Oireachtas Joint and Select Committees
Tuesday, 9 May 2023
Joint Committee On Health
Life Cycle Approach to Mental Health: Discussion (Resumed)
Frances Black (Independent)
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Minutes of committee's meeting on 18 April have been circulated to members for consideration. Are they agreed? Agreed.
The purpose of this meeting is to consider the life cycle approach to mental health, particularly in the context of younger people. To enable the sub-committee to consider this matter, I welcome Dr. Joseph Duffy, CEO; Mr. Declan Whelan-Curtin, youth mental health promotion manager; and Mr. Conor Boksberger, regional clinical manager, Jigsaw; and Ms Sarah Hughes, mental health programme manager, Union of Students in Ireland.
All present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.
Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any other person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of a person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.
Members are reminded 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. Parliamentary privilege is considered to apply to the utterances of members participating online in the committee meeting when their participation is from within the parliamentary precincts. There can be no assurances in relation to participation online from outside the parliamentary precincts. Members should be mindful of this when they are contributing.
Members are also reminded of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members participating via MS Teams to confirm that they are on the grounds of the Leinster House campus prior to making a contribution to the meeting.
To commence our discussion, I invite Dr. Duffy to make his opening remarks on behalf of Jigsaw.
Dr. Joseph Duffy:
I thank the Chair and members for the opportunity to contribute to and support the committee's important work in the area of mental health. Jigsaw was established as a charity in 2006. Over the past 17 years, we have gained a track record of achieving better mental health outcomes for young people and developing supportive communities by providing a range of primary care services and supports. Throughout this time, we have been able to support over 60,000 young people. This has been achieved through a range of direct one-to-one mental health interventions as well as indirectly by developing and rolling out innovative and effective solutions for young people and those around them in settings where they live, learn, work and play. With the support of public and private funds, and particularly the HSE, our current model sees us deliver a range of free primary care mental health services and supports to young people and adults, including delivering one-to-one services across 14 sites around the country; offering community-based programmes aimed at better informing, supporting, educating and empowering young people and those around them; undertaking pioneering research; and providing a wide range of online mental health supports through jigsaw.ie. We also have a comprehensive post-primary schools programme, One Good School, which is being rolled out with 147 schools across the country. There is an online schools hub that provides information on well-being and support and comprehensive information for all school staff. We also have a specific team that focuses on supporting mental health and well-being in further education and training, FET, and higher education settings.
Ireland’s youth mental health system is increasingly under pressure. It is overstretched, underresourced and, in large parts, inadequate. Demand continues to outstrip the system’s ability to cope. Funding, overall, is insufficient and integrated joined-up thinking remains an aspiration in many areas. Yet, behind a discourse that is increasingly dominated by demand, systems and integration, there are young people struggling to cope and parents left to shoulder much pain. Ultimately, something has to change. We know from the My World Survey 2, which Jigsaw conducted in conjunction with UCD, that there has been a significant increase in the levels of anxiety and depression among young people in Ireland over the past decade. While Covid-19 has contributed significantly to a deterioration in young people’s mental health, long before Covid the indicators were not good. Internationally, we see from large-scale studies increasing mental health difficulties among young people. At Jigsaw, we have experienced this first hand, with more and more young people seeking the services and supports we offer across the country. Last year alone, we had over 8,500 referrals for young people, the second highest number of referrals we have ever had in a single year. Over 36,000 individual appointments were offered to young people. Online, we provided nearly 1,500 live chats, which are anonymous supports for young people. Over 32,000 people participated in workshops and training. I previously mentioned our One Good School programme. Last year, significantly, there were nearly 20,000 users of our online schools hub, which has provided support across a lot of schools.
Many of our services continue to experience significant demand, resulting in the time between first contact and first appointment in Jigsaw services remaining too long. This is particularly concerning as we aim to provide early intervention services for young people. While we are encouraged to see that Jigsaw is recognised as a high-quality, youth-friendly and impactful service, and that young people are continuing to reach out for support, we are aware that much more needs to be done.
We are making five key recommendations to support the better development of youth mental health.
We firmly believe the current funding model must change. As members are aware, funding for mental health in Ireland is just over 5% of the total health budget. This compares with a Sláintecare recommendation of 10%. There is higher funding for mental health throughout the European community.
We must prioritise community-based primary care services and supports that are preventive and early interventionist in approach. This is very much in line with the Sharing the Vision policy. Much more attention should be paid at funding level to support this area. We must listen to young people. With a recognised and established history of youth engagement and participation, Jigsaw is aware of young people’s ability and right to be involved in the decision-making that supports them. This needs to be further extended across all areas of policy development on youth mental health. We also need to develop a workforce strategy. As a country, we simply do not have enough mental health professionals to deliver vital care. A shortage of trained mental health professionals, not only in Jigsaw but in the wider mental health services, continues to stretch the limited resources that we have.
We must strive for better integration of services that support young people’s mental health and offer smoother care pathways in the mental health and social care arenas. We believe increased shared ownership, leadership and accountability need to be in place throughout the voluntary and statutory services as a matter of urgency. As such, we must accelerate the appointment of a director of mental health services in the HSE to lead reform of our mental health system of care. While we welcome the recent recruitment of a youth mental health lead, a director of mental health services will ensure increased accountability, better integration of services, a strong strategic focus and, ultimately, will ensure better mental health outcomes for all young people. In line with this integration, and in line with Sharing the Vision, areas of immediate focus should include addressing how interagency referrals are made and managed, the funding model, data-sharing across services, the extension of the age range in the child and adolescent mental health services, CAMHS, from those aged between 12 and 18 to those aged between 12 and 25, as included in Sharing the Vision, and a more consistent application of the referral guidelines.
While much remains unpredictable, what is clear to us in Jigsaw is that increased investment, improved integration and strong political will are now needed if we are to make a meaningful difference to the mental health and well-being of Ireland’s young people, and to give them the best possible chance at a full and healthy future. At Jigsaw, we understand that the solutions are not always easy. However, we are adopting a wide range of strategies to improve efficiency, maximise clinical activity and enhance the timeliness of our services.
Our work outside the session room is also very important. Prevention and intervention must go hand in hand. As such, we are investing in our digital offerings and we are seeing a significant appetite for these. We continue to support communities to promote positive well-being with a range of offerings, including One Good School, One Good Club, Jigsaw hubs and more. In short, we are actively seeking solutions. State investment in this area is now required. The young people of today are our future professionals, parents and politicians, and our One Good Adults, who, in turn, can go on to support the mental health of future generations of young people. I thank members for this opportunity and I look forward to their comments and questions.
Ms Sarah Hughes:
The Union of Students in Ireland, USI, welcomes this opportunity to make a submission to the sub-committee on mental health and thanks it for this opportunity. USI is the national representative body for the 374,000 third-level students on the island of Ireland. USI liaises with its member organisations on campuses and has 21 welfare officers working on student mental health issues at local level. USI also liaises with other partners, agencies and NGOs on student mental health issues. USI is a member of the Higher Education Authority, HEA, Connecting for Life working group focused on suicide prevention and mental health in third level and was involved in the creation of the national student mental health and suicide prevention framework.
