Sub-Committee on Mental Health (2023) díospóireacht -
Tuesday, 7 Nov 2023

Mental Health Care for Migrants and Ethnic Minorities: Discussion

An Cathaoirleach

The minutes of the sub-committee's previous meeting on 2 October have been circulated to members for consideration. Are they agreed? Agreed.

The purpose of this meeting is for the sub-committee to consider issues relating to mental healthcare for migrants and ethnic minorities. In order to enable the sub-committee to consider this matter, from Mental Health Reform, MHR, I am pleased to welcome: Ms Fiona Coyle, CEO; Ms Emily Marchelewska, project co-ordinator with Cairde; Mr. Patrick Reilly, co-ordinator of mental health initiative for Pavee Point Traveller and Roma Centre; and Dr. Salome Mbugua, CEO of AkiDwA. From Doras, I welcome: Ms Sue Windle, welfare co-ordinator; and Ms Tahereh Fardin Tabrizi, project co-ordinator.

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

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

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

I invite Ms Coyle to make her opening remarks.

Ms Fiona Coyle

I thank the Chair for inviting MHR members to this important meeting on the mental health of migrants and ethnic minorities.

MHR is Ireland’s leading national coalition on mental health, with more than 80 member organisations working for progressive reform of mental health services and supports in Ireland. Many of our member organisations are actively involved in supporting and delivering services to migrant and ethnic minority communities and have actively contributed to this statement. To provide a deeper insight into the lived realities of some of these communities, I am joined by representatives of three of our member organisations, who the Cathaoirleach has already introduced.

Ethnic minority communities have been integral to Ireland for centuries. Today, they constitute a growing part of the population. The term "ethnic minority" encapsulates a broad spectrum, including a wide range of people with diverse nationalities, ethnic backgrounds and legal statuses in Ireland.

The term also includes the Irish Traveller community, which was officially recognised as a distinct ethnic community by the Government in March 2017. It is important to note that ethnic minority communities are not homogenous. Where mental health is concerned, the barriers for these diverse communities may differ significantly from one community to the next and from individual to individual.

Research, including an important new report launched by the WHO last month, shows that there is a higher incidence of mental health challenges among people from ethnic minority communities. The reasons for this disparity are multifaceted and include racism, disparities in health access, inadequate support structures and, in some cultures, a profound stigma associated with mental health issues. Our colleagues from Doras will speak more to the policy considerations stemming from this report and will also examine the specific mental health needs of those seeking international protection, which can be complex and multifaceted.

It is broadly acknowledged that services are designed and developed in a way that reflects the majority culture. There are a number of barriers for individuals from ethnic minority communities in accessing mental health services in Ireland, resulting in inequalities of access and outcome. Our mental health policy, Sharing the Vision, stresses the importance of providing culturally appropriate health care to meet the needs of service users from diverse cultural and ethnic minority communities. Recommendation 61 of Sharing the Vision reads: "The HSE should maximise delivery of diverse and culturally competent mental health supports throughout all services." There are also three recommendations that specifically mention migrants, asylum seekers and refugees. It important to acknowledge that this policy was written in 2020 and that, since then, we have witnessed evolving circumstances, including the war in Ukraine.

Ireland is in urgent need of a mental health service that can truly serve the entire population, with a particular focus on those identified as being at higher risk, including ethnic minority communities. MHR, along with our members, calls upon the Government to ensure the development of mental health services that respect the diverse beliefs and values of people from ethnic minority communities and deliver care and treatment in a manner that takes account of such beliefs.

I will set out our recommendations. First, we need accessible and culturally sensitive mental health supports and services. To achieve this, we need to provide all staff working with people with mental health difficulties training in the areas of anti-racism, cultural competency and unconscious bias. This training should be developed in consultation with ethnic minority service users. Services must provide assurances that disrespect or discrimination of any kind by staff should not be tolerated. Specific measures for reducing discrimination in mental health services should be implemented. This could include actions such as employing individuals from ethnic minority communities and educating local communities to target stigma and discrimination. Mental health services should undertake systematic evaluation and self-assessment to ensure that the mental health needs of people from ethnic minority communities are being adequately met. We must also enhance our data quality through ethnic equality monitoring, which includes the incorporation of a standardised ethnic identifier in line with the national census. This identifier should be integrated into all routine data administrative systems within mental health services, including the National Self-Harm Registry Ireland, to facilitate the monitoring of access, participation and, importantly, outcomes in suicide prevention and mental health services for priority groups such as Travellers, members of the Roma community and other ethnic minority communities. It is crucial that the implementation of an ethnic identifier is carried out within a human rights framework.

Second, we must deal with the needs of those seeking international protection and Ukrainian beneficiaries of temporary protection. It is imperative to act upon recommendation 63 of Sharing the Vision and ensure that persons in direct provision services and refugees arriving under the Irish refugee protection programme have access to appropriate tiered mental health services through primary care and specialist mental health services.

We must scale up and promote community-based interventions and peer support initiatives. We must provide family-centred support and child-specific interventions. Mental health and other services being provided must be trauma-informed in their approach.

The third area where we are making recommendations is in meeting the mental health needs of the Traveller and Roma communities. It is important that the Government implements the commitment in the programme for Government and the committee's recommendation to develop a national Traveller and Roma mental health action plan. This plan would be developed in collaboration with key stakeholders, including the Traveller and Roma communities, under the guidance of a national steering group to ensure effective oversight during its development and implementation. There is a need for a sustainable and ring-fenced budget to be allocated specifically for Traveller and Roma mental health to ensure the successful implementation of the national Traveller and Roma mental health strategy. We must ensure that evidence-based and culturally appropriate resources and supports are prioritised for the Traveller community due to the level of the mental health crisis. We must implement a cross-departmental approach through the new national Traveller and Roma inclusion strategy to rectify inequalities and inequities experienced by the Traveller community, especially in areas like early school leaving, low educational attainment, unemployment, poverty and inadequate accommodation.

In conclusion, addressing mental health disparities among ethnic minority communities in Ireland is a multifaceted endeavour that necessitates a cross-government and cross-agency approach. This is a really important point that I want to reiterate. By responding to the needs of these communities, we can pave the way for a brighter, more inclusive society, where every individual's mental health is treated with the care and respect they deserve, regardless of their cultural or ethnic background.

Ms Tahereh Fardin Tabrizi

We welcome the subcommittee’s focus on mental health care for migrants and ethnic minorities. We are grateful for the opportunity to attend here today. Although we are a refugee and migrant support organisation, and not a mental health organisation, we can highlight a number of issues from our work that we feel are important. We will speak primarily about refugees, international protection applicants and other high-risk migrants, as well as migrant workers from outside the EEA. However, there are other groups we hope the sub-committee will consider, including Travellers; black and mixed-race Irish people; international students; and EEA nationals from other countries.

The mental health requirements of the people we support differ from those of the general population. Within the broad categorisation of migrants and ethnic minorities, there are very diverse lived experiences and needs. Existing mainstream services are not meeting these needs and consequently, additional expertise, training and funding is required. A recent report from the WHO highlighted a number of policy considerations to benefit the mental health of refugees and migrants that we believe are important, including the implementation of policies and programmes that promote their social integration and their participation in society. Linked to this, the impact that anti-migrant sentiment and discrimination can have on mental health should be noted. Migrant policies should recognise and address the social determinants of mental health and prioritise basic needs such as food, housing, safety, education and employment. The capacity of healthcare workers to assess and treat mental health conditions among refugees and migrants from diverse cultural backgrounds should be strengthened.

From our work, we see how factors like poor accommodation, poverty, unemployment and homelessness adversely affect the mental health of migrants. Recognising and addressing these social determinants, and reducing the level of inequality and social exclusion faced by migrants, is essential.

The impact of restrictive immigration policies and practice and poor regulation of some sectors of the labour market that result in exploitation and other post-migration stressors increase the prevalence of mental health problems for migrants, and often result in people experiencing ongoing trauma.

What are the barriers to mental healthcare? Research indicates that barriers to access and use of mental health services by migrants include language barriers, cultural perceptions and lack of knowledge of mental health, as well as stigma around

mental illness. From our work, we know there are additional practical barriers such as a lack of childcare, waiting times and a lack of trained interpreters. Mental health service providers also face difficulties. In many cases, they do not have the appropriate training or protected time to care for the unique needs of refugees and migrants. We know from conversations with health professionals that the challenges they experience in attempting to meet migrant needs, while not being in a position to respond adequately or appropriately, is an ongoing cause of frustration.

A high percentage of people in the international protection system face ongoing mental health challenges that are linked to experiences of war, torture, human trafficking and other traumatic situations, including their migration journeys. They survive with little or no supports in direct provision or emergency accommodation where there is a very poor understanding of the effects of trauma. Lack of training for staff on how to respond is a real concern. So too is the lack of privacy and the fact that people have to live for years in a state of forced idleness. The consequences of this are withdrawal, high levels of domestic violence and substance misuse and, in some cases, suicide. Many of the experiences, including the ongoing trauma, are similar for beneficiaries of temporary protection from Ukraine, but more resources have been allocated to this group. For children in particular, the after-effects of forced migration are pervasive. Their needs must be included in all assessment of mental healthcare needs. A final point in relation to international protection applicants is that early and ongoing vulnerability assessments are necessary in order to identify pre-existing and new or ongoing conditions. Once a person is identified as vulnerable, effective access to adequate and appropriate supports need to be put in place for them.

