Mental Health Services: Discussion (Resumed)

We are now in public session. I welcome Mr. Martin Rogan, CEO and Ms Aisling Doherty, mental health promotion officer from Mental Health Ireland. From SpunOut.ie, I welcome Mr. Ian Power, executive director and Mr. Jack Deacon, deputy director. From Jigsaw, I welcome Dr. Joseph Duffy, CEO and Dr. Gillian O'Brien, director of clinical governance. On behalf of the committee I thank you for your attendance here today.

The format of the meeting is that you will be invited to make a brief opening statement and this will be followed by a question and answers session.

Before we begin I draw the attention of witnesses to the situation on privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if witnesses are directed by the committee to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode. Mobile phones interfere with the sound system and make it difficult for the parliamentary reporters to report the meeting and television coverage and web streaming will be adversely affected. I also wish to advise the witnesses that any submission or opening statement they have to make to the committee will be published on the committee website after this meeting.

I invite the witnesses to make their opening statements. I call Mr. Rogan to make his opening statement on behalf of Mental Health Ireland.

Mr. Martin Rogan

I thank the Chair and the members of the committee for the invitation to address them today. As members know, Mental Health Ireland, MHI, has already made a previous written submission on a number themes such as mental health primary care, staff recruitment and funding. I understand today's session is to look at the area of health promotion and early intervention.

Mental Health Ireland is a national voluntary body and our mission is to promote positive mental health for individuals and communities through our network of 82 local mental health associations operated by volunteers. We support people who experience mental health difficulties on their journey to recovery. Our vision is of an Ireland where mental health is valued as an essential part of personal well-being and the health of the nation. MHI leads the way in terms of society’s understanding of mental health and fostering a culture where people with mental health difficulties are respected and supported. Our work at a national level is supported by the Health Service Executive under a number of formal service level arrangements and these specify common objectives and quantums of service. Mental Health Ireland was founded following a commission of inquiry in 1966. The report recognised that people were recovering and moving from mental hospitals. At that time there was a need to promote positive mental health and community understanding of mental health issues and also to provide practical support for service users.

In Mental Health Ireland, we envisage an Ireland where all of our people have a better understanding of their own mental health and its needs, the factors that improve and the factors that can compromise their quality of life and mental health. We recognise that mental health needs to be reviewed and understood as a resource for life, where people have access to programmes that can help develop their skills and strategies for dealing with family life and daily life. These should be readily available throughout the community. We support a model where there should be an openness to discuss mental health issues among family, friends, and peers and where there is a sense of connectedness. This is vital to a sense of belonging and is protective of our mental health. As Irish citizens, we need to have confidence in health services, to feel they are available to us, that they are appealing and accessible and ultimately treatment will be successful. It is important that as people use services or following their use of services, they do not have a sense of alienation or being removed from their community in any way. It is important that positive mental health and well-being enjoys the same profile and parity as physical health.

Over the past 50 years mental health association volunteers and our affiliated partners have engaged actively in mental health promotion right across the country. This is closely aligned to a vision of a more positive Ireland where personal well-being, health and economic success are all recognised as of equal value. We see the importance of promoting positive mental health in an evidence-based way. We want to strengthen our efforts to promote the protective factors and reduce the risk factors and prevent mental illness to move towards a more flourishing and inclusive society. We understand that we have certain strengths in this field in terms of our long commitment and our relationship with communities right across the country. We have our own dedicated mental health department, we are building upon that and Ms Aisling Doherty has joined us here today. The model is that we would be in a position to adopt best practice in Ireland, learn from international colleagues and academic research and make this available to communities right throughout the country.

Over the years of our organisation the question has changed somewhat from "what is mental health?" to "how do I care for my own mental health?". Having begun this conversation over 50 years ago we feel a responsibility to advance that dialogue further and to deepen it. We work with many NGOs right across the sector to do so.

We see promoting positive mental health and well-being on three different levels. It is about building on strengthening the individual to improve emotional resilience through various interventions designed to promote self esteem and self efficacy, strengthening communities in terms of having an inclusive and participative community where neighbourhoods and environments are designed to be conducive to mental health and also reducing any structural barriers that still remain and we will talk about these in today's session. It is about reducing elements like discrimination and stigma and making sure people have access to meaningful education, employment opportunities and housing. We support people at a vulnerable time in their lives and that has been a continuing role. We are aware that there can be a lot of well intentioned activity in this space. While that can demonstrate a collective concern or a societal solidarity, we need to move beyond simple awareness. This is why mental health promotion needs to have the same robust evidence base and have a credibility, as with any other form of health promotion.

At Mental Health Ireland we have been delivering evidence-based services. This is why we are working further in this field and commissioning further research so that we have a much better understanding of what are successful interventions and why they are successful.

International research suggests that there are approximately seven principles we really need to be active on in order to succeed in mental health promotion. One is around empowerment. This facilitates individuals and communities to take greater control of their own decisions, health behaviours and life choices. This must be well-informed for it to show understanding and for us to have confidence in it.

Another important value is participation, meaning that all stakeholders play a much more active role in decision-making. This has been an issue in the past for many mental health service users. We are very heavily involved in working in the recovery space, especially in the area of co-production, where service users, family members and professionals collaborate in a more positive way.

We need to have equitable access. This is discussion that will come up later. There are quite limited resources in the mental health space, but are they evenly distributed? Equitable access means that there is equal access for all our citizens throughout the country to the resources that are available.

MHI supports an inter-sectoral approach. There is a recognition that mental health is not the sole preserve of any one component or agency, and we are very well positioned to work across different disciplines. We are working across a spectrum, with housing agencies, local sports, arts and cultural communities so that we can touch people's lives in a positive way. Working in health promotion, particularly mental health promotion, it is very important to carry out sustainable interventions and not just once-off actions. These need to have follow-through if the benefits are to be realised and sustained.

Another important principle is that the approach needs to be holistic, and not just working with the individual in one domain. Embracing people's physical health, mental health, social health and indeed spiritual health are really important if they are to enjoy full, happy and healthy lives in conducive communities. Finally, it is really important that we have a multi-strategy stance, so that there is no single approach that will be effective. Each of these enhances the other when they work in combination.

In Mental Health Ireland, our work is guided by the Healthy Ireland strategy, and by chapter 5 of A Vision for Change. Unfortunately, this is perhaps the shortest chapter in A Vision for Change, but it has very important points to make. It is a little overlooked that in Ireland we are at a key point in our history regarding the demographic shape and profile of our population. Some 23% of our population are children, so there is a real opportunity here and a closing window that we need to grasp in laying down positive life events and life approaches to build resilience. It is something that we really need to tend to very quickly.

In A Vision for Change the authors identify four different areas of priority including promoting positive mental health and well-being; raising awareness of the importance of mental health; enhancing capacity of mental health service providers and the general community to promote positive mental health, an area in which Mental Health Ireland has been actively involved; and suicide prevention, which is also an area of activity for our organisation. It also points to the need to build capacity to promote mental health in an effective manner that is robust and is evidence-based. That is certainly an area of focus for our organisation.

In regard to early intervention, which the committee is keen to explore today, the role of primary care is really important in mental health. Our written submission reflects this aspect. There are about 5.6 million occasions of care in Ireland in a year. Some 35% of all GP interventions relate to mental health issues. Not everyone recognises their GP or their family practice as a place where they can receive help. However, 90% of mental health issues can be effectively recognised and resolved successfully in primary care, with 10% of service users being referred forward to specialist community-based mental health services. There is a network of day hospitals and community mental health centres throughout Ireland, and this really should be the first point of referral for GPs. It is important that it should happen that way.

There are a number of factors that can delay referral and the acceptance of support in the mental health space. These can include the costs of service; its availability; geographic isolation; historical stigma and prejudice; negative perception of service; and perhaps the most limiting factor of all, hopelessness, where the individual does not believe that a successful intervention is possible. This belief limits a person's ability to step forward in a timely and effective way. It is important that we address these barriers, some of which are more pronounced for certain cohorts of the population. For young people the foremost difficulty may be cost. Men are sometimes reluctant to accept that they need help, and perhaps feel vulnerable at a certain time of their lives. There is also a tendency for people to minimise their difficulties, or indeed to self-medicate with drugs or alcohol. If we are to be successful in early intervention in Ireland, we need to have a much better understanding of help-seeking, help-finding and help-accepting behaviours. I note that the last of these is critical to successful mental health care.

We know that people with quite significant mental health needs can be reluctant to engage with services. Sometimes they fear a loss of independence or control of decision-making. They may feel that the relationship has something of a power imbalance. That needs to be revisited. This is why Mental Health Ireland has been working very closely with people with self-experience throughout the country to create roles for peer educators and peer workers. We have also been active in a collaboration with the HSE entitled advancing recovery in Ireland. These actions are intended to ensure that people who use services are very active not just in their own care and treatment, but also in designing models for others. Certainly the whole area of co-production is one about which we need to hear a lot more.