Students who are treated by on-campus counselling are largely treated by members of Psychological Counsellors in Higher Education Ireland, PCHEI, which is the largest provider of psychological services to young adults in Ireland. In the academic year 2020-21, just over 245,000 people were registered as students in higher education. In the same academic year, PCHEI members saw just under 15,000 students across 69,000 appointments. International research shows that 35% of students screen positive for at least one of the common lifetime mental disorders. As a result, while our expertise in USI comes from a student perspective, it allows us to speak to the broader implications of a life-span approach on those in the late adolescent and early adulthood age groups.
We know that mental health as a concept is a fluid state that varies through life and is impacted from a biological, psychological and social perspective.
In recent years, global approaches to mental health have moved away from a strictly biological approach as a result of better understanding of the interplay of these three elements. We also know that people do not stop developing or changing when they reach adulthood, and we know that childhood experiences, such as adverse childhood events, ACEs, can impact later in life. Taking a lifespan approach to mental health allows us to take account of all of those pieces of knowledge in a coherent way. It allows us to view the person as a whole being, in the context of their life and their experiences, not just as a diagnostic label based on a symptomatic presentation at a singular point in time.
A look at developmental theory tells us that the lifespan can be divided into stages, and defined by certain challenges. Meeting these challenges is thought to enhance mental health in later stages, and meeting the challenges of one life stage is in part dependent on how successfully previous stages were managed. There is some debate about the specifics of the challenges of each stage based on individual and cultural differences, but broadly, the stages of young adulthood include separation from parents; establishment of identity; critical education and vocational decision-making; negotiation of change in peer group affiliations; intimate relationship formation; and preparation to leave or leaving home.
The life stage of young adulthood is considered to be a critical developmental period regarding social and emotional wellbeing due to the many major changes which tend to occur simultaneously during this stage. As a result, processes that occur during this phase of life have a major long-term influence on the individual, and the onset of even relatively mild mental health problems can have profound and long-lasting effects.
In particular, health-related behaviours developed as young adults, when they are navigating the help-seeking process independently for the first time, and often having to transition to new adult-based services, have a major impact on later adulthood. This is important, as many first episodes of mental disorders, in particular depression, anxiety disorders, psychosis, eating disorders and substance abuse disorders have peak incidence rates during late adolescence and young adulthood. Overall, mental health disorders account for 55% of the disease burden in people aged 15 to 24. However, we know that around a third of students who had not sought any help on or off campus for their mental health have severe to extremely severe stress, anxiety and depression levels.
As an example, suicidal behaviours are more rare in younger children, but become more common in young adulthood. Childhood experiences can play a role in those suicidal behaviours. This means that active intervention should be mainly aimed at the older group, but that early intervention and prevention should take place at a younger age. Similarly, substance use disorders peak in early adulthood, but incidence rates decline thereafter. This makes young adulthood a key time for prevention work in this area.
In some areas we are becoming better at taking a wider-angled lens to mental health. For example, the student mental health and suicide prevention framework not only emphasises a whole-of-campus approach, but the framework itself came about from a collaboration between organisational partners in the areas of education, health and mental health. The recent roll-out of the Togetherall programme was also enabled by partnership between HSE mental health and the Department of Further and Higher Education, Research, Innovation and Science.
One of the major changes in Sharing the Vision involves moving the age of transition from child and adolescent mental health services, CAMHS to adult mental health services up to 25. This is based on research which suggests that brain development is in fact not complete until the mid-20s, and due to so many young people falling through the cracks of the system as a result of that transition happening at a time of so much other change within their lives. How services will be resourced and provided for remains a worry because while young adults may still be developing, they require different assessment and treatment approaches to children.
While in a practical sense we have moved on from Covid-19, from a mental health sense we are just beginning to process the fallout from the pandemic. Most students currently in higher education were in second level education for at least some of the pandemic, and many of them transitioned from childhood into adulthood during that time. As a result, the process of beginning to meet the challenges outlined above for this life stage was disrupted for many people, and the impact of that may not be seen until those individuals enter later life stages. This is just one example of the importance of understanding mental health from a lifespan perspective, as while these young people may not currently have tangible grief or trauma associated with the pandemic in an obvious way, that is not to say that there is no impact. This is from both mental health and developmental perspectives, and it also demonstrates the interconnected nature of the two.
Viewing mental health from a lifespan approach involves viewing the person based on a holistic view of their life, and what that means for how they are presenting in the current moment. This is beneficial, because it can help to inform prevention and treatment and help us, as a country, to move away from a reliance on crisis intervention, and thus have better outcomes for people. However, it also means that mental health cannot just be under the remit of health, and that student mental health cannot just be under the remit of higher education as it is currently.
It means things like housing must be considered as a factor in mental illness and housing provision must be considered part of mental health treatment. It means supporting young people’s mental health from the moment they are born, not just waiting until they present at an emergency department with self-harm and suicidal ideation. It means addressing issues such as screening, automatically including counselling during times such as physical illness or family financial trouble and not waiting for people and families to self-present. It means understanding that what happens at any point in a person’s life can impact his or her mental health, not just in that moment but into the future. Even if someone does not present in distress immediately after an adverse event, it means that person should have in-reach services and prevention models used with his or her. That means better resources, continual and sustainable funding and better interagency working. It means giving mental health from birth until death a priority slot on the list for funding, staffing, research and education. It means not further impacting individuals' mental health by refusing them services because their condition is not severe enough or the waiting list is too long.
Mark Ward (Dublin Mid West, Sinn Fein)
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I thank all the witnesses for the work they are doing in youth mental health. It is valuable and important. I will not use the language I was going to use but I am getting tired listening to myself talking about problems all the time. That is what I seem to be doing in the Dáil. I can call out waiting lists for services for young people left, right and centre but I would rather start focusing on solutions. That is something we need to do. We need to start focusing on improvements in young people’s mental healthcare.
I find Jigsaw’s recommendation No. 5 interesting as it is an area I have always seen as a problem. We must strive for better integration of services. Sometimes services are not having a conversation with each other. There is no integration or referrable pathways. How can we improve integration of existing services such as Jigsaw, CAMHS, primary care, general practice, community disability network teams and youth services?
Dr. Joseph Duffy:
It is about going at it from a number of angles. Much of Jigsaw’s relationship with GPs is through written connections. We are developing a data management system that will link directly with the GPs’ referral system. That is one proper way to connect services.
We have a connection with about half of the CAMHS teams in the country, and a really good relationship with half of those. That is based on personal relationships with the staff on the ground and in the CAMHS team. We do great work with them. What has to change is how that is encouraged, not just on a ground level but on a regional and national level. The struggle we have in Jigsaw is our community-based services are heavily supported by the HSE. That is State money. The CAMHS services are supported by the HSE but the sense is they are regarded as being separate and one must refer through a formal process to the other.
It is about having a sense of integration and also how we share data. Where we have managed to do that in communities, it has been through a group of professionals getting together - there is a really good example in the work we did in Donegal - and setting out a memorandum of understanding concerning how data will be shared. It is almost like a case management meeting but without getting into too much detail, and also talking about how the services can provide support. A GP, for example, may decide to refer to Jigsaw, CAMHS, a private counsellor or a whole range of people because he or she wants to get the most instant support possible. We have done significant work helping GPs to understand that Jigsaw works in one area but not in other places. That gives a better sense as, I hope, will the new role the HSE is creating. It is about having an agreed commitment to look at that integration.
