Gary Gannon (Dublin Central, Social Democrats)
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I welcome our witnesses attending today.

I welcome Dr. Sharon Lambert, from the School of Applied Psychology, UCC, and the Psychological Society of Ireland; Ms Caroline O’Reilly, addiction counsellor and psychotherapist; and, fromAddiction Counsellors of Ireland,ACI, Dr. James O’Shea, chairperson, Dr. Laura O’Reilly, vice chairperson, and Mr. Jay Collins, secretary. On our agenda today is engagement on the topic of intergenerational trauma.

All witnesses and members 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 statements are potentially defamatory in relation to an identifiable person or entity, witnesses and members will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I remind members of the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of the Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of the place where the Parliament has chosen to sit. In this regard, I ask any member partaking via MS Teams that prior to making their contribution to the meeting they confirm they are on the grounds of the Leinster House campus.

This is our fourth hearing in public session. All the opening statements have been circulated among members and will be published on the Oireachtas website after this session. As we agreed, we will limit each opening statement to five minutes to allow plenty of time for questions and answers. I am aware that a wide range of issues will be the subject of the discussion today. If necessary, further and more detailed information on certain issues can be sent to the clerk of the committee for circulation to members. Members will be in and out of the committee room, so I ask witnesses not to read into that. Unfortunately, we have not yet mastered the art of bilocation.

I invite Dr. Lambert to give her opening statement.

Dr. Sharon Lambert:

Today, I want to discuss briefly the powerful but often overlooked concept of intergenerational trauma. This refers to the transmission of the effects of trauma from one generation to the next, not just through stories or memories but also through behaviours, relationships and biology. Any discussion on trauma must first seek to understand what we mean by psychological trauma. The term is defined differently across disciplines. There are narrow definitions that situate trauma as exposure to actual or threatened death, serious injury or sexual violence, and there are broader definitions that imply trauma also includes emotional abuse, neglect, systemic oppression, racism and poverty. Our understanding of trauma has expanded with advances in research, and there is increasing evidence that toxic stressors are experienced as traumatic by many people. There are biopsychosocial impacts of trauma. Biological impacts relate to potential epigenetic changes that alter gene expression patterns without changing DNA sequences directly. Such alterations often involve stress-regulatory genes, with the potential to add to an individual’s children’s vulnerability to stress, anxiety or trauma-related disorders. Psychological issues relate to unresolved challenges passed on to the next generations, including relationship and communication difficulties. Social effects can be seen in the cycles of exclusion, poverty and other social challenges.

Psychological trauma can happen to anyone. It is reported that at least 50% of adults have experienced at least one episode of adversity during childhood, with 6% having experienced four or more childhood traumas. Intergenerational trauma is the transmission of trauma across generations. Traumatic experiences can be passed down through behaviour and parenting practices, leading to persistent trauma impacts across generations. There are those who have more than their fair share of adversity, such as people experiencing homelessness, people with substance dependence, those with criminal justice contact and other groups who face social exclusion due to poverty or ethnicity.

Community-based traumas are related to those communities that often experience an intersection of adversities, such as social exclusion, poverty and discrimination or exposure to political violence. In regard to the latter, consider the experiences of communities in the north of Ireland, Syria and Palestine. Socially excluded groups such as indigenous communities, ethnic groups, LGBT groups and working-class communities experience what are often termed as adverse community experiences, which have been linked to increases in individual adverse experiences. There are many reasons community-level adversity causes interpersonal difficulties. For example, experiences of racism, poverty and classism have an impact on mental health, and this might increase substance dependence, which in turn can have an impact on parenting.

Instances of this double jeopardy of adversity can be seen within most indigenous groups around the world. In Ireland, the Traveller community experiences the highest levels of discrimination in education, employment, housing and justice. This has a direct impact on Travellers’ health and well-being, with a subsequent risk of individual-level trauma, such as death by suicide.

Losing a parent or other family member to suicide may be experienced as a trauma. Within the Traveller community, sudden and traumatic deaths are more common than in the settled community, leading to more complex grief reactions. Similar patterns of multiple-level adversity are seen across various ethnic groups around the world, such as the Mori, Australian Aborigines and Native Americans.

The effects of trauma are not deterministic, though. There are many who experience adversity for whom the presence of protective factors mitigates the risk. However, for many there is potential for the impact of a trauma to last a lifetime and for it to be transmitted intergenerationally, particularly when we fail to provide appropriate responses.

The cost of trauma is huge and it includes harm to oneself and others. Data analysed in the US for 2018 estimated the cost of post-traumatic stress disorder at over $232 billion. In the UK, a conservative estimate was £14,780 per person. We do not know the true cost but what we do know is that the burden on individuals, families and societies is high.

Examples of protective factors that mitigate risk are socioeconomic status and service access. We can look to addiction for an example. Not all addiction is caused by trauma but research shows that between 60% and 80% of people who have a substance use disorder have experienced trauma. The health research board has identified that those in the lowest and the highest socioeconomic groups use equal amounts of drugs; however, people with a lower socioeconomic status experience a wider range of harms associated with that use. A recent case study example highlights how money is a protective factor. The waiting lists for addiction treatment are long and there are many hoops to jump through, such as the provision of drug-free urine. However, if a person has the ability to pay for the treatment, these barriers do not exist.

There are solutions that can break cycles of trauma. Individual-level interventions, such as counselling and other trauma therapies, will be discussed by others on today’s panel. These are essential for pathways to recovery, but to truly break cycles of trauma we need system changes such as access to housing, health and education services, youth and community projects, and trauma-sensitive and gender- and culturally appropriate public services. We must consider how we distribute resources. Only 1% of the health budget goes to addiction services and 5.8% to mental health services. This is well short of what is required. It costs approximately €100,000 to keep a person in custody in Ireland. For half that cost, it would be possible to provide residential addiction treatment and allied services. There is a plethora of evidence on the social determinants of health and well-being. By not investing in system changes, we perpetuate trauma cycles, with associated costs continuing to increase.

Gary Gannon (Dublin Central, Social Democrats)
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I thank Dr. Lambert very much for her contribution. I now invite Ms Caroline O’Reilly to give her opening statement.

Ms Caroline O’Reilly:

I thank the Chair and members of the committee for inviting me here today. I am an addiction counsellor and psychotherapist, and for 18 years I have worked with individuals and families affected by addiction. This work has included my work with Travellers at Exchange House Ireland.

Before I begin, I want to share the words of a Traveller woman I met recently in the Dóchas Centre following the suicide of her friend, who drowned in the River Liffey. Both had been living on the streets of Dublin, using crack cocaine and supporting each other to survive. Her words capture the deteriorating situation in our city:

We were sitting there at the river talking about the state of our lives. Drugs ... How did we end up like this? All our kids are in care, not a family member even to take us in and give us a bed or a bit of food. What have we got? Jail, jail, jail ... The system is ... [broken]. I ring the freephone ... they won’t give me a bed because I’m on ... [another council] list. I’m just on the streets of Dublin, being robbed, nearly raped, I woke up with three fellas over me ... We choose the drugs to block out the pain and cold but that’s not the life to live. I went away for less than ten minutes to get some drugs, walked back and there she is – her body floating in the Liffey ... I thought about going in after her.

This is not just one woman’s story. It shows how trauma and exclusion, left unaddressed, pass from one generation to the next and fuel addiction in our communities.

Intergenerational trauma occurs when unresolved harm from poverty, violence, abuse or exclusion is carried forward through parenting and family dynamics, and even biologically through stress responses. Children raised in homes marked by addiction, violence or neglect are more likely to struggle with mental health issues and addiction as adults. They repeat patterns not by choice but because trauma was never addressed and dysfunction became normalised. Trauma is therefore not only a personal issue; it becomes a social and cultural one, repeating itself silently unless we intervene.

On the link with addiction, trauma is one of the strongest predictors of substance misuse.

The Adverse Childhood Experiences study shows that people with four or more childhood traumas are far more likely to misuse alcohol or drugs and are at higher risk of depression and suicide. In my own practice I have seen families where three generations are caught in the same cycle: a grandparent institutionalised, a parent with untreated trauma turning to substances and children now entering care. Without intervention, the cycle simply repeats. The All Ireland Traveller Health study found that Traveller men live 15 years less than settled men, while Traveller women live 11 years less; and that suicide rates among Travellers are six times higher, with one in ten Traveller deaths linked to suicide. Almost 40% of Travellers report poor mental health, which is four times the rate among the general population. This is driven by discrimination, exclusion, poor housing and poverty. These are not statistics of individual failure; they are evidence of collective trauma carried across generations. In regard to the human and social cost, when trauma and addiction go untreated we see rising prison populations, children entering State care, homelessness, mental health crises and increased hospital admissions. The State spends enormously on prisons and crisis responses yet far less on prevention. Investing in community-based health-led programmes would save money and spare families the devastating costs of lost potential, broken homes and preventable deaths.

