by Padraig O’Moraín
“The Greek name for a butterﬂy is Psyche, and the same word means the soul. There is no illustration of the immortality of the soul so striking and beautiful as the butterﬂy, bursting on brilliant wings from the tomb in which it has lain, after a dull, grovelling, caterpillar existence, to ﬂutter in the blaze of day and feed on the most fragrant and delicate productions of the spring. Psyche, then, is the human soul, which is purified by sufferings and misfortunes, and is thus prepared for the enjoyment of true and pure happiness.”
That’s a statement which could have been written by a therapist with a fondness for purple prose. Its appearance at the start of the government’s Vision for Change strategy for the mental health services would suggest that the talking therapies have, at last, come into their own. But it wasn’t written by a therapist (I am using the term to include counsellors and psychotherapists). The quotation is from The Age of Fable by Thomas Bulfinch (1796-1867). Moreover, none of the organisations representing or accrediting therapists had elected nominees on the working group which produced A Vision for Change, nor do they have nominees on the monitoring body for the implementation of its recommendations.
So perhaps a quotation from a book about fable is appropriate in more ways than one in the context of the strategy on mental health. This, I think, illustrates the gap between official acknowledgement of the value of the work we do and the failure to make that work available to those clients of the mental health services who cannot afford private therapy. There is really very little argument any more about the desirability of making the talking therapies more widely available to persons being treated by the psychiatric services.The difficulty lies in bringing it about.
The consultation process which formed part of the drawing up of the Vision for Change report, “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” (A Vision for Change, 2006). It seems to me that such progress as is taking place in meeting these concerns is in general practice rather than in psychiatry. The Irish College of General Practitioners publication ,Health in Practice, acknowledges that medicine and counselling “are not as polarised as they once were, but there is still a lot of scope for growth.” It notes that referral to a counsellor gives doctors more time for other patients. “Patients who are in counselling are less likely to seek lengthy consultations and informal counselling from their GP” (Ryan, 2006). On an anecdotal level too I, and I am sure, many readers find that many GPs are open to referring patients to a counsellor they can trust. But I have never had a referral from a psychiatrist. It seems to me that the closing of the gap between the talk therapies and the official mental health services is something that will have to be brought about by our own efforts if it is to happen.
Given the constraints on public spending and given the status of psychiatry as the Cinderella of the health services when it comes to funding, I see little prospect of any drive from government to integrate talk therapies into the medical and mental health services at any time in the near to medium term future. The funding of psychiatric services has been declining for a long time. For instance, spending on mental health amounted to 13 percent of the total health budget in 1984 but this had fallen to 6.98 percent by 2005 (O’Morain, 2007). The Vision for Change document envisaged that the proportion would rise, if it was implemented, to 8.24%. It seems to me to be unlikely to the point of fantasy that funding will be made available for a new therapy structure within the mental health services. One could say, therefore, that we have policy more or less on our side but nothing too implement it with. I say it ‘more or less’ on our side because I was rather disappointed with the approach to the talk therapies in A Vision for Change . The most sustained reference in report to these therapies is one which expresses concern about the training of councillors and psychotherapists. That’s fair enough but I would like to have seen more written in the report in a sustained way about the value of these therapies. The only value that I can see mentioned anywhere in the report and – it is mentioned a number of times -is that the talk therapies can save money.
The report’s recommendation that ‘crisis houses’, to which persons could go for up to 72 hours at a time, be established states that each person coming to the crisis house would be offered “an opportunity to deal with issues surrounding their lives by accessing appropriate interventions such as counselling, family therapy, psychology, social work or other available holistic options as required” (A Vision for Change, 2006). That, if you will pardon the cynic in me, falls far short of saying that these therapies will be provided free of charge to persons in the crisis houses, either while they are there or after they leave. By the way, I am still waiting for an announcement that even one of these crisis houses is on the way. I suspect it will be many years before we see them, if ever. All that is cold comfort for people who would like to see our therapies incorporated into the mental health system for the benefit of those who cannot afford to see us privately. And indeed there are many therapists who would like to work in the mental health system if the opportunities were there.
