What are DHBs? According to the Ministry of Health (MoH) DHBs are “responsible for providing or funding the provision of…
I ask Facebook. It seems people on Facebook are okay sharing the inner workings of their brains, their good days, their bad days.
I post: “I’m looking for people who have experience with antidepressants and/or counselling, specifically, people who function well in ‘normal everyday life’. PM me.” Two minutes later, I’m overwhelmed by responses. Before I even speak to them, I’ve learnt the three most important things about mental health: People want to talk about it. Lots of people are dealing with it. The range of experiences is vast; the triggers, diverse. (See sidebar for a selection of people’s thoughts.)
My Facebook findings are a microcosm of the mental health conversation beginning to happen in New Zealand. The People’s Mental Health Report, a crowdsourced, crowdfunded report from Action Station, and Mental, a collective portal for mental health stories, are opening up an online discourse that’s attracting attention.
The Government’s Mental Health and Addiction Inquiry is looking more formally at gaps in mental health services and has carried out extensive consultation with users, practitioners and lobby groups. It’ll report back in October.
Speaking on the inquiry, and the Government’s recent commitment to putting $43 million into mental health by 2020, Mental Health Foundation boss Shaun Robinson says it’s a good start, but notes how far NZ still has to go. “We’d like to see increased emphasis on prevention, communities that are better equipped to help each other, and easier access to a wider range of effective choices in mental health support.”
Choices, communities talking about the issues, and early intervention – even better … prevention – are the clear calls-to-action for those at the coal face.
Cracks, gaps and limits
Unfortunately – and believe me, BayBuzz has tried – no health organisation in Hawke’s Bay can provide a reliable estimate of the number of people in our region who are presently receiving mental health assistance, let alone a number of those who might need and benefit from it.
Of all patients presenting with mental health issues, only 2% are seen by services at the DHB. Exact figures are difficult to pin down for numerous reasons … from a lack of clarity around defining mental illness to range of providers to commercial sensitivities (some services will not release figures for business reasons).
GPs say they see between three and five patients daily presenting with mental health issues, with some seeing as many as eight. One in six New Zealanders experiences a mental health issue at some stage in their lives; one in seven before they turn 24.
For those officially classed as ‘mild to moderate’ the options available are limited, short term and narrow, even with a GP’s expertise and recommendation. One of the issues is that some of those who have greater or more complex needs than ‘mild to moderate’ are serviced by the same pot of resources. Actual ‘mild to moderate’ patients then fall further down the priority list. Some persist, becoming proactive advocates for their own wellness; some self-medicate with drugs and alcohol; others give up.
The resource pot is itself limited. Up until last month each general practice in Hawke’s Bay was given a certain number of packages of care. One such practice is Taradale Medical Centre, where partner Dr Cormac FitzGerald specialises in mental health. Up until June, each quarter his practice has had ten packages of care to hand out to patients. With 10 full-time GPs seeing 15,000 patients the packages don’t go far.
The recently-introduced PHO bulk funding model has increased the care packages from 10 to roughly 15. One package can include four sessions with a counsellor or psychologist. It was once possible to extend this to eight, but it is now capped at four in most cases. FitzGerald explains: “If you’re giving Patient A another four, then you’re not giving Patient B any.”
FitzGerald says care packages run out in the first few weeks of each quarter. People who missed out in the previous round then access them as soon as the next round is released. The flow-on effect is that those left over must wait. With the DHB only able to take a small percentage of those in need, some waiting for GP funding rounds are in far greater need than ‘mild to moderate’.
Once the allocation of four sessions has ended, or before they make it to the top of the list to access those subsidised sessions, patients needing counselling are paying between $120 and $185 an hour for it. Most in the profession agree, for the majority of issues a series of 12 sessions is preferable, although some small issues can be resolved by seeing someone only once or twice.
“It’s daunting for anyone wanting counselling. They will have to spend $500 to $1,000 to get the help they need, which is probably why a lot of people decide to take the ‘blue pill’,” says FitzGerald. “A lot of people just go for the meds.”
Bulk funding has opened up the option to use nurses to deliver some mental health help.
“We’re upskilling a nurse to be able to offer more time because it’s cheaper,” explains FitzGerald, who has himself found ways to give more to clients without additional funding. “I’ve started doing a problem-solving approach for some people where I see them once a week to talk about their stuff. Again, that’s cheaper than seeing a counsellor.”
