There are significant challenges facing service providers of counselling and psychological therapies in the UK generally, due to a persistent lack of investment, funding cuts and the introduction of short-term models of practice. In Northern Ireland, additional challenges are encountered due to the sociopolitical landscape, which sets it somewhat apart from its UK counterparts.
Northern Ireland is emerging from many years of political conflict, and understanding of its impact is slowly emerging and will continue for many years to come. What is known about Northern Ireland, based on the emerging research, is that one in five people have a mental health problem at any one time and that mental health is one of the four most significant causes of ill health and disability in the province, thus making it a major public health issue.1 The political conflict alone has inflicted extremely painful and enduring psychological and physical wounds. In a study2 exploring trauma, health and conflict in Northern Ireland, the 12-month and lifetime prevalence of post-traumatic stress disorder (PTSD) was found to be 4.7 per cent and 8.5 per cent respectively, placing it at the upper end of the range of estimates from other international epidemiological studies. Findings also revealed that those who met the criteria for PTSD were twice as likely to have at least one co-morbid mental health problem; many victims experience ongoing chronic health problems due to physical injuries, which in turn contribute to psychological difficulties such as depression, restrictions in social and occupational functioning and, consequently, low quality of life satisfaction.2
Recent research findings show how traumatic experiences and exposure to violence have impacted upon the children and grandchildren of those who have been physically and/or psychologically injured.3 It showed how a ‘transgenerational cycle’ has developed. Furthermore, Northern Ireland’s suicide rates have increased over the years and, although the factors associated with suicide are complex, there is evidence to suggest that the conflict has been a contributing factor.4 As in any modern society, citizens of Northern Ireland grapple with socioeconomic problems such as poverty, unemployment and redundancy. There is a sense of dysphoria following the peace process, leaving many feeling cynical and disillusioned, with a sense of futility and hopelessness for the future.5 Added to this, citizens also grapple with issues such as bereavement, work-related stress, issues relating to sexuality, childhood sexual abuse, self-harm, child and adolescent mental health difficulties, financial concerns, parenting problems, ageing and its associated health-related challenges, crime and delinquency, to name but a few. For example, findings from the Health and Well-being Survey (2001)6 showed that in Northern Ireland around 21 per cent of individuals aged over 16 considered themselves to be depressed. Self-harm rates among 3,596 school pupils in Northern Ireland were approximately 10 per cent. Self-harm rates across the lifespan have been rising in recent years, with drug overdose being the most common method. In 2014 the highest number of deaths through suicide was for males aged 30–34.7 Furthermore, suicide rates in Northern Ireland are higher than the rest of the UK.7 Binge drinking has been shown to be increasing among young people, one in four people have used cannabis and alcohol problems have been shown to be a factor in at least 50 per cent of suicides and self-harm cases.8
An estimated 23 per cent of women and three per cent of men experience sexual assault as adults, and approximately five per cent of women and 0.4 per cent of men experience rape.9 An estimated 15,000 victims of rape and sexual abuse are receiving support across the province.9 The pain and shame of victims of institutional abuse has emerged in recent times. Undoubtedly, victims and survivors will be experiencing longstanding, complex, emotional difficulties that require sensitive, timely and ongoing support.10
Services in place to help support individuals who experience psychological and emotional difficulties are thin on the ground.11 They experience significant funding challenges, and stigma still prevails. Clients present with layers of difficulties and short-term interventions are limited in addressing such complex needs.12 Indeed, Northern Ireland is recognised as having higher levels of poor mental health than the rest of the United Kingdom, with prevalence rates estimated to be around 25 per cent higher than in England.13 Yet Northern Ireland has been known to receive less funding than its UK counterparts.13 The total cost of treating mental health problems is estimated to be over £3.5 billion per year, which is equivalent to around 12 per cent of Northern Ireland’s national income.2 The bill for treating anxiety alone is around £95 million, no doubt due to the high prescribing rates of psychotropic medications.2
Issues in counselling provision in Northern Ireland
Counselling plays an important and significant role in the prevention and promotion of mental wellbeing in Northern Ireland. There is increasing recognition of the limited role of the medical model14 when it comes to mental healthcare, which points to the importance of building the capacity of the counselling sector in the provision of psychological therapies. In 1998 the Park Report15 highlighted the negative attitudes that prevail among other health professionals in relation to counselling in Northern Ireland. The findings may be indicative of a lack of understanding of counselling and the important role it plays in improving the health and wellbeing of individuals experiencing psychological issues, bringing with it significant social and economic benefits.5 While the Northern Ireland Counselling Forum’s (NICF) Strategic Report16 points to a more recent positive view among health professionals such as GPs, there nonetheless remains a perception among counsellors that counselling is undervalued among health professionals.16 A key challenge, according to the NICF’s findings, relates to the lack of cohesion within the counselling profession itself in Northern Ireland. More information is needed to fully understand these challenges and complexities, as well as the needs of counsellors and service providers in Northern Ireland.