In discussing the importance of recovery, we need to understand that in the past, gaining access to mental health services was not always the issue. Gaining egress and leaving the service was a much greater challenge. In 1960 in Ireland, 23% of the entire health budget was dedicated to mental health spending. I began my career in 1983; in 1984, this percentage of health spending had dropped to 12%. The World Health Organization, WHO, recommends that 12% is the minimal threshold. If a mental health service is to be provided, 12% is the minimal standard. When A Vision for Change was published in 2006, a target for this figure was set at 8.4%, significantly below the WHO recommendation. Sláintecare, an excellent report published last year, recommends 10%, still below the WHO's recommended norm. We know that the past ten years have been a really difficult decade for the Irish public. There has been unprecedented growth in the demand for mental health services. Mental health spending is currently 6.4% of health spending. If it is going to be so low, it is really important that resources are evenly distributed right throughout country and available to all of our citizens equally. This is why recovery is such an important topic, certainly when we are talking about prevention and early intervention. If people are to avail of the mental health services, it is also important that they successfully leave the mental health services. They must be able to reposition themselves into community living and get back into their whole lives, be that in education, family, community or employment, and live full lives again.

Mental Health Ireland's mission involves working with people to ensure that they successfully make their way back into their communities and fully reintegrate by not living in a psychiatric model within the community setting, but fully availing of community life. In 1950, around the time our organisation was established, Ireland had the highest rate of hospitalisation in the world. There were 22,000 of our citizens living in psychiatric hospitals, with little prospect of return. Our volunteers throughout the country have been very active in ensuring that people have a way back to their communities, and that they can succeed in that pathway.

We also know that a huge level of hospitalisation created a very graphic image in the public mind. This is often quite a hopeless message regarding people's ability to recover and their likelihood of doing so. As a national organisation and through our volunteers and mental health associations throughout the country, Mental Health Ireland has been working to ensure that people succeed in returning to their community, are celebrated and feel absolutely accepted in that space. This is a really vital role and it absolutely wraps around our need to promote positive mental health in a much more effective manner, and to intervene early so that lifelong disability, distress, and unnecessary risk is not realised.

Mr. Ian Power

I would like to express my thanks to the Deputies, Senators and Chairperson, on behalf of the SpunOut.ie team, for the invitation to address the committee today. As Ireland’s youth information website, run by young people for young people, SpunOut.ie meets the information needs of over 140,000 young people each month.

One of our largest and most pressing areas of concern is youth mental health, where for over a decade we have acted as a trusted signpost to specialist services and as a non-judgmental provider of essential information services. In this role, we have developed a clear understanding not only of the general needs of our national mental health services, but crucially of where those gaps in the system have hurt young people the most. It is welcome that the committee has chosen to seek specialist information from the youth work sector. I hope our contribution today can go a way towards improving the future of mental healthcare, in particular for those whose futures are placed most at risk both by chronic underfunding and a lack of early intervention.

The fact that prevention is better than any cure is more than old cliché. It should be at heart of everything we do when it comes to mental health. Three quarters of all serious mental health difficulties start to present when a person is aged between 15 and 25.

It is at those ages that properly funded mental health interventions are not just crucial but, in actual fact, irreplaceable for ensuring long-term mental wellness.

There is enormous demand for accessible early intervention services for young people that charities, NGOs and acute services simply cannot satisfy on the basis of current levels of investment. I was encouraged to see the committee consider a recommendation that mental health spending be increased to 12% of the health budget. However, we have to bear in mind that even the 8.2 % figure set out in A Vision for Change has yet to be met. For all the talk of mental health as a political priority in 21st century Ireland, we remain far below the 13%, or even 23%, figure we managed in the 1980s, as mentioned by my colleague.

I say this to underline a simple truth, namely, that while we may advocate specific policy changes or reallocation of resources in isolation, without a meaningful and sustained increase in overall levels of funding, we will not be able to tackle the mental health crisis in our society. We should make no mistake; there is a crisis. The most recent EUROSTAT figures released last month put our youth suicide rate of males and females at seventh worst in the EU. Meanwhile, we continue to spend less than half of the percentage of our nearest neighbours in the UK. We need to build a consensus around funding services that work and can make early effective interventions that can have enormous positive impacts on individuals and communities.

There is a wide acceptance, informed by the work of the WHO and others, that the overwhelming majority of mental health interventions should take place in primary care. Therefore, any plan for the future of mental health services must have quicker, easier access to psychology in primary care at its core. The recent decision to appoint 100 new assistant psychologists makes for a welcome start. However, the apparent global shortage of mental health clinicians makes it more challenging than ever to attract the skilled professionals we need, especially in the context of services in rural areas.

The Seanad Public Consultation Committee has pointed out how, even as international competition for trained mental health professionals intensifies, we have not seen any steps taken to improve pay and conditions in the sector. This has been true not just within primary care but also for acute services, such as child and adolescent mental health services, CAMHS. In mentioning CAMHS, I am reminded of the ongoing work in which we at SpunOut are engaged in helping to build public awareness and understanding of that service. In choosing to partner with us, those involved in CAMHS have recognised the indispensable role of clear and engaging information provision in ensuring appropriate and effective mental health interventions. Moving forward, we would hope that CAMHS will receive the resources they need to create a truly accessible service.

Also of note and to be welcomed is the mental health digital and telephone support project, which is wisely exploring the possibilities of publicly provided, evidence-based ICT mental health supports so young people can potentially Facebook message a trained helpline volunteer in moments of crisis or use a digital signposting tool that helps them find the right service as opposed to needing to know the service for which they are looking. They could, potentially, even Skype with a therapist. I am sure the members of this committee who represent rural areas will intuitively understand the value and potential of remote services, particularly as rural isolation and distance from bricks-and-mortar services continue to hamper preventative and emergency mental healthcare.

The possibility of a genuine round-the-clock public service is one that would repay any required investment many times over. In that spirit of investment in long-term worthwhile projects, I wish to emphasise the excellent on-the-ground work carried out by the 13 current Jigsaw services, representatives from which are here with us today. Extending the reach of Jigsaw to more parts of the country or increasing its reach generally would be an extremely positive step for the future of Ireland’s youth mental health. The service meets an essential need for brief interventions and has a notable 98% satisfaction rating for those who have been able to access its services. Jigsaw will talk in much more detail about its service, but it is important that we see the impact it is having in local communities around Ireland and to state that as an independent organisation.

As the committee continues its work, I hope the need for more of these services will be front and centre, especially in light of Jigsaw's unstated role in supporting the case management of young people with mental health difficulties in many areas of the country, something that is absolutely pivotal in ensuring a joined-up and responsive national service. If we are to do that and do it well, I am absolutely convinced from my own time as a member of the youth mental health task force that the recommendations identified by that group will need to be addressed in full. The task force’s report highlighted, for example, the need for an independent advocacy service for children and young people and for new leadership structures in the area of youth mental health, including dedicated leads on national and community levels to enhance service co-ordination and accountability. The report also pointed out the need for legislative change that would allow 16 and 17 year olds to consent to their own mental health treatment and called for funds to be ring-fenced in order to satisfy the ever-growing need for counselling support services in third-level institutions. Each of these recommendations, if fully implemented, would remove barriers to proper treatment and strongly enhance youth mental health provision in key areas. I ask that the committee strongly consider the value of each of these proposals.

Crucially, I would like to point to the recommendations of another initiative, namely, the youth mental health pathfinder. Its proposals in this area would be transformative. However, a year after its approval by the Civil Service management board, implementation of the actions in its report has been delayed by the Department of Public Expenditure and Reform. The pathfinder report contains many innovative solutions to the challenge of co-ordinating cross-governmental action and of the existing accountability gap in regard to Government policy on youth mental health, while also making it clearer and simpler for young people to access appropriate services and receive standardised reliable treatment. I would again strongly encourage the committee to recommend swift action on these proposals within a clear and accountable timeframe.

I want to speak about the work of SpunOut in respect of health promotion. We have published the Survival Guide to Life for young people aged between 16 and 19, which aims to provide information across many of the issues and challenges faced by young people within that cohort. Over 10,000 copies of the book have been ordered by young people and sent to them for free. It has been availed of by many different statutory services, including HSE services, Garda diversion projects and other youth work projects throughout the country. We also produced "Ditch the Monkey", a five-part animation series about the five ways to well-being. Multimedia is becoming more important in getting across health promotion messages for young people. It is the way in which they consume information online. If a service does not have a video with subtitles that they can watch without sound on the bus, Facebook or their phone it is much harder to engage with young people.

On social media, the move from Facebook to Instagram is presenting us with challenges internally in the context of ensuring that we are where young people are today. In terms of the traffic on our website, some of the top issues young people have mentioned and come to us for include anxiety and positive mental health. Getting a good night's sleep, which is so important for physical and mental health, is a significant issue. We recently launched a campaign on problem gambling, which, we note, is a significant issue for young men and women. Being LGBTI+ in Ireland is still difficult and is presenting many problems and challenges for young people's mental health. Employment is the number one area visited on the website. We know that for young people being in employment or education is the number one protective factor in the context of their mental health.

While there is much more that could be said about the future needs of mental healthcare from a youth work perspective, I know that time is limited. Therefore, I will restate the need for genuine, sustained funding increases for mental health services which build on and support the best practice and innovation in care we see from certain service providers. I thank the Chair and members and would welcome any questions, either during this session or at a later time.