Another tool GPs are using is e-therapies. Practitioners say online programmes like ‘Beat the Blues’ and ‘Mood Gym’ can help in many cases, and they are easily accessible and cheap.
Accessing resources is a jungle gym of hoops and obstacles and FitzGerald believes patients must remain proactive and motivated to get the help they need. For those on a sickness benefit, or so extreme they are suicidal, help is more accessible. For those maintaining a ‘manageable’ life, it can be a costly exercise.
“Unfortunately, they do fall between the cracks,” agrees FitzGerald. “It’s going to take a multi-pronged approach to treating these people because there’s definitely never going to be the resources for the number of people. You make do with what you’ve got, and you keep on going.”
Dr Tim Bevin is Mental Health Medical Advisor to Health Hawke’s Bay (HB’s PHO) and a GP at Central Medical in Napier. He puts much of the blame for poor mental health statistics at the feet of New Zealand’s booze culture.
“There’s a lot of self-treatment these days with alcohol,” explains Bevin. “A lot of people I see have had an anxiety problem for years and they’ve self-medicated with alcohol or drugs.”
He believes prevention is the most important part of the puzzle. “If we had really good health education for our kids about looking after our mental health, particularly with regards to alcohol and drugs, it would go a long way towards forestalling all of this,” says Bevin.
Bevin believes many of the simplest, cheapest fixes are also the most effective: exercise, connecting with people. But once the blues hits, the hardest thing to do is get motivated … the effects of depression keep people inactive and withdrawn. Medication like Prozac, and packages of counselling, give patients some respite, but more time is required to make changes that will last longer than the meds or the limited sessions.
As well as self-referrals and help sourced through GPs, some people can access counselling support through their employer – generically referred to as ‘employee assistance services’ (EAP). One such provider is EAP Services, used by over 70 local companies in Hawke’s Bay, including manufacturers, wineries, the health and education sectors and government agencies. EAP Services equates this to approximately 7,500 people in the region, 70% of them women. EAP Services, like other providers, is paid for by employers under their Health and Safety at Work responsibilities.
Grant Wattie is EAP’s regional manager for Hawke’s Bay and Gisborne and a counsellor. “You are responsible if your employees are not functioning and they’re not safe at work. If they’ve got mental health issues and they’re not being addressed, then that will go straight back to the employer.” He explains this change in legislation means EAP is growing fast. “We are seeing a huge increase in our business; it’s just grown exponentially.”
Employers are using companies like EAP Services because they see a direct link between mental wellness and productivity, says Wattie. This does mean people are getting help early. “By having a brief intervention, paid for by the employer, people can get on top of these issues before it becomes a major thing.”
In most cases EAP Services will provide a person with up to six sessions. They believe in a short time they can tool-up clients to improve their mental wellbeing; this can include self-care plans and ways to develop improved self-esteem and coping mechanisms.
“The biggest trigger is anxiety, people are stressed, they’re not coping with life and they’re overwhelmed by their emotional state. Potential redundancy, uncertainty in the work place, communication, perceptions of different personalities in the workplace which leads to conflict. Then you take that home, [add in] the stuff that goes on in life, and you say, ‘I can’t cope any more’,” explains Wattie, who believes EAP-type services have a massive impact on the wellbeing of New Zealand.
Another avenue to access help can be through ACC. What is termed ‘Sensitive Claims’ – those linked to sexual abuse, often historical – can include time with a psychologist or counsellor. Much of this work is picked up by Gains@Geneva (such ACC claims make up 40% of their work load) whose HB regional clinical manager is Marie Young, a practising clinical psychologist. Young says Gains is often fully subscribed and turns people away, a difficult thing to do considering the amount of bravery it takes for a person to ask for help in the first place.
“It’s very hard to know what the volume is in Hawke’s Bay because it’s quite a fragmented system,” Young explains. “We’re not even aware of all the different organisations and what they do. That’s part of the difficulty. No one knows what each other’s doing or what resources are out there … it’s not a cohesive system.”
Young says there has been a shift away from services run by government agencies to private providers. There are gaps where people don’t fit the criteria for accessing resources.
“The area of difficulty is where you don’t meet any of the boxes: you don’t have a physical injury or you don’t have sexual abuse, there’s a real lack of funded therapy,” says Young. “We frequently get phone calls from people who have tried to commit suicide a couple of days earlier and have been told, ‘I’m sorry, but can you go private?’”
