Our mental health system has been the focus of much attention of late, as have the mental health services that operate under this system. It’s long past time we had an informed discussion as a nation about mental health, so thank you to Russell for the opportunity to add to the korero.
As always when discussing an integral aspect of human life, there are often a lot of voices saying things for reasons that are not clear, or which are aimed at achieving unknown outcomes. For the sake of clarity I am writing this as a person who uses mental health services, whose work includes the mental health system, and who stays up to date on developments in knowledge and practice. I believe our mental health system is long overdue for examination and change, I know that the framework for this already exists, and I know that our mental health workers of all job titles are already working to do things differently.
The people who work in our mental health services are, in my personal and work experience, thoughtful and caring people who want to effectively support the people who our mental health system exists for – people who experience mental health crises and people who experience mental health conditions.
Our mental health system, which is governed by legislation that Parliament passed and continues to authorise, limits our mental health workers capacity to work to their best. A simple example is that under theMental Health (Compulsory Assessment and Treatment) Act 1992 a person can be coerced by our system if they are seen as a possible harm to themselves. What this practically means is that anyone who has become aware of our system is extremely hesitant to discuss suicidal thoughts with mental health workers. Why would you, if you knew there was a risk you would be locked up against your will when you have done nothing wrong?
Everyone who interacts with mental health services knows that the greatest tool any mental health worker has is the therapeutic relationship that develops between them, the service user – and the service users whanau, if the service user chooses.
How can that therapeutic relationship operate when the system that governs it ensures that important truths are withheld? How can there be trust when both people know this is standard? How can a mental health worker manage this dance without being hauled in front of the Health and Disability Commission and risking their years of training and experience if they don’t toe our system's line? How can a service user in crisis get the support they know they want when they fear the consequences of asking for it? That is not a system that is fit for purpose.
Every now and again, you hear someone associated with the mental health system saying that if we just put more money into our current system everything will be fine. They often raise the spectre of the "violent and dangerous crazy person" as justification, even though there is no research to validate this stereotype.
These sorts of comments often come back to the thorny issue of causation. People who experience a mental health crisis understandably want to know what is going on. In our society there are many explanations offered as if they are truths. Unfortunately for people wanting certainty, the honest answer is that we don’t know. Despite stories of chemical imbalances and genetic markers we actually have no proof of a biological or genetic cause for mental health crises and/or mental health conditions.
The idea of a chemical imbalance still crops up despite people like the former head of the American Psychiatric Association, a painfully old-school outfit, saying:
‘…[T]he “chemical imbalance” image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding. In truth, the “chemical imbalance” notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.” [Psychiatric Times, “Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance” July 11, 2011]
Nonetheless, we are not entirely in the wilderness. If we imagine a bucket with ‘probable causal elements of mental health crises/conditions’ written on its side there are a number of things we can add to it.
I don’t believe that there are many people who would claim there is not likely to be some element of biology involved. Equally, in due course of time it is likely that some genetic component will be identified. Also there will be the impact of the unseen, often described as wairua or spirituality, which needs to go in our bucket. We also need to add environment including natural, built and whanau environments.
The element that we have the greatest amount of evidence for is the impact of trauma. It could be a natural trauma such as an earthquake, or it could be the experiences listed in the Adverse Childhood Events study, or intergenerational trauma as explored through the families of Holocaust survivors, or the many experiences of abuse and neglect covered in the trauma research.
There are likely to be more things added to our bucket as experience and research uncover new knowledge, and as our understanding of the interactions between any causal elements develops.
The best part about knowing what we don’t know is that it provides us with an opportunity for developing useful responses. The media has let us all know that there is increasing demand for mental health services. Given what we know about causation we can’t claim that some broken brain fever is loose in our country.
Rather, we know that the way we are living has increased the number of bad things happening to people which have impacts on their lives, and some of these people are experiencing mental health crises and/or mental health conditions.
The issue is not with mental health services. The issue is that our mental health system needs to look at the social determinants of mental health. That means we need government policies for early interventions that work across government departments. The ministers and departments who need to work together on this include Health, Employment, Social Development, Children, Maori, Pacific, Justice and Housing – at least.
We also need to incorporate the work of our leaders with lived experience, such as Sir John Kirwan and Mike King, who have put in the hard yards in this area for years. The personal risks John and Mike have chosen to take by their presence and honesty have shown a lot of people that mental health crises and mental health conditions are part of life, and it is how the person and how all of us respond to their experience that makes all the difference.
Until as a nation we really look at how we see each other and how we treat each other, and particularly how we see and treat our young people, we will continue to see an expanding flow of people into mental health services.
Making our mental health system fit for purpose will require Parliament to act. Our current system hinges on the Mental Health Act, a piece of legislation that it is 24 years old and does not reflect current knowledge. As a country, we have already agreed to follow the way forward that has been set out. We have ratified the United Nations Convention on the Rights of the Child, we have ratified the United Nations Convention on the Rights of Persons with Disabilities (which includes mental health) and we are signatories to the United Nations Declaration on the Rights of Indigenous Peoples.
Putting our obligations into practice is something our Parliamentarians have been obliged to do, and have yet to do. How our Parliament ratified the Disability Convention and let our mental health legislation stand despite advice of conflicts from the New Zealand Law Society continues to be staggering. You can see the extent of that ongoing breach by googling “CRPD Article 14 Guidelines”. In these guidelines the CRPD Committee has been very clear about part of the work our Parliament needs to catch up on.
For people in my community it is past time that these matters are comprehensively addressed. For our whole country to have a healthy and productive population we cannot have a crisis-based mental health system. That means we all need our Parliament to pass a single piece of capacity legislation that covers all people with permanent and impermanent diminished capacity. We need our Parliament to recognise that no one needs decisions made for them, but sometimes a person may want support in decision-making and be able to receive it. And we need our Parliament to examine the 159 legislative instruments on our books today that contain the phrase “mental health” and to repeal every one of them that is discriminatory.
Most of all, we need our Parliament to work with all people with lived experience to create a mental health system that works for us and proves to everyone in this country that we are all human beings who hold the same intrinsic value as each other.
Andrea Bates is the co-founder of Wellbeing Wellington.