Ulster University review
It was with these various challenges in mind that the authors of this article decided to carry out a review to gain insight into and understanding of the key issues that counselling service providers in Northern Ireland are currently facing. They were particularly interested in understanding the needs of service users and exploring how this information could help to shape the training and teaching of counsellors to promote best practice. They contacted 25 counselling organisations, inviting service managers to attend a purposively held Lunch and Learn event in September 2015. Invites were also sent to staff in the local regional colleges who teach on core counselling training programmes. In total, 15 service providers responded and a representative of each attended, along with three tutors/course directors from regional colleges. Focus groups were carried out to gauge attitudes and opinions on a set of predetermined topics. Due to the informal nature of the event, recordings of responses did not take place, but feedback was written down and later underwent a thematic analysis (see Table 1).
Table 1: Ulster University review - Breakdown of themes and sub-themes based on qualitative feedback
|Overarching theme||Sub-themes||Overarching theme||Sub-themes|
|Client issues||Increasing complexity or comorbidity||Trainee issues||Preparedness for placement|
|Risk||Lack of knowledge and skills|
|Trauma||Supervision - access, availability|
|Childhood sexual abuse||Use of supervision or preparedness|
|Anxiety||Post-qualifying issues facing counsellors||CPD - availability and cost|
|Role of medication||Supervision - availability and standard|
|Changing roles: for example, advisory or mentoring|
|Partnership working||Statutory sector||Peer supervision|
|Poor communication||Lack of paid positions|
|Lack of knowledge and understanding of referral pathways|
|No collaborative working||Service provider challenges||Funding|
|Lack of support from statutory services||Competitiveness between agencies|
|Poor communication between colleges, trainee and agency||Ethical issues|
|Poor communication between trainee, supervisor and agency||Focus on medical model|
|Longer induction period needed||Complexity of client issues|
|Need for standardisation||Increased demands|
|Preparedness of trainees||Lengthier waiting times|
|Lack of support||Lack of cohesion|
|Counselling training needs||Risk training||Increasing request for notes from solicitors|
|Addictions||In-house training: time and funding pressures|
|Depression||Challenges to the image and reputation of the profession||Lack of paid placements|
|Legal issues||Devaluing of profession|
|Ethical issues||Need for leadership and guidance from BACP|
|Note keeping||Need for greater promotion of value of talking therapies|
|Record keeping||Lack of recognition|
|Child protection training||Workforce training needs||Clinical issues|
|Vulnerable adult training||Assessment|
|Confidentiality||Expert witness training|
|Evidence-based practice||Trauma-focused CBT|
It was clear that service providers are struggling with clients presenting with complex mental health problems, yet they have to provide short-term interventions that, they believe, fall short of meeting the needs of service users. Service providers stated that this is mainly due to funding restrictions, as well as to the introduction of the Stepped Care Framework construed as unethical, as the provision of short-term interventions for long-term complex issues falls short of meeting the needs of clients.
