Psychotherapists, Counsellors should indeed be regulated

 
 
 
Irish Medical News: Published 12th November 2007

Psychotherapists, Counsellors should indeed be regulated

The emerging consensus is that psychological therapies should be regarded as fundamental to mental health services at primary, secondary and tertiary care levels.
Psychotherapy in Ireland is regulated by the Irish Council for Psychotherapy. We have currently over 1,050 psychotherapists on our register, which can be accessed via our website, www.psychotherapy-ireland.com.

ICP standards are in line with the European Asso­ciation of Psychotherapy, and accreditation as a psychotherapist generally requires at least seven years of training, a primary degree, a foundation year and three years part-time training in one of the psychotherapeutic disciplines. The total duration of the training for psychotherapists accredited with ICP is 3,200 hours, spread over a minimum of seven years.

There are five Modality Sections of the Irish Council for Psychotherapy: humanistic and integrative, cognitive behavioural, constructivist, systemic family therapy, and psychoanalytic. All sections have codes of ethics which oblige therapists to uphold a high standard of professional competence and personal conduct in their practice with their clients and each section also has a complaints and disciplinary procedure.

We are at present seeking to have our profession statutorily regulated and are currently working with other mainstream psychotherapy organisations on proposals in this regard which should be ready for submission to the Health Minister next month.
Ms Derval Ryan, Chairperson,

Irish Council for Psychotherapy,

Quinn’s Road,

Shankill,

Co Dublin

Standards in Psychotherapy: Letter to the Irish Times

Irish Times, Saturday 27th October 2007.
Letters Page

Madam,

In the light of Sylvia Thompson’s article “ Is Psychotherapy losing touch with reality?” (Health Supplement October 23rd 2007), and of recent events being covered in the media, I would like to clarify issues around standards in psychotherapy in Ireland today.

Psychotherapy in Ireland is regulated by The Irish Council for Psychotherapy.  We have currently over 1,050 psychotherapists on our register.

The purpose of the ICP is:

* to promote and maintain the highest standards of training and professional conduct among psychotherapists

* to develop psychotherapy as an independent profession

• to represent the majority of psychotherapists in Ireland to the public, the media and the Government

ICP standards have been agreed by all the major psychotherapy organisations in Europe. The total duration of the training for psychotherapists accredited with ICP is 3,200 hours spread over a minimum of seven years.

The Code of Ethics of the ICP obliges therapist to uphold a high standard of professional competence and personal conduct in their practice with their clients.  We also have a complaints and disciplinary procedure.
We are seeking to have our profession statutorily regulated and are currently working with other mainstream psychotherapy organisations on proposals in this regard for submission to the Minister for Health & Children.
Further information available at:  www.psychotherapy-ireland.com
Yours sincerely,

DERVAL RYAN
Chairperson:  Irish Council for Psychotherapy
Quinn’s Road, Shankill, Co. Dublin.

The Effectiveness of Psychotherapy: A Review of Research by Prof. Alan Carr

The Effectiveness of Psychotherapy – A Review of Research Prepared for the Irish Council for Psychotherapy by Prof. Alan Carr, Director of Clinical Psychotherapy and Training at UCD.
This review, which shows that psychotherapy is an effective treatment for an extensive range of psychological problems associated with physical illness and major life stresses in both adults and children, was published by the ICP in June 2007. At the launch, Prof. Carr urged the provision of a fully funded national psychotherapy service.  Attached are extracts from this research document:

* Preface by Dr. Brion Sweeney, Chair, ICP

* Executive Summary

* Recommendations

Professor Alan Carr has written over 20 books and 200 publications and presentations in the fields of clinical psychology and psychotherapy.

Download preface by Dr. Brion Sweeney

Download executive summary

Dowload Recommendations

Expert calls for fully funded National Psychotherapy Service for Ireland

One of the country’s leading clinicians and academics has called on the HSE to introduce a fully funded national psychotherapy service, which he says would be both an effective and cost effective way to treat a wide range of Ireland’s current mental health problems.  Prof. Alan Carr of University College  Dublin said a review which he has just completed into the effectiveness of psychotherapy shows unequivocally that it works.

