#reviewthesystem – Andrea Bates

Our mental health system is broken!

Our mental health system is doing exactly what it was designed to do. Our mental health system is based on a fantastical yarn (cheers Uncle Hec!), and it is not fit for the purposes our country requires of it. These are not signs of brokenness – they are fundamental flaws.
The current system is mandated by Parliament, funded by Government and enforced primarily by the Courts and DHB’s, and secondarily by NZ Police, primary health organisations (PHOs) and non-government organisations (NGOs). The system is designed to control and contain the people it decides are ‘mentally disordered’.
And what’s with attaching the word broken to mental health things?

It’s a disorder!

This is the belief that underpins the Mental Health (Compulsory Assessment and Treatment) Act 1992, which is commonly abbreviated to MHCAT.
MHCAT has a two-part test for ‘mental disorder’. A person needs to be in an ‘abnormal state of mind’ that is so bad it makes them either; a serious danger the health and safety of themselves or others; or it seriously reduces their ability to take care of themselves.
The first part about abnormal state of mind means that a person has delusions or ‘disorders of mood or perception or volition or cognition’. Basically if you think, feel or experience things that someone else says aren’t ‘normal’ you’re in the gun. Then if you’re also, somehow, a risk to yourself or other people in one way or another you’ve met the test.
The idea of an ‘abnormal state of mind’ is a concern in and of itself. Thinking and feeling and experiencing things that other people don’t has been part of human experience since at least our first written records. How can something intrinsically human be ‘not normal’? Clearly we’re not in the world of science. If you dig a bit deeper and look at the common law around ‘mental disorder’ it is based in the idea of a ‘disease of the mind’. Yup, we’re back to the fantastical yarn of broken people who ‘lack capacity’. Quite how the nebulous concept of ‘mind’ can acquire a concrete and identifiable medical disease I don’t know. If you look even further back you’ll learn that this all comes from political and religious battles for dominance. It’s definitely not medical science.
If the first part of the MHCAT test is that dodgy I’m sure you’re expecting the second parts to be as bad, and you’re not going to be disappointed. On what basis can anyone say what a person is going to do next? It’s impossible to predict human behavior so no one can know if someone is a danger to themselves or anyone else. It gets even worse if you look at the statistics. People who are judged to be ‘mentally disordered’ are no more likely to be violent than population averages. If we were to lock people up as a preventative measure based on statistical likelihood of violence it wouldn’t be the people with mental health conditions who would be under lock and key. Speaking of which, the process of handing down a sentence of preventative detention is far more rigorous than anything in MHCAT. As for the part about people not being able to care for themselves, well that goes back to the claim of a lack of capacity to make good decisions because a person has a ‘disease of the mind’. The whole thing is self-reinforcing and completely lacking in any research validation.
The result of this systemic two-part test is what we are constantly seeing in the media. If someone is suicidal but doesn’t fit the criteria for having an ‘abnormal state of mind’ they don’t fit within the MHCAT test.
MHCAT, and its test for ‘mental disorder’, does not meet the needs of our communities.

But it’s an illness!

I’ve written up a conversation I had with a Consultant in a physical health field some years ago. If you happen across such an experienced, smart and good-natured person I recommend that you try something similar:

Me: What, in a word or two, denotes illness in medical science?
Dr: <pause> Damage.
Me: So if you identify damage you are able to diagnose an illness?
Dr: <longer pause> Yes.
Me: What is the identifiable damage that allows a diagnosis of mental illness?
Dr: <extremely broad grin>
We both laugh.

At the time the ludicrousness of it all was very funny. In everyday life it is not even remotely amusing. Anyone who uses the phrase ‘mental illness’ as a valid scientific truth is saying that I have a damaged brain. There is no evidence to support this. It is the fantastical yarn writ large and too often accepted in New Zealand today.
When trying to make sense of their experiences people do describe themselves as having a mental illness as that is the story they are most likely to have heard. When anyone uses the phrase in a context other than self-identification they are saying that something that is not true is true.
The implications of the phrase ‘mental illness’ are incredibly damaging for me, my community, and our society as a whole. There has been enough research done on ‘awareness campaigns’ that shows that use of this phrase further reinforces existing prejudiced beliefs. It says that I have a broken brain, that I lack the capacity to make decisions in my own or other people’s best interests. It is an entirely patronizing mechanism of controlling my sense of self and my daily life, and its own scientific process does not support it.
‘Mental illness’ medicalises experiences of the mind. Different cultures and beliefs locate the mind in different parts of the body, and outside the body. To say that the experience of Madness is a physical illness of the brain is to impose the western psychiatric model on large groups of people who have different knowledge, practices and beliefs around extreme states.
Using the phrase ‘mental illness’ has become increasingly commonplace since the 1980’s when Prozac hit the marketplace. To sell a pill it has to believed that it does something medical. No matter how slick and sustained a marketing campaign is no-one can medically cure something that hasn’t been identified, even if all the people who have experience of mental health conditions were actually asking to be ‘cured’.

