Minding Ireland: How we can find our own pathway to mental healthcare
Several studies have shown that the pandemic has affected our mental health in Ireland, but it has also further opened up a national conversation in an area that was once silenced by shame and stigma.
People reach out for mental health support for a spectrum of reasons, from emotional distress in the form of low mood, to clinical diagnosis of psychosis or schizophrenia. Across that spectrum, there is everything from eating disorders to addiction and from self-esteem issues to bipolar.
Also see today's related article, Minding Ireland: 'Straight away I felt comfortable and, most importantly, listened to'.
When trying to access mental health care in Ireland, the questions can range from “what’s actually available?” and “what’s the cost?” to “how long do I have to wait?” and “where do I even start?”
Just under half (46%) of Irish people have some kind of health insurance cover, opening up a much wider range of treatment options than what’s available to those on the public system.
In the public system, both child and adolescent and adult services are free, as they’re funded by the HSE. However, waiting times are long and the service is under pressure.
For people without private health insurance who want to access private care, therapy sessions can range from €50 to €80 an hour, and residential stays can cost thousands of euro, but some centres and hospitals are able to financially subsidise treatment.
In the public system, the range of mental health services delivered by the HSE covers both specialist and non-specialist mental health supports, meaning everything from counselling sessions to inpatient or residential treatment is offered.
The starting point is often the GP who can refer people to a range of services, depending on their age and situation. An emergency department is another starting point for those in a crisis situation.
Young people aged between 12 and 25 can be referred to the HSE-funded charity Jigsaw, which provides free mental health support.
Young people can also be referred to CAMHS (child and adolescent mental health services) — this is a specialist clinical service for people under 18 with moderate to severe mental health difficulties.
“It is not for everyone; only a small percentage, approximately 2% of the population, would require access to this service,” said a spokeswoman from the HSE. She added that “urgent referrals” or “high risk presentations” are usually seen within 24 to 48 hours.
And “75.4% of referrals accepted by child and adolescent community teams nationally were offered an appointment within 12 weeks,” the HSE spokeswoman said.
However, 170 children have been waiting over a year for mental health services nationally, as reported in this newspaper last November. Clare, Limerick, and north Tipperary have the most children waiting more than a year, with 78 waiting over 12 months for CAMHS. And another HSE report last month shows Cork and Kerry have one of the longest waiting lists, with 60 children on it.
There are 72 CAMHS teams nationwide and four inpatient units — two in Dublin, one in Cork, and one in Galway. CAMHS treats conditions, including moderate to severe depression, anxiety, eating disorders, and self-harm.
For adults in the public system, there are different levels of support, depending on the mental health difficulty.
For adults experiencing mild to moderate mental health difficulties, the HSE provides community-based psychology through the National Counselling Service. The average wait time here for services is also 12 weeks. Specialist or clinical care, such as for psychosis or suicide ideation is also available for adults in the public system.
Pieta, the well-known mental health charity, provides free care for people of all ages. No referral is necessary.
Pieta’s care is based around their “suicide intervention model” which uses elements of cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT), a spokeswoman told the . However, it has previously been reported that Pieta does not treat people with moderate to severe mental illness.
All of the main health insurance providers in Ireland, VHI, Laya, Irish Life Health, and HSF Health Plans provide some support for accessing private or independent mental health services, and between them they cover 46% of the population.
While the support varies according to what plan people are on, it ranges from covering 100 nights as an inpatient to contributing to the cost of psychotherapy sessions.
In the private and independent sector, people either self fund or have some coverage from their health insurance provider. Services offered privately include everything from community-based psychologist appointments to inpatient treatment for conditions ranging from eating disorders and addiction to schizophrenia and bipolar.
Professor Paul Fearon is the medical director of the country’s largest independent mental healthcare provider, St Patrick’s mental health services and hospital.
It has the largest number of inpatient beds (314) in Ireland, 16 of which are assigned for adolescents and 11 of which are eating disorder beds.
They also have outpatient clinics in Cork, Galway, and Dublin as well as offering 14 different day programmes that run for a number of weeks.
About 90% of the hospital’s patients are covered by private health insurance. The remaining 10% either pay cash or have a referral from the HSE. Prof Fearon says:
“The main ones that are referred to us are psychoses, bipolar, so alternating highs and lows, depression — from mild to moderate to severe, eating disorders, addictions, issues specific to old age such as emerging dementia, obsessive compulsive disorder, generalised anxiety disorder and emotional distress in younger people — we accept referrals with all of those,” says the consultant psychiatrist.
