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Doing mental health differently

The Ministerial Inquiry on Mental Health and Addiction represents far more than another ticked box on the Government’s first 100 days job-list. Its mould-breaking potential shows we are already learning from history, writes Warwick Brunton.

The Ministerial Inquiry into Mental Health and Addiction is New Zealand’s sixth general mental health inquiry. Others were held in 1858, 1871, 1957-60, 1972-3 and 1995-6. Add the goading effect of political clamour for inquiries in 1903 and 1925, then we’re about due for another generational inquiry.

Health policy and services are characterised historically by peaks, troughs and long periods of incrementalism. General inquiries have usually followed troughs and preceded peaks of additional resourcing, organisational change or legislation which were eroded when politico-bureaucratic attention turned elsewhere. Nevertheless, general inquiries directly or indirectly prompted significant outcomes. They inspired or validated special purpose residential facilities (1858, 1871), general hospital psychiatry (1925, 1957-60), the end of institutional growth (1972-3), special purpose national administration (1871, 1995-6) and an enhanced public consciousness and profile for mental health (1995-6). Historical context shows how the Ministerial Inquiry seems poised to add 2018 to that list. How?

Previous inquiries interpreted mental health services as a euphemism for specialised intervention and treatment services for mental disorders. This Inquiry spans the full spectrum of mental health problems from mental distress to enduring psychiatric illness and warrants a definition of ‘mental health’ akin to those of the World Health Organization (WHO) or Mental Health Foundation. Mental health means enabling all New Zealanders to realise their abilities, deal with life’s challenges and stresses, enjoy life, work productively and contribute to their communities. Mental health is a positive sense of emotional and spiritual wellbeing that respects the importance of culture, equity, social justice and personal dignity.

Yesteryear’s inquiries were insular rather than universal in outlook. The template of objectives, actions and principles of WHO’s Mental Health Action Plan 2013-2020 offer a ready-made, straightforward and universally recognised framework that can encompass all aspects of the Ministerial Inquiry’s brief.

Principles of universal health coverage, human rights, evidence-based practice and empowerment of people with mental disorders and psychosocial disabilities underpin these objectives.

Putting the health in mental health

The Government hearteningly requires the Inquiry to consider the Government’s Chief Science Advisors’ reports into mental health and suicide. Those officials rightly say that planning should integrate longer- and shorter-term measures. Shorter-term plans enhance early identification and treatment of mild and severe forms of mental disorder. Longer-term measures promote mental health and wellbeing, psychological and emotional resilience, say, by reducing stresses that contribute to social alienation, isolation, withdrawal, broken relationships and vulnerability to bullying and shaming.

The scientists’ list complements that of WHO, e.g., parenting skills, early childhood education, healthy family relationships, reducing physical and sexual abuse and domestic violence, and regulating access to weapons. The scientists contend that the whole question of alcohol in society is central to any mental health policy rethink.

New Zealanders’ mental health is too important for the Ministerial Inquiry to be blinkered. Nearly half of us will experience a mental illness and/or an addiction at some time.

Incorporating the wide view of mental problems and giving equal weight to long-term and shorter-term measures is ground-breaking. That should spare this inquiry from limitations that beset some earlier inquiries: a narrow focus on shorter-term measures and marginalising or over-simplifying public health aspects. Inquiry member Sir Mason Durie, conceptual architect of the culturally appropriate model of holistic health, te whare tapa whā, with its interrelated components of physical, mental, family/social, and spiritual health, has much to offer public health aspects of the Inquiry’s work.

All but the last general inquiry was dominated by cognoscenti: a small circle of officials, departments, agencies and professionals. Fortunately that has changed. The experience and concern of consumers, carers and citizens were the “catalyst” for the 1995 (Mason II) and 2018 inquiries. The 1995 inquiry sparked 400+ individual submissions out of 720, thus testifying to the socially cathartic purpose of an inquiry. South Africa’s Truth and Reconciliation Commission chairperson, Archbishop Desmond Tutu, clearly understood that tacit function:

The wounds of the past must not be allowed to fester. They must be opened. They must be cleansed. And balm must be poured on them so they can heal. This is not to be obsessed with the past. It is to take care that the past is properly dealt with for the sake of the future ..."

