Joint Sub-Committee on Mental Health debate -
Thursday, 13 May 2021

Mental Health Supports and the Covid-19 Pandemic: Discussion

Chairman

Our witnesses will present virtually on youth mental health supports to cope with depression and the challenges arising as a result of the Covid-19 pandemic. From Pieta, I welcome Ms Elaine Austin, CEO and Ms Emma Dolan, clinical director and from Aware, I welcome Mr. Dominic Layden, CEO and Mr. Stephen McBride, director of services.

Before we hear the opening statements, I must point out that there is uncertainty as to whether parliamentary privilege will apply to the witnesses' evidence as it is given from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence on a particular matter, they must respect that direction. I call on Ms Austin to make her opening remarks.

Ms Elaine Austin

My colleague, Emma Dolan. and I greatly appreciate the opportunity to engage with the members of the committee today. As members of the sub-committee may know Pieta is a nationwide charity established in 2006 to offer free professional, clinical one-to-one counselling and 24/7 crisis helpline support for people experiencing suicidal ideation and self-harm, and those who have been bereaved by suicide across 20 locations and online.

On foot of the amazing and incredible support we have recently received through our Darkness into Light event, which happened just last weekend, it is important that we acknowledge the united and collective voice behind our purpose and in aid of our cause. This collective voice is greater than the sum of its parts. It speaks of a different and better future and is a voice that is filled with hope. More than 140,000 people got up in the dark and came out, in the wind and rain, to support a cause they have a deep connection to. They have shown that they profoundly care about the people we help and we are hugely grateful for their incredible support. We are listening and we know what we must do to deliver on their ask.

Over the last year, we have focused on increasing our impact and lifting our capability across three key areas - awareness, access and availability. We launched a nationwide campaign "Know Suicide, Know the Signs" to lift awareness and provide information and practical support for those concerned about loved ones who may be at risk of self-harm or suicide. We improved our access to intervention and bereavement counselling, launching phone and video-based counselling in addition to our face-to-face therapy across our locations nationwide. We stretched our reach, we remained open and we ensured consistent access to services through every lockdown, through every set of restrictions. We also launched a national booking line, making it easier for clients to receive a risk assessment and be assigned a dedicated therapist who will work with them through the 12-week journey of care. Our qualified team of more than 100 therapists supported more than 7,000 clients last year delivering over 52,000 therapy hours of counselling for people experiencing suicidal ideation, self-harm and those who have been bereaved by suicide. We received over 70,000 calls and texts and helped over 600 families and households in the immediate aftermath of a loss through suicide. We delivered more services, increasing our fully qualified helpline team, and have focused on expanding our therapist teams right across all of our locations.

This past year has been challenging beyond measure for both our clients and our staff. Our teams have been remarkably resilient and adapted again and again to ensure we continued to deliver a professional and highly governed clinical service, prioritising our clients' needs at all times. We recognise that this has been really tough at times, the road has not been easy. Our teams, like so many others, have had to deliver highly demanding clinical services, while balancing their personal and home lives. We are enormously grateful for their support and commitment to our clients.

As a charity, we exist for our clients. We know they have experienced higher levels of fear, anxiety, stress, hopelessness, isolation and loneliness across all age groups in the past year. We responded quickly to the additional needs of our clients. For example, we made significantly more outgoing calls last year, especially during the first lockdown and when we had transferred our face-to-face therapy to the phone while we prepared our physical locations to operate in the Covid environment. Over 25% of our clients have attempted suicide before and one third of our clients are under 18 years. We have prioritised our high-risk clients and our younger clients last year to ensure we could offer face-to-face therapy across our locations. We recognise that sometimes it is important to see the whole persona, to read the body language to get behind how a person can be feeling in that exact moment.

Last year we answered 30% more crisis calls and texts than in 2019, and this year we have already answered over 22,000 calls and texts to our helpline. These calls and texts are not simple statistics, they are real contacts between our people and vulnerable clients in the community.

In the past few weeks, we have started to see an increase in demand for our services. With an uncertain economic outlook, we expect this rise in demand to continue as we move further into 2021. Increased demand from vulnerable people who need our services is a challenge we will respond to as a priority. We will do everything we can with the resources entrusted to us. There is much work to be done.

Pieta is an organisation of 220 people. We are a registered and regulated charity. We have a responsibility to show good stewardship, efficiency and effectiveness to those who fund us, whoever they may be. The funding stability we received over the past year has safeguarded the delivery of our services. There was an outstanding response from our donors to our funding crisis, and the huge support for our Darkness into Light event, proudly supported by Electric Ireland and our Darkness into Light committees together with the increase in our State funding by 25% in 2020 positions us to deliver more.

As members know, our State funding of €3.4 million in 2020 represents about one-fifth of our total funding, with the other four-fifths coming from donations. We are increasing our impact and our reach this year across three key areas. We are expanding the scale of our one-to-one therapy to meet the existing and growing demand for suicide intervention and self-harm crisis counselling; we have completed research with UCD, supported by the National Office for Suicide Prevention, and will adapt our existing "Pieta Way" model of care to provide a greater support for families to help them better help their children through their counselling journey; and, in prevention, we want to invest further in building resilience, especially among our young adults and children, especially at this time of Covid. This will be delivered through our school-based resilience academy and our amber flag initiatives. We want to look at opportunities to provide a level of post-prevention care for our clients, giving them additional support if they feel they are falling back into crisis.

The reason we exist as an organisation is to bring about a simple, easily accessed crisis support counselling service that helps all people improve their mental health and ensures no one is left behind. Our purpose is to deliver on this. We have an extraordinary level of support from the collective voice that stands behind us. We see a great opportunity now, not only for Pieta but also for those with whom we work in partnership, including the Government and our public representatives, to get more work done. We know we are facing a particular challenge in dealing with the particular circumstances that have been presented by Covid. Our priority is to continue to deliver successfully for our clients. I hope that a number of things may come from our opportunity to engage with the committee today. There are many policy issues around the area in which we Pieta works, and we are always grateful for the help and advice in navigating the landscape of mental health services. The national mental health strategy Sharing the Vision clearly calls for a new multi-agency, multi-sectoral approach. We appreciate that a more integrated approach will help our clients receive the care they need regardless of where they enter or exit services.

One of our key priorities is that we have sustainable future funding for the organisation. We have ambitious plans for services and we want to be there to stay with our clients over the long term. To continue to be there, to be funded, it means having the support and standing not only with our clients and donors but also with the Government and Members of these Houses. In return for this, we must be in a position to demonstrate the value of what we do and our standards, our governance and our efficiency and effectiveness in stewardship of the funds with which we are entrusted. We want to see an increase in the volume of psychotherapists to ensure that overall all mental health services have the support and capability to be able to meet the current and future demand for services. It is important to us at Pieta, especially in this time of Covid, that each and every person who has the courage to ask for help is given the time, respect, and the support they critically need to find their hope.

Chairman

I thank Ms Austin very much for that fantastic presentation. I now call on Mr. Dominic Layden to make his opening remarks.

Mr. Dominic Layden

Good morning. I thank the sub-committee for the invitation to speak about Aware’s role within Irish society and the organisation’s key concerns, particularly within the context of Covid-19. I am joined this morning by our director of services, Mr. Stephen McBride, and both of us will obviously be available for questions after our statements.

In order to give the sub-committee a brief overview of Aware, it was originally established over 36 years ago to provide support and understanding to individuals experiencing depression and bipolar disorder, along with their loved ones. Importantly, the organisation also aimed to inform and educate the public on the nature of depression and bipolar disorder in order to reduce stigma and improve understanding for those living with a mental illness.

Over the years, Aware has evolved into a national organisation with a wide range of support, education and information services. Today, Aware’s free services include support and self-care groups nationwide, as well as a support line and a support mail service, both of which operate 365 days a year. Aware also delivers a range of evidence-based educational programmes designed to empower adults experiencing depression or anxiety with the knowledge and skills to build resilience and protect their mental health. Additionally, Aware offers a psycho-educational programme designed specifically for those supporting a loved one experiencing depression or bipolar disorder. We remain a volunteer-led organisation with over 500 volunteers, recruited and trained by Aware, delivering our support services nationwide.

