Oireachtas Joint and Select Committees
Tuesday, 5 April 2022
Joint Oireachtas Committee on Education and Skills
Future Funding of Higher Education: Discussion (Resumed)
Apologies have been received from Senator Eileen Flynn.
On behalf of the committee, I welcome Mr. Michael Ryan, national head of mental health engagement and recovery at the HSE; Dr. Joseph Duffy, CEO of Jigsaw; Dr. Joseph Morning, mental health content editor at SpunOut; Mr. Mark Smyth, past president of the Psychological Society of Ireland; and Ms Trish Murphy, acting director of the student counselling service and student learning development in Trinity College Dublin, representing the Irish Council for Psychotherapy. Mental Health Ireland has sent its apologies as a representative could not attend today, but it has made a comprehensive written submission, which we all have had the opportunity to read.
The witnesses are here for a round-table discussion on the future funding of higher education. The format of the meeting is that I will invite Mr. Ryan to make a brief opening statement, followed by Dr. Duffy, Dr. Morning, Mr. Smyth and, finally, Ms Murphy. This will be followed by questions from members of the committee. Each member will have an eight-minute slot to ask questions and for the witnesses to respond. As we have a sizeable number of witnesses, I will try to keep strictly to the time slots. I am conscious and wish to bear in mind that two of our witnesses will have to leave before 1.30 p.m.
As everyone will be aware, the committee will publish the opening statements on its website following the meeting.
I remind Members of the long-standing parliamentary practice to the effect that they 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. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.
I now ask the witnesses to make their opening statements in the order I outlined a few moments ago. They have five minutes each. Mr. Ryan, the floor is yours.
Mr. Michael Ryan:
I thank the committee for inviting me. I am the head of the office of mental health engagement and recovery for the HSE. What I will speak about relates directly to my work in that role and may come across as quite nuanced, but I think the concepts and what we are here to talk about are scalable in respect of a mental health promotion approach right across HSE work and all health domains. The role and function of mental health engagement and recovery is to ensure the experience of service users, family members, carers and their supporters informs the design, delivery and evaluation of our mental health services. This is achieved through co-production processes and ensures the personal lived and recovery experience of service users, family members and carers is used as a service improvement and therapeutic resource within services. The work of engagement and recovery is central to achieving the person-centred and recovery-orientated service set out in our national policy, Sharing the Vision. The contemporary understanding of recovery is that of an individual achieving a meaningful life and realising personal goals and ambitions regardless of the presence or severity of his or her mental health challenges. A recovery-orientated service is one that facilitates an individual in achieving those recovery goals through the provision of clinical excellence and is informed by lived mental health and recovery experience. Over recent years the HSE mental health service has enhanced the recovery approach in services with a number of innovative initiatives through the office of mental health engagement and recovery.
We have area leads for engagement in all community healthcare organisations, CHOs. These facilitate approximately 35 local engagement forums, whose membership is made up of service users, family members, carers and other interested stakeholders. Additionally, we continue to develop a lived experience cohort to our workforce through the introduction of peer support working on multidisciplinary teams and through our recovery education and recovery college structures in partnership with our NGO colleagues in Mental Health Ireland. Recovery education is about empowering service users, family members, carers, staff and other stakeholders to an enhanced knowledge of recovery and their role in achieving recovery, whether for themselves or in supporting or facilitating others to do so. In 2022 we expect to have approximately 130 experts by experience working directly in the HSE mental health services. I am one of those. Engagement and recovery also oversees the individual placement and support, IPS, programme, which supports people with long-term and enduring mental health challenges to find meaningful work. According to our latest figures, more than 1,000 people are registered in the IPS programme and 441 people have secured meaningful employment since the start of the programme.
In response to the Department's request for submissions on the future funding of education, engagement and recovery has made a submission on the requirements of a contemporary approach to mental health delivery. That approach is based on the principles of recovery and person-centredness underpinned and facilitated by lived mental health experience.
Recovery, as I have outlined, is not merely a clinical process. It also incorporates a personal development process that involves empowering individuals, their families, service providers and communities to be active partners in achieving, supporting and sustaining mental well-being and recovery from mental health challenges. This recovery approach is very well served by an educational and adult learning model that accesses, supports, uses and enhances personal lived mental health experience.
In a contemporary mental health service, lived experience is an expertise that is essential to the delivery of services that provide maximum opportunities for individuals to recover. This expertise, in the context of providing a recovery-orientated service, is comparable to other forms of expertise such as clinical, social, occupational etc.
Our third level colleges and further education providers must respond to these new paradigms in healthcare by meeting the educational and training needs of all stakeholders in the health community, notably clinical staff, service users and their families, carers and supporters, to ensure they have the necessary skills to fulfil their respective roles in recovery-orientated services.
Mr. Michael Ryan:
This is a form of "service science" and can be addressed through the five key approaches outlined in my opening statement.
I refer the committee also to the supporting document I have sent, which is a fuller submission on what I am talking about. I also include a descriptor of the work of engagement and recovery and some of the terms I have used.
I thank the committee for the opportunity to present to it. This is an important discussion, and I am grateful for the opportunity.
Dr. Joseph Duffy:
I am grateful to the Chair and committee members for this opportunity to contribute to, and support, the committee's important work. By way of brief introduction, Jigsaw is Ireland's primary youth mental health charity. Supported by the HSE and other funders, Jigsaw has, over the past 16 years, established a track record in achieving better mental health outcomes for young people by providing a range of primary care therapeutic services for those aged 12 to 25 as well as creating supportive communities around them.
With more than 240,000 students enrolled across the higher education system, our third level institutions are home to a large cohort of Ireland's youth population. Indeed, when we add those in further education, this number rises to almost 400,000. As an organisation focused on supporting the mental health of young people in settings where they live, learn, work and play, higher and further education represents an area of great interest for Jigsaw. At Jigsaw, we recognise that college years represent a key transitional life stage for young people, offering opportunity, challenge, experimentation, unpredictability, instability and more. Internationally, evidence points to increasing severity and complexity of mental health difficulties among third level students. Emerging international research also indicates that the Covid-19 pandemic, and its associated consequences have had a disproportionately negative effect on the mental health of third level students. At Jigsaw, we have experienced this at first hand, where more and more young people aged 18 to 25 are seeking the services of Jigsaw throughout the country and online, but long before Covid, the indicators were not positive.
Jigsaw's My World Survey highlighted the proportion of young adults reporting severe anxiety as having increased from 15% to 26% and those reporting severe depression as having increased from 14% to 21%. This is over the course of a decade. These, I am sure members will agree, are alarming figures. What is clear is the current landscape of mental health and well-being supports for students across higher education institutions, HEIs, nationally is fragmented and inconsistent in nature. We know that not all HEIs have fully documented guidance on key areas such as mental health policy or protocols for responding to students in distress. Where such guidance does exist, it is not always clear how it is implemented in practice or embedded in campus life. Far too often, HEIs rely on the efforts of individual staff members or student bodies rather than adopting a coherent, campus-wide approach. At Jigsaw, we believe it is imperative a whole-of-campus, collaborative approach is needed, part of which will include the active participation of students and the move towards embedding well-being within the curricula. This must be a core component of the educational journey of all students. Indeed, this whole-system approach to student mental health and well-being is recommended in the national student mental health and suicide prevention framework of 2020 and again in the higher education healthy campus charter and framework of 2022. Jigsaw has first-hand experience of successfully contributing to such an approach within the post-primary sector. Our One Good School initiative is currently supporting more than 150 post-primary schools in their implementation of a whole-school approach to mental health and well-being, supporting students, educators, school leaders and parents.
To inform this statement, we consulted our youth advocates - a large cohort of youth volunteers who support our work across a range of areas. What was clear is that, on the ground, many students feel unsupported. Key takeaways from our talks with young people include their sense of a widespread lack of awareness of where to go for help and, if support is identified, the need to jump through hoops to cross the threshold. Our youth advocates pushed for the need to create a more sustained focus on mental health and well-being as part of the student experience for all and to move away from once-off initiatives, such as well-being weeks. They called for a fresh approach, one that includes and involves all facets of the college community and that is collaborative, innovative and open.
At Jigsaw, we fully acknowledge the complexities of addressing mental health and well-being in HEIs, but we believe promoting student mental health and well-being requires much more than a functioning student counselling service. We need to work collaboratively to address the current fragmented and inconsistent nature of mental health and well-being support available to students to avoid duplication and ensure equitable access to an integrated mental health support system that best meets the needs of all students. Given the diversification of the student profile in recent years, it is crucial to ensure a range of targeted mental health supports and services are also provided to meet effectively the needs of students who may be considered more at risk. The valuable roles students play in the lives of one another need to be nurtured. Peer-based mental health and well-being programmes should be further developed and expanded and become a key feature of HEIs.
What is crystal clear to us in Jigsaw is that increased investment is now needed if we are to make a real, meaningful difference to the mental health and well-being of Ireland's young people and give them the best possible chance at a full and healthy future. The students of today are our future professionals, parents, politicians and One Good Adult who, in turn, will go on to support the mental health of future generations of young people.
I again thank the committee for this opportunity. I look forward to comments and questions from members.