The following are our key recommendations. It is important that the mental health services provide choices, particularly in terms of treatment approach, in order to improve access to care, empower individuals and optimise outcomes for migrants. Equally, it is important that mental health professionals are trained in and practice cultural competence and cultural humility, focusing on identifying their own implicit biases, self-understanding and building an appreciation for the multifaceted components of each individual, which may include culture, gender, sexual identity, ethnicity, religion, etc.

We have a number of further recommendations. A targeted approach to promoting mental health awareness and addressing the needs of priority groups is required, including outreach to vulnerable communities; strengthening community capacity to access mental healthcare by providing information about services and referral pathways and raising awareness. The acute mental health difficulties of international protection applicants in particular cannot be adequately addressed without additional resources, including ongoing vulnerability assessments, improved accommodation standards and specialist outreach services to accommodation centres. The lack of timely, confidential and consistent interpretation services and of trained interpreters and regulation in the industry needs to be addressed. More work is needed on collecting standardised data at local, national and service level in order to properly identify the gaps in mental healthcare for different migrant groups. Last but not least, support and training for healthcare professionals and community and voluntary sector organisations that support migrants needs to be provided in order that they can recognise and respond to the mental health needs of their service users.

I thank the members again for this opportunity to come before the sub-committee.

An Cathaoirleach

I now invite members to discuss the matter with the witnesses.

Deputy Gino Kenny

Unfortunately I must leave shortly as I have another committee meeting to attend. I thank the witnesses for their statements. They are very useful. I have a number of questions. In the past 18 months to two years, 100,000 people have come to Ireland and they are very welcome. They have come from terrible and traumatic situations. What services are there in reality for those coming to Ireland who are fleeing war, persecution and very traumatic experiences?

Ms Sue Windle

The same services that are there for the general population are afforded to international protection applicants. Unfortunately, people fleeing war and persecution have other ancillary layers of need that come along with this so it is probably more difficult for them. There are a number of voluntary organisations such as Spirasi which do great work. Spirasi works with victims of kidnapping and torture. There are resource and staffing issues. The waiting times are quite long.

Dr. Salome Mbugua

As Deputy Kenny has said, more international protection applicants are coming in and most of them are in emergency accommodation centres. Although they are provided with housing and food, our research in AkiDwA shows there is a feeling of powerlessness because of the lack of urgency. People are put in a situation in which they do not know what will happen tomorrow. Although people may have arrived 18 months ago, they are still there. Sometimes there is a delay in getting medical cards and other services. A good example of what has been happening is a project in Citywest, where most international protection applications are, which provides psychosocial support. This is very necessary to be able to support people who have come from conflict or war-torn countries. This psychosocial support is what is most immediately needed for people to be able to explore what happened before they left their country, what happened when they were transiting to Ireland and what has happened since they have been in Ireland.

We cannot say there are no supports but there is a feeling of powerlessness. My organisation deals with women. Sometimes women are in these accommodation centres without a medical card for three or four months. They do not know what will happen next. My colleague mentioned vulnerability assessments. Some of these people have mental health needs. After they fill in the vulnerability assessment forms, they are not called to be assessed or checked on to see how they can be supported and helped.

Ms Emilia Marchelewska

A good practice example with regard to people coming here seeking international protection or temporary protection, at least in the area where we work in Cairde, is that we collaborate with the HSE on health assessments and health screenings of refugees. Carrying out these assessments at least provides a way to identify people who may need additional supports and link them with those supports. There is a need for a more in-depth psychological distress assessment and this is being piloted at Citywest. Nonetheless, even with this structured system people fall through the gaps because mental health is a specific area of health and people need to have willingness and readiness to engage with supports.

For Ukrainian refugees in particular, Ukraine Civil Society Forum members collaborate with us and we have a mental health subcommittee. We have put together a list of services that have been specifically established to support the mental health needs of Ukrainian refugees. The issues are culture, language and the accreditation of people.

That is only when we talk about specific and tailored psychological or mental health supports.

On access to mainstream services, bureaucracy, forms and delays put people off. Some prefer to seek support in what they see as a more culturally appropriate way, for instance, back in Ukraine, especially if they face barriers here. My colleagues already mentioned the community development approach. Mental health is not only being resolved on the mental healthcare level. The emotional support provided in the community, the provision of safe spaces and opportunities to interact with colleagues, neighbours and other refugees and resolving practical matters are important determinants in the context of building resilience. It is interpersonal and intrapersonal. I emphasise that we need to look at gaps in services and provide targeted solutions and that person-centred care is underpinned by social determinants of health.

Mr. Patrick Reilly

It is a very good question. If you ask service providers what services are available, they really have to think about it. I am concerned about anyone coming from abroad, as Ms Marchelewska described, to Ireland and accessing mental health supports and services because in our community in particular, access to these services is a barrier. We identify people at risk and signpost them, but without the ethnic identifier, we cannot see where they go, what treatment they get or the outcomes. What tends to happen is that these people come to organisations for support, but it cannot be just left to the organisations. I am an expert when it comes to being a Traveller; I know and have access to my community. I am not a mental health expert. I cannot refer people. You need a referral to get into these services. We saw issues even with accessing GPs before and during Covid, and this is still happening. There is a broad issue regarding access. We identify the people, but it is about getting access. Many organisations are seen as expert when it comes to Travellers or a particular group, but we need a whole approach in which services have the expertise medically. I am concerned about people coming in and looking for supports. We talk about waiting lists. That applies to everyone. Unfortunately, Travellers go to accident and emergency departments, wait for 14 or 15 hours and get an outpatient referral for five or six months' time. That is not humane. It is the reality in which we are living, unfortunately.

Deputy Gino Kenny

I do not have a question; it is more of an observation. A very important part of all our well-being is integration. People have come to Ireland who probably never even heard of it previously and they want to integrate. Irish people are very welcoming. It is important that people integrate as much as possible and are welcomed. That has happened in Ireland in general. There have been a number of incidents which are pretty grotesque, with protests outside where people are staying. Most people completely object to that. It is important that there is integration. In the main, communities have welcomed migrants and refugees to Ireland. It has generally worked. We should work together, where possible, and welcome people who have come from pretty traumatic situations. I am sorry, but I have to leave.

Mr. Patrick Reilly

I know the Deputy has to go. We had this conversation only this morning. The word "integrated" can mean a lot of things to a lot of people.

Deputy Gino Kenny

Yes.

Mr. Patrick Reilly

I go towards the word "inclusion".

Deputy Gino Kenny

Yes, sorry.

Mr. Patrick Reilly

I get what the Deputy is saying in the context. I am a student in my final year, please God, in Maynooth University. I remember that I had a head of curls when I started there. It feels like that. I felt included as Patrick Reilly, a Traveller and a student. That is what needs to happen. The word "integrated" can mean so many things.

Deputy Gino Kenny

I was slightly clumsy with my words. I agree with Mr. Reilly. There is better language than that.

Dr. Salome Mbugua

I agree with what is being said. We saw on 18 March that many people Irish came to support the people who had been attacked at that time. When people feel they are not wanted, or when they are isolated, it triggers their mental health. When good people come out to support migrants and other groups who are marginalised, and to be there for them, it is very important and should be encouraged in a society which has changed quite significantly.

Deputy Gino Kenny

My apologies to the committee as, unfortunately, I have to leave.

An Cathaoirleach

I thank Deputy Kenny. Before I bring in Deputy Hourigan, I want to extend apologies from some of our members. Two of our members are very sick this week and could not attend which is why we only have two committee members in attendance today.

Deputy Neasa Hourigan

As I have many questions, I ask the Chair to stop me if I keep going for too long. I have a number of areas to cover, but I want to start with the issue we have just been discussing.

It strikes me that when we talk about mental health in this sector, we use a kind of shorthand. We are trying to deliver services to people who are dealing with something that has happened in their home country or on their journey. I wonder what our guests' groups are seeing with regard to how much the system currently is part of the trauma. I am saying this for Traveller and Roma people also. How much of what we are dealing with relates to past trauma? Are people presenting to the groups who are traumatised by current events, by a lack of housing or social supports, by the rise of protests or by racism? What are people presenting with? Are they trying to deal with things which have been experienced previously or with things that are more current?

Ms Emilia Marchelewska

I would say it is both. The current approach to the mental health strategy in Ireland is informed by research into the biological, psychological and social determinants of health. According to this research, for migrants and minorities in communities, social determinants of health are very significant, can cause further risk and can mediate the trauma such people encountered in the past.

Deputy Neasa Hourigan

I am not a medical professional, but as I understand it, Ms Marchelewska is saying that if someone who is already struggling experiences a difficulty finding a home or becomes sick, it can magnify those existing problems.

