1. To become familiar with the history of mental health in Ireland and develop a critical understanding of the dominance of the illness framework of distress.
2. To understand the impact of widening participation and concurrent decreased funding on universities’ ability to respond to the needs of an increasingly diverse student population.
3. To critically analyse the current model of support for students with mental health difficulties in higher education and interrogate the effectiveness and equity of this approach.
Sixty years ago this book would not have been necessary. Higher education was the preserve of a small minority, and those struggling with their mental health would likely have been housed in institutions, homeless, or hidden away. Since the 1960s, participation in higher education has grown 13-fold – from 18,427 students in 1964 to 246,300 students in 2021; our response to mental health has shifted from one of incarceration to inclusion; and there is a greater public awareness of mental health and well-being than ever before. This chapter charts these developments. It explores the history of our response to distress, the rapid growth of the higher education sector in Ireland, and the implications of consecutive policies of increased participation and decreased investment in higher education for students with mental health difficulties. Finally, this chapter engages with the “why” and “how” of universities’ support for students with mental health difficulties and asks if the current approach is achieving its stated aim of facilitating a more equitable engagement with higher education for students in distress.
The history of mental health in Ireland, like that of so many western nations, charts an unfolding array of words, descriptions, understandings, and approaches to the phenomenon that today we variously describe as difficulty, distress, or disorder. Our earliest ancestors understood madness as a form of supernatural retribution. One of the most dreaded necromantic powers of the Irish druids was that of causing madness. For this purpose and angry druids would prepare a “madman’s wisp” (dluí fulla), a ball of straw or grass, which he cursed and flung into the face of his victim who at once became insane or idiotic (Kelly, 2016; Robins, 1986). Little distinction was drawn at that time between those described as “mad” and those who today would be referred to as having an intellectual disability.
The arrival of Christianity to Ireland did little to alter prevailing supernatural or pagan beliefs but merely, as Robbins (1986, p. 4) puts it, “put a Christian gloss on existing notions”. This gloss painted insanity as the wrath of God as opposed to retribution from the intermediaries of the pagan otherworld. The belief in demoniacal possession, both in its older pagan and newer Christian forms, captured the imagination of the medieval mind. The world and its inhabitants were seen as the chief prizes in a constant battle between good and evil, light and darkness, God and Satan (Deutsch, 1937). Throughout Europe people, particularly women whose mental aberrance or abnormal behaviour failed to meet the Church’s and society’s rigidly ordained beliefs and practices, were accused of being witches, cruelly tortured, and put to death. This was particularly the case in Protestant countries where the sixteenth-century Protestant reformation had spurred what Robins (1986, p. 19) refers to as an “orgy of witch-hunting”. Throughout Europe tens of thousands of alleged witches were put to death, “many of them were insane persons” (Robins, 1986, p. 18).
Celtic Ireland largely escaped this frenzy of witch-hunting and instead adopted a more inclusive and pragmatic approach to managing “the mad”. The Brehon Laws, ancient statutes that governed pre-Christian and early Christian Ireland, outlined considerable provisions for the inclusion and protection of the insane (Kelly, 2005). For example, the Seanchas Mór, or “Law of Distress”, dictated that failing to support or provide maintenance for a family member resulted in a fine; five cows for failing to maintain a madman and ten cows for failing to maintain a madwoman, considerable fines at that time reflecting the unequal resources available to men and women. However, since the Brehon Laws focused on protection from abuse rather than neglect, life for the “mad” in the Middle Ages and Early Modern Ireland tended to be harsh and impoverished (Kelly, 2016). These harsh conditions were further compounded when, following increased control by, and eventual union with, Great Britain, Irish monasteries, and their monastic hospitals, were dissolved. This led to even greater levels of homeless, neglect, and incarceration (Finnane, 1981; Robins, 1986).
Little distinction was drawn between them. The beggar, the prostitute, the cripple, the scrofulous, the runaway apprentice, the imbecile and the mad were locked up in a variety of penal institutions where all were treated with great harshness.