Dr. Joseph Morning:
I thank the committee for the opportunity to speak to it today on the important topic of further and higher education and mental health. I am the mental health content editor at SpunOut, Ireland's youth information service run by young people for young people. We provide young people in Ireland with access to quality, non-judgemental information services with more than 181,000 readers relying on our information resources every month. We continually engage with young people through a range of exercises that give us significant insights into the challenges young people face when entering further or higher education.
As my colleague from Jigsaw knows better than me, findings from the seminal My World Survey 2 highlight that poor student mental health is a pervasive and problematic issue in Ireland. Roughly one fifth of the Irish student population experiences severe depression and anxiety and more than 10% of students reported a suicide attempt. Research conducted since the Covid-19 pandemic indicates further deterioration in student mental health. These findings reflect what we see on the ground. Since the start of 2021, our 50808 text support service has engaged in more than 2,000 conversations with young texters relating to further or higher education. Anxiety featured as an issue in 43% of these conversations, while 38% of texters talked to us about stress, 21% about isolation, and 15% shared that they were having thoughts of suicide.
Younger students are at an increased risk of mental health difficulties. For many young people in Ireland, entering further or higher education coincides with a key transition stage in their life. That comes with challenges and adjustments that impact on mental health. Young people are frequently presenting to our youth information chat service inquiring about whether they can defer a college course due to their mental health deteriorating. This underscores the need for sufficiently funded dedicated mental health support services that can provide students with the right intervention at the right time. We welcome the commitment of the Minister for Further and Higher Education, Research, Innovation and Science, Deputy Harris, to the issue of student mental health and the recent allocation of an additional €5 million for student counselling and mental health services. However, we need a longer term strategy for the resourcing of mental health supports in these areas. College mental health services are facing a rapidly increasing wave of demand. We urge the committee and indeed the Minister to continue to advocate for dedicated Exchequer funding for student mental health services.
In 2020, the Higher Education Authority published its national student mental health and suicide prevention framework for Ireland. We see a number of elements of the framework as being particularly crucial going forward. First, students experiencing mental health difficulties need access to safe, well-resourced clinical supports that are culturally appropriate and inclusive for all. This is vital, because those who identify as LGBTI+, international students and those from ethnic minorities are all at higher risk of experiencing mental health difficulties. Our student population is also changing in terms of how students engage with their education. A traditional approach to student mental health that solely relies on on-campus supports is no longer accessible to all. Hybrid approaches that include digital and online support services are a cost-effective solution, but they are underdeveloped in higher education and need investment. The framework also calls for the development of universal preventative interventions to maintain the mental health of all students. Adopting such a universal approach helps to identify those most in need earlier and it normalises help-seeking. Providing the necessary mental health supports will require a professional workforce trained in the use of high quality, evidence-based interventions. We need the Department of Further and Higher Education, Research, Innovation and Science to create more training places for clinical, counselling, and educational psychologists and to pay the associated fees for all trainees to ensure an equitable opportunity. We also need more mental health nurses, psychiatrists, social workers, occupational therapists and other allied health professionals.
Major steps must be taken to ensure further and higher education opportunities are genuinely open to everyone, especially those from disadvantaged socioeconomic backgrounds. The first review of the SUSI grant rate in ten years provides a vital opportunity to support students.
We can and must set the SUSI grant at a rate that adequately covers the costs of engaging in further and higher education. I would urge the committee to adopt a broad, societal approach to the intersectional issues of mental health inequality, social exclusion and economic inequality when setting out recommendations on the future of mental health support in further and higher education.
Our student population has never been more reliant on us to deliver in the area of mental health. We need the investment, leadership and structures of accountability in pursuit of a vision where students in Ireland are supported to achieve and thrive in further and higher education and beyond.
I thank members for their time.
Mr. Mark Smyth:
On behalf of the Psychological Society of Ireland I would like to thank members for the opportunity to address the committee in respect of discussion on the future funding of higher education. For many years there has been a growing imperative to expand our psychological workforce and this imperative has escalated because of the psychological impact that Covid-19 has had, especially on our young people. We know that as a direct result of the pandemic, demand for mental health support has significantly increased and is likely to continue to do so.
Successive HSE and Government reports have identified that there is a significant shortfall in the number of psychologists being trained in third level to meet demand. A 2021 HSE report estimated an additional 321 psychologists were required in mental health services alone to meet demand. This does not take into account demand in other areas such as education and higher education.
What we have failed to address thus far, despite repeated direct advocacy to Government, is how we plan to increase the number of training places and associated funding for the three professional training programmes to meet current and future demands. If significant funding were to be allocated in budget 2022 for higher education training places, then, at best, an increased cohort of trainees would begin in September 2023 and would go on to qualify in late 2026. Each year of delay to additional funding being allocated to third level psychology training programmes will add another three years to when they will qualify and enter the workforce.
In 2021, there were 66 funded HSE clinical psychology places in universities and, in addition, the counselling psychology training programme has approximately 14 places, with 20 to 22 on educational psychology programmes. This is not enough to meet current or future demand.
A petition of more than 2,400 signatories joined the PSI’s continued calls for the disparity in funding for psychology trainees to be addressed by Government. Currently, trainee clinical psychologists have 60% of their fees paid and receive a student salary, while counselling and educational psychology trainees in third level pay fees of approximately €14,000 per year and complete three years of unpaid work throughout the duration of their studies and training in university.
The PSI has highlighted to Government for the past three years in pre-budget submissions and direct correspondence to Government Ministers and the Taoiseach that one of the greatest barriers to getting qualified psychologists into the workforce is the inequity of counselling and educational trainees having to self-fund for the full period of their doctoral training, as well as pay €14,000 per year in university fees. This results in many not being able to afford to enter the profession, or a select few who can afford to self-fund, which risks the psychological workforce not being representative of the full socioeconomic spectrum of the community they represent and support. We have advocated with Minister, Deputy Harris to work with the PSI to find ways to alleviate the burden of fees on trainee psychologists in third level education.
Thus far, the PSI has been met with deafening silence from Government on additional funding. How should the PSI understand that, on one hand, we hear regular statements in the media and Dáil about the need to support the mental health needs of our population but, on the other hand, we have had no engagement whatsoever from Government about increasing the numbers of professionally trained psychology places in third level.
The PSI wishes to highlight the unjustified inequity of the current operationalisation of the disability access route to education, DARE, scheme which is a third level alternative admissions process for whom the aim is to reduce barriers to accessing education, but in the area of mental health it in fact does the opposite. The DARE scheme is administered by the Irish Universities Association, IUA, for school-leavers whose mental health difficulties have had a negative impact on their second level education. It offers reduced points for applying to third level education. The current criteria for entry via the mental health condition route specifies that the only profession eligible to verify a mental health difficulty is a consultant psychiatrist. The PSI is of the view that this is an unnecessarily restrictive practice and there is a need for a change in this specification. The PSI would argue that there is no justification for the exclusion of highly qualified chartered psychologists from verifying the impact of mental health on young people’s education. Extensive training in the assessment and treatment of mental health conditions forms a core part of the training programmes in psychology and, therefore, is a skill-set and competency common to both psychology and psychiatry. A young person may have attended an appropriately qualified psychologist for assessment and-or support for their mental health condition. With the current process, the young person will be forced to also attend with a psychiatrist they are unfamiliar with and incur additional costs to the family. This creates a situation of inequity of access for the young person and their family. The position of the IUA, in the view of the PSI, represents an excessively narrow and medicalised view of mental health.
The above position is not consistent with the core value of equity in the Government’s Sharing the Vision policy, which outlines that equity is access to services characterised by inclusiveness, fairness and non-discrimination.
The PSI is calling on the Oireachtas for support in petitioning the IUA and Government to urgently commit to a review and reform of these restrictive practices currently in operation regarding the validation of the impact of mental health conditions on young people and students and to remove this unnecessary barrier to accessing third level.
Ms Trish Murphy:
I am speaking from the position of the Irish Council for Psychotherapy, but also as a student counsellor and the acting director of Trinity Student Counselling Services. As our colleagues already said, we know that anxiety and depression are on the rise in our young people. Particularly, My World Survey 2 was fantastic in giving us those figures.
Mental illness is likely to surface in the ages from 17 to 25 and therefore is also likely to present in the student population. Increasing diversity in third level also means that students with pre-existing mental, physical and emotional needs are attending colleges and our international student population has significantly grown. All this points to the pressure on services at third level, including health, counselling and disability services. These are the primary points of contact for young people of that age in this country. A decrease in stigmatisation of mental health issues plus increasing anxiety and academic pressure to do well have all been factors in the huge rise in demand for counselling service and even the private sector is having huge difficulty in meeting the surge in need.
Psychological Counsellors in Higher Education in Ireland, PCHEI, was founded in 1994 by a group of student counsellors from third level colleges. They met for a number of years and the organisation has developed and represents student counselling services in the vast majority of higher education institutes, HEIs, in Ireland. Student counselling services are dedicated mental health support services available free to all third level students.
