Oireachtas Joint and Select Committees
Wednesday, 27 June 2018
Joint Oireachtas Committee on Future of Mental Health Care
Early Intervention and Talk Therapy: Discussion
I welcome Dr. Harry Barry, who is a general practitioner, GP and author. From the Irish Council for Psychotherapy, I welcome Ms Jean Manahan, CEO, and Ms Ann Murphy, who is a psychotherapist. I welcome, from the Department of Health, Ms Kate O'Flaherty, director of health and well-being, and from the Department of Education and Skills, Ms Anne Tansey, director of the National Educational Psychological Service, NEPS, and Ms Margaret Grogan, regional director of NEPS. On behalf of the committee, I thank the witnesses for their attendance today. The format of the meeting is the witnesses will be invited to make brief opening statements followed by question-and-answer sessions.
Before we begin, I draw the attention of our witnesses to the situation regarding privilege. Witnesses are protected by absolute privilege in respect of the evidence they are about to give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.
Under the salient rulings of the Chair, members should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I remind members and witnesses to turn off their mobile phones or put them on flight mode because they have an impact on our sound system.
Any submissions or opening statements the witnesses make to the committee will be published on the committee website after this meeting. I invite Dr. Harry Barry to make his opening statement.
Dr. Harry Barry:
I thank the Chairman and the committee for asking me here. I am a GP with 35 years' experience in full-time practice, including in the General Medical Services, GMS, scheme, and four years working as a GP in private consultation practice with a special interest in mental health. I am a member of the Royal College of General Practitioners, London, and the Irish College of General Practitioners and have a first-class master's degree in cognitive behavioural therapy, CBT.
The views I will express are my personal thoughts on the importance of early intervention and talk therapy. As I have a number of points to make, if the Chairman feels I am running over, she should let me know.
There is a mental health-mental illness spectrum and it concerns me that we spend too much time classifying people as mentally ill. Most people are mentally well for most of their lives but may go through a period of mental illness. It is important we make that point at the start. "Mental health" and "well-being" are the buzzwords of the decade but they are constantly confused with the words "mental illness". The main mental illnesses I consider as genuine ones are schizophrenia, bipolar disorder, severe depression, eating disorders such as anorexia nervosa and obsessive-compulsive disorder, OCD.
Mental illness is properly in the realm of the mental health teams, which are manned by wonderful people but let down by underfunding, poor staffing, poor supports and a patchwork quilt cover range nationally. I also feel that a lot of the time, there is very poor interlinking with GPs and difficulties accessing services.
The real reason I am here today is to speak on behalf of a lot of people in this country who are not mentally ill, who most of the time consider themselves to be mentally healthy but are going through significant periods of emotional distress. They are the two words the committee needs to listen to most today. Our adolescents, in particular, are going through a crisis of emotional distress. Many people, of all ages, are going through such periods. They are caused by life-crisis situations, mental illness or sometimes a combination of both. This is where talk therapy, as we will see later, excels.
We also need a rapid-access, 24-hour helpline national number, not just for people who are suicidal and in difficulty but one in which people can be rapidly assessed in terms of appropriate talk therapy and have easy access to it. We can talk about that later.
With regard to early intervention, awareness about physical healthcare started in 1979 with a guy called John McKinlay who noted he felt like somebody standing at the edge of a river seeing bodies floating by. As he jumped into the river and pulled the bodies out he was trying to resuscitate one after another. He noticed after a while that he was getting exhausted and was saving some and not others. He was a cardiologist. He decided to go upstream and find out where all these people were going into the river to start with. That was the beginning of the great journey physical healthcare has made in the past 30 years. It has gone through secondary prevention and primary prevention and eventually health promotion. Mental healthcare is at least one to two decades behind physical healthcare. That is the journey we need to go on. In the area of mental health, we not only need to go upstream and find out where people are going into the river, we need to go back a step further and teach people how to swim. If people learnt how to swim and fell into the river they would have a better chance of survival. That is where early intervention comes in.
I hate statistics because I think they can be used to say almost anything. There are some important details: 75% of all mental health difficulties occur before the age of 25. Anxiety and depression have increased in our adolescent population by 70% in the past 25 years and 50% of all cases of depression will present between the ages of 15 and 25.
A total of 25% of this group are between 15 and 18 years of age. At present, 9% of our school-going children are self-harming and 40% of those attending Pieta House are children. There is obviously a significant problem in this group. Early intervention will often prevent many people from becoming increasingly emotionally distressed and drifting into mental illness.
Some interventions involve drug therapy but in the majority of cases most people are best served with early intervention talk therapy. I have long believed that teaching people, especially children and adolescents, emotional resilience skills from the earliest age combined with a national protocol agreed by all of us on the use of smartphones by everyone, not only our children, would yield great benefit. This could be done between parents and teachers with feedback from young people. I believe this move, along with emotional resilience skills, might go a long way to reducing the significant emotional distress this group is experiencing.
Like all physical conditions, all mental health conditions are best treated holistically. This will involve lifestyle changes, talk therapy and, occasionally, drug therapy. We should remember that every therapy used on the brain changes the brain, including drug therapy, talk therapy and exercise. Everything we do has an effect on our brains.
I do not intend to spend much time discussing the key therapies like exercise, nutrition, sleep, alcohol reduction, stress reduction etc. Most people, if asked, would pick out exercise but I would pick out sleep. I believed we are a sleep-deprived nation.
Drug therapy is useful in the management of bouts of schizophrenia, bipolar disorder and severe bouts of depression and obsessive-compulsive disorder but it is often of limited use in other mental health conditions. There is widespread assumption that every medication we use is an anti-depressant. We have to accept that tranquillisers are often used for anxiety, anti-psychotics are often used for bipolar and schizophrenia, while other medications used for attention deficit hyperactivity disorder are not anti-depressants. There is also an assumption that all anti-depressants prescribed by my colleagues in general practice are for depression. From talking to many of my colleagues, it seems the reality is that they are often used for anxiety and stress.
Talk therapy is often called psychotherapy. Basically, it is the treatment of psychological distress through talking with a specially trained counsellor or therapist and learning new ways to cope, rather than necessarily using medication. It helps people to become more aware of their unconscious thoughts, feelings and motives. I will leave it to my colleagues to discuss counselling versus psychotherapy but, in a nutshell, counselling involves listening and psychotherapy involves more active intervention to get at the root cause of the irrational beliefs etc. of a person. I am aware that committee members will be listening to submissions on these areas. I do not intend to go further into them save to say that at present in Ireland, counselling is taught to degree level and psychotherapy is taught at masters level. For those who may not be fully aware of it, a degree is basically is where people acquire information while at masters level, people learn how to use information. That is the key difference between the two.
Irrespective of the type of talk therapy at issue I often say, when I am asked to speak to therapists, counsellors or my colleagues, that regardless of what therapy is under discussion empathy must lie at the heart of it. If we do not have a deep respect for the dignity of each human being in difficulty and empathise with where the person is, then no therapy will be successful.
In the academic area, the most researched forms of talk therapy are cognitive behaviour therapy and interpersonal therapy. CBT is helpful for anxiety and managing depression. It is also useful in many forms of emotional distress.
I will provide an overview of the talk therapy situation in Ireland. There are countless counsellors and therapists and there is a major concern among all of us about the lack of State regulation. I believe there has been a significant improvement in the training and supervision of therapists in the past decade but much remains to be done. It is interesting that the UK has chosen not to go down the road of focusing on regulation but has chosen instead to focus on access. The biggest single issue with talk therapy in my life as a general practitioner has been access. While vast amounts of money have flowed into the provision of drug therapy, some of which is justified and some of which is not, there is a definite dearth of State funding and organisation of talk therapy.
A major improvement in general practice was the counselling in primary care service. The service provides counselling for mild to moderate psychological conditions. It has been an improvement but certain concerns remain. I have talked to some of my colleagues about this. The concerns relate to the issues they see and the variety of experience of the therapist. There is a limitation on the number of sessions at any one time and sometimes there is even a lack of therapists. The decision to increase number of assistant psychologists is welcome. However, at the moment it is still necessary for a patient to go through a GP to access the scheme. Mental health teams are completely understaffed when it comes to psychologists and CBT therapists. Older GPs are very good at talking to people and have good empathy skills but are often not trained in talk therapy. Younger GPs are being taught mainly through the GP training schemes to incorporate brief CBT ideas into their work. That is a major advance.