By the late eighteenth century, growing concerns over abuses and conditions in Irish jails led to the establishment of Houses of Industry at Dublin, Clonmel, Cork, Waterford, and Limerick. These houses were punitive rather than charitable in design and sought to confine and control “sturdy beggars and vagabonds” as well as give some shelter to the “deserving poor” (Walsh and Daly, 2004, p. 14). The proportion of insane in these Houses of Industry grew to such an extent that, by 1810, a grant was provided to the Dublin House of Industry to establish an asylum “for the reception of lunatics from all parts of the kingdom” (Kirkpatrick, 1931, p. 17). This asylum, the Richmond Asylum, was filled to capacity within two years of its opening and led the British Government to launch an expansion of the asylum system that, by 1900, resulted in 22 public asylums throughout the country housing 17,000 inmates – 56 for every 10,000 Irish citizens (compared with 41 in England and Wales and 45 in Scotland (Inspectors of Lunatics, 1901; 1906). Medical doctors “were put in charge of asylums primarily because they were easy to hold accountable to the board of governors” (Burns, 2006, p. 37). In the absence of effective medical interventions the superintendent’s role was predominately administrative and disciplinary. In the 1840s superintendents began to found their own professional bodies and “the previously heterogeneous congeries of madhouse keepers had instead become a more and more organised group of specialists” (Scull, 2011, p. 50). The new profession struggled to reach international consensus on what it should be called: the French preferred “aliéniste”, the Germans “Psychiater”, while their English-speaking counterparts favoured “Medical Psychologist” or “Asylum Superintendent”. Ultimately, as a result of the early advancements of German physicians, the budding profession became known as psychiatry.
The development of psychiatry was supported and nourished by a variety of sociocultural conditions. First, at a basic level, physicians provided a useful service to the families and communities, “meeting the complex needs of troubled families (often unrelated to mental illness)” (Kelly, 2023, p. xvi). Second, their presence painted “a medical gloss” (Scull, 2011, p. 58) on the asylum system, a gloss that, in the wake of a series of significant medical advancements such as Pasteur and Koch’s breakthroughs in medical microbiology, generated much social approval. Third, a new concept of “degeneration”, which viewed the insane as “degenerate human beings” (Morel, 1857, p. 5), became increasingly popular in the era of Social Darwinism and resulted in the source of madness being firmly (re)located in the physical body. Finally, supporting the increasingly popular opinion that “patients with so-called ‘mental illnesses’ are really individuals with diseases of the nerves and the brain” (Griesenger, 1867, p. 1) was the discovery in 1906 by German psychiatrist Alois Alzheimer of brain anomalies associated with the disease that was named after him. This, combined with the discovery of an organic source of syphilis-induced psychosis, bolstered psychiatry’s explanation of mental disorder.
While the results of German laboratory-based brain research were impressive and placed psychiatry in the same realm as other biomedical disciplines, these advancements failed to make “any contribution whatsoever to clinical care, let alone cure” (Scull, 1979, p. 68). If anything, they only served to generate a very heavily pessimistic view of the long-term prospects of those in distress. The growth of large asylums also provided captive populations for those psychiatrists who wished to conduct research. Indeed, Professor Brendan Kelly, in his seminal history of psychiatry in Ireland, describes the history of psychiatry as “a history of therapeutic enthusiasm” (2016, p. 1). Insulin-induced comas, electricity-induced seizures, malarial mosquitoes (whose use in the treatment of psychosis resulted in its pioneer receiving a Nobel Prize in 1927), and prefrontal lobotomy (which too won a Nobel Prize in 1949) were all well intentioned but ultimately barbarous attempts to root out the biological cause of distress.
The illness framework is the dominant framework in mental health services because psychiatry is the dominant profession within those services. However, its dominance should not be confused with its conceptual superiority.