“The scientific evidence from hundreds of controlled studies involving thousands of cases shows unequivocally that psychotherapy works.  Prof. Alan Carr, who is Director of UCD’s Doctoral Training Programme in Clinical Psychology says that psychotherapy is an effective treatment for an extensive range of psychological problems associated with physical illness and major life stresses in both adults and children. It should also be available to help people adjust to physical illnesses, and cope with chronic pain and fatigue and to treat adjustment problems associated with developmental disabilities including intellectual disability and autistic spectrum disorder.

Speaking at the official launch of his report in Dublin this afternoon (June 25, 2007) Prof. Carr said that the evidence showed that psychotherapy was  not only effective but cost effective as those who availed of the service used fewer other medical services at primary, secondary and tertiary levels.   They are hospitalised less than those who do not receive psychotherapy and it could reduce attendance at hospital A & E Departments.  “So developing psychotherapy services within the HSE makes good sense in terms of patient care and it also makes good financial sense.  Psychotherapy keeps people out of hospital. “HSE psychotherapy service structures require development.   There should be psychotherapists on all primary care teams.  There should be more psychotherapists in secondary and tertiary care systems. 

Prof. Carr said that the average success rate for treated cases ranged from 65% - 72%.   He said psychotherapy should be offered as rapidly as possible, with short waiting times and recommended that within the HSE and other health service organisations, psychotherapy services should be developed in primary, secondary and tertiary care settings.  Since psychotherapy has also the potential to cause significant harm in a small proportion of cases, he recommended that psychotherapy only be offered by those appropriately trained and qualified and that psychotherapists employed in the HSE and other psychotherapy services be registered with the Irish Council for Psychotherapy.  

Dr. Brion Sweeney, consultant psychiatrist specialising in substance abuse with the HSE, psychotherapist and Chair of the Irish Council for Psychotherapy, which commissioned the research, said that to be successful at least six months treatment with a well trained psychotherapist was required for a number of conditions. He said that Prof. Carr’s review suggested that we need to broaden the scope of provision from brief interventions using counsellors to more complex interventions which psychotherapists are best placed to deliver. 

• Alan Carr is professor and director of clinical psychology training at University College Dublin and has a clinical practice at the Clanwilliam Institute in Dublin.  He has been involved in psychotherapy for 30 years in Ireland, Canada and the UK and has an international research and scholarship profile in psychotherapy.   Prof. Carr has written over 20 books and 200 publications and presentations in the fields of clinical psychology and psychotherapy.

• The Irish Council for Psychotherapy has been regulating the training and professional standards of psychotherapists for the last 15 years.   It maintains a register of over 1,000 qualified psychotherapists.    Accreditation as a psychotherapist generally requires at least seven years of training, a primary degree, a foundation year and three years part-time training in one of the psychotherapeutic disciplines.     

Suicide Risks and Psychotherapy

Suicide Risks and Psychotherapy
Letters Page:  Irish Times 13/08/2007
Madam,
I read with great interest the article on post-natal depression by the Irish Association of Suicidology, in response to the latest of a number of family murder/suicides (Irish Times, July 17, 2007)
The association mentioned that psychiatric services are, for many people, neither user-friendly nor readily accessible’,
Ireland urgently needs a fully funded national psychotherapy service which would be both an effective and cost effective way to treat a wide range of Ireland’s current mental health problems.

In the meantime, the Irish Council for Psychotherapy maintains a register of over 1,000 qualified highly trained psychotherapists, who are both accessible, ‘user-friendly’, and skilled in dealing with the emotional disturbances so often tragically highlighted recently.    Unfortunately, owing to the lack of a public service,  the majority are in private practice.

Yours etc.,
DERVAL RYAN
Vice-Chair,
Irish Council for Psychotherapy,
Shankill, Co. Dublin.