Mark Ward (Dublin Mid West, Sinn Fein)
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Would that be a model of care providing for referral pathways for people from one service to another? Young people could be involved in a number of services. A number of people are involved with the community disability network teams but also with CAMHS and the likes of the witnesses’ organisations. Would that mean more communications between different groups and organisations involved in a young person's care?
Mr. Conor Boksberger:
There is something about specific care planning for individual young people, which means ensuring that people have an individualised plan, it is not one-size-fits-all, services are not working in silos or at cross-purposes, everyone has awareness and there is open communication with clear and transparent consent.
We should ensure that when a young person who might be engaging with a range of services comes in, those services are working together to meet the individual needs and are not doubling up, duplicating and creating gaps in the services. If there is a need for transition between services, that should happen seamlessly and without fall-offs when they finish with one service and have to wait for another service. We can bridge those gaps. We have plenty of examples of good individual cases in different communities of services working well together. Something a bit more consistent across the country is needed, which can draw from-----
Mark Ward (Dublin Mid West, Sinn Fein)
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We need to move away from this personal relationship kind of system. We all build them up. I have personal relationships with people in different agencies whom I know I can pick up a phone and call. A model of care or something needs to be there. It is not that personal relationships are unimportant, but we should not rely on a personal relationship for a child to get care because they are not always around.
Mr. Conor Boksberger:
They should not. I come from working in community spaces in local services. There is a variance in relationships I have held with other clinical leads in statutory services. There have been some good examples but it has been driven by the leads of the services and they have been quite nuanced. While we have documents such as the standard operating guidelines, which is useful, how they are interpreted and used can vary from community to community. We need to make sure that there is consistency in approach, that we are learning from where it is happening well and, as the Deputy said, that it is less dependent on individuals to make it happen.
Mark Ward (Dublin Mid West, Sinn Fein)
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I will ask a parochial question. I was involved in the campaign in north Clondalkin when Jigsaw moved to Tallaght. It caused much concern in that area. Jigsaw was in the area because there were many youth suicides there. It was the children of many people with whom I grew up. It was a very emotional time for people. At the time, there was a commitment that Jigsaw would come back in to north Clondalkin and provide that service. Where is that service at the moment?
Dr. Joseph Duffy:
I am pleased to let the Deputy know that a couple of weeks ago we were able to open the outreach service in Clondalkin. We had plans to do that pre-Covid, as the Deputy will be aware, but were not able to do it during that time. We are there for one day a week now and that will build up to two days a week, depending on need. We are finding that young people are coming for their initial assessment, continuing to do some work by video and they might then come back again and have a follow-on assessment. We are able to provide that outreach. We are also able to provide outside of just the Dublin south-west area; we are able to do that in counties Laois and Offaly and across the country in some other areas as well.
Mark Ward (Dublin Mid West, Sinn Fein)
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That is welcome. I thank Dr. Duffy.
I will move on. Both Jigsaw and USI representatives might be able to answer this question because both mentioned Sharing the Vision and extending CAMHS to people up to the age of 25. In the recent reports from the Mental Health Commission, we saw there was what was called a cliff edge, where young people lost follow-ups. At the age of 18, they went to adult services and there was seen to be a loss of follow-ups on the young people, who were not getting the same care that they needed. USI’s opening statement mentioned that brain development is not complete until the mid-20s. The evidence is there. I know Jigsaw mentioned it as well in relation to the Sharing the Vision recommendation and the extension of CAMHS from 12 to 18 years to 12 to 25 years. What are our guests’ thoughts on that? How can we best help them have that? My party and I have been pushing a long time for the Government to follow up on that commitment of Sharing the Vision and increase CAMHS to age 25.
Ms Sarah Hughes:
From a USI perspective, we welcome the move up to 25 years old. Looking at the age most people move into higher education, it is 17, 18 or 19. Many of them do not just move from second level to third level education; many of them are moving around the country. Therefore, the local service that they might have been accessing for their mental health care is no longer their local service, even if they were transitioning to adult services. They were transitioning both area and service previously. That was one of the factors that made so many fall through the cracks and put a lot of pressure on on-campus services. In higher education, psychiatry is not available on most campuses; there is psychology, counselling, disability services and that kind of thing, but not psychiatric help. We would welcome that move. Again, there is a concern. We are all well aware of the length of the waiting lists for CAMHS. If a group of people from the adult waiting list are being moved to the child and adolescent waiting list, how long is it before that gap in service provision grows for those young people?
They have been receiving the care and are now going back to the end of the queue.
Mark Ward (Dublin Mid West, Sinn Fein)
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We are talking here about adequately resourcing and training for the services. Dr. Duffy wishes to contribute on that.
Dr. Joseph Duffy:
We would very much welcome that. It is important to note so that people are aware of it that CAMHS is a specialist service. We are talking about young people who are within a CAMHS service and if they need to receive continued support, that is very important because the mental health problems they are showing and for which they need support are at the more severe end. If the age limit is moved, and it would be excellent if it was, it will involve a significant amount of retraining, particularly for psychiatrists because the other mental health professionals are trained across the lifespan. That is why it works well within Jigsaw.
Within the primary care setting and within Jigsaw we have the 12 to 25 age group. When we align that with CAMHS I believe we will see much better value for money and greater satisfaction for young people but also specialist focused care for those young people who most need it. As has been said, we know that 75% of mental health problems occur for young people before the age of 18. That is, therefore, a critical time to support them. For the committee, it should continue to apply political pressure to ensure this is implemented in a timely way.
One of the things that has concerned me over the past 18 months, during which there has been considerable and appropriate focus on CAMHS, is that CAMHS has become synonymous with youth mental health. We need to move the lens back out and to ask what we are looking at in respect of the whole system. Are we looking upstream at early intervention and prevention and can we then think about supporting those areas before young people end up in CAMHS? When we speak to CAMHS colleagues they say they are overwhelmed. There is a general feeling now that parents are becoming greatly dissatisfied when they are told their child is not suitable for CAMHS. They see that as something of a disappointment or as their expectations not being met. In many ways, however, their child's presenting issues are not actually suitable for CAMHS and they need support much earlier on. The difficulty is that we know that pre-pandemic the Holy Grail on psychotherapy was a one-to-one individual session. It is now seen that CAMHS is the Holy Grail and everybody must go to CAMHS. I am appealing for a broader conversation and to pull the lens back out a bit to say there are lots of supports available and CAMHS is only for some people.
Mark Ward (Dublin Mid West, Sinn Fein)
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If that early intervention piece was in place - early intervention psychosis and primary care - fewer young people would be looking for assistance from CAMHS for their mental health needs. That would then take pressure off CAMHS, which would be a win-win situation.
Neasa Hourigan (Dublin Central, Green Party)
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I welcome everyone to the meeting. I will stick with some of the issues just discussed. The committee has been discussing the Sharing the Vision policy and its implementation, as well as the document published last year by the Minister of State, Deputy Butler. On the transition age moving from 18 to 25, that is a good indicator of how much integration we are actually seeing. We were advised that we had youth mental health transition teams in place under the national implementation and monitoring committee, NIMC. I have a fairly open-ended question on that. How much outreach have NGOs, such as those represented here, experienced from that central body? I will use the example of moving the transition age from 18 to 25 years because that is a big change.
