Dr. Joseph Duffy:

Jigsaw warmly welcomes this opportunity to contribute to the vital work of the Joint Committee on the Future of Mental Health Care in Ireland. The work it has carried out to date and the recommended actions it has put forward in its interim reports are to be commended. The task at hand is not an easy one. The landscape for mental health provision and support in Ireland is complex and mapping out a new vision for the future of mental health is challenging. Integrated, joined-up thinking in the area of mental health is both challenging and lacking.

Areas such as research and stigma reduction continue to be the subject of under-investment. Innovations in areas such as e-mental health, school supports and services operating outside 9 a.m. to 5 p.m. are limited in scale and ambition. The whole population approach to mental health promotion and support, as put forward in A Vision for Change and strongly advocated for by Jigsaw, is needed, now more than ever, against a backdrop of mental health support services across primary and secondary care being under-resourced and over-stretched.

Jigsaw, as Ireland’s national centre for youth mental health, will focus our contribution on youth mental health specifically. At Jigsaw, we value young people. They represent Ireland's future, not least because the economic future of the country depends on their health, productivity and vitality, but also because our society as a whole will be better and healthier with a stronger, more resilient youth population to the fore.

The public and political discourse is shifting. As a result of the collective effort of the Government, elected representatives, the HSE, NGOs, civil society, the media, educational bodies and more, Ireland is beginning to see a significant change in how we view, talk about, respond to and support our young people’s mental health. We in Jigsaw are proud of our involvement at the forefront of this progress, and we strongly believe that Ireland has the potential to be a global leader in youth mental health research and support services by 2028.

While many challenges exist in supporting our young people, we have come a long way in the past decade. Only ten years ago, psychiatric-based supports for young people were the norm; young people were treated in a very similar way to adults in terms of mental health support, and Ireland had completely inappropriate, inaccessible and non-youth friendly services in place. Fast-forward to today. If A Vision for Changewas the blueprint for a new kind of response, Jigsaw is a manifestation of many of the key principles in this seminal document.

Jigsaw’s vision is an Ireland where every young person’s mental health is valued and supported.It was established in 2006, as Headstrong, to meet an identified gap in service provision for young people struggling with their mental health, possibly with emerging mental health difficulties which did not require the support of specialist mental health services. Jigsaw is funded by the HSE mental health division, MHD, and provides services in a primary care setting. Jigsaw is an evidence-informed - through our Jigsaw data system, JDS - community-based mental health service for young people aged 12 to 25 years experiencing mild to moderate mental health difficulties. We provide young people in distress with a safe, confidential and professional service where they can access free talking therapies. We support young people to develop the coping skills and resilience that help them deal with present and future challenges to their mental health. These services are free, accessible, timely, impactful and evidence-driven mental health supports offered through our network of 13 regional hubs. It is interesting to note that 25% of referrals come directly from young people themselves, almost 40% from parents, just under 10% from GPs, and the remainder from other mental health services or educational settings.

The key features of the Jigsaw model include a focus on prevention as well as early intervention, accessibility and responsivity, and a commitment to meaningful youth participation and community involvement. In addition to the direct talking supports offered to young people and their families, Jigsaw is actively engaged in a programme of evidence-informed mental health literacy and capacity building in the community. This helps to ensure that parents, other concerned adults and those who work or volunteer with young people are better informed and more confident in promoting and supporting the mental health and well-being of the young people in their lives and become equipped to support young people in their community.

Jigsaw is engaged in ongoing evaluation and monitoring of the services we deliver and the impact of those services. This work is delivering with real impact. We know from our evidence that Jigsaw is making a difference in the lives of young people. Those young people who use our services are leaving less distressed, more resilient and better able to cope with the difficulties that arise in their young lives. Over the past 12 years, Jigsaw has supported, directly and indirectly, the needs of almost 24,000 young people. Most of those have been supported in the past three years. In 2017 alone, we supported 4,387 young people and offered over 13,000 face-to-face therapeutic sessions across the country, tackling issues such as anxiety, low mood, anger, low self-esteem and isolation. In evaluating our work, we found that last year 73% of 17 to 25 year olds who came to our services for a brief therapeutic interventions experienced a significant reduction in their psychological distress.

We value young people and their parents' feedback about their experience of the service. Approximately 92% of those who responded to an anonymous survey reported being satisfied or very satisfied with their service from Jigsaw. Alongside our face to face therapeutic work, we know that our mental health workshops and training, delivered to over 70,000 people across the country to date, increases awareness and knowledge about mental health issues, encourages higher levels of help seeking, reduces stigma and strengthens our communities’ confidence and competence in supporting the mental health of young people.

I would like to focus on solutions now. It is clear that the time is right to address some of the fundamental challenges that present themselves and look at sustainable solutions to support youth mental health. As my two colleagues have already mentioned, primary care is a hugely important issue. It has been our experience in the past 12 years that there is significant demand for a primary care youth mental health service that is free, easily accessible, responsive and acceptable to young people. There are large numbers of young people whose mental health needs can be appropriately supported in primary care but who do not need access to specialist care if they receive support early when experiencing mental health issues. The more comprehensive and advanced our primary care supports are, the less the likelihood of inappropriate referrals going to the secondary specialist care system, causing increased delays and the clogging up of an already stretched system. Mental health supports at primary care level in Ireland have been underdeveloped and underfunded for too long, contributing to the current problem we see in Child and Adult Mental Health Services, CAMHS, which are all too often characterised by unacceptably long waiting lists.