Applying a new Cognitive Model for Trauma in Northern Ireland

The latest research has shown that psychotherapy is an effective treatment for post-traumatic stress disorder related to terrorism and other civil conflict in Northern Ireland, consultant psychiatrist and specialist in the treatment of trauma disorders, Dr. Kate Gillespie told this month’s Dublin Conference of the Irish Council for Psychotherapy.
And treatment is effective, when delivered even more than 30 years following the trauma.
Dr. Gillespie is Clinical Director of the Northern Ireland Centre for Trauma and Transformation, which specialises in the assessment and treatment of trauma related disorders resulting from the Northern Ireland conflict.
She said that up to recently little was known about how to successfully treat trauma resulting from events such as the bombings in London in 2005, the attack on the World Trade Centre in New York and the train bombings in Madrid.
The only published evaluation of treatment after a terrorist bomb revealed that cognitive therapy – one of the psychotherapy disciplines – delivered three months to two years to survivors of the Omagh bombings resulted in improvements in post traumatic stress disorder on a par with treatment for non-terrorist related illness.
Following these results the Northern Ireland treatment centre was established to offer trauma focused cognitive therapy to people affected by terrorism and other civil conflict over the past four decades.
Dr. Gillespie said that a new study of 58 consecutive patients treated at the Centre – some up to 33 years after the trauma - had shown significant and substantial reductions in the symptoms of post traumatic stress disorder and depression.
A high proportion of the patient had experienced multiple traumas and these patients improved as much as those who had experienced fewer traumas.
The present or absence of another psychiatric disorder did not influence the extent of a patient’s reduction in symptoms of post-traumatic stress disorder. Physical problems resulting from the trauma did not predict poorer outcome, but high levels of depression at intake were associated with poorer outcome – a finding not observed in the Omagh bomb study.,
Dr. Gillespie told the Conference, that recent guidelines from the National Institute for Health and Clinical Excellence (NICE) in the UK recommend cognitive behaviour therapy as a treatment of choice – alone or in conjunction with drugs – for many psychiatric disorders.

Opening Address at Annual ICP Conference 2007

Speaking at the official opening of the Conference Dan Neville T.D., President Irish Association of Suicidology stated.

I note that the Council for Psychotherapy is fully supportive of statutory registration of psychotherapists. In fact the ICP has been very proactive in seeking to have the profession of psychotherapy included in the first wave of statutory registration for health and care professionals.

During the course of the debate on the Health & Social Care Professionals Bill 2000 I spoke very strongly in relation to the need of regulating counsellors and therapists and that it was unacceptable that the situation was not regularised. I note that the ICP has strict criteria for acceptance of psychotherapists into its organisation. Yet, we have a situation where there is no statutory regulation. There is an absence of control in relation to those who decide to act as therapists or counsellors. There is ignorance and not a little confusion within the general public as to what psychotherapy and counselling are and what the difference is. This is compounded by the fact that there are, according to U.S. estimates over 400 different named therapies which are used to tackle many medical and social problems including marriage and family difficulties, anxiety, depression, addiction, sexual abuse, rape, psycho sexual difficulties, eating disorders, bereavement, adolescent difficulties, Aids, HIV and many more.

In other medical professions there is a requirement for a basic qualification in medicine and professionals continue to specialise. The absence of clear roles and dedicated procedures for those roles fuse confusion in the absence of regulation and also a situation where many calling themselves counsellors in the community and private practice do not warrant professional recognition. One does not need a recognised qualification or skill base to call oneself a psychoanalyst or a counsellor. All that is required are premises, a gold plaque outside the door and the neck to charge the fee.

There are no means to regulate the present unregulated situation and the opportunity for untrained people acting as psychotherapists and counsellors to do damage is frightening.

Vulnerable people in crisis who need professional help can be severely damaged. This situation has been exposed by some practicing alternative medicines where people have been duped out of life savings. There is an urgency by which a regulatory process is introduced in the area of all administration of all areas of therapeutic intervention.

MULTIDISCIPLINARY TEAMS

The Report on the psychiatric services “Planning for the future” published in December 1984 recommended multi disciplinary community oriented psychiatric services. It stated:

“Different approaches to treatment and participation of people from a number of professional disciplines are required to cater adequately for the needs of the mentally ill.

