Transformation of Ireland's Mental Health Policy from A Feminist Perspective

Healing Ireland – A Look at the Transformation of Ireland’s Mental Health Policy from A Feminist Perspective

Abstract

This research report looks at the key changes in mental health policy in Ireland, both past and present.  It is necessary to track the changes that have occurred to create and overall picture of what mental health policy in Ireland is really like. These changes have brought us on a journey of transition, which will be explored in this research report. These changes will be looked at with feminism as the ideological base. This is because equality between the sexes is what feminism essentially strives for and this is the recommendation of this research report.

The focus of this research will be gender, within the context of Irish Mental Health Policy. If we are to tailor our approach to mental health services and practices, there should be an awareness that gender affects the treatment of service user’s and the delivery of services. Service user’s specific needs and wants should be at the centre of policy making and putting this policy into practice.

A variety of methodology was used in this research report. Desk-based research took the form of a literature and policy review which outlines the key aspects and changes to mental health policy in Ireland. A visit to Shine mental health services in Cork was the next piece of research which was carried out, which included an observation session, group interview and one-on-one interview.

They key finding of this research report was that the policy that is in place does not reflect the treatment of service users. The policy that is currently in place does not support services users, specifically, females on their journey of recovery. The aim of this research report is that it will contribute to shining more of a light on the failings of Irish mental health policy and how this affects Irish service users. It also aims to highlight the issue of gender so that going forward, in our continual reform, it would be taken into consideration when creating policies, that are tailored to the needs of service users.

Table of Contents

Declaration…………………………………………………….i

Abstract………………………………………………………ii

Chapter 1: Introduction………………………………………..Pg.1

1.1 Overview of Research Area…………………………….Pg.1

1.2 Global Context…………………………………….Pg.1

1.3 Irish Context……………………………………..Pg.2

1.4 Reform………………………………………….Pg.2

1.5 Context within Irish Social Policy…………………………Pg.3

1.6 Research Rationale…………………………………Pg.3

1.7 What is Recovery…………………………………..Pg.4

1.8 Researching Women’s Mental Health……………………….Pg.5

1.9 Feminist Approach………………………………….Pg.5

1.10 Research Questions…………………………………Pg.5

1.11 Aims and Objectives………………………………..Pg.6

1.12 Project Outline…………………………………………………………………. Pg.6

Chapter 2: Literature and Policy Review……………………………Pg.8

2.1 Introduction……………………………………..Pg.8

2.2 Gender…………………………………………Pg.9

2.3 Deinstitutionalisation………………………………..Pg.9

2.4 Solving the ‘Problem’……………………………….Pg.10

2.5 Institutions……………………………………….Pg.10

2.6 State and the Church………………………………..Pg.11

2.7 The Beginnings of Real Change…………………………..Pg.12

2.8 Further Reform: 1960’s………………………………Pg.12

2.9 Further Reform: 1970’s and 1980’s…………………………Pg.13

2.11 Real Change…………………………………………………………………………Pg.13

2.12 Conclusions…………………………………………………………………………Pg.14

Chapter 3: Methodology……………………………………….Pg.16

3.1 Introduction…………………………………….Pg.16

3.2 Literature and Policy Review…………………………….Pg. 17

3.3 Fieldwork………………………………………Pg.17

3.4 Shine-A support service for people affected by mental ill health………..Pg.18

3.5 Observation and Interviews……………………………Pg.19

Chapter 4: Results and Findings………………………………..Pg. 21

4.1 Introduction…………………………………….Pg.21

4.2 Observation………………………………………Pg.21

4.3 Group Interview………………………………….Pg.22

4.4 One on One interview……………………………….Pg.24

4.5 Conclusion……………………………………..Pg.25

Chapter 5: Conclusions and Recommendations……………………..Pg.27

5.1 Introduction……………………………………..Pg27

5.2 Reform…………………………………………Pg.27

5.3 Shine service users…………………………………Pg.27

5.4 Conclusions………………………………………Pg. 28

5.5 Recommendations…………………………………Pg.29

References…………………………………………………Pg. 31

Appendix………………………………………………….Pg. 34

Appendix A: Participant Information Sheet…………………….Pg.34

Appendix B: Consent Form……………………………….Pg. 35

Appendix C: Questions for Shine service users…………………….Pg. 36

Chapter 1: Introduction

1.1 Overview of Research Area

This chapter outlines the research topic: the key reforms in Irish mental health policies and practices. Ideologically this topic will be viewed from a feminist perspective. These key aspects of the research report will be explored in the subsequent chapters that follow in the report. The issue that is in question is the underrepresentation of gender when it comes to mental health policies and practices, specifically women, within the Irish mental health care system. We can see this from the international and national context that will be described in further detail below. I will outline the broader issue of mental health policy within the global context, and then more specifically regarding the Irish case. There will also be a focus on how this is viewed from the feminist perspective. Ireland has gone through a process of deinstitutionalisation, as will be described in further detail later in this report. It is this process that is key to this research report. The aims and objectives of this research report will also be outlined, while also introducing the methodological approach which will be undertaken.

1.2 Global Context

Disorders of the mind account for a huge portion of disease within all our societies. This has always been the case, even though it has not always been recognised and dealt with effectively. The World Health Report (2001) states there is a need to redress the mental health needs of the population around the world. The World Health Organisation (WHO) is pushing to move mental health policy from the margin of policies and practice to a hold a major stance in global health. To understand the current state of mental health policy and practices, it is necessary to hold a historical viewpoint. This shows the reasons behind previous efforts to reform the situation and shows the development of the services provided to, and the treatment of those who are mentally ill. For many societies, religious values have controlled how people with mental illnesses are treated. The 17^th century saw in increase in religious explanations of madness being a physical state of being. (Foucault, 1965). Rising numbers of poorer people with mental disorders were incarcerated in prisons, workhouses, hospitals and private asylums in Europe and North America between 1600 and 1700. (Goffman, 1961).

The need for change within these institutions corresponded with the increase in humanitarian concerns during the 18th century, with a lot of institutions introducing moral treatment programmes. (Goffman, 1961). Since the 1950s, the disapproval of mental asylums based on humanitarian grounds has led to the growth of a community care movement and a process of reducing the number of patients in mental hospitals, the closure of hospitals, and the development other options, such as community mental health services. This process is also referred to as deinstitutionalisation.

A more optimistic view came with the 21st century in the improved care of persons with mental disorders. Advances in the social sciences have led to new recognitions into the social origins of mental disorders, for example depression and anxiety. (Goodwin, 1997). This has led to changes in worldwide mental health policy, which favours a person centred, recovery approach to dealing with mental health issues. The scientific advancements that occurred combined an increased awareness for the need to care for human rights led to the increased interest in improving mental health policies and practices.

1.3 Irish Context

I will be focusing on Ireland, and the changes to policy that have taken place that lead us to where we are today. I will be looking at it from a feminist point of view in examining how these changes have affected women. Ireland is not totally unique in the way we deal with mental health, as we can see from global policies and practices surrounding mental health. We have seen dramatic changes from the 19^th century onwards in Irish mental health policy. Torrey and Miller describe mental illness as ‘The invisible plague’, in the title of their book, an issue intertwined in the very fabric of our society that has always had a presence. (Torrey and Miller, 2001). The introduction of acts and policies by the Irish government to care for its citizens, with regards to mental health has not always worked out favourably. This can be seen from our history of workhouses, Magdalen laundries, psychiatric asylums and industrial schools. (Prior, 2012). The effort to institutionalise the undesirables of Irish society proved to be a harrowing segment of Irish policy making and its history.

Current mental health policies have dramatically shifted how the state and our citizens view and deal with the sufferers of mental illness. The promotion of positive mental health and well-being through networks of voluntary and state mental health programmes now support people and aid in their journey of recovery. The needs and rights of the mentally ill are now considered and they are at the focus of policy making. (A Vision for Change, 2006). This starkly contrasts with 19^th and 20^th century Irish policies.

