Joint Sub-Committee on Mental Health debate

Dual Diagnosis and Mental Health: Discussion

An Cathaoirleach

The purpose of the meeting is to consider dual diagnosis and mental health and substance abuse issues. To assist us in our deliberations, I am pleased to welcome: Dr. Liam MacGabhann, associate professor in mental health practice, from Dublin City University; Ms Sarah McGillivary from Chrysalis Community Drug Project; Mr. Mick Williams, manager, from Sankalpa; and Ms Em Murphy, educator and administrator, from the Dublin North, North East Recovery College.

All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that any such direction be complied with.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. Parliamentary privilege is considered to apply the utterances of members participating online in a committee meeting when their participation is from the parliamentary precincts. There can be no assurances in relation to participation online from outside the parliamentary precincts and members should be mindful of this when they are contributing.

Members are also reminded of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members partaking via MS Teams to confirm that they are on the grounds of Leinster House campus prior to making a contribution to the meeting.

To commence our discussion, I invite Ms Em Murphy to make her opening remarks.

Ms Em Murphy

I am employed as a peer educator with the Dublin North, North East Recovery College and the Recovery Academy of Ireland. My work gives me the privilege to share my experience and to witness the lived experience of a diverse range of people with mental health and substance use histories. I will share some of my story with the disclaimer that I represent a tiny fraction of the wealth of experiences of dual diagnosis and that I am one of the lucky ones. Some people are still unable to access support and many people are dead.

I started using drugs before my brain was even developed enough to understand why I was doing it. By the time I reached an age of being able to understand, I was already using drugs as my only means to cope with the weight of the world and how unsafe I felt in it. I did not know there was any alternative or even that this was abnormal until a much later stage. It is not an unrelated coincidence that I grew up poor in a deprived council estate. Substance use and mental health issues do not develop in a vacuum separate from the social conditions of the people experiencing them. These issues are socially determined.

My adult engagement with services began in 2017 when, due to mental health issues and substance dependence, I lost my job and subsequently lost my home. Within a few months I lost all security in my life. I was on a welfare payment of about €100 per week while battling a worsening drug dependence and health crisis. After some months, at the stage where I was barely able to feed or wash myself and had very little grasp on reality, I went to a GP to ask for a counselling referral. I was refused a referral because of my substance use. I was instead put on anti-depressants and told to sort out my substance use issues first. I was not advised about any resources to help me to engage with my substance use issues such as information on local drug projects. Many addiction services refuse care to people with mental health issues. They are told a similar story, that is, that they should sort out their mental health issues somewhere else and that the service is not qualified to deal with them. Many addiction services also refuse to see people who are not drug-free.

I was using drugs to cope with my mental health issues, which in turn was worsening my mental health, but I could not get help with my mental health until I stopped using drugs and I could not stop using drugs because it was how I coped with my mental health issues, which in turn meant I could not access addiction support services. Where did that leave me? It left me, as it leaves countless people, in a situation where I gave up trying. I reached out for help at the beginning of 2017, but my recovery journey only began in 2020.

My recovery journey started when I heard about a community drug project that accepted self-referrals and took a harm-reduction approach, which meant that I did not have to be abstinent to access the service and I did not have to face the humiliating retraumatisation of going to a GP who might turn me away. As well as this, I got on a disability payment which meant I was able to access low-cost private therapy.

The community drug project I attended put me in touch with a housing agency that advocated for me and helped me to access an education and employment officer. Its officer met me where I was at and recognised the social complexity of my experience, that is, that the problem did not lie simply in my drug use, or my mental health issues.

She did not judge me, dismiss me or prescribe me a behavioural solution. She asked what I felt I needed to feel connected and empowered in my life. She saw me as a person with potential and value. She gave me the hope, the care and the information I needed to start my journey.

An Cathaoirleach

I thank Ms Murphy for sharing. I now invite Mr. Mick Williams to make his opening remarks on behalf of Sankalpa.

Mr. Mick Williams

I would like to begin by thanking the Chair and the members of the committee for inviting Sankalpa to make a presentation. Sankalpa welcomes the opportunity to address the sub-committee and to discuss with members the issue of dual diagnosis.

Sankalpa began providing a community access programme for the Finglas and Cabra areas in 2008. We are a section 39 HSE-funded community-based recovery treatment service for people with drugs and alcohol issues.

The average participant attending Sankalpa is an educationally disadvantaged early school leaver who is unemployed, has experienced homelessness and time in prison, and has been involved in substance use for more than five years. Presenting to Sankalpa, they are seeking support to reduce their current substance usage, stabilise on their prescribed medications and move forward in their lives. However, assessment usually highlights a history of mental health difficulties, inadequate social attachments, experiences of trauma and poor coping skills.

Sankalpa runs four core programmes that are underpinned by a commitment to evidence-based intervention, professionalism and quality of services adhering to national protocols for drug and alcohol services. These four programmes are: stage 1, "Access", is a low threshold pre-entry assessment; stage 2, “Turning Point”, is a full-time non-residential stabilisation day programme; stage 3 , "Connections", is a full-time non-residential substance free programme; and stage 4, “Connect”, is a targeted training and employment community employment programme.

Sankalpa is different. Sankalpa's service and the integrated pathways we provide are unique among the range of services available elsewhere in this sector. No other service provider can be compared with our bespoke model, which has proven success rates. Sankalpa is changing people's lives.

Sankalpa is entrenched in the communities of Finglas and Cabra. We have forged a close working partnership with community-based hubs, including Safetynet and HSE case management teams, that refer participants to our services. We work directly with other agencies for efficient case management in order that people do not fall through the cracks, especially on completion of residential treatment programmes.

Sankalpa has adapted over the years to meet the changing needs of the people we serve. We continue to evolve and provide accessible and meaningful supports for people in our communities experiencing drug and alcohol issues. We also provide intervention for their unmet issues of mental health and well-being.

Sankalpa does not operate on the basis of a deficit model of care and is certainly not restricted or ill-equipped in the context of working with people with dual diagnosis. In 2022, Sankalpa worked with 162 new people seeking supports. Of these, 79 were recorded as having dual diagnosis. Some 58 were male and 21 were female. More than half, or 46, were people aged between 30 and 50.

On completion of our programmes, our participants reported that non-medical interventions, specifically our mental health and well-being workshops, gave them a greater understanding of their diagnosis and provided them with practical coping skills.

Recovery is contagious and has the potential to be transformative at family and community and societal levels. Up until now, in the initial stages of rehabilitation, treatment has focused on harm reduction and acute clinical care. Now there is a growing movement towards a more holistic recovery paradigm which involves developing insights into thoughts and behaviours to prevent relapse. Sankalpa seeks to optimise recovery capital by providing specific and practical supports. We focus on three key components, namely, personal, social and community, and how they influence and shape each other. We do this by channelling our interventions to support and help participants to develop personal resources, like resilience and coping skills, and by fostering social skills, such as by means of belonging to recovery groups, that have an impact on society, such as via access to recovery communities and pathways to training and jobs.

We are operating in a changing policy context whereby we frame the drugs problem as an individualised issue rather than one that is situated in the context of poverty, inequality and social exclusion.

Sankalpa seeks to be at the lead in developing an effective drug and alcohol service by meeting current complexities and providing recovery services in Finglas and Cabra. Central to this, Sankalpa pledges a commitment to working with the dual diagnosis teams, offering our expertise and excellent and effective treatment support for the growing number of people seeking recovery help.

I thank the committee for its time. We welcome any questions and are happy to share our thoughts and experiences on the issues.

Ms Sarah McGillivary

I thank the committee for the opportunity to speak today. I am the team leader for Chrysalis Community Drug Project. Chrysalis has provided harm reduction support and care to thousands of people negatively affected by substance use in the north inner city since 1998. Chrysalis offers a case management service, counselling and therapeutic groups. All our programmes are open to men and women over the age of 18 living in Dublin 1 and Dublin 7. Treatment programmes at Chrysalis are client led and client focused. We believe in recovery for all and that recovery does and should look different for everyone, and we advocate for individualised treatment plans. By request of the HSE, we expanded our service to the north-east inner city in 2019. This saw us develop community and clinical case management teams working in opioid substitute treatment in the community healthcare organisation, CHO, 9 area. We recognised the emerging need for dual diagnosis support for our service users. This has been a constant undercurrent which services have worked with informally for a very long time.

The framework of case management working with dual diagnosis does not mean we work beyond our limitations as case managers. In practice, it permits a platform of onward referrals to ensure appropriate access to service. It is a process that supports and encourages people who use substances at each stage of their cycle of behavioural change. It can only be effectively delivered through an interagency approach. The benefits are that it permits personalised service, continuity of care, improved recording and a high level of accountability, alongside regular reviews. The approach of case management working with dual diagnosis was an obvious position for us to take. We have been working this model alongside psychiatric services since 2020 in the north-east inner city. The evidence from our practice is that it limits the possibility of individuals becoming lost or overwhelmed in the system. It supports and advocates the needs of the individual, ensures timely follow-ups and promotes service user autonomy in treatment.

Overall, the case manager is responsible for ensuring any identified blocks or barriers are addressed or alternative routes are taken. The role of the case manager requires a high level of specific skills coupled with ongoing continuing professional support and development. These skills warrant acknowledgment and appropriate remuneration. They are professionals in their area of expertise and there is a high level of accountability for this job. There is a considerable difference in pay scales in voluntary versus statutory services. To maintain service delivery, we find it challenging to retain case managers with relevant experience as, financially, we are not in a position to offer salaries matching their counterparts'. Our staff receive approximately 20% less than their counterparts in statutory services. This is extremely problematic as it impacts our service delivery and continuity of care, which ultimately is disruptive to our service users.

Services like Chrysalis and others have, effectively, been treating dual diagnosis for many years. Going forward, it makes sense to invest further in existing resources and services currently working within this remit to fine-tune the reach and effectiveness of service delivery. If there is anything to take from our practice, it is that addiction and mental health issues do not discriminate based on postcodes. We hope the mantra of the no wrong door policy driven by the national clinical programme for dual diagnosis is afforded to all seeking access to care.

I thank the committee for its time on this matter. I welcome any questions.