The psychiatric team should have a consultant psychiatrist as its leader and should include the services of psychiatric nurses and have access to services of clinical psychologist, social workers, occupational therapists and a health administrator.” I fully accept this except for the issue of team leadership which should rotate on a 6 monthly basis between the professionals.

It further recommended community orientated service and “by community orientated services we mean a service providing a full range of treatment to persons with psychiatric problems with minimum disruption to their normal way of life. This definition implies that most patients should not be admitted to hospital and that treatment services should be delivered to them in their normal social environment”

One of the key recommendations of “A Vision for Change” published in January 2006 again stated that “well trained, fully staffed community based community mental health teams should be put in place for all mental health services. These teams should provide mental health services across the individual life span.

To provide an effective community based service, community mental health teams should offer multi disciplinary home based and assertive outreach care and a comprehensive range of medical psychological and social therapies relevant to the needs of service users and their families.”

A study published in January 2007 by the Irish Psychiatric Association informed that “only a tiny minority of respondents indicated that they had a fully staffed multi displinary clinical team as set out in “A Vision for Change” and there was considerable variation both within and across services in what constituted for them a generic community mental health team. Clinical staffing deficits were apparent in adult mental health services, community mental health teams which must have a less than optimal impact on the services delivered”.

There has been a serious lack of resources invested in the development of our mental health services. We have consistently received reports and submissions in relation to what is required, yet little attention has been paid to responding to the needs of the service to provide a 21st century world class service. There is urgent need for greater psychotherapy in the mental health area. The Irish College of Psychiatry has reported to the Joint Oireachtas Committee of Health & Children, of which I am a member that 83% of psychiatric consultants do not have access to a psychotherapist, 76% to a family therapist and 33% to an occupational therapist. A senior consultant psychiatrist in the public service informed the Oireachtas Committee that he has 480 patients with a staff compliment of one community nurse, one social worker, 2 junior doctors who are changed every 6 months and one third of a psychologist. Mental illness treatment requires more time per patient than such a regime permits.

This means for example that in a catchment area of 100,000 which has 4 or 5 general adult psychiatrists would have just one psychologist.

The treatment plan for a patient with a mental illness should address both the pharmacological, psychological and social needs of the patient. In 80% of cases in Ireland the psychological and social needs are ignored.

Private psychotherapists and psychologists are available in the community. Why can we not buy 8 or 10 sessions for the individuals concerned under the treatment purchase fund.

I cannot see the reason why varicose veins and now removal of tattoos is more important than the treatment of depression. Both the national treatment purchase fund and waiting lists initiative has never been available to the mental health patients even though there are many areas of psychiatry in which there are long waiting lists. Child and adolescent psychiatry is one such area which there is a waiting periods of up to two years and more.

It is accepted that early intervention to deal with psychiatric and emotional difficulties is the key to cure. Delay in treatment allows the condition to deteriorate and become chronic. Investment in early intervention is not alone cost effective but also reduces the number of consultations required subsequently. It is accepted that mental health is a serious public health issue, that mental health affects one in four of us during our lifetime and causes more disability than lung problems. Therefore it is a disgrace that development of the services are neglected year after year.

There is no confidence among the public in the support for services for people who are suicidal. A recent survey conducted on behalf of the Irish Association of Suicidology asked the question “Can you tell me what support services or organisations you are aware of that are available to people who are suicidal.” The response showed that 50% identified the Samaritans, 22% identified AWARE. Just 7% identified counselling services with 6% hospitals or psychiatric hospitals. In fact 80% of those surveyed identified non government organisations as the support service for those who are suicidal.

Just over one in four people are unable to state any organisation that provides support services to suicidal people. Of concern is the fact that this level rises to almost 40% amongst 15-24 year old males.

This is a serious indictment of the government in relation to its concerns for people who are suicidal and in crisis and are in need of support. Recent tragic events in relation to seeking of assistance by suicidal people demonstrates the lack of service especially at night and at week-ends when the demand for such assistance is at its highest.

Immediate investment should be made in psychotherapy and counselling services in all communities and this should be readily available to people in crisis on an around the clock basis.