The role of student counselling services, first and foremost, is to provide psychological counselling to students who may be experiencing personal adjustment, development or psychological problems. They also play a preventative role by assisting students to identify the learning skills required to effectively meet their educational and life goals. They are involved in the support and enhancement of student well-being throughout the campus community and play a role in contributing to safety and risk on campus. Student counselling services provide a range of key mental health interventions: clinical assessment; one-to-one counselling; group counselling; online support; risk and crisis management; outreach and prevention; training for HEI staff to support students; policy and procedural development; psychological health workshops and programmes; and developing peer support programmes.
PCHEI is full of highly qualified, professional student counsellors. Its psychotherapists are eligible for accreditation with the Irish Council for Psychotherapy. They are also eligible for qualification with PSI, which we just heard about, and the Irish Association for Counselling and Psychotherapy. Accreditation means that practitioners are properly qualified to work to recognised standards of professional competence.
I added a slide that members will see. The numbers of unique students presenting for counselling last year, across the HEI sector, was 14,500. They served 70,000 clinical sessions for that age group across Ireland. As members can see, that is a huge number. However, this year will completely overshadow that because already the rise in demand this academic year has far exceeded that of previous years. Currently in Trinity we have a 23% rise in demand for one-to-one clinical services.
I turn to our funding issues. Most funding for student counselling comes from core budgets of colleges. In the past two academic years, the Government has given funding to colleges, which has allowed for more counselling sessions to take place, plus outreach work on the consent and suicide prevention frameworks.
However, the reality is many counselling centres have become rapid access in that they serve crisis and emergency demands first, and this lessens the possibility for therapeutic change as there are consequences for ongoing short-term therapy models. If this cohort, that is, student counselling, continues to be the main provider of mental health services to this age group, more resources need to be made available to meet properly the psychological and psychiatric needs of the students. This will necessitate more counsellors, more access to psychiatry and a more varied response to our rising international and diverse student needs. The expectation is that a large number of students will enter our third level system as they flee war in their countries. This will necessitate a mental health and trauma-informed response that will put extra pressure on a system already under excessive duress.
I apologise that I have another meeting so I will have to leave at 12 noon. It is no reflection on the discussion and I thank the witnesses for their work. This is a discussion around the general question of higher education funding. I refer to what Ms Murphy and Dr. Morning were speaking about. At present, funding of services such as counselling comes from the core grant. In the allocation of funding, should there be a specific top-slicing made available for counselling and other services? We saw in the past year that the Minister made additional funding available for additional hours. Perhaps Ms Murphy and Dr. Morning would respond to my first question and others can come in if they wish. Should that funding be top-sliced rather than a decision made by each higher education institution?
Ms Trish Murphy:
It should be anything that would guarantee ongoing funding. If we are going to get extra counsellors, we need to have them for years. There is no point in having them for one year only and not being sure if we will be able to provide them the following year, which is sort of the case at present. If it was top-sliced and guaranteed, it would allow for planning, prevention and many of the suggestions we have about implementing peer programmes and other programmes that we could use. At present, people can only be employed for one year with the hope they can be employed again, but many people get other jobs because they are in such demand, so we have to train in new people. It is really undermining the work. Yes, of course, I think it should be top-sliced.
Dr. Joseph Duffy:
Sometimes if funding is top-sliced, it might be equated with a number of counselling hours, in that institutions might be told they are getting 100 hours. Jigsaw would suggest that it should be looked at in the round and how that money could be spent in a preventative way. If it is dedicated just for hours, potentially a whole-of-campus system might not be developed. It is about a range of supports that could be supported through consistent year-on-year funding.
Mr. Mark Smyth:
We need to remember we have a limited pool of people available to work in these roles. We are not training enough counsellors, psychotherapists or psychologists. Without multi-year funding, it is very difficult for people to make a choice. Between taking a one-year contract or a permanent and pensionable post, they will take the latter all the time. We need that continuity. If it is a post for one year and the person moves on to something else, we have lost that expertise. In each area, people working in youth mental health develop an interest, expertise and skills. If they move on because of the promise of only one year, that skill base is lost to other areas. I echo the calls that it needs to be multi-annual funding.
Mr. Smyth raised the specific issue of the shortage of counsellor numbers. I do not think we can create a Springboard programme within the sector, but is there anything we can do in the short term to address some of the challenges?
Mr. Mark Smyth:
The reality is that if we were to provide the funding for additional counselling, educational and clinical trainees in September, those trainees would not be qualified for three years but would enter the workforce as trainees supervised by senior staff. They would provide an input and direct mental health work during that time, which is an added bonus and a service to it. I work in a child and adolescent mental health service, CAMHS. When we take trainees onboard, it is a help to us. It is someone else who can work under supervision. They cannot work independently for three years, but we would get the benefit of them from day one once we increase those place numbers.
It is interesting. Dr. Morning made the point about the need for SUSI grant reform. It is my view it should be a priority, but the Government has to make difficult investment and spending choices. Dr. Morning will be aware there is a proposal being floated around cutting student fees. My personal view is that if there are resources to be made available at higher education level, it should be an increase in the core grant, because of underfunding, and in reform of the SUSI grant scheme. I do not know whether Dr. Morning has a perspective on this. I know budgetary negotiations are going on. In an ideal world, everything could be done, but what should be prioritised? I am always concerned that if the core grant is cut, one of the first services to be cut would be counselling. If the fee income is reduced, that is what universities and higher education institutions will do.
Dr. Joseph Morning:
It is a difficult decision. In an ideal world, one would not have to be prioritise over the other. The impact financial pressures can have on a person's mental health cannot be underestimated. Working and supporting oneself through education is becoming the norm more than the exception to the rule. There are substantial pressures associated with that and it has a very real impact. It also has an impact on who is able to access third level education. Certain groups within our population are disproportionately negatively affected while there is no reform to the grant. That has an impact on everything. It trickles down to the people who can get to the point where they can engage in graduate programmes and become trained.
Mr. Michael Ryan:
I thank the Senator for his question. It is important we do not become too micro too soon and that we look at the overall needs of what keeps people well in third level education. We need to think about prevention as well as intervention and what are the self-management and resilience techniques we can build into the student population to keep them well. Having a bird's-eye view is important as well as identifying the holistic needs exactly.
Dr. Joseph Duffy:
I wish to reinforce some earlier points. If we look at the evidence of young people who are at the highest risk of developing mental health difficulties, they are students from disadvantaged socioeconomic backgrounds, those with a disability, those from the LGBTQI community and those who are ethnic minorities. Some targeted funding, such as through the SUSI grant, would potentially make the most difference. The other issue we have not talked about yet is the drop-out rate. We know from the My World Survey that there is a significant difference in terms of those young people's mental health in the university sector versus the IT sector. We should be looking to support them and looking from a more equitable base.
I thank the guests for coming before the committee and for the papers they have prepared for us, which are very helpful. This committee is examining the issue of funding of the third level sector. We invited the witnesses in to deal with an important aspect of it, namely, the funding of mental health and support services for students in that sector. Three witnesses have referred to the My World Survey 2. I will start with Dr. Duffy. Jigsaw was partly responsible for that. Is that correct?
As Dr. Duffy said, the figures are alarming. The witnesses will emphasise that they want to see increased resources but there is a responsibility on members of the committee to also look for the cause of the alarming increase in the number of young people reporting severe anxiety or depression. The statistics Ms Murphy provided in respect of Trinity College Dublin have given us greater cause for concern. What does Dr. Duffy believe is the cause of these alarming rises? Is it that more people are reporting it or is it actually increasing?
Dr. Joseph Duffy:
That is a good question. The My World Survey was developed in conjunction with the school of psychology in UCD. We first published it in 2012 and did another cohort in 2019. As has been referred to this morning, it showed a negative picture regarding those young people who are struggling. The Deputy asked about looking at what is behind that. The positive side is the reduced stigma in terms of young people able to talk about mental health and access supports. That is a positive thing. That is potentially reflected in young people being more aware and able to say they feel down, worried or stressed. It is a good thing that they are telling us about those things.
That is important in what we do with that data. There is a sense of increased stress among students, particularly young female students and young female pupils in schools. They are the biggest cohort coming to Jigsaw. There has been a significant change over the past five years. We traditionally saw about 56% female and 44% male. That has changed to approximately 70%-30%. That can be seen in third level.
The following is one of the things that makes a difference in trying to support young people, particularly thinking about young men. It does not mean when more young women are coming that mental health is equally divided between genders, because it is not. How it is expressed certainty is not equally divided. It is thinking about resources in third level, how they will be accessed and how to provide that level of support. Useful in further developing that is providing anonymous support, 50808 text support and the live chat we do in Jigsaw. It is looking at a range of supports that will help people.
Ms Trish Murphy:
Traditionally, it would be the same. That is all the way up. Men tend to have more dramatic crises when they have them. More succeeded suicides are by men, so we need to target those and we put a lot of effort into doing that. We use online supports. Many of them use the online SilverCloud, which is a counsellor-supported support, and a variety of things to access them. Young women present more often but the crises often tend to be around young men.
Ms Trish Murphy:
I find it hard to say "Yes" to that. It does not help situations and is how people try to cope with them, which is not good. I see people putting huge pressure on themselves. There is perfectionism and the idea I have to be the best I can be across a range of things. Our young people put huge pressure on themselves. Their parents' expectations are very high, as are their own expectations of themselves. When they come to college and find they are not the head of the class like they used to be, the effect on them over years can be devastating.
