Mental health workers and suicide prevention strategists tell Jess McAllen that while the public system has its flaws, the unrelenting attention on a ‘broken’ system is dangerous too.
Six hundred and six pairs of shoes are currently making their way around New Zealand. They represent the number of suicides in the past year. The organisation spearheading the vigils is called Yes We Care, a branch of the Public Service Association. On the website of the campaign, under the call for volunteers, there’s a section for the “super keen”, with a string of leading questions: Do you feel mental health services let your loved one down? Have you been in the media before? And “are you happy to wear a yellow t shirt saying Mental Health Inquiry Now?”
The push for an inquiry into New Zealand’s mental health system comes off the back of The People’s Mental Health Review, which itself was initiated by community campaign group ActionStation, former comedian and current mental health activist Mike King, and Kyle MacDonald, a psychotherapist and co-director of the Robert Street Clinic, a private psychotherapy and counselling service in Auckland.
But many people who work in the mental health sector — in suicide prevention, on the frontline in hospitals or as peer support workers — say too much attention is being spent on this review. There have been multiple reviews which were barely acted upon, and reviews provide an easy way for governments to pay lip service to the problems of the mental health system, without actually doing anything. They say the answers to our high suicide rates have been clear for years, but the government isn’t doing what needs to be done.
They are also being attacked on social media when identifying where they work (The Wireless has seen these messages). When 13 Reasons Why – a Netflix show culminating in the main character’s suicide – was released, suicide prevention worker Alice* waded into the comments on Facebook to impart her opinion.
She wanted to tell people that everything isn’t quite as terrible as it seems (our suicide rate, while far too high, has decreased significantly since its peak in 1998), and that help is out there. Yes, the system needs an overhaul (she’d know, she’s been through it) but there are good people working in it. And maybe watching a series that glamourises teen suicide wasn’t a great idea.
But the social media environment surrounding vocal anti-suicide campaigners is “one where anyone who disagrees for any reason is immediately seized upon by a hungry crowd, regardless of how polite they are or their own lived experience of mental illness.” She says she was accused of being a “shill” and a “government plant”.
When another suicide prevention worker questioned someone on Facebook who was saying that people kill themselves to hurt others, he received a private message that said: “I know more about you than you realise”.
The anti-expert rhetoric currently dominating national conversation, one that seems to favour personality over facts, means valuable voices are being ignored. But these people are experts for a reason and many got into this area because of their own experience with mental health struggles.
‘Under immense pressure’
Nearly two years ago I interviewed Andy (not his real name), a mental health nurse at a psychiatric inpatient unit.
“We remain extremely understaffed,” he says now, “especially in not having enough available psychiatrists. Waiting lists in Community Mental Health are growing and all staff in mental health services in our region are under immense pressure.” But there are also positive developments at his hospital to do with Māori mental health. Unfortunately providing details would identify Andy.
According to the Mental Health and Addiction Workforce Action Plan 2017-2021, demand on mental health services is predicted to increase in the future since our population is both growing and aging.
Forty per cent of doctors and 45% of nurses are aged over 50; mental health and addiction nurses, in particular, are older than the average age of nursing staff.
In 2014, nurses made up 28% of the total mental health and addiction workforce. In 2016, 1893 full time community nurses and 1723 inpatient nurses were registered. That’s set to barely increase over the next decade, all while the population and demand grow.
“Based on these figures,” say the report’s authors, “we can expect the number of mental health nurses per 100,000 population to fall by 2026.”
Helen Garrick, chair of the New Zealand Nurses Organisation’s mental health section, says the current attention on mental health “does nothing to promote mental health as an attractive career option and nothing for the morale of current mental health nurses”.
However, “the other side of this publicity is that it highlights aspects of the mental health system that need to improve … it has some value in possibly encouraging political action.”
Carrick says the justified public interest in suicide prevention needs to be balanced with ensuring care is delivered without breaching the rights of mental health patients.
“I certainly am concerned about how this reporting might lead to a reduction in the nurse graduate interest in mental health as a career choice – new practitioners need to feel confident and respected and this is difficult when faced with negative publicity.”
