. What does the Government propose? To treat them in a facility located on the same site as a prison.

Further Stigmatisation

Those with mental illness are already stigmatised in our society. Locating the national forensic psychiatric hospital beside a prison will, in effect, be a public policy endorsement of this stigma and will serve to further stigmatise the mentally ill. Locating the hospital adjacent to a prison will inevitably and irreversibly associate its patients with criminality. This surely is against the ethos of mental health care in any civilised society. There is no possible therapeutic reason to associate the hospital with the new prison.

Social Isolation Impedes Rehabilitation

The proposed new complex, Thornton Hall, at St Margaret’s in north County Dublin, is in a rural location with a dispersed population. Such a location is most unsuitable for a hospital whose ethos is treatment and rehabilitation in the community.

In its present location in Dundrum, the Central Mental Hospital is accessible to family members and other visitors coming on foot, by car, bus and LUAS. Thornton Hall, whilst being relatively close to the M1, will be far from readily accessible by foot or by public transport. Even if the current very limited public transport provision to the area were to be improved, the relocation would still mean that the time and effort involved for families and other visitors in getting to and from the hospital would be much greater than is the case for Dundrum.

Furthermore, the socially isolated location proposed will impede the rehabilitation of those who have to use the hospital’s services. Low security patients in Dundrum avail of training, college courses and facilities in the city as part of their rehabilitation and re-engagement with community life. Attendance at these activities would not be possible from Thornton Hall.

Lack of Community Support Impedes Rehabilitation

Over a period of one hundred and fifty years, the Central Mental Hospital has become integrated into the local community in Dundrum. Patients avail of education, training and social activities in the locality without stigma or rancour. This is a vital part of the rehabilitation and reintegration of patients into the community and into society. On a very practical level, the remote location of Thornton Hall will make the rehabilitation of patients extremely difficult, even before one considers the issue of acceptance of both the hospital and its patients by a dispersed rural community. The scale of the area will not be conducive to integration, since its population is too small to allow recovering patients to grow in confidence and to re-establish social skills.

Loss of Experienced Staff

The Central Mental Hospital Dundrum comprises not only physical capital, in the form of land and buildings, but also social and intellectual capital residing in the human resources of the hospital – that is, its staff. This should be taken into account in any policy decision on relocating the hospital. The task of providing ‘safe treatment for high-risk patients in conditions of therapeutic security’⁵ involves very specialised knowledge and skills. Over the years, such expertise has been developed in Dundrum by a range of staff members – clinicians, psychiatric nurses, social and care workers, occupational therapists, psychologists – who work in the multidisciplinary teams needed to provide services in this very specialised niche of psychiatric care.

It can be anticipated that a large portion of this intellectual capital will be lost in the proposed move to Thornton Hall. This is borne out by the experience of some specialised government services being decentralised. We believe that it is likely that at least 50 per cent of the clinical and nursing staff in Dundrum will leave as a consequence of the relocation of their place of work to the other side of Dublin County. Such intellectual capital can not be quickly replaced. The ethos of the hospital is to provide the specialist skills of multidisciplinary teams offering active programmes of assessment, intervention and rehabilitation to service users through individually tailored care plans which are reviewed on an ongoing basis. This process will be severely disrupted with the loss of staff on the scale envisaged.

Contrary to Human Rights Obligations?

Article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations recognises ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. Ireland has ratified the Covenant, which means that under international law the State is obliged to ensure that the rights enshrined are guaranteed for all persons on its territory.

The UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care6 outline the basic rights and freedoms of people with a mental illness that must be secured if states are to be in full compliance with the Covenant.⁷

Key among the UN Principles are:

All persons have the right to the best available mental health care, which shall be part of the health and social care system. (Principle 1)

Every patient shall have the right to be treated in the least restrictive environment…(Principle 7(1))

The environment and living conditions in mental health facilities shall be as close as possible to those of … normal life … (Principle 13 (2))

These standards apply equally to all persons who suffer mental illness, including those ‘detained in the course of criminal proceedings or investigations against them’. (Principle 20(1))

This requirement is elaborated as follows:

All such persons should receive the best available mental health care as provided in Principle 1. These Principles shall apply to them to the fullest extent possible, with only such limited modifications and exceptions as are necessary in the circumstances.(Principle 20 (2))

Other principles in the UN document emphasise the right of patients to have access to educational, training and placement services to promote their rehabilitation and reintegration into society.

As a member of the United Nations, and a signatory to most of its human rights treaties, Ireland should see the principles laid down by the UN as setting the standard for policy in relation to the redevelopment of facilities for patients  in the Central Mental Hospital. The Government has failed to show how its plan to relocate the hospital to the grounds of a super prison could meet the requirements of the principles set out by the United Nations.

Contrary to Government Policy?

A Vision for Change, the Government’s template for mental health policy, states:

Priority should be given to the care of individuals with severe and enduring mental illness, in the least restrictive environment possible.⁸

Locating the hospital in the same complex as the country’s largest prison is surely in direct contradiction of this recommended approach.

The report further states that:

Forensic mental health units need to be clearly identified as being intervention and rehabilitation facilities that operate in particular conditions of security rather than facilities offering mainly containment.⁹

Again, locating the hospital in a prison complex sends signals of containment rather than treatment and rehabilitation, thus directly contravening the Government’s own stated policy.

In addition, A Vision for Change states that forensic mental health services should have a strong community focus.¹⁰ Uprooting the hospital from a community where it is now naturally embedded and relocating it to a small rural community will deny that community focus to the country’s only specialised forensic psychiatric hospital; it represents a further discrepancy between the Government’s stated policy and the likely outcomes of its decision to relocate the hospital.