Looking at the attitudes of psychiatrists as expressed through the submission made by the Irish College of Psychiatrists to the Vision for Change working group, one can see cause for both hope and doubt. The College strongly emphasises the need for psychotherapy in the psychiatric services and this is hopeful. However, its emphasis is on the provision of the service through teams led by consultant psychotherapists. These are envisaged, my reading of the submission suggests, as psychiatrists who take on psychotherapy as a speciality. Such a model, if it was to come about, would continue to leave therapists as represented by IAHIP and the IACP out in the cold. This, in my view, would not only be bad for us but also for patients who may very well find themselves engaged in a form of “psychotherapy” shoehorned into the medical model which dominates psychiatry.
As for persons who could be defined as counsellors rather than psychotherapists, there is very little comfort indeed in the College’s document. “Counselling is a type of psychotherapy of the supportive and educative type,” it declares (Irish College of Psychiatrists, 2003). This statement could be taken, on a pessimistic reading, to suggest that counsellors provide tea and sympathy and little else. It also suggests that the gulf between psychiatrists and therapists, particularly counsellors, is one of ignorance as well as practice.
So while the value of psychotherapy is not only accepted but promoted by psychiatrists, the threat remains that this will be seen as a psychiatric speciality and that the division between the psychiatric services and the talk therapies as provided outside that setting will continue to be as great as ever. As stated earlier, though, I doubt if the funding constraints with which the mental health services struggle will allow, in the short or medium term, for the development of the sort of system the Irish College of Psychiatrists envisages.
As this article was being completed, the HSE advertised a range of consultant posts including posts for consultants in “General Adult Psychiatry, specialising in Psychotherapy” (Sunday Independent, 13th April 2008). A story on the Sunday Independent website stated that the advertisement had been placed “in a bid to recruit 19 new mental health consultants” (http://www.independent.ie/breaking-news/national-news/hse-advertising-for-19-new-mental-health-consultants-1346380.html). This suggests that the incorporation of psychotherapy into psychiatry as a branch of psychiatric medicine is under way. However, my earlier point stands: I do not believe that there will be any robust level of funding for this development given the historic trends in the funding of psychiatry. This will be a slow and patchy development. It is for us as psychotherapists and counsellors to advocate a relationship which involves a collaboration between the mental health services and ourselves in the interests of clients and the placing of the advertisement makes it more urgent that we do so. We need to avoid the medicalisation of psychotherapy or at least to try to ensure that this is not the only or the main model supported by the HSE.
It’s not all doom and gloom, though. Interesting models for the future are being developed, though mainly in the area of general practice and community provision. As mentioned earlier, many counsellors and psychotherapists are now receiving referrals from GPs. On a policy level, the government’s 2001 health strategy sees counselling as one of the services which might be provided by the envisaged primary care teams (Primary Care, A New Direction, 2001). The creation of these teams is proceeding very slowly but at least the talk therapies are recognized as a desirable component of such teams. In my view, such progress as is occurring on the ground is on the initiative of counselling organisations of various kinds.
For example,The Village Counselling Service in Tallaght sees clients who either self refer or are referred by doctors, public health nurses or other community projects. Clients pay an average of about €15 per session. The service was established by the Institute of Integrative Counselling and Psychotherapy (www.iicp.ie), based in Tallaght and accredited for training purposes by the IACP. Most clients are seen either by trainee counsellors working towards a diploma or by persons with diplomas who are working up their hours for accreditation. These counsellors are linked to the Institute in some cases and to other recognised training bodies in others. They are supervised by qualified supervisors. The service receives some funding from the Health Service Executive and from the Family Support Agency. Another example is provided by the charity Pieta House (www.pieta.ie) in Lucan, Co Dublin which has the prevention of suicide through a counselling service as its primary focus. Pieta House uses the services of trainee psychotherapists under supervision. It raises its income through private fundraising and provides therapy free of charge.