Dr. Liam Mac Gabhann

I thank the committee for the opportunity to speak today at what seems to be an opportune time in relation to dual diagnosis in Ireland, with the imminent launch of the national clinical programme for dual diagnosis and the finally released model of care. There are some links and briefing documents to support this statement.

I have been involved in or have been leading out, or both, on dual diagnosis service development, education, research and community capacity building since 1999 in another jurisdiction and since 2004 in Ireland.

I led the first and, to date, only national study on dual diagnosis management in 2004and have been researching and developing practitioner and community capacity in this area to the present day. With the Dublin North, North East Recovery College and community partners, we have been actively developing community capacity to respond to dual diagnosis since 2019. I am on the national dual diagnosis clinical programme subcommittees for capacity building and evaluation. I have submitted a brief overview to the committee.

In Sharing the Vision, dual diagnosis is defined as "the coexistence of mental health problems and significant substance – drug and alcohol – misuse problems in an individual". This broad definition is helpful and in keeping with international evidence on how to encompass and respond to all the people who experience these issues. There are other narrower definitions that are not useful regarding service development or service user experiences and that have historically been used divisively to deny effective systemic treatment to this client group and service users, serving only to double-stigmatise them. However, the narrower medical definition can be helpful where access to specialist services warrants specified criteria. Internationally, the number of people warranting specialist integrated dual diagnosis care is minimal, at around 10% of those needing intervention for substance use and mental health problems combined.

We finally have a policy mandate in Sharing the Vision to respond to people with identified complex needs associated with their dual diagnoses. I would like to note a couple of points in this regard. Approximately 90% of clients will not need, or be able to avail of, specialist services identified in the model of care. They will require their needs to be met by generic statutory addiction and mental health teams and community organisations. The clients requiring dual diagnosis interventions will not be new; there will not be a new avalanche. They are already clients of our services, only not yet receiving the care they need. We now have a policy mandate, though non-mental health governed services may now attempt to absolve themselves of responsibility, as we have seen before.

We have known the challenges for dual diagnosis and the solutions for many years, and there is no new evidence to suggest otherwise. In this statement, I purposely allude to Irish publications to demonstrate we have home-grown evidence commensurable with international evidence. Interestingly, as can be seen from the three sample reports, namely, the Health Research Board report, the mental health reform report and our research involving the communities of Finglas and Cabra, there is consensus on what we have to do if, conservatively, 50% of clients using our mental health, community health and addiction services are to begin to have their needs met. As an example and reminder, members will see the illustrated diagram in their briefing statement. We have seen that we will now have a national clinical programme. We have seen that there is now a joined-up policy, which is, in relation to the Government response, very helpful. We have seen communities respond. The statutory services are slow to respond to the mandate and the required evidence base.

We can see where policy has responded. The dual diagnosis model of care has been developed and the clinical programme is about to be piloted. We can see where non-statutory community organisations with attempts to engage statutory services have started to collaborate and engage in capacity building to enable community responses to dual diagnosis, though there has been little else as yet.

There are three pilot sites where the clinical programme is to be implemented, and much of the focus at these sites is on the recruitment of the specialist teams for the 10% of people – a minor part of the required systemic response to dual diagnosis. There is a danger that services will wait for outcomes from the pilot sites in a couple of years and wait for funding etc. Neither is necessary. Indeed, to wait is to perpetuate the problem of unmet needs for 50% of our service users when we know already what we have to do. We have already developed, and in some cases are still providing, evidence-based dual diagnosis services. Community networks are already engaging in basic dual diagnosis awareness programmes. We now need all relevant services to engage in systemic preparation, for example, following the training needs analysis by the national programme for dual diagnosis, and to ensure all relevant stakeholders now have access to the required learning processes so they are all equipped to provide an open door with joined-up signposting to the required integrated service provision. "No wrong door" does not mean a one-stop shop. It means that wherever a person in a community presents with complex substance use, mental health and other needs, this door will open the way to integrated care.

There are significant structural, cultural, territorial and educational barriers to overcome. These can all be overcome through engaging in the initial capacity-generating possibilities for all relevant service providers. That will take time.

The model of care does not need to wait for pilot sites to report back, remembering we already know what needs to happen. The solutions are already beginning to happen, though they need bolstering. Statutory services need to engage more. The resources to respond to 90% of people with dual diagnosis are not insurmountable, given that many of the requirements are to capitalise on whatever is already established and free up interagency collaboration.

The committee is hearing from a person who knows what they need, from a community service that already provides dual diagnosis response and a service that provides the international gold standard approach - case management-dual diagnosis co-ordination - to ensure a systemic response can meet inevitable complex needs. I hope I have been able to signpost with an overview that the solution is already at hand, though needs a push if we are to respond now effectively to dual diagnosis in this land.

An Cathaoirleach

I will now invite contributions from committee members. I will start with Deputy Hourigan. I wish to tell the other committee members that Deputy Hourigan and Senator Hoey asked to go first and second because they have other commitments. I hope that is okay.

Deputy Neasa Hourigan

I thank the witnesses, particularly Ms Murphy, for their useful opening statements. It is difficult when people have to come and tell their stories in order to exact change, but it is very much appreciated.

The witnesses have all touched on my core question. Ms Murphy said, for example, that she would be faced with “We are not qualified to deal with you”. That was the phrase she was hearing. Ms McGillivary talked about staffing, retention and all of those things. I know how much work the witnesses are doing on the ground in Finglas, Cabra and Dublin 1 and what that means to the people there. I refer to the broadness of the factors that are coming into play here, such as homelessness, criminalisation and dealing with people coming in and out of prison, who are then being turned away. How do we staff or make sure that people behind the door do not get to say “We are not qualified to deal with you”? I know this all interacts with Sláintecare and Sharing the Vision. Is that peer to peer? Is that people who have experienced it or is it that every single medical professional – I suspect I know that answer – needs specific training in this? How do we get to a place where no matter what medical professional or peer-to-peer support a person is getting, nobody says to them “I am not qualified to deal with this”? My core question is how we get there.

Ms Sarah McGillivary

We have a high turnover of staff across all services across community services. There is an under-recognition for what they do. Our case managers are expected to be experts in housing, legal, mental health and addiction, which is our kind of bread and butter. Coming from a service perspective, we can put initiatives or incentives in place to try to retain staff. However, with the cost of living and everything else that is going up, that will not pay their bills. It just simply will not pay the bills. Despite the efforts that we have made as an organisation to retain staff, we have been unsuccessful. Statutory services are approaching our staff to go there and get more money for the same job and our staff have bills, kids, mortgages and families and need to be able to tangibly pay for those.

On the no wrong door policy, there have been a number of occasions where we have had to refuse access to care to people looking to address dual diagnosis issues because they do not live in Dublin 1 or Dublin 7. I can give a recent example. Somebody contacted our service, which they had seen through Twitter. They do not live in either of the catchment areas. They have been disengaged from the service within their catchment area due to behaviour issues – I use that term very loosely – and they have no where to go. What was my response? “I am really sorry but I am not funded to serve that cohort of people. I am funded to serve Dublin 1 and Dublin 7.” I can absolutely try to signpost it for that person.

However, in the place that person comes from, there might be two services, both of which the person is excluded from due to behavioural issues. As a service provider, I find it very difficult to say to people that we cannot help them. The job we are in is like Marmite in that people either love it or hate it and they will stay in it or they will not. Overall, what we want is to be able to help people. We want them to be able to access the appropriate care. When service providers have to say there is nothing they can do other than suggest the person should present at an emergency department, it only fuels the problem. By going through an emergency department - this is nobody's fault; I am not pointing fingers here - people will not get access to appropriate care. They will be asked how they are feeling and told they need to go back to where they came from. It is a really difficult issue for service providers to address.

As a community project in the north-east inner city, we have started more recently to work alongside HSE psychiatric services and we started a dual-diagnosis clinic in the Summerhill Health Centre. We can offer that service for four hours a week. As members can imagine, we absolutely will not be able to serve the cohort of people who are looking to gain access to that level of care. We do not want waiting lists but, unfortunately, it is absolutely necessary that we have one.

I do not know whether what I have said answers the Deputy's question and gives more context as to where I am coming from.

Deputy Neasa Hourigan

It does.

Dr. Liam Mac Gabhann

I am hoping to test the evidence against the experience. The answer to the issue the Deputy raised is quite simple but, unfortunately, the simple answers are usually the most difficult to implement. From the evidence, we are looking at a trauma-informed underpinning model. Whatever door people go into, from the Intreo office right up to the specialist medical services that were referenced, there must be a trauma-informed model of care. We know that in the majority of cases, people with complex needs are coming from a traumatised place, to which there has not been an effective response. That is the issue at one level.

Deputy Neasa Hourigan

Would Dr. Mac Gabhann put the Garda in that category of people who are trauma-informed?

Dr. Liam Mac Gabhann

Yes. Where we are involved in this, the Garda is involved as well. Everybody needs to be involved, from the pharmacist to the receptionist in the emergency department and everybody else. That is the baseline.

The second consideration is what is leading service providers to say they are not trained to do that or they cannot do it. That is about cultural positioning and the way the training is rolled out. If I come from a mental health professional point of view, I do not understand harm reduction because my culture says my work is not to do with harm reduction. If I come from an addictions field, I do not understand about people hearing voices and experiencing delusions. That frightens me. Both of those instances are easily resolved through dual-diagnosis awareness and a very basic tiered approach to education. That is neither expensive nor difficult to roll out. We have perfect examples of how it can be done. Those are two very simple issues.

The challenge relates to cultural change and operational responsibility for what people have to do. One of the advantages is that probably 60% to 90% of people will be managed in integrated, systemic community services and if those service providers are talking to each other, we will be able to respond to that. For the 10% of people needing specialist intervention, specialist training and a trauma-informed approach are required. At a very basic level, the solution is neither expensive nor difficult. I say that with my fingers crossed behind my back because cultural shift is very challenging. If everybody is doing it together, it is easier for the culture to move. I do not know whether the evidence I have outlined reflects what is needed.

