Prison or nothing: The ‘self-perpetuating downward spiral’ in New Zealand’s mental health system
With specialist mental health services in ‘chaos’, people who need help end up in destructive cycles and prison. Experts say there are solutions, but is political will and leadership lacking?
The house was on fire. Electronics melted; flames engulfed the walls and turned furniture into piles of charred wood and ash. Children had grown up in this house. Thick, dark smoke gathered around the ceiling. Family had visited, had meals together.
Students at the high school next door saw the flames lick the windows. The fire brigade was called, but when they arrived, a man in his 50s came out of the house wielding a knife. So the police were called, too. The man did not do as they asked. He was tasered, arrested and taken away.
It was June 2019, and it wasn’t the first time the police had been called to deal with this man. His daughters felt like life was stuck in a loop. A few years before the fire, he’d gone into an uncontrollable rage, attempting to stab a visitor in that same house. He was admitted to a mental health unit for a few days, where it came to light that he’d been hearing voices, and that his meth smoking was inducing psychosis. Trauma from his past was materialising in the present. He was given medication that made him soft and docile, and with a prescription to keep paranoia and aggression at bay, he was released.
For a while, he would take his medication and everything seemed fine. His wife worked and took care of him, and he cooked. According to his daughters, he was a good cook. Then he stopped taking his medication because he didn’t realise or believe he was sick. Psychosis returned. When aggression came, and it always did, the family would call the local DHB’s mental health crisis team, pleading for help.
At first, mental health support workers would come to the man’s house and persuade him to take his medication. He learned how to assure them that he would, so that they would leave. He became skilled in feigning compliance and good mental health, but his episodes grew worse.
His daughters would plead with the crisis team members to admit him into care, but they didn’t believe he met the threshold for compulsory treatment under the Mental Health Act. They said they couldn’t intervene because he was not an acute danger to himself or others. When his daughters said the danger was acute, they were told to call the police. The police would tell them to call the mental health crisis line. He fell into gaps within, and between, the systems.
And then, the fire.
No one to help
The gap their father kept falling into may be widening. Police received one mental-health related call every seven minutes in the year to May 2024, but from November, they will only respond to these if there is an immediate risk to life and safety. Events which fall short of the threshold will be directed to “more appropriate” services, police commissioner Andrew Coster said in a statement at the time. While on the surface alternative services seem appealing, in reality they’re threadbare and overstretched. In April, it was reported that the national telehealth service was struggling to recruit enough qualified clinical staff to operate the mental health phone lines. This is symptomatic of sector-wide challenges.
Growing demand for mental health services has been reported in Aotearoa for at least 15 years. In June, the mental health and wellbeing commission released a report which analysed changing patterns in accessing services and the options available over five years between 2018 and 2023. It showed an increase in the number of people accessing primary and community services, but a decrease in those accessing specialist services like inpatient mental health programmes.
More people with milder needs were being supported, while the commission heard that many with acute needs were having difficulty accessing support services. The report concluded that this was partly due to high vacancies in the mental health workforce, especially in specialist services, and a resulting need to focus on those with the most severe needs – in other words, there aren’t enough people to help. Put even more simply, fewer people accessed specialist services because there were fewer specialist services to access.
According to the report, the thresholds for accessing acute care have not formally changed in those five years, but their enforcement has become firmer. Doctors who make referrals perceived that thresholds had become higher. In some districts, specialist services (like mental health units) had told primary services (like the GP) they were full, and requested people suffering from mental health problems be cared for within primary and community services as much as possible.
The staff shortage is a “self-perpetuating downward spiral,” says Paul Skirrow, executive advisor of The New Zealand College of Clinical Psychologists, and senior lecturer at Otago University’s department of psychological medicine. In the 13 years he’s lived in New Zealand, he’s seen the mental health workforce “gradually deteriorate” from the inside out.
Data from the Health NZ workforce information programme shows vacancy rates have increased for psychologists, psychiatrists, mental health registered nurses and drug and alcohol counsellors in the past five years. “We see really, really poor retention rates for psychologists and psychiatrists in particular,” says Skirrow, echoing data that says vacancy rates for psychologists are 21.9% and 19.1% for psychiatrists. On top of that, the workforce is ageing (nearly 20% of psychiatrists are over 65); there’s a shift toward private practice; and the remaining staff are overworked.