The real issue is the countless numbers of people in emotional distress. I would love for members to be at the end of the telephone to listen to some of the stories that I have to hear and the difficulties of access for people and what these mean for those people and families. Some countries have chosen to go down the road of spending a great deal of time, effort and money on talk therapy and they are benefitting greatly from it. I have visited different countries in different continents in different parts of the world and I have seen how the systems vary from continent to continent. I would like the committee to examine perhaps a system in England called the improving access for psychological therapy. It was started in the mid-2000s. It is under the auspices of Professor David Clark from Oxford University. It is a system whereby anyone in emotional distress can be assessed within 24 hours of contacting the system and assigned to an appropriate form of talk therapy for that person. It is the main vehicle by which talk therapy is transmitted in England. Most of the therapists are fed into that system. I believe it is a wonderful idea. I have talked to some people about this system and there are definitely issues. It has perhaps too heavy an emphasis on CBT. There is a view that access might be too easy, thus putting too much pressure on the system. I believe it is a wonderful concept and something we could look to in this country. If we combined regulation with this type of access system, then we might begin to see our systems getting the care they require.
Finally, I wish to talk about the world of emotional resilience and talk therapy interventions. If all of us became more emotionally resilient through a combination of simple CBT skills and mindfulness, we could transform the mental health of our generation. The classical example is anxiety, which, I believe, is at epidemic proportions. One need only talk to any principal in the country and ask about the number one problem they are seeing in their schools. They will say it is anxiety – it will not be depression.
My experience is that simple CBT and mindfulness exercises can profoundly improve the care of conditions like panic attacks, which are rampant, social anxiety and general anxiety. They can also teach us how to assist better with negative emotions such as hurt and frustration. If we had a properly funded and well-organised talk therapy structured group that incorporated these skills, we could revolutionise the mental health of our nation. Failure to look at the whole way we access and deliver talk therapy in Ireland over the next decade will lead to an over-reliance on drug therapy. More important, it will lead to increasing levels of emotional distress and self-harm and consolidation of risks of further mental illness. By not prioritising early intervention with our child and adolescent services, the services will be over-run by children. However, if we got to them early and had some simple talks with them and sorted out what is going on in their minds and lives, they would not get into such distressed situations. It can get to the stage whereby parents are sitting in an accident and emergency unit at some crazy hour of the night trying to access some psychiatric service that, in the majority of cases, the child does not actually need.
We also need to educate our parents and teachers in emotional first aid. A new movement called the raggy doll movement was launched by my friend and colleague, Enda Murphy, last night. He is a leading psychotherapist. It was officially launched by the Minister of State at the Department of Health. The initiative involves teaching parents and teachers about the tools necessary to further the mental health of their children. As I have said repeatedly for years, the best psychologists in the world are parents, if we could only teach them the skills.
We need teachers and parents to be actively involved in this and not have a situation where everybody is sitting back and waiting for the system to roll in and sort out the child.
Finally, many of our citizens are in pain, and we are failing them. We talk about self-harm and suicide but we will not provide the talk therapy and early interventions which might reduce the risks of these occurring. Allowing people in emotional distress, through early intervention therapy, to explore the causes of their pain and learn how to manage them might result in much less falling into and drowning in the metaphorical river I spoke about earlier. All these interventions require funding, organisation, genuine political backing - not somebody saying it is a good idea and we will see about providing it five years hence - and a real vision for change. I started reading A Vision for Change before coming to this meeting but I gave up half way through it. I found it profoundly sad that so much work had gone into it and all those lovely ideas were there; I hate to think what percentage of that document has been put in place.
I will shortly ask the Vice Chairman, Deputy Browne, to take the Chair but before that I must say that was the clearest and most profound statement. You use the analogy of the river and you are absolutely right. Teach people how to swim first. You were also very clear when you said we should hear what you have to hear as a GP. We are getting that idea. Certainly, we have invited people who provide services and people who are accessing the services to appear before the committee, but I ask the members to ask Dr. Barry to disclose more about what he is hearing because if we do not include that in the report, nobody will know.
Ms Jean Manahan:
I thank the committee for the opportunity to make this presentation on prevention, early intervention and talk therapy. I thank Dr. Barry for his comments as well. I will focus on the psychotherapeutic input that is possible, the fact of how little talk therapy is available and accessing talk therapy.
One issue I have seen in reports from the joint committee and which has been identified by the HSE as a major barrier to effective service delivery is the difficulty in recruiting professionals, yet there is a significant cohort of highly trained psychotherapists on the Irish Council for Psychotherapy, ICP, register who are under-utilised in the State’s response to early intervention and crisis intervention. The ICP represents more than 1,500 psychotherapists who are trained to the highest European standard. Psychotherapy is the most in-depth talk therapy available and requires intensive preparation and training. This includes an undergraduate degree followed by four years of academic and clinical preparation. In all, ICP psychotherapists complete a minimum seven year preparation, comparable to a medical doctor. In addition, the ongoing continuing professional development, CPD, and personal care requirements continue for as long as a psychotherapist practises.
I emphasise this point of intensive preparation to underline what is often missed by service planners. There is a lack of recognition of what this highly trained cohort can add in terms of additional professional capacity both in quality and quantity. A skilled psychotherapist can treat challenging conditions, including serious psychological disorders. Psychotherapy does not merely aim to ameliorate symptoms, but can bring about significant change and the resumption of psychological growth where, for example, development has been suspended as a result of trauma. However, as a profession, psychotherapy is, in the main, excluded from the health system, depriving patients of the option of in-depth talk therapy. The general public, including health administrators, assume that many mental health professionals such as psychiatrists and psychologists have specific training in psychotherapy. This is not the case. A very small number of psychiatrists may do a specific psychotherapy training and psychologists are trained in a range of techniques but they are not trained in intensive psychotherapy unless they undertake additional training. It is interesting that patients hospitalised for depression, anxiety and so forth can spend months in a psychiatric hospital without having even one session of psychotherapy. In spite of so much talk about suicide and prevention, people who present to accident and emergency departments with suicidal thoughts or suicide attempts are generally sent home with a psychiatric follow-up, but are not offered psychotherapy.
A Vision for Change recommended that community mental health teams should offer multi-disciplinaryoutreach care and a comprehensive range of medical, psychological and social therapies across the lifespan. Psychotherapy needs to be instated as a crucial part of the multi-disciplinary approach to prevention and treatment of mental illness and psychological distress. In addition to lack of recognition by service planners, another major challenge to access psychotherapy is affordability and availability. It is expensive for a client on an average income to pay for private short-term or long-term therapy as may be required. While direct service provision may be part of service configuration, as it is at present, consideration should be given to other funding models which put the client or the patient at the centre in terms of need and not ability to pay.
Psychotherapy may be practised in a variety of settings – medical, private practices, voluntary organisations, State agencies and so forth. If we are to be truly person-centred then one of the ways of making psychotherapy more accessible is to allow clients or patients in the community to choose their therapist with financial support from the HSE rather than only providing institutional services which create a funnel effect leading to logjams and long waiting lists. This funding model of money following the client or patient directly, bypassing overburdened organisations, is practised successfully in other countries and it is something the former Minister for Health, Senator Reilly, considered in respect of hospital care. It could work in the community setting.
It has been a major concern for ICP that the title "psychotherapist" has been and still can be used by anyone, regardless of length, depth or breadth of training or, indeed, without any training at all. The need for quality training, stringent ethical guidelines and a robust complaints mechanism is clear. For this reason the ICP has long advocated for statutory regulation to safeguard the public. We have sent the committee our submission on statutory regulation, and we are pleased that the Minister for Health, Deputy Harris, has designated two separate titles of "psychotherapist" and "counsellor" to be safeguarded and regulated by CORU, the Health and Social Care Professionals Council. This is in process as we speak.
Finally, ICP is ready to contribute ideas and suggestions as to how we can work collaboratively to improve service delivery and to make talk therapy more accessible. Such collaboration would take into account the additional significant resource which psychotherapy offers, other funding models which would facilitate a more responsive referral system and inter-disciplinary co-operation which uses all the resources available in a coherent manner. I look forward to the members' questions.
Ms Kate O'Flaherty:
I thank the committee for the opportunity to address it on our Healthy Ireland framework and its relevance to the committee's work. I should preface my remarks by saying I head the health and well-being unit in the Department of Health but interact with our colleagues in mental health policy. I was a member of the steering group that developed Connecting for Life, our suicide prevention strategy, and I was a member of the youth mental health taskforce.
