Mental Notes No. 2 (September 1997)

Better to light one small candle, than to curse the darkness

Glad to get your feedback

One of things you liked about our first newsletter was the fact that it was fairly blunt. Another thing was the fact that we tried to tackle some difficult questions. It’s always risky to write about the hard things, but we’ll try to keep up that style. Thank you to all those people who gave us feedback! This newsletter follows the same format as the last, but in this one we put particular emphasis on the Blueprint and discrimination.

Circumstances for recovery

We live in a world where we’re supposed to know the answers - and fast.

But sometimes we have to stop and check that we’re asking the best questions.

For example, a question often asked is "How do we deal with people with mental illness?" This question creates a negative mind set, images of doing things to people. What say do the people have in all this?

A better question is "Under what circumstances do people have the best chance of recovering from mental illness?" It’s a subtle shift, but it forces us to look at recovery.

By recovery we mean getting through the experience of mental illness - coming out the other end of some episode or learning how to live with mental illness in the least painful and most positive way. When you listen to people who experience mental illness you hear that they are faced with many kinds of recovery: recovery from the actual illness - its symptoms, its limitations; recovery from the treatment - the sheer impact it has on their life; and recovery from the social reaction to their even being ill - the discrimination which pervades our society.

We believe that mental health services must not simply "treat" the illness, nor even simply "treat" the person. What services must do is provide the circumstances for recovery - in all senses of the word.

This "recovery" perspective is what we are going to promote in the Blueprint. It means asking the question "if this were me, would this be how I would want to be treated?"

If that, and that alone , were the only change to occur in mental health services in New Zealand, we would have taken a gigantic step forward.

The danger of words!

One of the most powerful things we can all do in the mental health sector is to stop hiding inside language. Pull ourselves out. Challenge ourselves. One of the best ways to counter cynicism within and about the sector is honesty. That means saying what we mean and making no false promises.

At the MHC we are making a concerted effort to talk "plain-speak" – a bit like doing breast-stroke against a tidal wave. Have you ever noticed how some people assume that saying things simply means simple-minded? And things said in complex ways must somehow be clever? But when you peel back language to its basics, you certainly find out whether anything is really being said.
1 Thanks to Roger Hewitson of Paraparaumu for this phrase.

Who is accountable for what, and to whom, and how?

The Acuity Review.
The Paki Report.
They say the same things.

Very few acute service providers have any form of discharge planning. This is disgraceful given that discharge planning is supposed to be one of the key guidelines in the funding agreements and contracts. Follow up between inpatient and outpatient services has huge gaps in it. And communication between services continues to be poor.

Both reports were critical of the level of cultural safety and access for Maori to all mental health services. There was a lack of Maori personnel and culturally appropriate residential accommodation support. The Acuity report recommended that these gaps be urgently addressed.

The Paki report said someone had to be accountable. And the obvious question is how will people be held accountable for improving services?

This is exactly what the MHC is going to make sure is known. We are starting to find out exactly how clinical accountability is supposed to work and how it does work across the sector. We will do the same with management accountability by working with the new Transitional Health Authority (THA) to make sure that funding is explicitly tied to a national plan (the Blueprint) and that it is not given unless there are clear and robust procedures of accountability. We will not tolerate a "shrug and hope it will be okay on the day" approach any longer.

We move from crisis to crisis, because crisis feeds on itself. We have got to break this cycle. If you are committed to improving mental health services then help us. Question what you say. Question how you think. Question what you do.

First draft of the Blueprint Project is complete

The first draft is complete of the Blueprint. This is an outline of minimum standards for services throughout the country. We thank Derek Wright of Waitemata Health for his dedication and commitment in pulling together an enormous amount of material and setting out the range of services needed and the volumes required. Joy Cooper has joined the MHC last month and is further developing this draft. We can now also link the Blueprint to our Monitoring Project (see page three) and emphasise the need for activities to counter discrimination as part of the range of services.

The Blueprint is a chance to get things on the right track. It will be a guidebook for service development which:

1: Is based on a clear statement about why and how mental health services need to develop, as far as the outcomes we want to achieve, the values on which they are based, the principles which stem from the values, and the actions which we need to take to realise the principles.