While there’s a staff shortage across the board, it’s in the specialist services for patients with acute needs that the shortage is most concentrated. Skirrow says that as staff members move into “easier work” in the private sector, primary care or elsewhere, specialist care has become “more and more crisis-driven”. There’s not enough staff or time to “do the kind of good-quality work that they want, that you’d want them to do”. Helping patients becomes about patching them up and sending them away, rather than truly helping them get better.
Skirrow says that staff having to work in these conditions are increasingly suffering from moral injury. The term, coined roughly 10 years ago, describes the damage done to one’s conscience from transgressing moral beliefs, values, or ethics in war time. It is being applied to beleaguered healthcare settings around the world where professionals do not feel able to provide the care that their patients need.
Moral injury can lead to feelings of profound shame, guilt and anger. People enter the profession to help people, says Skirrow, and if this is no longer possible, they burn out and leave. “We’ve seen lots of reports of burnout among psychologists and psychiatrists in the public health system over the last few years, and mental health workers in general,” he says. With these outgoing workers go qualifications and experience that will take years, if not decades, to build up again.
The staff shortage is also the legacy of government underfunding for the training of psychologists. Clinical psychology training has been funded at substantially lower rates than all other health disciplines, with funding rates so low that courses typically run at a loss.
Many professionals in the mental health sector feel that it’s been treated like the second-class citizen of the health service for decades. Funding for specialist mental health and addiction services is based on an expectation that 3% of the population will need access to these services. The most recent national prevalence survey, Te Rau Hinengaro, conducted in 2003/04, estimated that 4.7% of the population experienced a serious mental disorder each year – experts think that over the past 20 years this has increased further.
The brick and mortar is in bad shape, too. Ministry of Health assessments of 24 mental health units in 2018-19 found that 70% did not provide adequate privacy, safety or therapeutic space. Many of these were in buildings which had been refurbished and repurposed to accommodate the mental health units and which did not have appropriate floor plans. Day, seclusion, interview and meeting rooms were being used as bedrooms. Most of the buildings were low-rise and therefore easier to maintain, yet their interiors were in worse condition than other parts of hospitals like emergency departments and surgical wards. There were holes in walls, leaks in ceilings, rippling worn carpets and poor bathroom facilities.
Although their family home had been reduced to a charred skeleton, the man’s daughters felt a sense of relief mixed with their grief. Surely the fire was unignorable proof of their father’s mental illness, and of his danger to himself and others. This would be the end of their pleading, they thought. Now, their dad would get the help he needed.
At the scene of the fire, the man was arrested. No one told the family where he was taken next. His daughters called the police, but were told he wasn’t in the custody system. Then they called hospitals all around the city, but he wasn’t there either. Court officials and lawyers didn’t know where he was.
Weeks went by, and the man’s daughters kept calling people who didn’t know his whereabouts. The daughters hoped their father was in psychiatric inpatient care. Then, by chance, someone said he could be at the remand unit at the Mount Eden Corrections Facility, where people who cannot be released on bail are held while they await trial. It was difficult to find out if this was his location – the daughters had to call several times before a worker bent the rules to tell them that yes, he was. By then, it was August 2019.
After an ongoing court process, the man was sentenced for the crimes of arson and obstructing first responders in December 2020, a year and a half after the fire. He had been held in remand almost the entire time and the judge gave him no extra prison time beyond his time already served. However, the man was ordered to attend community drug addiction services, as he had been diagnosed with meth-induced psychosis by a forensic psychologist.
Surely the fire was unignorable proof of their father’s mental illness, and of his danger to himself and others.
For a while, things seemed good. The man was taking his medication regularly. The burned house was sold to developers, and the family bought an apartment with that money where he now lived with his wife. That’s where the family gathered for Sunday night dinners.
The man’s sentence required him to use community addiction services for a few months. When he was no longer obliged to use them, he stopped, and the aggression and paranoia crept back in. His episodes became more frequent and violent, and the family kept calling the mental health crisis line. The helpline workers alternated between saying the man was not acute enough of a danger, or that he was too dangerous for them to help.
The daughters were at a loss for how to deal with him. They began to call the police. When the police came, they would usually detain him for a few days, then release him again. The daughters continued to ask if there was a way to refer him to a mental health institution, but the police referred them back to the mental health crisis line. For months they were stuck in this loop.
During this time, much of the man’s violence and outbursts were directed at the person closest to him: his wife. It came to a point that she no longer felt safe, and so daughters helped her file a protection order. It didn’t take long for him to break it – by throwing a brick through the window of her home. He was quickly put back on remand.