The College of Psychiatrists backed up its claim by revealing there had been an increase in cannabis-related diagnoses in admissions to hospital between 2005 and 2017 of 300%. Does Dr. Morning think there is any substance in what the college is saying?
Dr. Joseph Morning:
It is important to be careful when trying to interpret data like that, especially when looking at causal associations between something like substance use and mental health difficulties. There is a strong evidence base that people experiencing mental health difficulties self-medicate with substances. To purely address the substance is not getting to the root of the issue.
Mr. Smyth pointed out how we should avail of the services of psychologists to treat people with mental health issues and challenges. Is the facts psychologists do not have the capacity to prescribe medication part of the reason they are excluded from what he says is the work they should be doing?
Mr. Mark Smyth:
No, I do not think that is relevant. One of the greatest difficulties so many struggle with anxiety and to such a significant degree is that we are failing spectacularly when it comes to early intervention. Anxiety, particularly, responds well to primary care level intervention but we have primary care waiting lists of up to two years in some areas. With any mental health difficulty, the longer someone waits for help, the more impact it will have and the more resources that will be needed. CAMHS is getting flooded with young people sitting, waiting without intervention and deteriorating to the point where they need it. We do not want to medicate children for mental health when we know that, in the first instance, talk therapy is effective. We do not have enough people to deliver it. I echo Dr. Morning's point that we have done huge work in reducing stigma. We are encouraging people to come forward, talk and share, and they are doing it. The are doing so in the expectation there will be someone to listen and help them, and, unfortunately, we do not have those people available to provide them with support when they need it.
Mr. Ryan referred in his paper to wanting to see recognition of the importance of the recovery approach. Is that approach to be instilled in students who subsequently become workers in the healthcare sector? Is that the point or is it a broader point?
Mr. Michael Ryan:
It is a broader point and relates to both. The trends in mental health and health generally in WHO statistics and so on are that lifestyle-related issues are becoming the predominant challenges, pandemic aside, to mental health. The response has to incorporate a much stronger upskilling of people to self-manage, build resilience and learn how to manage their mental health more. It relates to the point about early intervention. If we teach people skills as early as we can to manage and improve their mental health, it will not stop everybody going to a more acute phase, but it will certainty help. That is what we mean by the recovery approach.
I was tuned in from the beginning and had to turn off when I got on campus to get down to the committee room. I have listened with interest to what everybody has said and I thank the witnesses for their submissions on this important subject. I also listened to the contributions that went before me from committee members.
It is clearly established that once-off funding on a yearly basis is not working or cutting the ice. It might make for good political announcements but it is not where we need to be or what we need to do. I want to tease out what exactly we need to do. Has the number of clinical psychologists needed in the third level system been quantified?
Mr. Mark Smyth:
The national accreditation of counselling services has recommended a full-time equivalent ratio of one counselling therapist psychologist per 1,000 students. We have a benchmark but, as far as I know, we do not have the data to see how far we are from that figure. Once we have the data, we need to engage with Government to say what the shortfall is and ask what the plan is to reach the benchmark.
We know what is recommended. We do not know what we currently have. One of the concerns is that even if we knew how many we needed, where we would get the staff to fill the gaps.
The first thing we need is more data to see the extent of the problem. We know what is happening. We know because young people ring politicians in the middle of the night. They should not be ringing us to ask us for clinical help. We also know from the Irish Patients Association report and yesterday's HSE report that many people who present at emergency departments get fed up waiting for hours and they leave. This is a very dangerous situation for us to be in, as well as the fact that it compounds the problem in emergency departments. We have to quantify the problem and then see that we do not have enough.
With regard to the Psychological Society of Ireland, the sponsor pays 60% of the course fee and the student pays 40% in the case of clinical psychologists. What are the terms and conditions associated with the sponsorship? Is there a public service requirement in it? Could the students emigrate or move to the private sector on completion of their studies?
Mr. Mark Smyth:
My understanding is there is no obligation to continue in the public service as there are plenty of jobs. There are not enough graduates coming through. In my experience many stay and continue to work in the HSE. We have a limited pool. As I mentioned in my submission, it is estimated that more than 300 are needed in mental health alone. This does not take into account the Prison Service, the Higher Education Authority or Tusla. As well as this there are not enough people in private practice. People cannot ring someone to get an appointment privately because it is the same pool of people. There are terms and conditions for this but the counselling and educational trainee psychologists are not employees. They have no rights, they get no pay and they pay €40,000 for a three-year course. When they are asked whether they want to work for a system that has asked them to work for free for three years and pay €40,000 for the privilege, many will choose not to and, to be honest, we cannot really blame them.
No, we cannot. We cannot stand over that. This feeds into the precarious working conditions throughout the third level sector. We certainly cannot ask people to do it free. This was my next question. They must undertake 300 hours of unpaid work in the course of their studies. How does this compare with the number of working hours for a clinical psychologist? I am trying to get a sense of how closely they compare.
Mr. Mark Smyth:
They are very similar. There are slightly different metrics with regard to the number of hours required. Overall the same amount of experience is required in the HSE criteria to work in the service. As a senior clinical psychologist I often have a counselling or educational trainee or a clinical psychologist with me. They do the same work. They provide the same public service. One gets paid and two do not. The equivalence of what they deliver to young people in mental health is equivalent but they are not treated with equivalency.
Ms Trish Murphy:
Psychotherapists have four years training and it costs approximately €40,000 to get through it with the same number of clinical hours. They have never had sponsorship. All psychotherapists pay for themselves. Clinical and counselling psychologists work in the student counselling services with us. Without them we would be stuck.
Mr. Mark Smyth:
Ministers pass the buck. One says we need to contact another and when we contact that Minister we are told we need to talk to somebody else. Eventually we got back to the Minister, Deputy Donnelly, whose response was that his diary is full. We also wrote to the Taoiseach about the fact that each Minister has said it is not their responsibility. So far nobody has taken responsibility. The Taoiseach's response was to thank us for the correspondence. In three years of engagement on this and highlighting this issue we have had no direct engagement with the Government on it.
Therein the problem lies and it is quite shocking. As was said earlier, lip service is paid to it. Everyone says they deeply care about the mental health of young people but we do not do what we need to do, even the very simple things, to fix the problem.
Mr. Mark Smyth:
One of the big concerns we have is about the socioeconomic profile of the people getting into psychology. We have a lot of people from disadvantaged backgrounds and ethnic minorities. The prospect of paying €40,000 over three years and working free is just not possible so they do not enter. We have a very diverse population now. We need to make sure our workforce represents this. It is not possible to pay €40,000 over a three-year period.
Mr. Mark Smyth:
A sum of €1.5 million would cover the costs for one year for a cohort of counselling education psychology trainees. This would be €4.5 million for the full three years. In the context of how much we spend, it is a very straightforward solution. Unfortunately, we need engagement to make it happen.
Ms Trish Murphy:
The colleges have been preparing for this. Certainly TCD has been corralling many people. The psychology department has offered its students to help. It will take a lot of resources. I do not think the short-term model will work for very traumatised students. We will have to change this and find some funding somewhere to support it.
I thank the witnesses for their attendance. I will be very specific with my first question. My subsequent questions might be a bit more general. My first question is for Mr. Smyth. He made the point very well on the issues surrounding trainee clinical psychologists and educational counselling psychologists. I will make a general point first. We discuss mental health a lot in these institutions. It is a big political issue. It is not just related to third level, albeit it is a huge issue there and among young people. Fundamentally there are certainly issues with the allocation of resources and how systems are managed. The fundamental problem is we do not have enough mental health professionals in the system. No matter what way we chop and change it there are not enough to meet the demands. This is a huge political issue. A significant element of this is the fact that people cannot afford to become psychologists or psychotherapists.
I will come back to my point on clinical psychologists, which may also apply to educational and counselling psychologists. An issue arises prior to becoming a trainee. There are approximately 60 places for clinical psychologists and to qualify for them they also need clinical experience. To obtain this clinical experience they need to be from money or be willing to get into debt or work lunatic hours at the weekends. Perhaps there are similar issues with psychotherapists. Does Mr. Smyth have a response on this? Some of the solution probably relates to assistant psychologist positions that are funded. There are probably not enough of these that provide sufficient clinical experience for people to qualify for the funded programmes. Perhaps there are comparable issues with counselling and educational psychologists. The issue is how to get clinical experience without getting into €20,000 or €25,000 debt.
Mr. Mark Smyth:
A HSE pilot project for assistant psychologists was launched by the then Minister of State, Jim Daly, a number of years ago. It was just formalised this year as a specific grade. There are 114 assistant psychologist posts in the HSE.
There are some within the Prison Service and some within the section-38 organisations, but there is still a large cohort who end up having to work for free.
While we greatly value the role of assistant psychologists, we are a little concerned given the experiences of our colleagues in the UK, where the British Government invested a huge amount in assistant psychologists only to find a bottleneck resulted. In other words, assistants remained stuck at assistant level for a number of years. The HSE has addressed this issue by imposing a three-year limit but we want those concerned to progress to training programmes. Assistant psychologists, while they assist with the work, cannot work independently. With regard to setting up an expectation that they will work independently and address all the issues we have, there is a really important adjunct, but we really need to get the individuals onto the training programme. While the pilot programme - with its 114 posts - is good, it is not enough to meet the demand from graduates coming through. Therefore, we hope there will be an expansion. The HSE commissioned research to find evidence as to whether the model worked. It found it did so it set it up as a programme, but 114 will not meet the demand.