In terms of what needs to change, as we cannot break the cycle with piecemeal responses, addiction services must be trauma-centred. Front-line staff see the realities every day yet their insights are too often lost in bureaucracy. We need direct conversations between front-line practitioners and policymakers. With that in mind I urge the committee to consider more residential treatment and detox places where beds must be available when people are ready, and not months later, and recovery programmes in prisons and communities. Prisons should be a gateway to change, with detox counselling and education provided and community-based alternatives prioritised. Housing solutions should support sobriety. In that context, safe recovery housing and step-down accommodation are essential. Relapse is almost guaranteed if people leave treatment and go into homelessness or prison. Training is required for social workers and front-line staff. Skills in trauma and addiction improve decisions, reduce stigma and strengthen families. This requires investment in the workforce through training, regulation and recognition of addiction professionals. Quality trauma-informed care is needed. Staff across addiction, mental health and justice must be trained to ask "what happened to you?" rather than "what is wrong with you?". This means expanding evidence-based therapies already piloted in Ireland such as Seeking Safety, coping skills for addiction recovery, trauma-focused CBT and eye movement desensitisation and reprocessing, EMDR. Early intervention for children, school-based supports, counselling and parenting programmes like Parenting Under Pressure reduce the risk of repeating the cycle.

Intergenerational trauma does not have to continue. With timely treatment, recovery supports and trauma-informed services shaped by front-line knowledge and the voices of marginalised communities, we can break the cycle. The choice is ours to keep managing crisis or to invest in real recovery.

Gary Gannon (Dublin Central, Social Democrats)
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I thank Ms O'Reilly for that powerful contribution. I invite Dr. James O'Shea to give his opening statement on behalf of Addiction Counsellors of Ireland.

Dr. James O'Shea:

Addiction Counsellors of Ireland is grateful for this opportunity to contribute to the committee's deliberations on the important issue of intergenerational trauma. A written submission has been provided to members in advance and this oral statement will highlight key themes therein. Our members work in a trauma-informed manner on a daily basis to provide therapeutic interventions that are designed to promote safety, stabilisation and recovery. Our submission identifies three key areas for consideration: contributing and contextual factors for intergenerational trauma; priorities for reducing its impact; and a continuum of proposed psychological interventions to respond to trauma.

As others have cited, intergenerational trauma tends to emerge within a broader context of family difficulties, community structures and social disadvantage. Poverty, marginalisation and unequal access to resources place additional pressures on both families and communities. Intergenerational trauma is shaped by a range of interacting factors, which can include parental substance use; adverse childhood experiences; family dynamics; and a whole sleuth of broader community challenges. However, the research is clear and demonstrates that appropriate intervention can support families and communities in breaking cycles of harm.

Reducing the impact of intergenerational trauma requires a strong policy direction. This means embedding trauma-informed practice across our health, education, social care and justice systems. It requires the strengthening of protective environments through evidence-based family and youth programmes. It involves ensuring that trauma and addiction are treated in a timely manner and treated together. Investment in early intervention is critically important so that challenges are identified and can be addressed before they escalate. Long-term progress depends on building collaborations across all sectors of our health and social care systems. This allows for services to operate in a co-ordinated, consistent and sustainable manner.

We suggest that a continuum of psychological interventions is an essential part of effective evidence-based responses. Universal trauma awareness programmes would ensure that front-line staff across all sectors are trained to understand, to provide safe environments and to respond sensitively to trauma. The next level is early recognition. This might involve staff training to identify signs of trauma but also to be able to signpost and make appropriate and timely referrals. This would prevent people from falling through the net. Building on this foundation are skills programmes such as the Seeking Safety and Coping Skills in Recovery programmes, which have already been piloted within the HSE and some of our voluntary and community services. They provide structured skills-based supports at low to moderate levels of intensity. For those with more significant trauma problems, as Ms O'Reilly mentioned, specialist trauma therapies are required. These might include cognitive therapy for post-traumatic stress disorder or, as Ms O'Reilly also noted, EMDR. If members have questions about those specific therapies, I am happy to speak to them afterwards.

International evidence is clear that concurrent treatment of trauma and substance use is more effective than sequential treatment. Long periods of abstinence are not necessary before trauma therapy can begin. What we are saying is that we should be treating trauma and addiction at the same time, together, in a speedy and timely manner. We should not be mandating long periods of abstinence in order for people to be able to access those services. Those with the most complex needs, such as severe mental health problems or complex PTSD, require referral to integrated HSE-led dual diagnosis services. At this level, highly trained trauma-focused addiction counsellors, psychotherapists, psychologists, nurses and other professionals would be embedded within the HSE's emerging dual diagnosis teams.

Intergenerational trauma represents a major challenge for health and social care systems. However, this is far from insurmountable. Ireland has the potential to provide a co-ordinated trauma-informed and evidence-based response across all our services. We in Addiction Counsellors of Ireland, the only body that specifically represents addiction counsellors in Ireland, are fully committed to working in partnership with colleagues across the health, social care, education and justice systems to ensure that families and communities affected by trauma are supported to recover, thrive and prosper.

Colm Burke (Cork North-Central, Fine Gael)
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I thank all the witnesses for their contributions and for the work that they are doing. The work they are doing is difficult and challenging. I very much appreciate the contribution they are making.

The supports offered within the prison system when people - male and female - end up in prison have been raised. From the witnesses' own information and from dealing with people, what is their view on how we are dealing with drug addiction and on the issue of trauma within prisons? What is their view regarding the medical care within prisons? I am not sure who wants to contribute on that point.

It is an issue I have come across previously.

Ms Caroline O'Reilly:

I am happy to address that. I run addiction and mental health clinics in the Dóchas Centre. My colleagues do so in Mountjoy and Wheatfield. It is no secret that prisons are really overcrowded. There are three in a room, one on the floor. That is very tight. It can lead to other complications or dynamics particularly in the women's prison because it is so small. On the mental health supports available, the prison probably relies heavily on external services that come in to support the women inside. Similarly with the men, they have core supports for addiction counselling within the prison but there are only so many staff. A client might report they are on a waiting list or they get to see the counsellor once a month, which is not adequate. It is not the service's fault, as such; it is just the resources are not available.

Colm Burke (Cork North-Central, Fine Gael)
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I came across a case where someone was providing medical care in a prison rather than people being taken to clinics in hospitals because the problem with that is there is no continuity whereas if someone comes into prisons providing care, there is continuity. Have the witnesses come across that issue?

Dr. Sharon Lambert:

The issue is someone should not have to go to prison to get access to the services he or she needs. The prison experience in itself is traumatic for some people because they can be exposed to violence in custody and can experience other harms. The majority of people who go into custody serve short sentences. In reality, they just come in and go out and they do not get access to the services. If someone is on a long sentence, they have a better chance of eventually getting through that waiting list. I know what the Deputy says about continuity.

Colm Burke (Cork North-Central, Fine Gael)
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On people going in and out, is there a problem with continuation of support - even if they do get care inside - in that there is no structure to make sure the care they require is available once they leave the prison system?

Dr. Sharon Lambert:

It costs money having them come in. If the money was invested in community approaches instead, they would get continuity of care in the community without having had that prison experience. We know going to prison is bad for your health. People who go to prison have more physical and mental health issues.

Colm Burke (Cork North-Central, Fine Gael)
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Dealing with issues and trying to prevent people going down the wrong road and getting into difficulties, there are various projects in all cities, including Cork, Limerick and Dublin, that are trying to support young people. Could more be done in providing support to the organisations providing care to young people who might have dropped out of the education system and got into minor difficult with the Garda? Could more be done in that area, also dealing with the issues Dr. Lambert spoke about, at an earlier stage?

Dr. James O'Shea:

Many of our young people who go into prison have had significant traumatic life experiences. As Dr. Lambert pointed to, these life experiences contribute to substance misuse problems and a whole range of social problems as well. The difficulty with trauma and traumatic life experience is that trauma fuels trauma. People have traumatic life experiences, get themselves in bother, go into prison and are involved in various activities where they experience more trauma. We have become very good at responding to addiction and doing so early. I have spent most of my adult life working in or around addiction services. There has been a huge improvement in the quality of our addiction services over that timeframe. We are only early days and our services are only emerging for treating trauma. We need to recognise, as Dr. Lambert said, there is such a high overlap between traumatic life experiences and substance abuse. We need to treat them both early, quickly and efficiently using evidence-based interventions.

Colm Burke (Cork North-Central, Fine Gael)
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The reason I asked that question is I was involved in a project in Cork with young people who had dropped out of school and got into difficulty with the Garda. At any one time, we had about 50 people in. We provided even simple things like literacy and numeracy, which they were running into difficulties with, providing support for them and eventually getting them out onto the jobs market. When we did research about people who had been with us five years earlier, over 70% of the group were in full-time employment. The important thing is intervention. Can that be replicated in areas where people are going down the road towards drug misuse? Can more be done in that whole area?

