The new Government's mental health inquiry will need to move beyond a focus on symptoms to underlying causes if we are to understand the failures in our system, writes Victoria University's Mary Barnao
The announcement of a ministerial inquiry into mental health and addictions by Prime Minister Jacinda Ardern has been welcomed by many, but critics have argued that the Government is already sufficiently informed about the issues and an inquiry is an unnecessary and costly exercise that will only delay tackling problems in the sector.
While there is a pressing need for action to prevent and respond more effectively to this country’s mental health and addiction problems, the Government may not know as much as some purport they do — particularly with respect to the problems in our mental health system.
Much of the public discourse on the topic revolves around the symptoms of an ailing system: limited access to services, poor quality services, service users and their families not being listened to, too few treatment options, and ineffective responses to people in crisis. In fact, many of these known problems are listed in the new Government’s direction to its inquiry team. However, we will need to move beyond a focus on symptoms to their underlying causes if we are to understand the failures in our mental health system and figure out how to effectively address them.
We don’t have to dig too deep to recognise that underfunding of mental health services in the face of burgeoning demand is a core problem. Health Minister David Clark has already acknowledged this is an issue, and yet a boost to funding, though vital, will only go some way to tackling the symptoms of a poorly performing system. The many and varied symptoms of system malfunction suggest there are other fundamental flaws.
So what are they? It is here that the picture becomes murkier. The fact is that we don’t know that much about what is really going on inside our mental health system.
Many important questions remain unanswered. For example, what are the barriers to delivering high quality services and good outcomes for all those who use mental health services? How do service users perceive their treatment and care? What are the key areas of concern among those working in the sector? What is the culture of mental health services, and how does it impact on the way services are provided?
It is critical that we listen to service users and mental health practitioners, among others, if we are to get beneath the surface and understand the system's key problems.
This begs the question as to why we have heard so little from these groups. David Clark’s statement that the inquiry will have subpoena powers, “because we have heard from some people working in the sector that they feel vulnerable and that speaking the truth might be difficult in terms of their employment situation”, is cause for concern. It may shed some light on why mental health staff have not been more vocal in raising concerns about services, but it also makes you wonder what it must be like for the even more vulnerable people who use these services.
If knowledge of how staff perceive mental health services is scant, the service user perspective is virtually non-existent. A failure to seek out their views has led to a critical knowledge gap that urgently needs to be filled. Understanding the perspectives of those who use, or have used, mental health services then is integral to providing effective care.
A few years ago I conducted some research that illustrates just how vital it is to obtain the views of the “experts by experience”. The study, which explored detained forensic service users’ perceptions of their care, was the first attempt to give a voice to people with both offending and mental health issues since the service was established more than 20 years ago.
Participants’ representations of their care pointed to a rehabilitation landscape characterised by a fairly low level of person-centeredness, professional-led decision making, relationships with staff that were of variable quality, and confusion about their rehabilitation pathways. Their narratives also suggested an overemphasis on psychiatric symptoms and diagnosis, which many considered obscured their individuality.
These perceived problems appeared to be underpinned by the absence of a service-wide framework to govern all aspects of people’s rehabilitation. In its absence, a medically-oriented institutional culture shaped attitudes, practices and policies in ways that did not routinely place the service user at centre stage.
Whether these issues extend to other mental health services remains unknown. But what the study does highlight is the importance of getting beneath the surface to a deeper examination of the context in which care is provided. Only then can we make sound decisions about what needs to change.
To be effective, the inquiry team will need to dig deep and consult widely, including seeking out the experiences of people with lived experience of mental health and addiction problems, and those tasked with responding to these issues. Judging by the inquiry’s terms of reference this is exactly what we should expect from them.