Ms Trish Murphy:
Psychotherapy is slightly different. A four-year postgraduate programme is available in various institutions. Psychotherapists are slightly older so they fund themselves, for the most part. We operate a training programme in Trinity with up to 20 trainees, whom we supervise. All those trainees are offering their time for free, and that is why we can see so many students. There is no funding at all for any of the programmes. The strength is in the mix. We have assistant psychologists, clinical counselling posts and a variety of modalities represented. It makes for a very rich offering. The diversity we are looking for in our system is very hard to achieve. We cannot get people from different backgrounds to come in because it simply costs too much money.
Forgive me but my next question is somewhat negative. I will direct it primarily at Mr. Ryan and Drs. Duffy and Morning, but if Mr. Smyth and Ms Murphy want to respond also, that will be fine. The figures from the My World Survey show an increase of 15% to 20% in the number with severe anxiety and an increase in those reporting severe depression from 14% to 21%. These are not small increases; they are very significant. They occurred before Covid, which I presume could have been an exacerbating factor. My question on this might be a bit nebulous. What is behind the increases? I am sure there are all sorts of environmental issues. At third level there are particular pressures but these statistics are not necessarily specific to third level. Has much research been done on this? Some of the factors could be global but some could be particular to Ireland. Why are the increases so significant?
Dr. Joseph Duffy:
We know most mental health difficulties that span across the lifetime occur by the age of 17. The entry path to adulthood is the key developmentally. If mental health difficulties are going to occur and be lifelong, they will most likely occur at this time. That is why we do the work in Jigsaw on supporting young people between 12 and 25. We know that piece of it. We also know that, before Covid, there was a significant difficulty regarding the needs. In this regard I am referring to reduced stigma and better awareness, including better awareness among parents, in schools and in the wider environment. Better awareness is helping people to seek help, but part of the difficulty concerns who is available to support people once they say it is okay not to be okay and that they are reaching out for help. Recognising that we focused on psychology this morning, we need to note there is a significant need. That has been identified in surveys, not just in my work but also in other work. We can see that when we introduce new initiatives, such as those online, the uptake is significant. However, we end up competing against each other, with each of us looking for the same mental health professional. In Jigsaw we operate a transdisciplinary model, which means we can have social workers, mental health staff, occupational therapists and psychologists all coming with some form of psychotherapeutic training. That is really needed. What we want to do is ascertain how we can support that with an early-intervention model. What is lacking, however, is a focus on connectivity overall and the journey regarding primary care, secondary care and third level. Some need support at primary care level when young, and then they enter CAMHS and services at third level. They should be supported to work through a recovery model, enabling us to go along. The difficulty is that there are no supports even for us to have conversations about coming together to think about this and how to plan for some factors in the longer term.
I welcome all the attendees. It is great to have them here. They have a huge wealth of knowledge.
I have a couple of queries I might pose on some of the submissions. I thank the attendees. Mr. Ryan, from the HSE, referred in his submission to some of the elements in the HSE and community health organisations, CHOs, in respect of local engagement. That was quite important to raise. How do area leads for local engagement link in with third level? I was missing a step concerning local engagement in the community regarding people facing mental health issues. Do they link in at third level?
My next question is for Dr. Duffy, from Jigsaw. I come from Ballinasloe and represent east Galway and Roscommon. Last Saturday an amazing event was held at the GAA club in Caltra, working with Jigsaw, other sports clubs, including the athletic club at the ladies' club. It was a wonderful initiative. The organisers brought together local or national sports celebrities, such as Michael Meehan, whose family did so much for Galway football, in addition to referees and commentators. There was also a comedian, Sir Stevo Timothy, also known as "Farmer Michael". They spoke to local families and children about the pressures on young people. It was an amazing initiative in a rural area, bringing all the groups together to say the issue is huge for us right now. I pay tribute to those concerned and acknowledge what Jigsaw does at local level. Jigsaw's local group supported the initiative to which I have referred.
Inequity of access was mentioned. It is important to address this at second level in addition to third level, but it is at second level that we make a difference. There was recently an allocation through DEIS funding whereby more than 240,000 students can now access DEIS supports. This means smaller class sizes and additional access to mental health supports within the school. That is what we need to move towards. We need to be providing additional supports at school level. While we can talk about Student Universal Support Ireland, regarding which there is a review involving the Minister, Deputy Harris, the rolling out of DEIS supports at both primary and secondary levels is crucial.The delegates might have some comments on it.What other supports can be considered at secondary school level to prepare our children because dropping out is a huge issue at third level?
Ms Murphy, with her background in psychotherapy and who is representing Trinity College, might answer my next question. Given the drop-out rate in the first year at third level, we need to focus on secondary schools to make sure all the careers guidance teachers have a role. Considering the apprenticeship programme, the additional courses being made available through the CAO and the new report on leaving certificate reform issued by the Minister for Education, Deputy Foley, could Ms Murphy comment on the expansion of the transition year? With the broadening of the apprenticeship programme, how can the third level sector work with secondary schools and career guidance teachers on opportunities for those who do not take the traditional route to college and on how they can achieve qualifications? I will leave it at that but I will ask a couple more questions if I have time.
Dr. Joseph Duffy:
I will refer to the question on second level. Transitions are particularly important, particularly in respect of youth mental health. We are aware that the transition from primary school to secondary school is a key stressor for young people. The same is the case with the transition from secondary school to third level, if that occurs.
One of the points I was making in my opening statement was on the importance of including well-being in the curricula.
It is hugely important to do that within the second level system in order to enable and support young people who can have the skills, the wherewithal and the confidence to apply for third level. That is a really big issue. When one reads some of the reports and research that has been done, they looked at those from socially disadvantaged backgrounds. Their experience was that they were relying on a teacher or a career guidance counsellor, or somebody else, to help them to think about their career choices. How do we ensure that the have the competence to do that? My main point would be to think about not just the funding of higher education separately, it is also about thinking about the supports at second level. Once they funnel in the supports, early intervention and prevention are key.
Absolutely. Following on from that, I am aware that my university, the National University of Ireland Galway, NUIG, was the first mindfulness university. This is something that all universities are now putting in place. That mindfulness theme is so crucial.
On local engagement, there were 35 local engagement leads. When will Mr. Ryan clarify if there is a link there with third level?
Mr. Michael Ryan:
The Senator has asked a very good question. There is an expertise we have developed in engaging with communities and service users, and tapping into their knowledge around recovery. That is very transferable to the colleges. We already have a partnership with our recovery colleges, which is linked to NUIG, DCU and the Galway-Mayo Institute of Technology, GMIT. That has been recognised as a world first with third level.
Ms Trish Murphy:
Obviously, we are very conscious of dropout levels across all of third level. The feedback from student counselling is that we are usually extremely impactful in retaining people in college. There is an innovative and transformational programme currently under way where there is a model of peer-assisted support happening in third level. We had this for a long time in Trinity College and it is called Student2Student. This is where every incoming student has a student mentor who is trained and who stays with them for one year. We hope that the new pilot programme for more support will be implemented across all third level colleges. It plays a huge part in getting people to stay and making them feel that they belong.
It is crucial. Ms Murphy spoke about the mentorship being crucial, and we have spoken about this before along with Dr. Morning and Mr. Smyth. It is crucial that we get those additional supports. I am aware that more than €500,000 has gone to Trinity College in terms of mental health supports in the past two years. This has been to recruit additional counsellors and to support those students. I would love to see that this year. The CAO form has been expanded to include apprenticeship programmes and further and higher education. With regard to the levels of drop out across all of third level, if we are to use these other resources and supports through further and higher education where we are pumping in a lot of investment into our technological universities as well, we must ask if the level of dropout changes at the end of first year. Again, my apologies. We might get time at the end to come back to this.
We might keep Senator O'Loughlin in the Chair for future weeks. My background is that I was involved in education for 15 years, and even in my time would could see on the ground how the prevalence of students dealing with issues such as anxiety, and the increasing levels of students receiving a diagnosis of ASD or ADHD, and so on. I have said before that as a teacher I had never really felt adequately trained to deal with a lot of the issues that presented themselves to us as a teaching staff.
I wish to pick up on one point that Dr. Duffy and Ms Murphy mentioned, which is around embedding resilience in the curricula in higher education institutions. Reference was made to the practice being particularly ad hoc. Will the witnesses please define for the committee what they mean by embedding? Is it similar to implementing a well-being module at second or third level? Perhaps the witnesses could expand on that.
Dr. Joseph Duffy:
I thank the Deputy for his question. It is about looking at the appropriate knowledge base and providing the students with the knowledge about their own mental health, and the mental health and support of others. It is about including this as part of knowledge raising at first and then skills development. Seeing it as something that is really important is also part of it: for example, if students are doing an English degree, that they would all have access to a particular module. That would be very helpful in terms of people understanding and having a knowledge about themselves, knowledge of language, and being able to see whether those skills are transferable. It also reduces the stigma and helps people to understand where supports are available, what supports they can have themselves, what level and range of supports are available, and what is the threshold for those supports.