Jigsaw strongly believes that primary care mental health supports should be holistic and systemic in their focus. In addition to the provision of widely available talking therapies, there should be an emphasis on the promotion of mental health and the prevention of more significant difficulties. In order to drive the change we see as essential in youth mental health we need to better inform, support, educate and empower our communities, enabling a better understanding of our collective responsibility in and ability to support young people’s mental health. While resources are limited, funding a range of services should not be viewed as taking resources from one area for another. In order to provide a single long-term vision for mental health services, all services should be acknowledged and resourced for the role they play in preventing, supporting and managing mental health issues.

Jigsaw employs psychologists, who are wither clinical, counselling or educational, social workers, occupational therapists and mental health nurses in its trans-disciplinary clinical model of clinical care. Recruitment of sufficient numbers of appropriately qualified mental health professionals is a significant challenge to all agencies within the sector. Jigsaw, just like other mental health service providers, faces daily challenges in this area. What is clear it that there are a limited number of mental health professionals graduating into and entering the system. There is significant competition for posts between services who are all struggling to resource their teams, with particular challenges in some geographical areas. In Jigsaw’s view, some of the elements that would contribute to easing the challenge of recruitment include increasing the numbers of university courses or places in relevant disciplines; for allied health professional training courses to include a greater emphasis on mental health, thereby facilitating a smoother and quicker transition for graduates into mental health service positions; and the promotion of the mental health field as a positive, progressive, recovery-focused place to work where one can make a real difference in the lives of others. We involve our youth advisers in the recruitment process as we believe having an interest and passion for youth mental health is an important factor in ensuring that there is the right fit between a prospective staff member and the work they will do in Jigsaw. 

A Vision for Change clearly references the need for greater integration across the various strands of the mental health system. An augmented primary care system will work best and meet people’s needs to the extent that there are linkages and more joined up thinking and pathways between primary, secondary and tertiary care. We acknowledge that we are stronger when we work together, linking in and working with like-minded organisations, individuals, agencies and funders. It is only through this collective action that we can truly develop innovative responses and seek fresh, bold perspectives in the area of youth mental health.

We see mental health as something that is part of our community, part of our workplaces, schools and part of our lives. In Jigsaw, we are working with the HSE and with corporate partners – MSD, Three, Lidl, ESB and more - to bring about this change. The CAMHS standard operating procedures, SOP, lists Jigsaw as a direct referral agent with the provision that Jigsaw referrals must be made by a senior clinician in collaboration with a GP. However, some CAMHS services do not accept these collaborative referrals from Jigsaw, insisting instead that the young person go to their GP for a referral. This causes delays and puts another step in the process that is already difficult for the young person and his or her family. We would like to see a real commitment to interagency working that is based on meeting the needs of young people and their families which supports their movement across the mental health service system in as seamless a way as possible.

We believe research in the area of mental health is wholly under-resourced. Jigsaw’s seminal My World survey of 2012 remains the largest and most impactful study of its kind in Ireland. However, data contained within the study is nearing its tenth anniversary and we need to review at the full range of risk and protective factors at play for today’s youth population. In line with Jigsaw’s strategic objective to deliver robust research and evidence to better inform systems change and effective service delivery and to increase our collective understanding of youth mental health, we believe in the value of investment in a new research agenda on the modern-day lived realities of our young people. We believe that is needed now more than ever and we are planning to repeat the My World survey this year.

As has been mentioned by my colleagues, e-mental health is another important area. At Jigsaw, we believe that digital technology can make a significant contribution to enhancing public understanding of mental health. We see the potential for digital technology to transform the way young people look after their mental health and to transform the way we, as a country, design and deliver mental health supports and services. We are currently working with two corporate partners, MSD and 3, to initiate the development of a high-quality, accessible e-mental health platform that has both a prevention and early intervention focus.

Since Jigsaw was founded, young people have been involved in helping us to develop and design our services. We now have youth advisory panels in each of our services and in the national office. These panels are made up of young people aged between 16 and 25 who may or may not have experience of the mental health system but who are all passionate about this area. More than 130 youth volunteers help to inform and guide our decision making at all levels of the organisation. They have representation at the board of directors meetings and on board subcommittees and are involved in the recruitment of staff and in representing Jigsaw at national and international events.

Our youth advisers asked me to emphasise the following points to the committee today. It is important to start at the start and not to wait until the end to support a young person. Early intervention needs to be emphasised more. There is a lot of focus currently on second level services - child and adolescent mental health services, CAMHS, etc. - but there needs to be a focus on supporting young people earlier, in schools and colleges, to let them know more about what will support their mental health. Greater knowledge and supports for young people who have more significant mental health problems are also needed. Services need to be more youth friendly and the transition from CAMHS to adult mental health services needs to be looked at. If one needs a CAMHS service when one is 17, being put on a waiting list for adult services just because one turns 18 is not acceptable. More resources are needed generally to ensure that requests for support are responded to appropriately. The age of consent for accessing mental health services needs to be reduced to 16 years. Young people may want to access support due to family issues but may not feel able to tell their parents what the real problem is and having to get parental consent when one is 16 or 17 is a barrier for some young people. Young people also highlighted the importance of being greeted in a service by friendly staff and being made to feel respected. This will have an impact on their engagement with mental health services. Mental health overall is about human experience and we need to remember this aspect.

By continuing to invest in youth mental health specifically, we can ensure that we continue to enhance and evolve the services we provide, to increase our knowledge, to deliver more impact and to increase supports for adults, families and parents. We need to work together and to create meaningful partnerships and we need to work tirelessly to ensure that no young person suffers alone without access to the help he or she deserves and may desperately need. As the landscape of mental health evolves and changes, so too must our responses. We very much welcome the opportunity to discuss further some of the issues that we have raised during this meeting. I thank the committee for the invitation to participate in this process.