In 2020, Aware responded to almost 35,000 people seeking support for their mental health, almost 12,000 adults and young people participated in our education programmes and over 1 million people accessed our website for information.

Turning to the impact of Covid-19, Aware has experienced similar financial and operational challenges as the majority of organisations over the past year. For Aware, this was within the context of a dramatic and immediate increase in demand for our services, highlighting the impact of the pandemic on the general public and those with pre-existing mental health issues. We recorded an overall increase of 36% in calls to our support line in 2020, with peaks of over 80% in April, May and June of last year. Our volunteers observed higher numbers of very distressed callers and increased engagement with our service users sharing more intimate details than we have experienced before.

Like everyone else, we had to modify our services for virtual delivery to ensure continuity of service for the many people who depend on us. While technology presented a challenge for both our volunteers and service users at the beginning, it was remarkable how quickly everyone adjusted. We have also observed the benefits of these adapted offerings, specifically around improving the accessibility of our services both for volunteers and service users. We have been particularly interested to see the uptake of our Zoom and phone-in support and self-care groups which have allowed us to reach new audiences who may not have attended in-person groups.

There are a number of key concerns for the organisation within the context of Covid-19. Adversity is a well-established risk factor for short-term and long-term mental health problems. Research on past epidemics has highlighted the negative impact of outbreaks of infectious diseases on people’s mental health, with multiple studies suggesting a threefold increase in general mental health difficulties. We need to be prepared and adequately resourced for a sustained surge in demand for mental health services over the coming years.

It has been very positive to see an increased focus on educating and supporting the general public with their mental health over the past year. However, this approach is weighted towards protecting and promoting good mental health. It has not addressed the needs of people with existing and enduring mental illnesses like depression and bipolar disorder.

There is clear evidence that isolation, loneliness and lack of social connectedness are considerable risk factors for mental illness. Over the past year, Aware’s service users have expressed legitimate concerns that the safety measures employed to protect our physical health are having a negative impact on their mental health, exacerbating pre-existing mental health issues, triggering depressive episodes and reducing their ability to access healthcare services and social and community supports which they previously depended on.

Reinforcing these concerns, a 2020 survey of consultant psychiatrists reported an increase in the numbers of emergency referrals and relapses and increased complexity in presentation. It is therefore clear that the impact of these safety measures is not equal across society and that individuals living with depression and bipolar disorder have been disproportionately affected. We are gravely concerned that an already vulnerable cohort is now at risk of significant and long-term distress with very few measures in place to support these groups.

Additionally, loneliness among young people and the related impacts are also a concern following substantial disruption to their social and educational lives. It is important that we understand the potential outcomes and long-term impacts on the mental health and well-being of this generation.

In conclusion, as we emerge from the pandemic, it is crucial that we also prioritise the mental health needs of those living with mental illnesses like enduring depression and bipolar disorder. We now need to educate the public on the symptoms and empower people to reach out for support, offering clear pathways of care and timely access to mental health services. This will also serve to increase awareness and empathy among the general public, therefore reducing stigma for those living with depression and bipolar disorder.

We have a number of recommendations that we would like to present to the committee. Along with promoting positive mental health to the general public, we strongly encourage the Department of Health to be more targeted in its approach to mental health and allocate resources to the most vulnerable in our society, specifically those with enduring depression or bipolar disorder. Aware considers the reinstatement of a national director for mental health within the HSE as a matter of vital importance to ensure a centralised approach to mental health as we deal with the impacts of Covid-19 and with clear responsibility for implementing the Sharing the Vision strategy for mental health. The Government needs to prioritise increasing the mental health budget. While additional funding has been allocated to mental health services over the past number of years, it still falls far short of 10% of the overall health budget, as recommended by Sláintecare. In fact, percentage-wise, it has fallen to just over 5% in 2020 despite the expected surge in demand for mental health services after the pandemic.

Finally, Aware is a volunteer-led organisation and we could not survive without our volunteers and funders. Our total income is approximately €2 million each year. Of that income, 25% is derived from the HSE and the balance of that we have to raise from our own resources and from the corporate sector.

In total, we have 11 full-time and six part-time staff, in excess of 500 volunteers, and approximately 70 trainers we bring in on a short-term basis to deliver our programmes. I thank the members for their time and we look forward to answering their questions.

Chairman

I thank Mr. Layden for his presentation. I request that members who have questions adhere to their time allocation in order to facilitate all members participating in the meeting. We will start with the Fine Gael member, Senator Aisling Dolan.

Senator Aisling Dolan

I welcome the witnesses here today. It is wonderful to have Ms Austin and Ms Dolan, from Pieta House, and Mr. Layden and Mr. Mc Bride, from Aware, are very welcome. It is wonderful to hear through the contributions what both organisations have been doing during the year particularly in lockdown due to Covid. Witnesses have spoken about the increase, nearly one third, in calls to the organistions for support.

I participated in the Pieta House Darkness Into Light event last week. That particular campaign is fantastic because it is driven by local champions. I am from Ballinasloe and represent Roscommon and east Galway. It is very strong in certain areas and it is down to people driving it as opposed to having a structured approach. It seems to be people who lead it. I take this opportunity to thank those champions, those in particular in Ballinasloe, and Castlerea and Strokestown in County Roscommon. They stood up and got all of the community involved. They go out of their way in doing that. I know they are there to support participants because they see the benefit they bring. We see the importance of having organisations like this to support people. One does not always have those services in rural and regional areas. Perhaps next year we will look to improve the weather. I do not know if Ms Austin can do anything about that. It was great to put on the rain gear and the T-shirt over it. I made my way into the fairgreen in Ballinasloe and they had put up a lovely sign at St. John's Church which read "Hope". In every other place, they were doing something similar as well. In spite of the rain, it was great to see that message of hope. As was stated, in excess of 147,000 people supported Pieta House. The fundraising done over recent weeks shows the impact it has on many families around Ireland.

Some of my questions are about the Pieta House organisation. It is very impressive. It was said there is a team of approximately 200 in the organisation to offer supports. The witnesses mentioned clinically trained staff when it comes to one-to-one counselling. What is the importance of that when dealing with people calling in relation to suicide or self-harm?

I thank Mr. Layden for his impressive presentation. I know he has spoken about Aware and enduring mental health conditions, such as depression and bipolar, and that there needs to be a different approach when it comes to enduring mental health conditions. How can we use technology? We have seen during the past year how technology has been used in telehealth and telecounselling. What other ways can we use technology going forward now that we are coming out of Covid?

In regard to partnership for both organisations with the HSE, it has been mentioned that there is approximately 20% funding, which is depended on. That is why the advocacy and fundraising part of everything the organisations do is important because they need the funds to drive the services they deliver across the country. How would the witnesses see the potential future partnerships with mental health services in the HSE?

Could the witnesses outline the top three goals of their organisation for the next three to five years? I might have time to come in again at the end.

Ms Elaine Austin

Senator Dolan mentioned the Darkness Into Light, DIL, communities. We are in awe of our DIL committees. They are absolutely amazing. They start supporting the Darkness Into Light event months before it happens, as Senator Dolan knows. It is incredible for us in the organisation. The encouragement we get from them keeps us lifting our chins, it keeps us moving forward and fills us with hope. The work we do is intense and the support we get from Darkness Into Light communities, our local communities, fills us with hope and gives us encouragement to keep on going. It is amazing and we are so grateful and thankful for them.

On Senator Dolan's question about the importance of having a strong health professional clinical team, it is important for the services we provide and the vulnerable people we support. We provide crisis intervention support for suicide ideation and self-harm, and for those who have been bereaved by suicide. It is really important to us that we ensure they get the best level of care they can possible get, that it is professional and governed, and that there is a standard level of care across the board so that regardless of where our clients come from, or what community they belong to, they receive the same professional level of care. All of our therapists are qualified and accredited. We have in excess of 100 qualified therapists on staff. Ms Dolan might like to expand on that point.