The illness framework, as we will see in the next section, is not just the dominant framework in mental health services but also underpins the provision of support for students with mental health difficulties in higher education. This framework seeks to identify sick individuals (diagnosis), predict the future course of their illness (prognosis), speculate about its cause (aetiology), and prescribe a response to the illness to cure or ameliorate its symptoms (treatment). The difficulty with applying an illness framework to mental health is, as the introductory chapters to the Oxford Handbook of Psychiatry (Semple and Smyth, 2013, p. 30) attests, (a) there are “no objective diagnostic or prognostic investigations” for mental illness (diagnosis); (b) psychiatrists “lack knowledge of the aetiology and pathogensis of most psychiatric disorders” (aetiology); and (c) the treatments or interventions are “often minimally or only partially effective” (treatment).
The dominance of the illness framework, or biomedical model, of distress has been repeatedly called into question by sociologists (Coppock and Hopton, 2000; Goffman, 1961; 1963; Horowitz, 2020; Rogers and Pilgrim, 2014; Rose, 1998; 2006; 2019), psychologists (Cromby, Harper and Reavey, 2013; Hornstein, 2017; Johnstone, 2000; Johnstone et al., 2018; Watson, 2019; Watts, 2017), psychiatrists (Bracken, 2015; Bracken and Thomas, 2001; Kleinman, 1991; 2012; Laing, 1960; Moncrieff, 2007; 2013; Szasz, 1961), philosophers (Bracken and Thomas, 2005; Foucault, 2001; 2006) and those with lived experience (Dillon, 2011; Dillon and Hornstein, 2013; Rose, 2017; Watts, 2012). The role of trauma, adverse childhood experiences, power, inequity, and discrimination, in their many complex and nefarious forms, is increasingly recognised as critical to our understanding of, and response to, human difficulty or distress (Felitti et al., 1998; Johnstone et al., 2018; Maté and Maté, 2022; Van der Kolk, 2014). However, in spite of increasing recognition of its limitations, Ireland’s Higher Education Authority (HEA) continues to rely on the illness framework as the basis for the delineation of “deserving and non-deserving”, to borrow the popular phrase from nineteenth-century social policy, students in their allocation of scare resources (Farrell, 2022a; Farrell and Mahon, 2021).
Education has always been highly valued in Ireland. Even in times of great political, social, and economic difficulty, when harsh penal legislation denied Irish Catholics (who represented the majority of the population) access to education, there was in existence a vast network of illegal “hedge schools” which catered for the majority of the Irish school-going population (Raftery, 2011). During the seventeenth and eighteenth centuries, the prevailing political and social climate meant that many Irish people had to travel abroad to access higher education – drawing on the Irish colleges network and a rich tapestry of scholarly diaspora. When access was provided to state-funded primary (1831) and secondary (1966) education, Irish people were quick to utilise and take advantage of these opportunities.
The 1960s was a transformative decade in the history of Irish education, one in which the economic and societal imperative of education drove a new policy agenda. The numbers accessing third level education soared, from 18,427 in 1964 (Clancy, 1996) to 246,300 in 2021 (Institute of Public Administration, 2024). The introduction of the “Free Fees Initiative” in 1996 contributed greatly to this growth as more and more students accessed higher education, unencumbered by undergraduate tuition fees. Prior to the introduction of “free fees”, 22 per cent of Irish adults had a third level qualification (Central Statistics Office, 2000). Today this figure stands at almost 50 per cent (Central Statistics Office, 2016) and looks set to rise even further as, 80 per cent of school leavers progress each year to higher education (The Irish Times, 2023). However, from the early 2000s onwards successive governments began to reintroduce a “student contribution charge” which, following the economic crash in 2008, increased to €3,000, making Ireland one of the most expensive places to go to university in the European Union (Citizens Information, 2023). The government could no longer afford to fund free higher education and, at a time when student numbers were on the rise, exchequer investment dramatically decreased. Today it is estimated that the higher education sector in Ireland is underfunded to the tune of €307 million per year (Irish Universities Association, 2023).