Ms Em Murphy

I was going to make a similar point. There is a culture based around a hierarchy of knowledge. We do dual-diagnosis awareness training with people, many of whom are working in community addiction services. They often say they do not know how to deal with this issue. However, when we go through their day, it comes out that they already are dealing with it. A person-centred approach to care is what is needed, and a person does not need to be a specialist to provide that. In fact, the specialists we spend years chasing our tails trying to access are the people who dehumanise and retraumatise us. It is the people in community-based projects who see us as people, sit us down for a cup of tea and ask us what we need. That is the difference and it is the intervention that is needed. It is not about the specialised knowledge people think they need to have but which, in fact, they do not need. There is a confidence issue in that people think they are not qualified to do it.

However, in reality, addiction services deal with dual diagnosis. Some 50% of people who present to addiction services have a dual diagnosis. They are already doing it. It just takes confidence and a cultural shift, as Dr. Mac Gabhann has stated.

Ms Sarah McGillivary

The term dual diagnosis is itself a block. It has been politicised and medicalised. When we hear it, we think that we do not know it. We do know it. As Ms Murphy has said, it has been an informal undercurrent across addiction services for many years. That is another barrier. We think we are not medical professionals. We do not need to be medical professionals. We are not suggesting we are medical professionals. We do not come from medical backgrounds. We work within our limitations and refer to the appropriate services for people like Ms Murphy and anyone else who needs access to that type of care.

Senator Annie Hoey

I thank the other committee members for allowing me to come in a little earlier today. I appreciate them facilitating that. I particularly thank Ms Murphy for sharing her story. I also thank the other witnesses for sharing their stories, and for the work they are doing and the lives they are helping change within their respective organisations. If we take a step back we can think about how we have not, for some unknown reason, tied addiction and mental health together in these services. Perhaps it is for political reasons. It seems insane, when we know about the percentages and number of people with addiction issues who also suffer from mental health complications and difficulties. It is mind boggling that we are having this conversation and only now getting to the stage of having a national strategy to deal with this. However, as has already been said, many of the witnesses have been dealing informally with this undercurrent for years. When I listen to all of them, it is mind boggling that we are only now getting to a plan.

This is not a question about whether the organisations agree with decriminalisation. However, there is a reference to the fact that we still have a political system and some political leaders who are very much of the abolition mind-set. There are also strategies like Just Say No, and quite hard stances on the war on drugs approach. Will we ever get to fulfil the full plan, the full potential and the full implementation of a meaningful dual diagnosis process or system in Ireland, if those people continue to be criminalised? I am struggling to see how we will be able to bring so many people with us, and away from that stigma. This also applies to people working in the medical sector, if we continue to criminalise people. Our current criminal system is allegedly about harm reduction but that is not necessarily always the case because we still have criminal sanctions. Can this process ever fully work if the legal system continues as it currently does?

Mr. Mick Williams

It will only work with questions like the Senator is asking, and if people on this committee continue to chip away at what we need to chip on. We have a health-led model. We believe in a health-led model. We do not have a moralistic model. We do not have a punitive model based on the justice system. We have a health-led model. That is how operate our service, and that is how we have always operated our service. We do not get into arguments about what constitutes hard reduction or decriminalisation. We run a recovery based model. There is no wrong door in Sankalpa. We treat everybody the same, whether they have convictions and have spent time in prison, or whether they have a job and the social capital for long-term recovery. Our mindset is in recovery and in providing opportunities for people.

We can and will reach a point where a health-led model is at the forefront of everyone's mind, but we are a few years and battles away from that. I believe in the model. The health-led approach is the model we should be using. We will continue the roll-out.

Dr. Liam Mac Gabhann

There are two parallels. We need to realise that dual diagnosis of substance use is not confined to illegal substances. A wide approach is necessary, one that includes alcohol and prescribed drugs. We induce dual diagnosis in some of the treatments we provide. It is more of a parallel process. As Mr. Williams said, as long as services are enabled to provide a harm-reduction approach despite the criminality involved in a minor element of substance use, we can deal with people. There are examples of this in Dublin and across the rest of Ireland where people are providing a harm-reduction approach that technically flies in the face of the criminalisation of drugs but does not fly in the face of harm reduction, for example, needle exchanges and acknowledging that people are using illegal substances. These services are being enabled as we speak and should be enabled further. As long as we as service providers are not prevented in this, the parallel argument can continue.

Ms Sarah McGillivary

There is a platform of understanding when it comes to addiction, mental health and the duality of experience in both respects. We often think that people will learn from the consequences of a loosely termed behaviour, but the people accessing these services are experiencing cognitive dissonance - whenever any of us makes a decision, we experience some degree of cognitive dissonance - and it is not always understood for what it is. If I am doing drugs down the road, gardaí catch me and I get put in prison for a little while, it will not reduce the harm. It will not stop someone from returning to drug use after six months in prison. What has he or she done in those six months? Has he or she used time effectively to look at the reasons he or she engaged in substance use? Has he or she had access to mental and physical care? Is the person returning to homeless accommodation or transitional housing? We can set up specialised residential care and have stabilisation units, detox wards and treatment centres where people go to address their substance use, but what if they are returning to homeless accommodation? I understand that the staff in homeless accommodation do their best to provide care, but it is often like firefighting for them, with staff not having the time to sit down with individuals.

Behind what society might see as a behavioural issue is a person who is suffering, who usually does not want to engage in criminal behaviour and who does not understand the reason he or she is doing so. During the heroin epidemic in the 1980s and 1990s, there were drug marches. We have moved away from that to some degree, but we still have another further to go. We have a responsibility to educate not only services and the people who access them, but also society about what it means to be someone who wakes up and has to reach for a drug to be able to get through the day. That is not a life – it is an existence. One definition of "addiction" is the deadening of emotions that someone might not be able to cope with. Why do we not consider people's emotions or situations instead of saying that they just use drugs because they want to, so they are going to prison for six months and everything will be fine afterwards? There is so much reoffending because we are not addressing the issue. We are removing it from society for a period and then returning it to society and telling people they will be fine. This is an important point.

Ms Em Murphy

The Senator answered her own question as to why they are still separate. It is because drug use is criminalised. As Mr. Williams mentioned, it is viewed as a moral issue whereby someone who takes drugs is a bad person in some way. There is the idea of individual responsibility. I felt it as well. It took me a long time to understand the social conditions around me that led to me having to reach for drugs every day because I could not cope with the world. The culture that we exist in tells us that that was my fault – that I was a criminal and was morally wrong and bad and that something was wrong with me.

It is the same with mental health in the context of something being fundamentally wrong with me that I want to die or whatever the case might be. As long as this continues to be the way we approach it, the Senator is right in what she said. The situation will be the same as long as the gatekeepers of care are people who still stigmatise people who use drugs and who do not understand the social complexity of why people use drugs. I started using drugs, as I said, before I had any understanding of any of this stuff. Many people who stigmatise drug users will talk about people just choosing to do this. How was I, as a 12-year-old, making that choice and then getting locked into a behavioural pattern of coping? I am still criminalised and held individually responsible for that situation. This will continue as long we do not shift away culturally and systemically. I refer to specialists, GPs, gardaí and all these key services engaging with us and seeing us as criminals. A large part of the reason people with dual diagnosis get turned away from GPs is because they are criminalised. If there is not a shift in this regard, whether in the training of those people or, as I would advocate, just allowing us to self-refer to the services we need without having to get permission from somebody who sees us as criminals.

Mr. Mick Williams

From what happens in other European countries, it is my understanding that addiction and drug use are placed in the context of mental health institutions and policy in that regard; they are separate in Ireland. There is addiction, social inclusion and then mental health, but in other European countries this is placed under the umbrella of mental health. It is where the start should begin.

Senator Annie Hoey

I thank everyone. It was all really helpful. The situation became clear to me as the witnesses were speaking. I refer to making the dual-diagnosis system work through harm reduction, and whether this approach is backed up by what the legal system may look like at some point. I also refer to the imperative of political leaders and Government ensuring societal structures are in place as well to ensure that people get support from the witnesses' organisations, which are sometimes working around the system, they have homes to go to, community supports and access to GPs and all these other underpinning services. This came through very clearly in whatever everyone was saying. I am done with all my questions. I thank everyone very much. It was very insightful.

An Cathaoirleach

I call Deputy Ward next.

Deputy Mark Ward

I thank everyone. I am sitting here enjoying the debate. I really do not want to take part in it because it is so good. I met several of the witnesses before in different walks of life and other professions. Dual diagnosis is something I have always been passionate about. As someone who has worked in addiction and community services, as was said and articulated much better by the witnesses, we saw people who arrived at a service. We sometimes did not have the confidence or the ability to be able to help a person, but we helped as best we could anyway. This is what seems to be happening. I worked in a service in Inchicore for several years and we were trying to get some kind of dual diagnosis service there. I could see the mental health service across the road which some of our service users were also using, but there was no connection between that mental health service and the addiction service until I started knocking on that door. That broke down that barrier, but it should not be necessary to do that.

Mention was made of people falling through the cracks. I thank Ms Murphy for telling her story. She was brilliant. It was a fantastic description of how someone with lived experience feels and of having to go to deal with an addiction issue and then return to deal with a mental health issue, or vice versa. Ms Murphy explained it very well. I am delighted she eventually found a service that saw where she was at, because this is so important. It is important for that service, and the people within it, to see this as being about a person and not a statistic. It is about a person with a real life, real hopes and real dreams. As Ms Murphy said, it is about a person with potential and value. We all are, but sometimes when people are in services like that they do not always get that recognition. This is very important.

My Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill 2021 was debated in the Dáil recently.

The Bill was the first legislation I introduced after I was elected. It was probably the worst-written legislation I introduced and I have no problem saying that. It was my first Bill and I wished to tackle dual diagnosis. The Government decided it would push the legislation down the road for a year, last week. I did not oppose it, because the Government said there were many things coming down the road. I said I would work with the Government in a tangible and real way on this.

The model of care for dual diagnosis is coming down the road. I will ask Dr. Mac Gabhann a question about that in a second. The review of the Mental Health Act is what we will go through on this committee in the next while. There is an opportunity there to have dual diagnosis. It was mentioned that the citizens' assembly is coming up as well, where there will be an opportunity to include dual diagnosis. Due to those three things, I decided work with the Government and give it a chance to put things in place. I hope that by next year, we will not need that dual diagnosis bit, but we will see.

