February 13, 2009

Publication: Forum

Date: Wednesday, February 11, 2009 Page: 23

Headline: Huge deficit in psychology services

Irish families are suffering because of a lack of psychologists in community mental health teams, writes Eoin Galavan

IN RESPONSE TO A LACK OF PROGRESS in rolling out the 'Vision for Change', the Irish Association of Psychologists in Mental Health (IAPMH) was established in June 2007 following a national meeting of psychologists who work within the mental health system. Currently, we represent approximately 80 psychologists (60% of the national total) working within the public child and adult mental health services.

The aim of the IAPMH is to publicly highlight the lack of psychological services available to patients within health-care systems. Currently, patients entering the mental health system are likely to receive an exclusively medical-model approach to dealing with their problems. It is highly unlikely for most of the patients within the service to ever get the opportunity to see a clinical psychologist due to the serious lack of psychologists within the system.

Minimum requirement

The Mental Health Commission (MHC) Inspector's report (2008) noted a basic minimum requirement of 156 incommunity mental health teams for each of the child and adult services (total of 312). Currently, there are 81 within the adult services and 52 within the child services, leaving a deficit of 179 nationally. Each of these teams requires a basic minimum of one psychologist per team (with a team serving a catchment of 25,000 people as per Vision for Change). In other words, there is the equivalent of 179 teams nationally without access to a psychologist. It is important to note that this one psychologist per team would bring services levels up to a bare-minimum requirement. As such, there is a radical shortfall in both child and adult mental health services. Another important point is the value of the various disciplines within the community mental health team. Psychiatry and psychiatric nursing for example, are highly important components of these services; however, they still only provide a limited service. In other words, they do not provide the type of service that clinical psychologists provide. Many so called 'teams' have exclusive medical personnel, with no or extremely limited access to psychological services, social work services or occupational therapy.

What happens if there are no psychological services?

Many clients will wait for months or years to gain access to highly pressurised psychological services. Most will never be referred despite having conditions/disorders that are treatable with psychological intervention. The Alliance of Mental Health Professionals (made up of the IAPMH, the Irish Psychiatric Association, the Irish Association of Social Work and the Association of Occupational Therapists in Ireland) notes the importance of all disciplines. Each discipline brings a unique and critical skill set to working with individuals with mental health problems. It is also important to note that a well-functioning, fully-staffed multidisciplinary team is an extraordinary entity with enormous therapeutic potential. Furthermore, psychological wellbeing and general health benefit from an early investment from clinical psychologists in child and adolescent development. There is considerable evidence that failure to tackle emerging problems in childhood leads to the development of adult mental health problems and social exclusion. This lack of appropriate treatment means that people's conditions often worsen, and the risk of self-harm and suicide that is often associated with these conditions persists. In short, people suffer. Decades of research indicates that psychological interventions are critical for a significant majority of mental health service users. Conditions such as depression, anxiety disorders (eg. OCD, PTSD) and personality disorders require psychological assessment and intervention, and in many cases a psychological intervention is the recommended gold standard first line of treatment.

The American Psychiatric Association and the National Institute for Clinical Excellence recommend that psychological interventions be the first line of treatment for personality disorders. The WHO indicates that psychological interventions are critical as a first line of treatment for eating disorders. For many other conditions, research indicates significant efficacy for joint interventions (eg. schizophrenia or bipolar disorder), where medication and psychological therapies can both play crucial roles. These are just some examples of how psychological interventions can play a critical role in treating psychological and psychiatric disorder within a multidisciplinary context.

Clinical psychologists or psychotherapists?

This is a very complex question with a proliferation of various psychotherapy training programmes over the past decade. It is important to note that the clinical psychologist trains to doctoral level, with training on average taking about eight to 10 years. Clinical psychologists train within the health system, across care groups, and specifically within the child and adult mental health system. The training is designed to provide professionals who are qualified to provide psychological assessment and treatment for clients of the mental health service. None of the other psychotherapy training options provide this as a basic requirement for all of their trainees. Transforming services If the Government wishes to transform our mental health services from the outdated, medicalised and expensive nstitutional care model into a modern multidisciplinary focused community-based service, investment in the training and recruitment of clinical psychologists is critical.

A thought on costs There is significant research evidence to indicate that treating people with psychological approaches is considerably cheaper than with medication and inpatient care. The MHC for example, recently published a report indicating that the community care model is likely to be a far cheaper form of treatment, reducing inpatient stays and long-term reliance on medications. The report also stresses the need to invest in mental health service provision: "policymakers cannot afford not to invest in mental health". This is not news! This information and understanding has been available for years, and several international reports confirm this, eg. the 2006 Layard report (UK). We have clear evidence to indicate that investing in clinical psychologists is likely to save the system money. Almost every developed country in the western world recognises these facts; every major health body in the world, including the NHS, the NICE in Britain and the WHO to name but a few, recognise the critical importance of providing psychological services.

Roll out Vision for Change

The simple answer to this problem is to quickly move to rolling out Vision for Change, and train and hire psychologists to fill posts on community mental health teams. If not, clients and their families will continue to suffer needlessly, their conditions and quality of lives will continue to deterio- rate and the risk of self-harm and suicide will persist. As we are all aware, mental health and wellbeing not only make for a better individual quality of life: they are also associated with better physical health outcomes, improved educational attainment, increased economic participation and rich social relationships. It is in society's interest, in terms of our overall economic and social wellbeing, to invest in services that ameliorate psychological difficulties. 

Eoin Galavan is clinical psychologist at Kilbarrack Health Centre, Dublin, and co-ordinator of the Irish Association of Psychologists in Mental Health (IAPMH)