The new psychiatric institutions
While in New Zealand, two in 10 people experience mental illness in their lifetime, over nine in 10 people in prison have a lifetime diagnosis of a mental health or substance use disorder. The Department of Corrections is managing more people with mental illnesses than any other institution, which has led forensic psychiatrist Erik Monasterio to call prisons “the new psychiatric institutions”.
In prison, mentally ill people might be out of sight and out of mind for many other New Zealanders, but it’s unlikely they’re getting the help they need. “Prisons are probably the worst environments for mentally disordered people,” says Monasterio, who until last year was the clinical director of Area Mental Health Services in Canterbury. He says he resigned because despite his best efforts, systemic factors prohibited him from leading adequate services. Now he pushes for change from outside the system.
Monasterio poses the following question: “If you send mentally ill people to prison, and they don’t have the environment or the trained staff to understand and assist them, what are they [corrections officers and prison staff] going to manage?” The answers aren’t good. One “solution” is the intervention and support units (ISU) prisoners are put in if they have acute mental health needs, and are awaiting transfer to hospital or forensic inpatient mental health care (which can take weeks). In ISUs, prisoners are isolated for up to 23 hours a day, for an average of 6-7 days at a time, meeting the UN’s definition of solitary confinement.
During the 2022-2023 financial year, 3,296 prisoners spent time in an ISU. Though their use is widespread, Monasterio considers it unethical.
He is far from alone in his thinking. In March 2020, every single clinical director and forensic director of Area Mental Health Services around the country signed their name to an editorial in the New Zealand Medical Journal arguing human rights violations of acutely mentally ill people in our prisons, particularly in the ISUs. They noted that while our prison population more than doubled since 2000, “the increase in the prison population has been met by little increase in prison capacity or funding for specialist mental health services in prisons.” As a result, the signees saw the services as “unsafely stretched”, as many services had to put people needing immediate psychiatric inpatient treatment on waitlists.
“It’s very easy to blame the prison,” says Monasterio, but he thinks the origins of the problem are further up the chain, and that mental health services should be appropriately funded to help people before they end up behind bars.
There are legal avenues to compulsory psychiatric care, sometimes referred to as “sectioning”. The first and most common comes under section 29 of The Mental Health (Compulsory Assessment and Treatment) Act 1992. Anyone over the age of 18 can apply for another person to be assessed for compulsory treatment. From there, a statutory process follows, where ultimately a person can be brought before a judge (usually in Family Court) to determine whether they meet the definition of being mentally disordered, and so be subject to compulsory treatment under the Act.
If they do, it’s usually a community treatment order, where they remain in their own home – this can last up to six months. The use of community treatment orders is growing and has been described as “extensive”. In 2021, almost 7,000 people were under compulsory treatment in our communities. There were more Māori in that group than any other ethnicity.
Under a community treatment order, someone can be medicated without their consent, and have their movements restricted. They are visited at home (usually weekly) by community mental health nurses, who supervise their medication (tablets or injections) and must attend appointments with a psychiatrist (often monthly).
In July 2023, the Mental Health and Wellbeing Commission released a report on the experience of people under these orders. Hayden Wano, chair of the commission, said at the time that “the use of compulsory community treatment orders is a practice from mental health that is out of step with human rights and current approaches to mental distress.” The conclusions of the report were that the process was “disempowering” and people were silenced, excluded, overridden and marginalised from the processes of decision making. The report says that the process has a counterproductive impact on therapeutic relationships, and reduces people’s trust in services.
Work to repeal and replace The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been underway since 2019, but change is still years away. The report calls for intermediate change through a reduction in the orders, more collaborative decision making, and services moving from “exclusive to inclusive” by using plain language, taking more time for decisions and involving whānau and other support people.
In 2021, almost 7,000 people were under compulsory treatment in our communities. There were more Māori in that group than any other ethnicity.
Another outcome of section 29 are inpatient orders, where the patient must stay at a hospital. These are rare, and reserved for those who have a chronic and enduring mental illness for which hospital is the only realistic option. “It’s a fairly tight system,” says Warren Brookbanks, professor of criminal law and justice studies at AUT and founder and director of their Centre for Non-Adversarial Justice. “It’s not easy to get in, and it’s not necessarily easy to get out.”
Orders last for six months, and can be renewed for another six months. After that, patients have to be brought before a judge every year to assess whether their compulsory treatment should continue.
Compulsory treatment is not something that’s intended to be indefinite, says Brookbanks, who was involved in drafting the 1992 Act. (“I’ve been around mental health law for a long time.”) To Brookbanks, compulsory treatment is about giving someone support to be able to manage their difficulties, and develop skills so that they can live “reasonably comfortably” back in the community. “But it is a tension between personal freedom and state compulsion, which we need to carefully manage.”