Ms Emilia Marchelewska

It is basically an accumulation of different risk factors. We can see this in complex cases. For example, people coming from Mariupol are much more traumatised and it is much more visible. If they are trying to cope with the situation through drinking, for example, there may be a dual diagnosis. Their accommodation may not be suitable. Their behaviour may be labelled antisocial. They may be moved from one centre to another without getting the proper support. If they are moved from a centre in the west of Ireland to the east of Ireland and the care does not follow, they may have to contend with waiting times and all of that because the pathways are disturbed. There is, therefore, an accumulation of difficulties among people who are getting this help. I know of a gentleman who was thrown out of a centre because of these very issues: mental health and addictions. When he did not pay his meal fees, he was thrown out and could not get any other accommodation. He then turned up to hospital twice with suicidal ideation.

Mr. Patrick Reilly

With regard to the Roma community, in particular, we have a Roma programme in Pavee Point. We are hearing that there is a level of paperwork needed to prove that these people lived there or that they have come from that particular country.

Along with young Travellers, we have developed a mental health website, youngpavees.ie, which I very much recommend that committee members should visit. We covered this in the focus groups which we did with them.

Young Travellers spoke about how they have a fear of racism and discrimination taking place before it even happens. That is happening with Ukrainian and Roma people in particular. They already have a lot going on because they are fleeing these countries, but there is also that fear of being discriminated against. We talk about mental health, and that is having an impact on people's mental health. We are seeing that, in particular, with young Travellers this very day, unfortunately.

Ms Sue Windle

That is clear and I can also speak to this. We have clients who will not go into any public service without one of us to buffer them because there is the fear of being discriminated against. The capability is there, but the confidence is not, because at every hand's turn, the accessibility or the treatment has been poor. They would rather come via our service and use us as a buffer or a safety net when they access services. As Mr. Reilly said earlier, people will come to our organisations in order to access what they can do themselves. It is a matter of the safety piece.

Deputy Neasa Hourigan

It is a lack of trust in the State's ability to deal with them one-on-one.

Ms Sue Windle

Yes.

Dr. Salome Mbugua

I wanted to speak from a women’s perspective, because we get them every day in our organisation, AkiDwa. Any incident can trigger what they have gone through either before they came to Ireland, or on their journey and all that. It is when they are trying to seek asylum. In our organisation, we work with very vulnerable women who have, for example, gone through female genital mutilation, FGM, before they came to Ireland. This is very traumatic. We also work with women who are trafficked or women who are experiencing domestic violence. When they go to seek care services, the service providers are quite often not aware of what they have gone through, or they may not even understand what FGM and trafficking are. Therefore, their experiences when they go to seek those services, how they are treated, and how they are approached really trigger a lot of what has happened before. We had, for example, many cases of women who have had very bad experiences with the police. The police may be very brutal where we come from, but even here, the way they treat them when an incident happens actually triggers their mental health and it can be very traumatic. That is why we emphasise the need for cultural competency training for all front-line services.

Ms Tahereh Fardin Tabrizi

I would like to add to all the valid points my colleagues have raised. We need to realise that sometimes the services are there, but the approach most of the services take deters the service users. For example, when refugees or asylum seekers arrive here, nobody looks at their strength in how they have come through that difficult journey. They might have escaped war or torture. They might have escaped a very difficult journey on their way here, because migration is a highly stressful experience, even when it is planned and sought after. This is the experience that has been voiced to us by many of the clients. The approach is sometimes individualised, whereas in many of the cultures where the migrants come from, there is a collective approach.

To add to Ms Marchelewska’s point about being far away from the community, that is a huge factor for them. It adds to the mental health conditions. Sometimes, even though we want to help them, we might fall into that trap as well. The person becomes aggressive and agitated as a result of not receiving the kind of style that he or she is used to. That can lead to many different issues, such as domestic violence taking place in the direct provision, DP, centres. Also, the conditions in the DP centres themselves lead to a lot of those conditions. Sometimes we have to look at it as a strength-based model versus the deficit model. Rather than teaching them to go and wait for the fish, we need to teach them to catch the fish.

Deputy Neasa Hourigan

Can Ms Fardin Tabrizi explain the difference between a strength-based model and a deficit model?

Ms Tahereh Fardin Tabrizi

I will leave that to my colleague.

Ms Sue Windle

It is very simple. It is essentially saying to someone that they did really well to get here, rather than telling them that they have all the abbreviations, such as PTSD, etc. It is a matter of looking at how well they did, rather than framing it by saying to them that it is really unfortunate that they are not resilient.

Deputy Neasa Hourigan

I recognise this conversation from the disability community, by the way. When they go through diagnosis everything is about what is wrong. Then, when they meet the services of people who know, they will say that the person is brilliant at doing something.

Ms Fiona Coyle

I want to make a final broad point on the move from a needs-based to a human rights-based model. The Deputy referred to the UNCRPD, which is doing that for the community in question. It is the same for every individual. It is not about a diagnosis, but rather about understanding the journey, what happened to people and how they got there. It is important that we consider the area of intersectionality. People do not fit into neat boxes. As services and organisations, we are trying to work together more. People are from ethnic minority groups, women, part of the LGBTQI community or living with a physical disability. Everyone is very layered. The point I made earlier was that this requires breaking down some of the walls in Departments and agencies and considering how we can support people in their journey of life and the complexities that come with that.

Deputy Neasa Hourigan

That brings me beautifully to my next question on how Departments talk to each other. All of the witnesses, in various guises, are in the business not only of providing services but also providing access to services for people who might not know how to access them. In my job, people may come in with a housing issue but may also have medical problems. Those two things do not always talk to each other. What are the barriers for the witnesses? Somebody may have a severe mental health problem and also a housing issue. How are the witnesses approaching such matters? What are the barriers and challenges that exist? There are serious issues. However, in a perfect world, I presume a caseworker or somebody at the top could say that a person needs this, this and this. We are not quite there yet. I would be interested in hearing people's thoughts on that issue. As people who are dealing with mental health issues, how are the witnesses dealing with housing, education and health matters?

Mr. Patrick Reilly

It is a good question based in reality. Travellers have been highlighted, in particular in the context of social determinants. We know how important they are. Where people live can impact on their physical and mental health, education outcomes and employment. For example, Travellers have told me they are not interested in joining a gym or going to a football club because they are on a low income and are trying to survive week to week.

All of the Departments need to be in communication with each other. People under high levels of stress are trying to access appropriate accommodation and support for their children. The process seems to be long and people are looking for an immediate fix, but things do not happen that way because they are dealing with a person in a Department who tells them they need to go to another Department. We call for a whole-of-government approach.

Regarding mental health, the approach needs to be cross-departmental. As has been highlighted, when people present needing help, we have to unpack what is going on for them. We often hear the phrase, "The straw that broke the camel's back". The frequent mental distress people are experiencing triggers that.

Dr. Salome Mbugua

To support what Mr. Reilly has said, interagency co-ordination is very much needed. I mentioned the experiences of the police. In AkiDwA, we do not have a legal person who can advise people on legal issues, therefore we have to refer them. We work quite a lot with other groups and organisations which are working on the same issues in respect of migration in order to be able to help women in a meaningful way. Referral is key for us.

I have observed that Departments are doing quite a lot, but the work is not co-ordinated. I mentioned a good example in Citywest, where there are community mobilisers, counsellors and mediators all in one place so that if people come in with a housing issue they go to the community mobiliser and if they have mental health or psychosocial issues they go to a counsellor. That was developed by the Department of Children, Equality, Disability, Integration and Youth.

These services are lacking outside Dublin. They are not there at all, so it is very difficult for women to manoeuvre or for people who are seeking those services-----

Deputy Neasa Hourigan

But Dr. Mbugua feels that model works.

Dr. Salome Mbugua

It might work with Government co-ordination. Quite a lot is happening and much money is being spent on different things, but there is no co-ordination at all. Co-ordination is needed. There should be more emphasis on engaging with organisations that support the likes of migrants, Travellers and others seeking support.

Ms Emilia Marchelewska

It is very true that healthcare can be very focused and fragmented. Health assessments can be done by considering vaccination alone, for example, or they can be done by accounting for a person's entire set of needs and linking to appropriate supports. It does happen that mental health services look only at mental health and not at other needs. There is a huge role for social workers and occupational therapists in this sphere. Let me give a practical example. I supported a lady who, on the same day that she got a job and signed a contract, received a letter stating she was to be transferred to a different accommodation centre on the other side of the country. However, she was very resilient and built a support network, so what she wanted happened. She ended up at a Garda station, where she said she had a job and wanted to stay where she was. She did stay and really fought very hard to do so. If the services worked together, something that is health enhancing and that contributes to society and keeps a person healthy would not be denied. The whole situation was very traumatising. We talk about trauma-informed care and a trauma-informed society, but these are not really happening for the population in question. It is different in the community sector because we have a person-centred approach. At Cairde, we provide support and advocacy services and run community development projects through which we examine the needs of the person. We are needs driven, respond to people's needs and understand that we have to consider people as a whole, accounting for families, society and the environment.

Ms Sue Windle

From an advocacy perspective, when the right hand does talk to the left and when housing and mental health do talk and respond, it can take an enormous effort by one case worker. We have seen it happen, and when it works it is great. It is proven to work, but to get to that point is too hard.

Deputy Neasa Hourigan

It should not be that hard.

