A mental health and addiction system with a central vision of mental health and wellbeing, which recognises the aspirations of Māori and Pacific peoples, will offer services that look and feel different. Responding early and preventing further distress for people at all points will be an underlying principle across all services. Psychiatrists and appropriate medications will continue to be important – but they are only part of the picture.
We believe that many dimensions of the aspirations of Māori and Pacific peoples, especially the call for a holistic approach,97 point the way for all New Zealanders.
Our services of the future will be centred on the people seeking help and will ensure they:
A system with people at its centre will be flexible and connected, caring, underpinned by trauma-informed responses and focused on long-term outcomes for each individual and their whānau. It will protect and promote human rights, and will respond to people at risk with compassion and intensive support. Figure 1 from the Wellbeing Manisfesto 98 illustrates the range of responses and workforces in a transformed mental health and addiction system.
3.6.2 Responsive to age, background and perspectives
Services will meet the needs of people at various stages of their life. However, given the importance of intervening as early as possible, priority will be given to developing more and effective services for babies, children and young people. Access to mother and baby services will be widely available so that there is the maximum opportunity to support mothers with mental health and addiction challenges early to minimise the harm to their child. Support will be wrapped around mothers and their children and provided in a way that maximises their ongoing engagement.
Services for young people will be available in friendly settings including schools where young people can access them easily. There will be good coordination between early childhood centres, schools, universities and other tertiary providers, child health and mental health services to maximise the support available to children and their families. Early childhood centres and schools will promote resilience in young people through specific education programmes and by creating centre- and school-wide mentally healthy environments.
Families and whānau will have good information and support options to help them support their young family member when issues are first identified. Early intervention wrap-around services will be available to young people who are identified with more serious mental illnesses, self-harming behaviours or substance abuse concerns. Young people who have experienced abuse or trauma or are in care will have access to a full range of immediate and comprehensive support and interventions, seeking to avert long-term adverse impacts. Trauma-informed responses will underpin all interventions and services.
Services across the life cycle will be provided more flexibly so that consideration can be given to developmental needs. The transitions between youth services and adult services will not be driven by strict age criteria and will be smooth. Likewise, for older adults, transition to older people’s services will not occur automatically when someone reaches 65. Services that best meet the needs of the individual will be provided from the most appropriate service base.
Services will be responsive to people from different cultural backgrounds, life experiences and perspectives, for example, rural dwellers, Rainbow communities, migrants and refugees, and people in the criminal justice system. All services will respect the cultural, gender and sexual orientation needs of the people being supported. For disabled people, people with autism and neurodiverse conditions, and the Deaf community, the system will support their access and use of services, and not further stigmatise or marginalise them.
Hospital and inpatient units will not be the centre of the system. Instead, the community will be central, with a full raft of intervention and respite options designed to intervene early, keep people safe and avoid inpatient treatment where possible. Mental health and addiction services will be an important component of a broader range of support options available to people.
Housing, employment, income support, financial management and ongoing learning and education programmes will be available. Support agencies will be well connected to their wider communities and well placed to connect people into existing social support, self-help, and recreational and community activities and programmes. The whole system will be focused on building strengths and resilience to improve long-term life and health outcomes. Health promotion and prevention strategies will be embedded across all services, including services for people with complex and persistent challenges.
Support will be available as close to home as possible in local hubs. These will offer people a range of immediate health and social support options. The focus will be working with the person and their whānau to sort out what is causing their distress and help them to relieve it. These hubs will be the first points of contact for people (and their families and whānau) to access immediate support, assessments, brief interventions, talk therapies, peer support, alcohol and other drug services, and self-help, individualised and group therapies. Psychiatric and clinical assessment, advice and support will be more widely available through primary health care, Whānau Ora and community providers that will link strongly to, provide or be part of local hubs.99
A full spectrum of early interventions and support opportunities will be easy to enter and exit.
Local hubs will support people with differing needs, be well integrated into their local communities and have strong links with other services that help people with their physical health (including dental health), housing, employment, financial, education, recreational and general community support needs.
Support and service agencies will comprise a mix of peer, cultural, support and clinical workforces. Peers, cultural workers and specialists will offer a range of evidence-informed therapies, including talk therapies, family- and whānau-based practices, and clinical interventions. For Māori, interventions will be grounded in te reo, tikanga and the use of rongoā and other healing practices. For Pacific peoples, services will be grounded in their languages, core values and cultural and healing practices.
