The psychiatric hospital has again resurfaced in the news recently, when a patient challenged, in court, his seven year detention there.
In 2014 Nicholas Grech, an engineer who is now 44, was sentenced to be kept in Mount Carmel Hospital for as long as necessary following a four year period of mock crucifixions of cats and dogs.
Psychiatrists reported to the court that Grech was suffering from impaired judgment owing to his mental condition, that he was declared insane, and therefore not criminally liable for his actions.
The patient, who has a previous history of mental illness, is now taking legal action to determine whether, after this long period, there are still grounds for his continued detention. In the meantime, Grech has been running a website from the hospital, documenting in detail his saga, including psychiatric evaluations, treatment and complaints to internal and external authorities.
While refraining from entering into the merits of this particular case, it is interesting to dig deep into the past to see how mental illness and its treatment has evolved, how perceptions have been shaped, and where we are today.
Concepts of mental illness
In the middle or dark ages, scholars and physicians in the West were influenced by demonological theories that had gripped the Christian world. Thus the mentally ill were chained or worse, burnt at the stake. It took centuries for the humanistic approach to reprieve the mentally ill from their fate and to start being treated as patients with a condition. But the stigma remained.
In stark contrast, in the East, Arab medicine had looked towards the Koran and its three stage concept of mental illness, which stressed that there was no fault or stigma in one being afflicted by such a condition. One can be possessed by a Jinn, a supernatural spirit that could be good or bad; one can have an expansion of the self, be creative or innovative, and therefore be misunderstood by society; and finally, the internal balance between good and bad goes into disharmony, and the scales have got to be righted. Thus there was full tolerance of the mentally ill, who were treated as human beings.
Local developments
In Malta, on par with most European countries, the treatment of the mentally ill up to the first half of the nineteenth century is best forgotten. First catered for by the Knights of St. John in the basement of the Holy Infirmary in Valletta, the British then moved the mentally ill to Villa Franconi in Floriana, and later in 1861 built the present mental care hospital, then called the Lunatic Asylum. The name was changed to Hospital for Mental Diseases in 1928, and finally to Mount Carmel in 1967, each change reflecting altered perceptions and improved psychiatric treatment.
In the 1950s, the treatment of mental illness underwent a major upheaval with the discovery of major and minor tranquillisers and anti depressants. Despite the local introduction of this medication, there was no parallel improvement in the facilities for patients in the general setup of the hospital. Prof. Victor Vassallo, Superintendent from 1932 to 1962, later claimed that administrative indifference, incompetence and financial difficulties were at the root of this stagnation.
Following the Vassallo era, Dr. Paul Cassar was appointed acting Superintendent, but when he encountered opposition to his well meant reforms, he resigned. In the 1960s several World Health Organisation experts visited to assess and report on mental health conditions. One of them, Dr. Russell Barton, an expert on institutional neuroses, reported that the hospital was fifty years behind the times. He called for long overdue reforms, including the administrative and organisational structure, legislation for admissions and discharges, community care and staff education. However, the overhaul of the hospital took a long time.
The criminal wards
The famous, or infamous, Criminal Ward with its notorious single rooms was opened on the male side in 1909, and later a corresponding one in the female division. Patients were sent by court sentences, remitted from prison, or transferred there from other wards where they would have displayed aggressive or violent behaviour. The scope was genuine, but as often happens, besides good use, things can also become misused or abused.
The hospital sometimes became a dumping ground where persons were permanently parked for upsetting society’s applecart. In the late sixties, a person who had become a thorn in the sides of the authorities by opening a number of frivolous court cases, including his right to have his nickname added to his formal name, was sectioned, and spent many years out of the way in hospital. But when he was eventually released, he continued his legal battles, and won a landmark case against the police commissioner and the court registrar, in which individuals are now allowed to institute court proceedings in their own individual capacity without the signature of a lawyer or without being represented by one. This verdict has been quoted on a number of occasions in judgments of the European Court of Human Rights.
Sometimes, a criminal would be better off spending his sentence in prison, with a definite timeframe, rather than being transferred to Mount Carmel, for an indefinite period, which in the past would have meant life. Realising this after some years and the hopelessness of it all, a young patient who had killed his father for being violently abusive to his mother, decided to protest out loud. In the hot summer of 1977, he climbed on the roof of a room, continued his way up to the topmost part of the hospital – the stone platform of the flagpole – and threatened to jump unless he talks to the Minister of Health. Hours later, he came down quietly. But he had made his point, and some time later he was discharged from hospital.
As Dr. Paul Cassar pointed out, the unfortunate situation was not created by the staff, most of whom tried their utmost to change the restrictive conditions, but were held back by legal and political bureaucracy. Some staff spoke out without fear about injustice and against the system. On 15th October 1979, known locally as Black Monday, an armed man entered Castille. All hell broke loose, and eventually, the court sent him to Mount Carmel for life. Later, two of the man’s sons went to talk to the hospital Superintendent, Prof. Abraham Galea. As soon as he saw them, he got up, went to a wall and deeply etched the outline of a cross with his pen – a groove so deep that one of the sons said it would need a full trowel of filler to cover it up – kissed the cross, and shouted that in his medical oath he had sworn his allegiance only to God and to no government, while urging the patient’s sons to continue fighting legally for justice to be done. Eventually the patient was not found to be mentally ill, and was released.
The present
Great strides have been made in mental health in the last thirty years. Trained staff working in multidisciplinary teams, improved facilities and treatment, specialisations, development of community care, a new Mental Health Act (2012) giving many rights to patients and steps to safeguard them, the appointment of a vociferous Commissioner for Mental Health, various hardworking NGOs – the list is lengthy. Constant mental health educational campaigns have also helped to lessen stigma, which although far from being eradicated, has lowered its ugly head from its former prominent position.
However all is not well in the Kingdom of Holland. A mid nineteenth century building already outdated at the time of its inauguration, Mount Carmel suffers from periodic infrastructural problems. It has clearly expired its use-by date. So much so that two years ago a new mental health strategy was launched, the flagship of which was the building of a new psychiatric hospital near the general one.
The present positive aura has been brought about by motivated past pioneers and current frontliners working hard in the mental health field. There were also a number of militant patients, sometimes aided and abetted by supporting relatives, who by their lobbying, pressure and actions, accelerated the changes. Patient empowerment is of the essence, and in the case of Nicholas Grech, the fact that he could run a website from hospital is a sign of a democratic and enabling environment - although not all patients are as IT savvy or articulate as Mr. Grech. In the meantime, one awaits with keen interest for the court to pronounce itself on his case.
Joseph Busuttil was an occupational therapist in mental health who worked in Malta and abroad.