A link to the Workforce Review can be accessed here https://niopa.qub.ac.uk/bitstream/NIOPA/16782/1/doh-mental-he
Summary
This document highlights important concerns regarding how autistic individuals are involved and depicted in the Northern Ireland Mental Health Services Workforce Review 2022-2032.
Concerns have been raised regarding the insufficient information on acute mental health services, the exclusion of individuals with a primary neurological diagnosis like autism and ADHD, and the failure to engage the education and community sectors.
The significance of providing neurodiversity training to mental health professionals is highlighted, along with the necessity of ensuring psychological therapies are inclusive for autistic individuals.
The workforce plan focuses on “direct pathways” to employment, although not everyone follows those paths directly.
Individuals, like Person A, may graduate with a bachelor’s degree in 3-4 years, in line with the accepted direct path. Person B and others opt for an indirect route, starting with a 3-year foundation degree and then adding a 2-year “top-up” degree not currently acknowledged in workforce planning.
The review did not involve major counselling and psychotherapy organisations, such as BACP and NCPS, in the working groups. Because these organisations include many professionals capable of handling mental health needs, the workforce could face shortages.
This document indicates that the SCOPEd framework, which provides a standardized approach to counselling and psychotherapy, could help establish a psychological therapy framework for Northern Ireland.
Claire Thompson
PhD Researcher Ulster University
Belfast School of Art
NCPS Acred. Counsellor
HCPC Reg. Art Psychotherapist
Neurodiversity Ambassador for NCPS
#AFHEA #actuallyautistic#AuDHD
Pronouns: she/herSocial: @thompoclaire
Table of Contents
Gaps in Working Groups
The establishment of working groups for adult mental health and CAMHS, as detailed in P12, paragraph 1, contributed to shaping this review.
Reference is made to the term ‘professional bodies. Certain major counselling and psychotherapy organisations like the British Association of Counsellors and Psychotherapists (BACP) and the National Counselling and Psychotherapy Society (NCPS) are not listed, despite being registered with the Professional Standards Agency (PSA) as noted in Appendix I (8.1).
· The British Association for Counselling and Psychotherapy (BACP) was established in 1977 and is the UK's largest governing body for counsellors and psychotherapists.
· Since its establishment in 1999, the National Counselling & Psychotherapy Society (NCPS) has grown to be the second-largest regulatory body for counsellors and psychotherapists in the UK.
· About CBT therapists, only BABCP and IABCP are recognized, not BACP or NCPS, etc. ‘It is acknowledged that the staff trained in CBT have high competency skill levels that must be maintained and meet the standards of their professional body.’ (P82 paragraph 1).
· There is a focus on “direct pathways” in the workforce plan. Not everyone takes a direct pathway, for example:
Person A completes their undergraduate studies in 3-4 years, earning a level 6 direct pathway acknowledged in the workforce assessment.
Person B finishes a 3-year foundation degree and then a 2-year ‘top-up’ degree, achieving a level 6 non-direct pathway (currently not acknowledged in the workforce plan).
The lack of representation in counselling and psychotherapy organisations seems to have caused a belief in potential workforce shortages. This information is condensed into the three sections that follow.
Total Workforce Profile (CAMHS and Adults combined)
· The current workforce includes 52 counsellors, and there are no plans to increase this number. The lack of plans to increase the workforce might be attributed to counsellors being limited to the Lifeline service.
· The section on ‘gaps in working groups’ highlights the opportunity for BACP or NCPS registered therapists and counsellors to bridge the workforce gaps in CAMHS and adult services.
· Counsellor positions are exclusive to Lifeline (5.1) and CBT in Psychological Therapeutic services, not CAMHS or Adult services. For what reason?
· Child and Adolescent Psychotherapists (CAPT) currently have 2 members, with 43 more members proposed.
· There are currently 16 Cognitive Behavioural Therapists, with 73 more proposed.
· There are currently 2 arts therapists with 100 more proposed (P15).
· There are currently 52 mental health practitioners, with 202 proposed. Only GP federations will incorporate Mental Health Practitioners (MHPs) (P16, paragraph 1).
· Data at the patient level was obtainable for CAMHS but not for AMH inpatients/acute services (P32, 2.5.2.3 Paragraph 1). Acute mental health service data is excluded from this review. The system does not have data on capturing consultants seen, referrals, contacts, and the duration of a patient’s mental health journey (Paragraph 2).
Within CAMHS
· The counsellor’s present percentage is 1%, while their future percentage is 0% according to table 27 on page 67. Why?
· “Other therapies” should be updated to arts therapies, with current levels at 0% and projected future levels at 4% (Arts therapies: current 2%, future 35%, as shown in table 31, P73).
· CBT stands at 0 now and is expected to remain at 0 in the future.
· In paragraph 3 of table 31 on page 73, it’s mentioned that child and adolescent psychotherapy is scarce in the current workforce, with 0% representation and a projected future increase to 3%. P134 notes the absence of CAPT-accredited training in NI, despite established pathways for play and arts therapists specializing in working with CYP in NI.