There’s another route to compulsory care under the Criminal Procedure (Mentally Impaired Persons) Act 2003. If a person has been convicted of an offence, and there’s concern that they may have a mental disorder, the court and the lawyer can make the submission to the judge at sentencing. Under section 34, the person could be “detained in a hospital as a special patient” instead of going to jail or another punitive sentence. Historically, this has been thought of as a benevolent alternative to prison. Once clinicians conclude that the patient is no longer mentally disordered, they can be discharged straight back into the community.
Hybrid orders combine compulsory inpatient treatment and a jail term. The person goes straight from the court to hospital for treatment, and once the clinicians conclude that they’re no longer needing treatment, they then go to jail to serve their jail term. This was the order given to Lauren Dickason, who was found guilty of murdering her three young children. She was sentenced to 18 years, and began this time in a mental health facility where she will stay until she is deemed mentally well enough to enter prison. Hybrid orders can also be used for lesser offences.
If someone becomes seriously mentally unwell while in prison, the CEO of the jail can apply to have them assessed under the Mental Health Act, and they can be transferred to a psychiatric hospital for compulsory assessment and treatment. (The prisoner would likely have to spend weeks waiting in ISUs.)
The key to all these routes is meeting the definition of mental disorder and risk under the Act. One or more health assessors (at least one of whom must be a psychiatrist) must provide evidence that the defendant is mentally disordered. Brookbanks says someone has to have an “abnormal state of mind characterised by disorders of mood or volition or cognition”. There also has to be evidence that they are a serious danger to themselves or others, or that they are incapable of self care. “Both elements have to coexist,” says Brookbanks. “If you can’t meet one or other, then the person can’t be compulsorily detained.”
Though this legislation exists, its use is “never a given in any particular case,” says Brookbanks. People are wary of compulsory treatment, and the balance between personal autonomy and enforced care is always a thorny issue. Critique of compulsory care is often couched around the protection of human rights. Brookbanks says that typically people who are placed in compulsory treatment have serious and enduring mental illnesses, like schizophrenia, major depression or bipolar disorder. They will be seriously unwell and experiencing delusions or hallucinations and so are losing touch with reality. Often, orders for inpatient care are driven by concerns over public safety.
Political action
“I want to make sure that the role makes a difference,” says Matt Doocey. (The Spinoff spoke to him in April, when he was six months in as our very first mental health minister.) He’s got three priorities in this portfolio: increasing access to timely support, growing the mental health workforce, and early intervention and prevention.
Much seems to rest on the second priority, growing the workforce. National’s election pledges included increasing the number of psychiatry registrar placements by a third (around an extra 13 a year) and increasing the clinical psychology internship placements by 10 each year, until the current number, 40, is doubled.
But there was no money set aside in the budget for these pledges. “Budget 2024 was all about delivering the coalition agreement,” says Doocey by way of explanation, adding that he is “still committed” to National’s pledges. He says he has a specific mental health and addictions workforce plan underway to lay out the best way to address the shortages. It will include retention, migration, training and new registrations. “We’re starting from scratch,” he says, adding that he was disappointed to find a plan like this didn’t exist already.
In the short term, Doocey is trying to “think outside the box”. He has allocated a million dollar fund to train peer support specialists to work in emergency departments around the country. He is also looking at creating a new role: assistant psychologists. He says around 400 people graduate with a psychology degree, don’t get one of the 50 clinical internship placements, and then “disappear from the field”. They could instead become assistant psychologists. These roles can take the burden off psychologists and psychiatrists, he says, but shouldn’t entirely replace them. These changes can be implemented fairly quickly, unlike training a psychologist, which takes at least four years – longer than a parliamentary term.
Rather than treat mental health as a political football, Doocey says he firmly believes “New Zealanders want us to take a bipartisan approach.” He’s already met with the cross-party Mental Health and Addiction Wellbeing Group, which includes an MP from each party and aims to achieve cross-party dialogue and develop a collective vision and direction for policies regarding mental health, addiction, and wellbeing. Doocey was once a part of this group and plans to continue meeting with them quarterly. “I’ve made it very clear with them that I want to work collaboratively with them.”
The mental health minister role is not tied to one government department, but can rove between them. For example, Doocey can work within the health portfolio, the corrections portfolio and the education portfolio. In this capacity, Doocey has met with corrections minister Mark Mitchell and says they are assessing how budgets are currently being used in forensic mental health services, and how they might be put to better use.