Ms Emma Dolan

Everyone who calls us is in crisis and is vulnerable so it is critical that we have a standard of service provision. As Ms Austin said, all of our therapists are fully qualified and are accredited by recognised bodies. We have a specific approach and model of care they are asked to work to and we provide in-house training to support them in that. The work we do is a testament to them. It is down to their skills and abilities that we were able to adapt and cope so well during the year with the move to phone and video therapy. They had the skills and experience to be able to adapt their ways of working to continue to engage with our clients.

Senator Dolan mentioned the use of technology. We all had to become experts overnight in or around 12 March last year. That has not been without its challenges. As an organisation, we had to embrace and do that. Much of it is about learning how to use the technology, but also investing in the hardware and software we need to be able to provide the service in such a way that there is a positive and seamless experience for the client as well. We want it to be as simple as it can be for them, so they need to feel confident engaging with it. They need to know that we are confident in engaging with it and that they will get the best out of the treatment. Technology has been critical for us and will continue to be critical. We will have to continue to invest in it as we go forward.

We delivered the resilience academy programme for young people in schools. It was greatly impacted by Covid last year with the closure of schools. We were unable to get in to do what we do. We had to do a large amount of work to completely adapt all of our material so it can be delivered remotely. There has been much learning and investment in that team to be able to do that. They are getting back out to schools this term, which is brilliant. We will have a lot of work to do for September as we begin to see the impact of Covid more and how people have adapted to the school environment. We need to be flexible in our delivery. We will probably end up having a hybrid delivery method, with some of it on site and some of it remote, so we can continue to provide services. The continuity piece is a critical factor for us.

Ms Elaine Austin

On Senator Dolan's question about the HSE, we have a strong relationship with it and work very closely with it. We have quarterly meetings and work closely with the National Ambulance Service team as well. Actually, last year we launched an outreach service in Cavan and Monaghan, which was in full partnership with the HSE. We are delighted with that. Last year it did increase our funding, especially for our high-risk clients, given the Covid environment. We are thankful for the support of the HSE and we see opportunities to work more in partnership with it going forward.

To answer the question on the three goals we have, they are clearly about expansion. The demand for our services continues in this Covid environment. Given the support we have received from the incredible donors we have, it is really important for us to expand our current team and deliver more services.

That is what we are focused on. We are heavily recruiting therapists across all our locations and nationally.

On our second goal, as I said in my opening statement, we are drawing to a close our research with UCD, which is supported by the National Office for Suicide Prevention. We will meet representatives of NOSP in the next few weeks to walk through that research and adapt our model to be able to support our clients. Half of our clients are under the age of 25 and one third are under the age of 18. It is important we understand their particular needs and ensure we are continuously challenging ourselves and our model of care to ensure we are meeting their needs.

The third goal is to build resilience. We know the Covid environment has been difficult, especially for young adults. Mr. Layden reinforced that point. It is important we continue to build the level of resilience to give young adults the tools and techniques that will help them to be able to cope. That is another key area in which we would like to continue to invest.

Mr. Dominic Layden

I will address the Senator's points and ask Mr. McBride to deal with clinical governance and our oversight of recruitment and training for our volunteers. We have many volunteer-led services. These are an important element.

I wish address the Senator's strategic question on what our three goals would be. We are going through, with our board, an extensive strategic review for the next three to five years. We have to embrace the impact of Covid-19. Those of us who lived through and saw the impact of the financial downturn in 2008 and 2010 and the establishment of the National Office for Suicide Prevention will recall that the impacts of the downturn, including the loss of jobs and incomes, on people’s mental health were felt two or three years afterwards. We then had the many housing and other issues that arose. We are all hopeful we will be able to travel and put Covid behind us at some stage this year but we are likely to see major challenges, particularly within those communities that have been most impacted by Covid-19. Our strategy must reflect that and we are working through that. As we move forward, our key emphasis will be how to reach out to those with enduring depression and bipolar disorder, the 5% of the population who will have the condition of depression. We are concerned about that group and how we can provide services to these individuals as we move forward. That will be a key thrust for the organisation. Mr. McBride might deal with how we oversee the clinical aspect, how he envisages technology being used and how we will manage that in the future.

Mr. Stephen McBride

On the use of technology, we envisage continuing to use the Zoom platform to provide support and self-care groups, with a view to opening up the face-to-face offering of our support groups nationwide later in the year, as restrictions allow. We will continue to use that technology which, as Mr. Layden indicated, helped to reach new audiences by enhancing accessibility for people who were able to attend our support groups from the comfort of their own home.

With regard to people experiencing bipolar disorder, we are in the process developing a bipolar programme, which we hope to pilot later in the year. That is in the offing.

On the recruitment and training of volunteers, we have an open expression of interest on our website for any member of the public in Ireland to express an interest in volunteering with us. Following that, we have an interview process with the specific service manager followed by five half days of training before someone goes live with any of our services. Following that, we have ongoing routine education and refresher training mornings or afternoons to make sure people are providing excellence in service as per our standards.

Senator Aisling Dolan

I thank Mr. McBride for that information, which shows the importance of volunteers to many organisations. Where would we be without them? It is important to get training and support in place to help volunteers do everything they can in what will probably be difficult conversations they will have. I thank the representatives from Pieta House. Well done to them on everything related to the Darkness into Light event this year. It is incredible to see the support that has been given. Aware has been part of the support that is in place. The HSE needs to take into account the support it offers these organisations to maintain the services they provide.

Deputy Pat Buckley

I thank the witnesses for attending today. I know they are all busy. I always put my cards on the table. Any service that improves mental health services, people's mental well-being and the wellness of individual and families is always welcome. One of my passions in the mental health area is education. The other is destigmatising the issue of mental health and pointing out that it is not a contagious disease.

To address Ms Austin's point about introducing the issue of mental health in schools, I am running a survey in schools and a parallel survey on the effects of Covid with respect to mortgages and other matters. The latest survey done on this issue revealed children found the safest place to be was in school when it came to opening up about mental health difficulties. Have the witnesses from Pieta House and Aware ever found resistance from schools to the programmes they tried to introduce? I have had some ridiculous conversations on the subject down the years. I have been told that talking about mental health or suicide puts ideas into young people's heads and they will go away and do it. I cited the argument that giving a young person €20 to put petrol in a car does not necessarily mean he or she will crash it.

On the stigma issue, it is very tough for people in certain services such as the Army, the Naval Service or the Air Corps to come out and openly admit they have a mental health difficulty because they could be punished. They can forget about going for promotion, for example, or going overseas as it would involve using live rounds of ammunition. That is a bit deep. How would the witnesses overcome that barrier?

As was said, the reinstatement of a national director for mental health is vital. It is madness that we do not have proper procedure and a clinical director in place. I like the way the witnesses spoke about forward planning. The impact of what we have experienced will not be felt tomorrow, next week or in five months' time. Rather, it will be 12 or 18 months before the tsunami effect of Covid will hit. It will hit everybody, including children, people who have lost their jobs, the elderly and people in rural Ireland who have been isolated. Its impact will be felt all over.

I have two further questions. Do the witnesses believe their organisations were born out of frustration and the lack of genuine commitment shown by all Governments down the years? I am a firm believer in pilot projects and I have argued with previous Ministers about their merit down the years. Irish people are very slow to buy into something unless they see it working first. We can have a vision of a plan but people want to see it in place before they will buy into it. If the witnesses were to approach the Government for funding and point out that information is available, and we know the demographics of areas where suicide is higher than it is in others, they could propose a pilot project with full wraparound services, prove that it works and then try to replicate it. I have seen what has happened down the years and I am not attacking that. I know from my life experience that people get involved in this area because they have a connection to it in one way or another.