1.4 Reform

The key changes that took place in Irish mental health policy which brought us from the brutal treatment of those who were mentally ill and allowed for a more patient centred approach will be outlined, where a partnership between patient and caregiver is fostered and encouraged. This brings the individual on a journey of recovery, rather than incarcerating them to hide them from society. It is necessary to summarise these changes to truly see how far we have come as a society when dealing with mental illness. Those suffering are no longer seen as the outcasts of society, marginalised for their illness, but instead are now taken care of. Mental health policy is created to defend the basic human rights of people with mental illness and regulates the treatment facilities, professional training, and the structure of mental health services. These policies are concerned with the protection of patients, regulation of admissions, the procedures of discharge and appeals. This will be explored in greater detail in the literature and policy review chapter,

Failings in Irish Mental Health Policy occurred in the 20^th century due to several reasons. The Irish state was unwilling to provide the range of social services needed by the citizens of Ireland, so the Church inevitably took on this role. The poor economic conditions that Ireland endured after Independence meant that they didn’t have the financial or resource support to make any real reforms. The State was also reluctant to interfere with aspects of social policy that affected the poor, but instead were more concerned about the welfare of the middle-class. (Keogh, 1994). It was largely in the areas of sexual morality and the control of education that the Church held most of its power, and had little influence over many areas of public policy. (Brown, Miller and Larkin, 2000). It is these two spheres that shaped the coercive confinement in Ireland. ‘Deviants from the idealised self-image were liable to be cruelly punished by the society, no less than the church.’ (Brown, Miller and Larkin, 2000).

The traditional forms of authority came under attack by the onset of the economic affluence that Ireland experienced for over a decade from the mid-1990s. (Nolan, O’Connell and Whelan, 2000). This brought about large scale cultural and social change also. (Fahey, Russell and Whelan, 2007). Mental health began to emerge as a priority and something to be taken seriously. Key changes throughout the 20^th century have brought us to where we are today. A reformist approach is now being taken by the Irish government, to promote recovery and mental well-being. An inclusive approach, where the patient’s’ needs and wants are considered. The research aims to see how far we have come.

1.5 Context within Irish Social Policy

We have seen an increasing neoliberalist approach in Irish social policy. In previous years, the Catholic Church strongly opposed any political ideologies that had any association with socialism. Neo-liberalism was adopted through political pragmatism, rather than a clear ideology. (Mercille and Murphy, 2015). Ireland weakened its already inadequate welfare state by decreasing the finances to support it through taxation. After 1987, there was agreement on the three key principles of neo-liberalism, reducing public spending, cutting taxes to promote enterprise by individuals and corporations and reducing wage costs. (Allen, 2000). The result for the Irish population was socio-political environment that fostered stressful lives, filled with uncertainty and a disregard for mental health. Mental health policy was far from a priority for Irish Free State government and continued for several decades. Minimal state intervention and the privatisation of public services has led to the questioning if the government are making the efforts to promote good mental health and make the changes to policy that supports this. There are aspects of Irish social policy that promote negative mental health in this country. The economic downturn has played a key part in this.

1.6 Research Rationale

The research explores the reforms in mental health policy in Ireland from the beginning of the 20^th century from a feminist perspective. Mental health is an issue in our society that affects a vast number of people. In 2012, the Irish Mental Health Reform found that 25% of the population of Ireland will experience some form of mental health issues. This research also looks at mental health services. It was found that these services are not a priority of the Irish Government and these services do not have the same quality of standards in comparison to international mental health services. This issue is so prevalent in Irish society today, therefore it is of such interest and will be explored further in this research report.

The lack of research conducted into women’s experiences with mental health care in Ireland gives reason to explore this topic further. Women’s lack of representation within policy making justifies this research. It needs to be highlighted if we are to truly implement the recovery approach. The Irish government does not prioritise mental health in its policies and funding. For example, in 2017, it was proposed that €35 million was the budget for mental health in Ireland, while this budget will be reduced to just €15 million for 2018, after much contest from other Ministers in the Dáil. The apparent €35 million was never materialised, and the director of the Mental Health Reform. (Cullen, 2016). Shari McDaid commented saying “I am shocked to hear that there is scope for just €15 million of additional spending for improvements in mental health care for 2017, given the overstretched and under-resourced state of our mental health system,”. (Cullen, 2016). The policies that are created do not take gender into account and I believe this is key to continue moving forward in our mental health policies. There is an over reliance on medication, and an emphasis on psychiatric care, with few outpatient services available.

The progress we have seen that has shaped our mental health policy is of great interest to me. To think that our country, like many so many other societies around the world could treat those most vulnerable with such merciless cruelty and lock them away is a harrowing thought to say the least. The discredited procedures that took place could not have had any positive implications for the patients, and almost certainly worsened their mental states.

By looking at our history we can contrast the systems that are in place now and see the progress we have made. There is a story to be told about the Irish Government’s institutionalisation of the undesirables in our society. The transformation that occurred throughout the 20^th century to bring us from a story of neglect to now a new hope is what I believe is an integral part of this story. The reshaping of Irish Mental Health policy is what has driven this change. The inevitable question here is how far we have really come? Because of the horrors that occurred, the State now has a fundamental duty to the mentally ill, is this duty being fulfilled?

1.7 What is Recovery

“Recovery is a process; a vision; a belief which infuses a system… which providers can hold for service users… grounded on the idea that people can recover from ‘mental illness’, and that the service delivery system must be constructed based on this knowledge…” (Anthony, 2000). The recovery model for mental health care is a newly introduced idea in Irish mental health policy and was described in ‘A Vision for Change’. A recovery model is necessary when approaching mental health policies and practices as it moves from a care model, to the idea that individuals can fully lead a normal and meaningful life, regarding their health and place in society. “The recovery model too promotes a more optimistic viewpoint of the capacity for recovery from mental ill health. While recognising that persistent illness and impairment can be the experience of a proportion of people, the recovery model seeks to counter the uniformly pessimistic view of prognosis for those with severe mental illness” (A Vision for a Recovery Model in Irish Mental Health Services, 2005). Recovery is a process that describes an individual’s approach to their mental health and life. People can recover from mental illness and they take personal responsibility for the direction their recovery takes. It is based on everyone’s needs and wants. Therefore, it is necessary that gender should be considering when tailoring an individual’s care and treatment, if we are to truly abide by the principles of recovery. Hope, listening, autonomy, person-centred services empowerment and choice are among the key ideas that recovery is based on. (A Vision for Change, 2006).

1.8 Researching Women’s Mental Health

This research was undertaken from a feminist perspective because mental health is a gendered experience and it should be looked at from this angle. Women and men have different experiences, feelings and interactions with mental health. This is a crucial factor that should be taken into consideration more if we are to continue or progression. If gender is not taken into consideration then, the provision of services simply cannot meet the needs of service users Feminist research looks in more depth into social issues, such as mental health, in comparison to traditional methodologies to understand the structures and factors within society. This issue is prevalent throughout our history, which will be looked at in chapter 2. This is essential to the future of mental health care because taking this approach would allow for a connection between the power structures in mental health care. The lack of power women has against the professionals who care for them, who hold the power. This must be at the very core of recovery. To have the best possible chance of recovery, it is essential that everyone be treated in a way that suits them, taking into consideration several factors. This includes gender.

1.9 Feminist Approach

Looking at mental illness from a feminist perspective allows us to see those who are mentally ill as individuals, with specific needs and wants within their own recovery. Recovery must be person centred and this includes taking an individual’s gender into account. Mental illness is a subjective issue and experiences vary greatly amongst people. Therefore, to meet the needs of each person, methods of recovery and the services provided should too vary. David Karp writes: “Given the pervasiveness of depression, it is not surprising that both medical and social scientists have tried to understand its causes and suggest ways of dealing with…… As valuable as these studies might be, something crucial is missing. My view is that to really understand a human experience, it must be appreciated from the subjective view of the person undergoing it. …Underneath the rates, correlations, and presumed causes of behaviour are real human beings who are trying to make sense of their lives” (Karp,1996).

Feminism holds the view that “meaning which is established or constructed through the research process in consultation with all the participants”. (Byrne and Lentin, 2000). To understand the stance of women within mental health care, a system “capable of accommodating the diversity of women’s lives” (Byrne and Lentin, 2000), needs to be established.

