We tend to regard people who experience mental illness as "different", yet mental illness is a common human experience. One in four Irish adults will experience mental health problems at some stage in their lives.
When they do, they enter a psychiatric care system which is dominated by the view that mental illness is a biochemical problem best treated with drugs and electro-convulsive therapy (ECT) - both with potentially devastating side effects.
Critics of the medical model argue that we need to be more holistic in our view, recognising that mental and emotional distress can have psychological, social, spiritual and environmental causes. The Republic is unique in Europe in that we have no consultant psychotherapist (in other words, a psychiatrist who specialises in psychotherapy) working in the psychiatric system.
Many patients complain that their psychiatrists don't have time to talk to them and do little more than monitor medication. Psychotherapy is not refundable by the VHI, so people who seek to solve their mental health problems through a form of psychotherapy must pay for it - whether it's psychoanalysis, cognitive behavioural therapy or cognitive analytic therapy.
For their part, many psychiatrists complain that they do not like being seen as drug dispensers and want to be allowed to develop psychotherapy skills within the psychiatric system.
"It's quite extraordinary that consultant psychiatrists now want to be trained in cognitive analytic therapy, which would indicate that they have experienced that pills are not good enough," says Fierman Bennink Bolt, a former psychiatric patient who became a psychotherapist and trainer in cognitive analytic therapy (CAT).
Last month, at St Vincent's Hospital, Fairview and St Brendan's Hospital, Bolt began training a group of psychiatrists and other mental health professionals in CAT. It's a talking therapy which can achieve dramatic improvements within 16 sessions for illnesses such as chronic depression, and within 24 sessions for borderline personality disorder. A good result liberates the patient from the revolving door syndrome of repeated psychiatric hospital stays - and potentially saves money for the health system by keeping such people out of hospital.
CAT targets specific patterns of behaviour of which the patient is unaware, then changes these patterns in order to transform the way the patient relates to the world.
Dutch-born Bolt had been a lawyer in the public service in the Netherlands for 10 years when, at the age of 38, he became depressed and was hospitalised. This experience sparked his interest in the emotional and psychological roots of mental illness in childhood, which led him towards family therapy, in which he was trained at the Mater Hospital, Dublin. He then opted for training in CAT at Guy's Hospital in London. Now a trainer and supervisor, Bolt is a registered therapist with the UK Council of Psychotherapy. He has lived in Dun Laoghaire, Co Dublin for 13 years.
CAT is also effective in treating borderline personality disorder (BPD), a shattering condition considered incurable by the traditional psychiatric system. "Hospitals get stuck with these patients because they are considered untreatable," says Bolt.
Such patients appear to be untreatable because they are psychological chameleons, able to invoke "reciprocal roles" - ways of behaving in relation to others - which reconfirm their illness. In other words, says Bolt: "They act as if they are untreatable and then invite hospital staff members to accept this idea, so that staff react as if the patients are untreatable." BPD is experienced in individuals in many different ways.
People with this disorder often find it difficult to distinguish reality from their own misperceptions of the world and their surrounding environment. While this may seem delusional, it is caused by emotions overwhelming regular cognitive functioning. People with BPD often see others in "black-and-white" terms. For instance, a patient can initially view a therapist as being very helpful and caring. But if some sort of difficulty arises in the therapy, or in the patient's life, the person might then begin characterising the therapist as "bad" and not caring.
At the core of using CAT to treat BPD is the theory that acting "crazy" is not a pre-determined, biological incurable state, but a pattern of behaviour which has been learned through relationships from an early age. "As a very young child, you learn not only your own role but those of the nearest people to you, and so you act according to the way your mother expects you to act," Bolt explains.
IF your mother abuses or neglects you, you will become distrustful and wary and learn to adjust to your mother's expectations by developing different self-states. Your personality fluctuates as you learn to survive emotionally by adjusting from one set of reciprocal roles in one kind of self-state, to another set of reciprocal roles in another self-state. Thus, your personality appears to completely change from one moment to the next.
"What they normally do in psychiatric hospitals is to make zombies out of these patients using drugs. In understanding this, you have to take into account how powerless the staff in a psychiatric hospital feel," Bolt explains. With 24 sessions of CAT, the person with personality disorder can learn to integrate these different self-states to make a whole person again. The person does this by being given a map by the therapist - a map which helps the person to reformulate the world.
The person also learns to develop a self-observing eye, so that he or she can see how he or she is acting, feeling and thinking. This approach not only gives hope to people who the system has given up on, but it also contains a lesson for society at large, which is that when people become "mad" or "crazy", this is often because they have been made that way by early childhood experiences. Once that it understood, healing is possible.