2: Is consistent with the national mental health strategy. And builds on the Ministry of Health’s "Looking Forward" and "Moving Forward", which set out the ideals for the strategy and how to achieve them. The Blueprint is the next level of detail.

3: Is not a rule book to tell communities what to do or stop them from doing their own thing. But it will say what a good mental health service should look like and will describe the various parts of the service. It will spell out what services need to be available for every 100,000 people and will take into account the need to vary this picture according to geographic, cultural and demographic differences. It will give a realistic indication of what is actually needed to implement the national mental health strategy and give some ideas of the true cost. It will set priorities for action which make sure future services do meet the needs of Maori and children and young people. And, like all good guides, it will be updated as the territory becomes more familiar and the landscape changes.

When the Commission was established last year, it was given the mandate to get services right. This needs leadership, and one of the strongest messages we have received from the sector is that it wants leadership. The Blueprint is one thing we believe provides some decisive leadership.

We will publish the Working Blueprint in October. But we also expect that it will be modified as we go along and as we learn from the sector’s experience.

Early intervention knowledge is crucial in sector training

The Report of the Early Intervention and Prevention Group Workshop held in Dunedin in May is complete and has been distributed to the MHC Advisory Board for discussion and for feeding into the Blueprint. The Workshop team consisted of Jim Crowe, Pauline Hinds, Cath Allan, Marilyn Bartlett, David Barthgate, Alison Masters, Aroha Noema and Sue Thompson and the scribe was Chris Walsh.

The MHC strongly backs the need for early intervention and will make service recommendations in the Blueprint. We are also making sure that knowledge about early intervention is a key part of any workforce training. We have purchased multiple copies of the EPPIC training material which we will make widely available to community mental health services and agencies. We continue to liaise with the Early Intervention In Psychosis Steering Group.

Update on some priority issues

Good community housing is essential The Acuity Review found that 40 percent of people in acute services at the time of the review did not need to be there and were there because of inadequate community housing.

The HOMES National Accommodation Provider Network has given us a database on current levels of provision, price variations, costs, workforce training needs and barriers to better service provision. We have now seconded Linda Jacobs from the Ministry of Health to analyse this and give us:

* An accurate picture of current provision in relation to identified priority groups and needs.
* An understanding of the different models of service being provided.
* A better grasp of the way to tackle the issues of the use of the Resource Management Act, community consultation, education of local bodies, and the clarification of the responsibilities and accountability of the various agencies involved.
* A plan of action to improve accommodation provision.

We are continuing to work with the THA to change the current level of service provision so that it will meet the expected need on a population basis. We have also met with the Minister of Housing and the Board of Community Housing Ltd to come to a better understanding about resistance to community housing.

The Monitoring Project

To understand and monitor change, we need to see the whole picture - not just random bits and pieces of a canvas. So the Monitoring Project, led by Michelle Farrell, is drawing together and making sense of a whole array of information which will be used to tell us exactly what and how mental health services are changing.

This project is now combining the results of several projects. The base will use existing information, such as the performance indicators collected by the Ministry of Health and THA regions, and also new information such as our review of the practical relationship between funding agreements, purchasing plans, contracts, and business plans; and our review of clinical accountability.

The base will include both "quantitative" information like health and finance statistics and "qualitative" information like consumer and family opinions about services. It will be organised so that we can summarise information on the basis of geographical location, types of service, groups of consumers, and specifically on each of our three Terms of Reference.

Meet the Kaumatua

Denis Simpson is the Kaumatua. He is Chairman of Te Kaunihera Kaumatua Taurahera Council (Wellington Council of Elders) and has tribal affiliations with Mataatua Te Waka, Ngati Awa Te Iwi and Taiwhakaea Te Hapu.

Reducing discrimination against people with mental illness

Taking up the challenge of language again.

Think about the word "stigma" for a moment. Really think about it.

What did it make you think of?
Who did it make you think of?
Did you think about the people who make fun of people with mental illness, the ones who put them down, who don’t want to employ them, who don’t want them to live next door? Did you think about their behaviour? Or did you start thinking about people with mental illness? Did you mull over the kind of characteristics that prejudiced people attribute to people with mental illness?