1.10 Research Question

This research seeks to track the key changes that have occurred within Irish mental health policy. This will be done through a literature and policy review, to outline the policies both past and present. This will begin from the beginning of the 20th century, where the incarceration and institutionalisation of those who were mentally ill in society was the mental health treatment of the time, with little support of Government policy or society. This research will then seek to evaluate these changes to examine how far we have come in Ireland with regards to mental health policies and practices, by outlining the changes that took place in Ireland mental health policy, to bring us to where we are today. This will be undertaken from a feminist perspective.

It will explore the issue of gender within the context of mental health policies and practices. It will seek to show how mental health services and the policies in place have directly affected women in Ireland. The aim of this is to examine if mental health is a gendered issue and if a more tailored approach needs to be undertaken when creating policy, and then implementing it for service users.

Service users are at the centre of this approach. This research aims to firstly outline the policies that are in place, and then through fieldwork research, examine how this policy directly affects female service users.

1.11 Aims and Objectives

This research aims to create a detailed account of women’s experiences with mental health services from the beginning of the 20^th century, from a feminist perspective. The specific objectives of this research are:

• Outline the transformation we have seen throughout the 20th century to the present policy that is in place and investigate if the situation has truly changed
• To see how these changes have directly impacted female service users service users

1.12 Project Outline

Firstly, a literature and policy review will be carried out, and reported in chapter 2, to examine the history of the policies and practices and to facilitate a more well-rounded view of mental healthcare in Ireland for women throughout the 20^th century, up to the present day. The aim is to present an overall cohesive image of Irish mental health policy, by examining both the past and the present.

Fieldwork will then be carried out as the primary source of research. Qualitative research methods will be undertaken in the form of non-participant observation, a group interview and one on one interviews with service users. These service users will be a part of the Shine mental health service based in Cork City. This service will be described in greater depth, as well as the methodology used in chapter 3 of this research report. The results of the fieldwork will be outlined in chapter 4 and the conclusions and recommendations of this study will be outlined in chapter 5.

I hope to shed more light on the transformation Irish Mental Health Policy has seen and how this progression has reshaped the way we deal with those who are mentally ill. A mix of methods will be used to strengthen the findings of the research. This will be described in greater detail in chapter 3.

Chapter 2: Literature and Policy Review

2.1 Introduction

Irish mental health policy has seen dramatic changes from the 19^th century onwards. Torrey and Miller describe mental illness as ‘The invisible plague’, in the title of their book, an issue intertwined in the very fabric of our society that has always had a presence. Attitudes continually changed with each passing century, with the stigma surrounding mental health growing less and less. (Rogers and Pilgrim, 2010). The introduction of acts and policies by the Irish government to care for its citizens, with regards to mental health has not always worked favourable as we can see from our history of workhouses, Magdalen laundries, psychiatric asylums and industrial schools. (Prior, 2012). The effort to institutionalise the undesirables of Irish society proved to be a harrowing segment of Irish policy making and its history.

Current mental health policies have shifted dramatically the way in which the state and our citizens view and deal with the sufferers of mental illness. The promotion of positive mental health and well-being through networks of voluntary and state mental health programmes now support people and aid in their journey of recovery. The needs and rights of the mentally ill are now considered and they are at the focus of policy making. This contrast starkly with 19^th and 20^th century Irish policies. However, though we have witnessed changes, mental health policy in Ireland is unfortunately pays little attention to gender. Women’s mental health has never been specifically mentioned in Ireland by the Government.

The key changes in Irish mental health policy will be outlined here that allowed for a more patient centred approach, taking them on a journey of recovery, rather than incarcerating them to hide them from society. It is necessary to summarise these changes to truly see how far we have come as a society when dealing with mental illness. Mental health policies are concerned with the protection of patients, regulation of admissions and the procedures of discharge and appeals.

According to Prior (1999) women have been over-represented in studying mental health. (Prior, 1999). This can be seen throughout history because women were generally viewed in society as the weaker sex, and would therefore be mentally weak also. The traditional ideas of mental health, which saw mental illness as being cognitive and emotional difficulty have contributed to this.  (Women’s Mental Health: Promoting a Gendered Approach to Policy and Service Provision, 2004). Therefore, it would make sense for the policy to reflect the prevalence of women in mental health care, but this is not the case.  The introduction of behavioural problems in new definitions of what it means to be mentally ill have helped this situation. Women are found to experience anxiety and depression, while men experience personality issues. (Prior, 1999).

2.2 Gender

Gender can be defined as the “role division of men and women in society. Sex refers to descriptions of a division based on biological features…gender is a social description and sex is a biological one” (Pilgrim, 2005). Like many others studying the connection between gender and mental health, Pilgrim highlights the multifaceted relationship between gender and mental health. This is particularly apparent when discussing social roles and the representation of women in certain diagnostic groups.

Psychiatry is the dominant method used to answer to mental health care in Ireland. It focuses on the biology of an individual instead of the gendered structures of an individual’s experience. That is why a recovery approach is so empirical if we are to progress in our treatment of those who are mentally ill. No two patients are the same, with each gender having unique needs that must be met. Regarding feminist theory, gender is one of the “fundamental categories” (Bloom, 1998) used to analysis social and political systems, for example mental health care. Bloom demonstrates the rationale for using gender analysis in this research. Mental health is a gendered experience and women are often forgotten about in a system that favours males. To become liberated from commanding male dominated response to the care of those mentally ill, there needs to be a tailored approach for each gender, depending on their experiences.

2.3 Deinstitutionalisation

During the 1930s and 1940s new therapies and advancements in psychiatry occurred, which aided in the collapse of the system of asylums in Ireland. (Robins, 1986). Finnane then argues that this advancement had a ‘perverse effect’. By the 1960s Ireland had combined asylums into its health care system in the form of mental hospitals, and had one of the “highest rates of psychiatric hospitalisation in the world” (Finnane, 2005). The advancements in medication made way for the prescription of antidepressant drugs to be used as an alternative. Other alternative solutions include day hospitals and rehabilitation hostels. Robins argues that Ireland had “not an elevated level of mental illness, but rather an excessive commitment to the mental hospital” (Robins, 1986).

Health Boards that were created in 1970 contributed to improvements in mental health care policies and practices. The shift from hospital to community based care was beginning to emerge. The providing of a multidisciplinary service has aided in society’s and the media’s more positive view of mental health and the care of those mentally ill. There is now a political obligation to continue moving forward and making improvements to the care are treatment of those who are mentally ill. However, Dr. Susan Finnerty, Inspector of Mental Health Services in 2006, has concerns regarding application and delivery of Mental Health Services in Ireland. In her 2006 report, she stated: “absence and deficiencies in multidisciplinary teams” in Ireland. Finnerty also said: “The lack of coherent overall plans for services over the next five years is worrying.” (Finnerty, 2006)

“The unplanned nature of mental health provision has been noted in the past and there is no sign currently that this situation will change. There is genuine frustration and disillusionment from those delivering the service at their lack of information and participation in planning. Community mental health does not work without resources. In-patient units will continue to be the first-line treatment locations, long-stay wards will not close and there will be little or no access to alternatives to medication if community mental health and other multidisciplinary teams are not resourced. It is not good enough to condemn these practices and not give those who are delivering the service the wherewithal to provide alternatives and it is not fair to service users to promote community treatment, counselling, home-based treatment and rehabilitation and then not provide these services” (Finnerty, 2006).

2.4 Solving The ‘Problem’

Up to the 19^th century there was little or no care available for those who were deemed mentally ill or destitute in Ireland. It was then decided that this problem needed to be tackled and so began a time of largescale mental health policy reform. Finnane writes: “Confronted with the evidence of social disorder, overpopulation and an ailing economy, reforming politicians, political economists and social observers, rising professionals, philanthropists and humanitarians of various persuasions and motivations all sought to bring order to Ireland’ – including order to the problems created by mental disorder.”. (Finnane, 2005). The Lunatic (Asylums) Act, 1875, the Criminal Lunatics Act, 1838 and the Private Lunatic Asylums Act of 1842 resulted in Ireland during the 1800s, a solution of large district asylums emerging, paving the way for a mass coercive confinement to institutional care for the mentally ill or physically disabled.

