Submission to the Government Inquiry into Mental Health and Addictions Services 2018
Our recommendation to the Inquiry team is that there needs to be fundamental shift in approach to the provision of mental health and addiction services in New Zealand. Family and whānau provide the majority of care and support to their loved ones affected by mental illness and addictions. In our experience their expertise and knowledge is often disregarded or worse discounted. Seldom are whānau are accepted as equals and included as part of the team. We strongly suggest that addressing this imbalance will lead to improved outcomes for all those accessing support. Our recommendation is that there is shift in approach to mental health in the following interdependent arenas:
- Culture and attitude
In each of these arenas, we believe that there is an opportunity to develop a range of different services that respect each individual’s recovery journey, acknowledges the integral role of family and whānau, and addresses the power imbalance that often exists. We strongly suggest that the Inquiry team consider approaches that provide an opportunity to invest in family and whānau, whatever their circumstance or need. By investing in family and whānau, ensuring adequate resourcing, equitable access to support, education and services there will be a greater opportunity to build resilience within the whānau, leading to increased independence and autonomy.
1.1 Supporting Families in Mental Illness New Zealand (SFNZ)
Individuals do not function in isolation; they function in a network which includes family and whānau. Any other view is problematic because “both the problem and the solution are seen as existing with the individual, while the familial, social and economic contexts of mental illness and recovery are obscured. This is indeed problematic given that social determinants are consistently identified as among the strongest predictors of mental health outcomes.” https://www.tandfonline.com/pb-assets/tandf/Migrated/RAMH_VideoAbstract_Transcript.pdf
Families, whānau and their networks are critical in the recovery process and that without their genuine inclusion as expert partners in care then the cost both tangible and intangible increase exponentially.
We believe that the Inquiry represents a real opportunity to effect change and address the needs of all those affected by mental illness and addictions. It is essential therefore to acknowledge that people are not ill in isolation and that the impact of mental illness and addiction also affects family and whānau.
Information for this submission was gathered at an initial workshop from Emma Dorē (CE SF Auckland), Tatjana Karaman (Team Leader SF Auckland), Christine Zander-Campbell (Manager Supporting Families Manawatu), Ruth Morgan (Board Member SF Auckland), Debbie White (Family Member SF Waikato), Dan Mustapec (Manager Atareira), Diane Isaac (Clinical Team Leader SF Canterbury) and Fiona Perry (National Coordinator).
Family and whānau also met at a number of Hui around New Zealand to share their vision for the future provision of mental health and addiction services.
2 Key Concepts
In 1988, and again in 1996, Judge Ken Mason headed an inquiry into mental health services in New Zealand. Both reports suggested that a few key changes be made including setting up an independent Mental Health Commission, setting a funding stream (known as Blueprint), and an education programme (Like Minds, Like Mine), aimed at reducing stigma and discrimination for those affected by mental illness. We would like to acknowledge the work undertaken by Judge Mason and his team. The inquiry sought to improve equity and access to services.
Their work has contributed to significant improvements for those who feel the impact of mental illness and addictions in their daily lives. Strong leadership via the Mental Health Commission and the Ministry of Health led to changes and fundamental commitment to improving services. We believe that those working in the mental health and addictions sector continue to seek improvements, exemplified by the ‘Equally Well’ initiative. However, the gains made following earlier reviews have been eroded by underfunding and dilution of the vision espoused in the earlier inquiries.
However, we believe the issues underlying this inquiry are the result of a system that is ill-equipped and under resourced, despite the efforts of often well intentioned under-valued people working in both clinical and community settings. the system is overloaded and underfunded. This is partly due to the numbers of people presenting with social problems, not mental illness per se. Work is needed to help these distressed people effectively in a way which leaves the mental health system able to concentrate on mental illness. The underlying poverty, housing, budgeting, unemployment, loneliness and other social issues causing stress and anxiety need to be addressed with a multipronged approach. When people are distressed, they need someone who has time to listen to them and support them to make the best decisions for their welfare.
We applaud the current Labour led coalition government for their commitment to re-establishing an independent Mental Health Commission and the proactive approach to learning from the past while looking to the future. We believe that the Inquiry represents a real opportunity to effect change and address the needs of all those affected by mental illness and addictions.