With regard to the relevance of Healthy Ireland, we particularly note within the committee's terms of reference the aim to achieve a long-term vision for the direction of mental health policy in Ireland, and it is in this context that the vision, goals and implementation of Healthy Ireland provide a useful and supportive frame of reference for the future.
As committee members may be aware, Healthy Ireland is the national framework to improve the health and well-being of the population. It was approved by Government in 2013 and was developed in response to a number of significant public health challenges, including projected increases in the levels of chronic preventable physical and mental diseases and growing health inequalities. Healthy Ireland asserts that population health and well-being are critical for our social, economic and cultural progress, and our overall quality of life. These are not just health issues, but societal issues. The programme recognises the requirement for a whole of Government approach to addressing the social and environmental determinants of health, as well as the requirement for an inclusive, inter-sectoral approach to improve population health and well-being by shifting the emphasis more towards prevention, including primary prevention, and for empowering individuals and communities to take responsibility for their health and well-being. The vision is that we can achieve a healthy Ireland where everyone can enjoy physical and mental health and well-being to their full potential, where well-being is valued and supported at every level of society and is everyone's responsibility. This is a culture change in many respects for us as a society.
With regard to defining health and well-being, the Healthy Ireland framework uses World Health Organization definitions, which regard well-being as an integral part of overall health that reflects a person's quality of life, and the concept of positive mental health whereby a person can realise his or her own abilities, cope with the normal stresses of life, work productively and fruitfully, and be able to make a contribution to his or her community.
In recent years, significant progress has been made in getting implementation of the Healthy Ireland framework under way. Much of our focus in the initial years has been on building a more enabling environment for more and better cross-sectoral and partnership collaboration. We have an ongoing focus on stakeholder engagement, and communications is an important element of this with regard to the culture change I mentioned. Since 2013, much of the focus has been on the development and publication of a suite of national policies, strategies and plans to address risk factors such as obesity, tobacco and physical inactivity. All of these have been published and approved by the Government, and the policy direction in a number of important areas is now clear and we are into implementation. Healthy Ireland is also influencing and informing policy direction in a number of other important areas, such as our new cancer strategy, maternity care, substance misuse and mental health.
We have a range of cross-departmental initiatives to help underpin strategic partnership action and support the local implementation of national policy. My colleagues from the Department of Education and Skills will speak a little bit about this specific area in terms of well-being, but I would like the committee to note we have a very strong and positive working relationship with the Department of Education and Skills on all of the topics in Healthy Ireland. Wider societal initiatives include the establishment of a national healthy cities and counties network, in affiliation with the World Health Organization, the development of the first national healthy workplaces framework, due for finalisation this year, and in recent weeks we commenced a healthy campus initiative with the higher education sector. These initiatives will form an important part of the future architecture and environment for the implementation of health and well-being policies, including those aimed at supporting and promoting mental health and well-being.
Colleagues from the HSE will come before the committee to discuss more specific work under Healthy Ireland to promote mental health and well-being. Committee members may be aware of the work under way in the HSE on emotional well-being, emotional skills and resilience in early years for parents and infants. We have commenced work on specific actions in Connecting for Life. These include the development of a national mental health and well-being promotion plan, which is being worked on by a working group comprising the Department, the HSE and elsewhere. There is also a related action on the promotion of physical activity, or exercise as Dr. Barry referred to it, as a significant protective factor for mental health through the national physical activity plan. The implementation of the national physical activity plan is jointly overseen by the Department of Health and the Department of Transport, Tourism and Sport, with other stakeholders including the Department of Education and Skills. It aims to promote increased physical activity levels across the population, as well as promote enhanced understanding of the many and lifelong benefits of an active lifestyle, which include significant benefits for mental health and well-being.
In 2017, Healthy Ireland was identified by the Government as one of the priority areas for cross-Government communication and citizen engagement, and a new communications campaign has been running throughout 2018. The campaign aims to encourage and support behaviour change across the three key themes of healthy eating, physical activity and mental well-being, and a summer phase of the campaign #FeelGoodTogether is under way with a range of partner organisations.
I reiterate that the cross-Government, wide-ranging partnership working to implement Healthy Ireland will greatly contribute to the supportive and enabling environment and culture required to achieve the long-term aims of this committee's work. All of the Healthy Ireland programme stakeholders and partners look forward to contributing to future work arising from the committee's considerations and recommendations to help improve the mental health and well-being of people living in Ireland.
Ms Anne Tansey:
I thank the Vice-Chairman and members of the joint committee for the invitation to the National Educational Psychological Service, NEPS, to attend today to discuss mental health prevention, early intervention and talk therapy. My statement will primarily address the role of the Department of Education and Skills in the promotion of well-being and positive mental health and the role and purpose of NEPS in the promotion of well-being and positive mental health.
NEPS is a constituent section of the Department of Education and Skills, and, as such, promotes and operates within the scope of the Department's policy and practices. The Department promotes a whole-school, preventative, multi-component approach to the promotion of well-being and positive mental health in schools. It supports the provision of interventions at the universal level, focusing on the entire school community, and targeted levels, focusing on groups and individual young people with identified need. In practice, schools that successfully promote well-being are schools in which the voice of the student is heard, students experience a sense of belonging, and students feel safe, connected and supported. They are schools in which students experience positive, high-quality teaching and learning, and in which approaches to well-being are developed, implemented and self-evaluated. Furthermore, they are schools in which all adults listen to students, recognise the importance of well-being and can signpost students to internal and external pathways to support, as needed.
The Department of Education and Skills' Action Plan for Education 2016-2019 has set out a range of objectives and proposed actions for the development and promotion of well-being in schools, in line with best practice. In the coming weeks, the Minister, Deputy Bruton, will publish the Department's well-being policy statement and framework for practice, in order to further support all schools in this area.
NEPS is the psychological service of the Department of Education and Skills. Its goal is to support the well-being, and the academic, social and emotional development, of all students in primary and post-primary schools through the application of psychological theory and practice in education. NEPS prioritises support for students at risk of educational disadvantage and those with special educational needs. NEPS also prioritises the promotion of the well-being and mental health of all students in schools.
Each NEPS psychologist has a list of assigned schools and provides a school-based support service to these schools. A major strength of the service deliver of NEPS is that psychologists and schools are afforded the opportunity to develop strong working relationships over time. NEPS is organised regionally with 23 offices nationwide. Currently there are 179 whole-time equivalent psychologists working in the service and 15 more psychologists will be recruited later in 2018.
NEPS psychologists work with schools using a tiered service delivery model encompassing case work and systemic support and development work. Liaison with other agencies to ensure co-ordinated service delivery to students is an important element of our work. In addition, NEPS works to inform policy and practice to promote the positive mental health of our children and young people, within the Department of Education and Skills and at cross-sectoral level. NEPS works collaboratively with schools to identify those with the greatest need, in order to provide a responsive and reactive service.
Casework is the work NEPS psychologists do with individual students who are prioritised as having the highest level of need in their school. Psychologists work in collaboration with parents and teachers, as key agents of change in the student's life. Casework involves the assessment and identification of the student's needs.
It also involves supporting schools and parents to understand the difficulties and to implement workable, evidence-informed interventions for that student. As part of that work, NEPS psychologists may liaise with other service providers with whom the student may be engaged. All these cases include elements of managing the student's well-being and psychological health. NEPS psychologists do not generally provide ongoing talk therapy as part of our interventions. In the academic year, 2016-17, NEPS psychologists were involved in case work relating to 8,309 students, which equates to 80% of our school-based work.
NEPS psychologists help to build the capacity of schools to implement best practice in well-being promotion through the provision of consultation and training. At national level, NEPS currently prioritises the training of teachers in DEIS schools in three particular programmes. The first is the Incredible Years teacher programme, an evidence-based programme for teachers, which strengthens social and emotional competence in primary school children. The second is the Friends programme, an evidence-based programme which reduces anxiety and promotes coping skills and resilience in primary and post-primary students. The third is training in the development of student support teams in post-primary schools to co-ordinate supports and develop a whole-school approach to well-being promotion. In addition, at national level, NEPS is prioritising the training of teachers in all post-primary schools on the revised NEPS Critical Incident: Guidelines and Resources for Schools, which helps schools to have a plan in place to implement in the event of a critical incident. When it is prioritised by a school, NEPS psychologists may also provide more tailored support and development to strengthen school capacity in the area of well-being to respond to individual school need.