Ms Trish Murphy:
It is a conversation that is happening everywhere: should we embed resilience in the curriculum? Of course we should. It would be wonderful, but will it lower the numbers of students attending student counselling? I really do not know. What we are dealing with is quite serious. Of course we should do resilience. If we can, we should put credits in for it. I am not sure, however, that it would reduce the actual numbers of students attending counselling. That would take a while to work its way through, to be honest.
To come back to another point made by Dr. Duffy on the ad hoc arrangement at third level, does he believe that third level institutions are doing enough in providing professional development for their own staff members as they roll out those mental health services?
Dr. Joseph Duffy:
There is always a need to provide more. As my colleagues stated, there is often the difficulty, which we see in our own service, whereby the continuing professional development opportunities can be made available but people are really trying to work through a waiting list and really trying to devote the time to see the young person right in front of them. It is about looking at the whole experience. Sometimes, staff might be on short-term contracts and may be thinking that they must put the head down and do the work here. It is about looking at the whole person.
When we talk about the training of all of these mental health professionals, we are also talking about their own experience within third level. This is a very important time for having a very positive experience around their mental health because they are going to be the contributors into the future. It is, therefore, about not giving them a very stressful experience, then they just about come out and start in a role, and then feel another stressful experience. The number of graduates who say "Well actually mental health is not for me and I am going to leave that now because I want to do something else completely", is a huge pity because we actually want to encourage more and more people to enter into the professions.
Dr. Duffy mentioned two words there that I believe hit a bone with every Deputy and Senator, which is "waiting list". Whether it is a waiting list for a psychologist, a psychiatrist, or whatever consultant is required be it speech and language or physiotherapy, the pattern is quite obvious across all of our services.
Mr. Smyth referred to the 66 funded clinical psychology training places. I am aware also that there are a couple of others there. What kinds of figures do we need to be hitting? What is the turnover of graduates that we need to churn out from colleges in the context of training individuals to go into the services?
Mr. Mark Smyth:
It is 360 just for mental health, and we also had a disability capacity review from Government that looked up to 2032, which estimated a 110% increase in the number of psychologists required just for child disability alone. With regard to children with disabilities, there are significant waiting lists there and there is a huge overlap between children experiencing disabilities plus mental health. We just do not have the staff to do it. We do have staff who are close to experiencing burnout and they are under huge pressure from key performance indicators, KPIs, that relate to the wait time to bums on seats. All they get told is "Do more" and if staff move on it is "Do more with less". Staff on the ground very much feel this pressure to do more. They feel the pressure of the waiting lists and they feel the pressure of the families ringing up. I take five to six phone calls each week from distressed parents who are crying and upset, and we are not able to do it. It is extremely deflating. Reference was made to trying to keep good people in the services but we are failing spectacularly at that. People do not want to work in the services. They go off and they work privately because they are not put under these pressures. There has been talk about workforce planning reviews and we have yet to see the evidence of that. We see individual Departments and individual silos talking about what they need, but as I have mentioned before, they are all competing for the same pool of graduates, rather than thinking how many do we need and how are we going to get them. Those conversations have not started yet.
We are failing a generation of children by not having those conversations. We are also failing staff on the ground who are saying that they cannot cope with this and that they do not want to stay in the system. If we put children with mental health needs or disabilities into a system that is already broken, how is it expected to be able to meet their needs? We are not doing it.
This is not just about funding. As has been said, it is about how we support the staff. Most of us have no continuing professional development, CPD, funding. On the ground, we have seen an exponential increase in the number of children presenting with anorexia over the past two years. That is the condition most likely to kill a child, yet we are expected to do more. There is no individual allocated CPD budget for psychologists, occupational therapists, OTs, or counsellors on the ground, which means we have to figure it out for ourselves or we have to self-fund. We need to do more not just around recruiting but retaining staff. We have a national panel-based system of recruitment that means if somebody spends two years in CAMHS gaining an expertise in youth mental health, and that person wants to progress to the next level, he or she goes onto a generic panel and could end up in adult or disability services. We have systemic failures across the board in how we are recruiting, retraining and looking after our staff. It is not just about the numbers. We do not want to put more people in who have the same experiences the current ones do.
If I get time in the next slot, I might come back to Mr. Ryan about the HSE specifically regarding that issue. I will ask Mr. Smyth one final question. He mentioned that the PSI is of the view that consultant psychiatrists being able to verify that somebody has a mental health difficulty is an unnecessarily restrictive practice and there is a need for a change in the specification in respect of it. Will he tell us what the justification for that distinction is? What can we do to change it?
Mr. Mark Smyth:
The justification given to us is that mental health is an illness and only a doctor can verify the presence of an illness. As I mentioned, Sharing the Vision is a very progressive document which has moved on to that and looked at many different contributors to what impacts on mental health. We know from our consultant colleagues that there are not enough consultants. There are very few, especially in child specialties. We have set up a system that is supposed to enable us to access third level. I am a clinical psychologist working with young people for nearly 20 years. I could work, and have worked, with young people for a year or a year and a half who have anxiety or depression, and at the end of that process I am unable to verify the impact that mental health difficulty has had on their access to third level. They must go off, if they can, to find a psychiatrist. I had a family last week who are now going on a nine-month waiting list for one private psychiatrist they have never met and do not know. They will then have to self-fund to verify, when the young person and I already know what that impact is.
It is very undermining for them to have to retell their story. We have very experienced psychologists, OTs, speech and language therapists and people working in mental health settings, such as our colleagues in Jigsaw who, equally, are not able to verify the impact. We have set up a system that, on the face of it, is supposed to be about increasing access but in reality puts up massive barriers against families and young peoples.
I would like to put a few questions to the representatives. It was incredibly interesting and concerning listening to all of them. There are not too many surprises because, as has been pointed out by some of my colleagues, we tend to hear quite often about the challenges and issues in mental health services when it comes to responding to our young people. We are focusing on third level, what we need to embed in future funding to try to ensure well-being and supports for those who need them, and making those recommendations to the Minister.
I was alarmed by what Mr. Smyth said about the very large disparity between the funding for trainee clinical psychologists and that for counselling and educational training psychologists. I was certainly not aware of that. I would like him to address why that is. In response to one of my colleagues, he talked about a benchmark of one psychologist per 1,000 students. In 2020, there were 245,000 students at second level. I imagine it is close enough to that at present. How many psychologists are there at the moment? If there are 245,000 students, I would have thought from listening to Ms Murphy that we need more than the 23% increase she said happened in Trinity. Is there a problem getting the data? She said she does not have sufficient data to make the recommendation. Will she address that first?
Mr. Mark Smyth:
As Ms Murphy said, specifically on higher education, it is not just psychologists but counsellors, therapists and psychotherapists. It is a much more inclusive model of having mental health professionals in place. The internationally recognised benchmark is one therapist, counsellor or psychologist per 1,000 of the third level population. We know that is recommended but, again, we do not have, as far as I am aware, the benchmarks to know how many are currently in place.
Okay. That would be interesting. I ask Ms Murphy to send that on to us. We have talked quite a bit about the interventions that are needed when somebody presents with mental health problems, but I am particularly interested in the preventative measures mentioned by Dr. Duffy. We need to invest seriously in the preventative measures that are needed. I acknowledge the excellent work that SpunOut and Jigsaw do. I know that Jigsaw is starting in Tipperary and Wicklow. I understand Newbridge and Kildare are next on their list. I have been working with the HSE in trying to find a suitable premises there because it is an area that needs it. Will Dr. Duffy expand on the preventative measures that he believes should be in place so we do not get to a stage where we need urgent interventions?
Dr. Joseph Duffy:
I thank the Vice Chairperson for her support of Jigsaw. We know and have talked this morning of the significant need to support young people. Jigsaw is looking to philanthropic funding at present to support young people, particularly in further and then in higher education. One of the things we are looking at is one good peer or peer-to-peer support. We know students support each other very well.
The other part of it is thinking about focusing on some particular cohorts, such as student nurses, and helping them in minding their mental health, given the importance of their roles and the stresses that will be involved. We are also looking at improving mental health in the curriculum. As my colleagues said, that is a long-term piece. When we talk about a preventative measure in mental health, we are probably looking at returns across a ten-year period, but it is well worth doing it because if we just focus on the acute side of it we are not making any changes. The whole point of A Vision for Change and Sharing the Vision was to focus on primary care, especially in respect of mental health.
It also involves thinking about a broad understanding in making sense of mental health and thinking about the educators themselves. We know from our experience in second level, and the Vice Chairperson referred to it, that people were taught in teacher training colleges to teach a subject. They are now very much conscious of teaching the whole person. How do we lecture or provide support at a third level college for a whole person approach? It is thinking about it in terms of a broad, healthy campus. There are great policies and initiatives and so on, but how is that being supported in very practical ways? There is lots of information, supports and other agencies that are there. We are very willing to play our part, but how will that be co-ordinated and supported?
I have picked my own time here. My final question is about reducing barriers to accessing mental health supports. That came through very clearly in what was said. What is the best way of evaluating the outcomes of any well-being initiative bearing in mind that, as Dr. Duffy said, it could take ten years? I will take other speakers on that.