The Ministerial Inquiry is suitably empowered to facilitate catharsis using subpoena and witness protection. The professional record and style of chairperson Professor Ron Patterson, should quickly dispel anxieties on that score. This Inquiry also has innovative features of consumer, youth (and maybe other) advisory panels. The experience of Inquiry members Dean Rangihuna and Josiah Tualamali’i is well-suited to lead the two named panels.

Getting our act together

How different the Ministerial Inquiry will be if it can produce a thorough stock-take and the basis of what the scientists call an “over-arching plan” for all aspects of the mental health system. Getting that over-arching plan is critical, they insist. Hurrah for a blueprint that will be concise, coherent, comprehensive, easily understood, readily available, generally accepted and make sense of the bamboozling array of swish official documents handed to the Inquiry to digest. New ground will be broken and the risk of fuzzy or vague recommendations reduced if, unlike earlier inquiries, the Government provides indicative funding levels to guide the formulation of recommendations or plans.

The Inquiry is charged with studying roles and responsibilities of agencies in the health sector, including a re-established Mental Health Commission (MHC). Indeed, Health Minister David Clark says that the Inquiry would be a way to inform the MHC’s mandate. The appointment of Dr Barbara Disley, Executive Chair of the former MHC, provides continuity.

Hurrah for a blueprint that will be concise, coherent, comprehensive, easily understood, readily available, generally accepted and make sense of the bamboozling array of swish official documents handed to the Inquiry to digest.

Factors underlying the resurrection of the MHC echo the 1871 inquiry’s call for a specialised, stand-alone national government agency to provide professional leadership and direction through “the supervision and control of all the Lunatic Asylums in the Colony”. New Zealanders have looked to such an organisation for leadership and direction ever since 1876. The current version is the mental health directorate, a statutory fiefdom deeply embedded in the Health Ministry. The directorate sits well below decks, is not identifiable in the Ministry’s management superstructure and suffers under the Ministry’s management woes and poor standing.

Reviving the idea of a high-powered and autonomous MHC keeps pace with trends in Australia and Canada. It should certainly be accountable to the government and maybe even directly to Parliament like the Law Commission or the Parliamentary Commissioner for the Environment. The MHC should be armed with statutory “doing words” like facilitate, collaborate, coordinate, consult, advise, visit, investigate, gather information, publish, advocate and report. Unlike the directorate, the MHC should be backed by a strong advisory council.

The Ministerial Inquiry was formed under the Inquiries Act 2013 and its official guidelines. The “appointing Minister” (Health) and the “appropriate Minister” responsible for the “administering department” (Internal Affairs) jointly submitted the Cabinet Paper. That noteworthy duality also distinguishes this from previous inquiries. What the changes mean in practice remains to be seen. Of course, the ‘parent’ Ministry of Health will still be expected to provide background information and will undoubtedly present its own ideas. The prospect, however, of the Ministry’s previously undue influence in massaging recommendations to suit its own interests or leadership claims may be tempered somewhat. The Government has asked the Inquiry to name agencies to progress the recommendations, including relevant ministries and, perhaps more important, the MHC.

Breaking the mould

New Zealanders’ mental health is too important for the Ministerial Inquiry to be blinkered. Nearly half of us will experience a mental illness and/or an addiction at some time. One in five of us experiences some form of psychological disorder or a diagnosable mental disorder. That number is increasing. Sixteen percent of adults have been diagnosed with depression, anxiety disorder and/or bipolar disorder. People living in deprived areas are more likely to have been diagnosed with mental disorders. The haunting image of 606 pairs of empty shoes pricks the nation’s conscience about self-harm. We owe it to the victims to start from the preventive standpoint, just as we improve road safety to tackle the human cost of transport crashes.

The Ministerial Inquiry on Mental Health and Addiction represents far more than another ticked box on the Government’s first 100 days job-list. The mould-breaking features and potential of this inquiry show that we are already learning and want to learn further from history lessons in this field. It’s as if Labour’s pre-election mantra of “Let’s do this” is being boldly and differently applied to this Ministerial Inquiry in a way that distinguishes it from its predecessors since 1858.

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