I thank Mr. Power. We will now hear the opening statement of Dr. Joseph Duffy, CEO of Jigsaw.

Dr. Joseph Duffy

Jigsaw warmly welcomes this opportunity to contribute to the vital work of the Joint Committee on the Future of Mental Health Care in Ireland. The work it has carried out to date and the recommended actions it has put forward in its interim reports are to be commended. The task at hand is not an easy one. The landscape for mental health provision and support in Ireland is complex and mapping out a new vision for the future of mental health is challenging. Integrated, joined-up thinking in the area of mental health is both challenging and lacking.

Areas such as research and stigma reduction continue to be the subject of under-investment. Innovations in areas such as e-mental health, school supports and services operating outside 9 a.m. to 5 p.m. are limited in scale and ambition. The whole population approach to mental health promotion and support, as put forward in A Vision for Change and strongly advocated for by Jigsaw, is needed, now more than ever, against a backdrop of mental health support services across primary and secondary care being under-resourced and over-stretched.

Jigsaw, as Ireland’s national centre for youth mental health, will focus our contribution on youth mental health specifically. At Jigsaw, we value young people. They represent Ireland's future, not least because the economic future of the country depends on their health, productivity and vitality, but also because our society as a whole will be better and healthier with a stronger, more resilient youth population to the fore.

The public and political discourse is shifting. As a result of the collective effort of the Government, elected representatives, the HSE, NGOs, civil society, the media, educational bodies and more, Ireland is beginning to see a significant change in how we view, talk about, respond to and support our young people’s mental health. We in Jigsaw are proud of our involvement at the forefront of this progress, and we strongly believe that Ireland has the potential to be a global leader in youth mental health research and support services by 2028.

While many challenges exist in supporting our young people, we have come a long way in the past decade. Only ten years ago, psychiatric-based supports for young people were the norm; young people were treated in a very similar way to adults in terms of mental health support, and Ireland had completely inappropriate, inaccessible and non-youth friendly services in place. Fast-forward to today. If A Vision for Change was the blueprint for a new kind of response, Jigsaw is a manifestation of many of the key principles in this seminal document.

Jigsaw’s vision is an Ireland where every young person’s mental health is valued and supported. It was established in 2006, as Headstrong, to meet an identified gap in service provision for young people struggling with their mental health, possibly with emerging mental health difficulties which did not require the support of specialist mental health services. Jigsaw is funded by the HSE mental health division, MHD, and provides services in a primary care setting. Jigsaw is an evidence-informed - through our Jigsaw data system, JDS - community-based mental health service for young people aged 12 to 25 years experiencing mild to moderate mental health difficulties. We provide young people in distress with a safe, confidential and professional service where they can access free talking therapies. We support young people to develop the coping skills and resilience that help them deal with present and future challenges to their mental health. These services are free, accessible, timely, impactful and evidence-driven mental health supports offered through our network of 13 regional hubs. It is interesting to note that 25% of referrals come directly from young people themselves, almost 40% from parents, just under 10% from GPs, and the remainder from other mental health services or educational settings.

The key features of the Jigsaw model include a focus on prevention as well as early intervention, accessibility and responsivity, and a commitment to meaningful youth participation and community involvement. In addition to the direct talking supports offered to young people and their families, Jigsaw is actively engaged in a programme of evidence-informed mental health literacy and capacity building in the community. This helps to ensure that parents, other concerned adults and those who work or volunteer with young people are better informed and more confident in promoting and supporting the mental health and well-being of the young people in their lives and become equipped to support young people in their community.

Jigsaw is engaged in ongoing evaluation and monitoring of the services we deliver and the impact of those services. This work is delivering with real impact. We know from our evidence that Jigsaw is making a difference in the lives of young people. Those young people who use our services are leaving less distressed, more resilient and better able to cope with the difficulties that arise in their young lives. Over the past 12 years, Jigsaw has supported, directly and indirectly, the needs of almost 24,000 young people. Most of those have been supported in the past three years. In 2017 alone, we supported 4,387 young people and offered over 13,000 face-to-face therapeutic sessions across the country, tackling issues such as anxiety, low mood, anger, low self-esteem and isolation. In evaluating our work, we found that last year 73% of 17 to 25 year olds who came to our services for a brief therapeutic interventions experienced a significant reduction in their psychological distress.

We value young people and their parents' feedback about their experience of the service. Approximately 92% of those who responded to an anonymous survey reported being satisfied or very satisfied with their service from Jigsaw. Alongside our face-to-face therapeutic work, we know that our mental health workshops and training, delivered to over 70,000 people across the country to date, increases awareness and knowledge about mental health issues, encourages higher levels of help seeking, reduces stigma and strengthens our communities’ confidence and competence in supporting the mental health of young people.

I would like to focus on solutions now. It is clear that the time is right to address some of the fundamental challenges that present themselves and look at sustainable solutions to support youth mental health. As my two colleagues have already mentioned, primary care is a hugely important issue. It has been our experience in the past 12 years that there is significant demand for a primary care youth mental health service that is free, easily accessible, responsive and acceptable to young people. There are large numbers of young people whose mental health needs can be appropriately supported in primary care but who do not need access to specialist care if they receive support early when experiencing mental health issues. The more comprehensive and advanced our primary care supports are, the less the likelihood of inappropriate referrals going to the secondary specialist care system, causing increased delays and the clogging up of an already stretched system. Mental health supports at primary care level in Ireland have been underdeveloped and underfunded for too long, contributing to the current problem we see in child and adult mental health services, CAMHS, which are all too often characterised by unacceptably long waiting lists.

Jigsaw strongly believes that primary care mental health supports should be holistic and systemic in their focus. In addition to the provision of widely available talking therapies, there should be an emphasis on the promotion of mental health and the prevention of more significant difficulties. In order to drive the change we see as essential in youth mental health we need to better inform, support, educate and empower our communities, enabling a better understanding of our collective responsibility in and ability to support young people’s mental health. While resources are limited, funding a range of services should not be viewed as taking resources from one area for another. In order to provide a single long-term vision for mental health services, all services should be acknowledged and resourced for the role they play in preventing, supporting and managing mental health issues.

Jigsaw employs psychologists, who are either clinical, counselling or educational, social workers, occupational therapists and mental health nurses in its trans-disciplinary clinical model of clinical care. Recruitment of sufficient numbers of appropriately qualified mental health professionals is a significant challenge to all agencies within the sector. Jigsaw, like other mental health service providers, faces daily challenges in this area. What is clear it that there are a limited number of mental health professionals graduating into and entering the system. There is significant competition for posts between services who are all struggling to resource their teams, with particular challenges in some geographical areas. In Jigsaw’s view, some of the elements that would contribute to easing the challenge of recruitment include increasing the numbers of university courses or places in relevant disciplines; for allied health professional training courses to include a greater emphasis on mental health, thereby facilitating a smoother and quicker transition for graduates into mental health service positions; and the promotion of the mental health field as a positive, progressive, recovery-focused place to work where one can make a real difference in the lives of others. We involve our youth advisers in the recruitment process as we believe having an interest and passion for youth mental health is an important factor in ensuring that there is the right fit between a prospective staff member and the work he or she will do in Jigsaw.

A Vision for Change clearly references the need for greater integration across the various strands of the mental health system. An augmented primary care system will work best and meet people’s needs to the extent that there are linkages and more joined-up thinking and pathways between primary, secondary and tertiary care. We acknowledge that we are stronger when we work together, linking in and working with like-minded organisations, individuals, agencies and funders. It is only through this collective action that we can truly develop innovative responses and seek fresh, bold perspectives in the area of youth mental health.

We see mental health as something that is part of our community, part of our workplaces, schools and part of our lives. In Jigsaw, we are working with the HSE and with corporate partners – MSD, Three, Lidl, ESB and more - to bring about this change. The CAMHS standard operating procedures, SOP, lists Jigsaw as a direct referral agent with the provision that Jigsaw referrals must be made by a senior clinician in collaboration with a GP. However, some CAMHS services do not accept these collaborative referrals from Jigsaw, insisting instead that the young person goes to his or her GP for a referral. This causes delays and puts another step in the process that is already difficult for the young person and his or her family. We would like to see a real commitment to interagency working that is based on meeting the needs of young people and their families which supports their movement across the mental health service system in as seamless a way as possible.

We believe research in the area of mental health is wholly under-resourced. Jigsaw’s seminal My World survey of 2012 remains the largest and most impactful study of its kind in Ireland. However, data contained within the study is nearing its tenth anniversary and we need to review the full range of risk and protective factors at play for today’s youth population. In line with Jigsaw’s strategic objective to deliver robust research and evidence to better inform systems change and effective service delivery and to increase our collective understanding of youth mental health, we believe in the value of investment in a new research agenda on the modern-day lived realities of our young people. We believe that is needed now more than ever and we are planning to repeat the My World survey this year.

As has been mentioned by my colleagues, e-mental health is another important area. At Jigsaw, we believe that digital technology can make a significant contribution to enhancing public understanding of mental health. We see the potential for digital technology to transform the way young people look after their mental health and to transform the way we, as a country, design and deliver mental health supports and services. We are currently working with two corporate partners, MSD and Three, to initiate the development of a high-quality, accessible e-mental health platform that has both a prevention and early intervention focus.