‘Do Penance or Perish’ tells the stories from the Good Shepherd Magdalen Asylums that were founded for prostitutes who the state and the church, needed reform. Many of the inmates of these asylums were forcibly prevented from ever leaving these asylums, put to work unpaid and were subjected to harsh disciplinary regimes and enforced prayer. The church then looked for women who had children out of wedlock as their next victims. Many women were still being admitted to such asylums and the last of them did not close until 1996. The shocking mistreatment of 30,000 girls illuminates just how frightfully ill-treated the vulnerable in society were, specifically women (Finnegan, 2004). The policy was clear and defined and was enforced endlessly by central and local powers. Most these asylums were run by members of the Catholic Church. This disregard from women’s rights within society highlights the injustice and treatment of women in Irish society throughout the 20th century. These women were hidden away in shame, fostering mental illness in an environment that enslaved their autonomy.

2.5 Institutions

The treatment of individuals within these institutions was truly appalling. ‘Asylums mental health care and the Irish’ mentions many of the treatments they faced. (Prior, 2012). It was thought that they couldn’t feel pain so were subjected to many harsh and brutal experimental treatments. A popular treatment recounted the use of a circular chair which involved a patient that rotated up to sixty times per minute to “a sufficiency of alarm to ensure obedience.” (Prior, 2012). Overcrowding became commonplace in these asylums because the law changed to allow for easier admittance of patients, even if they had not been deemed a criminal or mentally ill. There was no notion of patients ever leaving these institutions, an almost prison sentence for life. Discredited procedures, overuse of drugs and their integration within communities, made them a staple part of 19^th and 20^th century Ireland. The Catholic Church’s involvements in the large custodial asylums meant that there was a certain trust, but also fear. The teachings and ways of the church were the almost unwritten law in the Irish society of the time. A force not to be challenged or deviated from, a society regulated by what the church deemed to be right in accordance to their teachings. (Coogan, 2004).

Reviewing the literature surrounding women and mental throughout history reveals their continued incarceration and institutionalisation. The treatment of women within these institutions reveals a harrowing segment in the Irish State’s treatment of those who are mentally distressed. William Shorter’s publication ‘A History of Psychiatry: From the Era of the Asylum to the Age of Prozac’, provides an all encapsulating summary of this history. ‘First there were those wicked biological psychiatrists in the nineteenth century, and then psychoanalysts and psychotherapists came along to defeat the biological zealots’. (Shorter, 1997). Shorter describes the changes that were occurring in society surrounding mental health care. To continue with the treatment of women, Shorter describes how individuals were being locked ‘…into asylums those who otherwise would be challenging the established order’. (Shorter, 1997). Women’s mental health is both a historical and contemporary issue.

2.6 State and The Church

The fundamental paradigm for Irish social policy hasn’t changed much since the beginning of the welfare state under British Rule. In the 20^th century the newly established Irish Free State allowed the Catholic Church to continue to dominate society, as it was the provider of education, health and some social services (Moran, 2009). The relationship between the State and the Church has proven to be detrimental in the shaping of Ireland’s mental health policies, with their ideals of incarceration and penance through work and prayer. Even though the Catholic Church retained a predominant position into the boom years in the provision of education and health services in Ireland, their influence on the population and policy making declined. Inglis suggests that “what has happened in Ireland is that … it has switched from Catholic capitalism to consumer capitalism” (Inglis, 2008). By the end of the 1980s the state began replacing the Catholic Church as a power alliance with the relationship being a social partnership.

The power the church held over Irish society at the time greatly affected the women of 20th century Ireland. The church’s supremacy came with it, a male dominated society. Women had little rights in society, adding to the ideals of a lack of consideration of the needs of women. The sexual oppression of women in society and their absence of economic use, according to the church, resulted in women’s needs and right being forgotten. Mental health policy was already not a priority, but adding to this, women’s place in society meant there was an added disregard for their mental health needs. (Maeyer, Schmiedl and Leplae, 2004).

2.7 The Beginnings of Real Change

A modernising era began to emerge in 1945 with the introduction of the Mental Treatment Act. (Mental Treatment Act, 1945). This act introduced measures that were designed to improve standards and practices in mental health care in Ireland. It introduced new admission procedures and tried to reduce the number of patients being admitted. It was aimed to reform legislation failings in Ireland, regarding mental health and to enhance the delivery of efficient care given to individuals suffering from mental illness. It was divided into nineteen parts and it was concerned with general matters and the wording used to describe situations. A ‘voluntary patient’ was defined as ‘a person who, acting by himself or, in the case of a person less than sixteen years of age, by his parent or guardian, submits himself voluntarily for treatment for illness of a mental or kindred nature.’ (Department of Health, 1945). Following this, the two key concepts that arose were deinstitutionalisation and medicalisation. In 1958, Ireland had the highest number of people in psychiatric institutions than anywhere in the world.

In his book ‘Irish Insanity’, Damien Brennan discusses the circumstances that enabled institutionalisation to continue in Ireland. (Brennan, 2014). He describes the structures within the asylums with psychiatrists and psychiatric nurses holding control over individuals who resided in community-based mental health service accommodation. He refers to these residences as the “multi-locational total institution” (Brennan, 2014). There was a move from large scale institutions to community based care in smaller outpatient facilities and care homes. The changes in Irish mental health policy have been slow but progressive. It has transitioned to reintegration within society and normalisation of the issue. The practices however, have been widely criticised. (Goodwin, 1997). There has been a scarcity of funds for new community- based facilities plus a lack of coordination between institutional and community services. (Hafner, 1989). As a result, some service users have been subjected to homelessness, deterioration of physical and mental health and failure to be integrated into the local community. (Taylor and Brown, 1988).

2.8 Further Reform: 1960’s

Higgins and McDaid (2014) show how the persistence of these two trends led to re-institutionalisation in the community and the widespread social exclusion of mental health service users. While mental health policy in the 20th century seemed like it was improving, hidden within its recommendations were the structures that would continue to segregate people with long-term mental health difficulties into living what she describes as “shadow lives” in the community. (Higgins and McDaid, 2014). She also argues that Ireland’s mental health policy on social inclusion remains largely unfulfilled. (Higgins and McDaid, 2014). During the 1960s, advances in medication allowed for individuals to be treated using, for example, anti-depressants, as well as the creation of day hospitals, outpatient clinics and rehabilitation workshops. These changes allowed individuals who would have previously been patients in mental institutions to live and remain part of the wider community.

By 1961 there were more individuals being treated as out-patients than in-patients, and sixty percent of all those entering mental hospitals were voluntary. Despite this, the number of hospitalisations between 1963 and 1978 in Ireland was still two and a half times more than those in England. Robins argues that the evidence clearly indicates that Ireland had inherited “not an elevated level of mental illness, but rather an excessive commitment to the mental hospital”. (Robins, 1986).

2.9 Further Reform: 1970s and 1980s

Health Boards were set up in 1970 leading to improvements in the general health service, by removing the responsibility from Local Authorities and to greater developments in mental health service provision. Care and provision for those suffering from mental illness started to make the move from the hospital to the community with the establishment of community-based services. If hospitalisation was needed, the emphasis was on psychiatric wards in general hospitals, instead of mental hospitals. These developments quickly made the transition from the traditional mental hospitals a reality.

Women in Ireland now were still playing the role of housewives and the maternal figure. Psychiatry at the time, be the most prevalent controller of women. If women deviated from this norm, they were at risk of being incarcerated. (Kelly, 2016). Incarceration was the result, and in some ways, the punishment of those women who did not conform in society. It was still being used as a tool of control. Women were still not given the recognition of specific mental health care or policies.

A new Health (Mental Services) Act 1981 was passed by the Irish House of Oireachtas to prevent the wrongful hospitalisation of individuals, as has occurred for so many people. (Health (Mental Services Act, 1981) (Kelly, 2016). It was however never enacted, because of political opposition from various stakeholders. The Act was created but never signed by the Minister for Health at the time, Michael Woods because he simply did not agree with it. The Ministers for Health who followed him also never signed to enact it so it never became law. (Kelly, 2016). This was, as a result, insignificant in contributing to any changes.

By 1986 the fall of district mental hospitals began, with the announcement that Carlow and Castlerea district mental hospitals were to close (Robins, 1986). The aim of deinstitutionalisation was to “prevent inappropriate mental hospital admissions through the provision of community-based alternatives for treatment; to discharge to the community all those in institutions who had been given adequate preparation for such a change; and to establish and maintain community supports for people receiving mental health services in the community” (Bachrach, 1976 & Mental Health Commission 2006).

