Second National Conference of the Irish Council for Psychotherapy
Title: Creative Horizons: Contemporary Practice; Venue: Dublin Castle; Date: Thursday, 26th January 2012
Keynote address by Dan Neville TD, President of the Irish Association of Suicidology
Mental ill-health is not only damaging to the sufferer, their family and community, it is damaging to the economy. In 2008, the Mental Health Commission published a Report which estimated the direct annual cost of mental health at a staggering €3bn in 2006! This is the cost to the taxpayer of decades of Government neglect and the isolation of services.
Mental Health is central in building a healthy, inclusive and productive society. Illness like depression and schizophrenia can be treated successfully for the vast majority of sufferers and with early intervention and treatment people can live healthy lives, fulfilling their individual potential.
In January 2006, the Government adopted A Vision for Change as the basis for the development of mental health services in Ireland. The policy framework set out in A Vision for Change which built upon the recommendations of Planning for the Future 1984, was greeted by near universal approval as the best model for a modern, comprehensive, world-class service to meet the mental health challenges facing our society almost universally accepted by all.
However, five years since its announcement, there is a lack of progress in implementing A Vision for Change.
The Independent Monitoring Group reported in July of last year that specialist services promised as part of the strategy has not been developed. These include forensic mental healthcare services, rehabilitation and recovery eating disorder services, psychiatric services for older people, services for co-morbid severe mental illness and substance abuse problems and intellectual disability services.
A Vision for Change set out a policy framework for the mental health of the whole population. In addition to recognising the importance of mental health promotion and primary care, it called for a person-centred, recovery orientated and holistic approach to mental health services. It also called for a shift from the current system, which is excessively reliant on institutional care and medication, to a system centred on community based care provided by multidisciplinary mental health teams. These teams would include psychologists, social workers, occupational therapists and service users who would work alongside psychiatrists, mental health nurses, psychotherapists and counsellors. It is important people with mental health problems are allowed access to the services and supports they choose while continuing to live and participate in their community, as is their right. Ireland is more reliant on institutional mental health care than any other country in Europe. While there are examples of good practice in certain areas, implementation of the plan to which I referred has been inadequate overall.
Services remain widely deficient with few complete multidisciplinary mental health teams in place and limited access to community care for the full range of psychological supports that should be part of a modern mental health service.
In 2009, only one in five staff in the mental health service was working in a community setting. In-patient facilities remain completely unsuitable, with 15 of the 63 approved in patient centres dating from the Victorian era or earlier. The Inspector of Mental Health Services has described some of these facilities as entirely unacceptable and inhumane. The position in respect of older people and people with intellectual disabilities is even worse as specialist mental health services in these areas are in need of comprehensive reform.
Non-capital expenditure on mental health services was cut radically from €1.1billion in 2008 to €770 million in 2009. These cuts continue an historical trend in which expenditure on mental health services declined from 13% of the overall health budget in 1986 to only 5.3% in 2010. A Vision for Change recommends that 8.4% of health expenditure should be allocated to improving mental health services.
The public sector staffing moratorium has also disproportionately impacted on mental health services which account for just 9% of the health care workforce but for 20% of the 1,500 posts lost as a result of the moratorium.
The Programme for Government contains a commitment to establish a cross-departmental group to ensure good mental health will be a policy goal across Departments. In the recent budget, there was an allocation, as promised of €35 million for the implementation of A Vision for Change. This sum has been ring-fenced because when the former Minister for Health & Children, Mary Harney, allocated funding to the HSE it was hived off for other purposes. In the recent announcement by the Minister for Health in relation to the reorganisation of the Directorate of the HSE, the Mental Health Service is included in the directorship where previously it was at the level of assistant director. This is in line with the recommendation of A Vision for Change.
There are no statutory regulations in Ireland for the registration of psychotherapists and counsellors. There is no State control over who and what qualifications are held by those practising in these areas. It is dangerous for untrained, unskilled people to probe others’ unconsciousness. They are dealing with human vulnerability and serious damage can be done to such delicate people.