A further challenge was related to counselling training and the need for trainees to be equipped to cope with the complex mental health needs of clients. There was a call for more emphasis to be placed during training on understanding mental health presentations such as depression, trauma and childhood sexual abuse. Skills in record keeping and training in child protection and working with vulnerable adults were deemed important. Service providers also agreed that more cohesion is needed between the agency providing the placement, training providers and supervisors, in order to ensure that trainees are fully supported. All raised concern about the lack of funding available for trainees in so far as having to work voluntarily during training. They believed that the profession was oversaturated with unpaid volunteers undergoing training, leading to a lack of employment opportunities for qualified staff. There was an overall recognition of the lack of parity of esteem between counselling training and other types of training in healthcare, which are funded; service providers believe that the lack of funding for counselling training undervalues the critical role that counselling plays in healthcare settings. A need for greater synergy between the statutory sector and community and voluntary sectors was highlighted: respondents raised concerns about the challenges they faced in either referring a client on or receiving a referral from statutory agencies and the lack of information and communication that prevails.
Feedback from service providers further highlighted the issues facing qualified personnel in relation to remuneration. Many believed that qualified staff were not being paid high enough rates. Participants believed that the image of the profession was a cause for concern and there was a call for a greater focus on improving this, which they considered relied on greater support and lobbying on their behalf by their professional body, the British Association for Counselling and Psychotherapy (BACP). The need for a workforce development plan for qualified practitioners was highlighted, alongside the need for this to be funded either in full or part. Respondents stated that emphasis should be placed on developing specialist skills and knowledge, for example by providing training in trauma-focused cognitive behavioural therapy, motivational interviewing, skills in assessment, including risk assessment, and ethical and legal issues. With regards to legal issues, service providers stated that they were experiencing an increase in requests for court reports, which they believed they had neither the time nor expertise to provide, thus highlighting the pressing need for training in this area.
Overall, service providers reported experiencing significant challenges in providing services that meet the complex needs of clients, mainly due to funding shortages. This lack of funding also impacts upon the provision of funded placements for students and qualified counsellors. Service providers agreed that greater efforts are needed by BACP to lobby on their behalf for more funding and to improve the image of the profession and the important and valuable role it plays in the prevention and improvement of mental health in Northern Ireland.
Conclusions and recommendations
Based on these findings, there is a clear and urgent need for leadership, guidance, training and ongoing professional development opportunities within the counselling field in Northern Ireland. Opportunities for networking, collaboration and sharing of good practice are vital, but equally important is the opportunity to collectively voice concerns in relation to funding restrictions that not only impact upon the standards, access and quality of services provided, but also potentially undermine the value of counselling. Investment in training, workforce development and remuneration are areas for attention. The following set of recommendations is put forward by the authors of this article in light of these findings:
- Improved networking and collaboration across Northern Ireland’s counselling profession
- Development of a workforce training plan
- Investment in local opportunities for CPD
- Review of funding processes
- Funding to be made available for placements during training
- Improved working conditions and pay for qualified personnel
- Improved liaison and co-operation between statutory, voluntary and community-based services
- Greater leadership from BACP
- Investment in research in counselling training and practice.
The funding provided by the Higher Education Innovation Fund (HEIF) for the review is gratefully acknowledged. Thanks are due to Dr Fiona McMahon for her guidance and support throughout the process, to the participants who provided candid and informative feedback and to staff from Ulster and Regional Colleges who provided support in the running of the event.
Jane Simms is a chartered psychologist, registered with the Health and Care Professions Council (HCPC). She has extensive clinical experience in the area of adult mental health with a specialism in the area of conflict-related trauma. Jane is Course Director of the BSc (Hons) Professional Development in Counselling course at Ulster University and runs a private practice.