Ms Sue Windle

It should not be. However, the process does and can work. We are lucky in Limerick to have a really good network that I link in with and have access to. There is a kind of a system in place but everyone is restricted by their own structures. As much those in housing might want to help – they do help and we work really well together – there are structural restrictions on everybody. The system can work but my point is that it is very difficult to generate the energy needed and to do the work it takes to achieve this. It should not be so hard.

Deputy Neasa Hourigan

Structurally, we need to realign to make it less painful.

Mr. Patrick Reilly

It can also be a matter of individual relationships. One might build up a relationship with the person on the other side of the counter but they might move on. It should be more structural and embedded, rather than having-----

Deputy Neasa Hourigan

It is a really Irish thing to rely on networks that you know. I do that. However, structurally, anybody should be able to take your place.

Mr. Patrick Reilly

Exactly.

Deputy Neasa Hourigan

Let me ask a question from a cold, hard legislator's point of view. Ms Coyle talked about data, access to data and ethnic identifiers, which matters have come up at meetings of the health committee several times. In fairness, they have arisen at meetings of several committees I used to sit on. I am referring to the deficit in data collection. To someone like me, who would go to a committee meeting and refer to the number in need, the lack of data is an important issue.

I remember a meeting about Travellers at the Joint Committee on Health where there was mention of research done in the last decade about getting staff members to ask questions about ethnic identifiers. It required a huge amount of training because staff were uncomfortable. They felt it was not appropriate to ask about ethnic identifiers. Do the witnesses have thoughts about the type of data we need? I know we need ethnic identifiers. However, as a number of witnesses said, people fit into multiple categories. What kind of training do we need for staff, and what staff need to be trained? Obviously, everybody in the HSE should be trained, but local authorities, Deputies and Senators are often a bit of a black hole in terms of information because we do not often get them in front of committees. The county council is a key point of access for a lot of people. I am interested in the lack of data. Do the witnesses feel they have enough understanding of the cohort they are serving?

Mr. Patrick Reilly

It is a good question. In Pavee Point we been lobbying for ethnic data for years. The best example is the census. It has your nationality, your ethnicity, your age and all of those things. We believe the training needs to be across all health administrators. It is not a case that one department would have it. There is also a good piece of work to it where you collect the information, analyse it and store it. The best example I can give is this. You will ask, "What is your name and what is your ethnicity?" You say, "I am going to ask you a few questions we ask of everybody." The Deputy can see what I have just done. You are saying that you ask this of everybody. I might think this person is asking me if I am a Traveller and ask myself why are they asking me if I am a Traveller. You have done your job. You have asked the question. It is up to me. I might look like a Traveller, talk like a Traveller or walk like a Traveller. I might be a Traveller woman with the earrings, and you know she is a Traveller from the area. However, you have done your job and asked the question.

Sometimes the fear is that collecting this data could make us show that we are not doing our jobs. It is really not about that. It is about capturing who is accessing and who is not accessing the services, and it helps tailor the service. It informs them. I spoke about "Mind Your Nuck", the young pavees website. We developed that and a lot of work went into it. We asked ourselves how we would capture if young Travellers and Traveller parents were accessing this. We worked with the website designer and added in Google Analytics. I am far from an expert, but I checked it before I came here. It shows that in the past 12 months almost 1,000 people have accessed the website. It shows what resources they are accessing. It informs us that young Travellers are checking out a particular resource.

Deputy Neasa Hourigan

I imagine a lot of the people in the situations we are talking about are wary of authority and giving extra information.

Mr. Patrick Reilly

Yes. Sometimes I might not ask the ethnicity question at the initial meeting. It might be that the person is not in the right space, but we build up that relationship and we can ask the ethnicity question down the line. That all comes with the training. I understand that people will think certain things if I ask the question, but it is about how you ask it. It is universal. We ask it of everyone. It is more welcoming.

Ms Fiona Coyle

I will make a point about data. The lack of data is a fundamental barrier challenge to our health service in general, and in particular to our mental health services. We do not have data on who is accessing, why they are accessing, and more importantly what their outcomes are. In terms of implementing our policies, we are unable to see how well we are doing because we do not have the data to show how well we are meeting the needs of individuals. That data point is fundamental because if we do not know who is accessing our services, we cannot resource them, develop them, or scale them up. We know that under Sláintecare we are moving towards population based budgeting and healthcare. That is the general direction of travel, and all of this fits in. We need to understand who is accessing. If that ethnic identifier is done in a way that is compliant with human rights standards and is not promoting racism or xenophobia, it would be useful.

It would be useful in the implementation of Sláintecare and what it is trying to achieve.

Ms Emilia Marchelewska

Data collection and monitoring data is important but it cannot be a barrier to delivering services to all populations. There is enough research that can be applied to this population in Ireland and internationally. There is also enough indirect research, for instance, on the impact of poverty on mental health. We have policies that state that migrants and ethnic minorities are at-risk groups - both Sharing the Vision and mental health promotion plan, for example. We need to implement the agreed policies.

Dr. Salome Mbugua

Regarding collecting data, now it is becoming even more complicated with the GDPR. People feel that if you keep asking them and putting their data out there, it could be problematic. It is also about services becoming more aware of the community they serve. The community has become diverse. In our work on female genital mutilation, FGM, for example, we spoke with the maternity hospitals to include FGM in the maternity form. This is very simple. If services become more aware of the community they serve, let us say it is a domestic violence service, they can perhaps be able to capture that data by linking up with groups and organisations working with migrants to help them frame the questions on the forms. This would be very important. The HSE has been trying in its second national intercultural health strategy by looking into the key performance indicators every quarter. We share the information with it of how many people we have seen who are experiencing domestic violence or are victims of FGM. This is then shared widely. The way services operate allows us to capture more data. It happens by services becoming more open and understanding of the society we live in and how we can serve that society. It happens by becoming more open not only in our policies but also the forms we have and anything we use to able to capture information for the people who attend those services.

Ms Tahereh Fardin Tabrizi

Through our experience, we have seen that the language barrier can sometimes add to the lack of data. Some of our clients will be illiterate as well, even in their home language. There is, therefore, a digital divide. We also see the fear of the immigration status and the fear of deportation. There is a fear that any information that will be given to the individual will go to the authorities. It is an active war zone for them. To add to that, there are the long waiting times for family reunification; fear of intention; general waiting times for IP applications, visas and travel documents; restrictive labour market access - we are seeing that labour market access has now been increased to, I think, 130 days and that is having an impact on their mental state; and restrictions to education. We have to target the delays and be able to address the cultural but also the language barriers. Language is a huge part for many of the migrants we work with.

An Cathaoirleach

Deputy Colm Burke is standing in for Deputy Durkan.

Deputy Colm Burke

I apologise to Deputy Durkan and the committee for being late. I had a meeting at 8.45 a.m. and I am just back from that.

I wish to raise two issues. I am friendly with someone who was involved with the Traveller community, especially women’s health. The person, at the time, was based in Ballinasloe and she did a number of videos to get across a message on women’s health for members of the Traveller community. Has there been any focus on the whole area of mental health and the way we try to assist people? For example, I could decide to do a ten- or 15-minute talk.

That might not make the connection with the issues people have. However, a professional video conveying a message can be very effective. Has there been any real focus on conveying a message through other ways than meeting or speaking to people? Has that occurred?

On ethnic minorities, for the vast majority of people here in Ireland, if they become unwell or need support they have immediate family. The big problem I see for ethnic minorities is that they do not have an immediate family around them to give them support. While we have a problem now, in 20 years' time we are going to have a huge problem. How do our guests plan for dealing with that real, challenging issue? For example, in the 2002-2008 period, there was a Polish building worker who was working in Ireland and did not have any English. He had a heart bypass in 2008 and ended up living on the streets because he had no immediate family to give him support. It was a huge problem for him as well that he had difficulty speaking English. I am very concerned about the future as regards ethnic minorities like that. They may not be proficient in speaking English and as a result may fall into a huge lapse. How should we deal with that?

Mr. Patrick Reilly

On the ethnic data, it is important to realise that as part of the training and awareness, GDPR is not an issue in collecting ethnic data. I wanted to clear that point because sometimes it gets mixed up. If I get the Deputy's first question, we do what are called awareness videos on promoting positive mental health, suicide prevention and all those things. We do this throughout the year, for example for World Suicide Prevention Day and World Mental Health Day. We do targeted initiatives. Travellers' organisations do this within local areas across the country.

The Deputy was asking about Travellers who would not have the supports. We have seen over the years Traveller primary healthcare workers who work with the community. During Covid, over 86% of Travellers received their Covid health information from Traveller organisations. That was a HSE report that showed this. We can see the importance Traveller organisations have on the ground. As I mentioned earlier, before the Deputy came in, a lot of this work falls on the community. We are not the professionals when it comes to these issues. I am not proud to say that in our community, mental health is beyond a crisis at this stage and it needs to be acknowledged that there is a crisis. No community, let alone my community, should be experiencing statistics with suicide rates seven times higher for men, five times higher for women, and with 11% of Traveller deaths being by suicide. No community should experience that. The Traveller organisations are doing all they can, in particular the primary healthcare workers. They are doing livesaving work. However, there is a need for that joined-up approach that Deputy Hourigan mentioned. Services and Departments need to be working together. The signposting - we are identifying people who need help and support but it is about getting them access to the right support in time. In our community they are ending up in emergency departments. They are not waiting around to access a GP or mental health professional.