Dr. James O'Shea:

There was an excellent programme very similar to what the Deputy described in Mayo some years back called Foundation 4 Life. Like he said, it offered skills, education and vocational interventions for young people at a very early age. There was huge uptake by young people either going on to further education or into employment. There is a whole slew of those kinds of projects in the community and voluntary sector that are highly effective. They should be resourced and supported.

Dr. Laura O'Reilly:

I agree in terms of resourcing the provision of those types of supports. They are absolutely necessary but if we listen to the points around trauma and how it contributes to addiction and mental health issues, we need to take a few steps back even further and begin to properly invest in early intervention supports such as early years programmes, working with families with children in the household and supporting them in an effort to even delay or prevent young people travelling towards those types of services. When we think of the impact of trauma on an entire family, we need to look at how to support and help families together. On the prison system piece, we need to really think about whether it is effective to deal with trauma, mental health and addiction-related issues through a criminal justice response. Unfortunately, that is often how we deal with and respond to trauma, that is, through a criminal justice response. There are lots of statutory, voluntary and community services available to work with people in an effort to ensure it does not have to be dealt with through a criminal justice response.

Nicole Ryan (Sinn Fein)
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I thank everyone for their opening statements. As full disclosure, I sit on the ACI board. It is lovely to see you in real life. We do not get many opportunities. My first question is about adverse childhood experiences, ACEs. All of the witnesses spoke about the importance of ACEs. When screening for ACEs in addiction services, sometimes there is a push and pull. A therapist is trying to screen for ACEs but also is trying to forge a relationship with the person before going into intrusive questions about their past. Then the therapist has to fill out forms like in the audit because they need to get the person into a treatment service. How can that be done ethically and safely? I recall having to do it with one woman and the story always stuck with me. A lot of people looking at addiction treatment services are not even aware of their own trauma. I had to ask her a question and she said she never had any adverse experience. Then she said she would sit at the table and eat her dinner and if she did not want to eat her dinner, her mother would force-feed her until she vomited. To her, that was not an ACE. How do we it ethically and safely? Do we also need to teach the people coming into the services what ACEs actually are?

Dr. Sharon Lambert:

Senator Ryan has touched on a very important topic, which is the increasing bureaucracy in therapeutic services. There is often pressure on funders to say a therapist has to complete X number of forms as evidence he or she is doing the work when the work is sitting in front of the person.

A trauma-sensitive or trauma-informed service offers a client-driven service, which allows services to know when it is the right time for specific clients. It is not dictated by the amount of paperwork that has to be completed to satisfy any one particular agency. There are organisations carrying out trauma screening using the adverse childhood experience, ACE, scale, but that was not designed as a clinical assessment tool. The study by Felitti et al.in 1998 designed that ten-item scale that the Senator talked about. It was designed for epidemiological research. It is not a clinical tool.

The Senator is right. There are ten items on the scale. It places all of the adversity within the family home, however. It does not consider things like bullying and discrimination. For example, a person might tick one adverse childhood experience, but that person’s experience of that one item could be the same as someone’s experience of ten traumas. It is not appropriate and should not be used. Some kind of national framework would be great.

With regard to the second point about some kind of national public health campaign regarding trauma, we have public health campaigns relating to a lot of different things because we want the public to be safe and well. There are ways of delivering public health campaigns on toxic stress that do not make people feel stigmatised. It must be remembered that a lot of the trauma that occurs in the family home is because of structural inequality. It would be good for people to have access to psychoeducation. The number of people who have been excluded from education and do not have access to information that many of us take for granted is incredible.

With the increase in the number of people listening to mental health-related podcasts, we carried out a study a number of years ago. We found that people with lower levels of education and socioeconomic status were developing reduced stigma, reduced self-blaming and increased help-seeking behaviour from the information they were getting from podcasts and that access to psychoeducation material. That is great, as long as the podcasts are good quality. Some of the podcasts that come from abroad, for example, are not necessarily good for people in terms of the messages they deliver.

Mr. Jay Collins:

I will say a bit on that as well. In the service we were in, that was something that was asked, but it has now been changed because of trauma-informed training. ACE questions are no longer asked at the initial stages. It is about that trauma-informed approach. It has to be embedded in the whole service. It is recognised that those questions must be asked at the appropriate time. In the service I work with, and in the wider south east, those questions are no longer asked for that reason. It is about embedding and investing in that trauma-informed approach across the whole organisation, not solely with the individual who is working with the person.

Dr. James O'Shea:

Mr. Collins more or less covered it. To go back to Senator Ryan's point, there is a push-pull dynamic. On the one hand, you are trying to build rapport and a relationship with clients while trying not to trigger traumas in initial and early assessments. On the other hand, however, you need to know enough about the client to be able to make a coherent response. There is always a tension in the therapeutic setting between having enough information to be able to respond effectively and not doing harm. Mr. Collins's point is well made that our addiction services have increasingly become far more trauma informed. Those more intrusive questions, which need to be asked, are being asked at a later point in the therapy when clients feel safer and there is a better therapeutic relationship.

Nicole Ryan (Sinn Fein)
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I thank the witnesses. At what point is early intervention most effective? Is it in schools or maternity services? Where is it?

Dr. Laura O'Reilly:

Although I am here with Addiction Counsellors of Ireland, ACI, I am also the manager of a community drug service that has a dedicated child and family centre attached to the service. We work with people who are at the pregnancy stage or have very young babies in the early months. We work with them through those preschool years. While the service we provide is an early years service, it is a wraparound service that considers all of these other socioeconomic issues, such as poverty, family, parents, trauma and a whole range of issues that we know potentially expose that young child to risk. That work is done in a way that recognises the family unit, rather than separating out the mother and father from the child. We try to respond to the risk factors that are contributing to where those parents are at and the potential impact of what might be happening in the family.

While that is not necessarily drug-specific work, there is drug-specific work happening with the parents. We are putting other holistic kinds of early years responses in place for those young people. Often, we get caught up in what drug-specific supports, drug education or drug prevention look like, but if we can work with those families at that early stage and respond to those factors that have contributed to trauma, addiction and mental health issues, then that is the early intervention piece for me.

Ruairí Ó Murchú (Louth, Sinn Fein)
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At times, we all use the same terminology around here. Sometimes, that terminology is correct, like the term “trauma informed”. It is about the idea of integrated services, which we do not necessarily have. Almost everything works in silos. We all love talking about early interventions and how necessary they are, but they do not always happen. For the past while in the children’s committee, we have been dealing with the issue of child poverty. This also relates to some of the pieces that came up in the disability committee, of which I am a member. This issue is like a Venn diagram across those committees. If we could put in place the best-case scenario or system to protect and support families and, obviously, kids who fall into particular and sometimes dangerous scenarios, we would be a lot better off.

A couple of weeks ago here, someone straightforwardly said that if we were to really up our game when it comes to the resources we put into addiction services across the board and all the rest of it, in a perfect world, a situation could be brought about where far fewer of those resources would be needed into the future. I am not under any misapprehension that drugs are going anywhere, however.

Intergenerational trauma and poverty are absolutely exacerbated by the issue of drugs and everything else that happens at this point in time. The piece that I have identified and cannot get away from is the need to have decent screening in place. I refer to decent engagement with families so that these issues can be caught and supports put in place. As the witnesses know, however, those supports do not exist.

Beyond that, the services we need at a later stage are obviously a hell of a lot more complex. The conversation we are having here is almost the same as those I have had in other committees. We can talk about housing, poverty and all the rest of it, but we live in the world that we live in. What does the perfect system, which deals with both that early intervention piece and then addiction services beyond that, look like? Everyone would agree that it makes no sense that sometimes people's only choice of getting these services is when they get prosecuted and put through the court system and into jail. It has to be a lengthy enough sentence, too, or it will not happen.

Dr. Sharon Lambert:

Sometimes, it feels like it is a really big issue that we cannot fix when actually-----

Ruairí Ó Murchú (Louth, Sinn Fein)
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It is very simple.

Dr. Sharon Lambert:

Sometimes, we could work smarter. For example, there are ways of working in collaboration. In fact, that is one of the principles of a trauma-informed practice. I worked in an addiction service before I worked in the university. In that service, we operated an interagency case management system. With every young person who came into us, we identified who the stakeholders were in his or her life and we invited them to a meeting after we had worked with that young person for six weeks. That could have involved a school, the justice system, a social worker or the Probation Service, etc.

We would then, with the young person, identify what his or her needs were. The people who were responsible for meeting those needs in those different domains then were at the table and they would make a commitment. Dr. Jo-Hanna Ivers did a study of this in Trinity and found there were missing partners, that is, there were people who do not turn up to those interagency case management meetings, namely, mainstream education and the mental health services. The longer you keep a young person in education, the better their life chances. Time is wasted and more problems are created if we do not get everybody sitting around the table. My number one is therefore that we have interagency case management with people and not waiting until they get arrested but as soon as they present looking for help themselves. One of the things you will find with many of the people who find themselves in difficulty with addiction is they have gone looking for help, have not got it and then things have escalated. The Deputy said poverty is exacerbated by substance dependence, I would say-----

Ruairí Ó Murchú (Louth, Sinn Fein)
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Both, yes.

