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The overarching kaupapa emerging from the collective voices is hope for universal, integrated, community-focused health promotion alongside a set of services accessible to those who need them, when and where required. (NGO provider representing voices of staff, service users and families)

We heard that our mental health and addiction system is not fit for purpose. We have a health system that focuses on responding to psychiatric illness, but people want a system that prevents mental distress and addiction, intervenes early when problems start to develop, and promotes wellbeing.

Repeatedly, people talked about the need for fences at the top of the cliff, rather than ambulances at the bottom. They called for policies to address the societal foundations of mental wellbeing as part of a strategy of promoting physical, social, cultural and spiritual wellbeing. We were reminded that “there is no health without mental health”.

People called for transformation in our approach to mental health and addiction, with a focus on wellbeing and community solutions.

  • New Zealanders of diverse backgrounds asked for a more values-based and holistic approach to promoting the wellbeing of individuals, families and communities.
  • The strong consensus among Māori was that Te Ao Māori, mātauranga Māori, whānau, and te reo me ona tikanga are essential aspects of wellbeing for Māori.
  • Pacific peoples called for Pacific ways and world views of knowing and doing, where connection is paramount through relationships with family, community and the environment, to be honoured.

The Wellbeing Manifesto (Table 2),26 with its call for a shift from ‘big psychiatry’ to ‘big community’, encapsulates several dimensions of the paradigm shift many submitters desire.

Table 2: Wellbeing Manifesto – from ‘big psychiatry’ to ‘big community’

Big psychiatry

Big community

Mental disorder is viewed primarily as a health deficit.

Mental distress is viewed as a recoverable social, psychological, spiritual or health disruption.

A mental health system with a health entry point led by medicine.

A wellbeing system with multiple entry points led by multiple sectors and communities.

Most resources are used for psychiatric treatments, clinics and hospitals.

Resources are used for a broad menu of comprehensive community-based responses.

Employs predominantly medical and allied professionals.

Employs a mix of peer, cultural and traditional professional workforces.

Has a legacy of paternalism and human rights breaches.

Has a commitment to partnerships at all levels and to human rights.

Focused on compliance, symptom reduction and short-term risk management.

Focused on equity of access, building strengths and improving long term life and health outcomes.

Responds to people at risk with coercion and locked environments.

Responds to people at risk with compassion and intensive support.

A colonising medical system that excludes other world views.

A bicultural system that embraces many world views.

All around the country, people advocated for Te Whare Tapa Whā,27 the concept that health and wellbeing are underpinned by four cornerstones: taha tinana (physical health), taha hinengaro (mental health), taha wairua (spiritual health) and taha whānau (family health).

People emphasised the value of community hubs and networks of peers who have themselves ‘navigated the storm’. Families and communities wanted to support tāngata whaiora to return to wellness, with expert help when needed.

What’s working in the community? It’s community that’s working in the community. (Kaimahi Māori)

As part of the widespread call for a focus on wellbeing, people asked for prevention initiatives and services to be integrated across the system. Suicide prevention, in particular, was emphasised in a high number submissions given the rates of suicide and the devastating impact on families across Aotearoa New Zealand.

There was a strong call in submissions to embed prevention services into the education system and workplace. These services include evidence-based resiliency programmes, particularly in early childhood centres and schools, whānau-based programmes, emotion regulation training, properly funded counselling, and mindfulness training.

Prevention was seen as a societal response, not simply a health service issue.

Strengthening protective factors is not a role that is best led by health services alone, but by whānau, hapū and iwi, Pacific peoples, Rainbow and other communities, universities and tertiary providers, schools and early childhood education providers, workplaces, sports groups, faith centres, social services, organisations that support positive parenting, youth development, and positive ageing, and a range of other community sectors.28

2.2.1 Help through the storms of life

People described grief, sadness and loss as challenging but ordinary parts of life. We were told that people need help through these ‘storms’ and that we should stop classifying them as ‘illnesses’. They said that defining mental distress as an ‘illness’ reinforces a deficit mindset and requires people to identify as sick in order to qualify for assistance. People want to be active participants in their recovery, not just passive recipients of services, and to be encouraged and supported to heal and restore their sense of self.