2.10 Real Change: 2001

Even though the 1945 Act brought about the changes necessary to improve standards, it wasn’t until the introduction of the 2001 Mental Health Act that there was a notable and substantial reform in how we dealt with those individuals who required a place in mental health facilities.  The Act removed indefinite detention orders while bringing in new involuntary admission procedures. It allowed for independent reviews of detention, free legal representation for patients, independent psychiatric opinions and evaluations and the establishment of the Mental Health Commission, which would oversee standards of care delivered to patients and protect the interests of the patients. This has been one of the most positive and implemented policy the Irish government has ever implemented and has been a major catalyst for what we know today as the ‘Vision for Change’ programme. (Department of Health 2001). The Commission does not however, consider gender when managing mental health care.

The act was fully implemented in 2006 with the intent of bringing Irish legislation more up to date with global ideals, such as the European Convention on Human Rights and United Nations Principles for the Protection of Persons with Mental Illness. The purpose of this act was to provide a modern framework for people who are mentally ill and who need support, can be cared for and treated. There are also mechanisms that monitors the standard of care and treatment, through regulation and inspection. (Mental Health Commission, 2007). The establishment of mental health tribunals allowed for an independent review of all involuntary admissions to approved centres. With the implementation of the Act, rules and regulations, such as formal registration of approved centres. Even in this most recent policy structure, women’s mental health is not considered.

2.11 Conclusion

Upon completion of the literature review, it was clear that a change had been made to mental health policy in Ireland overall. We have moved from the incarceration of the undesirables in society, to slowly, throughout the 20th century, creating policies that favour the needs and wants of those who are mentally ill. The introduction of the recovery approach provides a new sense of hope: that individuals can live a life free from the symptoms of their mental illness, and be a part of an accepting society.

We can see a transition from stigma and hiding those who are mentally ill away from society, to a new way of understanding what it means to be mentally ill. The key concepts of recovery are where we are today in terms of mental health policy. However, gender is still not a consideration in policy making. If we are to tailor or approach to mental health and fully support those who are mentally ill, male and female experiences of mental health needs to be considered. Upon the completion of the literature and policy review, there is still room for change. There is a lack of specific research conducted into women’s mental health and how the policies have affected women. There needs to be a recognition that mental health is a gendered experience. This project aims to contribute in some way to this disparity of knowledge.

This has not been without its fair share of battles and failings but we have witnessed improvements. That is not to say that we have completely changed our ways and are at the ideal stage of the treatment of those who are mentally ill. It just means we are moving in the right direction, in a more positive way. We are nowhere near where near perfect but they key idea that can be taken away from the literature review is movement and progress in the right direction. In the past, gender was not considered in the treatment of those who are mentally ill. The reform in mental health care and services has taken a more person-centred approach. Everyone’s strengths and experiences are considered. “One of the fundamental principals in this report is ‘recovery’, in the sense that individuals can reclaim their lives to their best extent and be involved in society – to be socially included” (A Vision for Change, 2006).

Chapter 3: Methodology

3.1 Introduction

This chapter will outline the methods used in the primary fieldwork research- visiting Shine mental health services in Cork City. It will also describe how the literature and policy review relates to the overall research project. The theoretical methods that were applied were based on gender because this focuses on the gap in literature and policy making, in that mental health is a gendered experience. This idea has not been explored or implemented in Irish Mental health policy making, or in mental health services. The literature and policy review was also completed from a feminist perspective. Information on women’s experiences with mental health policies and practices were gathered through the fieldwork research. This was done through observation and qualitative interviewing methods. This chapter describes how the information used was gathered. The findings of this research will be described in chapter 4. The themes that arose from the literature review, as outlined in chapter two, for example: deinstitutionalisation, the progress in policy in Ireland and gender, were used as the basis for the fieldwork. This allowed for the empirical study to reach an overall coherent point, using the themes that emerged in chapter 2, to be further researched in the fieldwork aspect of this report.

3.2 Literature and Policy Review

The literature review conducted narrows the broad topic of mental health policy in Ireland down to the key themes that emerged for this research report. I reviewed some of the central ideas relating to the research topic so that I could provide a comprehensive picture of the past, while creating a comparative stance of the present, through a combination of the primary research and literature review. As mentioned above, this includes deinstitutionalisation, gender and changes to Irish Mental Health policy. This provides a justification also, of why researching this topic further is important.

The literature review provided a rationale to delve deeper into the issue of a gendered approach to mental health policy. Women’s mental health care and their treatment is an issue throughout international and Irish history, as well as in our society today. The history of mental health services, for example asylums and other large-scale institutions, provided a basis to illustrate the transformation we have seen. We have moved in a more positive direction, and should continue to do this into the future. To further move in this direction, this research report argues that mental health is a gendered experience and the policies and practices need to reflect this. This development and reform concerning our policies throughout over the last century has led us to where we are today.

By tracking the policy, it provides the framework from which past mental health services are based on. This method of viewing the past was more favourable as it allowed me to go back to where mental health policy began, and our treatment of those who are mentally ill. This allowed for clear comparisons to then be drawn between polices which began with the turn of the 20^th century. The current policies and literature provide the foundation for further changes and reform, which will be outlined in chapter 5.

3.3 Fieldwork

This research uses service user’s experience as the primary source of information for the fieldwork. The research is of qualitative form, consisting of non-participant observation in a Shine peer support group and then followed a group interview session. The final part of the fieldwork was a one on one interview with a female service user. This research was conducted with a view on gaining a greater insight into the current services available, because of polices constructed by the Irish Government.  It is also an interpretive form of research methods, as it is focused on understanding the service and themes in a holistic and comprehensive way. The meaning was taken from service users experiences, while also showing how the practices in Shine mental health service can be used to observable outcomes. This is how the conclusions and recommendations from the study are drawn, which is outlined in chapter 5.

The literature and policy review carried out provided an affluence of information before the visit to Shine. This allowed for the understanding of the various aspects that can be related to mental health service users. The description of what the services should be in ‘A Vision for Change’ was the focus when collecting the data through observing the Phrenz group session and questioning the service users.

3.4 Shine: A support service for people affected by mental ill health

“Shine is the national organisation dedicated to upholding the rights and addressing the needs of all those affected by mental ill health, through the promotion and provision of high quality services and working to ensure the continual enhancement of the quality of life of the people it serves.” (Shine – Supporting People Affected by Mental Ill Health, 2017). I have selected Shine for my research and its service users as I think that this is a positive example of a service that exemplifies how far we have come in the treatment of those who are mentally ill. Shine is funded by the Health Service Executive (HSE), the sector of the Irish Government who runs public health services in Ireland, along with donations from the public. The Irish Government are now investing in mental health services, such as Shine. This is an extremely positive change in the Governments attitudes and behaviours towards mental health services. It shows that there is a willingness to put the policies that have been created, into practice.

It is an example of a service that reflects an increasing emphasis on the service users themselves in their own recovery. They aim to uphold the rights and addressing the needs of individuals affected by mental illness. They run centres throughout Ireland for people who experiences mental illness. These centres have multiple rehabilitation, personal development and social activities. They also have a counselling service available. The themes that emerged from the literature and policy review gave the reasoning to choose Shine as the site of research. Their focus on recovery and the service user being at the centre of their care and treatment, highlights where we are today with our treatment and care of those who are mentally ill. In view of this service being in place and available to people of Ireland shows that changes have been made. It shows the deinstitutionalisation process that has occurred in Ireland, from large-scale institutions to a community based care system.

Further questioning however, needs to take place as we have witnessed in the past, just because there are mechanisms in place, does not mean that they are fulfilling the role that the policy has set out for them. An example of this is the large-scale institutions themselves, such as the asylums, workhouse and Magdalen laundries. People in Irish society believed that these were institutions of care and reform, where inmates would somehow be ‘cured’ and then released. This was unfortunately not the case, as we know that many people who entered these institutions never left, and often made their symptoms and life much worse than when they entered. (Anthony, 2000). This is not to say that Shine, or any of the other mental health services available today have the same severity as the services from the past, it is just to recognise that the services in place should reflect the holistic policy in place in Ireland, and support and care for those who are mentally ill. This is an issue that needs to be continually explored and monitored.  The focus of the primary research being conducted at Shine is to see how the mental health policy in Ireland is affecting services and service users. The focus will be on the themes and ideas found upon the completion of the literature and policy review, rather than looking at the specifics of the Shine services available themselves.

