I thank the Chairman and the committee for asking me here. I am a GP with 35 years' experience in full-time practice, including in the General Medical Services, GMS, scheme, and four years working as a GP in private consultation practice with a special interest in mental health. I am a member of the Royal College of General Practitioners, London, and the Irish College of General Practitioners and have a first-class master's degree in cognitive behavioural therapy, CBT.
The views I will express are my personal thoughts on the importance of early intervention and talk therapy. As I have a number of points to make, if the Chairman feels I am running over, she should let me know.
There is a mental health-mental illness spectrum and it concerns me that we spend too much time classifying people as mentally ill. Most people are mentally well for most of their lives but may go through a period of mental illness. It is important we make that point at the start. "Mental health" and "well-being" are the buzzwords of the decade but they are constantly confused with the words "mental illness". The main mental illnesses I consider as genuine ones are schizophrenia, bipolar disorder, severe depression, eating disorders such as anorexia nervosa and obsessive-compulsive disorder, OCD.
Mental illness is properly in the realm of the mental health teams, which are manned by wonderful people but let down by underfunding, poor staffing, poor supports and a patchwork quilt cover range nationally. I also feel that a lot of the time, there is very poor interlinking with GPs and difficulties accessing services.
The real reason I am here today is to speak on behalf of a lot of people in this country who are not mentally ill, who most of the time consider themselves to be mentally healthy but are going through significant periods of emotional distress. They are the two words the committee needs to listen to most today. Our adolescents, in particular, are going through a crisis of emotional distress. Many people, of all ages, are going through such periods. They are caused by life-crisis situations, mental illness or sometimes a combination of both. This is where talk therapy, as we will see later, excels.
We also need a rapid-access, 24-hour helpline national number, not just for people who are suicidal and in difficulty but one through which people can be rapidly assessed in terms of appropriate talk therapy and have easy access to it. We can talk about that later.
With regard to early intervention, awareness about physical healthcare started in 1979 with a guy called John McKinlay who noted he felt like somebody standing at the edge of a river seeing bodies floating by. As he jumped into the river and pulled the bodies out he was trying to resuscitate one after another. He noticed after a while that he was getting exhausted and was saving some and not others. He was a cardiologist. He decided to go upstream and find out where all these people were going into the river to start with. That was the beginning of the great journey physical healthcare has made in the past 30 years. It has gone through secondary prevention and primary prevention and eventually health promotion. Mental healthcare is at least one to two decades behind physical healthcare. That is the journey we need to go on. In the area of mental health, we not only need to go upstream and find out where people are going into the river, we need to go back a step further and teach people how to swim. If people learnt how to swim and fell into the river they would have a better chance of survival. That is where early intervention comes in.
I hate statistics because I think they can be used to say almost anything. There are some important details: 75% of all mental health difficulties occur before the age of 25. Anxiety and depression have increased in our adolescent population by 70% in the past 25 years and 50% of all cases of depression will present between the ages of 15 and 25.
A total of 25% of this group are between 15 and 18 years of age. At present, 9% of our school-going children are self-harming and 40% of those attending Pieta House are children. There is obviously a significant problem in this group. Early intervention will often prevent many people from becoming increasingly emotionally distressed and drifting into mental illness.
Some interventions involve drug therapy but in the majority of cases most people are best served with early intervention talk therapy. I have long believed that teaching people, especially children and adolescents, emotional resilience skills from the earliest age combined with a national protocol agreed by all of us on the use of smartphones by everyone, not only our children, would yield great benefit. This could be done between parents and teachers with feedback from young people. I believe this move, along with emotional resilience skills, might go a long way to reducing the significant emotional distress this group is experiencing.
Like all physical conditions, all mental health conditions are best treated holistically. This will involve lifestyle changes, talk therapy and, occasionally, drug therapy. We should remember that every therapy used on the brain changes the brain, including drug therapy, talk therapy and exercise. Everything we do has an effect on our brains.
I do not intend to spend much time discussing the key therapies like exercise, nutrition, sleep, alcohol reduction, stress reduction etc. Most people, if asked, would pick out exercise but I would pick out sleep. I believed we are a sleep-deprived nation.
Drug therapy is useful in the management of bouts of schizophrenia, bipolar disorder and severe bouts of depression and obsessive-compulsive disorder but it is often of limited use in other mental health conditions. There is widespread assumption that every medication we use is an anti depressant. We have to accept that tranquillisers are often used for anxiety, anti-psychotics are often used for bipolar and schizophrenia, while other medications used for attention deficit hyperactivity disorder are not anti depressants. There is also an assumption that all anti depressants prescribed by my colleagues in general practice are for depression. From talking to many of my colleagues, it seems the reality is that they are often used for anxiety and stress.
Talk therapy is often called psychotherapy. Basically, it is the treatment of psychological distress through talking with a specially trained counsellor or therapist and learning new ways to cope, rather than necessarily using medication. It helps people to become more aware of their unconscious thoughts, feelings and motives. I will leave it to my colleagues to discuss counselling versus psychotherapy but, in a nutshell, counselling involves listening and psychotherapy involves more active intervention to get at the root cause of the irrational beliefs etc. of a person. I am aware that committee members will be listening to submissions on these areas. I do not intend to go further into them save to say that at present in Ireland, counselling is taught to degree level and psychotherapy is taught at masters level. For those who may not be fully aware of it, a degree is basically is where people acquire information while at masters level, people learn how to use information. That is the key difference between the two.