· ‘Lack of training spots within this group in Northern Ireland’ is noted by child and adolescent psychotherapists and adult psychotherapists in the report on page 81. However, we have play therapists and art therapists who are trained in a psychoanalytic approach.
Although not standalone routes, qualified counsellors and psychotherapists can engage in additional Level 5 training in Northern Ireland to work with this group.
The NCPS has achieved a significant milestone by establishing the first CYP counsellor and psychotherapy accredited register in the UK. The workforce is readily at hand.
Within Adult services
· Psychotherapist: 0 present, 19 future. Arts therapies: 0 present, 65 future.
· Currently, there are 48 counsellors in the lifeline service, but in the future, it will increase to 52 (according to p75 table 32).
· In Section 2.3, Page 23, the workforce plan discusses ‘allied health care professionals (OT, SLT, etc)’ and ‘other therapists such as art/drama/music therapists,’ yet art therapists are part of the allied health care professionals.
· In section 5.5.5, arts therapists are recognized as Allied Health Professionals.
· The workforce plan does not acknowledge BACP and NCPS as avenues to reach psychotherapists, with only lifeline being used to hire counsellors.
· Adult psychotherapy focuses solely on PBS (British Psychological Society) and doesn’t include NCPS or BACP (P135).
Failure to include the community and voluntary sector
· In paragraph 1 of P25 the plan states that the Community & Voluntary sector has been left out.
· Key recommendations for P99, number 3. ‘Assess the capacity available within the community and voluntary sector to inform optimisation of existing structures and ways of working to co-deliver the full range of MH services required.’
· Filling this information gap could help identify broader gaps in the existing mental health system (just like the education sector gaps in section 6 of this document). It is assumed that the provision will be addressed elsewhere, however, this is not always true.
Exclusion of individuals with a primary neurological diagnosis
· The reason for excluding those with a primary diagnosis other than a primary mental health diagnosis is stated as ‘In recognition of other reviews currently underway’ (Introduction, P12, paragraph 3). Individuals diagnosed with autism, ADHD, etc., will face ongoing discrimination and unequal access to mental health support.
· Whilst it is ‘agreed that a specific review for neurodevelopmental disorders such as autism and ADHD is required’, it states, ‘this will be considered.’ (P24 scope of CAMHS paragraph 1). Considering the current lack of services and highlighted gaps in the system, is there a timeframe specified?
Could neurodevelopmental ‘disorders’ be rephrased as neurodevelopmental ‘differences’ to decrease stigma and encourage more positive language?
Failure to include the education sector
· ‘The education sector has not been included,’ (Total workforce profile, CAMHS and Adults combined, P15, Paragraph 2) ‘the purpose of this assessment is to increase capacity within CAMHS.’
· The exclusion of this detail does not justify the lack of mental health support for autistic students in schools, who are typically categorized under the ‘Tier 3’ system that triggers CAMHS referrals.
· According to the National Autistic Society (2010), 71% of autistic youth experience a co-occurring mental health issue, with 40% having two or more. Under the ICSS tiered system, most autistic students are assigned to Tier 3, which focuses on complex or severe mental health challenges. Therefore, autistic pupils are unable to receive equivalent mental health support in school compared to their peers.
· Only 10% of CAMHS service users are autistic, and out of the 65% of CAMHS workers assisting autistic children, just 10% provide specialized support (NAS 2010). There are gaps in the system that are preventing autistic children from accessing necessary mental health support.
Terminology corrections (Intellectual Disability)
· In this paragraph (P24 scope of CAMHS paragraph 1), the term ‘learning disability’ is mentioned, and under Scope of services (P18, point 1), it refers to the integration of mental health needs from reviews related to learning disability, ADHD, and autism. It appears that the report is using ‘learning disability’ and ‘intellectual disability’ as if they are the same, despite their differences.
· An intellectual disability is linked to IQ, while a learning disability involves challenges in specific academic areas like reading, writing, and maths. Dyslexia and dyscalculia are examples of learning disabilities. Under the heading ‘ID CAMHS’ (P53), the switch to the term ‘Intellectual disability’ is made.
· Phrases like ‘moderate to severe’ and ‘Mild learning disability’ are unsettling to read (Adult services scope, Paragraph 1). Again, learning disability is used interchangeably in the report with intellectual disability.
These terms classify individuals into those who have access to mental health support based on IQ. Aside from the potential stigma of having your intelligence evaluated, this effectively isolates individuals. There is a risk of discrimination against those with intellectual disabilities seeking mental health support. The focus should shift towards support needs, specifically individuals with intellectual disabilities requiring high/medium/low levels of support.
· While I acknowledge the necessity of screening for suitability in talking/cognitive therapies like CBT, other options such as play, art, and creative therapies could be provided. Is there a chance to receive a copy of the LD review? (should be ID review).
· ‘Incorporation of mental health demand from LD (should be ID), ADHD and autism reviews’ (P103 recommendation 16). Again, a timeframe on this is needed, given gaps already highlighted.
· In the strategic context outlined in paragraph 1 of P20 2.1, aiming to implement a single MH strategy, how does this integrate with plans for separate services dedicated to autistic adults and young people?