The consequences of this underinvestment have been felt across the higher education sector; from increased student–staff ratios, to ageing infrastructure and a reliance on international student fees and private investment to sustain the day-to-day operation of the university. It has also resulted in a scarcity of resources by which to support students with mental health difficulties in higher education and a reliance on the illness framework as the means by which these scarce resources are allocated.
The number of students with mental health difficulties in higher education has risen in recent decades in line with the changing profile of students that is seen both in Ireland and internationally (Claeys-Kulik, Jørgensen, and Stöber, 2019). As the numbers attending university have risen overall, so too has the diversity and representativeness of the student cohort. The once largely homogenous student body has been replaced by non-traditional learners from diverse racial, religious, linguistic, and learning backgrounds as well as with a variety of personal circumstances and abilities. In Ireland, it is estimated that almost 40 per cent of the student body is “non-traditional” (Healy, Banks, and Ryder, 2023).
All university students in Ireland have access to some form of mental health support. This can vary widely from a specified number of free counselling sessions, to online resources and campus well-being initiatives (Higher Education Authority, 2020). For those students struggling over a longer term, or whose distress impacts their lives in more immediate ways, additional support and accommodations can be provided through the Fund for Students with Disabilities (FSD). This fund allocates resources to each HEI through the Higher Education Authority, the body with responsibility for funding and accountability in higher education. The purpose of the Fund for Students with Disabilities is to provide HEIs with funding to assist them in supporting “eligible students with disabilities so that they can participate on an equal basis with their peers” (Higher Education Authority, 2023, p. 3). Eligibility for students with a “mental health condition” (p. 15) is established by diagnosis and report from a consultant psychiatrist. Examples provided include “bipolar disorder, schizophrenia, clinical depression, severe anxiety, severe phobias, obsessive compulsive disorder, severe eating disorders and psychosis” (Higher Education Authority, 2023, p. 15).
This approach to including and supporting students with mental health difficulties in higher education is heavily predicated on the illness framework as described in the previous section. It belies a form of thinking based on Cartesian Dualism discussed in Chapter 1 that locates the “problem” in the person with little emphasis on the wider social environment and process. As McCarthy (in Quirke, Mc Guckin, and McCarthy, 2023) suggests, this implies that distress or disability is an individual problem to be fixed or accommodated so that those categorised as “disabled” (the term itself revealing the “dis”-ability) can lead a “normal” life. While initially designed so that students with discrete and medically discernible “disabilities”, such as vision impairment, hearing loss, or mobility issues, might be given the support needed to access and engage with university teaching and assessment, this discernibility between “eligible” and “ineligible” (or deserving and non-deserving as described previously) students is less clear when it comes to mental health difficulties.
The number of students with mental health conditions deemed eligible for additional support has risen rapidly from 643 students in 2011/2012 (AHEAD, 2012) to 3,939 in 2021/2022 (AHEAD, 2023). The reason for this increase in unclear but is thought to include a combination of (a) growing number of students with disabilities, including mental health conditions, progressing to higher education; (b) increased public awareness of mental health conditions with more people willing to seek help with their distress; and/or (c) the increased presence of the illness framework in everyday life (Davies, 2021; Foulkes, 2021; Rose, 2006).
In a climate of increased demand, and decreased resources, the task of determining who is to be deemed “eligible” for these scarce resources is increasingly complex. This task is further complicated by the fact that mental health conditions are difficult to define. As described above, there are “no objective diagnostic or prognostic investigations” (Semple and Smyth, 2013, p. 30) by which to determine what is “normal” or “abnormal”. Indeed, as the longitudinal birth cohort study, the Dunedin study, showed us, if subject to psychiatric assessment at regular intervals, 86 per cent of the general population will meet the criteria for a diagnosable mental disorder by the age of 45 (Caspi et al., 2020).