PARA SUICIDE

The National Suicide Research Foundation identifies in excess of 11,000 presentations of accident and emergencies at Irish hospitals each year. While this is a deeply disturbing figure and presents an enormous level of suffering for too many families and a tragic level of suffering for the patients involved,the true picture is much more serious and not researched. The reports of the Research Foundation highlights the incidence of attempted suicide and deliberate self harm presenting at Accident & Emergency. We do not have figures for people who attempt suicide and self harm and who present only to their family doctor or other professional.

We do not further have figures for the vast amount of sufferers who do not seek help and who with their families are in deep distress. Too many families are in crisis wondering when will their loved one again make an attempt on their life or when they will suffer enormous trauma of completed suicide. It is conservatively estimated that in excess of 60,000 people attempt suicide or self harm annually.

There is urgent need to invest in research to determine the full extent of the problem and to introduce prevention programmes. The responsibility of this rests with the Minister for Health & Children. Society as a whole must demand that the causes of this enormous public health issue are researched and those in crisis and their families are entitled to professional help. This is not adequately available at present. No amount of camouflage by a department can hide this fact. The work of the National Suicide Research Foundation would be useful in the allocation of resources.

It will identify groups which are particularly vulnerable and will be in a position to assist the Health Service Executive to evaluate the impact of preventative and clinical services being provided.

International studies have found parasuicide to be one of the most significant risk factors associated with suicide. Those who engage in self harm are 20 times more likely to eventually die by suicide. Studies have shown that at least one third of all suicides have a history of parasuicide. The development on delivery of interventions for this patient group should be a priority for the Health Services It is scandalously lacking. The Department of Health & Children cannot and must no longer ignore or be complacent about the growing incidence of self harm and suicide.

Suicide and deliberate self harm is also a symptom and indicator of the mental health of our population. How well do we treat those who deliberately self harm. ?

We must research the fundamental family, social, cultural, economic, educational and other determines of poor mental health and suicidal behaviour in our society. While the level of discussion and openness on mental health issues, including deliberate self harm and suicide has increased in recent years we have a long way to go.

Stigma still prevents frank and open discussion. It allows the authorities to hide behind the inaction in dealing with the problem. I fully agree with Professor Ivan Perry, Director of the National Para suicide Registry when he stated “we need to ensure that public discussion and media coverage remains measured, well informed and sensitive to the needs and wellbeing of psychological vulnerable and distressed individuals in our society”

In particular we need to continue to work with society to create a culture and environment where people in psychological distress feel able to seek help and have that help available through multi disciplinary community based mental health services.

STIGMA

I would like briefly to deal with the stigma surrounding mental and emotional difficulties. Why do so many people keep this type of illness hidden within their souls? Their illness is imprisoned within their psychic system and not be shared with anybody, even closest relatives, friends or loved ones .

Our society has cruelly failed many who are tortured by mental illness. This failure is directly involved in many suicides. Attempted suicide victims are often sworn to secrecy by their families not to reveal those attempts due to shame or embarrassment. Those who suffer mental illness feel stigmatised by attitudes and views from a time when psychiatry was not as developed as it is to-day.

The stigma associated with words such as “lunatic,” “mad”, “deranged”, “crazy”, “daft” ,“balmy” ,“crackbrained”, “nutcase” etc., reinforces prejudices and misunderstanding that many people have about mental illness. The stereotyping of mentally ill patients will allow people to continue to make fun of people who are suffering and will allow to continue the discrimination against this population.

We must raise above this type of abusive language and attitude. Those in leadership positions must make every attempt to educate people who don’t understand the pain of mental illness. Then and only then will people come forward and begin to admit the pain of their illness and seek solid mainstream help. Then and only then will we demand action from Government to acknowledge the scandal of the neglected psychiatric services.

Until there is a watershed of society’s attitude many will hide their illness because no one wants to be referred to as crazy. Until it is OK to be mentally ill as it is to be physically ill will we as a society have, at last, accepted mental illness as part of our human existence. Anyone may suffer a mental illness. Anyone may die by suicide.