Dr. Joseph Duffy:
At this stage, we are still involved in consultation and some of the planning but much of it rests with individual relationships. It is around that sense of waiting for some structural change to happen. What has been very useful recently is that people are learning a great deal from Jigsaw. People ask how young people aged 12 could be in the same waiting room as young people aged 25? There are, however, many different ways to manage that and think about it. There is a real openness and willingness there and we are seeing that this is beginning to shift and change. People are identifying key areas that can be targeted, such as learning from international practice in Australia, thinking about the training of psychiatrists, and the upskilling and development of particular teams. It is happening but it is very slow.
Neasa Hourigan (Dublin Central, Green Party)
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Is Dr. Duffy comfortable saying that the transition from 18 years to the cohort of 25-year-olds is happening on the ground right now? I am asking in the context of a document we are looking at which is from 2022 to 2024.
That recommendation was meant to be a short-term one. In the context of a two-year window, to me, the short term is six to eight months. To some degree, the witnesses are at one remove from the decision-making process. Are they confident that is actually happening? Is it their perception that it is?
Ms Sarah Hughes:
The USI does not directly provide services so it is not something we would see or not see. Mental health services for students are mainly provided for under the Department of Further and Higher Education, Research, Innovation and Science rather than the HSE. I suspect it would be at a further remove again.
Neasa Hourigan (Dublin Central, Green Party)
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I do not want to paraphrase Ms Hughes but is her answer that she is not aware or could not say for sure whether it is happening?
Neasa Hourigan (Dublin Central, Green Party)
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With regard to integration and services not working in a silo, it would be concerning if this was a short-term goal or recommendation that should have been addressed ten months ago. Is that overly critical of me to say?
Dr. Joseph Duffy:
We know there is a lot of talking about it and a lot of planning around it. The question is how much can happen immediately. Some of the things I would like to see more immediately include the standard operating guidelines, which have been mentioned, being accepted, particularly with regard to NGOs such as Jigsaw. What does that mean in practice? If a young person comes to Jigsaw, we may believe his or her issues would be more supported in CAMHS. For half of the CAMHS teams we deal with, we can write a letter, that letter will be accepted, the young person will be seen and the team will take our assessment. However, the other half will say that we need to bring the young person back to a GP, get that GP to write a referral and bring the young person back through that process.
Neasa Hourigan (Dublin Central, Green Party)
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These teams do not accept Jigsaw's recommendations.
Neasa Hourigan (Dublin Central, Green Party)
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Within the document the Minister of State, Deputy Butler, issued or published, youth advocacy services funded by the State, such as Jigsaw, are highlighted as supporting partners in the recommendations. How can we advocate on Jigsaw's behalf for its recommendations to be taken seriously by every team within the CAMHS system?
Neasa Hourigan (Dublin Central, Green Party)
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Is that happening because of some kind of capacity issue within the system in particular regions or does it simply come back to the issue of personal relationships?
Mr. Conor Boksberger:
They are interlinked. Personal relationships and capacity within individual services are both required. To manage transitions in the best possible way, the resource within a team is needed. What we hear from individual teams at local level is that they are stretched to even do what needs to be done from day to day well enough and to keep things running. Things like transitions can feel like an extra burden. Teams might be dealing with crises every day and may feel that is where their attention needs to be. There is a resourcing issue and we would see much more coherent development with regard to transition if the whole system was better resourced. If there was more staffing and resources in local services, it would be much easier to-----
Neasa Hourigan (Dublin Central, Green Party)
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To have the time and space to make those connections with people.
Neasa Hourigan (Dublin Central, Green Party)
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I will follow up on a couple more-----
Ms Sarah Hughes:
May I make a point on that issue? It speaks to the Deputy's idea regarding the timeframe for and feasibility of this kind of thing. We recently saw that counselling psychology training was to be funded for the first time, which is a major milestone in moving this forward. However, it will be three to four years before those trainees come through on the ground. On the question of matching that sort of timeline to the sort of timeline the Deputy is referring to, that sums up the kinds of issues being faced with regard to resourcing.
Neasa Hourigan (Dublin Central, Green Party)
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That is a good point although it is the Minister of State's timeline rather than mine. It is important to make that distinction. I will follow up on a couple more of those recommendations, specifically those in which NGOs are cited as partners. On the out-of-hours response for children and adolescents in every single geographical area, has there been outreach to the witnesses' organisations? I imagine this is particularly difficult in the higher education space because, while we actually have pretty good coverage at third level, it is a cohort that moves around a lot.
Neasa Hourigan (Dublin Central, Green Party)
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Everything is out of hours under Jigsaw's service. No specific hours are applied.
Neasa Hourigan (Dublin Central, Green Party)
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Programmes have been beefed up in recent years as conduits for better services. For example, Healthy Ireland has received considerably more funding. NGOs are cited as partner organisations, though. Is that happening? What is the relationship between Jigsaw and Healthy Ireland?
Mr. Declan Whelan-Curtin:
Yes. Jigsaw's health promotion arm works specifically with groups like the HEA as key stakeholders in implementing our health promotion programmes throughout the country. We work with the USI and other agencies to ensure that our health promotion programmes are policy informed. Healthy Ireland is a good example of that, as is the HEA's mental health, well-being and suicide prevention framework. These policies and frameworks guide our work when we design, develop and implement health promotion programmes, which we then roll out nationally.
Neasa Hourigan (Dublin Central, Green Party)
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That sounds more like leadership, with Jigsaw taking those policies as templates. That sounded more pejorative than I meant it. Healthy Ireland is not a partner for Jigsaw in any of the latter's programmes.
Mr. Declan Whelan-Curtin:
We would consider Healthy Ireland a key stakeholder and we work closely with the HEA on alignment with our programmes. Ultimately, health promotion is focused on implementation and action. As such, it is appropriate for Healthy Ireland to act as a framework for us to follow.
Neasa Hourigan (Dublin Central, Green Party)
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Recommendations in the 2022 document overlap significantly with Jigsaw's work, for example, the well-being promotion process, but that is 100% owned by the Department of Education. Where something is owned by the HSE or the Department of Health, I imagine that there are relationships, but the Department of Education might be another step again for Jigsaw, albeit not for the USI. How do the witnesses' organisations approach integration in that sense?
Ms Sarah Hughes:
The USI probably has an easier job than others. Within the HEA, there is a subsection of Healthy Ireland called Healthy Campuses. Healthy campus charters are being rolled out on campuses nationwide, to which the national mental health and suicide prevention framework is linked, and there is a specific staff member within the HEA whom we work closely with in that respect. All of our funding and so forth in that regard comes through the Department of Further and Higher Education, Research, Innovation and Science and the HEA. I mentioned the great Connecting for Life working group, which brings stakeholders together from the HSE and the Department of Education and has proven fruitful in recent years.