I know from my life experiences that people get involved in this because there is a connection to it, one way or another. It makes one passionate and when one is passionate, one is stronger and will drive it. However, I have noticed over the years we have so many NGOs in the country which are all, obviously, passionate but we are all running parallel when it comes to mental health services. Will there be a possibility in the future of national conferences on A, B and C, in which organisations such as Pieta House, Aware and SpunOut are in one room and pool their resources to come up with a full plan in which everybody can help everybody?

I am not talking about Twenty-Six Counties but Thirty-Two Counties, because this has to go across the island of Ireland. It does not matter what colour, class or creed we are, we all bleed. I am still looking at that big conference in which the organisations pool their resources, because the disability sector is something which has been left behind also and there is significant mental health stress there. I had the opportunity to go to Middletown two years ago, which is strange given I am from Midleton originally, but I am referring to Middletown Autism Centre which is the only all-Ireland autism specialist unit.

It is funded by both the departments of education here and in England. I am trying to paint the big picture. Would the witnesses ever envisage coming together to say they were more or less doing the same thing for the right reasons and could complement each other by pooling their resources and tying up together. Do they ever envisage that? I know that is a lot to take in but that is the only time I will speak here today.

Ms Elaine Austin

I thank Deputy Buckley for asking the questions and giving us his insight and thoughts. I would like to answer the last of his two questions first. The journey we have been on in the past year has made clear to us we have to focus on expanding our services. We appreciate the tough year people have had. Considering the impact Covid-19 has had on people's lives, it is important we are here and can deliver our services.

I want to be clear on the services we deliver. We deliver crisis support services for people suffering from suicide ideation experience and self-harm and people who have been bereaved by suicide, so we are different from other charities doing fantastic work in mental health. For us, it is about delivering crisis support.

We should most definitely come together to be able to support each other and work collaboratively. It is important. Together, we can do more and create better outcomes for our clients. It clearly states in our national mental health strategy it is important there is an integrated, multisectoral and multi-agency approach. We can work better right across our services to ensure everyone gets the appropriate care, regardless of where they enter or exit the service, and ensure there are appropriate referral pathways and a journey to a better client experience.

It is important we collaborate and come together to see how we can support each other for our clients, to ensure they get the help they need, because we support people in a vulnerable place. It is important we support them to find their hope and move forward.

Deputy Buckley asked us whether we have ever felt frustration. In 2006, our founder, Joan Freeman, had a vision. Our love for Ms Freeman runs deep across the organisation. She had a vision of being able to provide crisis support. It is important to us we continue to be able to support our clients and offer counselling so they can improve their overall mental health and well-being.

I will pass to Ms Dolan, if she has anything she would like to add on those two questions.

Ms Emma Dolan

I will speak to the point on collaboration. Core to the present national strategy of sharing the vision is agencies collaborating and working together and we are behind that. As Elaine said, we work in a specialised area within mental health and suicide and self-harm are complex. Not everybody who experiences mental health issues will experience suicidal ideation or self-harm and not everybody who experiences ideation or self-harm will end up in mental health services, but many people who come to us will have depression or bipolar disorder.

I am conscious there could be an organisation here today we would be able to collaborate with and complement in the services we provide and there are many agencies out there we could complement with our service provision.

Deputy Buckley talked about awareness raising and reducing the stigma. Darkness into Light and similar events contribute to creating a conversation on mental health and on bringing it out into the open and creating a space to talk about hope and recovery. Pieta House is rooted in a recovery model and approach and events such as Darkness into Light support that. The members are probably aware of our campaign "Know Suicide. Know the Signs". That is about creating those spaces and conversations and getting people to ask the questions and feel confident they can hear how people are and then support them to access services, which is critical.

Going into schools is at the core of prevention in terms of ensuring one can build resilience for young people and ensure they feel safe and comfortable in talking about their mental health. Our experience has been schools are calling out for these kinds of programmes. We have not seen any resistance at all. We have had a year-on-year increase in schools calling for us to look for our resilience academy programme to go into them, which means they recognise the need for it.

I talked a little bit about developing our programme further, going forward. Critical to that is supporting teachers to feel confident to have conversations with young people about their mental health as well. We know they have had incidences in schools. There are young people who are engaging in self-harm and, sometimes, teachers are wondering what is the best way in which they can support a young person through that and help them access the right services. Sometimes we put a lot on teachers to hold everything. It is giving them the information and making sure they are clear about the pathways which will help. The resilience academy has helped with that.

Deputy Buckley talked about pilot projects. He is right in that they are critical. We have talked to vulnerable groups today who will probably be particularly affected by Covid-19. They are groups which may have had pre-existing conditions, groups we already know are at increased risk of suicide and self-harm. We need to focus on developing solutions we know will work for them and break down barriers for them to access our services.

Historically, mental health services have been set up in a particular way, so we all have a responsibility to look at our models and ways of working to ensure we are accessible and that what we do works. As Deputy Buckley said, the only way to do that in a safe way and to ensure that evidence base is generated is by having pilots through which one builds up that knowledge to build programmes which work.

Deputy Pat Buckley

While Darkness into Light fabulous and worldwide now, I want to make a point after having spoken to people who attend it. There could be thousands of people there but I want to make people conscious that I spoke to people who still feel as though it is the loneliest place in the world for them. It is no reflection on anybody, it is just the personal view of some people that even when surrounded by people in similar circumstances, they still do not get it and feel very lonely.

I will go back to Ms Dolan on the education programmes. I said to the witnesses the funding from the likes of the HSE is small enough. Did Ms Dolan find any resistance in the schools? Is the HSE supportive of the organisation going into schools or does she find resistance there? I am trying to get a bigger picture.

Chairman

I will go to Mr. Layden and Mr. McBride before Ms Dolan answers that question. I am concerned about time.

I will come to Mr. Layden and Mr. McBride for the moment. Maybe they can respond first. I will come back to Ms Dolan.

Mr. Dominic Layden

To answer the Deputy's questions on collaboration, I will, for the benefit of the committee, comment on the strategic issues Ireland is facing. We previously had the health boards, the structure relating to which was decentralised. Then we moved to the HSE, a centralised structure. We have decentralised that again and we have Sláintecare coming on stream. I suppose what it might reinforce is why Aware is calling for the reinstatement of a national director of mental health. That was contained in the original recommendations in A Vision for Change in 2006. There is a need for a director of mental health at national level. The best way of bringing collaboration of organisations is at a policy, structural and infrastructural level which can allow that and conversations relating to it to take place.

Ms Dolan referred to the National Office of Suicide Prevention calling for collaboration. We fully support that. The other aspect is that there are eight or nine HSE regions and we have to go around each one of those looking for funding. We are a national organisation asking a region to give us, in some cases, maybe €8,000 in financial support. That should be done at a national level. In some instances, the National Office of Suicide Prevention is supporting us at a national level and that is really welcome. We have an excellent relationship with the team in the HSE at a central level and with the National Office of Suicide Prevention but the message I would like to get across is that the structural issue is the important aspect.

In the context of Pieta House, Aware and the Samaritans, in Aware's case, we have a senior manager in Pieta House who will be addressing our volunteers where we are informing our volunteers of the Pieta House services. At a ground level, there are many different collaborations that take place. We transfer our support lines at 10 p.m. to the Samaritans, but the Samaritans, because it is handling 500,000 calls a year which relate not only to mental illness but also to relationship issues, financial issues and distress, refer the people who are calling about depression back to Aware. At ground level, there are different levels of co-operation.

On the Deputy's question regarding the schools, we have been going into the schools for over 20 years with different programmes. Demand, in simple terms, far exceeds the supply that we can deliver. We have never had a situation where somebody is concerned about us coming to a school and how the programme might be delivered. Clearly, there were Government guidelines worked out between the then Department of Education and Skills and the Department of Health when the former Deputy, Kathleen Lynch, was Minister of State in respect of the type of programmes that should be delivered in the schools. People going in for an hour or half an hour to give a talk - in the past we would have brought in somebody who might have experience of depression to give a talk - is not best practice. There is a need for structured programmes. We need to make sure that the people who are going into schools know what they are talking about and delivering their message in a safe way. This is so that we can avoid the types of issues to which the Deputy referred

The final question was on whether we would get funding for a pilot project if we were to go back to the HSE and ask for it. I am delighted because Mr. McBride referred earlier to our programme for people who are bipolar. We went to the HSE, only last October or November, with a proposal for funding for a pilot programme. Thankfully, the HSE is supporting us with the programme. The entire amount of funding for that programme is coming from the HSE and we will be piloting that this year for a roll-out.

