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Psychotherapy matters. Edward Boyne

Statutory Registration for Counselling /Psychotherapy and related issues.  August 2020.

Counselling and psychotherapy (CP) is a new profession in Ireland. It grew in response to long-standing severe deficits in mental health services. and the need for an effective and accessible alternative to the 'medical model' of treatment.  It is now developed and well respected. It embraces a huge variety of issues including addictions, depression, anxiety states, family problems, rape crisis, bereavement, PTSD, children and adolescents etc. There are now 4 year trainings to Masters level in Psychotherapy as well as 3/4 year courses to BA level in Counselling  in some universities and ITs. It’s currently self-regulated with 2 main professional bodies. There are about 6000 practitioners.

After lengthy public consultation, Statutory Registration for CP was specifically approved by the Dail in 2019 under the Health and Social Care Professionals Act 2005.

A Registration Board for CP was recruited by Coru (the regulator) and established in 2019. All along in this process the Government  position was that they were pushing through with this registration quickly and decisively as an enlightened policy etc.

There are to be two registers under the new Registration Board, one for Counselling and one for Psychotherapy. Registration requirements for counselling is expected to be a level 8 BA degree and for Psychotherapy a level 9 Masters degree. The existing Professional bodies eg ICP, IACP, IAHIP would lose all accreditation powers in respect of both individuals and courses under the new arrangements.

However Coru suddenly announced (verbally in meetings with CP professional bodies July 2019) that progress was to be stopped and Statutory Registration wouldn't happen for a lengthy period.

Apparently,  it's all now much too complex for Coru to manage to deliver the registration quickly, and Coru  therefore apparently need ages to  figure it all out.

Why is this important?

We live in an unequal society and the very means individuals need to achieve equality for themselves are frequently blocked, sometimes deliberately, sometimes incidentally. This is particularly true in the area of higher education, health and mental health. We know that, of the people who present with mental health difficulties in Ireland, over 90% are dealt with in reality at primary care level, mostly by GPs. Many people don't want to be referred to psychiatry because of the stigma and the waiting-lists.. Resources for GPs  in dealing with mental health issues are very limited. They also get little training in mental health. Despite some changes over the years, the vast majority of patients in primary care presenting with mental health issues are treated by medication only, with maybe a few words of encouragement from the GP. The many exceptions to this can obscure the overall reality. 

We all know people who have been through this 'process'.  A short meeting with the over-worked and well-meaning GP, a prescription and nothing else to follow, except renewed prescriptions or increased dosage. Medication is cheap and indeed helpful for a minority. The majority don't benefit from it however  and are left, effectively, untreated.  We know that a high proportion of filled prescriptions for eg anti-depressants are not fully used. and are put away in bathroom cabinets. We know that rates of depression are rising despite the fact that prescribing rates for anti-depressants are also at an all-time high.

Lack of effective treatments or attention can cause difficulties to worsen and lead to painful human outcomes and greater pressure on hospital services. Lack of  effective treatment and of treatment options beyond the narrow medical model for the majority and in particular for working-class people, is a legitimate human rights issue.

Those on higher incomes can afford the full range of options available, including privately accessed psychotherapy. Evidence shows that they vote with their wallets in large numbers. Proportionately middle class people have far less mental illness issues and when they do have a need in this area they get far better treatment and greater treatment options. This is deeply unfair.

Medication often promotes dependency, whereas counselling is about developing autonomy and developing independence on a lot of levels via what  can be a tough process. This applies also to children. There is an alarming trend now to medicate children. Of course CP doesn't always work either but research worldwide  confirms that it is highly effective overall and there very few examples of it doing harm. Medication on the other hand has many side-effects . A good summary of these issues by my colleague Dr Shari McDaid is at:

What now?

Joined-up thinking

There's a  startling lack of  Govt joined-up thinking right now on this issue.  The newly issued mental health policy document, which is a follow-on from ‘Vision for Change’, states at page 61, recommendation 16 that:

'Access to a range of Counselling supports and talk therapies in the community /primary care should be available on the basis of identified need so that all individuals across the lifespan with a mild-moderate mental health difficulty can receive prompt access to accessible care through their GP/Primary Care Centre. Counselling supports and talk therapies must be delivered by appropriately qualified and accredited professionals'.

The last line reading: 'must be delivered by appropriately qualified and accredited professionals' unmistakeably refers to a requirement for statutory registration. These days, given the recent history of the implementation of the 2005 Act by Coru , there can be no other meaning possible. Yet as I mentioned above, we have Coru already blocking this just announced policy with its insistence on taking 'at least 5 years' . There is no clear reason given by them not to deliver what is now an urgent policy requirement. The question may at some point need to be asked: is Coru fit for purpose ?

The case for a 'political push' at this point

I'm of the believe that politicians in general  can underestimate the potency and importance of mental health issues in the community and among their constituents. . A lot of voters are touched by these issues but that message does not reach politicians from constituents in any way comparable to information on the relevance of other issues such as poverty, crime, local amenities.  All politics is local but sometimes certain issues touch people too deeply to be readily articulated.  There is embarrassment and stigma.  There is also a lot of respect for GPs and their medical opinion. You won't find delegations being formed or grassroots campaigns sprouting up so much in relation to mental health.

However, people will respond positively to clear and visionary local and national  leadership on these issues. Ordinary people know from experience that there's something wrong with the  solo prescription medication approach. Leaders who show they can take positive steps to respectfully improve the situation and help open up more options for people and more hope will be much appreciated.

It's very difficult for a political campaign to advocate for increased funding and creative thinking to provide a nationally distributed  range of counselling services beyond the narrow medical model, when the likely main  providers of those services are not yet allowed to be a fully recognised profession.

It's even more difficult for the CP profession itself  to argue for some State assistance to make Counselling and Psychotherapy more evenly accessible to working class people throughout the country when, officially and in terms of recognition, Counsellors and Psychotherapists are tolerated but not recognised. How can the CP profession help make the new mental health policy ‘Sharing the Vision’ work as envisaged in these circumstances?

It’s one thing to claim to have a ‘Vision’ It’s quite another thing to take a close look at it and implement what’s needed to achieve it.

Is there a cost factor?

Not in the medium term. There would be of course be Coru set-up costs but, following set-up, the 6000 practitioners will pay an annual registration fee which should be pegged at a level to offset administration costs. A figure of €300 per practitioner would be normal. About €1.8m per annum. There may even be some net revenue for the State.