The Government introduce the Health and Social Care Professionals Act 2005 to provide for the registration of persons qualifying to use the title of a designated profession and for the determination of complaints relating to their fitness to practice. Some 12 professions are listed as designated professions under the Act. The professions of Psychotherapy and Counselling are not included. When I challenged the then Minister, former Deputy O’Malley, on this issue during the debate on that Bill in the Dail, he stated that the professions which he included in legislation had become so regulated by a process of discussion and consensus. However, the psychotherapists and counsellors group failed at that time to agree an approach to such regulation. The Minister stated that statutory regulation in such circumstances would have serious legal implications. He accepted the principle that all psychotherapists and counsellors should be properly qualified and pointed out that in consultation with the professional groups involved he was unable to obtain agreement on the criteria. In response to the Minister’s position, 22 organisations established a Psychological Therapies forum for counselling psychotherapy.
The forum accepted that it was imperative that the public is protected by the promotion of high standards of conduct, education, training and competence among the professionals of counselling and psychotherapy. It pointed out that all bodies involved with the forum provided a code of ethics by which their members must abide. It further stated that while this form of self-regulation provides protection to clients of these organisations, it falls short of optimal protection, as under our common law system it is possible for any person to take the title of counsellor or psychotherapist and practise accordingly without any training or competence. In other words, any person put up a sign stating they are a counsellor or psychotherapist and charge €80 per hour for performing an act as psychotherapist or counsellor, which is extremely dangerous to vulnerable people.
The current position does not lend itself to good clinical governance and the maintenance of high standards of patient care. The Health and Social Care Professionals Act 2005 provides a mechanism to drive forward the clinical governance agenda. It creates a framework through which practitioners are accountable for continually improving the quality of their service and safeguarding high standards of care by creating an environment where excellence will flourish and optimal protection is afforded to the public who access counselling and psychotherapy.
The psychological therapist forum provided a proposal for statutory regulation of counsellors and psychotherapists.
We have been informed that the 12 organisations already designated under the act must have full recognition of designation before psychotherapists and counsellors are included in the Act. I do not accept this. The inclusion of psychotherapists and counsellors is critical to vulnerable people in crisis who will be damaged by counsellors and psychotherapists who are not properly trained or qualified. We believe the issue of their designation should be given priority under the legislation.
This is critical to vulnerable people in crisis who will be damaged by counselors and psychotherapists who are not properly trained or qualified. Yesterday, I asked the Taoiseach to outline when the proposed Health and Social Care Professionals (Amendment) Bill will be published. He informed the Dail that this bill will be introduced during this session to Easter. I was further informed by his office today that the bill is at the final drafting stage and will be sent to government for consideration in February. The purpose of the bill is ‘to amend the 2005 Act to change the current provisions regarding the professional membership of the Health and Social Care Council and make other technical amendments’
While again reiterating that regulation is necessary for a profession that has come to play such a significant role in modern Irish society, I suggest that the Irish Conference for Psychotherapy consider some issues in relation to the Health Care and Professionals Act. This slots the psychological therapies into a legislative position alongside other professionals including social work, with which they have some things in common and a number of others including physiotherapy, radiography and chiropody, with which they have little in common. The registration approach which we accept require as a minimum conditions to be registered as a psychological therapist should include a primary degree, in addition to having undergone a certain minimum number of hours experience of personal therapy and of supervised therapy of others. These are eminently sensible suggestions to which no reasonable person could object and provides the basis for a successful registration scheme. This approach is an appropriate measure where there is clearly agreed core body of knowledge such as the medical profession, the law, in engineering and in any profession that applies a branch of psychical science.
I ask the IPC to consider if this pertains in a limited fashion to the field of psychological therapy. Psychotherapy is the practice of a way of thinking, a style of thinking and not only a body of thought. The profession is the knowledge to listen for nuances, for the subtext beneath what is expressed overtly. It involves a technique of thinking, not just only a body of facts and does this mean that the field is not defined by a particular body of accepted knowledge. There is an absence of an objective test by which competence of practitioners can be assessed in this vital area. The registration system based on the 2005 Act, excluding the objective test of competence will make the task facing the registration board enormously difficult.
Will the granting of registration to practice hinge on how the candidate fits into the therapeutic philosophy favoured by the members of the registration board. In practice, this is how candidates are selected for membership for many associations in psychotherapy worldwide.
It is not possible to predict exactly how things would play out in practice. Could a scenario happen over time that the registration board would be dominated by one group or perhaps a small number of groups within the profession. With over twenty associations in the field, only a minority of these could have representation on the board. Could smaller groups find their candidates be denied registration and that with time be squeezed out of the field. Could the long term result be that dissenting views, which have always been the lifeblood of the profession, be discouraged.