My first question is to Dr. Mac Gabhann and to anyone else who may wish to answer. Dr. Mac Gabhann mentioned it and that is why I wish to bring it up. It is good to see him in person and not on Zoom. He mentioned the dual diagnosis clinical programme and the finally released model of care. This model of care should have been released last year. It was ready to go. It was sent to the College of Psychiatrists of Ireland on 13 April 2022 and it was only endorsed on 2 March this year, a couple of weeks ago, which is absolutely not good enough. It shows a real lack of urgency to get this issue resolved. I have seen the model of care and I have had meetings with the HSE. The HSE seemed to tell me that there will be a separate entity, whereby addiction services will look after people with an addiction and people within mental health services will look after people with mental health issues and a dual diagnosis service, to which both services can signpost people. Dr. Mac Gabhann mentioned that 90% of clients would not be able to avail of the specialist services. I wish to tease that out a little bit. Who are the people who are likely to fall through the cracks of the new model of care the HSE is bringing in?

Dr. Liam Mac Gabhann

What is interesting is who one asks about a model of care and what answer one gets. The answer the Deputy has got is a long-term cultural response, of many decades, to dual diagnosis. It is also the medical response to dual diagnosis, that is, that the world will be okay if we are given a specialist team, but that is only for 10% of the population. The 90% the Deputy asks about will still continue to receive care from community services and statutory mental health services. The model is not as the Deputy described. There is a specialist service, training is provided to statutory mental health addiction services and there is a requirement to resource communities and provide a case-management approach to care.

What often happens is that the pieces of models that are seeing perceived funding and resources are the small medical pieces that really target the smallest number of people who need the services. We have seen it with previous claims for programmes. I know we cannot comment on what happened to those. However, we already know what happened to those - it is in the public domain - because of the focus on a very small medical aspect of them. There is an opportunity whereby 10% of people do not receive the medical response and that we do not remain that cultural kind of hierarchy, because that suits the status quo, but it does not suit the people who use our services. This is an opportunity for the 90%, as well as the 10%, to receive care.

It depends on who one speaks to. If one speaks to somebody in mental health services, they do not even know the model is there, to be honest, to send the additional services. We have had conversations recently, where we are speaking to senior management, one of whom asked if that was what the model says. I am on the sub-committee of both of them. The model is a four-quadrant model. Some 10%, or maybe a little bit more, that need specialised care is in one area. The rest of the people need an integrated, systemic approach, with addiction mental health services and people trained up. It is that simple point, in response to Deputy Hourigan's question, about awareness of trauma. The majority of resources can be used - our mental health policy allows for this, it is just whether there is a will - to resource community responses. Community, as in all international models, is the one that will respond. The likes of Sankalpa, Chrysalis and many others will be the ones to respond. Where the Deputy worked in Inchicore is among them.

Deputy Mark Ward

The three locations mentioned with regard to the pilot programmes that are coming out, are CHOs 3 and 4 and CHO 9, with regard to adolescents and young persons. Are those programmes for the 10%?

Dr. Liam Mac Gabhann

Arguably, they are for the full model, but all of the focus is on the 10%.

All of the focus is on the recruitment of the specialist team. To take CHO 9 as an example, this CHO is building up and bolstering the existing team. That team does a great job but it will be able to do an even better job. It is about a specialist approach rather than a broad approach. This is our worry. If we get this programme right, there is an opportunity to undo the damage done by past programmes. It is interesting to note that evidence-based dual-diagnosis models had already been created in two CHO areas, CHO 3 and CHO 4, in the past ten years. A perfectly adapted model was created in the South Lee area but it was shelved by the three areas of social inclusion, primary care and mental health because those areas were waiting for a model of care. It is ironic that now, five years later, we are going to pilot something in an area that already had an effective model. The problem with the model was that it was too cheap and too simple. It is the same in Limerick, which is in the CHO 3 area. There was an effective service run by Connection and Recovery in Mental Health and Addiction, CARMHA, which came before this committee a few years ago. CARMHA was delivering a community-based and evidence-based dual-diagnosis service that was not funded. We are now going to back to pilot a model again. It is kind of a funny circle.

Deputy Mark Ward

Absolutely. Ms McGillivary and Mr. Williams might be able to answer my next question. On that 90%, the service users who are more likely to be using the Chrysalis Community Drug Project and Sankalpa services, what can we, as legislators, decision-makers and people whose voices are sometimes, although not all the time, heard in here, do to help these services? How do we get their message out with regard to what exactly they need?

Ms Sarah McGillivary

As I said in my opening statement, what is really important for our service users is continuity of care. As Ms Murphy has touched on, people should not be retraumatised every time they come back to a service. There is an assessment form that we and some other services use. It is designed to follow and stay with individuals so that they are not traumatised by having to tell their story time and time again every time they go somewhere new, while not really moving forward.

Our service is funded yearly. Our funding stream is not secure. That causes quite a high level of anxiety in light of the society we are now living in. That is another thing I named in my opening statement. Why should the counterparts of our staff at Chrysalis get 20% more in salary than they do? Are other services more financially attractive? Of course they are. How can we expand the four-hour dual-diagnosis clinic we currently have in the north-east inner city? Could we expand it to two days? We do not have the finances to do so. The first thing we, as a service, want is the security of ongoing and permanent funding so that people feel secure, safe and able to put their best foot forward going into work every day, rather than having to worry about whether they will have a job next year. That is not a worry our staff need. The job is difficult enough without the financial burden of worrying about contracts from year to year.

In addition to the clinic we hold on a Thursday, we applied for community enhancement funding, which we were lucky enough to get, to develop a dual-diagnosis group, allowing us to see more people. Obviously, groups need to be maintained at a safe number so we can have a maximum of 12 participants. We run these groups weekly over a three-month period on the platform of the Seeking Safety model, which was originally designed to treat substance use and post-traumatic stress disorder. We could run that group more often, two or three times a week, if we had official funding to do so. Those who currently facilitate that group are also case managers within our service. This is an add-on to some case managers' current role and remit that they are essentially not paid for.

We also need to enhance training. With Recovery Academy Ireland, we are currently looking at how to build on capacity training, what it is and how we can access it. As an organisation, we got mental health first aid training last year and it cost an arm and a leg to train staff in something so obviously important to the field we work in. What we took away from that training is that we knew it all already but had to pay a lot of money to get a certificate. The training budget is extremely low. The majority of our funding currently goes on salaries. For anything outside of that, we have to be very careful about what we might be taking funding away from. Overall, we need security in contracts, for statutory bodies to provide security and appropriate recognition or acknowledgement.

That is what we need to be able to move forward as a service and to deliver to the cohort of people looking to access care the gold standard of case management and dual diagnosis that Dr. Mac Gabhann spoke about.

Mr. Mick Williams

Ms McGillivary has said it all. The working projects are very creative with what they do with their money. They are extremely creative. We in Sankalpa have to be very creative when we are delivering mental health-specific modules. We do this to the best of our ability. As Deputy Ward knows, the staff in our projects invest in their careers. They are constantly paying for courses. They are constantly trying to upskill themselves. All of this needs to be supported by the organisations but they can only do this if they have the resources to do so. The trauma-informed-care models that DCU has led on are very specific but they are easy to deliver with the proper manpower resources. We only get manpower resources through extra funding. We want to continue the work that we do but we want to be equal to any other service, such as psychiatry. Their models are producing results and people are recovering. This is the crux of it.

Deputy Mark Ward

Yes.

Mr. Mick Williams

People are recovering in the community. The community needs to recognise this. It is sometimes said that communities cannot deal with mental health issues but people can recover in their communities. This is the model we want to get to.

Exactly.

Deputy John Lahart

I confirm I am on the campus. I am normally in the committee room so I ask the attendees to forgive me for not being there this morning.

I thank the contributors for their very different presentations, including the presentations from the people in the field and at the coalface and the more academic - and by that I do not mean theoretical - presentations that enlightened and informed us about some of the ongoing academic work that is informed by the professional work on the ground. The theme of today's meeting is the consideration of dual diagnosis. I used to be a psychotherapist. I practised as a psychotherapist until I became a Deputy, so I am familiar with the subject. I have always been fascinated by this topic. Perhaps to bring us back to first principles, we have all had experiences of the medical system in Ireland and I am always amazed that this challenge we face in the mental health space is a challenge that is faced throughout the health system. We have specialists in a range of exclusive disciplines. As some of the members will be aware from the Joint Committee on Health, I had reason to have an intervention on my heart approximately three or four months ago. I am amazed at how brilliant surgeons are but also at how focused they are on their particular disciplines. I had to undergo heart surgery but the surgeons undertaking that were not specialists in, for example, the vascular area and so on. If I wanted to chase up that area, I would have had to go to see a specialist in that area. No cognisance was taken of the role of something such as stress as a contributory cause of heart disease. Cardio- rehabilitation is available but that is not part of the structured recovery programme.

I hope I am conveying the point I want to convey, which is that we tend to pigeonhole diseases, not only in Ireland but in all of the western world, and tend not to see connections. We do not seem to be trained to see connections. We are trained to treat the symptoms as opposed to look at the wider context. Therefore, we have specialists in many areas who often do not engage with one another. If a person walks into any modern hospital in Dublin or any part of the country, they will see various departments. Any patient who goes into hospital may have symptoms or issues that relate to many different departments, but they will be sent to the department that covers the symptoms that are presenting most acutely in order to deal with that problem.

Why do I raise that? If there is a criticism - it is a criticism with a small "c" - it is that having listened to the debate this morning, I think all of the speakers took for granted or made an assumption that the audience who might be listening to the debate, or who might read the report of the Joint Sub-Committee on Mental Health at some stage in the future, knew what dual diagnosis was. Dr. Mac Gabhann from DCU furnished us with a few definitions which were helpful. We have known the challenges of, and solutions to, dual diagnosis for many years and there is no new evidence to suggest otherwise. Perhaps the witnesses could rehearse what the challenges have been for dual diagnosis and why there is no evidence to suggest these challenges have changed or that they are any different now.