Mr. Stephen McBride

On Deputy Buckley's first question, in the context of the training that we give to our training partners and contractors and their ability to establish solid working relationships with the schools that they work with, we experienced little or no resistance in the delivery of our life skills schools programme. That is great to say and all credit to the training they receive and the calibre of candidates who apply to train on our behalf. To date, we have delivered 65 of those programmes across ten counties in 2021, reaching approximately 900 senior cycle students, both virtually and in class.

Deputy Pat Buckley

Excellent. I thank Mr. Layden and Mr. McBride for that. It is just my passion. Education is the key.

Chairman

Did Ms Dolan want to respond to Deputy Buckley with a short answer? I am concerned about time.

Ms Emma Dolan

In the context of resistance on the part of the HSE, the HSE is keen to ensure that there is a proliferation of education programmes going in to schools. It wants to engage with providers, such as ourselves and Aware, to ensure there is consistency and that we meet best practice guidelines. Therefore, there was no resistance. Definitely, the HSE is keen to have that partnership approach and we are keen to engage in it.

Chairman

I thank Ms Dolan.

Deputy Pat Buckley

My apologies, if I took up too much time.

Deputy Neasa Hourigan

I welcome all of our guests and thank them for their incredible work over the past year. I am sure it has been a very challenging time in terms of service provision and their own working environment.

I want to stay with our discussion around complementary service provision and the future of service provision. Hopefully, we are moving into an era of Sláintecare. We have some announcements around that this week and the true implementation of Sharing the Vision. I suppose I want to give both groups an opportunity to outline what they would hope to see. What would their vision be for mental health service provision at that community level in terms of a primary care system? What should it look like? What would be the important staff positions for them to be able to interact with? What could their role be within that or how do they hope that would play out for their organisations?

Chairman

Does Ms Dolan want to come in there?

Ms Emma Dolan

Complementary service provision is obviously key to our current national strategy. I think we do that very well at present on the ground. Going forward, what we need to do better is to construct our services around clients, their needs, their pathways and what will work for them. Too often, we look at it from the perspective of how we provide the service and how we manage our resources within that. There is a challenge for us all there to ensure that we are accessible, no matter what service somebody comes to initially or no matter where he or she first reaches out and asks for help. That is critical. Within that, there is work for all organisations to ensure that there are clear referral pathways between us and that there is good inter-agency co-operation. Much of that requires detailed thought about issues such as consent and information-sharing and trying to keep the client at the heart of that so that he or she is fully aware of the services that different entities provide.

When people access health services, they can have many professionals engaging with them and they are not clear what are the roles of all of these various people. The onus is on us to be clear about what we do and what we are there to help them with and multidisciplinary working becomes critical. Over the years, we have become better at that. There are challenges involved. Every individual discipline usually has an ideology, a way of thinking or an approach to working that those involved bring to their engagement with clients. That can differ from profession to profession and from organisation to organisation. There is a challenge to make sure that we all have a language that we can use with each other that is consistent, that we understand where we are coming from and that we are doing the work to ensure that the client is being provided with a seamless service and is not having to try and figure out who is filling in what piece of the puzzle for him or her. Person-centred care planning becomes critical in that, as does good case management that one has one person who his holding the lead on cases and co-ordinating the full package of care that is offered to people.

For ourselves, we are very clear that our specialism is suicide and self-harm. We would, I suppose, anticipate that we would be called upon to participate in case management situations where people were experiencing those sorts of crises. That is the specialism we are bringing to the table in that regard.

I do not know if that answers the Deputy's question.

Chairman

Does Ms Austin want to come in there?

Ms Elaine Austin

I thank Deputy Hourigan for the question. We deliver a really high scale of service delivery to our clients so it is really important to us that they have access to our services and that there are therapists available to support them. Last year we delivered 52,000 hours of therapy for clients so it is really important that we are nationwide, that we can support communities right across this country and that we are integrated into our community services. That is really important for us going forward. Given the sheer scale of service delivery we do, it is important we are an important part of that overall system, especially the primary care system.

Mr. Dominic Layden

I might be able to answer the Deputy's question about the vision and what we would like to see in five or ten year's time. To do that we just have to look immediately at what are the key issues and obstacles before we get to the vision-----

Chairman

We lost Mr. Layden for a moment.

Mr. Dominic Layden

Can everyone hear me now? There are significant waiting lists out there for people waiting for counselling and services. The second issue is the demands being placed on our GPs in primary care. If a person goes into a GP today, how much time is he or she likely to get from them? Probably 15 to 20 minutes. When a person with depression turns up at a GP's office, he or she does not go in and tell the doctor he or she thinks he or she has depression. That is not the language the person will use. Also, men express it differently to women. Men might come in and say they are stressed and will not use the word "anxious". Therefore, to have a conversation about somebody's mental health takes longer, it takes a period of time and GPs do not have the resources.

Recognising that those are two of the issues, the vision we would like to see is one where organisations like Aware, Pieta House, the Samaritans, Jigsaw and others are actually integrated in a much closer way and seen as part of the solution and part of an integrated package of primary care. In that scenario, a person having suicidal ideation and talking about suicide can visit the GP, who is the best person to figure out that he or she needs to get an appointment for Pieta House and refer the person on. Similarly, if a person is coming back and is a regular patient with enduring depression over a number of years then he or she needs to be going to Aware and the GP can refer him or her on and set him or her up. Also, if people are waiting for programmes from the HSE or for counselling, we have a number of free adult programmes. There is no reason why a person cannot, instead of being on a waiting list and not getting a service for 12 months, be referred to a free cognitive behavioural therapy, CBT, programme delivered by Aware.

Therefore, our mindset must change, such that the role of the HSE is not just about grant-aiding but is about looking at a number of the organisations and seeing how they fit as part of an integrated solution in respect of mental health. That may now fall into the Sláintecare piece. My vision is that eventually, when a person walks into a GP practice or into the HSE, that we are integrated and somebody can tell them which door to go through based on the right pathway for him or her. That might be a bipolar programme from Aware, a counselling service from Pieta House or youth mental health counselling from Jigsaw. It would be much clearer for everybody with much clearer pathways, and would be integrated.

Deputy Neasa Hourigan

I thank the witnesses. Mr. Layden said some really important things there that are worth reiterating. One is the importance of the referral system and clear pathways that include the type of services the various organisations offer. I refer also to the availability of free services out there, in case anybody is watching this and needs services. There is also the piece around the incredible work GPs are doing. They are often the first person someone will come to for help and they often struggle with referring people on to waiting lists and lack resources to support people adequately, so it is really important to say. They are doing incredible work.

I will ask one more very quick question if I have time. Perhaps this is more of an issue for Mr. Layden because he has mentioned it. I am interested in the family supports aspect. It is something that comes up a lot, certainly in my constituency. I am thinking of the impacts on children and on the wider family and the recognition that it is a closed loop because if a person's family has been struggling, that puts stress on the person who is already struggling and recognition of that could really help many people. Does Mr. Layden believe that Sharing the Vision adequately recognises that? How does he think we should progress that issue?

Mr. Dominic Layden

That is a great question and a really important one. For anybody who is living with or who has a loved one who is experiencing depression, not only is it having an enormous toll on the individual with depression, bipolar disorder or other mental illness, but the toll it takes it takes on the family is absolutely enormous. The first question we must address is whether the family is equipped. Do they have the language, understand the symptoms or understand what their loved one is going through? How do we educate them accordingly? At Aware, we have, over the past three years, developed a relatives and friends programme specifically to address that self-care piece for the individual and family member. I might hand over to Mr. McBride. He might give a brief synopsis of the relatives and friends programme and who it is addressing.