Just for interest. Stop using the word stigma and start talking about discrimination for at least a month. Keep pulling yourself up when you say stigma. Say discrimination instead. When you hear other people talk about stigma, say discrimination in your mind. And watch what this does to the way you think.

The discussion paper Discrimination against people with mental illness

By now, some of you will have seen the discussion paper we published in July called "Discrimination against people with mental illness" written by Margaret Thompson and Tessa Thompson. Its purpose was to look at the problem of discrimination logically and then come up with some ideas about how it should be tackled.

Here is a thumb-nail sketch of the paper:

It assumed that discrimination experienced by mental health consumers has a great deal in common with discrimination experienced by other groups.

It compared other areas of discrimination where significant social change has been achieved, such as discrimination on the basis of age, gender, sexual identity, race, size, culture, physical disability.

It concluded that effective change has principally come about from the assertion of rights, political activism and positive discrimination.

It suggested seven principles for action:

* There must be an enforceable and accessible legal framework to stop discrimination.
* People who make policy must make sure that consumers are involved in the decisions. This may mean specific resources and support.
* It has to be made easy for consumers to assert their rights.
* Agencies have to spell out what they are going to do to make sure that consumers are treated fairly. And then do it.
* Positive discrimination might be necessary to change things.
* Political activism by consumers is likely to change things.
* Consumers need to be more visible and society needs to be shown positive experiences with consumers.

We had a lot of positive and helpful feed-back on our discussion paper and have improved our plan of action as a result.

World Mental Health Federation Congress

Discrimination was a major theme of this Congress, which was held in Finland in July. People from the UK, USA, Germany, Russia, Argentina, Italy, Australia, and Iceland told the same kind of stories about how society fears and mistreats people with mental illness. Commissioner Julie Leibrich gave two talks about discrimination. One was a personal account of recovery from mental illness and the other was about the logical analysis we have made at the MHC about discrimination. Janet Peters from Waitemata Health also gave a paper on discrimination, in which she talked about the kinds of discrimination which people with mental illness have to deal with.

The approach we are taking in New Zealand made quite an impact. So much so that Julie Leibrich has been invited to Britain next year to take part in an international meeting to work out a "global strategy" to eliminate discrimination against people with mental illness.

The role of the MHC

Some of you said that you were not clear about the role of the MHC in fighting discrimination, since there are a lot of agencies and individuals already working in this area and particularly since the Ministry of Health has a big "public attitudes" campaign under way.

The MHC does not want to take over what other agencies are already doing. But we do want to make sure that everything which needs to be done is being done by someone, somewhere.

The Ministry and THA have made a huge financial commitment to this area – nearly $12 million over five years. They have to get it right first time, because we are unlikely to see this amount of money spent on this problem again in the future. Some of this money is being spent on the national attitude campaign, but most of it is being spent at regional and district levels. We really support the emphasis on local initiatives and are working with the THA to help develop a strategic approach to spending this money wisely.

But our examination of discrimination also told us that there are many other actions which need to be taken to deal with the problem effectively. We have to make sure that:

* Consumers are strongly supported. For example, Maori must get access to these resources so that programmes meet their needs for increasing awareness and reducing discrimination. Pacific peoples will also require programmes that are tailored to meet the needs of their communities.
* Rights legislation is adequate and used effectively.
* All Government agencies and all services become committed to getting rid of discrimination and know how to do it.
* The Ministry and THA campaigns don’t just focus on "the public" in some vague way but also tackle important pockets of discrimination such as the attitudes and behaviour of the mental health sector itself.
* Critical issues such as the resistance to community housing are dealt with in a concerted way.

To do all these things, the sector has to pull together. We need to share our information and ideas. Talk to each other about what we are doing. Not reinvent the wheel. Get rid of wheels which are bent.

The MHC has taken on the role of keeping an eye on the whole picture. And making sure that the fight against discrimination is coordinated and makes sense.