It’s the same as a physical illness!

Oh please.

System equals services!

Our mental health system is a legislated construct. Our mental health services come in many forms and operate under our mental health system. You’ve probably heard about people having a go at services. If you look a bit more closely at most of these situations you’ll see that the objection is really systemic.
Our mental health system breaches so many of our countries human rights obligations by its mere existence it can only be described as inhumane. The people who work in our mental health services by and large slog their guts out to bring some humanity to the situation.
Any system that gives individuals extreme amounts of power will create abuse, and some people are still treated inexcusably in our mental health services. If you look at the most recent report by the Director of Mental Health you will see that it clearly records that there is no statistical validation for the rates at which Māori are subjected to compulsion under MHCAT. You will see that while our rates of forcing people to have electrical currents passed through their skull without any evidence that this is a scientifically or medically valid practice are slowly decreasing, yet 225 people endured an average of 10.2 of these events in 2015.
People do not embark on careers in mental health with a wish to harm people. I believe the opposite to be true. Some people do let the side down, and our mental health system is very hierarchical. But if you have half an eye on the vacancies in public mental health services, and if you listen to the anecdotal evidence, you will know that the burnout rate for trying to bring humanity to our mental health system has been high for a long time and it’s getting worse. I think it’s getting worse because people who are caring and want to provide support are constantly being confronted with the truth that the system does not allow them to do this. We see very little consideration for the experiences and feelings of our mental health workers in our media, and services at their core are simply a collection of people.

It’s a problem/issue/difficulty!

Just stop. Everyone experiences problems, issues and difficulties. My experiences of extreme states of all kinds have given me far more benefits then the sum total of the troubles they have given me.

This person needs a psychiatric label!

There are a number of systems to describe people’s experiences of mental health conditions. The one most people have heard of is the Diagnostic and Statistical Manual (DSM) that was created by a small group of members of the American Psychiatric Association. It has a European equivalent in the International Classification of Disorders (ICD). These are the classification systems that can best be described as narrative sciences, if you would go so far as to attribute any scientific reasoning to them. Fortunately we live far away from both these systems and you would be hard pressed to find a psychiatrist here who considers them to be definitive. You will find DHB systems requiring people’s experiences to have ICD codes, and both the Ministry of Justice and the Ministry of Social Development are fond of referring to psychiatric labels as scientific diagnoses.
Currently there are two main opposing systems, the Research Domain Criteria (RDoc) out of the US Federal Government’s National Institute of Mental Health, and the Formulation model created by British psychologists. RDoc is all about throwing money at the elusive biological and/or genetic cause with the scary aim of ‘preventing and curing mental illnesses’. Thanks, but hands off my Madness. Formulation is based in trauma theory, in essence ‘what happened to this person’.
Then, of course, there are the people with lived experience who may or may not find parts or all of these systems useful at any given point, or who may have reached their own understanding of their experiences.
I believe that everyone has their own level of Madness and that certain events can bring experiences of Madness into a person’s consciousness in particular ways. Too many people have had inexplicable experiences for too long for extreme states to be a fantasy story. Exponentially increasing numbers of people who live in the western world, or who encounter western psychiatric drugs, are having these experiences. This suggests that somehow something, or some things, in the western way of life are contributing to this increase. Madness is making itself known as a very human experience, maybe it’s time we started listening.
This calls to mind a quote from the wonderful Maya Angelou: ‘What I think the political correctness debate is really about is the power to be able to define. The definers want the power to name. And the defined are now taking that power away from them.’
Next time you hear someone calling something crazy, nuts or insane, or you hear someone state that schizophrenia is a valid medical concept, or you hear that only people with ‘serious’ mental health conditions kill themselves, know that you are listening to someone who is claiming the right to define someone else’s experience. They are exercising power to name mental health crises and conditions as bad things, and not normal things, that need to be controlled and contained. And that is not ok.

The system is underfunded!