Mr. Stephen McBride

I thank Deputy Hourigan for the question. It is a psycho-educational programme that puts the supporter, relative and friend right at the centre of it. What oftentimes happens in the relationship dynamic is the mental illness becomes front and centre of the whole family dynamic. Therefore, by supporting oneself, the reverberations of that are manifold and there is a positive impact on the relationship between the partner, loved one or parent and the person who has the mental illness. It is really about trying to allow and facilitate the space for such individuals themselves to pay attention to their own needs and mental health and to buttress and support themselves in this supported psycho-educational environment. That is the thrust of the relatives and friends programme.

To return to the Deputy's earlier point, it is also important to see how research informs practice and vice versa, how practice informs the research that can be done into the future to keep on top of the current trends to do with the people who are presenting and the difference as life goes on. The needs of 2023 may very well be different to those of 2021.

Deputy Neasa Hourigan

I thank Mr. Layden and Mr. McBride.

Chairman

Does Ms Austin want to come in there?

Ms Elaine Austin

I just wanted to reinforce what Mr. McBride said there about the research piece. This year we invested in research roles within Pieta House to support us in dealing with our overall information internally within the organisation but also to look at starting to ensure we are consistently challenging ourselves to deliver a really effective service.

The other piece I wanted to mention is that in Pieta House, we offer key support as well to family members and friends to support that person as he or she moves through his or her 12-week counselling journey. Going forward, part of our key focus will be that adaptation, which will also bring in more support for that family to be able to support the child or young adult who is receiving the therapy.

Deputy Neasa Hourigan

I thank Ms Austin for that information.

Chairman

I call Senator Conway.

Senator Martin Conway

I thank both organisations for their presentations of superb quality and insightfulness and for the incredible work they do. I have been a long-time participant in Darkness into Light. Ms Joan Freeman was a colleague of ours in the last Seanad and we certainly all benefited from her passion, commitment and clear determination to deal with what was, and still is, a major crisis. She can be rightfully proud of what Pieta House continues to do for people in this country.

Something crossed my mind when I was listening to Deputies Hourigan and Buckley speak about the proliferation of organisations. As a committee, we have to sit down, compile a report and make clear recommendations to Government in terms of the way forward and then advocate to try to get those recommendations implemented.

Mr. Layden said Aware has clear recommendations that it wants to send on to us. We would welcome them. I have no doubt that Pieta House has ideas and recommendations as well. From listening to the representatives of Pieta House, the past year has demonstrated the need to expand our services. I believe we would all welcome that.

I have a concern about the proliferation of organisations. As Deputy Buckley rightly said in his contribution earlier, a local organisation is usually set up because of a personal tragedy and people wanting to give something back. Usually, either a close friend or family member decides to do something. Fundraisers are set up and then we have people doing good things. While many people are doing good things in many parts of the country, my fear is that it is not co-ordinated and channelled in a professional way and that although they are well-meaning, they are not achieving what they should.

I would like to hear the witnesses' thoughts on how to deal with that. When a community left bereft by a suicide decides to do something and sets up its own organisation with its own ideas, how can we benefit from and channel that energy but at the same time ensure that the money raised by people is directed in the right way? What protocols should be in place or what should be done in that regard? Do the witnesses understand the point I am making? One wants to harness the community that wants to do something but at the same time channel it in the right direction. We will have to address that in our recommendations and I do not quite know how we can deal with it. That is the first point.

A point was also made about the importance of education. A great many of these local community organisations are going into schools and talking about mental health and mental health challenges. Again, I am not sure of the quality of the programmes they are presenting. How does one go about respecting the sensitivities of people who want to do good while at the same time ensuring that what is being delivered is appropriate and achieves its purpose? I have no doubt but that the common goals are the same but the manner in which people try to achieve them may vary. I have concerns that people who are going into schools around the country and delivering well-meaning programmes, talks and engagements with young people may not be achieving the results they would desire. The witnesses might give me their thoughts on those two points.

Chairman

Who would like to come in there?

Ms Elaine Austin

On Senator Conway's point around the community, we are unbelievably thankful for the support we received last weekend for the Darkness into Light event when 140,000 people came out right across communities nationwide. The Senator made the point about passion and challenging that support. The support that Pieta House received was really incredible. The Senator is correct; it does often come from that lived experience. It comes from people who have lost a loved one to suicide hoping there is an opportunity that they can help someone who is currently struggling and that through their support, they can help that person to get the services he or she needs to really move forward.

The support and passion for the Darkness into Light event on the part of those who come out and support us also shows they really want to reduce the level of stigma attached to asking for and receiving help. That is really important. It is clear to us in Pieta House that each and every person who participated has a deep connection to our cause, to the services we deliver and to the people we support. Having the event is really fantastic. It is an unbelievable support to us with our funding structure, with 80% of our funds coming from donations. It is, however, also a nationwide event that allows people to really come together and unite.

In my opening statement, I talked about that collective voice. That collective voice is really clear to us; we must continue to expand our services and challenge ourselves to do more. It is an unbelievable and fantastic example of people really coming together and showing that passion and commitment. I wanted to make that point regarding the Senator's statement on communities and what we can do. For me and the team at Pieta House, the amount of support we receive from our communities is phenomenal and we are hugely grateful for it.

Senator Martin Conway

In the case of communities that go on solo runs, for instance, which do not necessarily connect with Pieta House and which sometimes set up their own type of services, have the witnesses thoughts on that or on how they can reach out to perhaps bring these services under their remit?

My concern is that a community might set something up in the name of a loved one who died, which happens in various parts of the country, and collect money and then set up their own localised services. The witnesses spoke about expanding Pieta House's services. Perhaps there is something it can do as part of its expansion to bring these various existing groups into its structure .

Ms Emma Dolan

As service providers, we are acutely aware of the importance of having people with lived experience involved in the development and delivery of services. It is great when one sees such community activism and the communities feel empowered that they can do this. The Senator is correct; there is a challenge with regard to ensuring that those organisations understand and appreciate the need for good clinical governance with the work they are trying to do. That is a challenge for the HSE, in particular, in its commissioning process when it is engaging with communities to educate them on the need for governance, what is involved in that and how they can put those structures in place.

I believe the Senator also spoke a bit about schools. I know the Department of Education has brought out excellent and comprehensive guidelines in terms of the standards it requires when delivering programmes into schools. Again, there may be a piece of awareness raising to be done with community groups on the need for governance by both the HSE and the Department of Education in that respect.

Senator Martin Conway

I know I am probably running out of time. Finally, the problem is that those-----

Chairman

I am sorry, Senator Conway. Did Mr. Layden wish to come in before the next question?

Mr. Dominic Layden

Yes, I will follow up on Senator Conway's question and what Ms Dolan said. Is the Senator's question around somebody starting up another organisation in a local community on the basis of perhaps a suicide in a family?

Senator Martin Conway

Exactly.

Mr. Dominic Layden

First, I do not believe it is unique to Ireland at all. In fact, if one looks around in other jurisdictions, one will find very similar situations. People are coming up with different solutions and ideas and the public are looking for different choices as well.

The fundamental point, however, which perhaps we are addressing, is whether there are too many organisations in the space of mental health if we have leading organisations such as Pieta House and its Darkness into Light event and Aware. I am not sure, however, if the organisations here today, or any others, can actually control that. That is a commissioning issue. If somebody wants to start something in a local community and is seeking funding from the State, then ultimately, the State and the HSE have to decide if that organisation should get funding or not. I do not believe our organisations can control that. That is what we would impress upon those who are involved. That is why I believe the solution is that it would come under a national director for mental health services. One does not, therefore, have a situation whereby it can happen locally without a national director. While the local HSE region in Limerick or Donegal or wherever might, therefore, decide to fund somebody, who is looking at the bigger picture at a national level? The co-ordination at a national level is important to address those questions but in my view it can only be addressed by the HSE in terms of the funding that might be coming from the State.