I will give an example that only happened recently. I accompanied a person to an emergency department who made an attempt on their life. At the end of it all, the doctor asked me, "What do you want me to do? I am only a medical doctor." I said that the person needed a referral to a mental health professional and at least to give us that so we could get him the supports.

That person told me as we left that if we had not been there, they would have gone home. That is unfortunate, but it is the reality for Travellers and for a lot of people, not alone Travellers. I went on a roundabout there trying to capture some of that. I hope it answered the Deputy's questions in some shape or form.

Ms Fiona Coyle

The Deputy brought up a very personal question around digital platforms and mental health. Mental Health Reform recently launched a report with the HSE mental health engagement and recovery office. It was a substantial piece of work looking into digital inclusion and access to mental health services. As part of that report, the migrant and ethnic minority communities and the Traveller and Roma communities were identified as groups that are very digitally excluded but it also noted that there are huge opportunities to leverage in relation to the opportunities digital platforms or digital tools give us around access to culturally competent services and reduced barriers to accessing mental health services. Transport in rural Ireland can be a huge barrier for those in centres. There are also inreach opportunities for bringing particular trauma-informed services into the services. The report also found that these groups are digitally excluded at the moment. There are huge hardware issues like access to laptops, phones and all of that and also access to the Internet. In the centres and on halting sites, there is no privacy. These individuals from these groups can often be at risk of what is called double jeopardy because they have their mental health issues but they are also digitally excluded, which is another burden that impacts their mental health difficulties. That report has a number of recommendations. The world is moving at pace; digitalisation is happening fast. We need to look at those communities that do not have access to these digital tools because there are huge opportunities there, but they are being excluded and that is adding to their burden. I would be happy to share that report with the committee.

Ms Emilia Marchelewska

Again, these are very insightful questions. I just wanted to thank the Deputy for already having insight and understanding of some of the issues of the populations we work with. The first question was about the ways of conveying different messages. As Ms Coyle said, a digital barrier exists, but it is also an opportunity. Some of the examples include videos that are produced by the HSE on various health topics but the issue is how we disseminate that information and how this information reaches our communities. At Cairde, we have developed a platform called HealthConnect. It is a multilingual platform that is designed with a mobile user in mind, because our research shows that migrants may not have access to computers but almost everyone has a phone. We have various information there and we work with some health departments to devise messages around chronic illnesses or sexual health. We do not work as much with mental health services yet on this. That will be crucial and is something we would like to develop further. With HealthConnect, we also work with migrant communities, with leaders and with ethnic media. We reach the communities where they are and where they obtain information, like through Ukrainian Telegram channels, Arabic-speaking WhatsApp groups and things like that. There are also communities like Roma where it is empowering because our Roma programme actually delivers an educational programme online. In a way, there are enormous barriers. There is also an opportunity, however, because we teach the women how to use digital devices. Because of the large families and other commitments they have, they can actually avail of the information from home.

We need to remember that a living message alone is not enough. We say physical activity is beneficial for mental health, but what does it look like for me and who is there for each of us? We need to convey how people can implement the advice of having more physical activity in their lives. What do self-care practices look like for me? Who is helping me to build my support systems? The messages are there, but they are not as effective if there is no support to personalise them. That is where healthcare is going now. It includes a coaching approach to health behaviours. The Deputy made another great point about the lack of supports. This is the story of migration, loss and having to rebuild, develop and maintain new support systems. We know from research that if we develop formal and informal support systems, health outcomes are much better so it is a good investment. At Cairde, we promote peer support and advocacy services not only in the health services but also on the ground in the community. We need patient empowerment, patient education and the coaching approach to help people to imagine what it looks like, to do health planning and to craft stress control programmes. We need to do cultural adaptation of these programmes and help people to manage their health and create healthy environments.

Dr. Salome Mbugua

I thank the Deputy for his question. I will try to address the supports more because he mentioned how some people do not have family networks or supports. When we talk about mental health, we must bear in mind that for people who come from a migrant community, in particular the African continent, mental health is stigmatised. Shame, and therefore stigma, come with it. In AkiDwA we have noticed that most people do not want to talk about mental health as mental health, so we had to mask the term "mental health" by saying "let's talk". When we want to talk about mental health issues we frame them by saying "let's talk" or "we need to talk" and we find people come forward. On available supports, there are many organisations and it goes back to different small groups based on where people come from. As we said at the beginning, migrants are not a homogenous group. For example, there are 54 diverse countries on the African continent. People come from different ethnic backgrounds and have different beliefs. The stigma is framed by where people come from and the beliefs they bring with them. It can sometimes be difficult for a person to go to a community or group of people from their background because of the shame and stigma that surround the topic. In AkiDwA, we try to reach people where they are and encourage them to speak and engage with the rest of society and the rest of the community. I cannot emphasise enough how important peer-led support is. In Dublin, the HSE has established peer-led supports in the community. In AkiDwA, we have always called for programmes like the ones for Travellers, such as the health promotion programmes where migrants can be their own champions in reaching out to migrants who are needy and are not able to reach out. This is needed.

Rural set-ups can be an issue because Dublin tends to be the centre of everything where most of the specialised supports are based. For example, there is only one centre for female genital mutilation, FGM, and it is in Dublin. This means that a women who has FGM issues has to come all the way from Kerry to Dublin for treatment and then has to go back there. Sometimes travel and commuting can be difficult. There are also childcare issues. For women with children who have mental health issues, it is a worry that they may end up losing their children to the care of the State. That increases mental health issues for those people. We have to take a holistic approach to working with those people and come to the point of asking how we can better serve people from different services, while they are perhaps still being served from one port.

It is important to ensure that we have a holistic approach of dealing with the needs people have but also with what they are bringing with them and their understanding of the systems we have in place.

Ms Sue Windle

Dr. Mbugua nailed it there. I wanted to talk about peer representation and how important that is when dealing with the migrant community. There is little point in somebody like me standing up in front of a group of women who do not look like me and telling them my experiences. We have run a number of workshops. Ms Fardin Tabrizi was part of a workshop. We have looked to run workshops with Doras where we have asked GPs who are from an Arabic and Muslim background to come in and give the talks, and the response was significant. We know that when somebody is representing people, it is much easier to take what is being given. I know from the work we do in Doras that migrant women tend not to look after their health or mental health. They are focused on family. The women themselves come last. The work we did was really important and highlights this.

It is the same in schools. Our client base is not represented in education. We have many migrant doctors. However, they are predominantly based in physical health, including many consultants. We need more consultants from migrant backgrounds in psychiatric and psychological fields. It is much easier to access care when an individual is not scared of the person who is trying to help them.

The Deputy mentioned the social capital issue with regard to the Polish chap who sadly had a heart attack and did not have anybody there. Many of our clients have that. Staff have had to attend really important medical appointments with clients. We get to the point in the form where a person lists next of kin and there is no one, so one of us goes down as the next of kin in case, God forbid, something was to happen. The reality with our client base is that many of them do not have any social capital. They do not have aunts or uncles. Doras is special in that they will access us as all of those things, then we point them in the right direction. There need to be more organisations such as Doras and more of all the things we do to provide that support.

Mr. Patrick Reilly

I support the statement that when you create the space, your community will engage. We have seen that. I would go further than meeting people where they are. It is about meeting them where they are but not leaving them where they are. Regarding the next of kin, what is it worth written on paper? It is basically a person to contact in the event of an emergency. There is no consultation or input around what care or support the individual involved can get.

Deputy Colm Burke

I have to leave to go to another meeting. On the scale of the issue we are facing, last year, 305,000 new PPS numbers were issued. Some 69,000 were to Irish people. The remaining numbers were issued to people from 202 different countries. Some 68,000 were issued to Ukrainians, about 18,000 to people from Brazil and 21,000 to people from India. All of them are coming here and working. If any one of them ended up with a health problem, is there support available for them?

To give an example, I know a couple who came in on student visas in 2016. They have a child who is a year and a half old who is not entitled to get children's allowance because they were here on student visas. She has since been diagnosed with multiple sclerosis. Where do we even start in trying to sort that problem out? That is the kind of thing I am talking about. She does not want to go back home because she feels she would not get the supports. They are paying something like €700 a month for an apartment. He is only entitled to work 20 hours a week because he has a student visa. I have a file in front of me, and I am not sure where I am going to start. That is the kind of challenge that we now have. They come at us in so many different ways. The question is whether we can set up enough structures to give supports to people in that kind of scenario.

An Cathaoirleach

I thank Deputy Burke.

Does anybody want to respond to Deputy Burke? He has to leave.

Ms Emilia Marchelewska

We have two Ukrainian outreach workers who assist people in such situations as that. Sometimes it means interpreting all night at a hospital during a blood transfusion. We have many dedicated workers and these two outreach workers work alongside the HSE. If we were to build from the examples of good practice that already exist, we would build a much better system.