Dr. Sharon Lambert:

-----poverty is relieved by substance dependence. It makes it tolerable. Getting in there much earlier and having all those agencies would be effective and that is easy to do.

Ms Caroline O'Reilly:

Following on from what Dr. Lambert was saying, having interagency work is vital but having multidisciplinary teams within organisations is also really important. It works really well. Clients who access a service are often running across town, or are expected to, to have their basic needs met. The bulk of what clients need could be under one roof. The organisation I work for has a multidisciplinary team within my department for addiction, social work, psychotherapy, play therapy and a mental health team. Then for the youth service we have a team that works with young people on the ground. They do after-school projects and summer projects and work with the schools to help prevent early school-leaving. We also have an education and training department that caters for early school-leavers who do local training initiatives or community employment schemes. It is a one-stop shop. A person or their family can use every aspect of the service. It works by duty referral where it is a social work-led duty system that is nine to five every day with a drop-in service. That system works exceptionally well for particular client groups who are marginalised and have issues of trust with services. It needs to be adopted or looked at being adopted as a model of best practice, especially in this area, because it covers all aspects of biological, psychological and social issues, which is what we are looking at here.

Ruairí Ó Murchú (Louth, Sinn Fein)
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It is about having everything where it is needed.

Ms Caroline O'Reilly:

Absolutely, just to break down the barriers.

Ruairí Ó Murchú (Louth, Sinn Fein)
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It is no different to talking about kids. We can put the supports they need in there, largely, and engage families and all the rest of it and then you get a far better bang for buck.

Mary Fitzpatrick (Fianna Fail)
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I apologise for being late. The Senate was sitting so that delayed me. I thank the witnesses for their opening statements and for the work they do. This trauma is a real characteristic of the Irish psyche, from the Famine, occupation, the Civil War, economic depressions and social repression. One of the witnesses included a statistic that 50% of every person had at least one traumatic experience in their childhood and many more have multiple ones. Often it has become so normalised and accepted that individuals do not recognise the trauma incidents as trauma. I was really heartened to hear the witnesses’ contributions. It was very encouraging to hear Dr. O’Shea recognise and acknowledge - and it is important to recognise and acknowledge - the progress that has been made and is being made. It is being made by people in the witnesses’ professions and in their sector. It is professionals like them taking their skills and expertise to improve our addiction services, improve counselling and improve the resources. The model Ms O’Reilly described is the holistic model that is required. Humans are not one-dimensional. We do not have one problem. It is all connected and this is essential.

Our committee wants to bring forward recommendations that will support the witnesses and their sector to further develop to meet the needs adequately. I would like to ask each of them to talk about prevention for a moment and tell me what they would do if they had a blue-sky opportunity to put in place their priorities for preventative action. One of them mentioned a public health campaign about trauma, but what would that look like? Is that a public health campaign about resilience, wellness or respect, dignity and empathy? I would like their views on prevention because already we all recognise there is an inadequate percentage of the budget – the almost €30 billion that will be spent this year on health – for mental health and addiction and we obviously want to correct that. A big part of it also has to be a very significant increase in funding for prevention as an investment in people’s health and wellness. I would appreciate it if each of the witnesses could give me their views on that. Dr. O’Shea might like to go first.

Dr. James O'Shea:

I thank the Senator. She is absolutely right. In many ways we are like the fire service and we think we provide a pretty good firefighting service but nonetheless, there is a fire alight by the time we get there. I believe trauma runs through the lives of individuals, families and whole generations like a fire and the Senator's question is how we stop that fire starting. There are definitely simple things we can do. Many years ago I asked a public health nurse how we could stop this cycle. She said at the time she did the first baby visit, she could see the risks. One of our colleagues said we need to be working with young men and women before they have kids. It about working with people from the very start of their lives. It is intensive supports, especially for vulnerable families. We need to provide supports for all families but we need to target vulnerable families. We also need intensive resources and supports in our community, intensive youth programmes, education programmes and employment programmes. When young people are engaged in positive activities, education and employment they are far less likely to be engaged in problematic drug use and far less likely to be engaged in the whole range of behaviours that go with that. We need to be aware of the risk factors and try to minimise them, but we also need to invest heavily in protective factors. I mean protective factors around families, particularly in vulnerable families and in communities, especially vulnerable communities.

Dr. Laura O'Reilly:

I agree with a lot of what Dr. O'Shea has said. It is that investment in protective factors. When we are using the language all the time and we focus on addiction, it is really important to think about what is fuelling and driving the addiction. It is all these issues we are talking about and that is where the prevention needs to start. There is another conversation about drug prevention. We often think about a drug prevention programme being delivered in a school or out-of-school setting. It is important that drug prevention piece is considered within a broader health promotion aspect and a broader health and well-being one, so it is not just information about drugs and alcohol and the potential risks. It needs to be a broader health-promoting approach to understanding drugs and alcohol and choices about them. We also know that where children have access to those other protective factors like sport and extracurricular activities, which are often costly, they benefit. If we invest in communities to have those available to young people then that is a good start.

Mr. Jay Collins:

I echo what has been said. As the Senator herself said, it is a holistic approach. Someone else said that addiction is seen as the issue. It is not the issue.

Mary Fitzpatrick (Fianna Fail)
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It is the symptom.

Mr. Jay Collins:

That is the symptom or the solution. It is about looking at the factors that contribute to it and investing in those. That holistic and interagency approach is what needs to be looked at to address those factors.

Dr. Sharon Lambert:

On the interagency part, I have already said that there are missing partners. Sometimes the mental health services are not there. It is about re-examining that medical model of mental health. There are lots of committees that happen in different departments where it is fundamentally a mental health issue, and often there no psychologists or psychotherapists on those committees. There is somebody representing the medical aspect, which is great, but there has to be psychological and social understanding of factors. In terms of prevention, it is the first three years. We know those risk factors. We know there are people who are disproportionately impacted. Those are people who are parenting alone, and who have a disability in the household. The data is clear. When you look at the data from the Health Research Board, there are two groups of people who use drugs in equal amounts. Those are people with lots of money and people with no money. They are using exactly the same amount but one of those groups is experiencing significant harm as a result of their use. That is simply and purely because of economic status. It is clear that we have to reduce social inequality because when we do, people are happier and healthier, and they participate more. We really have to understand why young people are not participating in education. There is lots of discrimination and racism against people because of their ethnicity and sexuality. There are children who do not go to school because it is a very unhappy place. The protective factors need to be improved and the risk factors need to be reduced. We have known for a very long time what those are.

Ms Caroline O'Reilly:

I echo what everybody has said. While intergenerational trauma and addiction do not discriminate, for the purposes of this discussion we know it is far worse and, for want of a better word, affects marginalised communities a lot more. Where do we start? In terms of prevention, we need more facilities and safer home environments for children. Homelessness is a huge crisis and is growing, and is contributing to this issue. We need more secure homes for children. We need mother and baby facilities for mothers who are in treatment with their children or are pregnant. It is about having a safer road to recovery for them and their child. There is a need for psychoeducation and reducing the stigma of reaching out for supports and making supports more accessible. We need more family support services and inclusivity within communities. As Dr. O'Reilly said, sports are a huge factor in reducing risk. We could do with more of that in marginalised communities. I could go on.

Ann Graves (Dublin Fingal East, Sinn Fein)
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I thank the witnesses for their contributions. I found it useful to have evidence-based presentations, particularly for someone like me who comes to this with fresh eyes. If it works for the witnesses, I will go briefly through each of their presentations and ask them one question each to focus things.

I will start with Dr. Lambert. Her work has clearly put intergenerational trauma on the map for policymakers, particularly the piece on Cork Simon, which highlights the link between adverse childhood experience, homelessness and substance abuse. It is interesting to note that the figures do not match with the general figures. I have spent the past ten months meeting and visiting with community-based addiction services. The biggest eye opener for me was the level of trauma people are enduring. It also appears the issue is not that people are addicted to a particular substance but that the actual childhood trauma they went through is the biggest problem. Does Dr. Lambert agree that to tackle the causes and long-term intergenerational trauma will take complete structural system changes, which will only come about when the Government makes this a political priority, which it does not currently do, and that is taking into consideration the factors she has already outlined in the context of education?