NEPS provides direct support to schools in the event of critical incidents that overwhelm the coping mechanisms of schools. The purpose of this support is to enable schools to regain normal functioning and minimise the impact of trauma on the school community. NEPS continues to develop its thinking and approaches in this area. At present, NEPS is conducting research into the current and evolving approaches to developing the skills of our students in order to promote their resilience and well-being. We continue to work with our partners within education and at cross-sectoral level to further improve and align the services schools receive in this regard. I thank the committee for the invitation to present this paper and to contribute to the discussion. I am happy to take any questions committee members may have.
I thank the witnesses for the presentations. I will get straight into it as I want to ask as many questions as possible. There are 179 whole-time equivalent posts in NEPS. If there are 3,000 primary schools and more than 700 post-primary schools, it seems this would be an incredible workload. How does that compare with other jurisdictions with education psychologists? Ms Tansey indicated that 179 NEPS psychologists dealt with 8,309 children, which is an incredible workload. Ms Lorraine Dempsey of the Special Needs Parents Association was yesterday before the education committee of which I am a member. She was critical of the insufficient number of education psychologists available. I am just curious about how we compare with other jurisdictions. What is the maximum and minimum number of schools assigned to a NEPS psychologist? Is there a cut-off point?
The Action Plan for Education 2016-2019 indicated that 65 psychologists would be recruited in the first quarter of 2017, with the aim of bringing the total to 238. Since 2016, a total of 16 whole-time positions have been recruited when resignations and retirements are taken into account. The 2018 plan has a target for ten to be recruited, which would bring the total to 189. Where do the other posts come from? Will Ms Tansey outline the recruitment process for a NEPs psychologist? Is it time consuming? How many are there to be recruited? She mentioned the intention to recruit 15 psychologists this year. On 12 June, In reply to a parliamentary question the Minister indicated the intention was to recruit ten psychologists. Ms Tansey mentioned that NEPS psychologists do not generally use talk therapy. Does that mean some do and some do not? Is talk therapy valued and should it be introduced to assist students? Is there a plan to introduce it via NEPS or are the qualifications not there? I am wondering what are the obstacles.
The Irish Council for Psychotherapy mentioned the snapshot of the national experience. It did not look good in any way. One person in particular was accepted for interview, placed on a panel but received no further contact. Do we know how long this person was waiting or is the person still waiting? Is this reflective of a wider experience? Do many people face such significant delays between the interview and hiring? What effect does it have on staffing if a person is put on a panel but never hears from anyone else again? What are the dangers for our most vulnerable people of not having proper regulation for psychotherapists and counsellors? Are they being exploited, even in a financial sense?
Ms O'Flaherty referred to a framework document in it there is a breakdown of several key health areas, such as weight, smoking, alcohol and well-being. Each is broken down under headings that include a Healthy Ireland indicator description, baseline indicators, targets or sources for development of potential indicators. Of the seven health areas listed, well-being is the only one that has no targets or sources for development of potential indicators. Why is that the case?
I fully agree with Dr. Barry that we are not doing enough with the toolbox of skills to cope in a time of crisis. It is something we dealt with on the education committee. There was mention of emotional resilience skills for children so how could they be realised best in schools? Would it be a whole-school approach or should there be specific teachers? Do we need to put this on the teacher training course? There is anxiety in young students. Should we introduce mindfulness and how could it be done? Should we be careful that a teacher, even with the best intentions, could do something dangerous? What training exists? I presume the resilience and mindfulness education would start from primary school.
Ms Jean Manahan:
The Deputy asked about the snapshot and the recruitment. That was a small survey we did because we were continually being told by our psychotherapists about the uneven recruitment practices around the country for posts within the HSE or Counselling in Primary Care, CIPC. We spoke with HSE officials and we had a number of meetings since last autumn where we mentioned this data. Steps have been taken to ensure recruitment agencies to which this has been outsourced have received the message to, at a very minimum, reply to people and to ensure standards of recruitment are uniform. We were finding that in the west of Ireland there was one standard but another somewhere else.
Another issue has been the HSE moratorium, which has been lifted. It also only recruits under certain titles and, therefore, regulation will help with this. The title of "psychotherapist" will exist and the HSE will use that title in time. It is recruiting additional posts but it is still not using the title "psychotherapist"; it is using the title "psychological therapies". It is an evolving process but we were trying to get at the recruitment processes being more uniform. That is being dealt with. Ms Murphy can speak to proper regulation.
If anyone can practise psychotherapy, where people are in a vulnerable situation, the openness for abuse be it financial, sexual, or emotional, is there in the absence of regulation, and without a proper complaints procedure. The Health and Social Care Professionals Council, CORU, will eventually take over complaints. At the moment it is the psychotherapeutic modalities that look after complaints. Our colleagues in the UK took a different approach but our country is so small in that colleagues are having to examine other colleagues' behaviour, or ethical standards etc. Ms Murphy may wish to say something about this.
Ms Ann Murphy:
The issue here is one of informed consent. I do not have data on widespread exploitation of people, but in going to see any practitioner in any area, informed consent is essential. At the moment, there is a lack of clarity about qualifications. The titles are confusing for the general public in any case, and there is an overlap between different titles. There is no way a person can make an informed choice about what is the appropriate qualification, what is the kind of therapist he or she should look for, and are they regulated. Do they belong to a professional body? Are they duly accredited, etc.? That is a very unsatisfactory situation for anyone, particularly a vulnerable person, seeking any kind of care.
I also understand that where children and adolescents are concerned, parents are sometimes completely at sea when they have to go into the private realm as to what might be appropriate.
There is a further issue that touches on accessibility. Without the regulation of title, the insurance companies that provide some cover for some degree of psychological service, cannot do that because they do not have the confirmation of the qualifications. When the titles and the professions are regulated, that will make it possible to have some funding from private insurance for some number of sessions, as is available for many other areas.
Ms Anne Tansey:
With regard to NEPS numbers, how well we are organised and can provide the required support, we have to consider this service in the context of the schools to which we are providing support. The Department of Education and Skills resources schools with 60,000 teachers and 1,300 special education teachers to provide what we call a continuum of support in schools. Schools are providing support for all children and tiering this support for some children with emerging need or those at risk in addition to children with complex and enduring need. The role of NEPS is to support schools in that role. We broaden our reach by using our capacity-building work. We provide training to schools. We work by advising schools and providing a consultation service and assisting schools in setting up structures that maximise the support that children receive in schools. We have broadened our reach in that way in recent years.
With regard to the schools, the average number of schools our psychologists serve would be around 24 schools. It varies from urban districts to rural regions, because there are very small schools in rural regions, but the average is 24 schools.
We have recruited 11 additional psychologists last year. The 16 referred to would have included replacements due to retirements. This year, of the 15 additional psychologists to be recruited, ten of those are newly sanctioned posts and five are replacements due to retirements or resignations.
Dr. Harry Barry:
Very good questions have been asked. If we take something like mindfulness, short mindfulness, up to three minutes at a time, could be practised in all schools, even as an automatic way of starting and finishing their day. Schools that have done this have noticed a definite improvement in the well-being of their students.
There are a few critical skills that I would be very concerned about. There is a massive epidemic of something as simple as panic attacks. We need to be teaching children in primary school all about emotions, and the physical reaction to emotions. We need to teach them the skills - in a very simple way - to deal with them. Students are arriving in as adolescents and hitting all of the difficulties that adolescence brings. They are swamped by the world of social media and smartphones, and they simply lack the appropriate skills. I would hear about a young person, for example, who might be self-harming and cutting themselves because nobody has taught him or her how to deal with panic attacks. Teaching students simple skills to deal with these attacks can often eliminate their self-harming and its causes.
I have talked to many teachers about this and many would love to receive some very simple training techniques that they could apply in their classes. We are not talking about rocket science here. I love my psychologists friends but part of the difficulty is there is a feeling among the lay population that we need a psychologist to tell us how to do everything. We need psychologists. They are superb at what they do, they are really important and give us these academic, solid foundations. We also need, however, very simple skills. Sometimes our children do not need massive psychological interventions. They just need somebody to talk to them, to ask them what is going on, to allow them to express their emotions and to teach them how to handle physical symptoms. These skills could be learned quite simply by many teachers and applied. We must also involve parents. A number of parents have told me they feel almost out of control. They feel they do not have the necessary skills to know what to do when their child or adolescent is in trouble. A lot of those skills are equally very simple skills.
The more work we put in in trying to educate parents and teachers as to how best to apply these very simple techniques in primary and secondary school will head off a lot of difficulties. We are waiting until the child is in crisis and then we are all jumping in asking what we are going to do. Our CAMH services are overrun. The reason they cannot handle the numbers is because so many of the children being referred to them are inappropriate referrals, or else people have been waiting until the child is really distressed and in trouble before trying to intervene.