“It’s a responsibility of the government that if someone is in jail, we do everything possible to support that person turning their life around,” Doocey says. “If that means, for instance, screening them for neurodiversity, or it means providing them with timely assessment for addiction issues or treatment in mental health which they haven’t potentially received before, then I think we should be looking at doing that.” As of yet, there are no set plans.
Having a mental health minister is “a really bold and positive move,” says Dougal Sutherland, an adjunct teaching fellow in clinical psychology at Te Herenga Waka and CEO of Umbrella Wellbeing. “Any time you’ve got a particular strong need in the society, then having that top level representation is really helpful.” Sutherland says that compared to physical health, mental health has been treated like “the cousin that you didn’t want anybody else to see, so you kept them in the back room.” He hopes that having a dedicated minister in cabinet will take mental health out of that back room.
But not so long ago, the mental health sector’s previous high hopes that political help was on the way were dashed. In 2019, the Labour government claimed to be “the first government to take mental health seriously”. They dedicated an unprecedented $1.9 billion to improving mental health services.
“I remember being amazed, gobsmacked, by the $1.9 billion when it first was announced,” says Sutherland. Finally, the mental health sector would stop being thought of, and treated like, the second-class citizen of the health service. Four years later, Sutherland wrote, “it is clear these high hopes have not been realised”.
The government “spent a lot on primary care, which was great and useful, but it wasn’t matched with spending into acute mental health areas,” Sutherland says. Very little “was directed towards the more acute services that are offered by a DHB or Te Whatu Ora.”
This skew of funding has had mixed outcomes. At the primary level, it has given a wide range of people with mild needs quick access to mental health support. “Investing in primary mental health is supposed to be a preventative measure,” says Sutherland. Yet it’s also created an “ironic position” in that providing more primary support uncovers more need for specialist services. “A good proportion of [patients] will end up needing some secondary level support anyway, so we kind of create more demand and then can’t fill that,” he says. “It’s like they open one gate and let people into the first paddock, but then there’s still really tight gates into the second paddock.”
Another outcome is a shift of staff from acute to primary care. Since there are sector-wide staffing shortages, Sutherland says this is like rearranging deckchairs on the Titanic. “We shouldn’t have to say, ‘Either we have people in primary mental health or we have psychologists in secondary services.’ We should say, ‘Actually, we need more in the workforce across primary and secondary settings.’”
While the government increased the number of funded clinical psychology internships to 28 in 2022 from 12 in 2017, Sutherland says it was nowhere near the extent needed. In 2021, the then health minister, Andrew Little, had claimed New Zealand did not need an “army” of psychologists. To Sutherland, this didn’t align with reality, “all the evidence we had was that people did want, need and were searching out psychologists.” Sutherland thinks the lack of focus on this area could be put down to the fact that psychology training takes at least four years, and an election cycle is three.
Forensic psychiatrist Monasterio says that while the challenges are compounding, “because of the ageing population, because of drug and alcohol problems, and because of growing inequality,” they can be tackled – “it just needs active leadership, clear vision, and courage.” he says. “Let’s come to some cross party agreement here – a set of priorities for health with long-term perspectives.”
The district court is a brick, two-storey building with a flat roof. Inside, courtrooms with low ceilings are connected by tiled hallways with big windows that overlook a crisply mowed lawn. Earlier this year, the man’s youngest daughter asked the duty lawyers there for help. She wanted to know how to request that the judge sentence her father not to prison or to community services, but to inpatient psychiatric care.
The first lawyers she asked were unsure – it’s not something they had experience with. They led her upstairs to a senior lawyer. The daughter remembers him being tall and holding a leather briefcase. He explained that what she’s asking for is called “sectioning,” where someone is treated under the Mental Health (Compulsory Assessment and Treatment) Act. It’s technically possible, he told her, but difficult for a lawyer to argue for. He said it was unlikely any of the duty lawyers in the building would be willing and able to build that kind of case, and he couldn’t direct her to any private lawyers who could, either.
This was the moment when the daughter began to think about things differently. For years, she and her sister had tried to navigate the mental health and legal systems with the aim of getting their dad long-term psychiatric help. It seemed impossible.
In May 2024, the man appeared in court again. The judge-only trial was scheduled to last a whole day. His eldest daughter took a day off work to watch from the public gallery. About an hour in, the man pleaded guilty. Again the judge decided his time served on remand was sufficient punishment. He made no order for the man to seek psychiatric care. He was simply let go.