The words of the women Ms O'Reilly referred to really hit home. I recently met a group of women who spoke to me about survival sex. That was basically having sex with someone to have somewhere to sleep at night because they felt safer doing that than going into hostels and things like that. I met representatives of UISCE in Leinster House last Tuesday. It was heartbreaking to listen to the stories of the people there. It was also inspirational to see how they worked through it and where they moved on. I raised this question in the Dáil yesterday evening. We have a vast homelessness problem but it affects those in addiction far more than others. If they are in hostel environments, they tend to be with other people who are going to break their recovery because they cannot get away from it. How does Ms O'Reilly think we could delivery emergency housing that is trauma informed and helps people rather than retraumatising them? That is where they have a safe environment and they feel secure, but they also have access to services they need, that others may not.

I was particularly impressed by Dr. O'Shea's emphasis on the dual diagnosis, which is a massive problem. We all know people in addiction have been sent to drug services and told they need mental health services and never the twain should meet. That is a huge problem because people do not fit into a box. I agreed 100% with his analysis that reducing intergenerational trauma requires strong policy direction. Do we need somebody central, at a departmental level, who would co-ordinate this and ensure we really have a comprehensive health-led approach to drug use? If not, what else would he suggest?

Ms Caroline O'Reilly:

The Deputy spoke about prison. That client group I work with would echo what she probably heard from that group of women. It is a serious crisis for women on the streets in particular. The hostels are not safe. They are mixed gender. If somebody is leaving prison and has had a period in there where they have become detoxed, somewhat stable or accessed some form or treatment or support, they may be ready to access something else. However, when they are leaving the prison system back into that hostel system, they can forget it. The bottom line is that there is no hope. I am currently piloting cocaine and crack health-led approach programmes within the south inner city in the Dóchas Centre. What has emerged from those groups is that they are terrified at the prospect of leaving. When they are preparing to leave and literally walking out the door, they really do not know what is ahead of them and it is bleak.

They can go left or they can go right, if they are lucky enough to have a support worker from Tus Nua, or a similar organisation, to meet them at the gate, to bring them to their service, to get their first payments and so on, which is not really realistic across the board. If they are lucky enough to have that, there is some kind of hope but again, it is just really difficult to avoid. There needs to be a reinforcement of services within organisations like Tus Nua which has, for example, a drug-free house. We need more of that. We need more safe housing or more halfway homes for women and men leaving prison who are ready to access treatment. That can help people to move on and reduce the rate of recidivism in the system. It is so costly and we really need to divert money elsewhere, that is, into systems that will work, have longer-term health effects and give us more bang for our buck. It is only fair to people because it reduces levels of trauma for women out on the street. The sexual violence that happens and the trading for drugs that goes on is a sad reality and it is happening in broad daylight. It is not that anybody wants to do it but it is happening. We need to really examine this.

Gary Gannon (Dublin Central, Social Democrats)
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Senator Ní Chuilinn is next.

Ann Graves (Dublin Fingal East, Sinn Fein)
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Sorry, but I asked questions of the other witnesses too.

Gary Gannon (Dublin Central, Social Democrats)
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Apologies Deputy Graves. Does anyone else wish to respond?

Dr. Sharon Lambert:

The question to me was about how the Government could prioritise it and the answer is by having a health-led approach to drug use. While there has been a lot of talk about that and various committees, as well as the citizens' assembly, have discussed it over the years, we still do not actually have a health-led approach. We still have a criminal justice approach and Ms O'Reilly just spoke about the amount of money that is spent on that. If that money was actually diverted into health, it would make a real difference. Addiction is a mental health issue but it is still hanging around the edges of justice. My recommendation would be to move addiction into mental health and implement a serious health-led approach, not a health-led-light approach that would satisfy people who have a moral objection. We need an actual evidence-based, health-led approach.

Dr. James O'Shea:

In terms of leadership and pushing initiatives forward, we have emerging dual diagnosis services and they will develop but specifically for trauma, which is what takes up a lot my attention and thinking, we need a centralised initiative to increase and improve trauma treatment within addiction services in both the HSE and the voluntary and community sector. Addiction is very difficult to treat and outcomes, even with the best of addiction of services, are going to be poor and we are going to see relapses. Trauma is eminently treatable. We see people every day whose lives and the lives of their families are absolutely destroyed by trauma. PTSD can be treated and cured. If we focus our energy on training addiction services staff in the voluntary and public services to be able to effectively treat trauma, that will give us the best bang for our buck.

Evanne Ní Chuilinn (Fine Gael)
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Thanks very much. I am sorry I was late but I was actually listening in remotely so I heard the opening statements. I will start by picking up on what Dr. O'Shea just said about PTSD and other traumas that are treatable. He also mentioned CBT in his opening statement and I spoke to Mr. Tom Conlon, a psychotherapist in Cork, about CBT recently. I understand it can be used to effectively treat people with a dual diagnosis, that is, those with both mental health and addiction issues. I ask Dr. O'Shea to give us an insight into how that works because we do not hear enough about it, frankly.

Dr. James O'Shea:

In terms of the work we do, the interventions that have the best evidence are cognitive therapy for PTSD, which used to be called trauma-focused CBT and EMDR, which is a trauma reprocessing therapy. They are the ones that are most recommended under the international guidelines. If we want to be on the button with evidence for treating trauma effectively and efficiently, we are looking at either CBT or EMDR. They are the interventions that get the very best outcomes. They are also the ones that are easily located within the family of structures for treating addiction. Addiction treatment generally works in quite a structured way and addiction services are generally structured. These interventions are also quite structured so they fit hand in glove into the services that we have.

I treat trauma for a living and I treated addiction for a living for most of my career. It is far easier to treat trauma and to get good outcomes. We still have to treat the addiction alongside it but imagine the levels of distress we can take out of people's lives and their families' lives by treating their trauma symptoms. We have talked about the different levels of trauma intervention, about trauma-focused and trauma-aware care but from an addiction work point of view, one of the most significant interventions is the use of trauma stabilisation programmes, which really teach clients self-regulation, self-management and coping skills to be able to manage their trauma symptoms so that they are able to function in the world despite the fact that they had traumatic life experiences. The other significant intervention, if we want to treat the trauma, as in cure it, is the use of trauma-focused approaches that reprocess the traumatic memories. That is the gold standard we want to be aiming for. There is no reason anybody should have to live with traumatic life experiences if we can offer the appropriate, evidence-based interventions and that is where we need to put our money.

Evanne Ní Chuilinn (Fine Gael)
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Dr. O'Shea makes a great evidence-based case for the ability to recover from trauma and for trauma to be treated How much more challenging is it in the case of a dual diagnosis, where an individual is obviously self-medicating and that is where the addiction begins in the first place? When individuals are gone beyond initial treatment, how difficult is it for medical professionals to treat those with a dual diagnosis?

Dr. James O'Shea:

It is difficult. People with complex trauma and current active addiction will struggle the most in terms of any psychological intervention or trauma intervention. That said, there is a lot of evidence, particularly in the past ten years, to suggest that good addiction treatment stabilises trauma. In this country, we have good addiction treatment right across the public, voluntary and community services. We have increasingly very good and very evidence-based addiction treatments so we probably do not need to invest a lot in the trauma stabilisation programmes. We need to invest in good addiction treatment programmes so that people are able to engage with specific trauma-focused treatment approaches. Historically, what we have done is to try to stabilise the addiction before treating the trauma but obviously, the traumatic symptoms cause people to relapse. I conducted a search of all the international evidence on this last year and it is clear that the gold standard is to treat them together. Addiction workers and mental health workers, with appropriate training, are well able to hold the complexity of that kind of intervention.

Evanne Ní Chuilinn (Fine Gael)
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The question then is how widespread that service is and how easy it is to access. It is very difficult to get access to a dual diagnosis treatment plan. Am I right about that?

Dr. James O'Shea:

Our dual diagnosis services are only emerging.

Dr. Laura O'Reilly:

There are specific dual diagnosis programmes that are emerging but from a practice point of view or a community-based service provision point of view, while that can seem quite simple on paper, we often do not have that concurrent treatment approach. Unfortunately what happens then is the person is getting bounced back and forth between two different services or else those providing addiction service are spending a lot of their time trying to route or signpost the person to mental health services rather than doing the addiction work. It has come up a few times in today's discussion that there is a need for more joined-up, shared working and an acknowledgement that these issues are presenting at the same time and need to be treated at the same time too. We need to work out what would make that easier for people themselves and for the service providers. We know how to do the work that we are meant to be doing but sometimes it is those blockages that create difficulties for us. We have seven community-based services around the country that are resourced to deliver a seeking safety programme that is very much set up to work with people who are presenting with trauma-related challenges, addiction and other mental health issues, alongside issues like domestic violence.

That is only present in seven sites across the country, five of which are in Dublin. If services like that were to be a little bit better resourced, we could see an expansion of them. That is a service that invites people in and acknowledges that a range of issues that have presented are what has brought them there.

Evanne Ní Chuilinn (Fine Gael)
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The point Dr. O'Reilly makes about seven centres and five of them being in Dublin demonstrates this is not an urban problem but a problem occurring everywhere. There was a conversation around public health and public health nurses. I spoke to a public health nurse recently who is dealing with many of these challenges on an ad hoc basis. There is no service in this particular town. This practitioner said she would like to see more clinical nurse specialists in dual diagnosis based in public health clinics. Our witnesses are the experts in the room. Is that something that would work and would be easily rolled out if the initiative and funding was there?