We need to think of the idea of the river and teach children how to swim. This applies not just to children, but a lot of adults-----
I thank the witnesses and appreciate their time today. I agree with a great amount of Dr. Barry's work and what he has said. To me, a lot of it - because I may be more trained in it - is common sense. I am very much converted to how he feels about this subject. Without getting too hifalutin, cultural and societal shifts are required here and that may sometimes take a generation in how we think and how we relate to each other. Dr. Barry spoke about how we naturally relate to each other.
I have just come from the Joint Committee on Children and Youth Affairs this morning and we spoke about play and physical health. Everything now seems to have to be structures. There has to be a structure and there has to be a label. If there is not a structure and a label we do not even think about it. We are becoming technically minded, perhaps due to technology. This is eradicating a lot of the organic relationships of the past. What the witness is saying may be a manifestation of that. I am not so sure if the witness would agree.
In how we work together, we need to get that message out there about how we relate, talk and listen and we need to have early intervention. It is a natural communication - to use two ears and one mouth - when someone has a difficulty.
I wish to push back on Dr. Barry's comments on Members' offices. I am sure all Members listen to the people who come into their offices and speak to them about the issues. Members are human beings and may have faced challenges or have relatives who faced the challenges of life. I accept that we as legislators need to harness the political will to push for effective services.
Will Dr. Barry elaborate on his thoughts on regulation? He mentioned that the UK has an access model as opposed to our over-regulation model. Will he address the positive and negatives of that?
Applying the money follows the patient model was mentioned. Is there data on this model?
On Sunday next, it will be 25 years since the decriminalisation of suicide was signed into law. I draw attention to the strides we have made and the momentum from that low base to the establishment of this joint committee. We still have a long way to go.
Dr. Harry Barry:
I could not agree more with the Deputy. The word "empathy" is terribly important, and face-to-face interactions with children, teaching children to talk to each other and talk to us face-to-face rather than through technology and machinery. I could not agree more with him about structure. I worry sometimes that we are heading towards a country that becomes so regulated and so structured that normal humanity gets sucked out of it. There is a risk if we allow things to become too regimented. There has to be a certain amount of give and take in terms of humanity.
On the question of access versus regulation, it is critically important that counselling and psychotherapy is subject to some form of regulation because all GPs will tell us that they are asked by their patients regularly to whom can they go or to whom can they bring their child if they have mental health issues. Many will say that they are not sure to whom he or she could send the patient. The GPs do not know so the benefit of properly organised regulated system would allow the GP to say that the person has been properly vetted so he or she would be comfortable sending a patient to the therapist. That is a big plus of regulation. However, if we spend all our attention on just getting everybody regulated, then we have this beautifully regulated system and nobody able to access it. We have highly trained psychotherapists, some of whom are excellent, but nobody is able to access them because we do not have a proper structure. The vision for the future has to get the intermingling of the State system in funding organisations. I do not how to do that but I suggested the English system, but we need a system whereby people can access a service quickly. I wish to emphasise "access quickly". When people are emotionally distressed, they do not want to be told that the nearest appointment will be in six weeks by which time they will have been down at the river or in the emergency department or have spent six weeks in total emotional distress. If that person could have telephoned a number, and talked to a human being, not a machine, and been assigned to a professional who would assess them within a 24 hour period, at least it would have lessened that person's emotional distress. Just talking about our distress often goes a long way towards reducing it. If a person cannot reach anybody, and this applies to parents who are becoming increasingly distressed because nobody will speak to their child. They are being told that it takes six weeks before the child can be assessed. We need a more rapid access system and a system under which people are not told that if they can pay this amount they can be seen. Surely as a modern country, if we love and care for our people, we should provide the services they require.
Ms Jean Manahan:
I absolutely concur. It is a source of major frustration for the member of the ICP, knowing that we have 1,500 highly trained psychotherapists who have gone through this extraordinarily intensive preparation but who are not being utilised. I have this vision that somebody goes into the emergency department- and we will all be familiar with this scenario - who is left wandering around being monitored by the porter to make sure that the person is kept safe. The person eventually leaves and is not seen again because he or she goes down to the river.
What is there to prevent the establishment of a system whereby one could lift a phone and ask for a psychotherapist to come and see the person. At the very minimum they can be held by the psychotherapist. It is so human to have an interaction that I call, "an I and thou", where two people can come together, with one holding the distress because that is the issue. Not everybody can hold the level of distress that may need to be held but the highly trained psychotherapist can do that and can also make a decision on whether this person needs to be referred, held or can be seen. There are waiting lists full of people, who do not need to be on them, as Dr. Barry said, but because of the length of time waiting to see somebody, they end up on incorrect waiting lists.
Deputy Neville asked about the concept of money following the patient. Many countries such as Denmark, Luxembourg, Germany, US and the UK practise the model of the money following the patient. It is not a difficult model to think about. When Senator James Reilly was the then Minister for Health, he considered this model for hospital care. It could be applied to community care, which means that people could access the therapists they want in the community. It could be a voucher system or payment on production of a receipt to the HSE. It is not beyond our imagination to figure out a way to do it. If one is paying €70 per session, it would aggregate to €700 in ten weeks, which is a great deal of money for an average person to be able to afford, and yet the long-term benefit and gain financially to the State is well worth the investment in this service.
I regret that I missed some of the meeting but I had to go elsewhere.
Ms Manahan just touched on the cost benefit analysis which was one of my questions. We need not just to convince the VHI and other private insurance companies, which cover about 45% of our population but the HSE as well. Currently some €400 million is being spent on psychotropic drugs as opposed to the €10 million that is going in to underpin talk and other therapies. Have we got figures for that cost benefit analysis in the long-term to push that?
I just love Dr. Harry Barry and think he is brilliant. He talks such common sense. I want RTÉ to approach him to do a series on well-being education for parents and young children. It would blow people away. I have talked about this idea passionately for at least two to three years. We need to instill a sense of well-being and take on illness.
I have a great deal of contact with Ms Helen Bevan, chief transformation officer, and one of the directors of the NHS. This is about agents for change. They have established three foundation trusts so far that have taken out the word "illness" and replaced it with "well-being". We have to focus on that. We have a small population that needs the wrap-around service for serious enduring mental illness. The rest of it is social; it is about being able to function and having a contented life. It is also about well-being. I am not sure about the term "mindfulness"; I prefer the term "thoughtfulness". Let us simplify everything and instead have plain simple clarity. Let us claim back our children's lives instead of overburdening them. We have nowhere else to go, so we get a diagnosis and medication that will follow us all our life.
I hope RTÉ is listening and will contact this man to commission a series because it would do wonderful things for education and would reach a broad scale of the population. It will also bring back our common sense and our innate ability to care for, mind and educate one another.
I wish to mention the legislation on the use of digital devices in schools, with which we grappled previously. The use of such technology injures face-to-face human interactions, socialising and maturing. Therefore, we need legislation to tackle the problem yet not curtail rights. People need to be responsible parents, leaders and legislators and introduce legislation that allows children to grow up in an environment that promotes social interaction. If we do not take action then within a generation people will simply keep their heads down and be unable to say hello, snarl or smile at anybody.
The river journey is extremely important. A YouTube clip on same would go viral.
Dr. Barry mentioned a national talk therapy structured group that would act independently of the HSE. I ask him to outline the practical structure and operation of such a scheme.
Dr. Harry Barry:
I thank the Senator for her kind comments but I must be careful with what I say because my wife is seated in the corner of the Gallery.
I could not agree more with the Senator that we need to take a lot of the mystery out of this matter and revert to plain, common horse sense because so much of this is common sense. I appeal for a national protocol on smartphones, which I have sought for five years. I would love if teachers, parents and perhaps representatives of young people met and collectively produced a voluntary code. As a community of people and for the sake of young people, let us put some structured order on this matter once and for all. I could not agree more with the Senator that if we do not do so then it will be to the detriment of young people. I am not sure but I believe Professor Mary Aiken called technology the greatest social experiment of our time. I wish to God that I did not have to sit around for the next 15 to 20 years to see the effects. Everybody says that such comments are scaremongering and that when television became commonplace, we all felt the same but I must stress that digital technology is different due to the intensity and level of involvement in the lives of young people. I do not oppose coding or any sensible use of technology. If, however, it leads to a young person learning to see him or herself in the way other people on this machine tell him or her, then we are doomed to a nation of anxious, depressed, self-harming or anorectic children. I believe this device has been very much responsible in this regard. Of course adolescence is full of all of its difficulties, traumas and problems. We have all been there, we have all reared children and, therefore, know what adolescence involves. However, we must stand back and realise this is something different. As a people, we need to acknowledge that and try to do something about the matter.