PRISONERS

Research published in the mid 2006 highlighted the fact that 60% of female and 35% of male prisoners have suffered from mental illness. Each year, 300 people are committed to prison who have had 6 months prevalence of severe and enduring mental illness.

Most of these prisoners are not a danger to society and they require medical intervention. Of the prison population 40% of women and 25% of men in prison have self harmed or attempted suicide. These people are in urgent need of treatment which they do not receive.

Over 600 prisoners each year end up in padded cells as they are in danger of taking their own lives. We had a miserable description of one such unfortunate individual as reported to the Inspector of Prisons who told us of an inmate who was 28 days in a padded cell screaming his head off and urinating and defecating all over the place. The prisoner was not seen by a doctor. Unfortunately the situation has been well known for many years.

The Government must introduce two distinctive but co coordinating systems, one outside the prisons and community and one inside the prisons. First, we must deal appropriately with psychiatric illness before it becomes criminalised. Secondly, consideration must be given to establishing a mental health court system. This has been effective in some other jurisdictions. This court could have 4 broad objectives. To preserve public safety, to reduce an appropriate incarceration of mentally ill offenders and promote their wellbeing, to relieve the Department of Justice as regards correction of inmates with mental disability and to reduce repeated criminal activity among mentally ill offenders.

Such courts could have the option in relation to low risk mentally ill prisoners of following a carefully monitored individual plan of mental health treatment instead of a custodial sentence.

However, a mere court system will not be sufficient if it is not an inherent part of a well planned and co ordinated monitoring and service provision programme which involves the mental health services. The approach would involve the court services, the Department of Justice, Equality & Law Reform and the Department of Social, Community & Family Affairs, the Probation and Welfare Services and the Health Services Executive all functioning in partnership. The chief aim would be to be make available schemes for those who are judged fit to live in the community.

The programme would address both the need for humane treatment of the mentally ill via suitable community schemes and the largely wasteful and ineffective financial burdens placed by the Department of Justice, Equality & Law Reform.

I thank the Irish Council for Psychotherapy for inviting me to declare its Conference officially open.

Psychotherapist shortage slammed

PUBLICATION:   IRISH HEALTH.comPsychotherapist shortage slammed[Posted: Fri 08/06/2007]

The lack of psychotherapists in our mental health services has been slammed by Dan Neville, Fine Gael TD and Chairman of the Irish Association for Suicidology.Mr Neville pointed out that 83% of psychiatrists did not have a psychotherapist available to them.Speaking at the National Conference of the Irish Council for Psychotherapy in Dublin, he said there was an urgent need to establish multidisciplinary community psychiatric services, as first recommended 22 years ago in a Department of Health report and again last year in the new ‘Vision for Change’ strategy plan.Mr Neville said it was universally accepted that psychology input is vitally important in dealing with mental illness.

Dr Brion Sweeney, Chairman of the Irish Council for Psychotherapy, said that provision of psychotherapy in Ierland is largely limited to the private sector. And there is little or no provision of psychotherapy for public patients, apart from a very small number of key posts, the majority of which are in childrens’ hospitals.

He said it had been shown that most people who attempt or commit suicide never have any contact with mental health services and are most likely to have visited their GP in the month prior to the suicide.Dr Sweeney added that young men, who are the group moist vulnerable to suicide, are unwilling to access the necessary support. 

Little or no provision made for Psychotherapy: Irish Medical News

Published in the Irish Medical News: Magazine 18th June 2007  Julie-Anne Barnes There is little or no provision of psychotherapy for public patients and “we really need psychotherapeutic services provided by the HSE for those who cannot afford such services”, according to Dr Brion Sweeney, Chairman of the Irish Council for Psychotherapy. Speaking at the Healing the Hurt event during the national conference of the Irish Council for Psycho­therapy in Dublin Castle recently, Dr. Sweeney said the provision of psychotherapy is largely limited to the private sector. Dr Sweeney, a consultant psychiatrist, specialising in drug and alcohol abuse, said psychotherapy can be valuable in treating conditions ranging from anxiety disorders to substance misuse, depression, agoraphobia, or more severe mental health problems such as schizophrenia and bipolar depression. In addition, Mr Dan Neville, who is Chairman of the Irish Association of Suicidology, deplored the absence of psychotherapists in the Irish psychiatric service. He said the Irish College of Psychiatrists told an Oireachtas committee that 83 per cent of psychiatrists did not have a psychotherapist available to them.  He said that there was an urgent need to establish multidisciplinary community psychiatric services, as first recommended 22 years ago in the Department of Health report Planning for the Future and again in the Vision for Change document published in 2006. He added that there was a need to develop other therapies such as family therapy and occupational therapy.