Dr. Joseph Duffy:
There are two levels for Jigsaw. As Ms Hughes mentioned, there is a series of working groups. Listening to us, the Deputy might believe they are just talking shops, but they are actually practical and help to implement well-thought-through strategies properly. This is useful. There has been much more openness in the past five years in bringing everyone around the table. That is positive.
On another level, we develop a fair number of relationships with other Departments, for example, the Departments of Education and Children, Equality, Disability, Integration and Youth, even if only to share our work. Much of our work that is not one-to-one based in the community is funded through fund-raising or philanthropy. In that vein, we speak to the Department of Education about the One Good School project, for example, and how that can be integrated and connected. We do that at the highest level in the Department. More regionally, we work positively with NEPS and others within the communities. There is an openness in that regard now that we have good structured national policy platforms and frameworks from which to draw.
However, I would make a point that applies to many of them. While Sharing the Vision, for example, is a ten-year plan, it is still in its first quarter. I hope Deputy Hourigan will see the further development of it in the next while.
Neasa Hourigan (Dublin Central, Green Party)
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I have a question for Jigsaw specifically. Its opening statement referred to accountability across services in both the voluntary and statutory sectors. Could Jigsaw elaborate on what that might mean? Are we collecting, collating and making available sufficient data on this whole sector for the use of Jigsaw and for its policy development?
Dr. Joseph Duffy:
As there is no one dataset, we are not making the best use of the data. Accountability starts with thinking about the best care needed for the young person at the centre. Rather than somebody saying it is above their pay grade or it is not part of the service they provide, what we model within Jigsaw is that when somebody - a parent, a teacher or anybody else - calls us, it is great if we can bring the young person into our service; but if not, we will have a clinician call them back. Mr. Boksberger might want to comment on this. Many parents are relieved to have a conversation on the phone for 20 minutes or more. We are probably saying to them that Jigsaw is not for them but another service might be for them. Our sense of accountability means that somebody is just not left hanging and that they know where to go. There is a sense of how we manage that in a more central way. That comes from some of the work of Sharing the Vision. We think about how in order to integrate, there must be a central repository, particularly for senior clinicians who will be at the end of a phone line to be able to respond to a parent and maybe take some of the heat from a conversation.
Mr. Conor Boksberger:
It is such a valuable piece. It is not something we have huge metrics for. It is an often underappreciated piece of work that happens at the fringe of our core business but it is so important. Having been on the other end of the phone with countless parents over the last nine years in Jigsaw, I know that a person does not have to know anything about mental health services until the moment their child is in crisis or in distress. At that point, everyone is frightened and scared and nobody knows where to turn. They know about CAMHS services because everyone has heard enough about them but people do not know where else to go. We often meet parents at that point. As Dr. Duffy mentioned, that is when Jigsaw redirects parents to clinicians who have the expertise around different types and levels of support, such as community-based care, or primary, secondary or tertiary levels of care. We can work with the parent, firstly to help to bring them down so they can be an effective resource for the young person in that moment, and secondly to help them to know where to go and how to navigate the system. Jigsaw can send a letter to their GP outlining what they have said in a language that can communicate with more medicalised services. We can help the parent to know where they can go to get other types of support in their community. It is happening on the fringes. It would be great to see something more robust and centralised so that there is a place where every parent and young person knows they can go as a first point of call and then be redirected out. It should not just be about CAMHS or Jigsaw - a range of different supports should be tailored to the needs of the young person in that moment. A front door is needed before we can consider what is in the rest of the house. People need to know where to go first.
Neasa Hourigan (Dublin Central, Green Party)
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I have heard this described in addiction services as a "no wrong door" approach. No matter who someone asks first, that person sends them to the next person. No wrong door seems to be a good operating principle.
I have a question for the USI on the addiction and substance abuse issue. I imagine that in the cohort the USI deals with, there is a higher level of addiction or substance difficulties. Could it outline how it is dealing with the issue of dual diagnosis, which is discussed a lot at the committee? Are there supports or planned supports for a particular cohort who might need those supports, such as people with disabilities, Traveller groups, or whoever they may be?
Ms Sarah Hughes:
Absolutely. One of the things we see is an increase not just in substance use but also in the struggle to manage substance use. Students who came of age during the pandemic and during lockdown are now that little bit older when trying substances for the first time and are doing so in different environments with different levels of peer pressure, and that kind of thing.
Within the student mental health services on campus we would not have capacity to deal with that at all so it would be referral into HSE services or into the wider NGO sector.
Neasa Hourigan (Dublin Central, Green Party)
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What about particular cohorts such as people with disabilities and Travellers?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank everyone for their statements. My first question is about Jigsaw services. When people are seeking intervention, what are they presenting with? I know it is not one size fits all.
Mr. Conor Boksberger:
I can give a sense of our top presenting issues at the moment, which have tended to be fairly typical over the last years. Anxiety is first and foremost, followed by low mood and sleep disturbance. They tend to be the big-ticket items. What we need to get to is what is underneath that, what has led to that presentation of anxiety. That is where we really open up the lived experience of the young person. In Jigsaw we invite a young person in, and often a parent for part of that if the young person is under 18 or even if he or she is over 18 and wants to have a supportive adult there. We find out what has been going on for the young person and try to help them make sense of why they are feeling the way they are feeling at this time. Every young person will have a different story about why that is. There can be some common threads in that. We know we have gone through a very particular point in our history and that is bound to have an impact. However, there are no two narratives that are the same. We can classify them and say that anxiety is a big issue, and the research is telling us that young people are feeling highly anxious and the levels of depression are higher, we know there is a lot more prevalence of suicide and self-harm and things like that. However, what we are really trying to do is get under the surface of what is happening for that young person.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Is there any particular trigger that is a general narrative in situations like this?
Mr. Conor Boksberger:
It really depends on the individual young person. I am mindful of the purpose of this sub-committee. Triggers can often happen at points of transition as well. If we consider the tasks and journey of a young person through that period from the ages of 12 to 25, say, we think about those points of time that require something new or different of the young person. There is the first time I have to sit State exams, the first time I face a relationship break-up, the first time I get excluded by a group of friends, the first time I have to start third level education, or if I do not get to go to third level education. That is before we start to consider young people who have those extra layers of challenge, those who are growing up in marginalised communities, poverty or in unstable housing situations and those who have specific health concerns or other levels of diversity that exclude them further. There is any number of triggers.
Rather than us coming from a very expert level and saying we know what triggers young people's distress, we want to hear from young people about what is happening for them. That is both in the session room and how we approach our therapeutic work but also very much in how we approach our youth participation strategy and engage our youth advocates. I am too far away from it to understand what it is like to be aged 12 to 25 but we have young people who have a voice and want to tell us and want to share their experience. We draw quite a lot from that as well to help us understand what is happening.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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In terms of intervention via drugs, would it be common to prescribe mediation to treat some of the conditions Jigsaw sees?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Yes.
Mr. Conor Boksberger:
Just to place where Jigsaw sits in the landscape, we are a non-medical service. While we have complete appreciation for our colleagues who work in that medical model, it is not the model under which we were set up. It is not how we conceptualise mental health as such or how we view it. Clinically I feel there is a place and we need to be open to any intervention that might work for a young person but what we need to steer away from is an assumption that one size fits all.