These are two examples of how therapists, training institutions and others can provide therapy for persons who would otherwise be left to rely on the psychiatric services and largely, therefore, on medication. They provide an indication of how we might reach a broad range of people who need our services but cannot afford to pay the full price and how we can do this within the financial constraints that limit mental health services.
A way forward?
To promote the greater availability of therapy for those who need it but who cannot afford it and to promote the talking therapies generally as a core part of the mental health service we need to make efforts at national and local level. Following are a few ideas:
We need to maximize our voice on the Vision for Change monitoring body. However slow the implementation of the strategy may turn out to be, the monitoring body remains an arena in which policy can be influenced. Psychiatric nurses and social workers could, in my view, play an invaluable role in doing talk therapy with clients. Anecdotally, I understand that more psychiatric staff from these grades are undertaking counselling diploma courses. I suggest that we ought actively to encourage this trend. We need to put forward the argument that the talk therapies either on their own or in conjunction with conventional psychiatry can lead to cost savings, particulary in the psychiatric service. The submission by the Irish College of Psychiatrists to the Vision for Change working group had this to say:
“Several studies provide evidence of the savings produced by psychotherapy. One study of patients with severe personality disorder suggested that inpatient psychoanalytic psychotherapy produced savings of £7,423 per patient in terms of reduced usage of health service resources (Chisea M, Lacoponi E & Morris M, 1996). An Irish study conducted in the Cluain Mhuire service under the auspices of the Order of St. John of God noted that a significant saving was achieved (Blennerhassett R, 2003).”
The more familiar we are with this sort of evidence and the more assiduously we put forward figures like these, the better the hearing we will get from those who hold the purse strings.
I outlined earlier the provision of, respectively, low-cost and free therapy by the Village Counselling Service and Pieta House. This model, in which counselling is provided by students of accredited training courses working up their hours, is capable of being followed in many other locations. Many of us, in promoting our services, write to GPs in our area. I wonder how many of us write to the psychiatric services? Do we even know what psychiatric services are provided in our local area? Creating such links could have important implications, not only for our own flow of clients, but also for the future relationship between therapists and psychiatry.
In conclusion, there are things happening at a policy, institutional and local level to narrow the gap between the provision of talking therapies privately delivered and the public mental health services on which thousands of people must rely. But there is no sense of a commitment by the state of the funding which would close the gap. Therefore, it is up to those organisations which wish to see such a development to continue to press their case nationally and locally and to continue creating ‘facts on the ground’ in the form of viable models of involvement. And we must do so with the faith that one day, in the words of Mr Bulfinch, we will see that butterfly “bursting on brilliant wings from the tomb in which it has lain…..to ﬂutter in the blaze of day and feed on the most fragrant and delicate productions of the spring.”
Padraig O’Morain IACP, is a faculty member of the Institute for Integrative Counselling and Psychotherapy and is the author of a number of books including Like A Man – a guide to men’s emotional wellbeing (Veritas, 2007).
A Vision for Change, report of the expert group on mental health policy, (2006) Stationery Office, Dublin.
Bulfinch, T, (1913) The Age of Fable or Beauties of Mythology, Crowell, New York.
Chisea M, Lacoponi E and Morris M (1996) Changes in Health Service Utilisation by Patients
with Severe Personality Disorder before and after Inpatient Psychosocial Treatment BJ
O’Morain, P, (2007) The Health of the Nation, the Irish healthcare system, 1957-2007, Gill and Macmillan, Dublin.
O’Morain, P, (2007), Like A Man, a guide to men’s emotional wellbeing, Veritas, Dubin.
Primary Care, A New Direction, (Quality and Fairness, a health system for you), Stationery Office, Dublin, 2001.
PsychotherapyServices,astrategyforIreland,(2003) Irish College of Psychiatrists, Dublin, 2003.
Ryan, T, (2006) Doctor and counsellor can work together, Health in Practice, Irish College of General Practitioners, Dublin.