A Feasible Alternative

If it is accepted that an urban location is required for a national forensic psychiatric hospital, one must ask the question ‘where?’ If not Dundrum, where else does the State have sufficient lands? We understand that the only other possible location is at Abbotstown in Blanchardstown.

We suggest that there is a feasible alternative to relocating the Central Mental Hospital to either another urban location or the Thornton Hall complex.

As already noted, the current hospital site in Dundrum is thirty-four acres in size. It is located in what is now a prime residential area. On a conservative valuation, the site could be worth €5 million per acre, giving a total valuation of €170 million. However, the true valuation could be up to €400 million.¹¹

The Government does not need the entire proceeds of the sale of the thirty-four acre site in order to finance the building of a new Central Mental Hospital. If ten to fourteen acres to the front and/or rear of the site were to be sold for residential development, the remaining twenty acres would be sufficient to facilitate the provision of a new state-of-the-art hospital. The sale of fourteen acres could raise up to €140 million. This would be more than adequate to construct a new facility, which could be provided at an estimated cost of around €100 million. Such an option would deal with all of the aforementioned problems and objections associated with the proposal to move the hospital to Thornton Hall. This outcome could be achieved at no cost to the Exchequer. Most importantly, it would be the best outcome for patients, for their families, and for the medical, nursing and other staff in the existing facility. Furthermore, with this option there would be no question of proceeds of the sale of lands at Dundrum not being reinvested in mental health care services and there could be no hint of ‘asset stripping’ on the part of the Government.¹²

Conclusion

There is an urgent need for the Central Mental Hospital to be replaced by a modern facility and for the number of places provided to be expanded. The Government has decided to relocate the hospital onto the site of the new ‘prison super complex’ at Thornton Hall, north County Dublin.

There is a strong chorus of well-founded objections to the relocation of the Central Mental Hospital to Thornton Hall from a wide range of mental health professionals, and from families and friends of patients.

We in the Central Mental Hospital Carers Group believe that co-locating the hospital with prison facilities is not in the best interests of the patients, will increase the stigma associated with mental illness, impede the rehabilitation of patients, is contrary to the Government’s stated policy on mental health and is against the spirit of international human rights law. Furthermore, it is not, in our opinion, the best economic option.

We call on the Government to revisit the decision. There is a viable alternative that would answer all the objections raised and at the same time provide a state-of-the-art forensic mental health care facility to serve Ireland’s expanding needs in this area.

We propose that the Government sell off up to fourteen acres of the grounds of Dundrum for residential development and with the proceeds of the sale build a new hospital on the remainder of the site. With this option it would be clear that all the proceeds from the sale of the property were being reinvested for the betterment of the mental health system. Above all, it would show that the welfare of the users of the services of the Central Mental Hospital, and not administrative convenience or financial gain, was the priority in updating and expanding the facilities for this vulnerable and often overlooked group in our society.

Notes

1. Pauline Prior, ‘Prisoner or Patient? The Official Debate on the Criminal Lunatic in Nineteenth Century Ireland’, History of Psychiatry, Vol.15, No. 2, 2004, pp. 177–192.

2. A Vision for Change: Report of the Expert Group on Mental Health Policy, Dublin: Stationery Office, Recommendation 15.1.4, p. 140.

3. Speaking at the launch of A Vision for Change on 24 January 2006, Mary Harney TD, Minister for Health and Children, said: ‘This comprehensive mental health policy framework outlines a set of values and principles that will guide both Government and service providers as we proceed to develop and put in place a modern high-quality mental health service for our citizens.’ (To view click here )

4. Council of Europe, Report to the Irish Government on the Visit to Ireland Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 31 August to 9 September 1998, Strasbourg: Council of Europe, 17 December 1999, CPT/Inf (99)15[EN], par. 101–104, p. 48;

Council of Europe, Report to the Government of Ireland on the Visit to Ireland Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 20 to 28 May 2002, Strasbourg: Council of Europe, 18 September 2003, CPT/Inf (2003)36[EN], par. 83–85, pp.33–34;

Council of Europe, Report to the Government of Ireland on the Visit to Ireland Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 2 to 13 October 2006, Strasbourg: Council of Europe, 10 October 2007, CPT/Inf (2007) 40 [EN], par. 111–113, pp. 45–46.

5. The National Forensic Mental Health Service, Central Mental Hospital, Submission to the National Steering Group on Mental Health, Dublin, 2003, p. 2. (to view click here )

6. These Principles, often referred to as the MI Principles, were adopted by the UN General Assembly Resolution 46/119 of 18 February 1992.

7.  Amnesty International (Irish Section), Mental Illness: The Neglected Quarter, Dublin: Amnesty International (Irish Section), 2003, p. 27.

8.  A Vision for Change: Report of the Expert Group on Mental Health Policy, Section 15.1.1: ‘Principles Central to the Delivery of Care by FMHS’, p. 137.

9. Ibid., p. 135.

10. Ibid., p. 138.

11. Jim Power, ‘Is Thornton Hall Prison Suitable for Central Mental Hospital or is there an Alternative?’ Paper Presented at Schizophrenia Ireland/Central Mental Hospital Carers Seminar, 30 January 2008.

12. A report by the Irish Psychiatric Association (IPA), published on 24 January 2008, highlighted several instances where lands adjacent to psychiatric hospitals were either given away or sold at below-cost prices to other public bodies, so that the potential to ‘ring fence’ money realised from their sale for the development of mental health services had been lost (Irish Psychiatric Association, The Lie of the Land, Dublin, 2008). This occurred despite the recommendation of the Expert Group on Mental Health Policy (in its report, A Vision for Change) that the funds generated from its proposed closure, over a period of ten years, of the State’s psychiatric hospitals should be used to improve mental health services generally.

The Central Mental Hospital Carers Group can be contacted at [email protected]