Shine conducts weekly ‘Phrenz’ group meetings where service users which is a support group facilitated by two Peer Facilitators and has about twelves people present each week. They also organise frequent day trips for their members. This group is where I will be conducting my research. Service users speak about their mental health experiences and describe their thoughts and feelings towards various aspects of their mental health care and treatment.

3.5 Observation and Interviews

Participants

The data collection took place at the Shine support service in Cork City, on the 21^st of February 2017. The people who took part in the research were Shine service users who attended the Phrenz group support meeting, at Shine in Cork City. There were ten service users present, with two peer support facilitators. Six of the user’s present were female. A large group was used for the group to ensure accurate conclusions and recommendations could be drawn. These are outlined in chapter 5. The individuals who took part in this research had varying mental health problems. These included anxiety disorders, schizophrenia, bipolar disorder and depression. In this particular Phrenz group session, the majority of the service users were female, though this was unplanned, it was helpful in that this report focuses on females and the gendered issue of mental health care. What they had in common was that they were on a journey of recovery, each in their own way and each dealing with their specific circumstance. Many had the experience of institutionalisation and then went through the process of deinstitutionalization, to bring them to a community care based recovery that is Shine. This study was not focused on their medical analysis, and instead focused on their personal experience of the reform in mental health policy and how it has affected them. The participants varied in ages, but were all over eighteen years of age. Their experience of recovery varied and so did the quality of the treatment they received. However, the common thread between all participants was that recovery should be person centred and tailored for everyone. This was relayed to me in all three forms of my research methods that will be further explained below. They strived for this to occur without the presence of medication to assist them.

Scheduling Interview

It was decided in advance of the session that the interviews would take place at Shine so the service users could feel comfortable in a familiar setting. This was particularly important for ethical reasons. The one on one interview was conducted in a separate room to allow for privacy and to again ensure that the service user was made feel as comfortable and possible.

Questions

I began with broader questions, moving towards more specific questions as the interview progressed. I had to be aware of the service user’s openness with me and how they reacted to what I was saying. I had to make them feel at ease while gathering the information I required, while also respecting the ethical boundaries. The questions were mostly open ended and the service user could respond in whatever way they choose. Service users could speak as much or as little as they wished. The responses were greatly appreciated as it is an exceptionally difficult topic to discuss and very personal. This was the case for both the group interview and the one on one interview. The group interviewees and one on one interviewee were asked the same question, that are in the appendix section of this report. The questions were based on the themes and ideas that emerged from the literature review, to see how these ideas affect service users in their daily treatment and care.

Observing

This was a non-participant observation session. I sat amongst the group while the Phrenz group session took place. I took short notes throughout but tried to respect the activities of the group also. This allowed me to see what was really going on within a mental health service in Ireland, and listen to how the people that the mental health policy was made for, really felt. The ultimate purpose of the observation was to view individuals within the mental health service setting, and to see how they were behaved and were being treated. The advantage of this was to really see what happens within mental health services, and if they are recovery orientated.

Data Recording

I observed the Phrenz group session and took short notes and what was going on, not recorded the specifics of what each service user said, but rather the ideas and topics they brought regarding mental health. During the group interview, a few of the service users did not want me to record using the microphone on my phone, what was said. This was completely acceptable, so instead I took short notes on the group interview. For the one on one interview however, the service user was comfortable with the interview being recorded so I did so using the microphone on my phone. This proved to be invaluable when drawing the results and conclusions as I could replay the interview several times to hear exactly what was being said.

Using these methods of data collection allows for an account of the real-life experiences of mental health service users in Ireland today. To relay it back to this specific research report, it allows for the issue of gender to be explored, through observing and interviewing female service users and to see if mental health is a gendered experience, that needs a more tailored approach when creating the policy. It allows for a first-hand look at if the policies that are in place in Ireland are being implemented in services, and experienced by service users. This approach helps to answer the research questions as it explores the issue of gender within the context of mental health policies and practices. It also shows how mental health services and the policies in place have directly affected women in Ireland. The literature and policy review aims to complete the first objective of this research report: outlining the transformation that occurred throughout the 20^th century in Ireland to bring us to where we are today with our mental health policy, while the fieldwork aims to fulfil the second objective of this research report: looking at how this transformation directly affects female service users.

Data Analysis

The data collected will be analysed from a theoretical basis, examining the themes that emerged and how they relate to the overall topic of the research report. The results will be outlined in chapter 4 while, the analysis and specific conclusions from the research, and the recommendations following this, will be outlined in chapter 5.

The recovery model for mental health is based on five key mechanisms: partnership, choice, hope, social inclusion and listening. These elements were taken into consideration when conducting the research. This allowed for the identification of the strengths and weaknesses that could be identified in mental healthcare services, as per ‘A Vision for Change’, recovery should be the basis for all mental healthcare in Ireland.

Issues of Reliability

It must be understood that it is the intention of this research report to give a small insight into the current situation in mental health services and the thoughts of service users. As it is based on human experience, the fieldwork that was carried out on this day, may vary to the results gathered by other researchers at various times. The thoughts and experiences of the service users who participated in this research, may not reflect those of every service user in Ireland. It is just a small cohort that was research, innkeeping with the scale of this project.

Ethical Issues that arose and Consent

As the topic of mental health is a sensitive subject in its nature, and the research conducted was based on human experience, issues of ethics were inevitable. Informed consent was firstly needed before conducting the research. A participant information sheet and consent form was presented to the service users before the research took place. These are attached in the appendix section of this report. This ensured complete anonymity and knowledge of what would happen during the session. The participant information sheet and consent form was also forwarded to the director at Shine prior to the session. Ethical approval was also received from University College Cork, to ensure the nature and procedures of the research were ethical. This took the form of filling out a questionnaire based on the research and outlining what the research would entail. This was reviewed by the ethics review board in University College Cork. There was also respect for the anonymity of the service users and complete confidentiality was used when recording their answers and behaviours in the session. Their privacy was also respected in that if they did not wish to discuss a certain aspect of their mental health, that was completely acceptable.

Chapter 4: Results and Findings

4.1 Introduction

The aim of this chapter is to report the findings from the research undertaken and interpret these findings by looking at the three separate methods used: observation, group interview and one-on-one interview. I will then relate this back to the research question and find the meaning in the data I have gathered. I will outline my findings from my visit to Shine. The purpose of this chapter is to solely display what happened at my visit to Shine I will then delve further into what my findings mean and how they relate to the subject matter I am interested in later in the report. The process of interviewing and observing afforded me the opportunity to gain great insight into the recovery services and issues that service users face. I learned first-hand how the policies that have been made impact on the people they are made to help and support. All the information I gathered was unable to be included in the small research report. This is the limitation of the study as mentioned in the methodology chapter. I analysed my notes and recordings with my research aims and objectives in mind. Due to the varied responses and topics that were discussed, the focus was on the data which was relevant to the research questions.

4.2 Observation

The Phrenz group is a weekly meeting in Shine in Cork City for mental health service users to talk about their experiences of the mental health service and with their mental health in general. When I arrived, there was a group seated around a small table with twelve people, with eight being female. Irrespective of their mental health problems, it was a chance for service users to reflect on their thoughts and experiences. This is what I observed throughout the session.

The session was constructed more as a friendly chat, rather than a counselling session. Everyone seemed very relaxed at ease speaking to the group. Before the session started I noticed that many of the service users who attended the meeting were friends as they chatted about everyday topics. There was tea and refreshments also available. Again, making the session quite informal while also being intimate and friendly.

The session began with each person who was in attendance taking a few minutes to tell the group about their previous week, mentioning any highs or lows they may have experienced. They received feedback from the group and were encouraged to vent their feelings in a way.

There was then a mindfulness session where the group took about fifteen minutes to quietly meditate to calming music being played in the background. Different breathing techniques were taught and practiced, most the service users said they felt more relaxed and calm after this part of the session.

