John Fitzgerald, President-Elect of the New Zealand Psychological Society

Soon after taking up office in October 2017 the Labour government announced an Inquiry into New Zealand’s mental health and addictions services.

Service users, their families, and those working within the sector had called for this Inquiry and the $6.5m Inquiry is scheduled to report back to the Minister by the end of October.

Among the main areas of concern which prompted the Inquiry were: inequities in mental health and addiction outcomes; underfunding of services; and lastly the high suicide rates. These, and other areas of concern, where highlighted in the People’s Mental Health Report[1], a crowd-sourced, story-based report of experiences within our mental health and addictions system by those who use the services and those who provide them.

In announcing the Inquiry the Minister of Health, the Honourable Dr David Clark, has been clear that the current government will not shy away from a major overhaul of mental health and addiction services if this is what is required.

As over half the members of the New Zealand Psychological Society (NZPsS) are clinical psychologists, who work primarily in the mental health sector, the society is preparing a submission to the Inquiry focused on promoting a broader psychological view of mental health.

Our existing mental health services are based largely on a biological understanding of mental health and mental illness. That is, mental illness is viewed as a disturbance of biological/neurological systems as a result of genetic, medical, social, environmental or other factors.

Whatever the cause the remedy most commonly offered is to restore biological/neurological balance to the individual by chemical means, that is, the prescribing of medication. The most obvious difficulty with this approach is that it treats symptoms not causes.

While providing medication to help a person sleep more soundly, or feel more alert or less anxious may be useful in the short-term, such interventions are unlikely to help a person to be less afraid of spiders, improve the quality of their relationships, or make their experience of trauma disappear.

The Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM5) is one of the international categorisation systems for mental health. It specifies the signs and symptoms that must be present for each disorder to be diagnosed. Using this system as the benchmark for entering and exiting the mental health system unhelpfully focuses attention on the presence/absence of symptoms, and makes symptom removal a core task on mental health services. While this is an important function of mental health intervention, it is seldom an adequate solution to mental health problems.

What changes do we want?

Against this background what changes might we want in our mental health and addiction services as a result of the Inquiry?

The most fundamental change would be a substantial revision in the way services view those experiencing psychological distress, stepping beyond the biological symptom-based perspective. Such a perspective does not help us to understand or offer meaningful support to people in our community who experience mental health problems.

Alongside this we need an approach to mental health that has a greater focus on building strengths, not just attempting to find a ‘quick fix’ answer to problems. A symptom-management approach, which is consistent with an over-reliance on medical diagnostic systems, is about resolving symptoms not dealing with underlying causes.

It is important to acknowledge practitioners who take on the challenging role of supporting those with serious mental health problems when this requires intensive residential care, either in hospital or elsewhere. This includes those who provide residential support for people who cannot keep themselves safe in the community because of suicidal thoughts, or because their capacity for self-care is compromise by their psychological difficulties. However, in many such cases hospital (or a police cell) is not the most therapeutic environment. As a civilised and caring society we need to offer more varied options to support people while they become stable, returning to full health, and build resilience for the future.

To build community, family/whānau, and individual resilience we need to be doing more than focusing on the individuals, more than fighting proverbial fires. Building resilient, caring, and knowledgeable communities will go some way to mitigating the risk of people experiencing psychological problems. To do this we need to see mental health as being a community-wide concern, not simply an example of individual fault or failing. This resilience will be built in our schools and homes by enhancing mental health literacy, increasing awareness about the myths and reality of mental illness, and resourcing accessible and expert services.

The information/support provided must be evidence-informed and presented in a practical, useable format. In summary, we need to demystify mental health, challenge prevailing stereotypes and stigma, and see mental health as part of health, and not separate from it.

Finally, it is important to recognise that all this will be much harder to achieve if communities continue to be challenged by inequality, violence, unemployment, and other social difficulties – ‘stressed systems’ do not learn and do not change.

The People’s Mental Health Report contains stories which emphasise, among other things, the importance of making psychological interventions (‘Talking Therapy’) more readily available at an earlier point in the help-seeking journey. To make this a reality – in the way it is in England under the Improved Access to Psychological Therapy (IAPT) initiative – will take significant financial investment in the workforce, and a restructuring of care pathways.

In part this can be achieved by a redistribution of the resources currently committed, but the funding shortfall is still likely to be significant. Without substantial additional funding and support for the further development of a skilled and motivated workforce, little is likely to change.

This shift from symptom management to addressing underlying cause is exemplified in the view that we should not be asking those in distress “What’s wrong with you?”, but “What’s happened to you?” This question reveals a different understanding of mental health and leads to a different, and perhaps a more caring, approach to support giving.  

John Fitzgerald, PhD is the President-Elect of the New Zealand Psychological Society and a Senior Lecturer in Clinical Psychology at Massey University, Wellington. The society is the national professional association for more than 1200 psychologists (plus 600 student members) working in a wide range of health, education, justice, corrections, children and young people’s services, academic and NGO settings.

[1] Elliott, M. & Cloet, A. (2017). People’s Mental Health Report. Wellington: ActionStation Aotearoa. https://www.peoplesmentalhealthreport.com/

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2 COMMENTS

  1. May I quietly remind John Fitzgerald that endogenous depression and schizophrenia are genetically determined mental illnesses. So eo ipso, “shifting from symptom management to addressing underlying causes” is an impossibility.

    These two mental illnesses are, you know, the most destructive of them all – in fact the only two we ever need really worry about.

  2. Thank you John for your timely and helpful overview of the need for a fundamental re-visioning of the mental health field and the sort of services needed. We still need to take the research on the effects of trauma, especially childhood trauma, seriously in planning and implementing mental and all health services. However I believe that we will still ‘miss the boat’ or end up ‘fiddling while Rome burns’ if we do not address the fundamental issues of inequity in the distribution of income, wealth and the decision-making influence they confer. Between the previous two censuses I understand the percentage of the national wealth owned by the richest ten percent of the population rose from 55% to 60%. The poorest 40% of the population still owned only 3% of the nation’s wealth. The vast bulk of those needing mental health services are clustered in that poorest 40% of the population. Ten percent of the wealth of the richest ten percent of the population redistributed to the poorest forty percent might make that fifty percent of our population significantly healthier!

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