Young’s view is antidepressants do have some benefits, but they are not suitable for all mental health issues. She has no criticism of GPs in prescribing them and feels they’d use other options if they had them.
“The problem is they typically don’t. If they know they’re not bad enough for Mental Health [Services, through the DHB], they’ve run out of packages of care, and the person can’t afford to go private, what are they going to do?” Young explains. “Their only option is to provide a script.”
As a clinical psychologist, Young believes the reality is that many issues can’t be solved with medication.
“If it’s grief, no amount of medication is going to sort that out. If you’ve living in a violent relationship, there’s no medication that’s going to cure that for you,” says Young. “The GPs do what they can, but without access to a wider and more extensive range of care … they are going to inevitably rely on medication. Not because it’s a preference, but because it’s a reality.”
Psychological difficulties are multi-factorial, rooted in a range of different triggers, and as individual as the people experiencing them. There is no one-size-fits-all approach. Some people want to talk, others prefer art therapy or exercise programmes. The key is making connections with other people.
“What we need is a broad range of options,” says Young, who feels we are getting more savvy at looking for lateral solutions, although everywhere money is tight. “There’s a skills shortage. We don’t have enough highly trained people to do it. And there’s no funding because it’s a bottomless pit.”Ray of light
Within the spectrum of service providers that includes GP clinics, clinical psychologists and psychotherapists, there is a range of counsellors all working within different modalities. Verona Nicholson is a US-trained psychotherapist who works here as a counsellor, as well as training and supervising other counsellors. She feels limiting counselling sessions limits their usefulness.
“It takes time to create a safe bond. You spend some time doing that, then getting clarity, before you can work on what’s happening for that person.” The alternative is beginning a process that needs to be followed through to get results. “Do you start to open something up and then say: ‘We better pack all that up again’? We need a little time to practise, to learn some tools and try using them. Some people don’t even know what they need yet.”
Building a relationship and trust with a practitioner is key to successful engagement. That comes with time. Before work even begins, clients are battling with a stigma around seeking help. And working on many levels is the best way to activate changed habits and improved wellbeing. Alongside exercise this can include diet, art and crafts, making connections, working with spirituality, learning a new skill.
“Some people don’t even have themselves on the list of who they need to look after,” explains Nicholson.
Connections, conversations, creativity are all necessary parts of a holistic mental wellbeing picture. From GPs to counsellors, all agree on this. And providing a wrap-around service with room for these as well as practical problem-solving skills – like budgeting advice, or physical wellness – is crucial. But there are limited places actually walking that talk.
One of the very few is Heretaunga Women’s Centre. It’s the tiny light of hope and a signal of what can be achieved with the right mix of volunteer time, forward-thinking governance, clear management, and partnerships with providers and funders. While there are practitioners holding clinics for paying clients from the Centre, there are also subsided and koha sessions available, either one-on-one or in group work.
Radhika Soni is a counsellor who works out of the Women’s Centre seeing paying clients and contributing volunteer hours. “When we gift somebody something it’s free of any expectation. You gift from the heart and don’t expect anything in return,” explains Soni. She has identified that with women, the main seekers of mental health help, an inbuilt tendency not to prioritise themselves adds to the combination of mental wellness factors.
“Self-care, self-love, these are things that are kept on the back burner,” she says. “When [clients] talk about self-care they think it’s selfish, but actually it’s self-preserving and it’s so important.”
Counselling is only part of what’s on offer, with art, yoga, budget and legal help, peer support group sessions, or just meet-ups with conversation and cup of tea. That wrap-around care with the individual’s story as the focus is what many practitioners are talking about when they identify the gaps in the current conventional system.
“We know we are a very helpful service and we wish we had more of them because we sometimes have a very high case load,” Soni says. “We don’t want people to wait, but sometimes that happens.”
As a society, we would like to think we are open to this conversation about mental health. But there is still stigma attached. People see counsellors, but are likely to pass that off as an unspecified ‘meeting’. They’re more likely to see their GP about a raft of other things, then slip in talk of mental health near the end of the appointment … even hide their call for help from their spouse or family.
We’re all talk when it comes to talking about our minds. It’s still much more acceptable to discuss an ingrown toenail or a varicose vein than a case of the blues.
Radhika Soni believes change can happen within each individual and so effect wider cultural and societal change. “Ask someone how they are, then wait to hear them talk. Listen to them without feeling pressure that we should do something. Often, we can’t,” she says. “But we can listen.”