Andy says the more coverage, the better: “It seems to be the only thing influencing policy change at a governmental level. Mental health services remain severely underfunded and it is at crisis level.”
Pressure is increased by high profile media stories, he says, which are often “scathing of mental health services”.
“There will always be a moral dilemma when measuring risk against coercive practice. Also, media reporting of individual cases can be very unbalanced as clinicians are unable to speak out due to being bound by client confidentiality.”
“Of course, the media is essential to keeping mental health services accountable and this is a good thing. Acute mental health units clearly are less than ideal, and we may look back in 50 years’ time and consider them draconian. Maybe more money is the answer for purpose-built facilities but then you are entering asylum territory.”
Andy believes the answer lies in strengthening community support, with more mental health funding in GP clinics, police stations, emergency departments, schools and respite accommodation.
“Instead the powers-that-be seem to be pulling resources from hospitals and community services, resulting in more pressure on acute services, GPs, the police, whānau and leading to people feeling more helpless and often forced to live on the street.”
‘We need to be talking and supporting each other’
In May, there was an uproar about the government’s draft Suicide Prevention Strategy after Mike King resigned from the panel informing the strategy.
One of the panel members, Shaun McNeil, says the criticism from the wider public was “extremely valid”. He was particularly disappointed when the suicide reduction target, an aspect that the panel all had consensus on, was removed. He expects the target to be reintroduced in the final strategy.
The panel received more than 600 written submissions, he says, and more than 2000 people went to the public hui.
McNeil is someone who has experience of mental distress but also helps those in his shoes. He’s a suicide attempt survivor and is also responsible for ten mental health services in the Capital & Coast area, advises the Health Quality and Safety Commission, and used to be the chair of depression.org.nz (of John Kirwan fame).
“It is dangerous to do what New Zealand did in the ‘90s, to only focus on youth suicide,” he says (our youth suicide rate and number was at its highest in 1995).
“The person who most often completes suicide in New Zealand is a middle-aged male, with a high number being Māori. If we prioritise youth, we should equally prioritise Māori and Pākehā middle-aged men.”
Auckland counsellor Sheree Veysey expands on this further, saying that it’s worth acknowledging our self-harm hospitalisation rates: women have twice the number of hospitalisations than men in New Zealand. Many professionals feel that we focus too much on completed suicides, when the pain that causes someone to attempt should be taken just as seriously.
“There is evidence suggesting the suicide rate is more higher in men because they are more likely to choose methods which we consider violent. Whereas women are more likely to try less violent methods where there’s actually more of an intervention possible. People don’t hurt themselves when they are feeling good about themselves and their lives.
“We need to make sure the suicide conversation doesn’t become a pain competition.”
Veysey, who also manages projects for rethink.org.nz, an educational website about mental distress and stigma, is nervous about how some of the discussion around suicide is shaped.
“People have this really simplistic thing like OK, the current guidelines don’t work because our suicide rate is going up so let’s completely change the way we talk about it.” She thinks it’s important to have frank discussions about suicide in communities but notes the media can sensationalise stories on suicide and over-simplify causes.
“Suicidality is what happens when people are hugely overwhelmed and not well-supported. We need to be talking about supporting each other with our small ups and downs and our griefs and our stress long before it gets to that point.”
McNeil also is concerned about some of the language around mental health inpatient units (of the 3.5% of New Zealanders who access specialist public mental health services, only 10% are admitted into psychiatric wards each year).
While he understands the pain that occurs when a loved one “escapes”, self-harms or completes suicide in an inpatient unit, he says “the reality is we cannot lock people up and throw away the key”.
“If there isn’t sufficient therapy available while a person is held securely…the problem may not have been addressed and as soon as the person is given some freedom, a tragedy may occur. Psychiatrists and mental health nurses are not clinicians who can do all that is required for everybody — some people are going to find the inpatient unit counter to recovery, rather than assisting recovery.”
Should there be another inquiry?
Earlier this month New Zealand’s Mental Health Commissioner, Kevin Allan, appeared before Parliament’s Health Select Committee. The committee is considering the petition of Corinda Taylor (interviewed in last year’s Wireless mental health series) on behalf of the Life Matters Suicide Prevention Trust and 1740 others. It calls for a parliamentary inquiry into mental health services to determine if they meet requirements and if future planning is adequate to meet demand.