Michael McGibbon is a psychotherapy and counselling lecturer at Ulster University, and a senior accredited clinical psychotherapist with the Irish Council of Psychotherapy and Irish Association of Humanistic and Integrative Psychotherapy. His previous experience includes over 15 years both as a principal social worker in child and adolescent mental health services and as a senior clinical psychotherapist with adults presenting with complex developmental trauma.
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1 Department of Health, Social Services and Public Safety (DHSSPS). Transforming your care: a review of health and social care in Northern Ireland. Belfast, Northern Ireland: DHPSSPS; 2011.
2 Ferry F, Bolton D, Bunting B, Devine B, McCann S, Murphy S. Trauma, health and conflict in Northern Ireland. Londonderry: The Northern Ireland Centre for Trauma and Transformation and the Psychology Research Institute, University of Ulster; 2008.
3 O’Neil S, Armour C, Bolton D, Bunton B, Corry C, Devine B et al. Towards a better future: the trans-generational impact of the troubles on mental health. Report prepared for the Commission for Victims and Survivors. Northern Ireland: Ulster University; 2015.
4 O’Neill S, Ferry F, Murphy S, Corry C, Bolton D, Devine B et al. Patterns of suicidal ideation and behaviour in Northern Ireland and associations with conflict related trauma. [Online.] PLoS ONE 2014; 9(3): e91532.doi:10.1371/journal.pone.0091532 (accessed 30 November 2015).
5 Heenan D, Anderson C. No one left behind: Heenan-Anderson Commission report. Northern Ireland: Heenan-Anderson Independent Commission; 2015.
6 Northern Ireland Statistics and Research Agency. Northern Ireland Health and Well-being Survey. [Online.] Belfast: Northern Ireland Statistics and Research Agency; 2002. http://www.csu.nisra.gov.uk/Mental%20health%20and%20wellbeing%20bulletin%202001.pdf (accessed 30 November 2015).
7 Northern Ireland Statistics and Research Agency. [Online.] http://www.nisra.gov.uk/demography/default.asp31.htm (accessed 30 November 2015).
8 Royal College of Psychiatrists in Northern Ireland. Alcohol. What does it really cost? [Online.] Royal College of Psychiatrists, Northern Ireland. https://www.rcpsych.ac.uk/pdf/NI%20Alcohol%20%20What%20does%20it%20really%20cost%2010%2011.pdf (accessed 30 November 2015).
9 Torney K. 15,000 victims of rape and sexual assault receiving support in NI. [Online.] Belfast: The Detail; 2015. http://www.thedetail.tv/articles/15-000-victims-of-rape-and-sexual-assault-receiving-support-in-ni (accessed 30 November 2015).
10 Sanderson C. Counselling adult survivors of child sexual abuse. London: Jessica Kingsley; 2006.
11 Simms J. The provision of psychological therapy in Northern Ireland. Healthcare Counselling and Psychotherapy Journal 2013; 13(1): 14–19.
12 Wilson G, Montgomery L, Houston S, Davidson G, Harper C, Faulkner L. An evaluation of mental health service provision in Northern Ireland. Report prepared for Action Mental Health. Belfast: Queen’s University Belfast; 2015.
13 Fitch C, Daw R, Balmer N, Gray K, Skipper M. Fair deal for mental health. [Online.] London: Royal College of Psychiatrists; 2008. http://www.rcpsych.ac.uk/pdf/Fair%20Deal%20manifesto%20(full%20-%201st%20July2009).pdf. (accessed 30 November 2015).
14 Mental Health Foundation. Starting today: the future of mental health services. London: MHF; 2013.
15 Park J. Living with the trauma of the ‘Troubles’. Northern Ireland: DHSS:Social Services Inspectorate; 1998.
16 Swain, S. Northern Ireland Counselling Forum strategic report summer, 2012. Belfast: Northern Ireland Counselling Forum; 2012.
17 Department of Health, Social Services and Public Safety (DHSSPS). A strategy for the development of psychological therapy services in Northern Ireland. Belfast: DHSSPS; 2010.