Mr. Patrick Reilly

I was thinking about this a good deal yesterday and this morning and wondering how to say it in a way that it will be received the way I want it to be received. Where do the priorities lie with the Government? In 2020 it committed to a Traveller and Roma mental health action plan. We have not seen that go any further. When I ask where the priorities lie, I mean that as Deputy Gino Kenny referenced, different groups are coming into Ireland for a variety of reasons. It is not about separating them, definitely not. It is about inclusion. We spoke about that. However, where does the Government see its priorities? We are getting farther away from being heard when it comes to the issues because Pavee Point, the Traveller and Roma Centre and many other groups have been here before presenting on issues on Traveller mental health with colleagues from different organisations. There is frustration as to where the Government's priorities lie. A landscape has been made for that; that is my input regarding that piece.

Ms Fiona Coyle

In regard to mental health reform and our members, one of our key messages is for increased funding into mental health services. We are still very far away from the Government's own target of 10% of the health budget being invested into mental health. I believe it stands at around 5.6%. The figures for this year are not fully clear yet. We need to look at that investment piece. When we talk about investment, our mental health services are staff based and there is often an acknowledgement, which we all acknowledge, that consultant positions and certain other positions are difficult to fill. However, there are other positions that are equally critical. We have heard so much about peer support workers and the value of lived experience, being an expert of lived experience and how rich that role can be in assisting people in accessing mental health services and accessing their rights. As mental health reformers we have a concern that even this year a number of mental health peer support worker roles were due to be issued but now there is an embargo on new roles in the HSE. We heard from colleagues throughout the country that those peer support roles are crucial. Also, individuals are going into training to be trained as peer support workers in anticipation that there will be jobs. Everyone needs work, and when there are no jobs there they may go elsewhere and that richness of what they can bring to our healthcare service is lost. We have a concern on the current recruitment embargo and what that might lead to in terms of some of those really crucial roles that we know are much needed.

An Cathaoirleach

Does Dr. Mbugua wish to contribute?

Dr. Salome Mbugua

I want to echo what the Deputy said. It is true that there are many people, especially in the past two years, who have ended up here in Ireland. I spoke earlier about the feeling of powerlessness and lack of agency for most of the people who come because they are kept in a situation of limbo. Work is available in Ireland but the majority of those people have to wait for six months, if the hearing is not negative, to get the right to work. When, after six months, a person gets that right then it takes three months or however many more months for that person to get to use that right and apply for a job.

That creates a lot of powerlessness for people because when they leave their countries of origin because of issues affecting them, they do not want to stay idle because that triggers what has happened before and adds more to their problems and their mental health needs. We have therefore advocated for the right to work from three months because people may have already got used to what is happening in the country by then. Then it may be six months before they get the right to work. That feeling of powerlessness and lack of agency needs to be looked into as to how it impacts people who end up in a country where there are a lot of jobs. We have people here but we do not allow them to work. We keep them waiting, and that affects their mental health. We definitely need to look into that.

We also have to uphold human rights. I am a human rights activist. I am also a commissioner with the Irish Human Rights and Equality Commission and I believe in upholding the rights of people regardless of where they are. We spoke about that earlier. It is a matter of the life experiences of the people we are speaking about. Upholding those human rights is very important. I refer to the basic rights: the right to housing, the right to work, the right to health. I talk about issues faced by Travellers, for example, who are also affected so much by the housing issue. Sometimes we have the money to build these houses, but why are they not built? We again ask ourselves Mr. Reilly's question: where are the priorities we have in place to be able to sort out some of these problems we are talking about? We have the resources but we are not actioning what should happen to be able to overcome these barriers and issues that are affecting the people who are affected by mental health issues.

Mr. Patrick Reilly

I will wrap up this point. It goes back to the national Traveller health action plan that was launched last November. There is a national implementation group attached to that. This goes back to the point that, as regards the implementation, it is great to have that group but it cannot be left just to the implementation group or to the people here to follow through on the implementation. It needs the whole approach I spoke about. It is the stuff we have all talked about. Ms Coyle and I met this morning, we had a cup of coffee and a chat, and it was ironic that the similarities across the groups are such that we could nearly represent one another. Mental Health Reform does that really well in that it is not left just to us to lobby and advocate on issues that are impacting our community. We need that solidarity. It is a case of nothing about us without us and, again, not leaving it just to us to highlight, challenge and raise.

An Cathaoirleach

Did you want to come in, Ms Fardin Tabrizi?

Ms Tahereh Fardin Tabrizi

Yes, please. Yes, Mr. Reilly and I share a lot. As a migrant woman, when I first came to Ireland I was surprised to see how much I shared with the Traveller community, for example.

The point I wish to raise is having the diversity within the workforce. About half our healthcare workers are migrants, but that is not the case specifically in mental health. That poses a huge challenge because the vocabulary of mental health is very different from one migrant to another. Sometimes clients will come to us and say, "My heart is burning." That means the person is not mentally and physically doing well. As regards the diversity within the team, we are fortunate in Doras to have a few languages within our organisation in order that when individuals come to us distressed, we are able to communicate with them in their own languages and in a culturally adaptive way.

Deputy Burke referred to new PPS cards being issued, which is great. It shows we have more diverse communities in Ireland. However, we are also seeing with the Afghan admission programme, for example, that many families are starting to come into Ireland now but their PPS cards have been delayed massively. That puts a toll on their mental health because they do not speak English and cannot register for English classes without PPS cards, so it just goes on and on. The mental health state of the host families is affected as well because they cannot possibly carry the financial burden or the responsibility. They are interpreters and breadwinners for the family and have to do literally everything, and that needs to be noted.

On the point of having a diverse workforce, there is the possibility of making qualification conversion easier.

We have people who are qualified as psychotherapists or psychologists but they face a challenge because they are not able to work in Ireland even though they can speak the language.

Ms Sue Windle

I will add something on the Afghan admission programme, AAP. When the takeover by the Taliban happened and the Irish Government allowed this access for Afghans, the process of them applying to get their family members was incredibly difficult. It involved a 40-page document. It was very convoluted, even for us old hands who are able to do applications. What we are finding now is that for people who applied for the AAP, obviously out of fear and concern for their family, when at the time it was just a case of "Let us get them in and get the applications done", things have changed. In the time it took for those families to arrive, people's circumstances - specifically the sponsors' circumstances - have changed. They may have lost their job or had to move to a smaller house. Now we have a situation where sponsors are responsible for the welfare of maybe two or three family members but the money is not there. The housing is not there or there are not enough beds. If you look at the application process, you could not blame anyone for applying. At the time, a terrorist organisation had taken over and they wanted to bring their families in safely. Now, because they have signed up to this agreement whereby they are not entitled to any form of social welfare or housing benefits, we have people coming to us who have no English and no PPS number and cannot get a job. Everything is against them. That was maybe the shortsightedness of the programme, that the aftercare thought did not go into it. It is left to organisations like ourselves to try to pick up the pieces and advocate and say to the Department that it said they could not have social welfare, but in this instance they are not going to eat otherwise. It is about bringing it back to that fight. There are a lot of factors.

It is the same with family reunification. We are on year two. A lot of families are applying for their spouses and children to come in. We are going into year two because the staffing is not there in the Department to process these applications. In the interim, other things have happened. Pregnancies have occurred and the whole application process goes back then. Again, you have the mental health of the sponsor to think about, who is worrying about the immediate safety of their family. That process just goes on and on and on. It is really difficult. I am dealing with a lady at the moment who is waiting for her citizenship application to come through. Sadly, she has been diagnosed with stage 4 breast cancer but she cannot travel to see her mother because she is waiting for her citizenship and now there has been a delay on that. We do not know. It could be months. There is a myriad of stuff in terms of immigration that is really difficult for people to process. That is what we are dealing with on the ground as well.

Deputy Neasa Hourigan

The example Ms Windle has given there is terrible. This is something I have come across with constituents as well. In her experience, what is the average waiting time for a PPS number now? In the good old days it was three weeks and in the bad days it was months. Where are we now?

Ms Sue Windle

It is about 16 weeks.

Ms Tahereh Fardin Tabrizi

I have seen four months.

Deputy Neasa Hourigan

Wow. That is very difficult.

Ms Tahereh Fardin Tabrizi

It is.

Deputy Neasa Hourigan

We were given assurances recently that it would be faster.

Ms Sue Windle

Again, it comes back to the networks and if you are lucky enough to know a friend of a friend. If the circumstances are extreme enough, those will be expedited.

Ms Tahereh Fardin Tabrizi

Apologies for coming in. It is also about the knowledge. Once they enter the country nobody actually tells them they need a PPS number. I met an Afghan lady yesterday who was here for six months on the Afghan admission programme and she did not have a PPS number.

Deputy Neasa Hourigan

Nobody had told her.

Ms Tahereh Fardin Tabrizi

She did not even know why she needed it. Building awareness is also very important.

Deputy Neasa Hourigan

A person should be told to get a PPSN the moment they arrive here. We talked about how it is not possible to silo people off into particular areas. However, I am aware that members of the LGBTQI community who come here need specific help and might sometimes find it difficult for ask for that help. Women from ethnic minorities often have poor outcomes in maternal care, for example. However, this country has done a huge amount of work in the past few years around mental health supports during the maternal time for women both pre- and post-natal mental health supports. I can only imagine that is much more complex for women who are in an ethnic minority and have language barriers. There are probably other groups that I am just not citing. Have the witnesses any thoughts about we could be better in this?