Support, self help and training for people with mental illness and their families

As part of our plan to make sure that good quality information is available to consumers and care givers, we have given financial support to:

* ANOPS, for the publication of their book "Psychiatric Drugs and Side Effects". This shows consumers how to take greater control over the way in which they manage their illnesses and gives information about commonly used drugs and their side effects along with alternative intervention options. It is available from ANOPS, Unit 1B, 163 Stoddard Road, Mt Roskill, Auckland or phone 09 620 0224.
* The Wellington Mental Health Consumers Union , for the publication of their booklet "About Antipsychotics - A Consumer View." It is free from the WMHCU at PO Box 6228, Te Aro, Wellington or phone 04 801 7769.
* The Manic Depressives Society for the reprinting and distribution of their comic "What’s Going On...?" and the copying of three videos on manic depression. Anyone wanting to know more about these resources should contact the Manic Depressive Society, PO Box 25-068, Christchurch.

The ADAPT team

Mary O’Hagan, Margaret Thompson and Tessa Thompson continue to work against discrimination in a whole host of ways. A lot of energy in the past two months has been put into work on the housing area and into responding to the gun lobby’s attacks on people with mental illness. With that in mind, as we go to press, we welcome the Thorp Report with open arms because it refused to be seduced by emotive and misguided ideas about the dangerousness of people with mental illness.

Two workshops are planned this month. One is to figure out how the sector can make a coordinated response to the influence of the media. There is also going to be a series of media seminars, run in conjunction with the Mental Health Foundation. The other workshop is to get ideas about how best to deal with discrimination within the mental health workforce. This is a topic which Mary O’Hagan is also preparing a discussion document on.

Valerie Bos is also doing work for the MHC developing extensive contacts with consumer networks across the country and working out how we can get the most input from consumers.

Strengthening the mental health workforce

In July, we held a workshop to get input into the National Mental Health Workforce Strategy. It was part of a two-day forum discussing mental health workforce issues. The workshop was run by Marion Clark, who we have contracted to lead the development of the workforce strategy, and about 60 people attended.

The strategy is a joint project with the Ministries of Health and Education and the THA Regional Divisions, coordinated by the MHC. Its aim is to make sure that there is good training, retraining, recruitment and retention in the workforce.

The MHC is also working with the Ministry of Health to develop standards of training for community support workers. It is hoped that new courses will be introduced in 1998.

Works from other agencies

The Ministry of Education has just produced some excellent Guidelines for Schools on the prevention of suicide. They contain clear, concise material to help schools identify students who have poor mental health or increased vulnerability and provide assistance to them. The guidelines will be accompanied by training for principals, members of Boards, counsellors and health teachers. The guidelines are a start, and given that the health and physical well-being curriculum will also provide incentives for schools to improve what they do, there is a real opportunity now for schools to move much further ahead in helping prevent suicide.

The Ministry of Youth Affairs, has released a discussion paper "An Approach to Action for Preventing Suicide in Young People". This should promote a higher level of awareness of the problem and give communities and agencies ideas about what they might do to provide a more positive environment for young people. It is critical, however, that after consultation, the discussion paper is followed by a clear action plan which is properly funded. The Department of Corrections is coming to a revised agreement with the Ministry of Health to improve mental health services for inmates. The agreement will provide purchasing guidelines for the THA regional divisions.

Developing the Community Mental Health Service Team Leaders

In June, we called together a group of community mental health team leaders to help us set up some practical training seminars. They were: Stephen Boyd (Ashburton), Colin Reid (Gore), Eddie Smith (Whakatane), Jackie Edmond (Hutt Valley), David Ramsden (Hawkes Bay), Annette Shea (Auckland) and Wi Keelan (Auckland). The seminars will give every community mental health team leader in the country the chance to attend, learn new skills, share experiences and build links. The first seminar is being held this month.

Meet the Advisory Board

The Commission’s Advisory Board has six members appointed by the Minister of Health.

They are:

Mason Durie is a psychiatrist and Professor of Maori Studies at Massey University. His tribal affiliations are Rangitane, Ngatu Kauwhata and Ngati Raukawa.

Pauline Hinds is a consumer advocate in the South Island and a staunch supporter of consumers on our Board.