They said their desire to participate in decisions about their lives was often ignored by clinicians wielding power or seen as an obstacle to be ‘managed’ rather than an essential aspect of their pathway to wellbeing.

I think there are messages we are supposed to learn through this storm and medication is only a temporary fix, but most importantly is exercise, healthy eating, sleeping … the spiritual side … Feeding my mind with positives ie, reading my spiritual devotions, shopping, only connecting with positive friends/family. (Service user)

2.2.2 Seeing the whole person

People complained that the biomedical approach fails to see the whole person, so provides only part of the answer (and sometimes no answer at all) to restoring and maintaining wellbeing. They said that merely matching people to a diagnostic label such as depression, psychosis or schizophrenia and treating their distress as a problem of brain dysfunction or a problem that can be relieved by medication, does not address their overall life circumstances or their personal histories, traumas and challenges.

The ideal system would acknowledge and attend to the whole person in the one facility. An overall positive transformation would take place without compromising other aspects of health and wellbeing as a result of service delivery. (NGO provider of Kaupapa Māori services)

Workers at all levels of the system questioned the effectiveness of current clinical practice models. We were told that medical science is only part of the answer and that the health system alone cannot solve the crisis in mental health and addiction.

Although medication can often be necessary and life-saving, we also need comprehensive services that mean people’s mental health can be looked after fully – this would involve root causes of issues being explored. (Service user)

People noted that, although many service providers aspire to a more holistic model, it’s often not evident in their practices and 15-minute general practitioner (GP) consultations don’t allow it. The Wellbeing Manifesto listed 12 aspects of a holistic model, with psychiatric treatment being only one aspect alongside advocacy and navigation services, education and employment support, and whānau and parenting support.

In my experience, the patient is not treated as a whole, but a fragment of the area of expertise the particular doctor is trained in … A band aid will eventually wear off, fix the wound and there will no longer be a need for the plaster. (Family member caring for service user)

People criticised current services for failing to acknowledge how much mental wellbeing is a function of meaningful work, healthy relationships with family, whānau and community, good physical health, and strong connection to land, culture and history.

Employment is a huge part of recovery. It is important for self-esteem, routine, social connectedness, physical health, and of course it helps to relieve the poverty that is very often part of the lives of someone with poor mental health. (Service provider)

A person’s connection with their family, culture and identity can be a significant source of strength and recovery. (Advocacy group)

26  Developed by Mary O’Hagan in consultation with tāngata whaiora, Māori, Pacific peoples, health promotion experts, mental health professionals and mental health system leaders: M O’Hagan. 2018. Wellbeing Manifesto for Aotearoa New Zealand: A submission to the Government Inquiry into Mental Health and Addiction (prepared for PeerZone and ActionStation). www.wellbeingmanifesto.nz/.(external link)

27  MH Durie. 1985. A Māori perspective of health. Social Science and Medicine 20(5): 483–486.

28  Le Va, Te Rau Matatini, Changing Minds, A Beautrais, Northland District Health Board, Clinical Advisory Services Aotearoa, Victim Support, Te Rūnanga o Ngāti Pikiao Trust, Skylight, and Mental Health Foundation of New Zealand. 2018. Five Key Solutions for Suicide Prevention in New Zealand: A submission to the Government Inquiry into Mental Health and Addiction – Oranga Tāngata, Oranga Whānau. www.mentalhealth.org.nz/assets/Our-Work/policy-advocacy/Five-key-solutions-for-suicide-prevention-in-New-Zealand-a-submission-to-the-Inquiry-on-Mental-Health-and-Addiction.pdf.(external link)

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