03/17/2014

QQI proposes Awards Standards for Counselling and Psychotherapy in Ireland

The QQI (Quality & Qualifications Ireland) has subsided a working draft for Award Standards for Counselling and Psychotherapy in Ireland. The document is published for consultation purposes to give interested parties the opportunity to comment directly to QQi. The QQI is a government appointed body who are responsible for the external quality assurance of further and higher Education & Training in Ireland. They validate programmes and make awards to certain providers in these areas. QQI is also responsible for the maintenance, development, and review of the National Framework of Qualifications (NFQ). The awards standards are designed to help programme designers and developers ensure that intended programmelearning outcomes are appropriate to the programme’s terminal qualification and they are for use by validation or accreditation panels when recommending whether a new programme should be approved for a specific qualification. The document will become an important step forward in quality management.

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Awards Standards - Counselling and Psychotherapy (Working Draft)

Ireland

Country

• Republic of Ireland. Population. 4.5 million. Health care expenditure was 8% of GDP,  2008 ( 6% public, 2% private) with 8% of public health expenditure on mental health in 2005 ( it had been 13% in 1984) i.e. mental health care accounted for less than 1% of GDP.

Psychotherapy in the health care system

• Psychotherapy defined
  Although psychotherapists are not generally employed within the adult psychiatric services, the public service does make mention of psychotherapy in numerous policy documents. Psychotherapists are employed to work in the Adult Counseling Services, provided to treat people who have been abused within state institutions. Psychotherapy is defined as ‘forms of intervention which through the use of the therapeutic relationship and the application of psychological techniques, aim to reduce distress and symptoms and enhance coping skills and self-knowledge, thereby improving quality of life’. (HSE, 2005 Working Group). It is envisaged that psychotherapists will be employed in the future as part of the primary care intervention strategy.
• Types of psychotherapeutic treatments available: types of treatment are not prescriptive within the health services, but generally C.B.T. based approaches would be the treatment of choice, delivered mainly by clinical psychologists and psychiatric nurses.
  More than half the population has some level of private health insurance. Private insurance covers full psychiatric treatment and a percentage of the work of clinical psychologists for seven treatment sessions. Private insurance does not specify cover for psychotherapists.
  % population availing of public service health care: 75% approx.
• Indication: not prescriptive, evidence based model of service delivery, using NICE criteria ( see appendix a. ).
• Preconditions (e.g. prior authorisation, prior treatments): Those presenting at Primary care to their G.P. will be treated based on guidelines issued by HSE ( see appendix b. ). Once in the specialist mental health service it is a mental health team decision as to how a patient will be treated.
• Quality management requirements (guidelines, outcome evaluation): based on the Quality Framework for Mental Health Services in Ireland (see ref. 4). This framework does include outcome evaluation using evidence based protocols and performance indicators.
• Patients’ access (e.g. direct access, access via a general practitioner or specialists): for specialist community mental health services, access is primarily through G.P.’s. Specialist community mental health teams are organized on a geographical basis covering between 25,000 – 50,000 of the general population. Also self-referrals can be made to the adult counseling services for victims of institutional abuse and to private practitioners. Inpatient treatment is provided to the individual through their local approved mental health centre and the care and treatment while in the centre is provided by the local specialist community mental health team. The range of interventions offered are determined somewhat by the availability of therapeutic resources. 

Psychotherapeutic Professionals

• There is a statutory register of psychiatrists and nurses in Ireland. The law has been enacted to regulate psychologists but this has yet to be operationalised. There is no statutory registration for psychotherapists. There are no restrictions on those who can be trained to be psychotherapists or on those who can practice psychotherapy. There are approximately 3,000 psychotherapists accredited by the various professional bodies in Ireland and the majority of these are working in private practice as sole traders.
• Professions, qualifications prior to specialization and post-graduate training in psychotherapy, accepted psychotherapeutic schools/approaches: Within the public health services there is not a focus on specific acceptable schools of psychotherapy, but more on evidence based practice. Any of the following professions may be involved in delivering psychotherapy with the health service, under the supervision of an appropriate professional and following the professional guidelines laid down by the HSE in this regard : psychiatry, clinical psychology, counseling psychology, psychiatric nurses, addiction counselors, some psychotherapists ( non-psychology / psychiatry), occupational therapists and social workers.
• Consultant psychiatrist posts with psychotherapy as a specialism are now being introduced into the public health service for the first time to meet criteria set out by the Royal College of Psychiatry. The majority of psychiatrists within the public service would not engage in psychotherapy work with their patients. Similarly in their private practice. The biggest delivery of psychotherapy is in the private sector by psychotherapists who are neither psychiatrists nor psychologists.
• Clinical psychologists working in the public health services would be expected to be competent psychotherapy practitioners and to deliver psychotherapy as an integral part of their work.
• Typically the Principal Psychologist for any region would have governance over the delivery of all psychological therapies being delivered in that region.
• Requirements for providing services within the health care system: any one of the above professions may be involved in delivering psychotherapeutic services. In specialist mental health services it is common to have psychiatric nurses delivering CBT programs for depressed patients for example. Those delivering psychotherapy are expected to have completed a satisfactory post-graduate training in psychotherapy and practice in line with their own professional guidelines.