The Role of Psychotherapy in Primary Care

Published on the 28^th May 2007 in the IRISH MEDICAL NEWS

THE ROLE OF PSYCHOTHERAPY IN PRIMARY CARE

By Dr. Brion P. Sweeney

There are a number of reasons why primary care is seen as a pivotal role in the delivery of care to modern populations.  In a sense, it reflects the development of medicine beyond the paradigm of diagnosis and treatment to one of risk identification and management.  This is very good news as it has the potential for prevention of illness and for prevention of progression of illness, if managed properly. For example, proper management of blood pressure or indeed diabetes can ameliorate the risk of these conditions down the line.  In the area of mental health too, there are huge opportunities for primary care in identifying and managing risk. Primary Care is well placed to deliver early intervention and thereby prevent more severe and chronic illness later on.

General practitioners are being resourced, both in terms of diagnostic facilities and the building of multi-disciplinary teams in order to enhance the capacity to provide specialist primary care within the context of family and community[1].

EVIDENCE BASE FOR PSYCHOLOGICAL INTERVENTIONS

In a context where there is huge demand on funding and where healthcare provision has become increasingly expensive, it is very necessary to target interventions that are effective. It is reasonable that evidence therefore should drive funding and resourcing.   Under the economic pressures of the 1970s and 1980s there was a withdrawal of resources from psychotherapy provision and psychological intervention because there was an insufficient evidence base to justify such interventions.

Twenty years on, the evidence for psychotherapy and psychological interventions in general has been greatly enhanced.   The flood of evidence for psychotherapeutic interventions continues to grow.

The first modality to show significant evidence has been Cognitive Behavioural Therapy.  This is in part because these interventions being already standardised have lent themselves easily to measurement, and also because practitioners working in this area have been trained from an early stage to understand the need for scientific investigation of the method.  Evidence has accumulated for brief interventions using other theoretical frameworks for example Motivational Interviewing based on Client-Centred Psychotherapy (Humanistic/Rogerian) and perfected by William Miller and collaborators (Miller,W et al[2]).

In a recent review of the literature on psychotherapy  Professor Alan Carr, of UCD (Professor Alan Carr:  “The Effects of Psychotherapy: A Review of Research) on behalf of the Irish Council for Psychotherapy in press), has shown other methods, including Systemic and Family Psychotherapy, Constructivist Psychotherapy and Psychoanalytic Psychotherapy to be effective in a broad range of mental health disorders. There is also evidence emerging that slightly longer interventions, of perhaps six months to one year, can bring benefit to the more complex problems. For example, Psychoanalytic Psychotherapy has been shown to be effective with more disturbed patients who would normally attract a diagnosis of personality/developmental disorder[3].

In a primary care context, perhaps there are certain conditions which are particularly important to highlight where evidence based psychotherapy interventions can be of assistance to general practitioners in their care of patients.  In particular, of course, we must start with the mention of Cognitive Behavioural Therapy for affective and phobic disorders and more recently, increasing evidence of their effectiveness in intervention with substance misuse disorders (Carroll and Onken[4]).

A recent study in the North East of the provision of counselling/psychotherapy services within a primary care context has been very encouraging.  Fiona Ward[5] s review of counselling and psychotherapy provision within the primary care units in the North East has shown that they have been highly successful and that psychological provision and psychotherapy services can be provided in a primary care context in Ireland and contribute significantly to the overall care delivered through the primary care services. Evaluation of the pilot project concluded that the pilot project had been effective in providing an accessible, high quality, accountable counselling/therapy service in line with the primary care strategy.”