A short interval followed this where everyone took a break to chat amongst themselves. I took this chance to speak with some of the service users about their experiences and ask them some of the questions I had previously prepared. This was the beginning of my interview sessions. I also observed in the Phrenz group session was the unfortunate barriers that occur within recovery. Several of the service users were reluctant to speak out as they normally would with my presence. This was completely understandable so I had to be aware of their reluctance and tailor my approaches to getting the information I wanted accordingly. Many of the service users discussed the issues they had while in their recovery process and many of the service users shared the same problem. These included:

Over reliance on medication:  Several of the service users also said that they didn’t have much of a choice when it came to medication. They vocalised their struggles to the group their issues they faced with their medication and many of the service users seemed to have similar issues.

Gender: One service user brought up the issue of gender. She felt that because she was a woman she felt that she needed to be treated differently to the males. However, this was not the case. She wanted to be treated for who she was, having her needs met, instead of a one for all approach.

Waiting: Many of the service users felt that they had to wait too long to access services, making it harder to keep their treatment consistent. They felt that this added to their mental health issues as they did not feel like they were a priority.

I was then given the chance to conduct my group interview, which will be described in more detail below. The group then discussed and upcoming trip they were organising to a mindfulness seminar that would take place in the following weeks. Then I conducted my one on one interview with a female service user. This will be described in more detail below. the session finished with thank you and goodbyes as I mentioned my appreciation for their willingness to participate and the session coordinators took care of some administrative work that involved service users signing in their attendance.

4.3 Group Interview

Gathering the Information

The feminist methods examine data from the feminist point of view. It seeks to overcome prejudices within research, feminist’s forms of research are also highly interactive.  This allowed me to gather a lot of very useful information through an open discussion with the questions I asked the service users. There was of course a large amount of data collected so I will select the key aspects which relate to this research report. This includes information that relates to recovery, the process of deinstitutionalisation and gender.

Questions

I began with asking the same questions as the one on one interview to collate a more accurate and well-rounded image of our mental health services. The overall picture I observed was that we have come along way but we still have a long way to go. Respondents had their own views and experiences of their mental health journey so it is important that these findings do not generalise their specific experiences. This instead gives a snapshot of the opinion of a small sample.

Policies

There was a consensus that the recovery approach that was outlined in ‘A Vision for Change’ document was positive but they, as service users were not feeling the full effects of what was outlined. We discussed ‘A Vision for Change’ and the principles that affect the service users. the five key aspects of recovery were mentioned and the service users said they “hoped” that these aspects would be implemented in the future but currently, “not all” could be seen within everyday services. These aspects included: partnership, choice, hope, social inclusion and listening. They were mentioned in several ways such as the forms of treatment. The service users wanted a partnership approach in their recovery between healthcare professionals and themselves and a choice in their care and treatment. This then brought up being listened to by healthcare professionals and playing an active role in their treatment. They also wanted a supportive sense of hope to be continually mentioned, as they felt this would increase their confidence that they can live a life free from mental illness and have an integral part in society. This is also the social inclusion aspect they mentioned.

I was surprised to hear that the service users had a great understanding of the past and present mental health policies that are in place in Ireland.  They had however some experience of what is being implemented in the innovative ways they were being treated. For example, one service user mentioned that visiting Shine made her feel more at ease that being treated in a hospital and it made her feel more “normal”. They also mentioned it wasn’t as progressive and the Government were making it out to be. They felt a lot of the existing policy had clever ideas but they were angry and disappointed that it wasn’t being implemented into their treatments. For example, they understood the aspect of the recovery model, but as mentioned above, the five key aspects were not always being implemented. They felt angry and disappointed because they said that the policy that was in place is created for a reason: to support and help service users, but often they did not directly feel the benefits of this.

Treatment

Eleven of the twelve service users present felt that they were not being listened to when it came to their treatment, by the mental health professionals who were treating them. None of the service users had a positive response when questioned on this idea.  For recovery to be truly person centred, the thoughts and ideas of the service user need to be considered. Then everyone’s treatment can be tailored to suit them so they can go on to lead meaningful and fulfilling lives, free from mental health issues. The huge burden that these people carry cannot be overlooked and to move on from this, their treatment needs to be integrated into their everyday lives.

They felt that they were also no coherence between the professionals they saw. For example, one female service user said she was “sick of explaining” her situation to each new professional she saw, exhibiting a lack of communication and consistency in care. This issue also touches on the aspect of partnership and choice. All the service users agreed that this would be more helpful in their recovery. “It would make me feel more comfortable if I was a regular person rather than just another patient in a hospital”.

Shine

Half of the service users that Shine had impacted positively on their experience, as a community based service. While the other half said that were not using the service for long enough to comment. Many felt that it was preferable to be in this setting rather than a hospital. They felt included when at Shine, in the weekly meetings or the activities and outings that are organised. They said this helped them feel part of a community, interacting and connecting with other people in an analogous situation.

4.4 One on One Interview 

I interviewed a female service user who had both been an inpatient in a psychiatric hospital and a user of community based care. Her experiences with the Shine services were very positive, although she wasn’t aware of the service until around twelve months ago, until she applied to work for the service, and then became a service user. She saw the advantages of the service while working for Shine and felt it would benefit her mental health. Before encountering Shine, she had a “very high level of recovery”. She felt that if she was in crisis, Shine may not be a strong enough outlet to help her.

She mentioned that she works full time so she cannot avail of the full range of services that Shine provides, but felt the mentoring in the Phrenz group really helped her recovery. She prefers the open group style to counselling with a psychiatrist as it is “less intense”, not wanting to always dwell on her mental health journey up to now, but instead voice her current feelings. For her, recovery means “peace of mind”. It means that she is still able to work and live a normal life while being an outpatient, not to be reliant on a family member to care for her and to get her “independence back again”.

The struggle she mentioned with mental services is a staffing and funding issue. She said although Shine would never refuse anyone who needed care. She was aware that they were struggling to manage the numbers of individuals seeking the help of their services. Regarding gender, she felt gender was more of an issue in the psychiatric hospital setting, rather than in the outpatient services. She described one experience she had with a male nurse, who decided that he felt that she was an inappropriate case for a male nurse, so he swapped for a female nurse. She did not have the issue but the nurse did.

She was in an out of psychiatric care for decades, feeling like she never got the care she fully needed. The service user could see the benefits of both institutionalisation and community based care, but at the time she needed so much support she felt that the community based care option would not have been sufficient to deal with her and meet her needs. “There was no way a day service could cater for my needs at that time”.

Her view on the mental health policies in Ireland, she felt that the 2001 Mental Health Act “wasn’t as positive as it could have been, it hasn’t moved as fast as people think it has…. there’s still so much going on”. She also said, “I have had some good experiences in that I’m alive, but the smallest things have happened that you would call mistreated”. This service user then went on to explain several situations that she has been in where this has occurred. One day she “went up to the desk to get her medication and there was a new tablet in my cup and I asked what’s that for? And I was basically told shut up and take it… those kinds of things are all under the radar because I have not proof”.

Another experience she had was while in A&E with self-harm, one doctor refused to give her any pain medication because she said that he told her: “you did this to yourself now you can suffer the consequences”. She wouldn’t “knock the services but she wouldn’t praise them either”. She also said “everything isn’t as rosy as people make it out to be…. There is still a lot of work to be done”.

The responses of this service users echoed what was said in the group interview. There is an apparent frustration with the current state of our mental health policies in that they seem to be all for show, and for the most part, are not being implemented to the full extent. Mental health services, such as Shine, play a huge part in supporting those who are mentally ill. They are in their own setting, where they feel comfortable building relationships with people in similar situations. This is a far cry from the institutionalisation of the undesirables in our society we can see throughout our history. This primary research illustrated that we are taking steps in the right direction, however small they may be.

4.5 Conclusion

The strength of the women was apparent from my primary research. Their determination to push past the things that hinder their recovery so that can regain their lives was both inspiring and historical. There is now a sense that mental health difficulties are not the end, as they once were. These women are more than their difficulties and they can use the services available to recover, even if they are not perfect. However, these women are powerless to the other factors that hinder their recovery. Even though they themselves may be strong willed, they system that is in place often hinders their recover, despite the policy claims that our services are recovery oriented. For a time, ‘A Vision for Change’ was a new strategy and it was just finding its feet in everyday life. But now over ten years on, there has been little progress and what was outlined in the document doesn’t seem to be implemented, according to service users. The women felt that their needs should be taken into consideration when creating policies. Overall my experiences in Shine was very positive and impacted greatly on this research report. The next chapter will analyse my findings from this research report and I will draw my conclusions, recommendations and thoughts.