Since Jigsaw was founded, young people have been involved in helping us to develop and design our services. We now have youth advisory panels in each of our services and in the national office. These panels are made up of young people aged between 16 and 25 who may or may not have experience of the mental health system but who are all passionate about this area. More than 130 youth volunteers help to inform and guide our decision making at all levels of the organisation. They have representation at the board of directors meetings and on board subcommittees and are involved in the recruitment of staff and in representing Jigsaw at national and international events.

Our youth advisers asked me to emphasise the following points to the committee today. It is important to start at the start and not to wait until the end to support a young person. Early intervention needs to be emphasised more. There is a lot of focus currently on second-level services - child and adolescent mental health services, CAMHS, etc. - but there needs to be a focus on supporting young people earlier, in schools and colleges, to let them know more about what will support their mental health. Greater knowledge and supports for young people who have more significant mental health problems are also needed. Services need to be more youth friendly and the transition from CAMHS to adult mental health services needs to be looked at. If one needs a CAMHS service when one is 17, being put on a waiting list for adult services just because one turns 18 is not acceptable. More resources are needed generally to ensure that requests for support are responded to appropriately. The age of consent for accessing mental health services should be reduced to 16 years. Young people may want to access support due to family issues but may not feel able to tell their parents what the real problem is and having to get parental consent when one is 16 or 17 is a barrier for some young people. Young people also highlighted the importance of being greeted in a service by friendly staff and being made to feel respected. This will have an impact on their engagement with mental health services. Mental health overall is about human experience and we need to remember this aspect.

By continuing to invest in youth mental health specifically, we can ensure that we continue to enhance and evolve the services we provide, to increase our knowledge, to deliver more impact and to increase supports for adults, families and parents. We need to work together and to create meaningful partnerships and we need to work tirelessly to ensure that no young person suffers alone without access to the help he or she deserves and may desperately need. As the landscape of mental health evolves and changes, so too must our responses. We very much welcome the opportunity to discuss further some of the issues that we have raised during this meeting. I thank the committee for the invitation to participate in this process.

I thank Dr. Duffy. We will now hear questions from members of the joint committee. To explain how this process works, a number of speakers are known as lead questioners and they will have seven minutes to ask questions and get answers. There are four lead questioners and when they are finished, all other members will be able to ask questions in blocks. The lead questioners are Deputies Fiona O'Loughlin, Tom Neville and Gino Kenny. The fourth was meant to be myself but I propose that Deputy Buckley, who is not here at the moment, also be allowed ask questions if there is time before he takes the Chair.

I thank all of the witnesses for their contributions and submissions. I apologise for missing some of the oral presentations but I had the opportunity to read all of them beforehand. I have a few general questions and a few key ones. It is very clear, and we all acknowledge, that there is a crisis both in our mental health as a nation and in the mental health services available to those who are in crisis. We all agree that there is a necessity to promote positive mental health among everybody. As Chair of the Joint Committee on Education and Skills, one of the first tasks which members of the committee, including myself and Deputy Catherine Martin, undertook was to make very clear recommendations on promoting positive mental health both in formal and informal education. We are awaiting responses from the Minister in that regard. I commend the work the organisations have done. It is excellent. I also want to put on the record that we have some excellent community organisations which deliver really good responses on the ground, particularly Hope(d) in my constituency of Kildare South. It is a totally voluntary organisation which does not get any State funding. The work it does to help support young people in need in particular is incredible.

To move onto the specifics, the funding situation the witnesses have outlined is incredible. To think that in 1960 Ireland allocated 23% of the total health budget to mental health and that we now allocate 6.4% is absolutely shocking. As the witnesses have noted, we have recommended that allocation be raised to 12%, which is the standard recommended by the World Health Organization. We completely agree with that. Children comprise 23% of our citizens. We all acknowledge the levels of stress they are under and, very sadly, the levels of youth suicide. I believe we have the seventh highest rate in Europe. What interventions do the witnesses believe are most successful in promoting resilience in young people? That is what we are all about. This is about helping our young people to develop resilience and to develop the coping skills they need.

We have discussed CAMHS before. Speaking for many public representatives, very sadly we hear very negative anecdotal reports about CAMHS which is available when people can actually get into it. We absolutely need to eliminate the delay caused by the requirement for a GP referral before a person is referred to Jigsaw. That seems to be unduly time consuming. How can we improve interagency co-operation? I acknowledge that we did have explanations from the HSE in respect of the difficulties in recruiting appropriate personnel to deal with this area. That is part of the problem.

What interventions are most successful in combatting anxiety among all age groups? As I said already, that has been increasing. As a Deputy with many rural constituents I am always concerned by the lack of services available in rural areas because many of our younger people do not have access to public transport in order to be able to get to a place where they can get help. Obviously that is also the case for older and vulnerable members of the population. We have to ensure that those who need timely access to support get it.

I would like to ask Dr. Duffy why the GP referral rate to Jigsaw is so low. GP referrals make up only 10% of its referrals. Obviously it makes referrals to GPs, but there do not seem to be referrals in the reverse direction. Speaking locally, the nearest Jigsaw hub to Kildare is in Tullamore, which is obviously not feasible for Kildare residents to access. We have the fastest-growing percentage of young people in the country. Is there any hope that we could have one in Kildare? It would be really good. Obviously it would be good for every county.

On another general question, how do we make our primary mental healthcare supports more holistic? It is very important that everybody feels they have access to it. We acknowledge that recruitment and retention rates remain a huge issue in this sector. How can we encourage young people to enter this field and to feel that they have a contribution to make? Again I would like Jigsaw to expand on how allied health training courses can facilitate a better transition. Will Dr. Duffy advise further on the progress Jigsaw has made on e-mental health? This would be of massive help to that rural-dwelling population and to young people who are, perhaps, more comfortable using technology than having face-to-face interventions.

The witnesses have less than two minutes to answer all of that.

Dr. Joseph Duffy

I will start taking some of the questions, if that is okay, and then my colleague, Dr. Gillian O'Brien, might answer some more. I thank the Deputy for her comments. On the expansion of Jigsaw, we are working closely with the HSE. Some members of the committee may know that the initial model in Jigsaw was based on philanthropy, which was then matched by HSE funding. Jigsaw services are now predominantly funded through HSE supports. We are working with the HSE to develop a plan for the next number of years and it is currently carrying out an evaluation of the Jigsaw services. We would love to be able to expand further and to develop. We have done some work ourselves on how we would expand into the areas and how we would make those decisions, because we would love to see Jigsaw across all of the counties and across all the country but we need a plan in place for that. We are working closely with the mental health division to develop that.

Dr. Gillian O'Brien

I will speak to the issue of the GPs. It may seem that our rate of referrals from GPs is quite low at approximately 10%.

Our preference would be to encourage young people to self-refer to Jigsaw. What tends to happen is that the GP, after the consultation with the young person, simply tells the young person to make direct contact but that if he or she likes, he or she may be referred by the GP. The GP will say that, to make direct contact, the young person can lift the phone or send an email.

With regard to the interventions that are most successful in reducing anxiety and promoting resilience-building, there is a good evidence base indicating talking therapies have a lot to contribute. The nature of the therapeutic relationship is also very important. There is a lot of evidence but ultimately we need to help young people to develop an understanding of their emotional awareness, learn to regulate emotions and understand how, when they feel very anxious or distressed, they can soothe themselves and manage that. Not only do we need to support and educate young people, but we also need to support and educate parents and others around the young people, such as significant adults or "one good adult" in the community. Referred to already was peer-to-peer information-sharing and support. We have found this to be very valuable. We train many young people in second level schools in evidence-based programs so they can impart information to their peers on how to recognise signs of anxiety and what can be done about it.

Mr. Martin Rogan

What we have seen in recent years is a new conversation about mental health, particularly among young people. They have a much more mature attitude to mental health than previous generations. The question is whether we have the infrastructure to respond to that. There has been much focus, rightly, on the development of CAMHS. CAMHS is really designed for 2% of the population. It is a matter of what is to be done with the other 98% and determining what is happening in our communities, societies and family structures that has suddenly changed. There has been a sevenfold increase in the number of young people presenting with anxiety-based conditions. Sometimes within families, for a variety of reasons, including those related to housing and insecure employment, the opportunity for parents to spend time with their children and model life experiences is not what it might be. We must be very cautious in this space that we do not pathologise life. One of the experiences of childhood is that there are slings and arrows and various opportunities and scenarios that are adverse. We cannot treat these away, nor should we attempt to do so. The skills required are life skills but one needs to have access to "one good adult", perhaps a parent, coach or teacher but someone the young person can select and to whom he feels he can relate and who can give guidance or offer a listening ear. This is really valuable.

There has been a lot of work and some extraordinarily useful tools developed in the e-mental health space. E-mental health services can do things human therapists cannot do. The services can be available 24-7. They can understand where one is and the antecedents of one's behaviour and determine whether one is in a difficult position. They can determine whether one is active or texting at 4 a.m. and whether these are issues. We need to be careful to ensure that, while e-mental health services augment and supplement other initiatives, they do not supplant them. We need to be careful that we do not swing in a pendular way just to an e-mental health model.