Dr. Liam Mac Gabhann

The Deputy highlighted one of the ongoing challenges, which is that people can be pigeon-holed. In Ireland, one of those pigeon-holes is where we put the hierarchy of responsibility. It is on the medical profession. It is burdened with that responsibility. That is a societal issue. Doctors are also in the pigeon-hole of their specialties. There is an important place for a medical approach to dual diagnosis but it is an important place as opposed to all of the space. The special themes for 10% of the population will require quite a lot of that specialist medical intervention. What has happened over the years is that frequently and in fact eternally we have placed the responsibility for dual diagnosis at the doors of the medical profession which is not equipped to deal with dual diagnosis. Its members are equipped to deal with a small aspect of dual diagnosis and the ones that do so, do it well. We know of some of those people. For example, Ms McGillivary works with one of the people who understands dual diagnosis and the psychiatric profession well, but it is a systemic issue. If we work our way backwards, different Departments have always been responsible for alcohol, drugs and mental health. We have different policies for alcohol, drugs, mental health, housing and everything else that relates to the complex issues. That is the systemic challenge that continues. We also train professionals differently. We train professionals in mental health in one way, namely, to understand that taking drugs is bad, which means they are not able to deal with people who are taking drugs and they feel ill-equipped because their culture, training and operational managers tell them not to deal with people who take drugs and-or alcohol. It moves from Department, to policy to operationalisation. Staff in the statutory addiction services - community services are not like this - are ill-equipped, untrained and they believe it is not their job to deal with people who are mentally ill. Those are the challenges we have had over the decades. Going back many decades, to at least the 1990s, we have known how to resolve this. In some jurisdictions, it has been resolved. For example, dual diagnosis co-ordination is needed across the system. Case management, as we mentioned earlier, is the way to resolve the challenge of different cultures, different specialties or different pigeon-holes. Case management is the ability to do this without people falling through the gaps. That solution has been well-known since 1995 and where it is applied, it works.

The cultural shift has been identified as a necessity, but we have not changed the training, requirements or operationalisation of the mandate to enable people to embrace dual diagnosis. For example, mental health services have had a mandate since 2020 to assume responsibility for dual diagnosis, not only for the specialist teams, but to be able to link in with the community in a systematic approach to dual diagnosis. However, nothing has happened to operationalise that policy. We sent people away to come up with a clinical programme. Nothing happened for the first two years. It was dismissed. Then it was brought in again and now we have a clinical programme. Meanwhile the mental health services are not responding. That is because of structural issues. It is not because people do not want to respond. Ms McGillivary, Mr. Williams and I are saying that they have patients with dual diagnosis and want to respond but that they will wait for the hierarchical diktat before they will do so, and they are not getting it at the moment. The solution is to listen to the evidence and not to allow pigeon-holing of the response. Otherwise, only 10% of the population will get a look in. If we respond to the systemic issue of dual diagnosis, which affects, conservatively, approximately 50% of all our caseloads, the solution can be implemented.

The committee heard about at least two examples and, more importantly, heard what the solution is from a person who has tried to access and go through these services. What I mean when I say that the barriers have not been overcome is that we are perpetuating them. However, we have a wonderful opportunity for the first time ever. From a departmental perspective and policy-wise, we have the capacity to respond systemically and as one to dual diagnosis. That has not happened before in the area of dual diagnosis, so this is potentially an exciting time. I can say this because I am on the sub-committees relating to the dual-diagnosis model. Already we see a focus on the specialist 10% of services.

Everybody's gaze is moving towards this, to pigeonhole the medical response to dual diagnosis, but we need to gaze at the 100%. If we can manage the other 90%, there will be less need for the specialist services for the 10%. This 90% will never get a look in. It will only be 10%, maximum, including a residential unit, once we move from the pilot scheme. That is the solution. I do not know if I have answered all of the question properly. I got carried away with the response. I have been involved with this for so long and have been recycling and recycling but I have seen innovations. There are innovations all around the country. They are ready to be capitalised on, but we need the operational drive to make it happen. It is not about waiting two years for the pilot sites to report on how the specialist services have managed to respond to 10% of the population. It is about doing it now.

Deputy John Lahart

When given a platform, one needs to take it. Primary care was intended as a first response to this, was it not?

Ms Sarah McGillivary

Yes, it was. We were talking about that before we came in this morning. Primary care was set up to house all these disciplines and provide access to professionals where one could go to one building to address several issues. I am not quite sure it came out that way in practice. I am sure the intention was good but I think traditionally or historically, whichever is the correct term to use here, we have been very used to working in isolation. As Dr. Mac Gabhann alluded to earlier, we need to be looking at a cultural shift at this point because we have primary care centres and inclusion health hubs, which are designed specifically for people to be able to access one or more disciplines, whether it be addiction, mental health or dental, or whatever that might look like in practice. The cultural change needs to start in primary care centres and it needs to start very much from the bottom up. We talk about top down quite a lot but sometimes one is left waiting on the instruction. At some stage it needs to come down to the people who are working tirelessly day in, day out in these primary care centres, inclusion health hubs and community settings to be able to decide they do not have time for a particular mandate to come through. They need to respond to the needs as they are presented. In theory, the idea of primary care centres was fantastic but I am not quite sure everyone in every primary care centre will know who their neighbour is in the office next door.

Dr. Liam Mac Gabhann

One of the challenges is that when Joe or Josephine Soap on the street is asked what primary care is, the answer is that it is the GP. GPs are private operators doing the best job they can with the resources they have and the limits of the number of people in the profession. They will want to know where to refer somebody who is coming with a dual diagnosis. Where the GP refers the person and how are their needs are met are the issues. I hope we have given some examples of where they can be met. Primary care is a brokerage at the moment. This is not to say that is what it was meant to be but that is the case now and we need the brokerage to be able to move people through the general practice onwards to whatever organisations are dealing with the issue. That is the reality of much primary care at present.

Deputy John Lahart

That is very useful for a Deputy to know because in my constituency there are two or three state-of-the-art primary care centres, one of which opened quite recently. That gives me scope in terms of parliamentary questions to ask as well.

The witnesses have been talking about dual diagnosis which I found to be very informative and I thank them for that. What are the pitfalls of single diagnosis? I am asking this for the viewing public or people who might read the report of this debate and want to inform themselves. One of my nephews in a WhatsApp group would say he is asking for a friend but, of course, he is asking for himself. There is a bit of both in this.

Ms Em Murphy

On the last point, talking about parliamentary questions, the health system and the primary care system, the reality for a lot of people who are experiencing these things is that the best case scenario with a GP at the moment is that one gets a referral.

In Dublin, one gets a referral to a waiting list that is years long or one gets sent to the accident and emergency department if the issue is deemed severe enough. One waits there for 12 hours and probably gets sent away. Only a small percentage of people get sent on to inpatient care from there. This is a fundamental issue that needs to be addressed if we are going to have better care provision for people. This is not a criticism of GPs, who are doing their best, but on average, they have five minutes to see a patient. They are under so much pressure that they are trying to get people in and out as quickly as possible. If we are talking about trauma-informed communities and trauma-informed care underpinning everything, how is it possible for GPs or other underfunded services, to deliver trauma-informed care if they do not have the resources?

Dr. Liam Mac Gabhann

I am not 100% sure I understand the question. I think it was the issue with single diagnosis.

Deputy John Lahart

Yes, we have been speaking about dual diagnosis. In other words, the failure because of time or resources or any other of a range of reasons, the failure to dual diagnose and the propensity to focus on one diagnosis.

Dr. Liam Mac Gabhann

Historically, dual diagnosis was a diagnostic term developed because of the issues with people having comorbidity, perhaps addiction and mental illness, using a really strong medical term. There were also cultural reasons that people fell through the gaps because right across the western world, people had different kinds of services responding. The hope was that by bringing together a dual diagnosis, people would be seen in all their complexity. However, cultures throughout the world and particularly here in Ireland, still managed to separate those and call them two diagnoses. This allowed for people to continue to fall through the gaps and for different service orientations to be able to say "No, not on my doorstep".

Deputy John Lahart

Can Dr. Mac Gabhann give us a simple explanation of why that does not work for the individual?

Dr. Liam Mac Gabhann

Because an individual is neither single nor dual diagnosis. Each individual has a whole systemic set of complex needs. Even using diagnostic criteria itself is challenging and invalidates the experience of the person who is struggling with substance use and mental health and all of the other issues that come with that. It is actually unhelpful, other than politically and to try to get funding. Once it comes down to the person, however, it is quite unhelpful and probably insulting to reduce somebody to a single or a double diagnosis.

Mr. Mick Williams

Deputy Lahart mentioned specialist care and his heart issues. I wish him good health in that regard. On the question of not being a specialist, I am. The Deputy mentioned training in psychotherapy. I trained as a psychotherapist as well. I also did addiction-specific and mental health-specific training. All of them have the same correlations and modalities. They all work from a psychosocial perspective. When being delivered on the ground, each of these types of specialist care are similar or the same or are based on similar or the same theories. Recovery from mental health issues or recovery from addiction is similar, if not the same. To call one service specialist care over another one is sometimes a little bit insulting when one is working in community. We understand that there are specialist care services and we use them specifically for what they can do. It is not the whole model and it is not where we want to be.

In a community setting, especially in psychiatry, we cannot prescribe medication and I am not advocating that we do prescribe. However, sometimes the prescription substance is what we are trying to avoid or we are trying to get people to decrease and that is where it becomes challenging but that is where the specialist service is a need for the community.

It is not to undermine what community projects do. Community projects are very specialised in their area, and have huge expertise dealing with people who have mental health issues and addictions. On a huge scale they are just dealing with people, not with their diagnosis and not with their label. We do not see their label or their diagnosis. We see them as people. We treat people, and people are recovering.

Deputy John Lahart

I might have been long-winded. I was trying to say that, regardless of specialists or otherwise, we know that with the system, you go to a doctor, tell them you are suffering from depression and you may be prescribed medication. If he or she has time, a good GP might delve into that and discover that you lost your partner or your job in the previous six months and that one is connected to the other. Sometimes GPs do not have the time or the training to do that. What they focus and home in on is like the red light that comes up on the dashboard in the car as opposed to lifting the bonnet and having a good look at the engine. That may be a better way of explaining what I was trying to say.