Mental distress, at all points, will be viewed as a recoverable social, psychological, traumatic, spiritual or health disruption. Underpinning all services will be early, easily accessible support for people in crisis, maintaining their connections to family and whānau, homes, schools, workplaces, friends and communities.
When people are seriously distressed and need immediate support, they will receive an immediate response from services led by caring, competent and skilled health, peer and cultural workers. All emergency departments will have access to skilled mental health workers who can provide immediate support and advice. Appropriate physical spaces will mean people can have their immediate needs addressed safely and privately.
The immediate response service will be able to effectively de-escalate situations and support people into appropriate assessment and respite services, community hubs or inpatient services. Community hubs, assessment and immediate support centres that provide calming and safe environments will provide an alternative to police cells. Peers will be present in these services. Where people come to the attention of police and are in custody, they will have access to trained mental health workers who can assess their immediate needs and make referrals as appropriate.100
Police will be well trained and supported to provide trauma-informed backup and support to mental health immediate response teams. 101
Our new system will take a comprehensive harm-minimisation approach to alcohol and other drug use (and to gambling and other addictions) and seek to avoid criminalising people with drug abuse problems. This approach will underpin our health, justice and corrections services.
All services will be oriented to enabling people who want to address their addictions to do so and supporting them to engage with services that match their individual needs. People whose addictions are trauma-based will have access to trauma-informed services. We will review the wider issues impacting on an individual’s life. Primary health care services and community providers will provide brief intervention options for people with alcohol and other drug challenges. Community-based detox facilities will be supported by comprehensive residential, community and peer-support services.
We will respond more assertively to the growing alcohol and other drug and mental health needs of people who come to the attention of the courts or are in prisons. Alcohol and other drug programmes will be readily available to the courts and to people in prisons. People moving back into the community will be supported with a warm handover process to continue their recovery journey.
People who are detained (such as within hospitals, secure care, prisons or aged care facilities) will have access to more comprehensive support through tailored primary mental health care and alcohol and other drug programmes that include access to cognitive behaviour and talk therapies. They will have access to an increasing range of therapeutic interventions that are trauma informed and designed to respond to their mental health and alcohol and other drug needs early, while they are detained. A broad range of e-therapy and over-the-phone (telehealth) options will be available to support people across the full spectrum of needs. Peer-support options will also be greatly enhanced along with trauma-informed approaches and self-help options.
There will also be stronger connections and capability within forensic services for specialist psychiatric liaison into prisons for people who are incarcerated, and the capacity to more easily transfer people who are very unwell into a health-focused environment. There will be an increased range of community-based residential step-down services and supported housing options available to people who are in forensic services, offering culturally responsive, intensive therapeutic community environments for them to transition back to the community. When released from prison, people will be supported through a warm handover process to access ongoing support close to where they live.
We need radical changes in services, policies and laws to achieve mental health and wellbeing for all, recognise the aspirations of Māori and Pacific peoples, and realise our vision of mental health and addiction services in the future. These changes are the focus of Part 2 of this report – what needs to happen.
97 New Zealand’s Code of Health and Disability Services Consumers’ Rights entitles consumers to be provided with services in a manner consistent with their needs and that ‘optimises the quality of life’ – defined to mean ‘to take a holistic view of the needs of the consumer in order to achieve the best possible outcome in the circumstances’ (rights 4(3), 4(4) and clause 4).
98 M O’Hagan. 2018. Wellbeing Manifesto for Aotearoa New Zealand: A submission to the Government Inquiry into Mental Health and Addiction (prepared for PeerZone and ActionStation). www.wellbeingmanifesto.nz(external link)/.
99 A model used in Trieste, Italy, that treats mental illness and crises in community hubs has resulted in low levels of compulsory treatment, absence of restraint and seclusion, high levels of re-engagement in community life, and an overall reduction in the costs of mental health services.
100 We note that Counties Manukau and Canterbury DHBs provide watch-house nurses at a central police station in the district. For information about the original pilot started in 2008, see J Paulin and S Carswell. 2010. Evaluation of the Mental Health/Alcohol and Other Drug Watch-house Nurse Pilot Initiative. Wellington: New Zealand Police.
101 Many collaborative interventions have been developed and piloted around the world. Interventions tend to fall into one of three categories: increased training on mental health and distress for police officers; mental health staff working with police to triage, give advice or support over the phone or face to face if necessary; and ‘ride along’ models where police and health practitioners work together in response to mental health emergencies. Various forms of these interventions are in place in parts of New Zealand, but a collaborative national response, led by the Ministry of Health and New Zealand Police, could go a long way to supporting working partnerships and effective responses on the ground at a DHB level