Irrespective of the type of talk therapy at issue I often say, when I am asked to speak to therapists, counsellors or my colleagues, that regardless of what therapy is under discussion empathy must lie at the heart of it. If we do not have a deep respect for the dignity of each human being in difficulty and empathise with where the person is, then no therapy will be successful.
In the academic area, the most researched forms of talk therapy are cognitive behavioural therapy and interpersonal therapy. CBT is helpful for anxiety and managing depression. It is also useful in many forms of emotional distress.
I will provide an overview of the talk therapy situation in Ireland. There are countless counsellors and therapists and there is a major concern among all of us about the lack of State regulation. I believe there has been a significant improvement in the training and supervision of therapists in the past decade but much remains to be done. It is interesting that the UK has chosen not to go down the road of focusing on regulation but has chosen instead to focus on access. The biggest single issue with talk therapy in my life as a general practitioner has been access. While vast amounts of money have flowed into the provision of drug therapy, some of which is justified and some of which is not, there is a definite dearth of State funding and organisation of talk therapy.
A major improvement in general practice was the counselling in primary care service. The service provides counselling for mild to moderate psychological conditions. It has been an improvement but certain concerns remain. I have talked to some of my colleagues about this. The concerns relate to the issues they see and the variety of experience of the therapist. There is a limitation on the number of sessions at any one time and sometimes there is even a lack of therapists. The decision to increase the number of assistant psychologists is welcome. However, at the moment it is still necessary for a patient to go through a GP to access the scheme. Mental health teams are completely understaffed when it comes to psychologists and CBT therapists. Older GPs are very good at talking to people and have good empathy skills but are often not trained in talk therapy. Younger GPs are being taught mainly through the GP training schemes to incorporate brief CBT ideas into their work. That is a major advance.
The real issue is the countless numbers of people in emotional distress. I would love for members to be at the end of the telephone to listen to some of the stories that I have to hear and the difficulties of access for people and what these mean for those people and families. Some countries have chosen to go down the road of spending a great deal of time, effort and money on talk therapy and they are benefitting greatly from it. I have visited different countries in different continents in different parts of the world and I have seen how the systems vary from continent to continent. I would like the committee to examine perhaps a system in England called the improving access to psychological therapies, IAPT, programme. It was started in the mid-2000s. It is under the auspices of Professor David Clark from Oxford University. It is a system whereby anyone in emotional distress can be assessed within 24 hours of contacting the system and assigned to an appropriate form of talk therapy for that person. It is the main vehicle by which talk therapy is transmitted in England. Most of the therapists are fed into that system. I believe it is a wonderful idea. I have talked to some people about this system and there are definitely issues. It has perhaps too heavy an emphasis on CBT. There is a view that access might be too easy, thus putting too much pressure on the system. I believe it is a wonderful concept and something we could look to in this country. If we combined regulation with this type of access system, then we might begin to see our citizens getting the care they require.
Finally, I wish to talk about the world of emotional resilience and talk therapy interventions. If all of us became more emotionally resilient through a combination of simple CBT skills and mindfulness, we could transform the mental health of our generation. The classical example is anxiety, which, I believe, is at epidemic proportions. One need only talk to any principal in the country and ask about the number one problem they are seeing in their schools. They will say it is anxiety – it will not be depression.
My experience is that simple CBT and mindfulness exercises can profoundly improve the care of conditions like panic attacks, which are rampant, social anxiety and general anxiety. They can also teach us how to assist better with negative emotions such as hurt and frustration. If we had a properly funded and well-organised talk therapy structured group that incorporated these skills, we could revolutionise the mental health of our nation. Failure to look at the whole way we access and deliver talk therapy in Ireland over the next decade will lead to an over-reliance on drug therapy. More important, it will lead to increasing levels of emotional distress and self-harm and consolidation of risks of further mental illness. By not prioritising early intervention with our child and adolescent services, the services will be over-run by children. However, if we got to them early and had some simple talks with them and sorted out what is going on in their minds and lives, they would not get into such distressed situations. It can get to the stage whereby parents are sitting in an accident and emergency unit at some crazy hour of the night trying to access some psychiatric service that, in the majority of cases, the child does not actually need.
We also need to educate our parents and teachers in emotional first aid. A new movement called the raggy doll movement was launched by my friend and colleague, Enda Murphy, last night. He is a leading psychotherapist. It was officially launched by the Minister of State at the Department of Health. The initiative involves teaching parents and teachers about the tools necessary to further the mental health of their children. As I have said repeatedly for years, the best psychologists in the world are parents, if we could only teach them the skills.
We need teachers and parents to be actively involved in this and not have a situation where everybody is sitting back and waiting for the system to roll in and sort out the child.
Finally, many of our citizens are in pain, and we are failing them. We talk about self-harm and suicide but we will not provide the talk therapy and early interventions which might reduce the risks of these occurring. Allowing people in emotional distress, through early intervention therapy, to explore the causes of their pain and learn how to manage them might result in much less falling into and drowning in the metaphorical river I spoke about earlier. All these interventions require funding, organisation, genuine political backing - not somebody saying it is a good idea and we will see about providing it five years hence - and a real vision for change. I started reading A Vision for Change before coming to this meeting but I gave up half way through it. I found it profoundly sad that so much work had gone into it and all those lovely ideas were there; I hate to think what percentage of that document has been put in place.