 

Often in primary care, the question of prescribing medication arises, in particular, prescribing of benzodiazepines. It is understandable that GPs have become increasingly reluctant to prescribe benzodiazepines because of the abuse potential and because of the fact that many patients can become dependent on these substances.   Yet, with patients who present with phobic disorders or anxiety or panic disorders, often GPs have little alternative but to prescribe.  The provision of psychotherapy services gives a real alternative route of referral.  It is shown in the pilot study in the North East, that GPs will use these referral pathways and that patients would benefit, thereby avoiding prescribing of benzodiazepines and the longer term dependence, which those who suffer from anxiety disorders can so easily develop.

It is also clear from Government strategy review on Suicide[6]  that the vast majority of those who kill themselves never have any contact with mental health services and are most likely to have visited their GP in the month prior to the suicide.  It is a truism, and well understood at this point, that young males are at seven times higher risk of suicide than females. 

It is also clear that these young men are quite unwilling to access the necessary support.  It makes sense, therefore, that outreach to such vulnerable young men, and indeed women, is more likely to be effective if provided in a user friendly primary care context. Primary care is particularly well placed to provide such intervention, as patients are most likely to approach their General Practitioner in the first instance with such difficulties.  Having on tap a well trained psychotherapist whom the GP can confidently refer such complex cases makes sense. These types of interventions are envisaged in “ A Vision for Change” the expert report on Mental Health Services 2006[7].

Primary care is therefore ideally placed for the early intervention and management of risk factors and the treatment, at an early stage, of disorders that can lead to chronic mental health problems longer term. In particular, the provision of early intervention for phobic disorders can prevent these disorders from becoming chronic.  Such examples are obvious.  Patients, who present with an early agoraphobic pattern can, with vigorous treatment at an early stage, pre-empt a long term chronic phobic avoidance pattern which may have arisen in the context of a recent trauma or relationship difficulty.  Such early intervention can nip in the bud the chronic pattern of inadequate coping,

Such interventions may be highly significant in those who may be contemplating suicide. Prof.Apleby in a psychological autopsy of 100 persons who killed themselves in Manchester concluded that acute on top of chronic relationship problems were co-factors in completed suicides[8].

In conclusion with the increasingly important role that primary care is playing in the provision of health care within our society, then primary care needs to be resourced to play this key role.  Such resourcing would ideally include the appointment of a well trained professional psychotherapist as a member of each primary group care team.  The argument for a psychotherapist in this context is that they can work with a range of complex disorders which are increasingly faced by General Practitioners.  This may be everything from anxiety disorders to substance misuse, depression, or indeed, more severe mental health problems such as schizophrenia and bi polar depression.

If we are going to really see primary care as the backbone of healthcare delivery, then we need to resource primary care to deliver comprehensive services at a community level.  This will only happen when we have the range of specialist skills that are required to handle the range of problems that present in general practice.  Many surveys have shown that up to 40% of those who consult with General Practitioners have a strong psychological component to their presentation.  There have been further studies that have shown that where patients are provided with psychotherapy, their attendance at A & E departments is greatly reduced, and also their recurrent presentation in the primary care setting is decreased. At present, the HSE is planning that such psychological therapy will be provided.  Professor Carr’s paper has outlined that longer term therapy may be appropriate for certain groups of patients, while brief manualised interventions may be most useful for certain disorders.

  The Irish Council for Psychotherapy (ICP[9]) is playing its part in terms of ensuring that psychotherapists are properly trained before they are entered on the Register.  ICP is working with the Government to bring in statutory regulation and registration for all psychotherapists.  Effectively, the psychotherapy area has become a self-regulated profession, ensuring a certain quality of standard of training and practice.  This includes a four year part time post graduate level specialist training in psychotherapy; working under Ethical Codes and Guidelines. Psychotherapists are therefore well placed to be key members of primary care teams, and greatly enhance the options available to General Practitioners and their patients.

Refs on request

Dr. Brion Sweeney is Chairman of the Irish Council of Psychotherapy and a consultant psychiatrist specialising in substance abuse.

 

---