The second aspect concerns going into the schools. There is a framework, although I cannot remember the name of the document now, that the Departments of Education and Health came up with in 2004 or 2005. It is a clear framework, there was a big launch for the programme, and there has also been a follow-up document. Those framework and policy documents went out to all schools. The question now is if that aspect needs to be re-emphasised. Perhaps the Department of Health or the Department of Education or both need to reiterate the message concerning the importance of allowing organisations which are evidence-based going into schools instead of someone coming along and telling his or her own story.

Mr. Stephen McBride

To add to that point in respect of the quality of programmes, we have our own internal audit and assessment system. Our training partners delivering the life skills schools programme are assessed, if not twice a year then at least once annually, to ensure they are adhering to the training standards and framework with which we comply. That provides quality assurance in that regard.

Senator Martin Conway

That is fantastic, and that is where I was coming from with that point. Perhaps this is a matter on which we might ask representatives from the Department of Education to appear before the committee to find out how the Department feels its protocols, policy document and associated advice are working in schools. Are many schools breaching those protocols? I ask that because I had a situation where a very upset school principal contacted me. She had refused to allow representatives from a well-meaning organisation into the school because it did not meet the standards, in her view, set by the Department. That organisation took great offence and the situation caused a great deal of concern and pushback within the community, which was unfortunate. All the parties were well meaning and wanted to achieve the same thing. Clearly, however, there must be standards in respect of education. Part of our recommendations, therefore, will be on that point and concerning tightening up those protocols.

Regarding the proliferation of organisations, I agree with the witness. It can easily be argued that Pieta House was set up in an organic way and since then it has mushroomed and developed into the phenomenal organisation that it is. Sadly, many organisations do not follow that path and do not have the requisite capabilities.

On the issue of shared services, I like the idea that when people are diagnosed, they are recommended to go to Pieta House, and if it is a different and more long-term situation, they are advised to go to Aware. There must be some formalised structure in that regard, including service level agreements, SLAs, between the organisations. Does something like that exist now? Are there formal agreements between Pieta House and Aware or are there any formal links with the HSE? I ask that in respect of referring people on for help and the sharing of services. The most effective way of helping people is by referring them to the most appropriate organisation to deal with their needs.

Mr. Dominic Layden

My reference in this respect concerns primary care and GPs. Therefore, that is an informal aspect. It is about education and ensuring the information is available through the Irish Medical Organisation, IMO, and the other medical organisations. There is a type of referral path, again on an informal basis, at the HSE. We communicate what we are doing at the local level to the HSE and it can then refer that information onwards. We do have agreements with the HSE. Regarding the referral path and the pathways to care, where we are at and how we see it is that it is on an informal basis.

Senator Martin Conway

That is fine. I thank the witnesses. Regarding specific recommendations in respect of formalising these structures and having formalised service level agreements, if there is a structure that may be working abroad that the witnesses would suggest should be looked at as part of our recommendations to Government in our report, we would very much welcome that.

Chairman

Finally, I call Senator Hoey.

Senator Annie Hoey

I thank everyone for their presentations. This is always my favourite committee and my favourite part of the week, even though it is such a difficult topic. I find it to be one of the most useful things I attend and participate in because I learn so much and concrete aspects emerge in respect of what this committee can recommend and advocate to help the witnesses' organisations and their service users.

I have several questions. Pieta House and Aware emerged from a need because services were not being provided. Were we to go back and recreate the system, do the witnesses think if the structure we have of the witnesses' organisations, which are mainly volunteer led and which try to work in conjunction with our health service to provide these services, were fully resourced, it would be the most effective way to do this? I have spoken to people about this aspect, and there seems to be two sides to the issue. On one side, people say it is very effective to have specific organisations that deal with specific matters and go out into communities in that regard. On the other side, people say services in this regard should all be centralised and provided by the Government in one place and be filtered out from there. Do the witnesses have any thoughts in that regard? If we were designing the system now, how would we do it? I came to this question one year ago with a specific view, but now that I have spoken to organisations and seen the work people are doing, I have a different view regarding effectiveness. Do the witnesses have any thoughts in that regard?

Waiting lists are a topic that is a favourite for discussion by everyone. People have told me they would not even try to avail of a service because they know the waiting lists are so long. Will the witnesses elaborate a little on that aspect? We do not know who is watching this session, but regarding people who need to avail of these services, what is the reality of being able to access them in a timely manner? What is that timeframe? I was struck by this issue in recent months. When people contacted me about where to go for help, I suggested possible places but they would just say it would not be possible to access those services because the waiting lists were too long. What can this committee do to try to help the witnesses' organisations deal with this situation? The answer may be the provision of money and resources, as always.

I was also interested to hear about the bipolar pilot programme. Is there anything else being planned in this regard or do the witnesses from either organisation have any thoughts regarding other similar programmes in respect of visual processing disorder, VPD, or attention deficit hyperactivity disorder, ADHD, for example? We are miles behind in this country regarding adults with ADHD. It is very difficult to get diagnosed, and it is a challenging space for an adult to be in, especially regarding supports. Do the witnesses' organisations have any thoughts or plans in this regard?

Mention was made of an integrated package and GPs knowing where to refer people. I have spoken to several GPs who would love to have effectively integrated sites. They have offices in their buildings which are not in use and they sometimes end up renting them out. Instead, those GPs would love to have a dietician or a mental expert or both on site. In the long term, would that level of integration be something Pieta House and Aware would like to see between the organisations and GPs' offices, effectively becoming a central hub of well-being, or would the integrated model be seen more in respect of referring people on to the services provided by the two organisations, as outlined?

Reference was also made to auditing the trainers who go into schools. Is there any follow-on study of success for those students? I am not sure if we could define what success would even look like in that regard, but I refer to a follow-up regarding whether students are taking these life skills on board and using them. Are there any plans, even in the long term, to do something like that?

I have asked oodles of questions. I thank the witnesses in advance for their answers.

Mr. Dominic Layden

The first question was on whether the State should do everything as opposed to having a role for independent NGOs to operate in the sector. I am firmly in the camp that we need NGOs in the sector. The reason is that they are organic, come from a local community and can respond to real needs and issues really quickly in a very cost-effective manner. While I do not want to use the word "bureaucracy", large organisations must go through the recruitment process that might be involved, work out payscales and do all the other things that involves. We have kept an organisational model with a very small core staff of 11, alongside five part-time staff and over 500 volunteers and trainers who are hired on a sessional basis to deliver the programme. That model can be scaled up or down depending on funding. There are real benefits to that in terms of speed and access. We have only been in the process, as a clinical committee, of finalising the bipolar programme in the past two weeks but I am very confident that we will have the programme piloted and ready to go by October. That could take longer if the programme was moved into another organisation. That is why I am firmly in the camp of needing NGOs.

I am trying to remember all of the Senator's questions. She asked what the evidence base is for delivering the schools programme. That is a really difficult question. Jigsaw is not represented today. Youth mental health is its primary work and it is the expert in that area.

The programme we deliver as part of the schools programme is a psycho-educational programme. It is about teaching skills and is not designed to do interventions or treatments for individuals. We do not determine that a child had depression and his or her mood has improved. The programme is about teaching skills. It would be impossible to deliver another type of programme in four weeks in fifth year or transition year. If we consider the long-term impact of that on society, we are teaching coping skills to young people in combination with all of the services provided by Aware, Pieta and the State. There will always be a challenge around funding. If we decided that mental health was much more important than just spending 5% of the health budget on it, the State would need to really commit. The State is spending 5% or thereabouts of the health budget on mental health and we are trying to apply a sticking plaster to the issue in schools. That will not give us the desired outcome.

If, however, we adopted a strategic perspective and vision for mental health involving teaching skills, prevention and supports so that every child doing the leaving certificate was equipped with some basic skills, we might find in research in ten or 15 years' time that the mental health and mood of the nation had improved and we are able not only to deal with good mental health but also the cohort of people who have a mental illness. That is how I would frame the question. We have worked with UCD and had master's students evaluate all of the work of children who do the programmes with us in terms of their understanding. There is research and there are things that can be done.