Deputy Gino Kenny

I thank the witnesses for their presentation. It is a fascinating subject, as it relates to those in situations where they have both a dependency issue and mental health difficulties. I have always argued with myself about what comes first. Is it the trauma, is it the dependency or is it the social determinants? We all have experience of this. If somebody is suffering from a difficulty in their lives, they sometimes turn to something. That could be alcohol, or prescribed drugs, or controlled drugs and so forth. That can lead to serious difficulties. It is a perpetual cycle where it can be very difficult, not only for the person, but for their families, communities and so forth.

Absolutely.

It is not only a mental health service; it is also an addiction service, a residential detox addiction service.

I have been working in this area for 22 years. People coming in with a mental health diagnosis have sometimes asked whether they should tell the addiction service they do not have a mental health problem. When I ask why, they say that if they say they have a mental health problem, they will have to get a letter from their GP, psychiatrist and so on, which would hold them back in getting the care they need immediately. That is the risk. We do not advocate in this regard but have been asked questions such as the one I have mentioned. If I refer a person diagnosed with a mental health problem, I have to back up my referral with documentation from a GP and psychiatrist, if the person has one. It can take time and it is a barrier. If I do not, there is a risk that the person's mental health difficulties will be exacerbated. The person could be asked to leave because of their condition or because they do not have the required medication. There could be a medication issue. There are requirements that can slow the process down. Again, somebody who wants care immediately, having gone through a bad time with addiction or mental health issues, will do anything to get the care quicker. If this means misleading those carrying out the assessment, they may at times do so.

Ms Sarah McGillivary

There is another aspect in that we are perpetuating pain and trauma and reactivating unnecessary things for the individual trying to access care.

Overall, based on my understanding of what we are talking about regarding types of recovery, I believe the abstinence model of mental health services seems to be at the forefront regarding how to gain access. Abstinence is not for everybody. People are entitled to a choice and opinion as to how they want to live their lives. If somebody wants to continue to smoke two joints of cannabis per week, why should they not be allowed to do that? Why should they have to go through the process Mr. Williams referred to if they wish to access services? It is exclusionary in itself. The irony is that we are creating social inclusion teams in hospitals, including accident and emergency departments, and in community settings. On a positive note, the social inclusion teams in some of the hospitals have been very helpful to us as an addiction service in Dublin 1 and Dublin 7. They have been very forthcoming in referring people from accident and emergency departments to addiction services. However, if we look only at abstinence or one platform of recovery, or at what people perceive recovery to be, we will never get to where we need to go. That is the bottom line. I am not saying harm reduction is the only way; I am saying individualised treatment platforms are the only way, whereby Dr. Mac Gabhann would be treated differently from Mr. Williams because they are different, grew up differently and have different experiences. They deserve to be treated on the basis of individualised platforms rather than told there is but one centre, which requires abstinence, and that they can gain access to it only if they are drug and alcohol free. What if they do not want to meet that requirement? Then they do not get access to the care.

Ms Em Murphy

We need to see light at the end of the tunnel to start to want to recover in the first place. I entered recovery through a harm-reduction approach and was not ready to stop using drugs. I still needed them because I did not have enough meaning, connection, hope and empowerment in my life to feel I could stop. I needed a service that met me where I was at and gave me opportunities for training, development and education without asking me or caring whether I was drug free, because that was not what was relevant. Through being seen as somebody with value and potential, I was motivated to manage my drug use in a way that abstinence models just did not do for me. That is one approach. There is no one-size-fits-all approach to recovery, and that is just not recognised in the services.

Dr. Liam Mac Gabhann

It is also not recognised that up to 45% of people in urban areas use substances and alcohol recreationally. However, when you look for a clinical diagnosis, you might actually be diagnosed because of your recreational-use lifestyle. This makes researching dual diagnosis a genuine challenge.

There were two questions. Everyone has answered, in one way or another, the question, "Will this happen?" Members have heard, undisputed, the response "Yes" every single time. Policy and operations have allowed us to do that.

I cannot overemphasise the opportunity we have now. We now have a mental health policy, Sharing the Vision, that states we are not allowed to exclude people from any service anymore; yet, three years later, we are still doing it. That is something politicians can do something about. We now have a model of care that means we will respond with a no-wrong-door approach. We have the ability to operationalise mental health policy. On the ground, people are ready. Maybe it will take time to get the specialist teams recruited in respect of 10% of the people, but 90% of the people can be responded to now. On the question asked, we now have a mandate stating what was happening should never happen again, but we need political power behind it so people can operate on the ground.

The second question was on the chicken and egg. As Mr. Williams said, that is an old story. It is a bit like the story that mental illness is a chemical disturbance in the brain. Interestingly, the same people who argued that threw it out as a misconstrued basis for mental illness 35 years ago. It does not exist as a theory anymore although we still think it does and talk about it. I like to refer to what we colloquially call "Em's theory" in responding to questions on the chicken and egg, putting trauma first. Would Ms Murphy like to articulate it? It is now well known almost across the land.

Ms Em Murphy

It has come up in some of our workshops, and some participants have started calling it "Em's theory". It is essentially about the question already referred to: which is the chicken and which is the egg in the case of mental health and addiction? The chicken is the trauma, and it probably started in childhood. Mental health issues and substance use are eggs hatched by the chicken long ago that develop over time. There is false equivalence. The question of the chicken and egg is not trauma informed. It is trauma that causes both issues. They are very interconnected but we do not see that in policy or the culture.

Deputy Gino Kenny

I thank the delegates. That was very insightful.

Senator Aisling Dolan

I thank all the speakers for attending. All the members and our colleagues really appreciate it because the speakers are on the front line and see what happens day to day. I acknowledge the remarks of Ms Murphy. She really opened up about her experiences. I thank her for sharing them. It is so valuable to us, those listening to us and those who will be reviewing the proceedings later.

I have a few questions, on which the speakers can assist me, and probably a few remarks for the future. I wish to refer to dual diagnosis and the definition related to substance abuse and addiction coming together. Some of my questions are on the mental health examples the speakers see regarding dual diagnosis. Are depression, mood disorders and bipolar disorders the mental health conditions we are talking about, or are there others? Maybe Mr. Williams and Ms McGillivary will take that on.

I might pose one or two other additional questions. If I have time, I can come back in again. Mr. Williams spoke specifically about evidence-based programmes. I really liked his opening statement, which described some of them. Where does the name Sankalpa came from? I do not know. I am based in Ballinasloe, which is in the Roscommon-Galway area. I will be asking a few questions on how we do things in Dublin, or on the city-centre side of things, but wish to state for now that in Ballinasloe, as in many towns across Ireland, we are dealing with these issues. I am also dealing with issues associated with my area being regarded as deprived by Pobal. There are many intergenerational challenges. I am looking to how we can support people in my local area.

Could Mr. Williams say more about the evidence-based programmes? Could more be said about the clinical trials related to dual diagnosis? I really respect the fact that studies have been done in many different areas, but are there clinical trials or policies we can point to in addition to Sharing the Vision so we can say we have expertise and guidance that show us the importance of dual diagnosis, which has clearly been outlined as so important to us moving forward. Those are some of the questions I have.

Ms McGillivary might answer them first and discuss other issues relating to mental health that she has seen. Anyone else can answer as well. Mr. Williams might address the clinical trial side and the other elements.

Ms Sarah McGillivary

As to what mental health issues people are presenting to services with, it is important to recognise that drug trends have changed incredibly in the past ten years. They have moved away from using heroin and other opioids to using crack cocaine and prescribed medications, as well as overusing medication, which have different symptoms and side-effects. Using the term loosely, these are reduced to "behavioural presentations". In the clinic's dual diagnoses, borderline personality disorder arises quite a lot.

We can talk about all of these approaches but, as Ms McGillivary says, it is how we deliver and how we treat the person who comes through the door. It is compassionate care that is trauma informed. It is about using all our smarts and creating the right conditions for people whose trust has been eroded for whatever reason, whether it be abuse, trauma or institutional. When it comes through our service we recognise it. It is about creating conditions in which people can trust us to speak about the issues and tell us they have done certain things.

People speak about unconditional positive regard. I have worked with various professions and people always ask me why I have been working in addiction for 22 years. Why not? People ask how I can have unconditional positive regard for people who are addicts. I do not get that. I do not understand the question. What do they mean "how"? I just do it because I have been trained and that is who I am. I know what they are trying to say. Some of the people we work with are perpetrators of certain things. They have done certain things in their lives such as criminal activities. They may have sold substances. Unconditional positive regard is easy when dealing with victims. Dealing with perpetrators of certain things is the essence of unconditional positive regard. This is what we have in essence. As a manager I try to pass this down to our staff and service users. It comes back to what I said originally, which is that recovery is contagious. It starts at the top down. That is how we do it. It is unconditional positive regard, whether people are victims, which is not a word I like but I use it in this context so that committee members understand what I am saying, or perpetrators. This is unconditional positive regard. This is what we have in abundance in addiction services. This is our expertise.

Senator Aisling Dolan

I thank Mr. Williams. I appreciate it.

Ms Em Murphy

It is important from the perspective of the service user to say something on mental health diagnoses and presentations. Mr. Williams spoke about many people who come into recovery. I was somebody who was diagnosed with bipolar disorder, depression and anxiety. This was in a very fatalistic way whereby I was born with a broken brain and I would be broken forever. This is the story people are told. This is the story I internalised about myself. It is very much based on the medical model that we really need to move away from. We need to move towards a trauma-informed model. As Ms McGillivary pointed out, this does not look at what diagnosis somebody has or what medical issues they have. They are not seen through a medical lens but through a trauma lens. It looks at what happened to people to make them respond in a way that they have these behavioural adaptations to an unsafe environment. Most of this is about the adaptations that people develop to a lack of safety in their lives. If we reinstate the safety that people need often we find the symptoms or disorders are not really there at all.

Senator Aisling Dolan

It is dealt with from the inside. I thank the witnesses.

Dr. Liam Mac Gabhann

I want to clarify something with regard to clinical trials. Clinical trial is a route that can be taken but it is not relevant for dual diagnosis for many reasons. Until 2022 there was no published clinical trials on dual diagnosis. This is not because people did not want to do it. It is because clinical trials are challenging as a research methodology when speaking about complex systemic issues. A clinical trial is not the approach that we would take on dual diagnosis. It is an approach to research one condition or one intervention. This is where clinical trials are done.