Where some young people will and do tell us that they have benefited from carefully prescribed medication, there are other young people who feel it is not for them. Choice is the word that comes to my mind, with regard to how we work collaboratively with young people. We bring our expertise, that is, everyone around the table does, in psychiatry, social work, psychology and all the allied health professionals, but young people are equal partners at that table and are able to say "I hear you, but this is way I want to go with it".
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Correct me if I am wrong, but Jigsaw does not have the remit to prescribe medications.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I have a broad question for Dr. Duffy. Does he see there being a crisis in society with regard to young people's mental health, given all the pressures young people have to endure, especially around social media? It is difficult being young. We were all young and we all had difficulties in some periods of our life. When you get the intervention, it is revolutionary in some ways but these days, there are so many pressures on young people. It is different than it was 20 years ago. Is there a crisis in how young people are treated in society?
Dr. Joseph Duffy:
When I speak to the staff in the services, they talk about the levels of anxiety young people experience. As Mr. Boksberger was saying, when we begin to peel it back and ask them what is behind that, much of it is around the sense of social comparison. They ask "Who am I?" and "How do I fit in?". If we think about it - Ms Hughes mentioned it earlier on - there are normal tasks in adolescence. The reason we have adolescence is that transition from being a child to an adult. People can learn more about the world and get a sense of their identity. There is a real sense for young people now of wanting to know immediately what their identity is, because other groups on Instagram or other social media platforms are gathered by identity. Rather than letting it flow and letting it work itself out, there is a real sense of everything needing to be immediate and that is producing considerable anxiety. There is considerable anxiety around the broader sense of identity. People would have thought about sexual identity, but now it is thought of in a much broader sense. There is constant feedback and the sense, as Mr. Boksberger mentioned earlier on, and experience of being excluded. The other part of it, when we talk to the staff, is they say young parents are finding it difficult with regard to how they parent. How can they parent a child now who is experienced in and used to using technology in a way they are not used to using at all and of which they have no understanding? How do you take some of the heat out of that? How do you say it is normal to go through many different feelings, have many different friendships and not know what you want to do in life? How can we normalise that? There is still considerable pressure in our education system and our expectations with regard to being in school full-time, for people who cannot be, and all sorts of different things.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Does Dr. Duffy recommend any solutions - I know it is difficult - for young people not to be caught up this anxiety bubble? It is very difficult, but in Dr. Duffy's professional opinion, is there anything young people should steer away from? I know it is difficult.
Dr. Joseph Duffy:
It is difficult. It is about trying to think about what sort of a society we want. Are we thinking about the individual? If sports, writing, drama or walking up a hill is his or her thing, that is brilliant. What is that person's thing, or what is his or her thing for now? How are we thinking about the broad education of young people and what messages are we giving? What do we prize? I talk to friends from abroad and they are always quite surprised by the hoo-ha in Ireland around the leaving certificate. Back in my day, all of the points were published in the papers. There is a sense that we almost take national pride in it but that really excludes and puts on an enormous amount of pressure on people. It is about trying to think of the broad messages we want to give and how we help families and communities understand that looking after people's mental health is a normal everyday thing and not something that can just be done in Jigsaw, CAMHS, Pieta House or somewhere else.
Families and communities understand that looking after people's mental health is a normal, everyday thing and not something that can just be done in Jigsaw, CAMHS, Pieta or somewhere else. How we manage some of those messages as a society is part of the bigger conversation.
Mr. Declan Whelan-Curtin:
Could I just add to that? We are focusing a little bit here on triggers and things to avoid but there is a whole body of evidence to support things that young people can do to stay well and to protect their mental health. One of the things that is key and really universal is connectedness and belonging, whether that is online or in a physical environment like a campus, school or workplace. That is something that can be developed and can be really protective for young people. We need to focus not only things that we want young people to avoid that may be harmful to their mental health but also on things that we can promote that may protect them and keep them well.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Would Ms Hughes like to comment?
Ms Sarah Hughes:
Yes, I have a couple of thoughts on that and agree with what Mr. Whelan-Curtin said about connectedness and belonging. Pre-pandemic, USI did some research on student mental health and one of the key findings was that loneliness was a major issue. This was at a time when everybody was still on campus but despite that, there was a very high level of loneliness. We have moved a long way in terms of stigma reduction in this country. The conversation about mental health is national now. We trot out the phrases that "it is okay to be not okay" and that "it is okay to ask for help" but what we are finding, particularly with the student population, is that is accepted at a general level but not at an individual level. There is still a self-stigma going around. When we look at the sense of anxiety, there is a lot of perfectionism involved. People feel the need to get the first and not just pass the exam, to get the best work experience and so on. When all of these factors interplay, people end up with a lot of thoughts going around in their head but they are not really reaching out to anybody. At the same time, they agree that people should definitely talk about their mental health.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Did Ms Hughes say loneliness was one of the main factors?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Was there a reason for that?
Ms Sarah Hughes:
We did not delve into that within the survey but if one looks at the issue of perfectionism, there is a sense of people not wanting to admit to their peers that they are struggling so much. That was an interesting finding because on the flip side, there were a lot of people who wanted more information to build their confidence in how to support a friend. It goes one direction, but not the other direction in that everybody is prepared to help their friends but nobody wants their friends to know that they are suffering themselves.
Neasa Hourigan (Dublin Central, Green Party)
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Can I just ask a quick question around numbers? I was thinking about the numbers given to us earlier. I think Ms Hughes said that 15,000 people had reached out for services. Is that right?
Neasa Hourigan (Dublin Central, Green Party)
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There are 204,000 people in third-level education. I am raising this in the context of us only spending 5% of our health budget on mental health and it should be 10%. We are only at half of the level of funding required. I am under the impression that as a population, approximately 25% have a diagnosable mental health issue. The WHO would say that among the youth, that is around 20% so in the context of those numbers, only 7% or 8% of people actually reach out for services. We would have to more than double our funding to even get close-----
Ms Sarah Hughes:
That figure was for on-campus services only, which is not funded by the HSE at all. The figure of €2 million per year covered all student mental health services. It was not just for direct counselling but also for staff and so on.
Neasa Hourigan (Dublin Central, Green Party)
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This is absolutely not a criticism of Ms Hughes. I am just highlighting how far short the funding falls.
Frances Black (Independent)
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I will follow up now on the Sláintecare recommendations. Dr. Duffy said in his submission that we are far from the goal set in the Sláintecare recommendations of 10% of health spending being ring fenced for mental health. In that context, I ask our guests to outline what they think the priorities for young people's mental health should be in the next budget.
Dr. Joseph Duffy:
Jigsaw would argue that we look at an increased budget to focus on early intervention and prevention. We have a long tradition in Ireland of focusing on acute and chronic care and that is appropriate. We know there will be changes in the regional health areas and the structure of our health system but the larger, physical buildings take up a lot of the money. We also know, in terms of young people, about all the positive work that has been done around providing those supports much earlier on, as Ms Hughes has mentioned in respect of the reduction of stigma. CAMHS supports about 2% of the population. We know from our own research through the My World survey and internationally that about two thirds of young people are doing okay. They need some support, they need support through third level or second level, such as through our One Good School support, providing a mental health promotion angle. Then there are the roughly 35% of young people who need more support and that is where we would get really good value by increasing the budget and putting the money in there and thinking about that group. What we would hope then is that there would be less demand on CAMHS and other services a bit further down the line.
