Through the Maze, published in Stuff on 30 July 2017, takes us on a journey from the opening of the first asylums in nineteenth century New Zealand to some innovative practices in the twenty-first century. It doesn’t go into any detail about what needs to happen next but the article does quote a psychologist who says we need a ‘radical revamp’.
I’ve thought long and hard about what a ‘radical revamp’ would look like, initially as a mental health commissioner and more recently in my writing.
In Footnote3 I leave the tree in the forest which is Janet, fly over it in my ‘big picture’ helicopter, and describe what that transformed world and system might look like.
This is the third of three blogs I’m writing in response to Through the Maze, published in Stuff on 30 July 2017. I’m finishing the story with these footnotes.
A system fit for the twenty-first century
Today’s mental health system is at its core a medical system with powers of legal coercion, that started in the nineteenth century asylums. This system is founded on a set of hotly contested beliefs; that ‘mental illness’ is a medical disease that renders people incompetent, and that psychiatry has the role, not just to cure disease, but to contain and control people with ‘mental illness’ on behalf of the community.
After 200 years, psychiatry has yet to prove that mental illness is a disease, in the way that cancer and Parkinson’s disease can be proven. The drugs used by psychiatry create rather than correct abnormalities in the brain and some can be life-shortening. Studies have shown that the outcomes for people with a diagnosis of schizophrenia were the same in the 1880s as they were in the 1980s – 30 years after the introduction of psychiatric drugs, which were expected to eradicate ‘mental illnesses’ by the year 2000. Mental health legislation, which permits compulsory detention and treatment, is as discriminatory as the old sodomy laws, because it creates a lower threshold for loss of freedom to people who are not diagnosed with a mental illness.
A growing number of psychiatrists agree that psychiatry has largely failed – in its explanatory models, its diagnostic system, the safety and efficacy of its interventions, and in the poor health and life outcomes of people labelled with mental illness.
Despite this, the hub of the mental health system is still dominated by psychiatry and other health professionals. They are the guardians of the official discourse on ‘mental illness’ and most of the resources go to their expensive, ineffective and sometimes harmful institutional, medical and coercive interventions. The closure of the large psychiatric hospitals and the introduction of community support services over the last twenty years has not moved psychiatry from the hub of the system – it has simply added a few badly needed spokes to the wheel.
A new system needs to remove psychiatry from the hub and consign it to the position of a spoke – one of many approaches that can be called upon to support people in their recovery. Communities of the people most affected by mental distress and a collation of different sectors need to be at the hub of the system, leading the discourse and controlling the flow of resources to the spokes.
The new community-led hubs need to oversee and reallocate pooled funding for wellbeing and mental distress in their district – using the existing funding from the District Health Board funding and provider arms, social development, education, iwi and hapu, justice and other sectors that have all traditionally operated in silos. There would no longer be a ‘mental health system’ led by psychiatry but a wellbeing system led by affected communities and multiple sectors.
The community-led hubs’ mandate would be to use the pooled resources to fund and develop a coordinated set of services and opportunities for people in their district:
- Develop community wellbeing centres with an open-door policy where everyone can find something of value for them – information, education groups, talking therapies, peer support, drug therapies, suicide support and crisis support – whether they are there to enhance their wellbeing or get support for profound distress.
- Phase out all or most hospital based acute services and replace them with intimate community and home-based crisis services that use people and care to ensure safety rather than keys and coercion.
- Ensure that all the spokes of the service system are resourced so that all people who need them can get access to peer support, talking therapies, drug therapy, crisis support, support in education, support in employment, secure housing, livable income, and cultural support.
- Ensure that the services and supports people use are led by people with lived experience and genuinely accountable to the people who use them.
- Measure the services and supports they fund on people’s experience of using them and on their impact on quality of life, physical health, social networks, employment and housing
Government would support these local hubs by using some centralised resources to:
- Promote the view that madness is not a tragic pathology, but a profoundly disruptive crisis of being, from which value and meaning can be derived – an experience that adds to our humanity rather than diminishes it.
- Run anti-discrimination and social inclusion programmes with the same urgency they put into smoking and road deaths, and promote a world where discriminatory attitudes to madness are not tolerated, whether these attitudes come in the form of primitive fears about axe murderers or clever theories about brain disease.
- Publicly acknowledge the harm psychiatry has done over the last two hundred years to mad people, their families and to professionals and make a commitment to never do this again.
- Repeal mental health legislation and replace it with generic legislation that authorises the conditions for interventions without consent on an equal basis with other citizens.
- Promote the growth of wellbeing as much as the growth of wealth, with long-term strategies for reducing childhood trauma, income inequality and other social ills that increase people’s chances of experiencing disruptive mental distress.
There are thousands of Janets in New Zealand today. How long can we stand by and let their life chances be diminished by social exclusion and a system that dominated by the narrow, myopic lens of psychiatry? Nothing short of a ‘radical revamp’, like the one I have suggested, will restore self-belief, social networks, physical health, quality of life, housing, work and a decent income to all the Janets out there.
New Zealand led the world in mental health transformation up until a decade ago. Now we are in the doldrums after the money was squeezed, leadership was lost and the government took mental health off their priority list in 2009.
We could lead the world again if our politicians faced up to the problem, and if the leaders in all sectors had the courage and imagination to set aside their vested interests, challenge community prejudice, and focus entirely on improving the life chances of people with mental distress.
We have a moral responsibility to fight for the most radical revamp our failed mental health system has seen for over 200 years.