It is not that we have not done it. It is that it is not an approach that works for dual diagnosis. That is mimicked internationally as well.

Senator Aisling Dolan

I appreciate that. I thank Dr. Mac Gabhann.

An Cathaoirleach

Before we move on to our next speaker, I propose we take a short break. Is that agreed? Agreed.

Sitting suspended at 1 p.m. and resumed at 1.04 p.m.

An Cathaoirleach

Our next speaker is Deputy Ward and then I will bring in Deputy Ó Murchú.

Deputy Mark Ward

I thank the Chair. I thought the Chair would bring Deputy Ó Murchú in before me. I like skipping Deputy Ó Murchú, of all people.

This meeting has been fascinating. It has been so valuable for me to listen to this.

I was talking to the panel privately and I learn by listening. That is why at this meeting I usually stay for the whole lot of it. I usually try and box-off any other commitments I have so that I can be here. My learning style is to listen to interactions from the panellists and from other members of the committee, whether I agree with them or not, because sometimes it is good to hear the other side of conversations as well.

We have spoken about trauma-informed services. I get this 100%. There are various forms of trauma. I like "Em's theory". That makes sense to me. There is inherited trauma. I attended a meeting a while ago at which the intergenerational trauma of people who start to use substances in order to cope with the parental trauma that came down from the industrial schools, the Magdalen laundries and the mother and baby homes was discussed. I am from a disadvantaged community. There is the trauma of disadvantaged communities and the trauma of poverty. Other traumas have been mentioned. They do not know postcodes. It could happen to anybody. The thing about drink and drugs is that they give people the ability to escape the trauma. They work on a certain level until they do not work any more and the problems come in. They can calm anxiety. I remember somebody describing it to me with regard to poverty. He said that drink and drugs gave him an ability to have a holiday from being poor. Whether it was a brief hit or for a longer time, it does not really matter what drug was involved. Sometimes, the drug or drink of choice, whatever it might be, is the one that people can get their hands on.

People get to the stage of wanting to tackle their substance misuse whatever way they can. I understand how people might get to a stage where abstention is not for them. They might get to the stage where there are quite happy to have a couple of joints a week or a couple of pints at the end of the week. There are also people who go into detox. In my area, many people go into Cuan Dara in Cherry Orchard for detox. After they detox, they are drug-free but they are still left with all of the trauma, much of which has manifested and increased during years of substance abuse and addiction issues. What used to happen was that they would go to Keltoi in the Phoenix Park. Keltoi has been closed for the past three years. The services that I link with find this to be a big gap in services. Keltoi may not be down on paper as a dual diagnosis service but it is definitely a trauma-informed residential rehabilitation service. I have seen the work, recovery and progression of people after they have come out. They had time and space in an environment where they could deal with the trauma, whether it was from mother and baby homes, poverty or abuse. Whatever it might have been they had the space and time to be able to start to look at it. As someone else mentioned, they learned various coping mechanisms. The most recent answer I received in respect of Keltoi was most positive, namely, that it will reopen next year. I do not know when, but it will be open in 2024. Have the witnesses who work with front-line services seen the impact of not having a trauma-informed residential rehabilitation service available for people who use their services?

Mr. Mick Williams

Deputy Ward spoke about trauma and the link with addiction. Given the types of trauma that we work with and the people we work with, it makes sense for them to take drugs or whatever substance or to drink. The closure of Keltoi was quite sudden. Cuan Dara was one of the main referral institutes to Keltoi. Keltoi had a model of emotional regulation. It developed a system and model that worked for it. It trained other institutions on the model. It was trauma informed. It closed during Covid when things were very different. Many services were not fully operational. We were seconded to other areas to tackle Covid. Addiction services were very different during that time. We started to develop a service on Zoom, and we did what we could.

There have been replacements for the Keltoi services but not in a residential setting. There are certain things with which other of the committee's guests are involved, and the alcohol service in Barrymore House and things like that, but Ireland is lacking in residential services. The Deputy asked at what stage people need residential services and what they do when they come out of them. That is what we do. The closure of Keltoi had a big impact but it has been replaced. There has not been a replacement residential service but other services have developed because of the closure of Keltoi.

Deputy Mark Ward

That is because those other services had to be developed.

Mr. Mick Williams

That is exactly right.

Ms Sarah McGillivary

Any loss of residential beds is a loss, considering there are very few stabilisation, detoxification and treatment beds available in the country, particularly in the light of the overall number of people accessing services for help with drugs and alcohol. Any loss of a residential bed is significant. Keltoi was unique in its approach and it is important to recognise that. We had a direct referral pathway to Keltoi, which was a massive help. A five-week treatment period for people accessing residential care is fantastic because there are no outside distractions and they are allowed the time to sit with themselves and seek the help they need through key working sessions, psycho-educational group sessions and whatever each individual programme looks like because they are all different. What happens then? That is the constant question. What happens after the five-week or ten-week programme? The length of treatment depends on the treatment centre.

When we talk about recovery, there is an holistic change for somebody who wants to enter into, for example, abstinence recovery or complete drug- and alcohol-free recovery. There is a differentiation to be made between being drug free and being in recovery. Being drug free is physically walking past something but still being mentally and emotionally tortured by it. Recovery is a process that involves taking the time to get to know ourselves, to be nice to ourselves and to do the emotional and mental work required, as well as the physical work. That is what recovery is. It incorporates those three core components. If I am going to walk past a drug, I might be mentally okay but remain upset emotionally. If that is how I feel, I will return to drug use. That is the piece. The aftercare, transitional programmes and recovery groups are missing. They are not there. We can submit referrals to treatment centres until the cows come home but if those people are returning to the same environments they left, perhaps including homeless accommodation or no accommodation at all, which is not unheard of, they are going to default back to what they know how to cope with and how to manage best. They are going to go back to the thing that has been there for them consistently for the past 20 years, that has never let them down and that has enabled them to get away from the situations in which they find themselves. If we do not have transitional housing and are not looking at aftercare or the community initiatives that are currently in place in Chrysalis and Sankalpa, and other places in the north-east inner city, and if we are not looking to have such services around the country, the piece that comes before does not make sense. It does not fit.

Ms Em Murphy

It is a very common experience. We facilitate a lot of recovery education courses and I am sure that Mr. Williams and Ms McGillivary know it is a common story that people might not even recognise they have severe mental health issues because they have been using drugs. It is only when they enter a programme that they realise that putting down the drugs is only the beginning. That is the difference between stabilisation and recovery. The latter is a long process that requires constant work. Recovery needs wraparound care and aftercare supports. It is not just about detoxifying people and expecting them to be sorted. It is never that simple.

Dr. Liam Mac Gabhann

There is probably a clear message coming out in respect of everything, including residential services. To clarify, Keltoi is not going to reopen as it was. It will reopen as a dual diagnosis residential service. The whole wraparound seems to have a place as long as the rest of the stuff is in place.

Deputy Ruairí Ó Murchú

I am not a member of the committee but decided I would butt in. I apologise. I was told we had the guts of an hour. I listened to a considerable amount of the discussion before I made my journey in and as Deputy Ward said, it has been incredibly useful. Some of the questions I was going to ask have been answered. I will do what I generally do and engage in a brain dump. I might add that mine is a very damaged brain. As has been said, if we are talking about people who are looking for treatment for drug addiction or whatever else, we all know the hoops and obstacles that are involved. The people in question must also be in the frame of mind to be looking for help. There was a considerable amount of conversation about telling white lies and all the rest of it. That happens constantly. Sometimes, in fairness, those who are offering services are in on it. The whole thing is a scam. It is a needs-must situation and a very Irish solution. It can even be a cross-Border solution where I live.

Ms McGillivary spoke about something that has been said to me in the past by people working in addiction and homeless services. The true treatment that people pursue is by making the decision that the only way they will get clean is by going to jail. People rack up a lot of convictions, which is relatively easy to do, so they can go to prison for a year or more. They become clean and come out of prison but then find themselves involved with the Simon Community, or whatever other service, with a hell of a lot of time to hang around to contemplate the debts they owe. They find themselves operating in the same places with the same cohorts of people. The comparison we always use is with GIs coming back from Vietnam. It was thought there would be a problem with heroin addiction but those people were addicts in Da Nang, Khe Sanh and Saigon. When they returned to Pennsylvania, New York and wherever else, they were able to break that addiction. However, that does not apply to people who are returning to the same street corners. There is no part in this that works.

To move completely to a consideration of addiction, it is brilliant that we are talking about a citizens' assembly on drug use and entering into a conversation about a health-led response, harm reduction and all the rest of it. However, none of that will matter to making people's lives better unless services are available. We talk about the Portuguese model. Are we considering making services available for people who are coming out of jail to ensure they are given support to put them in a place to go through education, get employment and all the rest of it in order to break cycles?

The reason we have thrown this issue to the citizens' assembly and that politics has failed to deal with it is because we do not know how to sell the idea to a 50-year-old middle-class guy who does not realise his son is taking cocaine with everyone else after winning a GAA match at the weekend until it becomes a problem. That man will likely say we are going easy on addicts and will use a derogatory term about those who are in addiction. There are no proposals for change from that man, from politicians or from anyone else who talks about the issue. What we are doing at the moment is not working in any way from a criminal justice point of view. I am not proposing this because it would be utterly nuts, but what if somebody was to come out and say we could have street executions, along with carpet-bombing Colombia on a day-to-day basis? That would be a way to reduce supply. We could probably change the rules of engagement with drug dealers, of whom I am not particularly fond. However, I think such an approach would put us in breach of a number of rules. Even those people who talk particularly hard about the issue do not want such an approach.

That is one disaster.

