by Edward Boyne
In a previous issue of Inside Out, I promised to return to the deliberations of the ‘Expert Group on Mental Health Policy’ which was established by the Minister for Health in 2003. The Expert Group was given the task by the Minister of examining, analysing and mapping out the future of the mental health services in Ireland for the next 20 years. In setting up the Expert Group, the Minister was in part responding to pressure from human rights organisations such as Amnesty International. Amnesty took the initiative in publishing its own comprehensive report on the Irish Mental Health services in 2003 (see www.amnesty.ie/content/view/full/1407).
The Expert Group’s report entitled ‘A Vision for Change’ was published earlier this year and immediately adopted as Government policy for the foreseeable future.
The members of the Expert Group were drawn from all the mental health professions, from voluntary groups and from service users, in order to reflect the stakeholders in mental health in Ireland.
Apart from myself, members included (among others):
Professor Joyce O’Connor, President, National College of Ireland (Chair), Dr. Tony Bates, Principal Psychologist, St. James’s Hospital, Dublin, Noel Brett, Former Programme Manager for Mental Health and Older People, Western Health Board, Dr Justin Brophy, Consultant Psychiatrist, Wicklow Mental Health Service, Dr. Colette Halpin, Consultant Child and Adolescent Psychiatrist, Mr. Michael Hughes, Director of Nursing, Wicklow Mental Health , Dr. Mary Kelly, Consultant Psychiatrist, Dr. Terry Lynch, GP and Psychotherapist, Limerick, Mr. Paddy McGowan, Former Director, Irish Advocacy Network. Ms. Bairbre Nic Aongusa, Principal, Mental Health Division, Department of Health and Children, Dr. John Owens, Chairman, Mental Health Commission, Mr. John Saunders, Director, Schizophrenia Ireland, Dr. Dermot Walsh, Former Inspector of Mental Hospitals.
The wide-ranging and representative nature of the Expert Group was important from the beginning.
In accordance with the terms of reference, we undertook an extensive consultation process. This included the publication of a request for written submissions from the public, the circulation of a questionnaire seeking the views of those currently using mental health services, two consultation days for stakeholders (one in Dublin and one in Limerick), and the commissioning of a study involving individuals who were in-patients and who might not otherwise have had an opportunity to make their views known. The results of this wide consultation process were collated and published separately.
We also convened 19 advisory sub-groups in various areas to provide further, detailed input on aspects of the final report. Over one hundred individuals were involved in these multidisciplinary sub-groups, which included service users and carers, wherever possible.
It was my task to chair the sub-group on ‘Primary Care’, which included senior officials from the Dept of Health, programme managers from the then Health Boards and leading researchers in the area of ‘Primary Care’ in Ireland.
‘A Vision for Change’
The role of psychotherapy in the future mental health services
The issue of psychotherapy and its role in the mental health services was discussed extensively by the Expert Group. The Group met in plenary session on 23 occasions, often for 1 or 2 full days at a time. The topic of psychotherapy was frequently part of the discussion during these days in one form or another. Psychotherapy is given considerable coverage in the final report and its role in the mental health service of the future is clearly outlined.
It was noted throughout our deliberations that that service users and service-user organizations had consistently demanded that the ‘talking therapies’ be made available as a viable alternative to medication.
There was broad agreement among the Expert Group that psychotherapy should be ‘located’ in the policy sense, mainly as a key aspect of Primary Care and that the Government’s ‘Primary Care Strategy’ should reflect this (see Chapter 7 of the report). This means that GPs and psychotherapists and other mental health professionals should, as a matter of policy, work closely together. It also means that an expanded grant-aided ‘Primary Care’ sector should involve shared premises and teamwork among GPs, psychotherapists and other primary care professionals working together for the good of patients.
Prior to this, psychotherapy in Ireland had no coherent ‘home’ or firm ground in the policy sense. It was difficult for policy makers to incorporate it into national health or welfare strategies. As a result, psychotherapy has been historically unfunded and officially ignored. As a key element of the Primary Care strategy, it is envisaged that psychotherapy will flourish and assume its rightful role.
The current situation where GPs and psychotherapist work in separate ‘compartments’, with little mutual understanding and little contact with each other, is most undesirable. Within the health service it is recognized, through extensive research, that GPs deal directly with 95% of the patients presenting with ‘mental health’ or emotional difficulties. Many GPs have indicated to researchers that they urgently need psychotherapy resources to be available to them at the community level rather than within the specialized hospital settings. A recommendation of the report (7.9) is that ‘A wide range of incentives should be introduced to ensure mental health treatment and care can be provided in primary care’.
There was also general agreement among us that medication is over-prescribed and sometimes poorly monitored on an ongoing basis. The establishment of formal and clear operational links between mental health/psychotherapy professionals and general practice medicine should go a long way to improve this situation.
Training for psychotherapy
Chapter 18 of the report discusses training issues for psychotherapists at some length and I would like to quote part of the relevant section :
The consultation process that informed this policy revealed a concern on the part of many service users with the predominance of drug treatments and the limited opportunities for discussion and resolution of their problems through counselling and psychotherapy.
Counselling and psychotherapy may be described as interventions that, through the use of the therapeutic relationship and of psychological techniques, aim to reduce distress and symptoms, enhance coping skills and self-knowledge (see also Annex 11).
More recently there has been an expansion of techniques and target subjects deemed relevant for these interventions, for example family therapy, cognitive behaviour therapy, dialectic behaviour therapy, psychoanalytic therapies and so on. It appears that the availability of counselling and psychotherapy interventions is not equitably distributed across different income groups, however.