Embracing an approach that values different cultural perspectives and considers family and whānau in collaboration as part of the team aligns with the New Zealand Health Strategy.
The individual’s network, family and whānau must be involved throughout any interaction with mental health services as experts who along with the various professional experts contribute their intimate knowledge and expertise to creating the best path forward for the individual and family. The assumption is that each person sees things others don’t see and working together in equal partnership each party is able to take responsibility for their part in the recovery process. If all parties share all relevant information, ask genuine questions to ensure an understanding of others’ perspectives, test assumptions and inferences and focus on interest-based rather than positional problem solving then they will be in a better position to jointly design next steps. This approach is supported by David Rock’s research in neuroscience. https://www.epa.gov/sites/production/files/2015-09/documents/thurs_georgia_9_10_915_covello.pdf
Another option is that a qualified facilitator facilitates the meetings rather than have a medical professional run the meeting, to ensure that all voices are heard, and that all participants can maximize their contribution / collaboration.
Including all participants as experts in an authentically respectful way will result in higher quality decisions, greater innovation, greater commitment, increased trust, reduced defensiveness and reduced stress for everyone especially the individual who can sense that there is a strong supportive team behind them. While it may be that mental health professionals are unaware of the gap between espoused theories and theory- in -use the current attempts at family meetings are more often than not experienced as tokenistic at best. http://infed.org/mobi/chris-argyris-theories-of-action-double-loop-learning-and-organizational-learning/
This unilateral control approach (common in hospital settings) results in feelings of disempowerment which in turn can lead to lower levels of responsibility, inappropriate dependence on the professionals, blame and increased family stress, thus creating an environment not favourable to recovery along with the deteriorating wellbeing (financial, emotional and social) of family members who often struggle to barely cope. http://www.schwarzassociates.com/quality-decisions/how-unilateral-control-can-kill-you/
Our vision is for an integrated seamless approach to mental health services that embraces opportunity to find solutions, encourages recovery and healing for the whole family and whānau. This may encompass a move away from medical models of diagnosis and illness, which are often used to exclude people from the help and support they need. In addition, removing the barrier of having or not having the right diagnosis, and associated stigma, allows people to move in and out of services as their needs change, so that when a person or their family seeks help, where ever that may be, there is a positive and respectful response; the culture and the values of the person or family seeking help are upheld and respected. Once this is achieved we will truly have a system that supports and empowers, with a caring culture that is nimble enough to learn and adapt.
Culture and Attitude:
1. Changing the focus away from ‘service provision’ to ‘being of service’, offers an opportunity to address issues of ‘owner-ship’, trust, power and control over the lives of whāiora and their whānau.
2. Acknowledge the expertise and role played by family and whānau in supporting recovery.
3. Those with lived experience, who have an understanding of the “illness” are in a very good position to help families understand, accept and manage their interactions with the individual.
- Support and encourage family and whānau engagement by recognising their expertise.
- Greater emphasis is given to mana enhancing practice including mauri ora (wellbeing).
- Promote culturally appropriate models of care, with priority given to māori models of care.
- Promote services that support family and whānau as ‘Partners in Care’.
- Adopt a ‘wellness’ paradigm there is the potential to prevent escalation, the need for expensive treatment options and reduce risk of suicide.
1. All participants are treated as allies, with less reliance on diagnosis to access services.
2. Understanding mental illness and addictions in terms of behavioural or mental pattern that can cause significant distress that may include impairment of personal functioning, which may be persistent, relapsing and remitting, or occur as a single episode.
3. Erosion of real funding levels has put undue pressure on the mental health workforce, which has resulted in a loss of trained staff, reduced services and criticism in the media, and more insidiously as having a serious effect on staff resulting in a loss of esteem and disempowerment.
4. Improved understanding on the different needs for those who need support with addiction issues.
- Access to service should be determined by need rather than criteria; and
- referrals accepted from any source including self referrals and referrals from community organisations.
- Focus on treatment – not just assessment of risk and mood then pass them on to someone else.
- Family and whānau are supported via education, counselling and access to services including respite.
- Support for addictions substance abuse particularly for youth.
1. The hierarchical nature of hospital systems impacts on the culture. For instance, there can be lack of communication between different professionals. Often, an NGO staff (i.e. community and family support workers) are not seen as viable to provide any suggestions regarding consumer and/or family recovery. And yet, they are the one “walking alongside’ the person and their family in a community setting.