When a politician is dealing with someone, be it a case of dual diagnosis or even a worse-case scenario where you are dealing with somebody with psychosis, we all know we do not have the beds for mental health. Depending on what time of the day or night this happens, the person goes to accident and emergency in Our Lady of Lourdes hospital in Louth. There is no facility there to assess, so the person is sent to the Drogheda department of psychiatry in Crosslanes, where technically the consultants or doctors there are meant to deal with those in beds, of which there are not enough. Someone will come out and the assessment will be imperfect. Eventually, dual diagnosis will be the means by which the person is dealt with. I get that idea. Until we offer enough services, even if we get through that no wrong door, we will still have a huge difficulty. Gardaí will say that they fill out forms or get the forms done. What you are generally doing is throwing one person out of a bed to put another person in it. I am detailing what Ms Murphy already knows. We can talk about everything from the perspective of offering a better service but we do not have anywhere near the infrastructure to do it.

The witnesses spoke about pilots. I will use the example of Turas Counselling Services in Dundalk, which was given money for a dual diagnosis community project. The money has run out and Turas Counselling Services is keeping it going through self-funding, hoping that it can build up the evidence base to allow it to go back in. This State just loves pilots. We overstretch them or do not apply them across the board, or they exist in a little silo where obviously it is the only place dual diagnosis is dealt with. None of this is positive. That is before you deal with the fact that they will do the same complaining as everyone else in these groups, namely, that they get paid less, because they are in the community, they do not get multi-annual funding, they are cutting their cloth to suit their measure and they are dealing with a huge number of people so they are willing to use the baling twine to keep the engine going. None of this works.

I realise that none of this is a question. The witnesses have answered most of them. We know there should be no wrong door. My question concerns trauma-informed services. I spoke to the Chair earlier and I think she had been approached by some of the same people I had been approached by. We all get the idea. A number of the interventions from both sides of the room concerned the fact that you need to ensure everybody is trained in everything they will need, be that where the addiction piece meets the mental health service.

My question concerns eye movement desensitisation and reprocessing, EMDR, therapy, which has been used by the US military. It got very good at training people to kill people but the outworkings of that are significant levels of PTSD. This supposedly has been very useful in treating it. I would like to hear the witnesses' view on that because I get it. We do not have enough services and we need more of them. We need to ensure everyone who should be trained is trained. We know there are many other issues regarding payments.

We can have the best framework and modalities of care but none of it will make any difference, no more than the citizens' assembly and decriminalisation will, until we have that piece of paper and follow through on the reports, of which there have been many, and beyond that, until we put the people and resources in place instead of people who are using baling twine and doing extra in their own time. That is not sustainable in the long term.

Ms Em Murphy

As part of my trauma healing journey, I tried to see if I could get access to EMDR. It is not available through the public health system, or it was not available.

Deputy Ruairí Ó Murchú

I think maybe one CHO is looking at it.

Ms Em Murphy

At the time I was trying to access it, it was not publicly available. I was on the disability payment for my mental health issues and getting €200 per week. The cost of EMDR was €80 to €120 per session. That is a very specialised thing. It should still be available freely through the public system if the system functioned.

Dr. Liam Mac Gabhann

It must have been my hearing but I heard four questions and that was before mention of EMDR so I will respond to what I heard. I cannot believe I am going to say this but the question I heard was whether politics is working. I think the Deputy's way of questioning was politics has not worked for this. For once, maybe, or certainly in this case, politics is beginning to work. I will set out my reasons for thinking this. We now have joined-up policy, a mandate and a clinical programme, so as a result of some political activity, at least in this case politics is beginning to work.

Politics is beginning to affect funding so people are able to look for funding for dual diagnosis and organisations at local political levels are having to respond. There are three examples. I will come to Louth in a second. Finglas and Cabra were able to get charitable funding because dual diagnosis is now on the political agenda. We have provided dual diagnosis capacity building around the trauma-informed community in Finglas and Cabra. All of these organisations are part of that. For the very same reason, namely, politics, we were able to get funding for a community capacity-building project in north-east inner-city Dublin around creating a trauma-informed community regarding dual diagnosis. That was politically driven. Because of the political agenda, it is likely that the Finglas-Cabra project will be repeated in Louth in the summer. If the Deputy has any help or influence regarding that, it would be great. It is going through the Department of Health at the moment. Politics is doing that so the north-east inner-city project and the Finglas-Cabra Mental Health Ireland-funded project were politically driven. I am going to get tackled and go home saying politics is working. In this case, politics is playing a really good role.

Regarding the second question, we do not have the services. We have all said here that we do have the services but we do not have the appropriate resourcing for those services. The key answer to that is to resource the services we have and then we will have the dual diagnosis response.

Everyone has spoken about intergenerational trauma. People all come from a different place and the damage is already done. We do not need to have a further conversation on chicken and egg and all the rest of it.

Years ago, an educational psychologist spoke to me about resilience and the particular example they used was that of kids in a very difficult family setting who were put into care and then did the usual thing of kicking back against that. Perhaps those who were providing them with foster care were not up to it or were not fit for it and they kicked them back. It used to be said that people have a certain amount of resilience which after a couple of kicks reduces and then maybe something good happens and it gets up there. I do not have cellophane with me but they use the example of applying cellophane so that when they started pouring it did not matter at that stage; there was an element that you could not be reached with all of that. In the worst-case scenario we have seen families dealing with this for 50, 60 or 70 years. The community is aware of it. Everyone would say the State has failed to address it at particular points. I am just wondering what can be brought to bear for those individuals.

Mr. Mick Williams

I do not know that person whom we cannot treat. If the Deputy knows that person, they have probably passed away already. Earlier I gave the analogy of resilience. The person has already been kicked before they get to the service and their self-esteem and resilience have depleted because they did not have the resources in the first place.

Deputy Ruairí Ó Murchú

The wiring and all the rest of it.

Mr. Mick Williams

If they are placed somewhere with the resources and are exposed to those triggers but with the resources, the result will be a completely different person. That is what we do in essence. We expose them to people. People do a lot of damage to people. We expose them to society, emotional and environmental triggers. We cannot take them out of the community and put them in a utopian community somewhere else where everybody is hugging and kissing each other. It has not happened. They are back out in the real world with the resources and that is what we do.

Ms Sarah McGillivary

The people who access our services are incredibly resilient. If I were faced with the circumstances of sleeping on the street at night with a sleeping bag and not being able to manage the situation, I would not survive it. Resilience has been around for a very long time but it is a term that we use more commonly now. Sometimes we latch onto these words and they lose all meaning. I can only speak for myself and the people I have worked with. The level of resilience shown by some of the people I have come across through work is absolutely incredible. It is certainly not something to be dismissed or minimised or anything like that. I have often tried to put myself in their situation and ask whether I would survive that; probably not. That is down to exposure in childhood. That is down to different developmental stages that we might not necessarily have met throughout adolescent periods. There are many contributing factors to that. It is important to recognise that.

Deputy Ruairí Ó Murchú

Earlier is obviously better.

Ms Sarah McGillivary

Yes, for sure.

An Cathaoirleach

All the witnesses have done unbelievable work this morning. I sincerely thank them for coming today and for the amazing work they are doing in their own areas and communities. I know a bit about the benefits of the work they do, particularly in the community and how it can be life changing. I had a couple of questions but I will not ask them any more questions because they probably need a coffee and I am sure that the staff also need a coffee.

The language used today is really powerful and so refreshing to hear. We have done considerable work on mental health in here. Language like "person-centred care" and "wraparound services" is so powerful. Somebody coming to these services is lost, frightened and at the end of their tether.

Somebody coming to these services is lost, frightened and at the end of their tether. The witnesses have spoken very eloquently about their own experiences and how they got help because of the wraparound services and person-centred care. At the end of the day, it all comes down to treating people with dignity and respect, listening to their stories, listening to their trauma, being present for them and having that lovely compassion. As somebody said, unconditional positive regard is powerful. We need more of that language in the services.

The work Dr. Mac Gabhann is doing, particularly in the sub-committee he mentioned, is great. I loved what he said about the fact that politics is working. We, as a committee, need to hear that. I hope officials in the Department are watching today and recognise that what they are doing up there is starting to work. They also need to hear that. I have a tonne of questions here, but I think the witnesses covered a lot today. I have been inspired by listening to them and I thank them.

The dual diagnosis work is only starting. We need to work on many more areas, particularly when it comes to dual diagnosis. What the witnesses said about wraparound services is lovely. Nobody as a child wants to end up with an alcohol, drug or gambling problem or have a mental health issue. No family wants to see their child in that scenario. I hope the citizens' assembly will do the moral model and will start that whole conversation. It is vital that dual diagnosis is part of the citizens' assembly. That conversation needs to be up there big time; it needs to be a priority.

I thank all the witnesses sincerely for coming here today. I hope that down the line we can do another session on this because what we have heard today has been so powerful. I thank all the witnesses for aiding the sub-committee in its consideration of the very important matter of dual diagnosis.

The sub-committee adjourned at 1.38 p.m. sine die.

Joint Sub-Committee on Mental Health debate - Tuesday, 21 Mar 2023

Dual Diagnosis and Mental Health: Discussion

Ms Em Murphy

Mr. Mick Williams

Ms Sarah McGillivary

Dr. Liam Mac Gabhann

Ms Sarah McGillivary

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Ms Em Murphy

Ms Sarah McGillivary

Mr. Mick Williams

Dr. Liam Mac Gabhann

Ms Sarah McGillivary

Ms Em Murphy

Mr. Mick Williams

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Ms Sarah McGillivary

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Dr. Liam Mac Gabhann

Ms Sarah McGillivary

Dr. Liam Mac Gabhann

Ms Em Murphy

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Ms Em Murphy

Ms Em Murphy

Ms Em Murphy

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Ms Em Murphy

Dr. Liam Mac Gabhann

Ms Em Murphy

Ms Sarah McGillivary

Ms Em Murphy

Dr. Liam Mac Gabhann

Ms Em Murphy

Ms Sarah McGillivary

Ms Sarah McGillivary

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Mr. Mick Williams

Ms Em Murphy

Dr. Liam Mac Gabhann

Mr. Mick Williams

Mr. Mick Williams

Ms Sarah McGillivary

Ms Em Murphy

Dr. Liam Mac Gabhann

Ms Em Murphy

Ms Em Murphy

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Dr. Liam Mac Gabhann

Ms Em Murphy

Mr. Mick Williams

Mr. Mick Williams

Ms Sarah McGillivary

Ms Sarah McGillivary

Joint Sub-Committee on Mental Health debate -
Tuesday, 21 Mar 2023