Chapter 5: Conclusions and Recommendations

5.1 Introduction

This chapter will contain a brief outline of the key findings of the research, with an assessment of how these findings relate to the research questions as outlined previously in the research report. It will outline how the feminist approach to research relates to the process of deinstitutionalisation and the recovery process. It will also mention the recommendations from the service users at Shine which were discussed during the primary research stage, and will outline the changes they believe could further improve mental health care and policies.

5.2 Reform

The five-key aspect of recovery: hope, choice, listening, social inclusion and partnership, as mentioned in ‘A Vision for Change’ were the basis from which to draw the recommendations and conclusions. From my primary research and review of the literature we can see a move from a medical model of what it means to be mentally ill, in an oppressive society whose aim was to hide away from those who are mentally ill in society in the name of shame and deviance from societal norms. We have moved towards a recovery model instead, attempting to focus on the key aspects that are at the very nature of recovery. The Mental Health Reform paper (Mental Health Reform, 2013), provided also as the basis for this research. It outlines what recovery means and the steps we need to take to reach a recovery orientated model approach when dealing with mental health in Ireland. The basis for this report is research carried out by service user, the mental health commission and policy makers, as well as consultation groups. Shine services stated that their approach to mental health care is based on recovery. The Shine service upon research was found to be implementing the recovery process.

5.3 Shine Service Users

There were several thoughts recorded from the visit to SHINE mental health services. It is interesting to note that there was a huge awareness by the service users about the current mental health policies in Ireland. When asked if they had any knowledge surrounding the current mental health policies, they outlined their thoughts about the 2001 Mental Health Act and the 2006 ‘A Vision for Change’. Barriers that were identified included:

An over-reliance on medication

The service users felt that mental health care professionals would tend to rely on medicine in their treatment if another form of treatment wasn’t successful. This is both positive and negative. It is interesting to note that the service users stated that professionals were trying other methods of treatment, but if this treatment didn’t agree with the service user, then the old ways of medication were then being used. It is better than the way things were done in the past, but it still is not ideal

Fear and Shame

The Shine service users mentioned the fear and shame they felt at times in relation to their mental health care. Society still does not see them as regular citizens, though the situation has improved. At times, the services users said it was a challenging task to comprehend their diagnosis and carry on with their normal life. They did not feel this was possible all the time

Tailored Approach

Several of the service users felt that their approach should be more tailored to them as an individual in society, factoring in their experiences and lifestyles when discussing treatment options. This is another example of why gender needs to be taken into consideration.

5.4 Conclusions

Mental health is a huge issue in our society today. It is our duty as citizens of Ireland to care for and cater to the needs of those individuals who are suffering. This report argues that where we are today in terms of this care is certainly not where we should be, considering our intolerant and merciless history. We have indeed seen a change in our care and treatment of those who are mentally ill but we need to continue this progression if we are to reach the goal of a tailored system, that cares for each individual need and wants.

The current policies and documentation that is in place paints a very idealistic picture of the care of the mentally ill. ‘Recovery’ is the buzz word continually mentioned that insinuates that it is possible to live a life free from the symptoms of mental illness and to go on living a meaningful and satisfying life. The ideas are there but it is unfortunate that they are not being implemented to their fullest extent. The service users at Shine felt that this was the case. Their first-hand experience of mental illness and how they are treated was invaluable to this research and subject matter. The issues that they highlighted are what is really happening every day in Ireland,

The research succeeded in identifying the issues that women face within mental health care and services. Valuable information was gathered that reflected a change in the treatment of those who are mentally ill. We are going through a process, though it may be slow and imperfect, we are still moving in the right direction. This was consistent with the findings from the literature review and review of the policies in Ireland.

There is a clear connection between gender and mental health and more research needs to be undertaken to highlight this. The literature review outlines the transformation we have seen in terms of policies and practices and what other people have found while researching this topic. The primary research gives a first-hand account of what it means to be mentally ill in Ireland today, in terms of one’s care, treatment and lifestyle.

Looking at mental health as a solely medical issue is where we have fallen in the past. The primary research identified that often this is still the case. Human experience is key to moving forward in our mental health policy journey. It is even further an issue for women in the patriarchal and male-dominated society in which we live. (Busfield, 1996). Irish society tends to place its trust in the medical model, with psychiatric services holding much of the power when it comes to the treatment of mental illness. From the feminist perspective and because of the primary research, I believe that this power should be questioned and researched further in the hopes of making some real changes in society that affect service users.

The move away from institutions has been a major positive aspect of our mental health journey in Ireland. The policy documents which were created in the late 20^th century support a multidisciplinary method of treatment and care. However, these are just documents, this does not mean that they are being implemented in everyday practices, as the primary research gave a small insight into. Adequate funding and resources need to be provided for this to happen. The one on one interview with the Shine service user, mentioned the lack of funding which these services experience. This service user expressed: “even though they would never turn anyone away who was in need, the struggle with regards to funding is evident”.

5.5 Recommendations

Because of the research gathered and the conclusions that have been drawn, there are several recommendations. Throughout researching the issue of mental health from a feminist perspective, it was clear that there is a need for further changes in the policies and practices that take gender into account. I recommend that more gender sensitive methods in treatment and care be used in Ireland. The research gathered and the correlations with the literature review are unmistakable evidence to show that there is a great need for this to occur.

This area of mental health is not explored in enough depth, so I would recommend that a variety of angles be taken for future research. Currently, ‘recovery’ is the basis for mental health treatment in Ireland. Working with service users is key to further research. We must take into consideration what they say and experience, and continually move forward based on those findings. I would also recommend that this research be the basis for the new policies being put in place by the Irish Government. This policy should be updated and revised on a yearly basis so that service users receive the best care and treatment available, in line with international standards. The link between the community based care and the Government needs to be made stronger, and I think that research is intrinsic to this. This would solidify the need for improved policy making and ensure we continually progress out mental health policies.

The ‘Five Core Components’ (Mental Health Reform, 2013), that are at the very centre of the recovery services show where changes can be made. For example, services which take gender into account. This method would focus on service users and would further support them in their mental health journey. Listening, hope and social inclusion return power to those affected by mental illness and allow them autonomy when it comes to their treatment and care. Future research should include a more gender focused approach. This would ensure that our recovery approach in person centred and based on each service users’ needs and wants.

The policies that are currently in place do take many aspects of care into consideration but I believe that gender sensitive policies would truly propel our policies forward, and keep them up to date with current issues within Irish society. Gender is a way of identifying social processes of males and females, as opposed to sex, which is based on biology. It is not simply an issue of being male or female, but the social behaviours of the two. Recognising that mental health is a gendered issue is the first step for the Irish Government and the creation of polices would follow. An example of one such policies could attempt to remove the culturally defined roles of men and women in society, by challenging the patriarchal traditions that often occur in Irish society. The policy needs to be tailored for both genders, that considers the different mental disorders that affect men and women and the socioeconomic conditions that affect them. Another example is creating services that specifically deal the different mental disorders, for example because of domestic violence or sexual abuse for women. This would ensure an elevated level of support and care for female service users. These changes can only positively impact service users. This is the flaw I have identified in our mental health policies that should be researched further and changed to accommodate service users. This issue, if resolved, would truly make mental health care user focused. My recommendation is that greater awareness of this issue needs to be made, through further research and analysis, with the aim of tailoring future policies to suit both genders.

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Appendix

Appendix C: Questions for Shine Service Users

1. Could you tell me about your experiences with the Shine services?
2. Tell me about what you think recovery means?
3. Do you think that Shine has helped with your recovery?
4. How long have you been using the Shine service?
5. Do you feel your needs are being met as a service user?
6. What could be done to improve services?
7. (depending on length of using services) Have you seen a change in the services that are available to you?
8. Do you think that your gender has affected your recovery process?
9. Can you tell me on a broader level, your thoughts on mental health policies in Ireland and how they have been implemented?