Dr. Salome Mbugua

We work with the LGBT community now. We are starting a group in AkiDwa to support lesbians because they are experiencing many issues and challenges when trying to seek support and services. Again it goes back to stigma, which I spoke about earlier, from their own community when they go to seek those supports and services. The supports that are needed need to be set by the community itself, the community of migrant women supporting migrant women of diverse sexual orientation which has not been there before. Our organisation is starting this but we also refer them to other groups such as LGBTQ communities. We had several meetings this year with the different groups that support LGBTQ communities. I have heard from some of them in terms of these discussions that even at European level there is a lack of services and support that are tailor made for transgender women or transgender in general. From our work I know how it can be difficult and challenging for lesbian women to get that meaningful support. Even when they are living in direct provision centres sometimes their needs are not met. The managers and people working in these accommodation centres are not aware of them or of how better to help and support them, so it can be challenging and traumatising. Some of them have experienced hardship before coming here so there is a need for service providers to understand that. There is also a need for support for this specific group to be able to come out, to speak out and stand up when they go for services but also when they go out there.

Mr. Patrick Reilly

I should have said at the start that at Pavee Point we have the Pavee Mothers programme. The word "pavee" in our language means "traveller". There is a website, similar to the young Pavees "Mind your Nuck". There is a text message service whereby the mothers get semester one and semester two reminders, supports, tips and advice. On our young Pavees website the LGBT issue came up for young Travellers as well, so we have a resource there on LGBT as well. There is a group, the National Action Group for LGBTI+ Traveller and Roma Rights, that promotes this work. Every year we take part in Pride. As was said about stigma, being a Traveller and being LGBT, there is a fear of being discriminated against. We hear the saying "All the Same" but that is far from the truth. Ms Coyle said in the statement that what might work for one community might not work for another. That is an example.

Ms Fiona Coyle

In regard to perinatal mental health services, while there have been welcome efforts to make our mental health services more inclusive to the needs of women and other marginalised groups, there is still a long way to go in terms of perinatal care. We still do not have a unit in the country where a mother who is experiencing mental health difficulties and needs inpatient care can go with her newborn child. That is something we need to look at, invest in and resource. At the moment it is a huge gap. It is back to staffing.

I reiterate what my colleague said about the workforce. We need to encourage a diverse workforce. Even as regards the specialised perinatal units and services, there needs to be encouragement to bring in a diverse range of skill sets from diverse backgrounds. At the end of 2021, Mental Health Reform and the Mental Health Commission launched guidelines on delivering mental health services to ethnic minority communities, and some of those guidelines are about how to encourage more diversity within the staffing. We had some concrete suggestions that, in staffing, there should be references to cultural responsiveness in position descriptions, performance reviews and promotions. There is therefore a way for us to look at this from a HR perspective to ensure we are encouraging.

We also did a project with the Cabra community mental health team whereby we developed a cultural sensitivity toolkit. One of the challenges that came up was that these staff were so personally motivated to engage and to learn and that openness was there that many of them did it on their own time because their day-to-day jobs are so busy and they are so stretched. Those individuals who undertake the training probably have an awareness and an openness and want to build on the skills they have. We need to ensure that, within a training context, this involves everyone. That unconscious bias piece is really important for a country such as Ireland as to where we have come from as a small island. We all need to look at our own unconscious biases. That is really important.

An Cathaoirleach

Ms Marchelewska, did you want to come in?

Ms Emilia Marchelewska

Just briefly. If the question is primarily about vulnerability or the groups most at risk, it is definitely a matter of intersectionality. If you are a woman from a forced migration background, and if there is previous trauma or even childhood trauma, and now you live in direct provision, you will be in a more vulnerable situation. That should be considered. The research definitely says that those who come through forced migration channels are more vulnerable due to the accumulation of pre-migration and post-migration stressors. The research that has just been published, which analysed the psychological distress of newly arrived people seeking international protection, analysed data from 2019 and shows that women coming from Zimbabwe are in the highest psychological distress.

I am an EU migrant. As a community, as community leaders, we think we are sometimes a little forgotten because maybe we do not have it that bad and we enjoy a number of privileges that others do not have. Still, however, the EU migrants or the Roma migrants who access mental health services here, as I said, are a significant proportion of the people who access services who may have additional challenges as regards language, for instance. Looking at the solutions and the collaborative approaches, I am on the board and am chair of Centrum Konsultacyjno-Terapeutyczne, CKU, which is a counselling service for eastern Europeans. Communities are coming up with solutions by themselves and just need to be at the centre of the system. The healthcare system does collaborate with communities to fill in the gaps, and migrants are very resourceful and there is a lot of innovation coming. Take MyMind, it was set up by my colleague, a Polish migrant and psychologist, and is now one of the most innovative services in the country. It is a matter of looking at this from a positive angle in terms of the opportunities that exist and good practice models.

Deputy Neasa Hourigan

I have one last question, I promise. Does the privatised nature of the provision model present barriers for any of the Doras's services? It is not directly provided by the State, there is a private factor involved and there is a private managing of sites; there is a private piece to it. It is a fairly open-ended question. Perhaps there are positives to it but does it present challenges as well?

Ms Sue Windle

Regarding beneficiaries of temporary protection, BOTP, it is not regulated. There are 900 centres and none of the centre managers must have Children First and none are Garda vetted. Essentially, they are accommodating, housing and feeding very traumatised people, if that is a fair way to say it. It is ongoing trauma for Ukrainian people because the war has not finished. That comes with a myriad of issues. The people who are essentially supposed to be sheltering them-----

Deputy Neasa Hourigan

Sorry. They are not Garda vetted.

Ms Sue Windle

No.

Deputy Neasa Hourigan

This is something we have gone through with the Dublin Regional Homeless Executive, DRHE, in Dublin a lot with the homelessness services. It is the basic minimum to ask and they did not do so either. If I wanted to volunteer – which I actually had to do – to teach an art class to older people in my community, I have to be Garda vetted. Ms Windle is telling me that-----

Ms Sue Windle

To clarify, for IP applicants, all of the staff must have vetting and Children First. For BOTP, there is no requirement for providers to have Garda vetting, Children First or any training related to housing vulnerable cohorts of people.

Deputy Neasa Hourigan

Not to underestimate the importance of the training on the extra things, but Garda vetting is a basic minimum-----

Ms Sue Windle

Bare minimum.

Deputy Neasa Hourigan

-----that somebody involved in a local football club has to do.

Mr. Patrick Reilly

Before students go out on placement, let it be a community development or youth work placement, they are very clear that those students have to be Garda vetted.

Deputy Neasa Hourigan

But not if you are working with even children.

Ms Sue Windle

No. I believe the reason for that was some of the providers initially had asked to be vetted and it is something to do with there not being a corresponding piece for the bureau to sign off on the vetting, if you will. But no, they are not required to do so.

Deputy Neasa Hourigan

Tusla is involved in this in some cases. How is Tusla standing beside this? I know it is not the witnesses’ question to answer. I just do not understand how safeguarding organisations are allowing that situation to continue.

Dr. Salome Mbugua

The centres have mushroomed. We did not have so many of them, let us say, five years ago. Now there are many and there is no tracking of even control. When you are privatising, whom are you privatising? To whom are you giving that responsibility to take care of vulnerable groups? These are vulnerable groups. Like the Deputy said, there are children involved. Tusla may not even know because the way they are set up, the centre could be anywhere in the country.

In 2010, for example, AkiDwa did research, namely, Am Only Saying it Now: Experiences of Women Seeking Asylum in Ireland. We followed up with another report, namely, No Place to Call Home: Safety and Security Issues of Women Seeking Asylum in Ireland, on women living in those accommodation centres. There were issues of sexual exploitation, sexual harassment and many things happening. Most of them are private centres. There is a huge issue there. We attack the housing issue with privatisation with people who are ready to take. It is to fill the gap. It is hard to know who these people who are entrusted to take care of vulnerable people even come from. We heard from our services how security is not vetted yet this is security in women-only places. We have heard a lot of issues. There are many issues out there.

It is important to be on top of everything to ensure that the safety and security, especially of those vulnerable children and women, is protected and taken into account. Vetting is one of the key measures that can be taken to know who is in these centres providing the services and how they are providing them.

Also, when issues come up, what is the reporting mechanism? Quite often, when people report, they are transferred. They are moved from one centre to another. There are many issues happening because people are stressed and have mental health issues. However, the managers and staff are not able to deal with them. We talk about training, but those are the people who need the training on cultural competency, vulnerable people and all those kind of things the most. However, now anybody can be a centre manager or staff manager of vulnerable people.

Deputy Neasa Hourigan

We had a similar conversation with the homelessness services. The privatisation model means that there are staff who do not know which services to direct people to and they are in a role where they have to do that. I did not mean to derail this with the Garda vetting, but my mind is boggled that is the case. I am sorry; the fact that Garda vetting is not required seems to have passed me by.

Ms Emilia Marchelewska

Managers play a crucial role in those pathways of access. In the centres where there is a good relationship, let us say, between HSE social inclusion with the outreach teams, if there are any red flags, the managers or any designated person can highlight these health needs to social inclusion or mobile health teams on the ground.