Lack of current service provision (ID)
Paragraph 3 on page 13 of ‘Defining the Future Workforce Profile’ mentions that all current services within CAMHS have been incorporated. However, the planned future expansion of intellectual disability CAMHS is currently only offered in SHSCT. In other trusts, services for this group of patients are integrated into children’s or LD services.
The significance of neurodiversity training and inclusion
In the Educational Report (2023) by The National Autistic Society, it was noted that 87% of teachers reported feeling confident in supporting autistic students. Within the same report, a striking difference is evident as 70% of autistic teenagers expressed that teachers lack a proper understanding of autism. The report showed that just 26% of autistic students said they felt happy at school, but many struggle to access mental health support through the ICSS system.
According to NAS (2023), just 14% of secondary school teachers received over half a day of autism training. Furthermore, neurodiversity training is absent from the diversity module in fields such as counselling, psychotherapy, art therapy, play therapy, and more.
Therapeutic approaches are structured according to the typical neurotype (Kelly and Farahar). NICE guidelines recommend tailoring therapies for autistic individuals individually but do not provide specific adaptation suggestions. Psychological therapies assume there is a single correct way to perceive the world, known as neuronormativity. Autistics have a unique way of thinking and experiencing the world compared to non-autistics.
About 1% of the population is autistic, yet they account for 11% of suicides (www.rcsych.ac.uk). In a study of adults referred to an outpatient psychiatric clinic, at least 18.9% were found to meet the criteria for autism (Nyrenius, 2022). This emphasizes the importance of acknowledgement and training for all mental health professionals, as around 20% of adults referred to acute mental health services may be autistic.
Although future reviews aim to include those with neurological differences like autism or ADHD, the current review will perpetuate the exclusion and discrimination faced by autistic individuals seeking mental health support.
Have autistic advocates been involved in any part of the review process or any other mentioned reviews?
Psychological Therapy Framework NI
‘Re-defining the roles’ (Workforce capability, P17, point 4 & point 7). Has SCOPed been considered? https://www.bpc.org.uk/training/scoped/scoped-framework-latest-version-january-2022/
‘Single modality roles have not been included, as these roles are delivered by specific disciplines.’ (P80, 5.4.4 psychological professions, paragraph 2). ‘Delivery of interventions will be devised by the services based on service needs.’ The reference to re-defining roles makes this statement seem ambiguous.
Under key recommendations (P99 No 4) ‘Job profiles’ are mentioned and the need for a psychological therapies’ framework (P100). Again, has SCOPed been considered?
SCOPed Framework Potential
We are fortunate to have a diverse group of experienced counsellors and psychotherapists. The terms ‘counsellor’ and ‘psychotherapist’ aren’t formally acknowledged as distinct titles and can be interchanged.
The SCOPeds ‘shared standards’ framework was created by six Professional Standards Authority accredited bodies, which represent over 75,000 counsellors and psychotherapists, providing a standardised framework in the UK.
Within this framework, the British Psychoanalytic Council’s training pathways in clinical psychology are acknowledged as recognized disciplines (P80, table 36).
SCOPed’s initiative will group all 75,000 joint members into a framework, facilitating their transfer to an NI psychological therapies framework:
· British Psychoanalytic Council (BPS)
· Association of Christian Counsellors (ACC)
· British Association for Counselling and Psychotherapy (BACP)
· British Psychoanalytic Council (BPC)
· Human Givens Institute (HGI)
· National Counselling and Psychotherapy Society (NCS)
· UK Council for Psychotherapy (UKCP)
Considering only BPS as a pathway in NI, while excluding other reputable organisations, might be viewed as discriminatory since they will all follow the same accreditation routes.
Current workforces could be neurodiversity trained to improve recognition and support. The ICSS workforce has the potential to receive training on adapting their practices to cater to individuals with neurological differences if prevention is prioritized. This may reduce the barriers autistic youth encounter when trying to access ICSS mental health support.
Note
Autistic individuals have been the focus of concerns. Supporting ADHD typically involves a multimodal approach, which may include medication. The current lack of recognition, support, diagnosis pathways, and medication for ADHD needs to be addressed.
An important change is the recent decision by GP practices to eliminate the shared-care option for medication, providing a two-month notice period.
Since most trusts do not offer current HSC ADHD services, this will greatly affect many individuals.
Most people will be left without alternatives because of the costly private ADHD medication routes.
There is a significant amount of research outlining the dangers of stopping ADHD medication. Ceasing Vyvanse, for instance, should be supervised by a healthcare provider.
The initial withdrawal stage includes fatigue, depression, increased appetite, cravings, and prolonged sleeping (24-36 hours after the last dose).
In the Progressive phase, symptoms may intensify and include severe depression, anxiety, restlessness, insomnia, nightmares and intense cravings.
In weeks 2-4, symptoms can include emotional instability, continued fatigue, difficulty sleeping and lower energy levels. Beyond one-month symptoms may include mild cravings, occasional fatigue and emotional fluctuations.
The outcome of this decision might be counterproductive, as it will likely strain current mental health services further when individuals seek alternatives to regulated medication.
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