The hospital also provides treatment for schizophrenia, but for all care the intake is the same.
“We first do an assessment to clarify the issues and then come up with an individualised care plan,” he says.
Unlike the HSE, which works on catchment areas, St Patrick’s takes referrals from anywhere in the country, and treatment is multidisciplinary, meaning that care can include a psychologist, a psychiatrist, an occupational therapist, and a nurse.
While there might be some short waiting lists for their day programmes, there is always a bed available, emphasises Prof Fearon.
Outside of the hospital setting, treatment options for private patients include private counsellors. Dr Patricia Barber is a counselling psychologist based in Galway, but who also works online.
She offers one-to-one appointments for people as young as seven years of age, as well as running online courses in anxiety and low self-esteem, and treats many of the same presentations as St Patrick’s does.
“I work with a wide range of presentations, from mild and moderate anxiety or phobias and depression, self esteem issues, relationship difficulties, emotional regulation to the more complex presentations such as post traumatic stress disorder, childhood sexual abuse and personality disorders,” says Dr Barber.
“I’m trained in person-centred therapy and cognitive behavioural therapy but my practice is also informed by further training in acceptance commitment therapy (ACT), compassion focused therapy (CFT) and schema therapy,” she adds.
She also provides psychoeducation to help a person understand why they are feeling the way they are, as well as tools in emotional regulation. “For children and young people it is often about improving their ability to recognise and name their emotions,” she says.
The Psychological Society of Ireland hosts an online directory of psychologists where you can search under language spoken, area of practice and geographic location.
Psychotherapist and university lecturer Ejiro Ogbevoen founded Black Therapists Ireland, following the murder of George Floyd by police officer Derek Chauvin in Minnesota in May 2020.
“In the wake of the unrest after the death of George Floyd, many people of colour in Ireland searched for mental health support, particularly from therapists whom they believed would understand their experiences and the unique struggle of the black person,” explains Ms Ogbevoen.
She was inspired to create a directory specifically of black therapists after a young woman contacted her and described how difficult it was to locate one.
People from other ethnic minority communities in Ireland have also reached out to her “because they feel we are more likely to understand their culture and experiences,” explains Ms Ogbevoen.
The directory is currently made up of 15 practitioners with various areas of expertise, including in relationships, grief, trauma, addiction, male domestic violence, anxiety, depression, stress and much more.
Issues that people present with are low mood, anxiety and trauma as well as the experience of being raised by migrant parents in an environment with cultural differences. Other issues include managing discrimination in the client’s environment be it work or school.
However, there are two barriers that prohibit black people accessing mental health in Ireland — one is representation. When people cannot see professionals who look like them, they are less likely to reach out for help, says Ms Ogbevoen.
The other barrier is stigma. “Counselling and psychotherapy in the form that we understand it can be viewed as a western structure and many cannot relate to the idea of speaking to a “stranger” about personal and intimate matters. Mental health also comes with the massive stigma around weakness, irreversible illness, and fear,” she adds.
She says the cocooning and restrictions impacted her mental health, to the point where she did not feel like getting dressed or eating on certain days. “I was locked up for months and months and I had my family come to the window.
“I had days when I didn’t get dressed and I didn’t eat, it was a huge challenge. Speaking to other members [ARI], there is a fallout. I know people who still won’t go out, we’ve lost that repartee we all had,” says Kay.
As the mother of five children, another impact was not seeing one of her sons for close to three years, she says:
In her case, her sons knew when she was finding it hard and they had an open conversation about it.
“I’d have a vent, that’s half the cure, to be able to talk to someone because it gets worse if you bottle it up,” says Kay.
As well as talking to her family about how she was feeling, making a conscious “effort” to have a routine also helped.
“There was one day I didn’t even put on the TV, after that then I said: ‘This can’t go on’. I made a choice to be disciplined and I did make the effort,” says Kay.
If the pandemic affected her generation’s mental health disproportionately, have her peers managed to talk about it?
“But there are a lot of people who won’t put up their hand and say: ‘Please help me’. They’re nervous of people calling to their house and some don’t even have mobile phones, which is shocking, and that all plays into it,” says Kay.
On the other end of the age spectrum is sixth-year student Denis Lynch, 17, from Co Meath. He says his peers will talk about mental health, but are more likely to do so one-to-one.
“When we aren’t all together in a group my friends are a lot more likely to actually talk about their feelings and mental health,” says Denis.
