Terminal hopelessness

We will all die and that’s a fact.  What is not known is when or how we will die. For some their daily suffering is so intense that death becomes preferable to living.

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For some, the prospect of a lingering terminal illness creates such hopelessness that assisted suicide is an attractive option to put an end to the constant physical pain, total dependence on others and accompanying loss of dignity. This is not a legally available option.

Others with mental illness face the same terminal hopelessness. Their decision to end their lives is a much too common tragedy to be circumvented at any time but particularly during the troubled years of youth. Many of us experience depression at some time but most make a full recovery, with or without professional help.  Makes you wonder how effective our mental health services really are.

Wonder no more, because the Health and Disability Commissioner has carried out an independent assessment of the country’s mental health and addiction services. The Health and Disability Commissioner (HDC) Report was produced by this independent watchdog whose purpose is to promote and protect the rights of consumers of health and disability services.

The purpose of the HDC report is to assess the performance of mental health and addiction services and make recommendations for service and system improvement.  While there is a fleeting reference to the United Nations Convention on the Rights of Persons with Disabilities, the needs of the disabled are not evaluated in The Monitoring and Advocacy Report of the Mental Health Commissioner of February 2018.

Putting aside this important fact, the HDC report makes for grim reading. It states one in five New Zealanders lives with mental illness or addiction.  A New Zealand health survey conducted annually by the Ministry of Health, NZ Health Survey 2016-17 Update of Key Results provides this statistic, but it is tempered by the severity of mental illness.  Under 5% of New Zealanders will be considered to have a severe mental health/and or addiction problem, 7% moderate and 9% are mildly affected.  The most common group of disorders relate to anxiety, mood and substance use.

While the rate of suicide in the general population has been declining over the last 15 years, provisional figures from the Chief Coroner shows a recent upturn in numbers. 606 people took their lives in the 2016-17 year compared to 579 the previous year and 564 the year before that.  This is 15 deaths in the first year increasing to 27 in the most recent year. Of particular interest is the data from the 2016-17 year which says 180 deaths were suspected suicides in services.  Suspected because some deaths may have been an accidental drug overdose. In any case, the report acknowledges these numbers reflect badly on our mental health services but this is about real people dying, not statistics.

While growing numbers of New Zealanders are accessing health services for mental health and addiction issues, these services are under pressure and many needs are left unmet.

The report urges the government to adopt a policy of zero tolerance of suicides in services. If this goal had been achieved in the 2016-2017 year some of those 180 lives would have been extended.

Assuming we could have prevented all genuine suicide attempts, how many people would thank us for saving them? How different is their argument from that of the terminally ill who would end their wretched lives if they could? The difference is that the suicidal have the possibility of returning to a productive life whereas the terminally ill do not. If we cannot free the suicidal from terminal hopelessness we are only extending their misery.

The excuse for the poor performance of our mental health services is that funding has not kept up with the huge growth in demand for services over the last ten years where access to mental health and addiction services grew by 73% but funding increased by only 40%.

Over 70% of people who attend addiction services have co-existing mental health conditions, and over 50% who attend mental health services are estimated to have co-existing substance use problems.

Mental health is compromised by addiction issues, and the under resourced mental health services weakened by including them.  Surely the addiction issue needs independent resourcing? The report does not suggest this, but it does refer to the complexity resulting from the combination of mental health and addiction.

The report discusses the potential to deliver virtual mental health and/or addiction self care support through technology such as website, phone and text chat with trained counselors, online peer support groups and e-therapy.

This is a soulless retrograde step.  It may be cost saving to use technology to evaluate mental health, but how can it replace the warmth, understanding and dialogue provided by an actual person?  The answer is that it can’t.

Our fragmented society has developed a digital dependence where young people are reliant on TV, iPad, smart phone and computer for social interaction.  Families are not as large or cohesive as they were 50 years ago, removing the opportunity for daily dialogue between a confused family member and their siblings or parents.  Replacing real people with computer programs is ominous.  One survivor of mental illness believes the measure of how well we are doing, or how our success can be measured, is in how well we treat the mentally ill.  We need to treat the mentally ill as people, not  problems.

The HDC report is based on feedback from consumers [of health services] and their families and under its areas of concern the report notes:

A low commitment by services to shared planning with consumers and their family and whānau.

This lack of liaison between the mentally ill, their family and health services is indicative of a larger problem: the inability of health services to recognise the asset right in front of their noses, which is the family.  Despite the legal requirement under the Mental a Health Act 1999 (Section 7A) for services to consult with family, not only do our health services refuse to engage, they are actually obstructive to family involvement.

There is evidence that services create unnecessary barriers to family and whanau engagement….services used privacy as a way of disengaging with family.

The unconditional love and support provided by a caring family environment cannot be underestimated for its positive effect on a child’s development and mental stability.  It is also a crucial support for youth when they make bad choices.  Unsurprisingly, the state says it knows best, and although it canvassed feedback from family, the report does not acknowledge the importance of family, which is the backbone of society.

Currently there is a lack of integrated collaborative leadership in the sector. This is reflected in the failure to track tangible progress against and to develop a plan to succeed it.

The next HDC report will likely be a rehash of this report and the previous one, the 2012-17 plan Rising to the Challenge where it’s failure to achieve the defined goals is described as system inertia.

The structure of the health sector with the Ministry, 20 DHBs, PHOs and NGOs resents inherent leadership and coordination challenges.  However for a complex area such as mental health and addiction, effective, collaborative leadership within the sector and across the broader social system is essential for success.

Jacinda Ardern promised to address the high teenage suicide in her platform leading up to the 2017 elections.  Our youth suicide rate is among the worst in the OECD, the suicide rate for 15-19-year-olds accounted for 35% of all suicides in 2103. So will Ardern provide the leadership the sector believes will solve its inadequacies?

Probably not, because examining the wider effects, including mental health, of our current social welfare system will require a far more critical eye and a very different viewpoint to the nanny state that Ardern endorses. The effects of continuing to financially support dysfunctional families, and the changes needed to correct this, will take a strength of leadership seldom seen in political leaders and most likely outside the capabilities of our current leaders.

The HDC report acknowledges our mental health services are failing. They are not giving hope to the terminally hopeless and until they do, the number of resulting suicides will continue to grow.

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The subject evoked in the collage is the debating of political issues with friends in a public place

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