Dr. Sharon Lambert:

Something that worries me when we talk about dual diagnosis specific services is that we are othering a particular group of individuals. If we are going to argue addiction is a mental health issue, why are we saying there is one mental health system for one group and another for the other? For example, if I have a problematic relationship with food, that could be behavioural addiction. I am not excluded from any services, because it is food. However, because we have positioned drugs as a criminal issue, we have othered a group of people who have a chronic health issue. Ten years ago, I would have been sitting here and asking where are the dual diagnosis services but one of the aspects of being trauma sensitive is that one is supposed to be open to change and learning. More recently, my reflection has been on why this group is not able to use the same services as other people. If I had depression or anxiety in the morning, why would I be excluded from a service if I was also using drugs and alcohol?

Evanne Ní Chuilinn (Fine Gael)
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There is no reason for it. We have gamblers who are dealing with all sorts of trauma. It is definitely something to be explored.

Gary Gannon (Dublin Central, Social Democrats)
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I thank Senator Ní Chuilinn and I will come back for a second round shortly. I called Deputy Brabazon.

Tom Brabazon (Dublin Bay North, Fianna Fail)
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I thank the witnesses for their presentations. I missed a good chunk of them so I apologise if I am repeating a question. Earlier there was an intimation that if we intervene sooner and deal with intergenerational trauma, we can save a lot of money for the State. Have particular studies been done on that or does anybody have empirical evidence in respect of it? It is very significant. Not only would we be helping individuals but also the taxpayer.

Dr. Sharon Lambert:

In my opening statement I mentioned a study done in 2018 in the United States that said PTSD was costing approximately $232 billion. A more recent study in the UK from 2022 stated that per individual, the burden of cost to the State due to PTSD was £14,780. It argued that was a very conservative estimate because it did not include all of the other challenges coming on the person. In terms of emotional pain, trauma is costly for the individual and the family but it is also financially costly. We are sometimes coming too far in that journey and spending money on justice-related responses, which can keep people on the same path rather than deterring them from it, because it is not a health response. People in the Department of justice will not like me, but taking some of that money and shifting it to the Department of Health might be one way to start.

Gary Gannon (Dublin Central, Social Democrats)
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I should mention that Dr. Lambert has also given us a very helpful bibliography. That will be online if members wish to have a look.

I thank the witnesses for their contributions, they have been incredibly informative. I have a couple of questions I scribbled as they were speaking. A question was asked about drug prevention programmes. There will be education and drug prevention modules coming up in this committee. From their own expertise, what advice would the witnesses give the committee as we approach education modules? I am very conscious that when walking into schools, sometimes when you walk into certain places you can feel trauma bouncing off the walls, almost. This is walking in and almost offering a "just say no" or "drugs are bad" message. What advice would witnesses give the committee as we endeavour to complete that particular module?

Dr. Sharon Lambert:

I have strong views on this and they are not my views; they are based on research. There is no such thing as a neutral intervention. Every time one does something with children it has an impact. What some studies have found is that drug prevention education actually harms vulnerable young people. This form of education may be introducing information to them that they did not have yet. It might have been coming but they did not have it yet. We also know that the "say no to drugs" message, which has been around since the 1950s, has not worked and is clearly not working. Drug prevention must be seen in the context of mental health. We must talk about all that goes with that and not just drugs on their own. Otherwise, we are stigmatising people who use drugs and are placing them as being somehow separate than if I was talking about being kind on social media. All of these things impact on mental health. It should be integrated into well-being that currently exists, rather than targeting people. We also know that, for example, programmes in the past that targeted young people who were deemed at risk but had not yet committed an offence or participated in that behaviour, increased risk. What you are doing is saying to the community that this young person is a problem and although the problem has not presented yet, this is what we think of them. They become stigmatised as a result of that and it increases their risk.

Mr. Jay Collins:

From talking to people, I will say one thing that I would love to see. We talk about coping skills. Drug education would have nothing to do with substances or drugs. It would have to do with how to cope, manage emotions and do all that we do when we are working with people. I teach people how to use psychoeducation around that. If that could be introduced as part of education or if people learned that at an earlier stage, it would be really helpful for prevention even in terms of trauma, or anything like that.

Dr. Laura O'Reilly:

Helping young people with decision-making skills is important. It is a broader, health-promoting framework that often does not need a conversation on drugs or alcohol but is about health and well-being. It is also about trying to recognise the context that influences the decisions children are making. That is important from an education and prevention point of view.

Ms Caroline O'Reilly:

There is a gap with parents as regards their education around their own substance misuse. There can be normalisation of cannabis or alcohol at home that might send conflicting messages to children about whatever drugs prevention education they are doing. There is a broader case to be addressed with adults as well to complement that piece of work.

Dr. Sharon Lambert:

I wish to clarify one of the things I said in relation to drugs education. It is important to educate around harm reduction but what happens is that it is introduced quite late. In primary school students learn about well-being in a broad setting. We know that young people start to use drugs in early adolescence and drug taking is sometimes part of risk-taking behaviour. We ought to do the harm reduction piece at that stage. That is also important.

Dr. James O'Shea:

I have a quick comment on that.

Gary Gannon (Dublin Central, Social Democrats)
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I have two minutes but whatever Dr. O'Shea is going to say he will have the opportunity to say.

I want to ask about prisons as well. I know this session is not about prisons specifically but it will factor into a lot of the work we do. We have hugely high rates of recidivism in this country - I think close to seven out of ten people who go into our prison system will return there within three years. A friend of mine often says that if we had a hospital that had the same figures for returns, we would be asking questions. What are we getting so wrong in how we do prisons? I do not know if we are doing rehabilitation or simple punishment but whatever we are doing, we are just getting it wrong. What would the witnesses say to someone who held that belief?

Ms Caroline O'Reilly:

I think there is a massive missed opportunity in the prison system. I heard a high-ranking officer in one prison referring to it as "warehousing people". That is not rehabilitation. Unfortunately, from their point of view, it is probably what they have to do to ensure the safety of everybody in the building. We have, though, missed an opportunity here. We have many willing professionals going into prisons to provide therapy but it is on an ad hoc basis or at the will of the section 39 organisation doing in-reach into the prison system. The prison services could provide core rehabilitation programmes for people in there who want to access rehabilitation, even if it is preparation for release into treatment. We need to have more of a statutory focus on this aspect.

Gary Gannon (Dublin Central, Social Democrats)
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Would any of our witnesses like to talk a little about how we are doing prison, what we are misunderstanding and where the opportunity is we are not seeing? Effectively, what I am asking concerns the fact that a lot of people go into prisons and have an addiction that deals with a trauma that has been passed down. When they come out of prison, it seems as though everything has been compounded and made worse. How would we make it better?

Dr. Laura O'Reilly:

I will start with the question of whether prison is the place where somebody needs to be for help and support. I do not know the statistics, but we know a significant number of people in our prisons are there because of their drug use.

Gary Gannon (Dublin Central, Social Democrats)
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Yes.

Dr. Laura O'Reilly:

This is the trauma and all these other issues we spoke about. Is the prison the place to help and support somebody to overcome those issues? Are there other places where people can be directed when it is known there is an offence that is related to addiction?

Gary Gannon (Dublin Central, Social Democrats)
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Is the prison the place for this?

Mr. Jay Collins:

I do not think so. If I can say one other thing, and I am not disagreeing with anything that has been said and whether it is the right place or not, but a big thing is what people are coming out to. This is another big issue. I am not saying it is the right place but sometimes people may actually do okay in prison. They are in there for a while and may stabilise or whatever, but what are they coming out to and what supports are there? It not just about what environment they are coming out to. Very often, there are no supports, from what I can see. Once people are out of prison, that is it. There is no continuation.

Gary Gannon (Dublin Central, Social Democrats)
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Okay. I do not want to take advantage of the clock. I will let everybody else do it but I am the Chair and unfortunately cannot. We will go with the second round of questions now. I think we have gone through everyone. Members will have four minutes during this session to ask questions. Deputy Colm Burke is first.

Colm Burke (Cork North-Central, Fine Gael)
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I thank the witnesses for their contribution and for the work they are doing. When I was a Minister of State for a brief time dealing with this whole area, I visited quite a number of the centres providing support. I visited them right around the country, including in Cork, Wicklow, Dublin and Limerick. While every one of the organisations providing help and support was doing an excellent job, one of the things that occurred to me was the lack of co-ordination. From the witnesses' perspective and experience, could a lot more be done in relation to co-ordinating a whole range of areas from the perspectives of prevention, treatment and access to services? Everyone is doing a very good job. All the independent groups are doing so. Is there, though, sufficient co-ordination and organisation there? Might it be possible to deliver a far more comprehensive service? I am just wondering about this aspect from the experience of the witnesses.