Dr. Joseph Morning:
If we want to evaluate these programmes once they go in, again, evaluation is something that takes money, takes time and needs investment. Can there be university-based research that can track people? If we start off with pilots and contract people to follow cohorts, it is very important to measure the mental health of those cohorts before and after. It is difficult to measure reductions in referrals to mental health services, which is one of the things we would hope to get from preventative approaches, if the numbers are increasing anyway in the face of increased pressures on mental health.
It is about constant tracking. We want to capture the more qualitative data and person-centred picture of the impact these programmes are having. One of the main aims should be changing the campus culture. We know that an important protective factor is help seeking. There are barriers to help seeking in third level education. A lot of students do not feel comfortable in reaching out and postpone doing so. Capturing the changes in attitudes is difficult, but it is one of the things we would want to change.
Ms Trish Murphy:
Evaluation is what higher education does really well. Our students are surveyed out of their minds. We offer rewards for surveys so that students will do them. There are loads of methods, everything from qualitative research to whatever else. We would be well placed to give excellent evaluations of any programme we have.
Mr. Owen Ryan:
In terms of evaluation, we have to be very careful that we are gathering the right information. There is a great opportunity for a patient and public involvement, PPI, approach whereby we bring peers and students into the process so that we make sure that the interventions are delivering what people need rather than predetermining what is needed.
In terms of the barriers, Dr. Morning alluded to the fact that self stigma is a huge issue. We have to get people used to talking about their mental health. We need to do that as early as possible. That starts at preschool, when a fireman comes into a school to say he puts out fires. Perhaps we need people to know about counsellors being the people we talk to when we are not feeling well. We need to equip people to deal with the emotional stresses of life, which are the catalyst for more serious challenges later on.
We need strategic thinking about everything we do. If we wait until we need the kind of interventions we are talking about today, that will be too late for many people. We have to go back to early intervention and ensure that we are equipping as many people as possible to recognise their mental health issues and give them the tools to address them. That does not take away from the fact that there are times when extra support will be needed and have to be in place. It is about a holistic approach.
I thank the witnesses for their contributions. I have read all of their opening statements. As usual, I am bouncing between two committees. I thank them for joining us.
A few things occurred to me. In his opening statement, Dr. Morning spoke about intersectionality. It seems to me there is intersectionality between the things that impact on our mental health. Having sat on the governing authority of NUIG, our hope was to reach out beyond the community within the university to organisations outside of it. I think in particular of Jigsaw and SpunOut. Is there an opportunity, when we are looking at funding, to think about co-funding? We are not just talking about the funding of higher education, but about funding organisations that have a direct impact on the lives of students and staff within that organisation.
It is welcome that we have the €5 million from the Minister, Deputy Harris. In third level education, reaching out through the institute itself is only one way in which people reach out. There were comments on funding for counselling. Am I correct in saying that it is not just about funding for counselling for people in third level? There should be a lifelong approach that reaches out beyond the walls of our third level institutions.
We have done a significant amount of work in this committee on bullying in primary and secondary education. I would love to hear the thoughts of the witnesses on the impact of that, the trauma it causes in primary and secondary school and how it would have a knock-on impact on people in third level education. Is that thought through in terms of a trajectory and approach to mental health that runs through all of our institutions?
Dr. Joseph Duffy:
In terms of talking about a lifelong approach, in Jigsaw the aim is to help people have a healthy transition into adulthood. That transition might be through finishing full-time education after secondary school and then doing an apprenticeship, attending third level or a lot of other different things. If we think about what we want as a country for our young people, we want a healthy transition. We want young people to be resilient and robust and to be able to contribute very positively to all areas of life.
That involved thinking about third level institutions not just in terms of education. The original idea of a university was education of the whole person. We need to pull back the lens from that and think about how we do that much earlier. We have done that very well in terms of thinking about access programmes and how to support people, in particular in terms of the traditional view of education. How do we support someone much more psychologically in coming into third level and starting that much earlier?
Going back to what we said at the beginning, this involves thinking about particular targeted cohort of groups, intersectionality and who is under-represented and how we will support them in terms of being represented. On the argument made earlier about a certain homogeneity, how do we support other entries into the sector? We need to talk within secondary level about developing a career as a psychotherapist or psychologist and so on. How do we encourage people to do that rather than seeing it as a middle-class phenomenon only open to certain groups of people? There is a lot to be done and a lot to be thought about.
Dr. Joseph Morning:
A lot of fruitful output can come from collaborations between organisations like SpunOut, Jigsaw and universities. Our student cohorts are diversifying, including in how they engage with their education. It makes sense that we should also diversify how they engage with mental health support. We should have a diverse range because not every type of support will work for every student. Some will have preferences. Some types of interventions or support services will work better for some than others.
It is important to have options. They can come through collaboration. Sometimes it is as simple as universities being aware of the other opportunities and support that are out there. That comes from joined up working and having clear lines of communication. That applies to further and higher education, but is also one of the keys to solving transition periods and getting the transition from secondary school to further and higher education right. It is about joining up, communicating, working together and having a person-centred approach.
Ms Trish Murphy:
We would like nothing more than to collaborate as much as is humanly possible. A couple of years ago we invited everybody in. What Mr. Smyth said is right. We are inundated with such long waiting lists that we cannot even get our heads up to think about these things. That is what we would naturally do. It has been an extraordinarily difficult three years.
It does not look as if it will ease up soon. This is a weird opportunity to collaborate.
The Senator's point on bullying was very interesting. Another collaboration that has happened relates to a speak-out tool, which is about anonymous reporting and which all higher education institutions have recently operated. A section of that will be about bullying. We are getting in lots of information that we will be able to look at and resource. A lot of that information is about bullying. The Senator is correct. It would be interesting to see where that is coming from. Is it coming from an older cohort that did not benefit from the second level? That will be fascinating when we get it. We are approximately a year away from looking at that.
Mr. Mark Smyth:
I will touch on the point on outcomes. Working in mental health services, the predominant outcome is bums on seats and reducing wait time for first appointments. Those are the key performance indicators. We do not have outcomes that look at how the systems work with each other. A meeting between representatives of Jigsaw, CAMHS and third-level education does not count in someone's work return. He or she is not encouraged to do that but is instead encouraged to see people for individual works.
The systems around young people include the services that work together and another piece we have not spoken about, that is, the families. Young people do not exist in isolation. We talk about the fact that we want to teach them resiliency skills. We do not want to put additional pressures on them because we know they have standards of expectation and think they must be all of these things. We tell young people they have to be resilient in the face of a parent who is unemployed or who is struggling for housing and that we will teach them the skill of being resilient when what we need to do is to give them those supports at home so they have predictability and financial support. We also need the different parts of the system to be able to talk to each other. We should be encouraged to have meetings about how we work together. That is not the case because we are expected to firefight. We are left to decide whether to cancel appointments and not meet with young people so we can work with a service to improve the systems or to meet the young people and not get that pressure. Invariably, clinicians will choose the latter. There needs to be a mandate that directs services to work together because otherwise we will continue what we have done before, which is to work in silos in isolation, and be restricted in opportunities such as this, where we actually get to talk to each other. The parts of the system need to come together to improve the experiences of the young people.
Mr. Michael Ryan:
I thank the Senator for the question. That collaborative piece is very important because someone who is trying to recover from a mental health challenge has holistic needs. It is unrealistic to think that one clinician or one person could address them. A suite of expertise needs to be available. As others have outlined, different organisations are better equipped to respond to different things. We must always bear in mind the needs of the person who needs the help and ask what kind of intervention they want. Some people, for good reasons of their own, may prefer not to have a clinical intervention and may look for something else. We need to be able to respond to that sort of diverse demand as well. That is important.
Do our guests think there is a crisis in mental health in the third-level sector? What will happen if there is no intervention or proper planning? We have an opportunity here as we consider the future funding for higher education. We either take it or we ignore the problems and issues our guests have presented us with today. Is there a crisis? Can it deepen if nothing is done about it?
I ask Dr. Duffy how much progress has been made in the implementation of the existing policies, such as the national student mental health and suicide prevention framework. What are the greatest barriers to that implementation? In his submission, he referred to a fragmented and inconsistent approach. Are there disparities between different institutions in that regard?
I will also ask about inflation, the cost of living and the pressures on families and students. It seems rising inflation is here to stay. How big a factor will that be for the next 12 to 18 months in terms of the financial pressures on students? I know we did a survey last year - we are all surveyed out - to which nine out of ten students responded that they were suffering from financial stress, either extreme stress or stress because of financial circumstances, whether caused by Student Universal Support Ireland, SUSI, the cost of accommodation of the other costs of third-level education.
Dr. Joseph Duffy:
I will take some of those questions and I am sure my colleagues will come in. The Deputy asked whether there is a crisis and there absolutely is. There is a crisis of demand. There is a crisis in trying to meet staffing needs. There is also a crisis in terms of vision, how we are looking at the issue and how we understand it. Not understanding something and not thinking about is a stand-alone issue.