Perhaps Mr. McBride and Ms Austin wish to respond.

Ms Elaine Austin

If we look back at the last year and the impact of Covid, it all came upon us very fast and Pieta needed to react very quickly. As Ms Dolan will remember, we transferred all of our services to the telephone over one weekend because we had to take people out of the centres while we got them ready to go back, in a Covid environment, and ensure the safety of our staff and clients. We had to be extremely agile and adaptable in that situation.

We have a really strong, clinically governed model of care. We also adhere to the governance code and our standards to ensure we continuously deliver a professional service. We have more than 200 therapists. It is, as I said, a large-scale team. With regard to sustainability, our funding structure, where 80% of funds come from donations, and the scale of delivery of our clinical services, meant that is a significant year-on-year undertaking for Pieta. We are investing in training staff, expanding and adding more therapists to our teams. We are investing in governance, research, technology and infrastructure, everything a really good organisation needs to be robust and ensure the continuous delivery of a very high standard of care. We have to do that in the context of our sustainability and that is a significant challenge for us. The support we received last year and this year has definitely given us confidence and stability. Sustainability is always a priority for us in the organisation.

I will ask Ms Dolan to respond to the question on waiting lists.

Ms Emma Dolan

On the question of whether we would design the system again, I very much agree with Mr. Layden that the services have come about because there has been a need. As Ms Austin said, given what we do, how we do it and that we are an NGO, we have the ability to be flexible and adapt quite quickly. That is why we exist and it is recognised by the people who access and commission our services.

There has always been a demand for our work. Pieta has always operated a waiting list and we work really hard to keep it as low as possible at all times. Having our 24-7 helpline is critical because it means we are always there for people when they pick up the phone. While they might have to wait a couple of weeks for treatment, we also provide emergency appointments and make sure we have capacity within the system to do that. People may have to wait before they begin treatment with us but we are available to provide support if they are in crisis beforehand.

The Senator mentioned BPD and ADHD. There are other organisations that specialise in those fields. We would welcome the opportunity to collaborate with them if they felt that our skills and expertise were something that would help them.

On integrated packages, I love the idea of everybody being on one site but remote working has given us more opportunities to do that in a different way. There could be challenges with building planning and space planning. However, having some kind of a hub where people can come together makes a lot of sense because, as we all know, it is through relationships that we work better together.

That in-person contact and those forums are needed to meet, work through ideas, problem-solve and create environments for engagement and discussion in order to improve our services.

The final matter to which the Senator referred relates to the outcomes or the impact of the services we provide, particularly in schools. What is really challenging in the context of the fact that we work within our specialisms or areas of expertise is to be aware of the overall impact. It would be valuable to be able to pull together a study that would look at the social impact of a range of services going into a community. The National Office for Suicide Prevention has worked hard to pull together a community response plan in cases where a suicide has occurred in a community. That involves pulling together multiple agencies to be able to intervene in that community and support its members. Longer term, it would be wonderful to see a social impact study on that and on the benefits of those kind of initiatives.

Chairman

I believe Mr. McBride also wants to comment.

Mr. Stephen McBride

I wish to comment on the borderline personality disorder issue. We see presentations of the disorder, specifically to our support and self-care groups, in cases where people are struggling with emotional regulation and are feeling emotionally dysregulated. There can sometimes be a crossover - not necessarily a misunderstanding - in cases where people with bipolar disorder may have a diagnosis of borderline personality disorder. People present to our services with that diagnosis and attend some of our support groups. It is their level of mental health and being able to engage with the support groups that is at odds and in question. That is one aspect.

In the context of ADHD in adults, of course that has an impact on people's moods. People experience depression as a result of ADHD, whether they are diagnosed or not. That is something to which the Senator spoke to in her question. We provide services and people contact us in that regard, specifically in respect of speaking to the impact of those conditions on their mood.

Chairman

Does Senator Hoey want to respond? Have all of her questions been covered?

Senator Annie Hoey

Yes. I know that I threw quite a number of questions at the witnesses, so I appreciate them answering all of them. I also wish to thank them again for all of the great work that they do.

Chairman

We only have a few minutes left. I have a few questions that I wish to ask. With regard to the services, the first question I wish to ask is as follows. Perhaps they cannot answer this, but in the experience of the witnesses, how often do they see people with problems in respect of alcohol harm, recreational drug use or gambling coming through their organisations? There is no doubt that alcohol is a depressant. Even if somebody is not in full-blown addiction, he or she may be bingeing or going on the tear at the weekend and coming down off alcohol during the week. It is the same with recreational drug use. Obviously, gambling is a huge problem. Eating disorders are another aspect. I believe that gambling has the highest rate of suicide associated with it because of the secrecy that is involved. How do the witnesses see that playing out in terms of their experience?

Mr. Dominic Layden

The connection between alcohol and its impact on a person's depression is a most important issue and it needs to be addressed. Over many years, we have heard stories and people have related to us the impact of alcohol on them. We will be supporting research that is being done in Galway on bipolar disorder and the impact of alcohol on that condition. The more evidence that we get by doing research on the impact of alcohol on people who have a diagnosis, the better informed we will be in the future to have more concrete answers to questions on the issue. Alcohol and depression are not a good mix at all. We must be careful about that. Perhaps Mr. McBride wishes to add a comment.

Mr. Stephen McBride

I was thinking about the issue in relation to the presentation and the cyclical nature of it. There is a reciprocity between alcohol misuse and abuse and depression, with the depression being further exacerbated by the alcohol misuse, which feeds into that vicious circle. To answer the question, yes, people do present to our services in that regard. We also signpost them and refer them in the referral pathway, generally speaking, to the fellowship programmes. That is our course of action in respect of alcohol misuse or addiction.

Chairman

I should say that I am talking about alcohol harm rather than full-blown addiction. These people may not feel ready to join a fellowhship programme like Alcoholics Anonymous or Narcotics Anonymous because they do not feel they have an addiction problem. However, I am thinking about the fact that it does play a role just because it is a depressant. I am also thinking about recreational drug use and how that can impact an individual. It is a complex question and I understand that it is. Does Ms Dolan want to comment?

Ms Emma Dolan

There are people who come to us and talk about the impact of alcohol or drugs in their lives. That can either be in respect of themselves or their family. The Chairman referred to gambling. There are huge implications for people with gambling problems, both financially and in respect of the secrecy that goes with it. In the case of alcohol or drug use, the issue may be the impact it is having on their relationships and the fact it can increase conflict in the home.

As I have said, it is not necessarily that these people are in addiction, rather that their use is having an impact. We see it and people talk about it as a trigger. As Mr. McBride has stated and the Chairman has mentioned, when a person is in addiction, they do need to access appropriate services. It would be great to see more development in the whole area of dual diagnosis. That is an action under the current strategy. It would be great to see more development on that. Generally, providing education and raising awareness around alcohol and drug use, particularly with young people, is critical. When people think of the negative impact, they think of addiction rather than sometimes what can be problem use or the ways in which it can affect individuals or homes. I hope that answers the Chairman's question.

Chairman

I am conscious that the meeting will shortly come to a close. I have another question on volunteers. I must commend the organisations represented on the phenomenal work that they do with volunteers and with the management of all of that. I imagine that it requires a lot of skill. Perhaps I will tap into it another day.

I thank the witnesses for attending. Both of the organisations represented are phenomenal. They are changing and saving lives with the work that they do. I, for one, cannot thank them enough for the brilliant work they do. I can safely say that I am speaking on behalf of all of the members of the committee when I say that. We will do our best to highlight any concerns raised by the organisations in our report. I ask the organisations to keep in touch with the committee and thank the witnesses for coming in today.

The joint sub-committee adjourned at 11.28 a.m. until 9.30 a.m. on Thursday, 20 May 2021.