In the wider mental health space, there is a real prevalence challenge. We know from research done by Dr. Corey Keys in Atlanta that about 16% of the population enjoy good mental health. Approximately 54% have what is described as mental health adequate to cope with life's demands, and approximately 20% of the population will have a diagnosis and be in treatment. A further 10% are described as languishing. These are people for whom life can be difficult and awkward but who do not have a diagnosis. What is fascinating about the research is that it shows that over the course of time people move from one category to another. That one is enjoying good mental health today does not immunise one in any way.

In the past, we talked about one in four. Essentially, we are talking about four in four. Therefore, it is our collective mental health that we need to address. That is why this committee's work is so important.

I thank all the delegates for attending. I will be as brief as I can. Mental Health Ireland raised the issue of access. I was speaking to Deputy Crowe about this and I said that if somebody needs a newspaper, he or she knows they have to go to the newsagent. Newsagents are readily available. If one wants a drink, one goes to the pub. Gaining access to mental health services seems to be the biggest problem. We have many organisations going in the same direction but they are splintered. We and the delegates have all been very successful with regard to the mental health awareness campaigns. They are working but we do not have a mental health access awareness programme. If one's leg is broken, one knows one has to go to hospital and one knows the service one has to access.

In the past two years, anxiety has been a major issue across the board. I will not elaborate on this. Suffice it to say much anxiety has to do with isolation, social media and spending five or six hours in the bedroom. It is definitely leading to anxiety.

How do all the delegates feel about age-appropriate mental well-being in schools? I refer to children in primary school and even younger. Two of the speakers mentioned coping skills. We are not giving our young people the coping skills to deal with what comes along in life.

My next point is on the charities and voluntary groups that are supporting all the initiatives. The delegates referred to 6%, 10%, the Sláintecare report, the WHO, and the funding of 12% or 12.5%, which I totally agree with even though I worked on the Sláintecare report. Do the delegates believe many of the mental health services are being run on the cheap because of the funding? We know there is a lack of funding.

My final point is on recruitment, on which I am going to be very blunt. Could the delegates answer simply, with a "Yes" or "No", the question of whether we need the unions, all the sectors and the Government to agree the staff are not being paid and that if they cannot be paid, they cannot be recruited. If the staff cannot be recruited, there will be a forever-toxic system with a revolving door that will never be fixed.

Mr. Ian Power

On the point on accessing mental health services and awareness of how to access them, we often place emphasis on the burden of understanding what service one is meant to go to on the person as opposed to helping that person navigate towards the service he needs. One of the recommendations in the youth mental health task force guidelines was on a digital signposting tool that would use artificial intelligence to ask a person questions about what he or she is feeling in order to narrow down the number of appropriate services. There has been good work done on that in Australia. ReachOut Australia has a tool called NextSteps and it has sound clinical governance underpinning it. The HSE is currently considering replicating something similar here. We hope it could be done in a relatively quick timeframe to respond to the point the Deputy raised.

Similarly, with regard to texting, we know young people do not do anything by picking up the telephone anymore. Since they do not order a pizza or taxi by telephone, why would they talk about the most vulnerable aspect of themselves, namely, their mental health, over the telephone? Why would they feel comfortable in doing so?

One of the other recommendations in the task force report was on scaling the provision of active listening services, such as the Samaritans and Childline, but through texting and live chat, including services such as Facebook Messenger. In the United States, services such as Crisis Text Line are extremely popular, fulfilling a great demand for young people who want to talk to somebody in moments of crisis. Such services are obviously not to supplant other services, as my colleague from Mental Health Ireland mentioned, but they help to get people from a heated moment to a cool calm moment when they can move on to another service. We really need to step up the sense of urgency in regard to services like those.

I take the point on resilience and education. Education should start from the early years and extend right up through primary, secondary and tertiary education. With regard to one of the points Deputy O'Loughlin made on resilience and what is most effective, there are a number of really effective evidence-based interventions in terms of resilience-building but we need to come together to agree on which we are going to back and which we want to see mainstreamed. There is too much fragmentation in what is being provided. That leads to inconsistency in the educational experience of children and young people around the country. This is not dissimilar to the issue of sex education.

We need to have a situation whereby such education is standardised and ensure that every young person gets the same quality experience.

Finally, there is a supply and demand equation when it comes to recruitment. Let us remember that when supply is lower than demand then the price increases. Therefore, we should pay competitive rates to attract qualified people from around the world to work in the mental health service here. Such an initiative is difficult because it has ramifications for elsewhere in the public sector. We need to start working on what Dr. Duffy mentioned and increase the pool of qualified people here, domestically, over time through the Irish education system.

Dr. Joseph Duffy

Deputy Buckley asked whether the solution was just getting everybody in a room together, thrashing things out and considering the amount of money available. That is one factor but another factor to consider is the culture within the mental health service. As I outlined in my opening remarks, one should consider the promotion of the service as positive, progressive and recovery focused. When we think about mental health we need to think about the mental health of workers and that of staff working in the system. As we know from first-hand experience when people come to work for Jigsaw, the fact that the staff work directly with young people and focus on something that is positive and is very much recovery-focused in terms of early intervention and prevention, really gives a sense of energy and a sense of making a difference. If one works in a service that is very depleted and there is only a small number of people on a team then it is very hard. One can see people make the personal choice to defect and move and, as a result, there is a huge loss of significant experience across the board. Therefore, we need to think about the mental health service much more broadly, and consider ways to ensure Ireland, as a country, has a really positive view of mental health and views it as a spectrum and that early intervention is needed. There are long-term significant supports needed at other ends of it but by working together we can achieve and create them. We must also be mindful that people have different skills at different levels.

Mr. Martin Rogan

A number of really important points have been made about access. Research into access has been done in the north west. In Donegal, young people were asked where they would go if they found themselves in difficulty and they gave five primary responses, which were: talk to one's parent or parents; talk to a teacher; talk to a friend; get drunk or self-harm. These were all five live available options and, unfortunately, the last two are particularly harmful. One of the great elephants in the room is our relationship with how people self-medicate with alcohol. It is a huge issue for us and is one of the significant oversights in A Vision for Change. In fact, the policy outlined in A Vision for Change sometimes looks more like the mental health policy for Saudi Arabia than it does for Ireland because alcohol is only mentioned twice in the document, which is a problem.

In terms of health promotion in schools, preschools, crèches, etc. and other forms of health promotion such as the one entitled the First 1000 Days, the Mental Health Reform organisation has produced an excellent document that makes a strong bid for perinatal mental health. We know from research done in the US that there are lifelong benefits to be gained when one invests in early childhood interventions such as family supports, quality supports and coping strategies. They are very useful as well.

As Mr. Power has mentioned, e-mental health can help to extend the prevalence challenge and improve the qualify of signposting but we still need to be mindful. In Japan, there is a phenomenon called hikikomori, which refers to about 700,000 young Japanese men who live in their bedrooms and do not interact with humans at all. Their families know these men are still alive because a pizza slice will be missing from the fridge and the men will have retreated back to their bedrooms. Some of the men play computer games against other humans while others will only play against a computer. The men are not recognised as having autism or other mental health issues. They have simply opted out of their communities and we can expect to see some of that issue in the future. We need activities that include sports, culture, and young people being involved in their community space. People who are equipped and skilled to develop young persons in a rounded sense are really important to us. These are things on which we can get a heads up in order to avoid such a phenomenon in the future.

As Dr. Duffy pointed out, staff can work in this arena. It is more agile, responsive and can be more focused but there is a risk that we could strip staff from other front-line services. As an English-speaking country we have some of the finest graduates in mental health professions. I know from Australian and Canadian colleagues that they are thankful to Ireland, as a donor site, for offering up staff. This is an internationally competitive market. Over the past decade the HSE and other health providers were not in a position to outbid better performing economies at that time. The cost of possibly having a home, particularly in the Dublin area, has become prohibitive and it is quite a challenge for mental health services to retain staff in Dublin areas. We need to be creative and imaginative and not imaginary about recruitment. In the UK there is the London weighting model that recognises the additional cost of living in the city. Perhaps such an initiative should be revisited in this context otherwise we simply will not be able to provide services where we have the greatest concentration of the population. That is not a prospect we can entertain.

I thank Mr. Rogan. I shall pause the meeting for a moment to allow Deputy Buckley to take the Chair.

Deputy Pat Buckley took the Chair.

I call Deputy Tom Neville.

I thank the witnesses for their attendance and will first talk about Jigsaw. A year ago I visited the Jigsaw centre in Limerick. I was given an extensive tour and met the guys so I can attest to the fact that a fantastic services is being provided in Limerick. I spoke to the staff about rolling the initiative into rural areas in the form of pop-up clinics. Limerick is different, because the county is smaller relative to the size of Limerick city. Therefore, the city has a big influence on the county but the western and southern parts of the county do not have such affiliation. It is about trying to provide a service all over. Is there a timeline for rolling out the Jigsaw programme throughout the rest of the country? Will the scheme be rolled out on a phased basis? Is Jigsaw considering how to expand its existing 13 services into rural areas? If so, how does Jigsaw propose to set up in new counties?