Dr. James O'Shea:

The map for that is our national drug rehabilitation framework. It provides a really comprehensive framework for care planning, case management and interagency working. I suppose the ultimate way of getting really good co-ordination is to push very strongly for implementation of the national drug rehabilitation framework.

Colm Burke (Cork North-Central, Fine Gael)
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Was it found that people were providing very good services but there were gaps in certain areas or regions where the service was not being provided? Could a lot more co-ordination be done in this whole area?

Dr. Sharon Lambert:

Does the Deputy mean between services providing the same type of service?

Colm Burke (Cork North-Central, Fine Gael)
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Yes, between services, including the health service, the educational facilities and right across the board. There does not appear to be that level of co-ordination.

Dr. Sharon Lambert:

I think the national rehabilitation framework does provide a really good model of doing that, with services able to opt-in and opt-out. There is also the fact, though, that we create a situation where we have organisations doing amazing work but are worried at the end of the year about whether they are going to get the money the following year. It is possible to create pockets of people who all feel like they are competing for the same pot of money.

Colm Burke (Cork North-Central, Fine Gael)
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This would fit in with a three-year plan for all those organisations.

Dr. Sharon Lambert:

I would say ten-year plan.

Colm Burke (Cork North-Central, Fine Gael)
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Oh, I know, but it might not be possible initially to give a commitment for ten years because Governments and Ministers change. Something like a three-year plan is a start. I think Dr. Lambert would accept this would be helpful.

Dr. Sharon Lambert:

Community organisations are a vital part of a community. Statutory organisations are obviously very important. It is really good, however, to have both. It feels in the last few years that the community sector is becoming more and more stretched, pushed and concerned about funding. There are higher rates of turnover. Ms O'Reilly spoke earlier, I think, about the need to protect the welfare and well-being of staff too. It is hard for a staff member to be on a contract that is just renewed every year. How would anyone in that situation apply for a mortgage? A bit more strategic and long-term investment in community-based organisations would make them feel more solid and secure and allow them to retain their excellent staff and that people-----

Colm Burke (Cork North-Central, Fine Gael)
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A lot of these organisations have sprung up because there is a gap in the backup services for people. Once they are in place, therefore, the question is not only about ensuring they get the support but also that there is co-ordination in the services provided and that they work with other groups. I found that every one of them seemed to have been working very independently in many ways.

Gary Gannon (Dublin Central, Social Democrats)
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I thank Deputy Burke. Unfortunately, we have to move on and his time is up. I will have to be strict on this one, because I can see that everyone wants to get a second round question in. Senator Ryan is next.

Nicole Ryan (Sinn Fein)
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Dr. Lambert said that only 1% is spent on addiction and 5.8% is spent on mental health. This is really telling. Until addiction reaches the same level of spending as mental health, it will be increasingly hard - as great as the work is that everybody is doing - to get to that level where dual diagnosis is even a combined thing. Why is this level of spending so low? Is it because the Government is not taking addiction seriously as a health issue or is it that it has just been shoved to justice?

Dr. Sharon Lambert:

A significant amount of money is spent on a justice-related response to addiction. Moving addiction into the mental health space will reduce the stigma. There are people who will remember the 1980s in Ireland, when we did not talk about mental health at all. We just did not talk about it at all. Nobody had depression or anxiety. In fact, when people died by suicide, it was often not written down that this was how they had died because there was such stigma and shame. We have come an awfully long way from those days and this was a result of fundamentally seeing a shift in how we think about mental health. A public health campaign is needed that reduces the stigma and shame associated with addiction and that is also supported by the required amount of money involved in addressing addiction. The relapse rates have been mentioned. This is because there is such a queue of people trying to get into addiction services. They are really desperate and people are trying to get them through.

We looked at this situation before when I worked in a service. For every €4 we were spending on treatment, we were only spending €1 on aftercare, and this is when people are at the highest risk of relapse.

It is also when there is the highest risk of death as well, unfortunately, if you relapse and go back to using those substances. There is a huge amount of money invested in road traffic to try to reduce road traffic deaths. Reframing it as a public health issue, because it still feels very much like it is a criminal justice issue, is important.

Nicole Ryan (Sinn Fein)
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No one else has anything to add? That is great.

Gary Gannon (Dublin Central, Social Democrats)
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I thank Senator Ryan. Senator Fitzpatrick is next.

Mary Fitzpatrick (Fianna Fail)
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I have two questions. Dr. Lambert was talking about prevention, education and young people and introducing drugs education and how it can be counterproductive. She also mentioned, and I would like her to clarify this because I want to be sure I am understanding her correctly, youth diversion services and how referring a young person to youth diversion can be counterproductive. Did I hear her correctly and can she elaborate?

Dr. Sharon Lambert:

It is the way in which it is done. The issue is when you decide an individual from an area, community or family is at risk of committing crime and you take him or her into a group but that young person has not been in trouble or anything. It is kind of targeted. We have to be really careful about what message we are sending to that young person. I have worked on a Garda youth diversion project and I know when we went on activities that people would refer to us as “the Garda kids”.

Mary Fitzpatrick (Fianna Fail)
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My understanding of how the referral process works is that a young person has to have come to the attention of the Garda for him or her to be referred ,not into youth services but into a youth diversion programme.

Dr. Sharon Lambert:

Yes.

Mary Fitzpatrick (Fianna Fail)
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It is not that the Garda or any other authority figure goes knocking on the door and tells the young person to go into the youth diversion; it is that the young person has come to their attention. My experience of the youth diversion programmes is that most of them do work in a more proactive and constructive way. They do outreach, they engage with young people and in a preventative way are working to engage young people before they will come to the formal attention of the Garda or the authorities.

Dr. Sharon Lambert:

It has certainly moved from the time I was in it. It is not a great idea to bring young people to an activity centre, for example, in a Garda bus when other children down the road are going to that activity centre and they are not being dropped off there in a Garda bus. It interferes in the way in which the world interacts with those young people and it increases the stigma attached to those young people.

Mary Fitzpatrick (Fianna Fail)
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Of course it would, yes.

Dr. Sharon Lambert:

That has shifted and changed, 100%. My understanding is that it is when the person is at the point potentially of receiving a caution that the intervention is happening but there have been times in the past where people have gone out to particular children based on their surname or the street that they lived in. We have to provide services for all young people on that street so that you are not saying this one young person in particular is somehow special because that can create-----

Mary Fitzpatrick (Fianna Fail)
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The reason I questioned it is I am a director of a youth service and a justice youth diversion programme and I would be horrified to think any youth service would operate like that in this day and age or in recent times. I thank Dr. Lambert for that.

I wish to ask about the new regulations that have been brought forward by Coru for the regulation of counsellors and psychotherapists. I would like the witnesses' views on those new regulations being brought forward. Are they happy with them? Will they be positive for counsellors and psychotherapists? I see Dr. O’Shea indicating.

Dr. James O'Shea:

For Addiction Counsellors of Ireland, we have to be cautious in how we respond because our board is currently reviewing those regulations and will formulate a position on them. I can give a personal opinion if that is any use. To be clear, it is my own personal opinion and not the position of ACI. I welcome the regulation. I think it will bring counselling and psychotherapy on a par with the other regulated professions. When you regulate professions you improve quality, standards and continuing professional development. We will have views on particular aspects of the Coru regulations and we will write to Coru in due course about that. I can only comment personally and say I certainly welcome them and I think it is a hugely positive step forward for the professions of counselling and psychotherapy. Probably in the next month we will formulate an official position and we will communicate it to Coru.

Mary Fitzpatrick (Fianna Fail)
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That would be great.

Gary Gannon (Dublin Central, Social Democrats)
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I thank the Senator. Deputy Ó Murchú is next.

Ruairí Ó Murchú (Louth, Sinn Fein)
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I think Dr. Lambert was talking about the scared straight programme. That was the idea. It was talked up for years in America. It was the idea of taking kids in to prison. You can imagine what the interaction would have been. They found when they checked the percentages that a huge amount of those kids did not end up engaging. However, while there was a whole pile of kids that were probably never going to anyway but the other kids who went in would hear dreadful things from these guys and feel emasculated. What happened was they went out and felt a compunction to commit crime to big themselves up again so it did not work in any shape or form.

I know what Dr. Lambert is saying about the Garda bus and I understand that point around stigma but sometimes that is a decent enough interaction with the gardaí, which can be very positive for both the gardaí and the kids and their relationship. It is something positive. I understand there is a best practice way of doing it but a bigger issue is the Garda not engaging enough in those types of projects. We were talking about early intervention. They are now talking about youth diversion programmes working a lot earlier. All this stuff is not done at an early enough stage.

The witnesses have dealt with the majority of what I wanted to talk about. I will ask a question about EMDR specifics. I was completely taken away by this. I will let Dr. O’Shea talk rather than me wittering on.