Psychotherapy for Depression

• % population experiencing depressive illness: approx. 10% of population based on Dept. of Health and Children figs, 2001. Indications over recent years is that this figure has increased. Anecdotal evidence reports anything between 300,000 and 400,000 people experiencing depression in Ireland today.
• In 2006, the total no. of admissions for depressive disorders was 5,918 or 29% of all admissions to psychiatric services. 35% or 3,503, of female admissions and 23.5% or 2,415, male admissions to psychiatric hospital were due to depressive disorders.
• There is no uniform or prescribed approach to the treatment of depression within the public health system. However clear guidelines have been issued by the HSE for the management of Depression in Primary care. Currently the HSE is developing treatment protocols for the various disorders, expected to be largely based on NICE guidelines.
• Best practice models: NICE guidelines and evidence based treatments.

Desirable Changes to Health Policy

• If you were responsible for health policy in your country, what would your first decision be regarding psychotherapeutic care?
• Anti-depressant medication not to be prescribed before psychological intervention assessment has been undertaken. Have a more direct access route within a psychologically driven model of care, with medical back-up as necessary. Primary care psychology- psychotherapy hubs to be established throughout the country, servicing primary care medical clinics and the general public, similar to what is provide by the Adult Counseling Services.

Additional Information

• In Ireland, if you are feeling depressed you are likely to present initially to your G.P. This service will be free to medical card holders. S/he may prescribe medication for you and oversee your treatment him/herself. Alternatively s/he may feel you need on-going psychological treatment and will refer you either to the public psychiatric services, if symptoms are of a severe nature, which is freely available to everyone. Some of these services can also be accessed on a private basis. For less severe cases and if you can afford it he will send you to a private psychotherapist if you wish. Often the GP will have already prescribed anti-depressant medication for the patient prior to them presenting to the psychiatric services or to a private psychotherapist / psychologist. Once you present to the psychiatric outpatients service you will be assessed by the psychiatric team as appropriate and a decision will then be made on how best to approach your treatment. This may include medication only, psychological treatment only or a combination of both of the above. The patient in this instance is a patient of the consultant psychiatrist who has ‘clinical primacy under the current employment contract. However the professional providing the specific psychotherapy intervention has a high degree of clinical autonomy and responsibility irrespective of discipline.
• The more severe cases of depression are more likely to be referred to the specialist mental health services, where they have a greater chance of availing of psychological intervention. The milder depressed patients will likely be put on medication by the G.P. or referred to private psychotherapists / counselors.
• There is no uniform policy and procedure for the treatment of depression and service delivery models can vary significantly between regions with some services having a more biological model of care and others using a recovery model which includes a more psychosocial intervention. Both psychological and medical interventions will be considered in all services but with varying emphasis. Available resources have a significant influence on the model of intervention and service delivery to be used. Where there are more psychologists available there will be more psychological interventions.

References:
http://www.hse.ie/eng/services/Publications/services/Mentalhealth/Mental_Health_-_A_Vision_for_Change.pdf
http://www.nice.org.uk/nicemedia/pdf/CG90NICEguideline.pdf
http://www.icgp.ie/assets/77/77D7A752-C0BD-63AC-448B59552E2A469E_document/GuidelinesontheManagementofDepression.pdf
http://www.mhcirl.ie/Standards_Quality_Assurance/Quality_Framework/
The Role, Value and Effectiveness of Psychological Therapies: Benefits for the Irish Health Service. Report of the Working Group on the Role of Psychotherapy within the Health Service, 2005.

Author
Dr. Declan Aherne, Clinical Psychologist, University of Limerick

The text above is an excerpt from the paper "Psychotherapy in Europe – Disease Management Strategies for Depression. National Concepts of Psychotherapeutic Care".

You can download the paper here.