Jigsaw provides a fantastic service. Jigsaw has produced a self-help or self-awareness book. On 12 April I attended the launch of an initiative called Read Your Mind at the Kilmallock Library in County Limerick. The initiative brings together an invaluable collection of 100 books that promote awareness about mental health and energises local school children and makes them aware of the literary resource. The people concerned with the project want to make it normal for such information to be available. I found the initiative quite helpful myself when I spent a couple of hours there. Does Jigsaw have a roadmap for rolling out projects? How has interaction been between the Department and Jigsaw? What is the budget and timeline?

Mr. Rogan, from Mental Health Ireland, mentioned the stigma and prejudice associated with mental health issues. Can he suggest ways to combat same, from his experience? Such negative beliefs are intergenerational and have been passed down from one generation to another. I agree with him that young people nowadays are more open about mental health issues than older generations, even including my generation. Perhaps that is because mental health is talked about more. This committee provides a forum to speak about the issue. Mr. Rogan also said that men are reluctant to seek help. Can he flesh out his views for the benefit of men who are watching these proceedings or may watch it in the future?

In terms of SpunOut.ie, Mr. Power mentioned that three quarters of all serious mental health difficulties start to present when a person is aged between 15 and 25. I am very much on par with his views on early intervention and working on same.

In terms of the debate on funding and deciding whether to direct funding to providing acute services or early intervention and which do we consider first, I believe we must concentrate on both aspects and alleviate the waiting list for acute services. I hope this committee will provide a blueprint on how to proceed. As time goes on one can take more funding from the acute services and move it to early intervention. As he said, one will not have the same volume of cases presenting and that will have a knock-on effect on the culture.

ICT has been mentioned. What are Mr. Power's thoughts on same? I will play devil's advocate and say that we have a paradox. We have heard a lot about how social media puts pressure on young people and that young people spend so much time on their mobile phones that they are losing the art of interaction, communication or interpersonal communication. On the flip side, we are marketing an e-service to interact with services. Is there a drawback in having an e-service? I am not saying that it is wrong and simply wish to learn more. Should we start putting resources into education to foster or encourage face-to-face interaction or more human interaction in everyday life?

Could the witnesses tease that one out?

Dr. Joseph Duffy

I thank Deputy Neville for his comments on Jigsaw Limerick. He asked about development and expansion. Jigsaw is in 13 individual services in nine counties. There are five services in Dublin. We have done some future planning, which would be part of our strategic plan, to look to develop Jigsaw to have national coverage. We would expect that to be around 24 services. The reason we say that is because we know that for some counties, based on population, geography and the actual transport infrastructure, it is better to look at them as joint units so if we are in Sligo-Leitrim, it might be one unit. We are in Offaly at present and if we were to move to Laois, we could expand into Laois. We are looking at it in two ways. The first is to consider whether there are current Jigsaw services we can expand on an intercounty basis? In this context, Offaly to Laois would be one that would not demand a significant investment. The second part of it is looking to expand so that we are working to have nationwide coverage. As I mentioned earlier, we are working with the HSE in evaluating the Jigsaw service. This is being done independently. The HSE expects to have a report at the end of June on that. That is effectively looking at where Jigsaw fits within the wider mental health system. We would see it as very much fitting within primary care. What we hope to see coming from that would be an agreed plan we could develop on a phased basis and look at all the learning we have generated so far and how we work with communities where there is significant knowledge about youth mental health and there are significant other structures in place. That can really help Jigsaw to grow and develop very well.

In tandem with that and with support from the corporate sector, we hope to develop the e-mental health side of it because we know that we will not be able to see every young person in a Jigsaw service even if we had national coverage. We want to encourage and develop information giving and interaction and, ultimately, encourage online support, as has been mentioned before. There is no firm plan in place for the future expansion but we are very hopeful around that. We know that in terms of our development, so far, there has been very much a trial-and-error model in terms of developing it, looking for funding, developing the evidence and continuing to develop that. Our relationship with the HSE is very positive but it will take a significant amount of time. We would love to reach national coverage within the next five years.

Dr. Gillian O'Brien

I will respond to the Limerick-specific question. In a number of the counties in which we operate, we operate outreach. The Deputy asked about pop-up locations. This is something we are exploring in Limerick. The question is where are the other natural population centres for young people around Limerick county. It involves linking in with community groups and community partners to get a good sense of that, so that is certainly in the plan.

Mr. Martin Rogan

Stigma is an interesting term. It means a mark or sign. In mental health, a person does not necessarily have an outward sign of having a mental health need. There can be a degree of self-stigma. Traditionally, stigma has been associated with any phenomenon that has a poor outcome so in the past, it was TB, HIV or single parenthood if it was going to have a negative life course impact. We know that most people who use mental health services have a successful outcome but, unfortunately, the social narrative has not changed from the past.

Is Mr. Rogan saying that most people-----

Mr. Martin Rogan

Most people who use mental health services will progress and have a good outcome.

And have a positive outcome.

Mr. Martin Rogan

Absolutely.

That is a very important point.

Mr. Martin Rogan

One of the challenges for us is that often, when people have a successful outcome, they airbrush that episode out of their lives and can be very low profile. Unfortunately, when people do not have good outcomes, they can be very high profile, sometimes with tragic outcomes or very visible disability and social disadvantage. One of the things our organisation is looking to is creating real opportunities for people with self-experience. In the past number of weeks, we have recruited eight new staff, six of whom are people with self-experience. I was in Limerick yesterday meeting with four of our staff who are peer educators in collaboration with the HSE - the service improvement fund. Again, these are people with self-experience who have recovered and want to give something back. They have really powerful testimony and message to give and it is a message of hope. Sometimes in the past, people who have had quite severe and disabling mental health issues have tried not to mention it because it can have limiting effects on their career, employment or other social opportunities. We need to celebrate the people who really find it difficult every day and still step forward, come to work and are active in family life.

Mr. Rogan said it may detract from people's careers. Is there evidence that this is still happening or it is a perception?

Mr. Martin Rogan

The mental health service has 1 million service contacts per year and 20,000 people have been referred to the mental health service. If people have been referred to that service, people must also leave it in order to do that. It has a fixed capacity. Part of the role of our organisation is to make sure people have progressive pathways onwards and forward and that communities are more open to the space. We need to highlight that mental health services are increasingly successful in terms of people retrieving their lives and making progress in their lives. That is probably the untold story in mental health and is certainly one on which we need to focus much more effectively.

With stigma, we are inclined to locate the problem within the individual. If we use the language of discrimination, we are saying it is other people's attitudes that need to be adapted. This is the reason for initiatives such as Healthy Cities. The mayor of New York, for example, has dedicated 1% of his budget, which is $850 million, to a city-wide initiative to promote mental health. Limerick is a very good example of a Healthy Cities approach, which actively incorporates mental health into its objectives. Again, our organisation is very active in that process. Limerick Mental Health Association now has a three-week event that includes 34 different partners around Mental Health Week in October. It is much more positive, progressive and optimistic programme without airbrushing away some of the difficult challenges that are very real but that can be managed to allow the individual to go forward successfully.

Is Deputy Neville happy enough with that?

That was very enlightening in respect of discrimination versus stigma.

Mr. Ian Power

To pick up the point about stigma, we have had a really productive conversation around mental health over the past five or six years such that people feel a lot more comfortable talking about it. However, it is in a very sanitised way. We still have an issue with stigma around mental illnesses and some of the most severe mental illnesses and we need to do a lot more work to educate the public at large about illnesses like schizophrenia and other illnesses that people still do not understand and, therefore, still stigmatise. Coming back to the point about where to invest, I agree both simultaneously, in terms of prevention and acute services.

It is really important to point out that e-mental health is not a panacea. There are particular applications of e-mental health that are appropriate. We need to learn from the UK's experience, particularly the NHS, which has created a whole NHS digital team relating to mental health. The NHS has funded that research programme significantly to understand what types of e-mental health interventions work for particular issues. The learning there has been that one cannot design a one-size-fits-all e-mental health response. It needs to be individual with regard to the experience or the particular condition or issue experienced by people. There have been a number of key targeted responses for generalised anxiety disorder. Augmented reality has shown some real promise in responding to psychosis, so that is really important.

We have been talking about how lots of people have a positive experience of the mental health service. When people do not, we focus on the negative to the point where we potentially deter people from seeking help. We really need to start looking at being solutions-focused when problems arise, not dwelling on what has happened and trying to identify how to fix the problem. A number of service improvement projects are in train within the HSE, not least the one relating to CAMHS. The review of the standard operating procedure is ongoing. We need to build those services up because they contain staff members who are becoming demoralised by the public narrative relating to mental health services. Yes, we can all do better but we need to change the frame we put on this conversation.