I would love to see a lot more emphasis placed on early intervention by parents and teachers. I cannot emphasise enough that if one teaches a child to swim then if he or she falls into the river or a pool, there is a good chance he or she will get out the other side. If one throws a child who cannot swim into a pool he or she might, if he or she is lucky, scramble his or her way to the other side but there is a pretty good chance he or she will get very distressed and get into real difficulty. Just as we regard it as sensible to teach a child about weight, diet, nutrition and exercise, we also need to teach resilience skills such as how to be mindful and how to talk to one another, which is one of the simplest things of all. Sadly, technology is killing the art of conversation and the same applies to social skills. An awful lot of young people have social anxiety because they live their world through a technological device and do not learn those one-to-one empathy skills that are so important for real life. I argue that children must be taught the skills for life, not the skills to get X number of points. As life is tough, difficult and full of trauma, we need skills and support to learn those skills. I fully support such an approach.
I thank all of the witnesses for their presentations. I apologise to the witnesses but they have caught me using my smartphone to check something.
I thank Dr. Barry for his excellent presentation. I have heard about him before. I have brought one of his books with me and ask him to sign it before he leaves the meeting. I was given his book to use as a reference guide and research tool to inform me as a politician, rather than always looking at briefing documents. In common with Deputy Neville, I too get many calls at my clinics. As I am a member of the Oireachtas Joint Committee on Children and Youth Affairs and am my party's spokesperson on children, I get an awful lot of calls from very distressed parents because they do not know who to approach for assistance. I have a very good relationship with my local GP. One of the things he has told me, just like what Dr. Barry has said, is that this has all to do with signposting. If he had a colour card system in his GP surgery, he then would be in a position to advise parents where is the best place to go about their precious children, as opposed to telephoning the child and adolescent mental health services, CAMHS, for an appointment. He could carry out the initial consultation that lasts an hour or whatever but the question then is where people go. As opposed to parents sitting at home waiting a week, month, six months or whatever for an appointment, my GP would like to be able to tell them that he has contacted a person called X, who will conduct the next appointment, the appointment has been secured and he or she will see them at such a date and at such a time. Such a situation would reassure my GP as he would know that when parents leave his surgery, they have the tools to get them through the next number of days because he has the skill set to give talk therapy. That skill set will enable parents to cope until they meet a practitioner. If the problem is very acute, one hopes that CAMHS or the accident or emergency unit will be used. A lot of talk therapy can take place before that point and then it is all down to assessment. I call for such a service because as Deputies, we receive these types of calls regularly because parents have reached crisis point and their children are in national school and secondary school.
Earlier I tried to work out the hours involved on my smartphone. My next question is for the delegation from NEPS. Ms Tansey mentioned that NEPS officers had 8,309 cases last year and the staffing level is 179. I calculate that means there were 47 cases per day. What is the caseload for NEPS officers? What is the definition of a caseload? Does NEPS meet them once, twice or whatever? Are assessments carried out? Is direction provided? Where does the child go? When NEPS refers cases on, what criteria does it use? Does it use a colour coded system for referrals? What happens with a dual diagnosis? In the case of a child who has been diagnosed as having attention deficit hyperactivity disorder, ADHD, and other wellness issues, where does one refer such a child?
I understand the Galway Autism Partnership group has encountered children who have reached sixth class without a referral or having a meeting and are simply on the waiting list. There are many frustrated sixth class children in the CHO 2 area on a waiting list and they will start second level education without a diagnosis. On foot of the manner in which the mental health structures were originally established, dual diagnosis apparently is an issue. However, the system is being reconfigured at present. Obviously the parents in the area are very concerned about the situation.
I ask Dr. Barry to elaborate on the issue of signposting. My understanding from the GPs who appeared before the committee is that the GP computer systems are better than the HSE system.
Dr. Harry Barry:
On signposting, the difficulty for general practitioners is that they can do the assessment but the opportunities available to them after that are limited. Where a child is acutely distressed often the only place of referral is accident and emergency. If extremely fortunate, a general practitioner might get a child seen by CAMHS within 24 hours. However, many of these cases are not at the level of acute distress. Very often when a child is distressed he or she does not even know the reason for the distress. The child might not realise what is going on but the parent is desperately looking for help. The GP can try to calm the situation and assess whether in his or her opinion the child is depressed or, perhaps, just anxious owing to bullying and so on. The difficulty for the GP is that if the child is under a certain age the referral must be to the child psychology service. In that case, the GP can only complete the referral to the child psychology service in the hope that the child will be seen within a couple of months. Often, as happened to me on occasion, the GP will get a letter back from the child psychology service to the effect that the child should be more appropriately referred to CAMHS. This back and forth process is not helpful. If the GP is to have a signpost system then he or she must have access to a service where the child can be assessed within 48 hours. Very often one or two sessions with a psychotherapist skilled in a particular area can address the issue before it progresses. One of my greatest beliefs is that one should never allow emotional distress to grow legs because when it does it goes to bad places. We need to able to address emotional distress early and not only in respect of children but the wider community. We need to prevent emotional distress growing legs.
Ms Jean Manahan:
The Irish Council for Psychotherapy, ICP, has met the Irish College of General Practitioners and other groups on this issue. We have provided on our website a map of Ireland identifying the locations where psychotherapists are practising and detailing their specialism. Many of them will work with children but a number of them do not. I agree with Dr. Barry that regulation is helpful. The standard that the council upholds is uniform. A GP can access an ICP-accredited psychotherapist through our website. I recently asked my own GP what he would do in this scenario and he told me that as I have trained him well, he would refer to the ICP website, where, as I said, the location of services and their specialism is provided.
Ms Ann Murphy:
With regard to access and children, a specific case comes to mind. It involved a young woman, 19 years old, who has been on antidepressant medication for five years, from the age of 14. As Dr. Barry noted, all intervention in terms of what we do or take affects the brain, particularly the brain of a developing child or young girl. This girl was not clinically depressed. She may have required a small input of antidepressants initially, or not, but she had not been offered or received any type of therapy. At the age of 19 she is now in therapy, which is being paid for by her family, having been medicated for five years. This is not unusual. Rather, it is extremely usual.
Ms Anne Tansey:
The Deputy asked about our caseload and how we refer on to other services. On the number of children we see every year, we work in consultation with schools. We have a system in place whereby schools identify the needs of children and they put in place a student support plan for each child. The school assesses need and puts in place interventions, which are constantly reviewed. As a service, we are available to consult with the school on what it is doing and to support it in that regard. When a school gets stuck, it will ask us to become directly involved with the child. Our involvement with the child occurs in consultation with the school, having taken account of what the school is doing already.
In terms of onward referral, as a service we have built up links locally with primary care services, the network disability teams and CAMH services and we try to establish pathways for referral. As a service, for example, we do not diagnose autism. We are working in a school system where there is no longer a need for diagnosis to access support in schools. The Department of Education and Skills now front-loads resource teachers into schools in order that the support is in place and accessible by children in need. In terms of referral, if we believe that children need support from services that are provided by the HSE, we refer them on through the pathways available locally.
I thank all of the witnesses for attending. My first question is to Dr. Barry. Has he seen an increase in the levels of anxiety and depression in children and young adults since the advent of increased use of smartphones? Would smartphone usage factor into his assessment of a child or would he look at familial issues such as break-up and so on? Also, does he believe that alcohol abuse or misuse can cause a person to slide into mental illness?
Ms Manahan said that psychologists and psychiatrists are not trained in psychotherapy. Why is that and has the ICP engaged with the HSE's director of mental health services on the issue? We have been hearing of significant challenges in the recruitment of psychologists yet Ms Manahan said there are 1,500 psychotherapists here looking for work, which would indicate there is a breakdown in the system.
Ms O'Flaherty spoke about Healthy Ireland and its implementation across Government and society. On the healthy workplaces, given we spend on average eight hours a day at work, what type of programmes has the Department put in place to help people to develop and maintain their mental health and does it provide gatekeeper-type training in that regard?
On NEPS and the statement that no talk therapy is provided, how is this squared when critical incident supports are needed? Why does NEPS comprise psychiatrists and psychologists and not psychotherapists, such that there is no provision of talk therapy?