Wayne Miles is a psychiatrist, Director Area Mental Health Services at Waitemata Health and the Chair of the NZ College of Psychiatrists.

Maxine Gay is involved with the Schizophrenia Fellowship in Wellington and has a family member who has schizophrenia.

June Read comes from Wellington and has involvement with training carers.

Ray Watson is now the Chief Executive of Lakeland Health. His tribal affiliations are with Kaitahu.

Rehabilitation/vocational services model for mental health services

The Acuity Review found that very few models of psychosocial rehabilitation are used which look at the wider needs of the people who use those services.

It is not enough to have beds and staff. Services need to take into account the whole needs of individuals if they are to give them the best chance of recovery. We will be highlighting this in the Blueprint.

Laurie Curtis – Director of Training and Development at the Centre for Community Change in Vermont USA, has reviewed international best practice approaches to psychotherapeutic rehabilitation. Her report has now been widely distributed to the sector as it provides many ideas on how services can be improved. Chris Harris with Framework Consultancy in Auckland, has reported on current and needed practice in the area and this is being channeled into the Blueprint.

Here's a copy of New Directions: International Overview of Best Practices in Recovery and Rehabilitation Services for People with Serious Mental Illness - A Discussion Paper

Clinical guidelines prepared for dual diagnosis

The Acuity Review found that 48 percent of the people who were in acute services also have substance abuse problems.

It is no longer acceptable to argue about the boundaries and divisions between mental health services and drug and alcohol services. This is such an important issue that it has to be a core part of the business plan of every mental health service.

We have commissioned, jointly with the MOH and ALAC a set of clinical guidelines for the management of the substantial group of people with dual diagnosis, which will be published later this year. The Commission is also preparing a practice note that will clarify the legal situation relating to people with dual diagnosis problems, give ideas for best-practice service models, and say what changes need to take place to ensure the needs of this group are met.

Maori mental health needs included in Blueprint

The Maori Advisory Group worked with Derek Wright on the initial outline for kaupapa Maori mental health services for inclusion in the Blueprint. Further work will be done with the THA regional Maori mental health managers. There have been a range of new Maori services set up over the last year and the Commissioners are visiting as many of these as we can on our regional visits.

Pacific peoples make submissions

We want to thank the Pacific People’s Advisory Group for their extensive input into the Blueprint and also their crucial input into the Discrimination, Best Practice, and Workforce projects.
Newsflash!

Mental Health Commission Bill

Until now, the MHC has operated under general legislation. In July, our own proposed legislation, the Mental Health Commission Bill , had a second reading in Parliament. It is now with the Health Select Committee which will look at the proposed law, clause by clause. The Commission is happy in general with the legislation, although we want to be sure of having enough authority to do the job we have been asked to. One aspect that differs from the Mason Report recommendations and may not please some of you is that there is no intention for the Mental Health Commission to become the purchaser of mental health services. We investigated this thoroughly but considered that there was no need to build yet another bureaucracy. We think we can get the best results from working closely with the Ministry of Health and the Transitional Health Authority to make sure there is a robust service plan on a national basis and that it is acted on.

Congratulations

Hot off the press is the news that at the annual awards issued at the THEMHS conference recently held in Sydney, Winston Maniopoto and his team won the Gold Award in the Specialist Service Section. Winston’s work at Te Puau Ora in Auckland assists Maori people with a long term disabling mental illness to meet their basic needs; living in the community and managing their illness.

Also Rob Warriner and his team won the Silver Award in the Rehabilitation Services Section for their Transitions Supported Employment Programme, also based in Auckland which provides a supported employment service for people who experience a mental illness.

It’s lovely to be able to report some good news and the Commission warmly congratulates these two teams for their award winning work.

GIVE US SOME MORE FEEDBACK

We are always open to ideas and suggestions about change and improvement. It may be that Wellington seems a long way from your local community or from your particular involvement with the mental health area, but the MHC does not want to be isolated from the sector. We are part of the sector. So if you want more detailed information on any of the projects mentioned here, or have any ideas you would like pass on to us, then please contact us directly.

© Mental Health Commission, 1997