Professor Brendan Kelly is Professor of Psychiatry at Trinity College Dublin, Consultant Psychiatrist at Tallaght University Hospital, Dublin, and UCD Visiting Full Clinical Professor at UCD School of Medicine, University College Dublin. He has authored and co-authored over 300 publications in peer-reviewed journals, over 600 non-peer-reviewed publications, 21 book chapters and book contributions, and 17 books (11 as sole author). He speaks to Dr Emma Farrell about his recent book Asylum: Inside Grangegorman (2023).
Emma Farrell: In your historical writing you try to strike a balance between naming and acknowledging the hurts and harms perpetuated those ‘enthusiastic’ psychiatrists while not allowing psychiatry to be the ‘fall guy’ for all the things we don’t like, or don’t like to acknowledge, about our own history.
I quote from the opening lines of the book:
“Asylums were designed to treat and contain the mentally ill but soon assumed a life of their own: meeting the complex needs of troubled families (often unrelated to mental illness); alleviating social problems in surrounding communities (especially during times of poverty, famine or political unrest); and - possibly most of all - supporting local economies by employing tens of thousands of people.”
Do you think that psychiatry is still being tasked with dealing with the complex needs of troubled families, wider social problems and even support the economy and economic model that our government seems to value so much?
Brendan Kelly: Yeah, you know, diagnosis in psychiatry, such as they are, are based entirely on symptoms, not biological tests, and this is a direct response to suffering in one sense, but in another sense, it is a grey area. The edges are so fuzzy. Where we draw the lines within that fuzziness changes, and this still today leaves psychiatry open to being pressed upon or letting itself be put upon to accept all kinds of social roles that are well outside the core area of psychiatry. So we see this again and again as psychiatry is seen as…I call it, ‘medicalising problems off the table socially’ or ‘psychiatrizing them socially’. So we see this over the years. Often it's not entirely without basis, but it's carried to an extreme degree.
The [diagnostic] edges are so fuzzy. Where we draw the lines within that fuzziness changes, and this still today leaves psychiatry open to being pressed upon, or letting itself be put upon, to accept all kinds of social roles that are well outside the core area of psychiatry.
Take for example, the issue of assisted dying, medically assisted dying. We're seeing a lot of legislation introduced around the world in relation to this very complex and very important area where there is a balancing of so so many issues to be done. But what is slightly dispiriting to me is in many jurisdictions, you know, if the questions become very complex or difficult, the final line in the legislation is, you know, in the event of unresolvable issues about the decision making capacity, a psychiatrist should be consulted. So what we keep what we keep finding is that psychiatry has this malleable concept gets carted in when things become complex or difficult in other areas. Now, Ireland's new capacity legislation is very clear that all disciplines can engage in evaluations of capacity. It is not a matter for psychiatrist alone, or doctors alone, but very often in jurisdictions when the questions become very acute and when people become very uncomfortable with facing the difficult choices society faces, they still hive them off to psychiatrists and, dispiritingly to me, psychiatry remains willing to accept roles that are not appropriate to it quite a bit.
When people become very uncomfortable with facing the difficult choices society faces, they still hive them off to psychiatrists and, dispiritingly to me, psychiatry remains willing to accept roles that are not appropriate to it quite a bit.
And this doesn't just happen at the legislative level as well. This happens every day. This happens every day with this enormous, for example, this enormous pressure to admit people into psychiatric hospitals and units, that practicing psychiatrists of which I am one, come under constantly. This enormous pressure to admit people into inpatient psychiatric care and not to discharge them.
Emma Farrell: And is that pressure from the Gardaí? From families? From, you know, people who would probably otherwise be homeless if they weren't in the psychiatric system? If it's fair to offer those as examples or there are other ones?
Brendan Kelly: Yes. The pressure comes from people who are at their wits ends to know what to do and who know deep down that what they're proposing is not appropriate, but they propose it for the lack of any alternatives. So statements like ‘he's not terribly, mentally ill, but surely sleeping in a psychiatry unit is better than sleeping on the streets’ or ‘we arrested this man and we don't know is he mentally ill or not but he does appear to be violent’. So, you know, to an extent I can ] understand the impulse behind the desire that various people in those situations be admitted to psychiatric hospitals or inpatient psychiatric care. However certainly, when I'm on call, I'm thinking to myself, this is exactly how the asylums grew so large in the 1800s. And now that doesn't especially help me in the middle of the night in the emergency department, but let's say I have an enhanced awareness of the historic problems that will happen if psychiatry just yields to all of these pressures. I am not without empathy for these dilemmas, like I really really am, and these are failures of social care rather than medical care or psychiatric care, and the solutions proposed are inappropriate. But to put it another way if I had a large mental hospital with 2,000 beds and, you know, I was confronted with a homeless person who might well die if left sleeping rough. Or the violent person who maybe isn't mentally ill, but has a problem with alcohol. Would I occasionally be prevailed upon and yield to admit them to my 2,000 bed mental hospital if I had one? Yes! I am human! I do have empathy for these things, and sympathy and compassion, and all of that, and but those are the pressures that led to the mental hospitals, and those pressures are still present today.
If I had a large mental hospital with 2,000 beds and I was confronted with a homeless person who might well die if left sleeping rough. Or the violent person who maybe isn't mentally ill, but has a problem with alcohol. Would I occasionally be prevailed upon and yield to admit them to my 2,000 bed mental hospital if I had one? Yes! I am human!
Emma Farrell: Asylum is, by my count, your 14th book in ten years? You’ve written about human rights, Buddhism, mindfulness, literature, and of course the history of psychiatry. And I suppose my final question is, what’s next?!
Brendan Kelly: My interest is in psychiatry. My interest is in what we now call mental illness. But who knows? We might call it something different. And the direct experience of that. Its in ‘what happens’. So, the books are really all linked by that. The history of it. The law that governs it. The human rights implications of it, and various clinical matters, too. And what next? I don't know. There's a number of files on the desktop, and I struggle to know what anything will turn out to be. Although, I will tell you what is absolutely immediately next – Resilience: Lessons from Sr William Wilde on Life After Covid. This is a book looking at Sir William Wilde, Oscar's father, who was a physician, and wrote a lot about epidemics and pandemics in Irish history and trying to figure out the recurring themes that were brought up by Covid.
Emma Farrell: Professor Brendan Kelly, thank you for your time.
Professor Brendan Kelly is Professor of Psychiatry at Trinity College Dublin, Consultant Psychiatrist at Tallaght University Hospital, Dublin, and UCD Visiting Full Clinical Professor at UCD School of Medicine, University College Dublin. In addition to his medical degree (MB BCh BAO), he holds masters degrees in epidemiology (MSc), healthcare management (MA), and Buddhist studies (MA), and an MA (jure officii) from Trinity College Dublin; doctorates in medicine (MD), history (PhD), governance (DGov), and law (PhD); and a higher doctorate in history (DLitt).
He has authored and co-authored over 300 publications in peer-reviewed journals, over 600 non-peer-reviewed publications, 21 book chapters and book contributions, and 17 books (11 as sole author). His recent books include Asylum: Inside Grangegorman (2023). He is a Fellow of the Royal College of Psychiatrists, Royal College of Physicians of Ireland, and Trinity College Dublin. In 2018, he became Editor-in-Chief of the International Journal of Law and Psychiatry and in 2020 was elected as Dun’s Librarian at the Royal College of Physicians of Ireland.