Dr. Harry Barry:
On the Deputy's question regarding the increase in anxiety and depression levels, there has been a phenomenal increase. I do not have statistics but in my interaction with principals and parents, the word "anxiety" is increasingly being mentioned.
Has there been an increase in the amount of depression? We need to be careful about what we mean by depression. We have to define the condition of depression properly. Many young people suffer from periods of low mood but I am not convinced they are clinically depressed. The incidence of clinical depression perhaps might be slightly larger. I would point to one particular group that we never discuss, college students. College students are undergoing a huge crisis in mental health. That is when I see depression occurring. It is not so often with the 15 year old child but more the child who crashes in college because they cannot cope and do not have the resilience they need to survive there.
Dr. Harry Barry:
Smartphones are playing a massive role in this. One has to look at, for example, the effects of pornography and forced sexual activity on girls because of pornography. Boys and girls are comparing each other and every facet of their lives, particularly their appearances, continuously. Of course, they are anxious because they are creating this virtual world which is a completely false world. Then they are trying to live in the real world and cannot match the two together. As a result, they get incredibly anxious.
Alcohol is a massive issue. We all know Ireland has an alcohol problem. We have to be cognisant of the fact that the earlier one starts drinking, the more likely one will damage the dopamine system in one’s brain. Children drinking heavily under the age of 15 are far more likely to develop further addiction problems when they reach adult life.
One other area I would pick out is cannabis or hash. It is a sneaky one and we are not aware of it. The kind of cannabis used now is much stronger and much more likely to affect the brain. Those are key factors but I would go for anxiety as the number one condition.
Ms Jean Manahan:
Why are psychologists and psychiatrists not trained in psychotherapy? Some psychiatrists and psychologists choose to further train as a psychotherapist. Ms Anne Tansey is a psychologist but she is also trained as a psychotherapist. It does not follow as they are two separate professions. The parallel would be a solicitor who decides to train as a barrister or a medical professional who decides to take on another specialism. Since 1990, there is the Strasbourg convention on psychotherapy which makes the point that psychotherapy is a separate scientific, independent and free profession. That is important. I happen to know psychiatrists who also happen to be psychotherapists. There is a presumption that all do psychotherapy but they do not. That is the point I was trying to make.
We are very much engaged with the HSE. With the lifting of the recruitment moratorium, there is a more positive move in terms of employing more psychotherapists and more counsellors. There is movement afoot. Hopefully, we will see those numbers increasing.
Ms Kate O'Flaherty:
In terms of developing the positive mental health promotion plan, I know there is an interchange of words. We are talking about mental well-being and positive mental health. Counties and communities in which people live are core settings as well as workplaces. Colleges will also be a core setting by virtue of the significant number of our young people who are in further education.
Programmes and initiatives must be evidence-based and consistent in terms of people developing their own skills and resilience. There is a continuum over how one protects and maintains one’s mental health well-being into where there is a need for early intervention. For example, under the suicide prevention strategy, there are programmes, like SafeTALK, ASIST, applied suicide intervention skills training and Mental Health First Aid, which is part of the training of teachers, youth workers and others who are in contact with young people. An important feature of this training is a person being aware of, being in touch and comfortable with their own skills in terms of their own mental well-being. The widespread application of a skill set would be helpful not only in protecting one’s own mental health but being able to intervene as part of one’s professional role, one’s role in a community or as a good adult to young people. It is certainly something we will be looking at.
Ms Anne Tansey:
On the role of the National Educational Psychological Service, NEPS, the focus of the Department of Education and Skills in supporting well-being is through an early intervention and a preventive role. We set up a system in schools where all of the teachers are supportive of the children in that school system. Our role in that is supporting schools to do that. The way services are organised means the provision of therapy is the responsibility of the HSE and not the Department of Education and Skills.
Some of our educational psychologists, however, are trained in a broad range of therapeutic interventions, such as cognitive behaviour therapy, solutions-focused therapy or person-centred approaches. As part of their work, sometimes, psychologists engage in a small amount of therapeutic interventions. When it does occur, the focus is around skills building and the capacity building of the child to cope with the demands of his or her environment and to manage it, as opposed to psychotherapy. We do not provide psychotherapy in education. The focus of our service is to build skills and to inform teachers how to best support children who are presenting with anxiety or high levels of stress in school.
Ms Anne Tansey:
We define critical incidents as a time when the coping mechanism of the school is overwhelmed by a particular event or incident. The role of NEPS in that is to support the school and to return it to normal functioning. We support teachers to manage the critical incident within the school setting. Best practice indicates that when children are traumatised, the best people who can support them initially are those who know them best, their teachers and their parents. We support the teachers to support them. We also have a signposting system in place. As time goes on after an incident, if children do not settle or are presenting with continuing difficulties, we have an onward referral system to other services.
I thank the witnesses for their detailed presentation which I found very informative. As a Deputy, many people come into my constituency office with mental health issues and find they are not able to cope. I find many complaints about the CAMHS, child and adolescent mental health service. It is because it is reactive rather than proactive. I am concerned about families and other siblings when there is a problem with a child. The knock-on effect can be catastrophic. What supports should I advise a family to avail of in such cases? I have often found myself floundering and making calls to the HSE or organisations, such as Jigsaw or SOSAD Ireland, Save Our Sons and Daughters.
I come from an educational background and taught for 12 years. There is a need for NEPS input and I am glad it is there. How are those psychologists coping with a caseload of 24 schools? It would strike me that there is an urgent need to increase the number of psychologists in order to have more effective intervention, as well as to take some strain away from them who are only human.
I am delighted third level students were mentioned as I have concerns about that group too. I met with the USI only last week. I was aware when I was education spokesperson for Sinn Féin that there are long waiting lists for students at crisis point in third level institutions to see counsellors.
I know recruitment to increase the number of psychologists needs to be addressed first. Does NEPS have any plans to roll out a service where the colleges and universities can avail of some level of support? We need to tackle all levels of society. When considering education, we need to include third level in that.
Dr. Harry Barry:
Going back to the family, I could not agree more with the Deputy. If one imagines a group of things floating in a little tub of water, if one of them is banged, it bangs off the next, which bangs off the next. Unfortunately siblings often get very hurt by this. They often feel neglected and feel all the attention is going on the other child and they carry that little resentment into their adult life when it can start to cause difficulties later. This comes back to who is giving the parents the kind of support they need. Parents need to be learning those skills not just when the child is in crisis. This should be an ongoing process with parents and teachers learning the skills all the way along. One of those skills would be that when a child is distressed parents ensure they keep an eye on the other children. It can often be that the child they are not looking at will turn out to have the problem later on because they will feel rejected.
Were there any other issues for me?
Ms Anne Tansey:
Deputy Nolan will be aware of the youth mental health task force. One of its recommendations was that services would be provided to third level students. The HEA is setting up a working group to address that. There may be some progress on that in the coming months, years or whatever.
On the caseload for NEPS psychologists, we try to provide a national service. We have rolled out our service to all primary and post-primary schools in the country. I suppose that requires us to provide a service to a large number of schools. We work in collaboration with all schools. There are more than 60,000 teachers in schools, 13,000 of whom are special education teachers. We work with them within the system to try to provide an educational psychological service that also builds the capacity of that school to support the children within the system. We work a consultative model. We have broadened our reach. We provide an advisory service to schools. Some 80% of our work is working directly with children, but 20% of our work is working to build capacity to advise schools. We consult about children. We provide advice and support to teachers and parents on how to best support those children. We have broadened our reach in that way and we can reach more children in that way in an indirect service via the teachers to the children.
Many of my questions have been asked. I will make some observations. Most of the witnesses mentioned early intervention. Dr. Barry spoke about emotional issues and issues with smartphones. It is a poignant point that everything one buys in the world comes with instructions, but the Internet did not. It is something that should be flagged. I like Dr. Barry's analysis that there is a real world and a virtual world. I see it in my role as mental health spokesperson and also as a volunteer for the past 14 years with an organisation which has been providing free counselling for people. In the past two years anxiety has skyrocketed in the schools.
Turning to the schools and all the representative organisations here, again it goes back to early intervention. I recently wrote to all the secondary schools in east Cork. I did an anonymous questionnaire. I asked them about early intervention. I asked the principals of these schools if they would favour having all their staff trained up to the minimum level of SafeTalk or the extra little bit to the level of the assist course. About 99.9% of them came back positive. That tiny percentage was that they did not believe it would ever happen because of funding. The second question asked for their opinion on being trained up and everyone came back and said it would not happen because of funding. There is a big break-up there.