Dr. James O'Shea:

EMDR is a trauma-focused therapy. It is based on directly treating trauma memories. When we have traumatic life experiences our memories of those traumatic life experiences are stored in a different way to how normal memories would be stored. They are often stored in what we might describe as a slightly more chaotic way. When those memories are remembered they are remembered through flashbacks, nightmares and a lot of very disturbing, distressing stuff. What EMDR and other trauma-focused therapies do in different ways is they reprocess those memories so they are located within our normal memory networks and within our normal resources. As I said earlier, in terms of evidence-----

Ruairí Ó Murchú (Louth, Sinn Fein)
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As opposed to retraumatising, which can happen in some cases?

Dr. James O'Shea:

Yes, but EMDR is a very efficient, effective, evidence-based method. Absolutely. What you are doing is storing the memories in a more functional, healthy manner. They might not be good memories but they are not traumatic memories.

Ruairí Ó Murchú (Louth, Sinn Fein)
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I remember having it explained to me and I just wanted to put it on the record by Dr. O’Shea rather than me.

Dr. James O'Shea:

It is highly effective.

Ruairí Ó Murchú (Louth, Sinn Fein)
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That is it. We need to see more of that.

My last question goes back to the integrated service, which some of the witnesses spoke about earlier, and how even when you have some of the parts – mental health and other services – because of the deficiency in service which are not necessarily there, therefore anyone operating in the system is doing this with baling twine. Does anyone want to talk about those difficulties more and from the perspective of what we can do to rectify that other than the obvious things of resources and getting everyone talking to each other?

Dr. Laura O'Reilly:

It is a resourcing issue but also a question of how we view these issues that people present with. We need to change the mindset away from viewing these as stand-alone issues, and even addressing them on their own, but rather that they are issues that are occurring together and how we support somebody.

That relates to resourcing but it also relates to the change of mindset that we do not always need to fix one issue before we can fix something else.

Ruairí Ó Murchú (Louth, Sinn Fein)
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We set up silos in Ireland; that is the problem. Somebody is either dealt with in this service or not but it throws them out of another service where someone-----

Dr. Laura O'Reilly:

However, someone who is not dealt with in this service might remain trying to have all their needs met in a particular service that is not set up to address all those needs. In community services, we often tend to fill all the gaps because we do not want to have waiting lists and we do not want to send people away feeling or being unsupported.

Ann Graves (Dublin Fingal East, Sinn Fein)
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My question probably feeds into what Deputy Ó Murchú said. Ms O'Reilly earlier mentioned a one-stop-shop-type service for people but we are all in separate silos. How might trying to combine various services work, particularly in rural areas where there are no services? Many people are travelling to Dublin even from some of the bigger towns and cities around the country because there is nothing based in their community. How could that be rolled out in rural areas?

Ms Caroline O'Reilly:

Where I work, we have an outreach service. We could consider more of a satellite-type service that would provide an outreach service delivery to people's homes, in the nearest community centre or wherever the client would like to meet. That works quite well because our clients are spread all over Dublin some of them outside Dublin. We meet our clients where they are at, which has always worked very well. We could perhaps have more remote services, which is not always ideal. During Covid restrictions it was all we could do at the time. We need more accessibility for people, involving rural outreach. It is not possible to set up a service in every local town but having more flexibility and availability is-----

Ann Graves (Dublin Fingal East, Sinn Fein)
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This service was set up originally as a community-based service and grew from there over the years. That was fine when the vast majority of the drug problems were concentrated in Dublin's north and south inner city areas. As we know, every village and every town across the country is now affected, but the services are not there. Many people are seeking services and if they arrive in Dublin, there is nowhere for them to live meaning they end up on the street and it escalates from there. Having satellite outreach centres would be a start and it can grow from there.

Mary Fitzpatrick (Fianna Fail)
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Following on from what Deputy Brabazon said, I have a question on the cost. It costs roughly €100,000 a year to incarcerate somebody. Perhaps we can use the service Ms O'Reilly describes, this all-round holistic service, as a model. This is done in all the administrative work that she has to send back to qualify for the funding. While I do not expect her to know off the top of her head, what is the cost per client? It would be helpful to get that. I think we know how it happened that we have all the services primarily clustered in the capital and other big urban centres but there are needs throughout the country. Outreach can work but we need to try to cost that. The committee needs to be able to make a strong argument. If we want to have a truly health-led approach, it will require redeployment and reallocation of resources. To do that it would be helpful for the committee to be able to quantify it, even in ballpark figures. I might follow up with Ms O'Reilly on that.

Ms Caroline O'Reilly:

At Ratoath as we are a non-profit organisation, our funding is for staffing. Therefore, it probably would not be too difficult to get those figures for the Senator. I can speak to my colleagues about that.

Mary Fitzpatrick (Fianna Fail)
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That would be great. I thank all the witnesses.

Gary Gannon (Dublin Central, Social Democrats)
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At this point the witnesses should feel free to take the time to cover anything that has not been asked, a point they would like to build on or something not covered because I might have interrupted.

Dr. James O'Shea:

My colleagues, starting with Dr. Lambert, provided a really good model for drug prevention. They also highlighted the concerns. I spent five years of my life when I was much younger working as a drug education prevention officer for the old Eastern Health Board. Dr. Lambert's initial point, which should be a baseline consideration, is that at best most drug prevention programmes do not work and at worst they can do damage. Every penny the Government, the HSE or anybody else spends in supporting families and supporting communities is money spent on drug prevention because it is building resilience in communities and families.

Mr. Collins mentioned coping skills, resilience-building skills etc. Those are the skills we need to be teaching people because if people have good coping skills and good resilience, they do not need to self-medicate or take drugs. Even if they do, they know how to manage themselves out of it.

Finally, people like us should be kept out of schools because the people who are best placed to do education on drug awareness, health and social skills are teachers, youth workers, parents and peers. To go back to Dr. Lambert's point, for the most part the research and evidence would suggest that bringing in the guy from the HSE, AA or wherever actually increases levels of experimentation rather than decreases it. We are far better off resourcing the people who are already working with young people to do these drug prevention issues.

Dr. Sharon Lambert:

Sometimes drug prevention is confused with drug education. The reality is that people do use drugs. People have always used drugs and will continue to use drugs. Dr. O'Shea is right in saying that going in and talking about drug prevention has not worked. A few years ago, I believe the World Health Organization and the UN said we needed a fundamental shift in how we think about mental health. I spoke about the medical model, which views the individual as the problem. Every time we sit around and talk about human behaviour, it is asking ourselves who is in the room and who is not. There are too many times when decisions around health behaviour are discussed and there is not a psychological, psychotherapy or social part to that discussion.

There needs to be a class analysis of what we do and the way we do it. The statistics we have from the HRB show that some people in our country are able to use drugs without experiencing too much harm while others end up with their lives absolutely ruined because of social inequality and access to services. The Garda one is a good example. There are lots of amazing youth workers, Garda youth diversion workers and juvenile liaison officers, JLOs. Have we given those youth projects enough money so that they do not have to rely on a Garda van, for example? There are young people going to youth projects whose parents would not think it acceptable for their children to pull up outside a play activity centre arriving in a Garda van. Are those projects getting enough money so that they can deliver what from the outside looks like equality?

I have had the fun of arriving at an activity centre with a group of young people from a Garda youth diversion project in what was clearly a Garda van. The minute we stepped off the bus it was a hostile reception. Young people did not appreciate the reception and then we left within ten minutes. I know that if I brought that same group of young people there in a different van, that would not have happened. I know that their parents would not have thought it was acceptable and that is because we do not always do a class analysis.

Are all our young people getting access to the same thing in the same way, or are we doing it differently based on their ethnicity and class, which makes them always stand out? They then do not always get the full benefit of what it is we wanted to deliver to them, which is what the youth workers, the Garda youth diversion workers and the JLOs want. I apologise; that was a very long and roundabout thing.

Gary Gannon (Dublin Central, Social Democrats)
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That is absolutely fine and I thank Dr. Lambert. Do Mr. Collins, Ms Caroline O'Reilly or Dr. Laura O'Reilly have anything else they would like to say before I cut them off? Please feel free to do so.

Mr. Jay Collins:

As regards resources, lots of good things have been happening and resourcing can include training the people that are there. It is not always about additional things, which would also help, but training is also there. I will not speak too much about it but I was involved in something where there was some investment. I did the EMDR training, which we can now incorporate into our service as we are doing at present. That is an example of resourcing. It is a case of seeing it from that perspective and seeing what is working out there in order to replicate it, because there is lots of good stuff that is working.

Gary Gannon (Dublin Central, Social Democrats)
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With that in mind, I thank the witnesses for bringing their expertise into the room. We will see that reflected in the document we are developing as a committee in the coming months. I thank them for their time.

That brings our meeting to a close. The meeting is adjourned until Thursday, 6 November when we will hold our session in public at 12.30 p.m.