The structure and quality of training courses for these various therapies vary considerably, ranging from introductory weekend courses to accredited, university-based, masters and doctoral level courses.
Some of these courses form regular components of education and training for professional groups working in the health services, such as psychiatrists, psychologists and social workers. Others agencies such as the Irish Association of Counselling and Psychotherapy and Irish Council for Psychotherapy accredit their own courses.
This diversity of training bodies, courses, and target groups is of little help to service administrators attempting to answer the call for more counselling and psychotherapy. A training strategy is required to promote, fund and accredit psychotherapy courses that provide the required skills to respond to the needs of service users.
Currently, most counselling and psychotherapy programmes recruit students with a variety of professional backgrounds. This approach to multidisciplinary education and training has been cited as an example of best practice and should be considered for other post-graduate mental health training programmes.
Recommendation18.26: A National Manpower Planning Group should be established to make recommendations regarding the education, training and workforce issues arising from this report, with reference to clinical psychology, counselling psychology and psychotherapy.
This is the first time to my knowledge that an official report, adopted by Government, has recommended a funding and accreditation strategy for psychotherapy courses and the inclusion of psychotherapy in manpower planning. The vast majority of psychotherapists have to date had to fund their training from their own resources. In addition the foregoing endorses for the first time the practice in our profession of recruiting students from a variety of backgrounds.
‘A Vision for Change’- Other proposals
In terms of the other aspects of the report, the language and concepts of psychotherapy are pervasive, particularly in some of the policy conclusions. A Vision for Change proposes an ‘holistic’ view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. The report proposes a ‘person-centred’ treatment approach, which addresses each of these elements through an ‘integrated care plan’, reflecting best practice, and evolved and agreed with service users and their carers. Special emphasis is given to the need to involve service users and their families and carers at every level of service provision. Interventions should be aimed at maximising ‘recovery’ from mental illness, and building on the resources within service users and within their immediate social networks, to allow them to achieve meaningful integration and participation in community life.
The next steps
For Government to adopt a report which gives psychotherapy such a prominent place is an historic departure. It is now important that psychotherapists follow up on the policy principles of the report and seek actively to have them implemented.
The activities and orientation of organizations currently representing psychotherapists should now to be considered afresh. In my view, the professional organizations representing psychotherapists have been inward-looking to date and focused too much on arcane internal issues such as the differences between counselling and psychotherapy and the differences between the psychotherapy modalities.
If left unchecked, there is an obvious tendency in the existing professional bodies to invest energy in the refining of standards and the creation of more complex regulations, with little or no attempt to engage influential people outside the profession who may be skeptical and not among the ‘converted’.
While internal issues have a certain importance and can’t be ignored, the professional bodies seem disinclined to comment on or engage actively, via the media, with issues ‘in the world’ such as the rights of mental health service-users to a range of therapies, the privatized nature of psychotherapy and its implications for the less well-off, the modern dilution and loss of community etc. etc.
There has also been a disinclination to engage with other, more established professions such as medicine, social workers etc. In addition there has been little or no debate within the professional bodies about where psychotherapy fits in along with other disciplines. Instead there seems to be an expectation that statutory recognition or regulation will be ‘gifted’ to psychotherapists, without their first having to convince others of their usefulness, credibility, relevance and concern for the patient/client group.
The harsh reality is also that the fragmented nature of our field is a major problem where Government or statutory recognition is concerned. We need to be working in a genuine way for greater unity and cohesiveness among ourselves.
A recent unfortunate example will illustrate what I mean. The Irish Council for Psychotherapy, without prior consultation with its members, recently demanded of the Government two separate statutory registers, one for ‘counsellors’ and one for ‘psychotherapists’.
The idea of two registers each with strong legal powers and penalties attached is self-evidently untenable in a political culture which barely understands the single concept of ‘the talking cure’, confirms the impression of a fragmented inward-looking profession and gives the Government a perfect excuse to postpone statutory recognition for psychotherapists indefinitely.
In anticipation of this problem the recommendation of A Vision for Change is:
7.11.2 All mental health professionals on primary care teams need to have appropriate qualifications and training from recognized bodies…..Agreement needs to be reached on what qualifications can be recognised and what bodies are accepted for accrediting purposes. The issue of accreditation ……deserves separate consideration by an independent group.
Now that the crucial role of psychotherapy in Primary Care and elsewhere has at last been established and officially accepted, I hope that the early creation by Government of such an independent group or commission will bring together the disparate and fragmented elements of our field and facilitate an agreement in relation to the future of accreditation and statutory recognition for all psychotherapists. This sort of comprehensive recognition and clarity will ultimately be to the benefit of patients/clients and the community generally.
For anyone wishing to read the Expert Group’s report in full, it is available from the Government Publication Sales Office, Molesworth St, Dublin 2 (cost €10) or online at:www.dohc.ie/publications/vision_for_change.html
Edward Boyne MA, M Phil. is Director of training at the Tivoli Institute, a psychotherapy training agency based in both Dublin and Galway. He is editor of ‘Psychotherapy in Ireland’ (Columba 1993). He served for two terms on the Board of Amnesty International (Irl) and is a former Chair of the Irish Penal Reform Trust (2003/5). He is a founding member of both the IAHIP and IACP and has served on the Boards of both organizations in various capacities. He can be contacted at email@example.com