We are a reactive society when we should be proactive as one. I address this comment to all the witnesses. Early intervention has to be the key. The only way to foster early intervention is by starting them when they are very young and give them the coping skills. That goes across social media and everything.
A number of years ago I did night classes in UCC on non-formal guidance. After two years, the final line I heard was, "There is no such thing as depression..." and my ears really pricked up to hear the line after that. It was, "There is no such thing as depression; it is the inability to cope with life's measures." I ask for the witnesses' opinion on that because I think this is where we are at the moment. The generation coming up do not have the skills to cope with life's measures such as the death of a family member, a tragic accident, or being cyberbullied or sexually harassed. It goes across a broad spectrum. Should we not be going back to the bread and butter and possibly even in late primary school alerting them of the real hard knocks in life and say, "This is what's going to happen but this is what you do to help it."?
We have dealt with recruitment and retention, but the major issue is access. We have all heard of all these great services. When the crap hits the fan and people ask where they can go they are told they cannot go to a particular place because it is full, only open from Monday to Friday. There is no such thing as 24-7. While 7-7 is supposed to be on the way, it is not there yet. It is going to be great, but people cannot access it. It is a huge problem. Everybody knows if they want a sliced pan or a bottle of milk they will go to the supermarket or the local shop. If people want to watch a soccer match, they go to a soccer match because it will be on that pitch. The only thing that seems to be recurring here is an overreliance on the emergency services, GPs, the Garda and the fire service. God forbid, as the last resort probably one of the hardest things to do is go back and tell one's parents in the belief that a problem shared is a problem halved, but when it comes to mental health issues a problem shared is a problem doubled because the parents do not have the skills and so they are reactive. When they react they explode and it puts the onus back on the person in stress and is defeatist.
That issue of the coping skills, the inability to cope with life's measures, do we have to go back to a more cognitive realistic way and start at the very basics. We need to start with the five-year old, or the nine or ten-year old who is hitting puberty and tell them the truth. We need to target teenagers and tell them the truth. There is a huge issue with smartphones. Technology is fabulous, but the art of conversation has broken down and that has to be addressed. We have to be realistic about it. I will leave it at that. I would be very curious to hear the witnesses' reaction to what I have said about coping skills and life's measures.
Dr. Harry Barry:
I could not agree more. We need to teach our children how to problem-solve from the very earliest age and not just in late primary school. They should be starting much earlier. When a child has a problem, the parent should be taught, "What do you think we should do?" It is not a question of what I should tell them. A few years ago I was asked to speak to 150 leaving certificate students. As I was leaving - I do not normally do this - the last thing I said to the girls "There are two big messages I want you to learn about life. First, life is not fair. Second, life will be full of discomfort. If you can absorb those two messages into your life, you are going to find life a lot easier to cope with." That message should be all the way right back into primary school.
We need to teach children that human beings cannot be rated and teach children that anxiety is physical. We should be teaching all those very simple ideas in a graded way the whole way along so that when it comes to adolescence these are nearly absorbed as part of their training so that they will be much less likely to get into difficulty.
If we are to allow smartphones to rule the roost, which they are going to do, we need to have real conversations with children. I know I keep coming back to smartphones, but I think they are very important. We need to sit down with young people in groups to enable them to express their feelings. Young people have sometimes said to me that they were not allowed to use their smartphones for a while and, if they are being really honest, they felt much better during that period of time. They were pleased to be relieved of the hassle of everything that was going on. We never ask young people whether they really want to play certain games, for example. They say they have to play those games because if they do not, they will no longer be part of friendship groups. They feel alienated. We have to get young people and parents involved in this conversation. If a parent hands a child a smartphone at 9 p.m. and allows him or her to look at the most vile stuff on it when he or she is going to bed, he or she will be up all night and will not get enough sleep. We know that adolescents need nine and a half hours of sleep. Even though we understand that those who do not get sufficient sleep are far more likely to be anxious, to get bouts of depression or to self-harm, we hand our children devices that keep them awake half the night. All of these things are parenting issues. One of my favourite statements when I am asked about parenting is that the job of a parent is not to be liked - the job of a parent is to parent. I know it is not an easy job because I have been there. It is not easy.
Dr. Harry Barry:
It is not easy to say "No". Sometimes it is not easy to take a stance. Parents need to build up their relationships with their children over time so that their children understand why they are doing what they do. Children need to be involved as part of it. Everyone needs to start singing from the same hymn sheet as part of a national protocol or generally accepted view on how to use these devices. I include all of us in that. Can any person in this room put up his or her hand and say that he or she does not misuse his or her smartphone continuously? We all do it. We tell our children what to do, but we do not take responsibility for ourselves. We must start by being honest and responsible in our own lives. I guarantee that if we do not have these discussions, the anxiety levels that are being seen now are nothing like those we will see in the future. If what I can see going on continues, CAMHS will be swamped beyond belief.
Ms Jean Manahan:
I concur with everything Dr. Barry is saying. I am smiling to myself because when I was on holiday with my son recently, his smartphone got smashed on the first day. I thought it would be a major tragedy, but we had the most wonderful conversations and the most wonderful holiday. We had eye-to-eye contact in a way we had not had for some time. The other key thing is the question of access, to which I have referred. I emphasise that there is a cohort of highly trained professionals who could be part of the solution and would be able to respond more quickly and more proactively. I know this because I am coming from the Irish Council for Psychotherapy. I do not think the creation of an accessible and affordable service is rocket science. Somebody asked about cost-benefit analysis earlier in the meeting. Significant research has been done on that in other countries. I think we need to look at it because if we intervene in an effective way now, using the resources we have, it will save the Exchequer a substantial amount of money in the long term.
Dr. Harry Barry:
I want to add an interesting observation. The IAPT initiative was set up in England on foot of a report that was produced by an economist, Professor Richard Layard, who was asked by the UK authorities to look at the whole area of depression as an illness. I want to clear that up. The report showed that economically, the UK was losing billions in presenteeism and absenteeism as a result of this condition. Professor Layard was sent away to ascertain what the best form of therapy to treat bouts of depression would be. Everybody thought he would recommend that there should be a focus on drug therapy but, interestingly enough, he suggested that cognitive behavioural therapy seemed to stand out as the most effective thing in the long run. As a clinician, I would probably argue that some people who are going through bouts of depression are cognitively incapable of getting involved in counselling or cognitive behavioural therapy. Drug therapy can help some people in such circumstances by allowing their cognition to improve to the point where they can get involved in talk therapy, which is what will really help them to get well. It is important to mention that the UK's decision to pursue this entire approach was an economic one and had nothing to do with the well-being of the people of the UK. It was purely a hard-nosed economic decision. The bottom line is that if we really care about our people and where we spend money, we will have to sit down in a serious and honest fashion. Money is going to have to be assigned and ring-fenced, rather than used as a kind of coin to be thrown in here today and in there tomorrow. It needs to be ring-fenced properly, which requires some kind of organised structure involving groups like the ICP. I do not care how this is done. Surely it must be possible to create a system in which human beings who are in distress are able to talk to somebody. That is all I am asking. As a State, we should provide our citizens with something they desperately need. If it is properly organised and funded, it should not cost the earth. In fact, it might save the State a lot of money.
Ms Ann Murphy:
I would like to add to the excellent points that have been made. When we talk about what we should do or what we will do, I worry that we are paying lip service or ticking boxes. It has been said that counselling is now available in primary care. Counselling may be available for some people after a very long wait. The maximum number of sessions that is provided is eight. Two, three or eight sessions might be absolutely satisfactory and adequate for some people, but wildly inadequate for other people. When an administrator says this, it is like saying to a GP like Dr. Barry that he can prescribe no more than two days of antibiotics to one of his patients irrespective of his or her condition. We can think we are doing the right thing by providing all kinds of services and teaching coping skills, etc., but it is likely to be no more than a box-ticking exercise unless the service is provided thoughtfully, with integrity and in line with the actual needs of the patient.
I will conclude by returning to what we have heard about coping skills. Children do not just learn from what we tell them. Children learn most in life from how they are treated, which depends on the health and well-being of their parents and the resources of the teachers and others who are dealing with them. It is a good idea to develop programmes in schools to teach children how to deal with difficulties in life, but those programmes will have very little purchase unless those children experience healthy, warm and supportive relationships in their families from an early stage. More and more studies on attachment are showing that children's earliest bonding experiences have an extraordinary effect on subsequent brain development.