Psychological therapy is still a young field in Ireland. It has come to find a place in Irish culture several generations after being established in other Western countries. We have not yet assimilated it in the way other societies have done. We suffer a shortage of very experienced practitioners who have accumulated more than a decade or two of work in the area. There are few professions in which long term experience is more vital to exercise sound judgment.
Ireland has experienced one of the fastest rising suicide rates in the world. As a cause of death among young Irish people suicide exceeds both deaths due to cancer and road traffic accidents. Ireland has the fourth highest youth suicide rate in Europe. Recent research identified two suicides per month by children fewer than 15 years of age. Between 2003 and 2008 there was an increase in suicide of 40% for boys and 50% for girls.
According to the recently published provisional figures on suicide rates for 2010, 486 people died by suicide that year. For every individual who died, ten people were directly traumatised. For the purpose of making accurate international comparisons, undetermined deaths are included in the suicide rates. The figure for undetermined deaths last year was 123. Chooselife, which is the Scottish programme for suicide prevention and is regarded as very progressive in this area, advises that “the inclusion of undetermined deaths protects against under-recording and provides more accurate figures for international and geographical comparisons”. If we take this formula into account 603 people died by suicide last year.
Research going back to the 1890’s demonstrates suicide and mental illness increase at times of recession. The World Health Organisation, WHO, stated earlier this year: “It should not come as a surprise that we continue to see more stresses, suicides and mental disorders”. The director of the WHO also stated: “There is clear evidence that suicide is linked to financial disasters. The potential psychological impact of economic recession on public health is severe. Job loss, job insecurity, job uncertainty, economic strain, loss of income, home repossession and restricted access to credit lead to a reduction in mental well-being, an increase in mental health problems and mental ill-health, increased substance misuse, especially alcohol and drugs, and intimate relationship breakdown and divorce. There is a loss of perceived social worth.
There is a loss of purpose and daily structure, reduced social contacts and an increase in social isolation. An increased risk of suicidal behaviour occurs, both non-fatal self-harm and completed suicides.
People who are unemployed are two to three times more likely to die of suicide than those in employment. This high rate is partly because people with psychiatric illness are at a greater risk of losing their jobs. There is an association between unemployment and suicide. However, even among people with no record of serious mental illness, unemployment is associated with a 70% greater suicide risk. Prospective individual level studies show that unemployment has a causal influence on depression and suicidal thinking.
Job insecurity is associated with a 33% greater risk of common mental disorders, mainly anxiety and depression. People with mental disorder are more likely to be in debt than those who have no mental disorder. A United States research document indicates that a loss of income rather than low income was associated with suicidal ideation. In Hong Kong, 24% of all suicides in 2004 concerned people in debt.
Alcohol consumption rises during recessions, and this correlates with suicide. The figure for the 1990’s in this country was a 44% increase in alcohol consumption and a 41% increase in suicide.
It is clear that suicidal behaviour has a large number of underlying causes, which are complex and interact with each other. Identifying these factors and understanding their role in both fatal and non-fatal suicidal behaviour is central to preventing suicide. Factors, such as living in poverty, unemployment , loss of loved ones, arguments with family or friends, bullying, breakdown in relationships and legal, financial or work related problems are all acknowledged as risk factors affecting those who predisposed or otherwise vulnerable to self-harm. Other predisposing factors include alcohol or drug abuse, a history of physical or sexual abuse in childhood and social isolation. Psychiatric problems and a general sense of hopelessness also play a central role.
The influence of traditional religious values has waned, particularly among the young. The growing secularisation of society has changed the value system. Social controls are less strict and often people feel alone and lost. There is no longer a pre-arranged set of relationship with certainty within the relationships as were the case in past generations. Religious practice is not only has a spiritual, but also a communal aspect in that the sense that people met at the same time in the same place with their communities which had a socialising effect. Lessening religious ties leads to increased risks, especially among the young people in traditional periods of their lives.
In relation to attempted suicide and self-harming there was an increase of 4% in presentation to hospitals with 11,966 by 9,630 patients International research suggests that for each presentation at hospital, 7 others self-harm and do not present at hospital. This has been stated to be the case by the National Suicide Research foundation as relevant to Ireland. Therefore there are in excess of 70,000 who attempt suicide and self –harm each year in Ireland.
I thank the Irish Council for Psychotherapy for the opportunity to give this keynote address to your conference.