Further, more affluent students who are able to afford private psychiatric assessment, bypassing the long waiting lists and administrative delays associated with the public mental health system, are automatically advantaged in a system that relies on a psychiatric report to access services. This advantage is seen in the disproportion of students entering higher education through the DARE (Disability Access Route to Education) scheme who come from affluent backgrounds. DARE offers reduced points university places to school leavers who, as a result of having a disability, have experienced additional challenges in second level (high school) education. In effect, this means that students who come through the DARE scheme can access university places with lower “points” or grades than their peers. Data from the Higher Education Authority (2024a) reveals the 70 per cent of new entrants to university under the DARE scheme are from “marginally advantaged” or “affluent” backgrounds. Indeed, one quarter are classed as “affluent” under the deprivation index score. Given people with disabilities are known to be at higher risk of social exclusion and deprivation (Eurostat, 2022), these figures suggest that the DARE scheme is failing to represent its intended population. Indeed, anecdotal evidence suggests that the scheme is increasingly being appropriated by students, and their families, with the financial resources and know-how to pay for private assessment, diagnosis, and reports so as to access higher education through the reduced point DARE system and avail of additional supports and accommodations whilst there.
This trend is also seen in the US where a report by the Wall Street Journal (Belkin, Levitz, and Korn, 2019) highlighted how students from private, fee-paying schools were four times more likely to come to university with a diagnosis and thus automatically avail themselves of accommodations such as extra time in exams. Further, an ethnographic study of “mitigating circumstances” revealed a sense amongst UK university support staff that the provisions were not reaching all those for whom they are designed, but rather “the system has been co-opted by groups of vocal, confident, privileged students who know how to work the system” for personal gain (Armstrong and Byrom, 2023, p. 8). What these points serve to highlight is that the current model of support for students with mental health difficulties – indeed, it has been argued the current model of support for the entire student population (Healy, Banks, and Ryder, 2023) – is no longer fit for purpose.
In response to increased student diversity, and the recognition that the current provision of support to individual “eligible” students is neither fit for purpose nor sustainable (McCarthy, Quirke, and Treanor, 2018), there has been a shift towards a universal design for learning (UDL) approach that seeks to create more inclusive and equitable learning environments for all students – not just those identified as lacking or dis-abled in some way (Quirke, Mc Guckin, and McCarthy, 2023). Universal design for learning provides a framework for educators to proactively plan their curriculum and pedagogy so that it is more accessible to all students. It represents a shift in thinking from the university as oriented towards the “average” student, with specific measures to enable disadvantaged or disabled students “to participate on an equal basis with their peers” (Higher Education Authority, 2023, p. 3), to one that recognises the variability and individuality of all students. Research shows that by incorporating UDL into university teaching and learning many of the pressing issues associated with increasing participation and diversity in higher education – issues including student retention, performance, completion, and well-being – can be alleviated (Al-Azawei, Serenelli, and Lundqvist, 2016; Almeqdad et al., 2023; Capp, 2017; Healy, Banks, and Ryder, 2023; Soek, DaCosta, and Hodges, 2018). UDL is in its infancy in the Irish higher education context but has been received crucial support and stakeholder buy-in that has resulted in significant momentum in the introduction of UDL in Irish universities. It has been recognised and welcomed as a more inclusive and shared mode of higher education. Indeed, while there is still a distance to go before the disability model, and its reliance on the illness framework, can be consigned to history, it has been suggested that this momentum and enthusiasm positions Ireland to be a world leader in the successful implementation of UDL in higher education (Healy, Banks, and Ryder, 2023).
This chapter sought to set the scene by providing an overview of how Ireland has, historically, approached and responded to mental health difficulty or distress. It described the higher education sector in Ireland, charting the rapid increase in students accessing third level education since the 1960s. It aligned this rapid growth with a more recent period of austerity that has resulted in significant underfunding of Irish universities. In this climate of scarcity, a distinction is drawn between those students who are, or are not, “eligible” for additional supports or accommodations. Determining who is eligible for additional support for a “mental health condition” is, as discussed above, complex and efforts to provide a more equitable mode of support for all students have seen a turn, in recent years, towards a UDL approach to teaching and learning in higher education. The lived experience of entering the higher education context laid out in this chapter forms the focus of Chapter 3.
Irish University Students with Mental Health Difficulties
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