Hand in hand with that is helping people to know not just that the services are there but that it is okay to take them up. I take the point about self-stigma. I was talking to some of the team in one of our services recently and they were saying young people have got the message that they can sit in a group and talk about their mental health if it is in a positive way but actually, if they have low mood, then they get silent and they do not really want to talk about that. It is about how we go that next step, that we do not just think stigma has been completely eradicated. When we get into the more severe and enduring mental health issues, there is a serious stigma around those areas. It is about trying to be much more nuanced and not just putting funding into things that have happened already. Let us look at what the policy says and examine how to emphasise these areas. We should do so on condition that it is integrated and that agencies work together and share knowledge. Young people who are students do not spend all their time on campus. They will need support in different ways. Digital is a real game changer in thinking about that. When we talk to parents they say "no, they are spending too much time in their room, I do not want them to do that." In reality and particularly we will see it for males, if there is an anonymous service like Jigsaw Live Chat, they will take that up much more easily and will come with more severe issues than they might physically come through the door with because it is easier to talk about it in that way. They are the areas in terms of putting in support.
Frances Black (Independent)
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That is fascinating, that they are more inclined to open up online.
Mr. Conor Boksberger:
I am really struck by the idea of self-stigma. What I hear from young people and have heard throughout my own clinical practice is even that people are waiting until it gets to a point where they feel it justifies support. We hear that a lot. From my own experience working with young men, they can feel they are taking up somebody's space. I have heard that a lot from young people. The lovely thing about being in primary care and in early intervention is giving the message very clearly that there is absolutely no problem too small. While we may not need to talk for weeks, months or years, a good conversation right now at the right time can be just what they need. We are always trying to get that message out. Young people are very open to their friends getting support and would be the first to say they need help but there can still be a sense that "maybe it is not for me."
I will come back to the idea of choice. That is what I really value about the web chat that was developed over the last years. It gives another avenue of choice to young people. It gives them another way to interact when they may not be ready to come in and sit in front of me or one of my colleagues. That might be a step too far. The more points along the journey we can give to young people, the more likely we are going to be able to move them away from those secondary and tertiary care services, which will be needed for the few. Until we start to really beef up what is happening for the many, the some, that few is going to become larger and larger over time and it will reach saturation point.
Ms Sarah Hughes:
I largely agree with the points made. When we move away from focusing on a crisis model of care, we get to a point where we have fewer people in crisis.
We currently see that people joining the waiting list when they are in crisis are waiting months or years and getting more into crisis. It is more difficult to treat people when problems become much more entrenched. On the crisis side, there are a couple of specialist areas that need further investment and development, such as dual diagnosis and eating disorders, especially inpatient facilities for eating disorder patients and, in particular, those who require medical intervention and mental health intervention at the same time. There are a couple of areas like that which would benefit from further funding.
Frances Black (Independent)
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University students are under unbelievable pressure these days. Many need to work quite a lot alongside their academic commitments and many are in precarious housing situations. We can imagine people having to live at home or sharing a house with many others and so on. Is this impacting university communities in general around mental health? What role is played by housing?
Frances Black (Independent)
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Yes, that is huge.
Ms Sarah Hughes:
One of the reasons for that is that people living in a house with six, seven or eight other people do not have the privacy to do a telehealth appointment. We also know from our pre-Covid research that when students have multiple pressures, such as work piling up and deadlines for college, as the Cathaoirleach mentioned, the first thing that falls off are the likes of their social lives and hobbies. These may seem like small things but they are what builds their connectedness and sense of belonging, as well as their self-care.
Aside from people living near their campuses in precarious housing, we have students commuting ridiculous hours every day to and from college because they did not get accommodation. It could be a commute of two or three hours each way every day. That impacts on their sleep, as well as everything else, which we know has a knock-on impact on mental health. While there are direct links between precarious housing and students' mental health status, there are also many indirect impacts as well.
Frances Black (Independent)
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Yes. It is a minefield.
Frances Black (Independent)
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What has been the other witnesses' experience with housing?
Mr. Declan Whelan-Curtin:
From a health promotion perspective, we had a successful round-table discussion with key stakeholders in higher education a couple of weeks ago. We explored what the potential issues were as well as potential solutions. Housing and accommodation was a key challenge there, especially for staff working within settings who were very committed to solutions but felt quite powerless about what they could do. We had some lovely examples of initiatives. UL has a commuter hub initiative, which is again built around this idea of connectedness and belonging. That was having subsequent positive impacts in the sense that friendships developed through that commuter hub model were leading to further supports and things like that. Housing and accommodation was a key challenge we heard from our stakeholders at that higher education event.
Frances Black (Independent)
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Does what Ms Hughes said about the online services have an impact from Jigsaw's perspective? I am thinking of people living with their parents and so on.
Mr. Conor Boksberger:
It can. It was something we were acutely aware of during the pandemic and that forced a lot of innovation in how we did things. However, we did not stay out of the buildings very long because it quickly became apparent that, despite having access to trained mental health professionals by phone or video, the lived experience of some young people does not allow it. We work with people aged from 12 years to 25 years. This means we have college students who might be in digs or sharing a room, but we also have the young girl in the north inner city sharing a two-bedroom flat with four siblings who are running around and other people who just do not have access to privacy. We were always clear we needed to be able to offer something realistic. It is not good enough to have something if it is not accessible.
To speak more broadly on the impact of things like housing, we recently published our conceptualisation of mental health, in terms of what we believe around it.
It is very much based in that social determinants of health model, in that we recognise that the lived experience of us all has an impact on how we feel, day to day. We do not want to go down the line of pathologising a young person who is living in a precarious situation and say that they are anxious. Of course, they are anxious; they are right to be anxious. For example, if I am a young person living in homelessness accommodation and I not know whether my family will get to stay there for a week, a month or a year, and I do not know why mum is upset all the time, of course I will feel sad and anxious. We do need to create spaces, supports and resources but we also have to look at the broader structural issues, because we cannot keep patching over where the problems keep getting created for young people.
Frances Black (Independent)
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I am really interested in Jigsaw's provision of both traditional counselling and the email- and instant messenger-based support. Do the different services attract different cohorts of young people and are there differences in outcomes or efficacy? Does Dr. Duffy know what I mean?