Mr. Martin Rogan

The discussion and debate about mental health has been interesting in the past few years. Perhaps about ten years ago, we learned from colleagues in Australia where parliamentarians had come together to understand mental health issues. Mr. Ian Power has mentioned more significant mental health issues such as schizophrenia and bipolar disorder. We worked with a number of NGOs which asked if there was a Deputy or a Senator who had had a sustained interest in mental health or self-harming. Somebody said there was a Deputy Neville, a tall man from the mid-west. We said it was Dan Neville. We were all talking about him. At the time, when there were 166 Deputies, we had difficulty in identifying more than one. We are really encouraged in the sector. A little like John the Baptist, we have been out in the wilderness for a long time, but eating locusts is not what it is cracked up to be. However, it is encouraging to see this forum, with Deputies and Senators taking a sustained interest in mental health issues. I hope the committee will have a sustained future and take an in-depth interest, rather than have a veneer or superficial interest, in mental health issues. In the sector we are encouraged to see debate rightfully take place here.

It has been very different. The members of the committee have been and are very passionate. We are proud to be part of this unique forum; we will not call it a mission. We are here to ask the hard questions and do the right thing. It is not on our behalf or that of the delegates but on behalf of the people we all serve and future generations. I thank Mr. Rogan for his commentc. I knew Deputy Tom Neville's father very well.

We have to be out of the committee room by 3.30 p.m. We have two more speakers.

I asked Deputy Martin Kenny about it. There is one question, for those who may be looking in or may watch the proceedings later, to flesh out the point Mr. Rogan made about men. I do not think we get enough time to talk. Will Mr. Rogan outline the parameters of the reasons, from his studies, men are reluctant to come forward?

Mr. Martin Rogan

It is not unique to mental health but across a range of issues. Men are often reluctant to avail of health services, to which primary care is not necessarily always the best route to take. Last week, for example, we met representatives of Men's Shed which has a really active role in engaging with and mobilising men. It was not designed as a health initiative, but it has many benefits. Unfortunately, one of the primary carers when it comes to mental health is the Irish Prison Service, where many find themselves in difficulty by virtue of having very significant and mental health needs which are under-met in the community. In Ireland approximately 7% of the prison population have a psychotic illness. If someone has a psychotic illness, he or she should not be in prison but availing of a mental health service within the community. Some 80% of those admitted to prison who present with it are already known to mental health services. We need to listen more closely to men and devise models that are attractive to them that do not in any way undermine their masculinity, role or position. Coming back to the point about stigma, it has been found to have a chilling effect on some people's careers or their roles in communities, but we are much more optimistic in that regard as we see more people coming forward with initiatives such as social farming and sports activities in which men engage on mental health topics in a more constructive way. Models that work well for women may not translate easily for use by men. Sometimes men can find talk therapies difficult. The shoulder to shoulder conversation is easier for men than eye to eye contact, which is often considered to be confrontational. Self-medication with drugs and alcohol is far too appealing and accessible for men. We need to find much more progressive and healthier models.

Dr. Gillian O'Brien

On Mr. Rogan's point, we need to design services with young men in mind. We pay much attention to this in Jigsaw. One needs to brand and promote one's service in such a way that it speaks to the audience. We have found and are really proud - I looked at it this morning before I came here - that the ratio of males to females using our service is 44:56. Progress is being made, but one needs to put much time and effort into it. We ask young men what would make it more likely for them to come to a service, rather than presuming that we know.

Many questions have been answered and the meeting has been very informative. I commend the delegates from Jigsaw. Where I come from in Neilstown it is very good. I have been there a few times and it is well used by young people throughout the area. I have a couple of questions to ask.

I want to ask Mr. Rogan about his observations on the 1960s. If 23% of the health budget was spent on mental health services in the 1960s, that means many people would have been hospitalised in mental health services in the 1960s compared to 2018. Today some 6% of the health budget is spent on mental health services; therefore, obviously, a substantial number of people have been dehospitalised in the past 50 years. What is Mr. Rogan's take on it?

I have an observation on the use of social media and smartphones. We all use them and all think they are great to some extent, but they can have a serious dark side, too, particularly for young people. They can be individualistic in targeting young people because social media platforms are clever in targeting their market and their market is young people. That can play games with the heads of young people who can be so competitive against one another. We cannot get away from it, but social media can be detrimental, no matter who people are but particularly to young people. Will Mr. Rogan comment on this?

Are we dealing with bullying, specifically among young people? We are talking more about mental health services. The subject was taboo as nobody wanted to talk about his or her own mental health, but we are talking more about it than ever before. Since I became a Deputy, it has been one of the narratives of this Parliament. Talking about it is really good, but when one sees the flip-side, one sees that when people want to access mental health services, they cannot find them.

Some of the delegates before the committee have been really stark. They have shone a light on how mental health services have been really bad and let people down. It is due to a lack of funding, a lack of retention and recruitment of staff. I probably fell into the trap of playing this down a little a few times. Staff in mental health services are fantastic. They are both motivated and professional. It is important that the narrative from the public and here be that the service is in a perennial state of crisis. There is a crisis, from which there is no getting away. Where services are not available, people will fall through the cracks and when some fall through, they will die, as was seen on the documentary broadcast on RTÉ last week, "The Big Picture". It is unbelievable how quickly things can fall apart for families and individuals. There is major discontentment in a capitalist society which sometimes is so competitive. Alienation drives people away from each other. Therefore, the more we talk about things and the more we, as humans, get together to collectivise our experiences and problems, the better it is for everybody's well-being. The pressure these days, particularly on social media, is incessant. Young people are on the phone all the time. That cannot be good for their mental health.

Mr. Ian Power

The point on social media is important because they are here to stay and we need to get to grips with the issue. I liken it to healthy eating. We all know that we should eat healthily, but very few of us make all of our own meals and stick to a strict diet. It is similar with mobile phones in the use of apps and various other things. We all know that they are not necessarily good for our mental health, but we are still compelled to use them. There is an addiction which is not dissimilar to eating junk food, consuming soft drinks and that type of thing. There is marketing at play on platforms, similar to how there is marketing at play when it comes to junk food companies. Ultimately, we need to learn how to control our impulses, as we do in the case of healthy eating. Just as we need to make it easier to eat healthily by reducing cost and such like, we need to make switching off and unplugging easier.

One thing we would recommend to young people is, for example, given that many apps automatically have notifications switched on in order to pull the user back in when they might be idle, that they should switch off notifications so they only dip in and out whenever they want to, as opposed to the app trying to wrestle their attention and control them. There are various things like that. If a person knows they are going out for a walk on the beach, there is no real reason to bring a phone. There is a benefit to unplugging and having an experience with other people, such as knowing to put phones in the centre of a table when with friends, so people are not all mindlessly checking instead of being present with each other. There are lots of things we can do. We can blame social media companies, and I think they should be held to account for lots of things they could do but, ultimately, we have an ability to control ourselves. We need to support young people to find the ways to do that, which is very important.

On the point on bullying, a lot of young people experience bullying in schools and this is obviously creeping into their home lives as well. Of all of the interventions we have seen, and we have been very active in this space, it is vital to have a whole-school approach whereby sixth year students - or sixth class students in primary school - are built up to be the people who set the tone and say that bullying is not acceptable in a school and that trickles all the way down through the years. What we find is that, once we give young people responsibility and a standard to which they should be held, they rise to that challenge and they support and educate the younger children to make sure it is socially unacceptable within that school community. We have seen this in particular in Drimnagh Castle school, which has had huge success in implementing that type of model. This needs to be replicated everywhere. Schools used to have an issue in admitting they might have a bullying problem because it used to be seen as an issue, whereas schools are now being much more honest and open about it, which is very good.

Mr. Martin Rogan

In regard to the historical reference, in the past we had a very large institutional base in Ireland and I do not think any of us are nostalgic for that. These hospitals were often over-inclusive and included people with learning disabilities, people with mental health needs, people who were socially different and people who were graduates of orphanages and Magdalen laundries. We had a great fondness for institutional care. The pendulum has now swung in the opposite direction and we have gone from having the world's highest bed to population ratio to one of Europe's lowest. It is a kind of Celtic thing to do, in that we go from one extreme to the other. Even at that, the challenge is finding sufficient staff to serve that small number of beds, which is now lower than recommended norms. Ireland operates some 22 acute beds per 100,000 of population whereas the European norm is closer to 70, so we can see the pinch point when someone needs hospitalisation. Admission should be, if not a last, then a late resort, but there is really no substitute for it when that is the person's need.

We are very conscious that we simply will not be able to treat our way out of this demand. This is why we need prevention, promotion, early intervention, engagement with people and upskilling of people to survive in the world. As Mr. Power clearly said, smartphones exist and that technology is not going to go away, but while there is a certain level of "new toy" about them at the moment and they are probably over-intrusive in our world, they will fall back into the landscape over time. Nonetheless, we need to be very mindful that it is not a passive relationship and is a much more motivated relationship to which we need to be alert.

What is very important in this forum is that we do not continually restate the diagnosis. Restating the diagnosis is not treatment. Saying things are terrible, shocking and awful leaves a very unhealthy and unhelpful impression in the public mind. There are services and those services are far better than they have ever been in terms of the calibre and quality of both the services and the staff who are available. While there are capacity issues, they can be addressed. In the Victorian era there was an extraordinary investment in mental health and that continued up to the 1960s. I am not sure our generation will be judged well by history in this regard. We have the technology and the understanding, but the question is whether we have the willingness to invest in our mental health. That is a very simple question. One of the important roles for this committee is to sample public opinion and ask the public what they want and expect and whether they are willing to pay for that. If the answer is "No", then let us stop pretending, but if the answer is "Yes", then let us get on and do the work. This forum is really important and, as public representatives, committee members are immediately in touch with the pulse of the public and their attitudes and needs. If we want these services, we need to invest.