Another facet of the mental health conversation with younger people, that Denis notices, is that it centres around an external issue.
“My peers and I talk about mental health on occasion, but it’s usually around exam times and more often about the general effect of said exams rather than ourselves personally,” says the student.
Tools that he draws on if he’s having a bad day are mindfulness and just general relaxation. He has also once availed of supports in his school, as have a few of his peers on occasion:
For young people he recommends Jigsaw — a charity that provides free mental health support to young people aged 12-25.
Fabiana Mizzoni, 30, turned to therapy when she was 23 years old. She was studying for a masters in Scotland when a culmination of things saw her reach out for help.
“I’d come home from a night out, and stumbled into my bedroom. I was feeling really low in myself, I felt removed from my life and very lonely.
“I said: ‘This isn’t OK, I need to get this under control’. I just felt so low, and quite unstable, my masters was challenging and I felt under a lot of pressure to do well. Basically, I was feeling untethered,” says Fabiana.
Before that turning point, she had also experienced body image issues and disordered eating, especially in her late teens.
“I would take photos of myself and put them into this depressing weight loss notebook that I used to scrutinise and track my weight. I tracked my calories and exercise, I would make myself sick, and generally glorified skeletal celebrities. It was toxic,” she says, but also extremely “normalised behaviour” socially.
She then started university, undertaking a degree in psychology, and here she found a group of like-minded peers and enjoyed three years of learning and friendship.
“I was pretty happy in college. I was studying psychology so naturally that reduced the stigma for me, I was surrounded by people who believed in minding your mental health,” says Fabiana.
It was the departure from this group of friends and study setting, and moving to Scotland, that left her feeling both lonely and stressed. There was also the financial stress of studying abroad and paying for housing and living costs that played into her mental health challenges.
Fabiana decided to move home to Dublin to write up her thesis, and it was at this point she moved in with her girlfriend, and now wife, and also started looking for a therapist.
“It was shortly after I moved home that I reached out to my therapist, Anna. I’ve had three extended periods of therapy, so probably close to two years of regular therapy in total, and I’ve gone to her each time, I just loved her right away, it felt very natural,” says Fabiana.
And what did her therapy entail?
“It was firstly a space to have unbiased advice and an unbiased ear. It was great to have a space where I wasn’t feeling judged and initially the biggest take away was challenging my thoughts, asking: ‘Where’s the evidence?’
"I learned to listen for negative self-talk, and to challenge it when it was persistent. Then gradually we broke down some beliefs I had about myself, especially expectations I had for myself around being successful — that is something that’s come up again and again,” says Fabiana.
The talk therapy went hand-in-hand with yoga too, and she went on to train as a yoga teacher in 2015. But it wasn’t an idyllic yogic experience at first.
The combined therapy and effect of yoga, where she was forced to sit with herself, allowed her to properly identify how she was feeling.
“It taught me honesty with myself, how am I actually feeling? Nothing can truly change until you understand how you feel. And there are many feelings that we believe are ugly — anger for women, and sadness for men,” states Fabiana.
Fabiana met Anna, after her agency was recommended to her by her sister. She says finding the right therapist is crucial and that people should feel empowered to look around for the right fit. There was a sliding scale of payment too, as costs, as well as finding the right therapist, are what she identifies as the biggest barriers to help.
Fabiana would return to Anna twice in the following years, once when some unresolved grief arose about her parents’ divorce in her pre-teens and then when the pandemic hit.
“My profession had just been wiped out. I had been self-employed and I wondered: ‘Will this ever be sustainable again? The regret of: ‘What have I done with my career?' as mates were buying houses.
“But everyone was having a permanently bad time, and it was a place to voice how distraught I was and to receive validation from someone saying: ‘That’s a totally normal reaction’. “We went sale agreed on a small house a month before the first lockdown, our mortgage payment would have been totally manageable (it fell through), now our rent is three times that,” says Fabiana.
Fabiana doesn’t believe there is any shame in speaking publicly about mental health issues and she is also keenly aware that many people will have experienced some of what she has gine through, only have neither accessed nor had access to help.
“I feel I owe it to people to talk about it for those who are frightened or maybe can’t. It’s not painful for me. There is no shame. People will always have their opinions of you, but if anyone reading this decides to talk to someone, well then it’s been worthwhile.
“There is always going to be someone there so reach out, there’s a therapist for everyone,” says Fabiana. “I deserve a happy, beautiful life. Everyone does,” she adds.
• If you are affected by any of the issues raised in this article, please click here for a list of support services.