Allan, who considers more than 200 complaints a year and monitors the mental health system, told committee members there was an “urgent need for action” rather than another inquiry.
He has proposed an “action plan”, to be developed by people with a lived experience of the mental health system in collaboration with representatives of the Ministry of Health, District Health Boards and Non-Governmental Organisations. He says it should take one year to complete with fast results to follow. He also urges the government to adopt the World Health Organisation target to reduce suicides by 10% or more by 2020.
In a letter backing up his submission he wrote: “There is a high level of agreement about current challenges and what needs to change and improve. The plan should identify and build on the many strengths in the sector.”
Allan says that while improvements need to be made in specialist mental health areas (community and inpatient services), 20 percent of the population will meet the criteria for a mental disorder in any year (this number comes from the New Zealand Mental Health Survey).
“Funded treatment and care options for the approximately 17 percent of people with mental health needs who do not qualify for specialist services are limited. There is no systematic plan in place for addressing these needs.”
The People’s Mental Health Review would have had to hear many heartbreaking stories and their advocacy has probably helped many New Zealanders. Whatever your opinion on it, it’s undeniable that their call for an inquiry has opened up many avenues for discussion. The report was an important platform for voices that aren’t usually heard.
“People’s stories are so important and so are their desires to improve mental health,” says Alice. “But it’s all packaged as a big anti-government ‘we want an inquiry’ thing. People don’t realise how many inquiries we have, how many strategies, how many documents — and how little of that becomes a reality.
“We’ve spent so much time and money on writing documents. We know so much of what is wrong. We need to hear people’s stories because that helps people in the sector understand and to make change, but to have all of it geared at getting an inquiry is such a waste. Anyone who brings this up is shouted down.”
McNeil also doesn’t think there should be another inquiry. “A costly review is unnecessary and would delay the changes that need to happen. I believe that most people who are working in the sector, or connected to it as a consumer of family member, have a good idea of where the faults are and how they could be addressed collaboratively.”
Michael Naera is a project leader in Rotorua for Kia Piki te Ora, the Ministry of Health’s national Māori suicide prevention programme. His work is informed by a lived experience of suicide. In 2000 six people of his hapu Ngāti Pikiao killed themselves. He’s lost two uncles and a niece to suicide. In his early 20s he attempted to take his own life.
Naera is “bitterly disappointed” that Māori continue to be over-represented in the suicide statistics. He also thinks that election campaigns are missing the mark when it comes to suicide.
He’s in two minds about whether or not we need a mental health review. “Māori avoid clinical services at the best of times and the system is flawed in terms of its approach to Tangata Whaiora (those with mental illness) and whānau. A review would hopefully ensure services are accessible, timely and user-friendly.”
He believes the intent of the review is too narrow.
“Suicidal people don’t necessarily have a mental disorder or an addiction issue … I know stress and distress is a contributing factor to suicidal behaviour, which subsequently leads to clinical depression and anxiety if not treated earlier.
Around 37% of people who kill themselves accessed specialist (community, inpatient and NGO) mental health services in the 12 months prior to their deaths.
“I believe government funding would be better spent on kaupapa Māori services as first point of contact prior to accessing intensive treatment. This frees up mental health services to focus on more acute cases.”
Marianne Elliott, national director of ActionStation, responded on behalf of the People’s Mental Health Review. She says that the point of an inquiry would be to get to a place where there is “broad agreement on the change that needs to happen within the sector, and sufficient political and public buy-in to that plan to ensure that change will be both properly funded and politically sustainable”.
“But the bottom line is that this process – whether you call it a review, or a stocktake, or an inquiry – must be independent. The issue of mental health services in New Zealand has been politicised to a degree that is harming people who need help, and only a process which is both independent and seen to be independent can help us move past that.”
WHERE TO GET HELP WITH MENTAL HEALTH
Need to talk? Free call or text 1737 to talk to a trained counsellor, anytime.
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO
Depression Helpline: 0800 111 757
Samaritans: 0800 726 666
Youthline: 0800 376 633 or email firstname.lastname@example.org
Healthline: 0800 611 116
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