The witnesses are very welcome. I apologise for being late but I was at a meeting of the victims committee, which meets at the same time.

I was struck by some of the conversation we have had and I suppose it reflects what is happening in the Dáil Chamber today in regard to cervical cancer and the scandal around that. With regard to the public perception of services and the chance of successfully treating people, what impact does this have on the roll-out of the services and what can be done to counteract this while addressing service problems? Mr. Rogan referred to the message of hope and the untold story and so on. We know there is a role for those people who have been through the services but that stigma is still there and it is uncomfortable for people to come out and talk about whatever difficulty they have had in their life. Whether it is a health issue or a difficulty with alcohol or drugs or otherwise, it is unusual for someone to come out and say it.

It is a question of how we structure our response and this goes back to the issue of the services themselves. We have had people come before the committee from various mental health services and they have spoken about their own experiences and I presume that has also been reflected here today. They spoke about the pressure on them in their jobs. For example, the people who came in and spoke about CAMHS referred to the lack of psychiatrists, the lack of supports and the lack of a team, and given they did not have that, they could not do their jobs. The Chairman asked about the financial side and bringing people together. However, one needs to have a work environment where people feel needed, and this applies in hospitals and throughout the health service. The huge positive for anyone working in these services is that the work they are involved in is life-changing and life-saving. That, in itself, is a huge draw for anyone who works in these services. It is bit like the position with politicians, I suppose, in that we are all in it to try to improve things, and that, in itself, is a draw to the job and many people are motivated by those ideals. It is the same with the services represented here today.

This should not be so difficult. The frustration that comes from staff is that it is management-led, we do not know who the managers are and money is being spent but we do not know where. We have recently introduced our own report and these were some of the frustrations that came out in that report. The witnesses might give their own impressions of what can be done and what can be improved in regard to staffing levels. I believe salary is only a small part of it because there are bigger issues.

On a final point on what is probably the biggest issue, we have the seventh worst suicide rate. In the opinion of the witnesses, what is triggering that? Again, it is a crisis we are all being affected by and it is happening in every community. Is it our unhealthy attitude to alcohol, drugs, gambling or some other issue, given there is a whole list of issues I could point to? What are the witnesses' views?

Dr. Joseph Duffy

I thank the Deputy for his questions. I will concentrate on the first question, which was around the public perception of treating people. There is a very common discourse of talking about waiting lists, waiting times and the desire to get into the health service. There is very little discussion about what happens when a person is in there. One of the things we need to talk about is how effective services are, what are the outputs and how the services make a difference. When we work with young people, we are very much looking for feedback from them and their parents about the service.

The model that we operate on in terms of early intervention and prevention is that the young people come in and get some skills that help them over a crisis that they are in at the moment, but it also helps them to have skills to be able to make a difference in their lives in the future. They are very much encouraged, insofar as they can, to talk about that experience with others. We have had young people who were in a Jigsaw service check-in on Facebook and they let their friends and everybody else know through social media. It becomes a socially acceptable place to be. That is making a major difference in term of public understanding and in particular a generation to understand that one can talk about mental health in a different way. I hope that in ten or 20 years time, when that generation has children, there will be a big difference in this area.

We know from working with young people that it is necessary to be incredibly focused. We need to set goals with them that they set themselves. We need to know what their outcomes are and they need to see a tangible difference after four, five, six or seven sessions. That really makes a difference. Mr. Rogan mentioned earlier the recovery-focused care and it is about changing the conversation to know that when someone is within a service they know they can receive a treatment or support that will help them for a particular time and then move on from that. We want to move the conversation so that people can say if you go to Jigsaw or some other service, it will really help you. The biggest difference is that when peers do it, when young people tell other young people or adults tell other adults, that is how we learn the most. It is about changing that conversation to be able to say that if one can do it, it will help. The difficulty at present is that we are concentrating on waiting lists and it is also about the public being able to demand to know and ask about the effectiveness of the service. Is it value for money? Is it really making a difference? These are important questions.

Mr. Ian Power

In response to Deputy Crowe's first question, one of the things we do on SpunOut is to publish lived experiences from young people. We recognise that young people who are part of our service do not have a perspective on many of life's issues. When young people experience or get into difficulty many of them wonder if they are the only person who is feeling this way or the only person who is experiencing something. That is really important and it goes back to the point made by Dr. Duffy on the importance of a peer to peer approach. It needs to detail the good, the bad and the ugly, in particular in relation to what many young people find useful. Sometimes when they experience talking therapies for the first time, they might not click with the clinician, and when they do not, they often think that means that talking therapies are not for them, when in actual fact that young person just did not click with that one particular clinician. What is also important in terms of the experience is the culture within services. I welcome wholeheartedly the values in action programme. It is a viral cultural change movement that is taking place in the HSE to build both confidence and satisfaction and pride in the service being provided by staff because they continually see not just in the mental health services, but widely throughout services, that the narrative around the HSE can be quite negative. It is really important to make sure that the people who are working in the services know they are valued and that there is a culture of pride. That speaks to the issue the Deputy raised that it is not just about money but enjoying where one works.

I am conscious that this will be my last input so I would like to add that I think the work this committee is doing is really important. This report and the reports already published have the opportunity to be transformative in setting an agenda and roadmap that does not currently exist for mental health care, similar to that of Sláintecare. Mental health care should not be lost within the overall report. I am looking forward to leadership on that vision, because that is really necessary in the area of mental health care.

On the Youth Mental Health Pathfinder initiative, there is a proposal in the National Youth Mental Health Task Force Report 2017 calling for a team to be established under section 12 of the Public Service Management Act 1997, which is similar to the structure of the Criminal Assets Bureau, that is able to work across Departments. One of the major challenges we face as a country is the challenge in getting Departments to work together and take collective responsibility for issues such as youth mental health, which crosses the Departments of Education and Skills, Children and Youth Affairs and Health and be able to deliver co-ordinated actions that will be transformative for young people.

I ask witnesses to be brief because we have roughly four minutes remaining.

Mr. Martin Rogan

Public perception is really important. Sometimes in decision making perception can become reality very quickly. I was talking to some Canadian colleagues last year and they were describing how in the past they used to talk about new growth of the outer chest wall, when talking about cancer. I am very conscious there is a very difficult discussion on that in the Oireachtas today. In Canada they were not allowed in polite company to use the language of cancer or breast and when people did not talk about these issues there was a problem. I think we have moved on very radically from that. The National University of Ireland, Galway, NUIG, has done some interesting research on this with the public, asking them individually, if there was some funding to spend, whether it should be invested in older person services, cancer control services or mental health services. They discovered that even people who use mental health services were reluctant to step forward and say we need to invest in mental health services. Unless there is a credible and recognised prospect of recovery, one would not throw good money after bad. What is really important, as mentioned by Mr. Ian Power and Dr. Joseph Duffy, is there is a viral movement happening within the mental health community services. In the Bonnington Hotel, 200 people will hear from those who have experienced mental health services who will come forward to describe how they have rebuilt their lives and will share that experience. That is a really important message but it is happening below the radar. There is a very different vibe.

Dr. Duffy has also mentioned staff mental health. For those working in the mental health space, and I have worked in this space for over three decades, one is meeting people who are very broken and have had a lot of disadvantage in their lives. Depending on how we understand mental health issues, one may ask whether this is distress and trauma, disease, disadvantage, disability and sometimes it can be all of the above. For staff members it is really important that morale is kept high. The essence of good mental health care is what we call that synaptic space, where the person in distress and difficulty meets with a skilled professional. The morale of staff is really quite difficult to maintain. I heard it said that the floggings will continue until morale improves. Beating up on the staff who are doing extraordinary work in very limited circumstances is not helpful. It might be entertaining, it might be theatrical, but it does not progress things at all. It is really important that we acknowledge the work that is being done and recognise the work that needs to be set out to do next. There is a different dialogue happening in the mental health space, in terms of service users and our younger population, which is very new and I think it needs to be followed though with actions and resources. I am certainly encouraged.

Dr. Gillian O'Brien

We were asked a really important question, namely what we think is leading so many young people in Ireland to take their own lives. There are as many hypotheses potentially as there are answers. It is very difficult to know but one thing I always come back to in all of the young people I have worked with in terms of what underlies their sense of mental health is being able to develop a sense of belonging, knowing where they fit, having a sense of purpose and also a sense of identity. If we think of the modern Ireland we live in, it is very difficult for young people to feel okay about themselves, to know where they fit in, when they are under such pressure to achieve and to succeed. While it is difficult to give one defined answer, fundamentally it is about trying to create a culture in Ireland where young people feel valued and cared for and that is something that we all have a role to play in.

On behalf of the committee, I thank the witnesses for their attendance today. We thank them for their extremely useful information and no doubt it will assist us greatly.

The joint committee adjourned at 3.30 p.m. until 1.30 p.m. on Wednesday, 9 May 2018.