Is training important or not? We had cases where managers did not respond to the situations where someone was visibly displaying distress symptoms, for example, crying or shouting at night. The residents raised issues but the response was that the person has to come forward themselves. Training on the pathways is important.

On Garda vetting, it is sometimes annoying that we are not Garda vetting a person. Each service has to apply for Garda vetting themselves. I know individuals that have been Garda vetted multiple times.

Deputy Neasa Hourigan

Yes, me too.

An Cathaoirleach

I have a couple questions. An awful lot has been covered. I thank the witnesses for the amazing work they are doing. The work they do is mind-blowing. I wish to start by thanking them for what they do.

I am aware the HSE’s social inclusion office does much work in this area. I heard a member of that office speak at a mental health reform event a few months ago and she was extremely passionate and well informed. It was refreshing to hear how passionate she was.

Perhaps I will start with Ms Coyle. What experiences has she had with the social inclusion office? I note she put in a few recommendations. If the officials were listening today, what does she think their priorities should be? They want to learn as much as the rest of us. I will ask everybody this question. What are the priorities for the social inclusion office?

Ms Fiona Coyle

I reflect the Cathaoirleach’s comments in that there are amazing individuals across the HSE who are personally passionate about this issue. This is always on the list of priorities of the social inclusion office, the mental health operations office and the mental health engagement and recovery office. My point is that beyond the office and its priorities, there is a resourcing issue. They are doing what they can with the resources they have and I think more could be done. Both the HSE office for social inclusion and the mental health office have partnerships with all of the organisations at this hearing.

As part of our pre-budget campaign we were advocating mental health reform to increase the resourcing to the voluntary and community sector in budget 2024. Due to the increasing cost of living, what organisations can deliver on the same money as last year is less. Unfortunately, that funding did not come through. It is about funding. However, it is also about recognising that the HSE in itself is one of the biggest employers in this country. The HSE is in every county and community throughout Ireland. There are HSE services and it is about changing the culture and practice. These offices are doing great work in delivering services and supporting communities but where is the engagement with their colleagues across the different services throughout the country? Colleagues here have also said this. We need to ensure that it is not just left to that office. This is bigger than that and it needs to be bigger than that. My point is that this is not just taken up by a particular office. Delivering services for everyone, is everyone's business.

Mr. Patrick Reilly

I referenced the national Traveller health action plan that was launched this time last year. The national social inclusion office is supportive of that plan and the implementation. Sometimes we can fall under the national social inclusion office and the HSE. The Department of Health has a responsibility as well. It is about the ownership and it cannot, as we said, be left to a variety of groups. We have a positive relationship with the national social inclusion office and, as I said, we are supportive of the action plan, which is really important.

Dr. Salome Mbugua

I smiled when I heard that because the HSE has been our major key supporter since we started our work with female genital mutilation, FGM. Everybody pushed us when we spoke about FGM to the HSE because it was supporting us financially. It is open to listening, even in the case of ethnic identifiers. We have spoken many times, we ask for meetings and we meet the person who is linked to our organisation. The HSE has been providing us with support and we have been looking for more support because we have seen the increase in the number of people coming into Ireland. However, we are also a national network that works all over the country. We have just started a peer-led support project. We recommend that this is replicated around the country so that it is everywhere, not only in Dublin. As the organisation works with migrants and meets people, there is co-ordination so that things do not happen only in Dublin. Groups and organisations working around the country are able to share learning and experiences while at the same time structuring this project. Resources are important because they would help us to reach more people. I agree that everything should not be left to the social inclusion unit or the HSE in particular. It is important to have the Department of Social Protection, the Department of Education and other Departments, including employment co-ordinated in such a way that we can support people in a meaningful way. The HSE is already doing its work and needs to be complemented by all these other services.

Ms Emilia Marchelewska

To make sure everything does not fall on the shoulders of social inclusion, when looking at all the implementation plans or strategies, it is important responsibility is assigned and shared. That collaborative spirit should be fostered, so there is collaboration between different HSE departments, the Department of Health and other community partners. We receive core funding from the HSE's social inclusion and special projects, Dublin north city, and we also receive specific funding from CHO 6 and CHO 7, which collaborate with the national social inclusion office. We are, of course, grateful for their support and dedication. As I said, that co-operation and co-production in the approach should be emphasised more.

If more focus was put on mental health schemes, that would be a great improvement. Even if we focus on the implementation of the recommendations, for instance, sharing in the mental health promotion plan, that is a good start.

An Cathaoirleach

I agree with everybody about the national social inclusion office. It does a phenomenal job but it is stretched. Ms Windle mentioned earlier the cross-departmental working together piece and the difficulties when a worker is working with two Departments. Can she say a little more about the problems and why it takes so long? Why is it not quicker to get stuff done from a cross-departmental point of view?

Ms Sue Windle

In short, the answer to that is the individual working for the Department. I have been fortunate enough to work with some incredible individuals in all Departments but I have also worked with people about whom I would not say that. The frustrating part for staff in Doras is the effort it takes to get the right hand to speak to the left hand, particularly when the issue is so easily identifiable. In a particular case of ours, a gentleman with long-term enduring mental health issues lived six years longer in direct provision than he should have because he did not have the capacity to advocate for himself to get a house. Although he was linked in with a good mental health team, that addressed the mental health side of it. It took great effort for both that team and Doras to eventually get him into suitable accommodation. I am talking two years in planning. That is a case where you cannot drop the ball. If you drop the ball, then it puts you back another six months. It takes a constant badgering of people in various Departments to say, "We are at this stage now; we really need to assist." They have restrictions as well. They have very long waiting lists but ultimately we were coming from a human rights perspective with this gentleman who spent six years longer than he needed to spend in a centre because he did not have any social capital. That is the kind of case we see. That is one of many cases in Doras where individuals cannot advocate. They rely on us, but also on the services that we link in with, to respond. Everyone is doing their best. As we know, housing is in crisis at the moment. Allocating housing to individuals is an incredibly difficult area to work in at the moment. However, a more co-ordinated response there would have been far better - a multidisciplinary approach where the mental health team sits down with the housing team and ourselves. That happens but not in every instance. I can speak to that from my experience.

An Cathaoirleach

Does anybody else want to come in on that piece around cross-departmental co-ordination?

Mr. Patrick Reilly

Is there a hierarchy here whereby when one Department makes a request from another, it is not well received? They would be forgiven for thinking that way. Similarly, when we try to support Travellers, for example, that involves working to try to identify the go-to person. We deal with people who want an immediate fix and immediate support. What power have we? We make phone calls and we send the emails. I say to Travellers that I cannot promise anything other than that I will do my best but it does not mean anything will happen. We need to move past that stage.

Ms Emilia Marchelewska

A good systemic example of that co-operation would be between the Ukraine Crisis Temporary Accommodation Team, UKTAT, and the Department of Children, Equality, Disability, Integration and Youth.

The HSE has seconded a staff member to work with UCTAT to respond to people in medical priority situations, so there is one staff member who looks after the needs of Ukrainians who may be assigned to medical priority groups such as heavily pregnant or with a major disability, including a major intellectual disability. These solutions can be in place, and maybe some of the severe cases could be caught in the safety net. On the ground, however, we all work through that person-centred approach.

I remember a client who contacted us in a desperate state. He had a very thick folder of evidence of both his mental health and physical needs. He was granted status to stay in the country. However, he was left in emergency accommodation. He had a mobility issue, but he was placed on the third floor. He could not walk very much. He forgot about taking his medication. He was by himself here. At the point we met him, he did not have a medical card, he did not have a GP and he was asking for support with his mental health issues. He had already been seen by Safetynet doctors and then by Spirasi. He had documentation from Spirasi. He was in touch with the services, but the basics were not there. We supported him with access to health services. We also supported him with a family reunification case so his wife could come in and support him with his health needs. We also supported him in getting alternative accommodation that would be more suitable to his health needs mobility-wise. He also had diabetes, so the food he was receiving was sometimes not suitable. That is an example of how it looks on the ground.

Dr. Salome Mbugua

I wanted to come in on our work on sexual and gender-based violence, because it is key. One area we are dealing with is the personal issues of the person. In that area, we have the domestic, sexual and gender-based violence agency which is going to start. As regards the legal aspect and support for people who come to us, especially on issues to which Ireland is not accustomed, such as early and forced marriages, I have seen our work linking up with, for example, the Department of Foreign Affairs, which people may not think about. It is very important when Departments co-ordinate and work with one another because it is helpful not only in collecting data but also in looking at gaps in how we can better provide services. It is paramount that the Departments work together to be able to meet the needs of the person. It cannot be emphasised enough. That is all happening but it is not co-ordinated.

An Cathaoirleach

The witnesses have provided a wealth of information. I cannot thank them enough for coming in. In particular, I again thank them for the amazing work they do. It would be brilliant to see an integrated, cross-departmental approach going forward. That would probably work so well, not just in this area but in so many other areas as well. I thank all the witnesses from Mental Health Reform, Doras, AkiDwA and Pavee Point for coming in. They are amazing.

The joint committee adjourned at 12.24 p.m. sine die.