Dr. Joseph Duffy:
I do indeed. What the research says is that there is little or no difference, which is a really interesting and positive factor. We do think that there are different age groups and different young people who will be attracted to the services. Some of them will send an email - or their parents will - and that is all. They want to gather that information because they want to spend the time and have the discipline to write down the problem. Then they want somebody to consider it and come back to them. That works really well. There are also parents who will ring up and are in crisis themselves, who need to be talked to and talked down, and do well after that. As Mr. Boksberger mentioned earlier, one size does not fit all. When we look at further resources for services, we are thinking about what is the best resource. We also know, from young people, that it works if they can manage their own care. When we workshop this and when we bring young people in and ask them about it, a lot of the time they tell us that they would like information available to them that is provided, or spoken to, by another young person. They want another young person telling their story so that they can identify with it. Mental health has moved on in different ways. There are young people who would be very happy to read the transcript of an online group rather than participate in the group. That would provide them with assurance and help them to identify and feel they belong. That might be the only intervention that they need. We might not know about that, other than knowing that we have some traffic on the website. When you talk to young people, it is about that sense of transparency around mental health, making it much more obvious, but also trying to help young people - to use a medical analogy - manage the dosage themselves, rather than this very paternalistic view that they must attend eight sessions or do this or that. It is not like that. Also, looking at it in a very early intervention way, we have found through the live chat that if, for example, somebody is really concerned about waiting for a pregnancy test, they cannot be told to wait for two months to see a counsellor. They need to be able to chat to somebody-----
Dr. Joseph Duffy:
-----while they are sitting in the waiting room, to get that support there and then, and then perhaps come on the next day and say how it went. That is all they need. That is the sense of how we are thinking about mental health. We are very much being guided by young people to use technology in the most positive way we can.
Frances Black (Independent)
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That works for them.
Ms Sarah Hughes:
The key thing is that if we can reduce the overwhelm in terms of where to go and the knowledge of what phone number to dial or text, there is a sense of empowerment that comes from that which bolsters the young person. That goes a long way towards reducing the sense of helplessness that comes with issues around anxiety, in particular. If young people feel that they are a little bit in control of the steps that are being taken, it goes a long way towards actually helping reduce the symptoms overall.
Mr. Conor Boksberger:
I want to mention the more systemic piece around that with families. For example, if I am talking to a parent on the phone, often they might say that they do not think the child will come in because that 12-year-old or 13-year-old is not ready. Having the range of resources, as we have with Jigsaw online, is helpful there. If, for example, the mum has described the problem to me, I can say that we have a really good article on Jigsaw online around that, and can suggest that she has a read of it and then perhaps a conversation, when out for a walk with the child, about what she has read. It is about putting it back towards parents. Rather than us getting absorbed into the panic that can be there if they feel that there is a problem and they do not know what they can do, we can be solution-focused and recognise, and have the parents recognise, that they can do an awful lot and they are already doing an awful lot.
Usually, the very simple things are the most effective. There are things that can bolster that and help guide the parent in terms of that, and there are steps before they have to necessarily sit in front of a professional. With complete openness, that professional should be there for them, but that is not to say that this is a panacea and that if it is not a mental health professional, it is of no use. It is about recognising that parents, other trusted adults in the community, the communities themselves, clubs, societies, all of these things that exist will be what young people need in terms of their mental health resources. We are trying to bolster that as well as provide direct support.
Frances Black (Independent)
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That is fantastic. I have a final question for Ms Hughes. She noted in her opening statement the significant amount of psychological support provided in the university sector but that demand seems to be even higher. I know that on campuses there is periodic discontent about the long wait times to be seen. Do universities need to do more to support student mental health in general? The question I really want to ask Ms Hughes is how the Government can help in that.
Ms Sarah Hughes:
One of the key issues is the perception that the wait lists are all year around. There are times, such as at exam time, when the counselling services are busy. Where there is adequate funding, campus counselling services can hire additional sessional service staff because we know that time of year will be busy and can prepare in advance for it. The biggest issue faced by on-campus counselling services is that even when the funding is currently available they cannot hire enough staff because the funding is only provided year on year and nobody wants to take a job that only has a year's contract. Counselling services do not know year on year whether they will have to let staff go or will be able to hire more staff. Counselling staff are also expected to roll out things such as the mental health framework. It comes down to staff asking themselves whether they will roll out a policy or see a student. The key asks that USI always has is that funding on campus be ring-fenced and multi-annual. We are off the globally recommended ratio of counsellors to students by between 500 and 1,000, give or take, with the current funding we receive. We need more funding but we also need to change the model of how it is provided year on year.
Frances Black (Independent)
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Does anyone have any further comments to make or questions to ask before we conclude? Is there any message?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I have one question for Dr. Duffy. If a young person comes to Jigsaw and speaks about issues he or she is having and Jigsaw finds out the young person has a substance issue, what happens in that circumstance?
Mr. Conor Boksberger:
I will go back to the individualised nature of what is happening for that young person. Jigsaw would always try to find out what the young person is using, how it is being used, and whether he or she is safe. We look at that first and foremost. We also look at the interaction between the substance and the young person's mental health concern to figure out which of them is primary. We recognise that if the substance use is primary for that young person, and there is no amount of therapeutic intervention such as talk therapy that might be helpful at that point, we need to address what is happening for them in that moment. It is also about recognising that sometimes it is not safe to deliver talk therapy to someone who is actively using. If someone has smoked cannabis just before coming into us, ethically, we have to say that we need to keep this contained. We try to gauge whether we will add value or be able to offer something. That is where we are coming from. The interaction between the substance and the young person's life and mental health, and how he or she is using the substance and what it is being used for, will determine how we direct towards it. We are aware of services within our communities that offer support around substance use so if we feel the young person should attend those first and an intervention with Jigsaw is needed after that, we are always open to it. Young people should be able to traverse back and forth between services but we want to be careful to act within our remit while also recognising that young people use substances - they drink alcohol and smoke cannabis, sometimes very recreationally - and there should not be a blanket ban on young people accessing mental health supports for that. Sometimes the nature of the use is masking a lot and that needs to be treated in the appropriate way.
Dr. Joseph Duffy:
A number of members have asked what can they or the Government do. When we talk about an increase in spending, we need to think about the proportion of that that is spent on prevention and early intervention. We need to question that and ask about it. We often talk about an increase of X amount in the health budget or particularly in the mental health budget. We need to ask where that money is going. We have a fantastic policy and a real commitment to implementing it but are there adequate resources? So much of the health budget is spent before it is received because it is built on a year-to-year basis, as the committee will know. If there is an increase, how can that be focused? Can conditions be put on it in terms of looking at outcomes to see if that is going to have an effect, particularly as an early intervention? This area requires that support over a long term but if we are ever to change the narrative and the way we think, and I think we can and overall in terms of the size of the population we should be able to do it, it is about being much more direct and saying X proportion of funding must be in this early intervention area.
Ms Sarah Hughes:
It goes without saying that across the sector, we need more investment from a financial perspective but it is about more than that if we are talking about really transforming the mental health services. We should look at areas within the higher education sector where things have worked well. We were asked several times about solutions. Where different Departments and agencies come together in a co-operative sense looking to work together and knowledge-share and that kind of thing, that is where things start to come together. Seemingly small changes such as not needing a psychiatrist to be the lead on a multidisciplinary team can be transformative. That is something the Psychological Society of Ireland is working on. Currently, a psychiatrist has to sign off on applications to the DARE scheme to access higher education, so where a young person might have been treated and diagnosed by a psychologist all the way through, he or she must now go back and be added to the waiting list. Something as small as changing that can have a transformative effect, not just for the young people involved but also for the waiting lists and the mental health sector overall. While we obviously need to increase the funding, looking at how we work within the mental health sector could be more transformative.
Frances Black (Independent)
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I thank all the witnesses for coming in and for the phenomenal work they are doing in this area. We really appreciate it.