Best we turn to our good friend Mathematics. Or Accounting or Economics, depending on how you see the world.
The official word is that the annual budget for our mental health system is over $1.4 billion. Given that a straightforward Official Information Act request could double check this I believe it is accurate, and $1.4 billion is a lot of money. So where does it all go?
I understand there are around 1,000 inpatient beds of various descriptions in the country at present. That they exist to service the fantastical yarn is extremely troubling. I’m sure you can all recall the recent screaming headlines about one person ‘costing’ over $1 million to be held in a forensic inpatient unit. Let’s be generous and say that each inpatient bed costs an average of $500,000 a year to maintain. That’s $500,000,000 of the budget gone. All locked inpatient units are particularly troubling for two more reasons; there is no evidence they improve a person’s life; and there is a lot of proof that they cause people damage.
We’ve also had the construction and renovation of inpatient units in the last few years, and there is more of this work happening. There’s another large chunk of money gone.
The pharmaceutical industry has done extremely well out of peddling it’s so-called ‘antidotes’. The volumes of prescription for SSRIs, trycyclics, benzodiazapines and neuroleptics are astonishing on an anecdotal basis. How much this is costing I do not know, but it would be very interesting to find out. We know the drug companies are making trillions of dollars from their psychiatric drugs, and we also know that Pharmac negotiates with them on our behalf. How much of the remaining mental health budget has gone to the pharmaceutical industry?
As the People’s Mental Health Report pointed out, our mental health system encourages an over-reliance on these drugs. We know they are incredibly powerful drugs that cross the blood-brain barrier. We know they impact the person who takes them, or is forced to take them, and unborn children. We know that the clinical trials that are used to market them are known to be unreliable at best and corrupt at worst. We know they induce damaging side effects that can include suicidality and self-harm and there is no way to know who will be negatively affected. We know that they carry warnings that they are not to prescribed to children due to the the known risks of suicide, not to mention unknown impacts on development. We know that they are all highly addictive and difficult to stop taking. We know that abrupt withdrawal can create experiences that are equivalent to, or worse than, anything a person may have experienced as part of their mental health condition. We know that people are prescribed multiple drugs without any certainty of how they will interact. We know that people are prescribed multiple non-psychiatric pharmaceuticals in an attempt to manage the side effects of the psychiatric drugs. We know that psychiatric drugs impair cognitive function and alter people’s physiologies. And we know that all the long term evidence points to psychiatric drugs being safest as a short term intervention to manage a crisis if nothing less potentially harmful works. All this and we don’t know what they are supposed to be ‘fixing’.
If we added up all the flow-on costs from psychiatric drugs including physical health interventions, lost productivity and shortened life span, and if we could add that to our mental health budget we’d have spent far more then the amount currently allocated. Instead the remaining money goes into other DHB, PHO and NGO services that operate under our mental health system. Some of them are astonishingly excellent. Some of them are offshoots of compulsion.
No-one with knowledge of our mental health system is asking for more funding to go into more of the same. The system is not underfunded, it is directing funds where they are not meeting the needs of people in this country.
I believe an increase in funding is needed to support the transition to a fit for purpose system that is built around the principle and practice of Pae Ora. Pae Ora is described by the Ministry of Health on its website as ‘the Government’s vision for Māori health’. I see Pae Ora as another example of people in this country being given the opportunity to listen to and learn from the wisdom, knowledge and practices of tangata whenua. Pae Ora is another opportunity to live the partnership principles of Te Tiriti o Waitangi for the benefit of all people in Aotearoa/New Zealand. To gain a better understanding of Pae Ora right now you can’t do better than listening for fifteen minutes to Sir Mason Durie at the launch of He Korowai Oranga.
Our (mental) health system needs to support healthy and flourishing people, strong families, healthy environments and futures full of hope for us all.

It will all work out!

Actually I do believe this.
As Dr Crawshaw, Director of Mental Health, said on the radio last week – we couldn’t have had this public discussion ten years ago. We’ve come a fair way, but not far enough yet.
We are now having a public debate about the social determinants of emotional distress. We know that if we don’t address the issues of homelessness, familial violence and income inequality we will have more and more people experiencing extreme states. We know that our suicide rates are shocking and that prevention is a societal issue, not an individual problem. We also have a long list of interventions and treatments which are well researched and do produce good outcomes that we can build into a diverse system of interconnected individual, family and environmental health.
The way to achieve change is to ensure our decision makers take time to seriously rethink how our country is addressing mental wellbeing. One way of doing this is to sign the open letter that is part of the People’s Mental Health Report which recommends a review of our mental health system. Please consider doing this, and if it feels right sharing this opportunity with family and friends and on social media. Governments listen to large groups of people asking for the same thing. And this is going to need a lot of us.

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