2. The system design also creates “splitting” of services each operating within a tight scope. There are times where consumers get bounced between physical and mental health services with neither taking responsibility for treatment. There are numerous impacts on the family, whānau and individual including:
- a. Confusion about which service provides what support;
- b. How the services interact;
- c. Having to repeatedly form new relationships with a series of professionals; and
- d. Being subjected to numerous professional experts with differing diagnoses.
3. Access to mental health support is problematic in that an individual must be assessed as severe, and /or not coping in order to receive any treatment. Access to talking therapies, including E-Therapies are available, in some circumstances, there are long waiting lists, and paying privately is not always an option.
4. Availability of appropriate professionals: There are times when no-one is available to assess the individual who is then kept under guard in the ED department, a frightening situation for the individual, family and whānau. More frightening still is being kept in a police cell while bureaucratic decisions are made regarding which DHB is responsible (“post code healthcare”) or while waiting for a mental health professional.
5. Discharge system. Individuals are discharged into the “community” which is ill equipped to facilitate recovery often resulting in stagnation for the individual, “failed discharges” or the revolving door patient or their becoming a “career service user”. In our experience, the impact on family and whānau is given scant regard. Family end up managing any risk, and are not always provided with guidance from the discharging service on how to manage that risk.
6. there is a role for E-therapies, and other electronic assessment systems to provide early intervention, self-management and ongoing care. Any such system needs to be well integrated, understood by both the therapist and participant.
7. Clear systems for reporting, making complaints or complements are not always well understood or in place. The Marama real time feedback tool has provided an avenue for family and whānau to provide feedback, however there is little evidence of responding and acting on any feedback.
8. In our experience family and whānau are not encouraged to provide information. Often this stems from a poor understanding of family and whānau right to share information – provided for under the Privacy Act (1993).
- Address issues of power imbalance through family focused training.
- Address links between physical and mental health services to improve the flow of information between services.
- Promote services Family and whānau as Partners in Care, and require DHB’s to include how they have achieved this in their annual reporting.
- Address the interface between MSD and Housing to improve access and reduce.
- Services are funded appropriately to deliver a range core therapeutic interventions all participants, regardless of setting, in the sector working toward the same outcomes, across all social determinants of health.
- System that embraces a culture and attitude of ‘being of service’, and is capable and able to deliver a service that is timely and responsive.
- Mental health awareness must be addressed in all social service settings including government agencies.
- Accessible, reliable and sustainable internet services and/ or internet ready devices are available to support E-therapy.
- A range of therapeutic options – including E-therapy are made available.
- Counselling is made freely available to all New Zealanders.
- Family Advisors working within the DHB, but located within Community Organisations have been very effective in improving outcomes for family and whānau (Whanganui DHB is an exemplar of how these relationships can work well).
- All clinical and non-clinical staff are trained to understand and appropriately apply the Privacy Act (1993).
- Promote The Code of Family Rights.
3 What is Working.
1. Face to Face support, via our own Family Whānau support workforces, including access to counselling, has helped whānau increase their own confidence levels, build resilience and gain a greater understanding of mental illness and addiction, which in turn can help service users overcome their perceptions of stigma associated with mental illness.
2. Education and information sessions provided via our Carer support meetings cover a wide range of topics including:
- Mental Health First Aid.
- What is Schizophrenia.
- Effective Communication techniques.
- Understanding ‘P’ and ‘P’ advanced.
- Sensory Modulation.
- Self-care techniques.
- When Someone You Care About Has Mental Health or Addiction Issues
- Recovery and Resilience, including Mindfulness; and / or
- Safe Hands / WAVES or SAFEtalk suicide prevention training.
3. We have also developed and expanded a range of programmes for children. In Nelson, we have provided CUMI (Children Understanding Mental Illness), initially using our own resources. CUMI is also provided in Canterbury. In Taranaki, working with Tu Tama Wahine a programme for families raising children who are not their own, ‘Kin Raising Kin’, has been trialed. The programme is aimed specifically for those who are for kin raising kin due to the children’s parents having a mental illness or addiction. In Auckland, funding has allowed the development of a programme aimed at mental health professionals to develop their skills to become more family whānau focused.