The Deputy also asked about policies. I am not best placed to respond to that because it is about looking at the policies that are there, how they are implemented and how they will be implemented, tracked and supported over time. However, one of the things that our colleagues, including Ms Murphy, said earlier was that everybody working in the health system is, without a doubt, very well-intentioned. They are trained to work on a systems level. What is happening is that in many ways, as Mr. Smyth said, they are being forced to work on the individual level. There is a real need to think about how we can use the valuable resources that are there. What tends to happen, as we all know, is that we get invited to participate in the development of a particular policy. That is a fantastic opportunity that people love and that fills them with energy. It is then left to be implemented but the day job must be done. It is important to consider how we free up time to believe that we need to build this system and need to put the resources and time into it while, at the same time, the tide is coming in and there are so many needs and resource shortcomings, and so many young people needing support. That is why, as I said earlier, it is not just about deciding we are going to fund particular counselling hours. We must consider how we are going to free up some expertise. That is something with which we struggle within our organisation. If we want to run a new initiative, we need to take somebody who is experienced. We also need to think about the benefits of what that person is going to bring to the service. It is about having staff with a range of experience. Those are the benefits of assistance, of having people from multiple professions.
Dr. Joseph Duffy:
In Jigsaw, we are only beginning to work in the area so I would not feel confident to comment on that in an overall sense. Some of my colleagues may be better able to comment. What is important is moving to a whole-of-campus view and thinking about this as everybody's responsibility and not only that of the counselling service. What often happens, particularly with respect to mental health, is that people getting very scared and when confronted with someone who has a mental health problem, they refer them elsewhere because they feel they cannot do anything. It is important to send out the message that everybody has a role and everyone can do something. They do not have to do everything but these matters are not just the responsibility of the counselling service.
Dr. Joseph Duffy:
It is going to put enormous pressure on young people who are studying and trying to earn a living and keep their heads above water, particularly if they have to travel to college. We know, particularly in the first My World Survey, that anxiety about money was an enormous issue for young people. It was also a determining factor in their career choices and their consideration of what would be a solid profession. The idea of a solid profession and a career for life is gone.
Mr. Michael Ryan:
I will follow up on what Dr. Duffy said. One of the important things to remember is that the best outcomes come from a good therapeutic relationship. Some years ago, I was involved in a school where there were serious challenges and a lot of expertise was brought in but the young people would not engage with it because they did not have the requisite therapeutic relationship or trust.
What Mr. Duffy is talking about is very important, that it is everybody's responsibility, not just the counsellor but anybody who engages with young people, or any person for that matter, that they feel they are equipped to help them. There are programmes such as mental health first aid. They should be CPD requirements that everybody should look at.
I thank the Vice Chairman. As always, these interactions help to bring people together so that they can have conversations with people they may not have met for the past couple of years despite the fact that they work in the same area. We hear that quite a bit. Two things strike me. One is expanding on some of the previous points around the things that cause anxiety. There is the intersectionality, that element that Mr. Duffy spoke about earlier. We have come out of Covid-19, we are launched into the middle of a war and there is uncertainty about climate and the future for young people. There is an awful lot going on in young people's lives that I certainly hear about. As a Green Party member I certainly hear about the climate issue. All of us are aware that sense of security has been taken from under people. I see it with the young people I know. It is not just one issue, it is the fact that you never know what is around the corner. I do not think that it has to do with one issue or another, it is just the complete lack of security now in people's lives and things are moving so fast. That inevitably is going to bring more challenges. Where people may have felt we had come out of Covid-19 and will deal with the consequences, we will probably see more challenges going forward. Will the witnesses share any thoughts they have on that?
The other thing is, from the point of view of our work, at the end of these processes we come up with a set of recommendations based on witnesses' testimonies. It seems quite clear that recommendations about a systematic approach or process that works everywhere is what is needed, and that it is not about an individual who is overworked saying they must phone Jigsaw to see how they can work together. Do the witnesses have recommendations that would work for each of them? Should it be something outside of them that would pull everything together?
Ms Trish Murphy:
Mr. Smyth mentioned benchmarking to international best practice for counselling services that covers nine areas. It is everything from one-to-one, using local services, peer support and many different aspects. If we want to reach international best practice, looking at it systemically is exactly what we will be doing. We are well-placed to do that. Many systems are in place to do that now, if we could simply get time to model it and extra funding to get ourselves more time to model it.
Dr. Joseph Duffy:
The real point is thinking about the young person at the centre and what is going to work for a young person. It sounds very simple but it often gets completely lost because we end up in terms of ratios or looking at particular funding paradigms. It is about trying to think what will make sense for a particular young person and what are his or her needs. Their needs are going to vary. As Mr. Smyth and others were saying in regard to looking at services, when we think about our particular relationship around an SLA with the HSE or with particular funders it is about whether there is criteria for how it operates and how it works in a programmatic way with other agencies. That is useful in terms of looking at it. Rather than people doing it as a tick-box, there needs to be a qualitative piece for that in terms of how it leads to improving the lives of young people.
Dr. Joseph Duffy:
It certainly is. In regard to social media, news is now 24 hours. Some of us will remember when news was only on at certain times and that is where you got it and you had to tune into it. None of that is filtered now. It is always available. There is much more reliance on young people to manage themselves whereas society, news and everything else was managed in a particular way and there was a certain rhythm to it. People are very concerned in terms of thinking about are even the seasons gone, how do we know about that, or have borders gone. We are trying to think about where the young person gets a sense of security in themselves. That begins very early on and we know that from psychological theory. How do we embed and support that? As a society, things that are really important are the child-parent relationship, the relationship with the community and the importance of team, sports and connection around the environment. How are we prizing these things? Are we just prizing getting a first in your degree? What do we want as a society, as a country, as Ireland?
I have one final point. The committee on a number of occasions had engagement in particular around bullying in schools. Senator O'Reilly referred to the report we produced, which recommended that every school would have access to emotional supports and counselling. We are talking here about third level education but building on Senator O'Reilly's first question, sometimes at third level we see the impact of bullying that was not addressed or a situation where a young person has not been helped or supported. Dr. Duffy spoke earlier about the fact that around 17 is the age when young people start to demonstrate their mental health challenges. I have been working with a group led by Shona Brady who put much work into this. We feel strongly about this as a committee. That is bearing in mind the issues that Mr. Smyth raised about educational psychologists as well and the challenges that are there. What does Mr. Smyth think about something like that being put in place? I take on board what Ms Murphy said earlier about addressing bullying. Has anybody a comment on that?
Mr. Mark Smyth:
It feeds into a couple of conversations we have had about anxiety and what are the contributors. There are indeed those higher level pieces about Covid-19 and Ukraine etc. However, for me working with teenagers, and it touches on what Mr. Ryan said, the main anxiety they have is relational: am I good enough, do I fit in, do I have friends, do I have family. They are the main things they worry about. Obviously bullying is one of those things that directly impedes that because the impact of bullying behaviour is “you are not good enough”. Many people already inherently have that sense of “I am not good enough” and bullying reinforces that. I think Dr. Morning is right about that age of 17 being the time when significant mental health challenges arise. What I see is similar to what Dr. Morning said on transitions. At 13 years old young people moving from a primary school where they are relatively well protected. There is one teacher and there is predictability. In secondary education young people have 11 teachers, different classrooms and they are the youngest again and the question is how to fit in. There are different rules and different expectations of what is good enough. We see the early impacts of exclusion, bullying and not fitting in at 13 years old later on when they get to 14, 15, 16 and 17 years old. It is coming back to those pieces. We need counselling supports when those things have happened but we also need to prevent them.
We have talked an awful lot about firefighting and responding when the impact has happened but we need to do our best to eliminate it as best we can, to identify it and not to be afraid to have conversations, for schools to feel empowered to have those conversations and not worry about how this will reflect on them as a school or as a teaching environment so that everybody can have open conversations. We need a bit of both. It is both preventative but also being supportive. It still comes back to relations and what Jigsaw says – I have quoted Jigsaw for many years – about the importance of one good adult. Much of the work I do is actually not just about what I do with that young person, it is who can I support around them, who is the adult who can be there on Friday at 8 p.m. when the young person feels lonely because nobody has asked him or her out, or on Sunday evening before school. They are far more effective. If we support the families and carers about managing anxiety in the environment and in the moment when it happens we will have a far more effective approach than sitting with me for an hour in a room.
Dr. Joseph Morning:
It is very important to note that around age 17 is when you see these more obvious manifestations of mental health difficulties. Much of the time they are preceded by subclinical forms or warning signs as these conditions begin to develop. We know from research that things such as adverse childhood experience, which would cover things such as bullying, increase one’s risk. When talking about having universal preventative approaches that kind of focus on social aspects like within the family and so on, more targeted preventative and early intervention approaches can identify those who are at increased because of previous experience; that can be a very important piece of the puzzle.
We have had a very productive committee meeting. I thank all of the witnesses for their insights and experience. We ask them to please collaborate further. I can totally appreciate that balance because we all have to juggle every day deciding what is more important. Most certainly, this is an opportunity to work together. I can even see the synergy today between everyone, in terms of picking up different issues and where all the witnesses work. We all have the same endgame, which is to support our young people at every level, but in this case, in third level. In addition, we try to prevent situations where they are presenting with mental health challenges. Life is stressful enough as it is, without all of the challenges that the past few years have thrown at us. I thank Deputies and Senators as well.
The meeting is now adjourned.