*Content warning: This story discusses themes of suicide*
Activities and therapies are key to good inpatient care. In the third piece in a series on mental health units, Oliver Lewis examines how the ‘meds and beds’ model could change.
After giving birth to her daughter, Jude* experienced severe postnatal depression along with obsessive, frightening thoughts relating to her baby. The Auckland woman was admitted to respite crisis care and, from there, into a mothers and babies unit under the Mental Health Act. Being in the unit saved her life, Jude said, but it was a stark, clinical space with little to do.
Once, she asked a staff member if the advertised bonding with babies group was going ahead.
“They just laughed and said we used to run groups but we’ve got a bit lazy,” Jude said.
“It was so distressing and upsetting to not be able to connect with this baby, who was so wanted.
“I desperately wanted to connect with her, and she thought it was a joke that they got a bit lazy and didn’t run groups around that anymore.”
READ MORE IN THIS SERIES
* Part one: 'Dilapidated’ mental health units undermining care
* Part two: Overcrowded mental heath units breach torture convention
* Part four: NZ’s first ‘new wave’ mental health unit
Newsroom has spoken to a number of people with inpatient experience who complained there weren’t enough activities, of feeling bored and of not having access to talking therapies. Others who did have access to things like baking and art therapy found them highly beneficial. Ministry of Health mental health and addiction deputy director-general Toni Gutschlag acknowledged this in a statement, saying access to meaningful activities and therapeutic programmes was a cornerstone of acute inpatient care.
“Each inpatient unit provides therapeutic programmes and meaningful activity, with the type of programme and activity varying between facilities,” she said.
Occupational therapy, therapeutic interventions by staff, psychological and peer support, music, art and pet therapy, gardening, exercise, educational sessions and spiritual support were among the programmes being provided, according to the ministry.
Ombudsman reports praised some units for the broad range of activities they offered, but the reports and firsthand accounts also showed many were falling short. “Meds and beds,” is how one staff member, speaking to University of Otago, Wellington academic Dr Gabrielle Jenkin, described the dominant treatment model, where psychiatrists assess and prescribe medication to service users.
“I feel they’re designed and set up as a holding pen rather than a therapeutic space where people go for respite and recovery. And it’s very much to move people through as fast as they can.”
Newsroom spoke to people who said medication definitely helped; however almost everyone said they also wanted access to talking therapies. The problem: many inpatient units don’t have dedicated psychologists. District Health Boards (DHBs) often struggle to recruit, leaving vacancies open for months or even years. Nurses and other staff were often too busy to provide this kind of support.
Helen Garrick, chair of the mental health nurses section of the New Zealand Nurses’ Organisation (NZNO), a union, said overcrowded, short-staffed wards were challenging places to work.
“Nurses spend a lot of their time dealing with crises that have occurred around the ward rather than actually proactively being able to work with people at an individual or group level.
“That’s quite difficult when you’re putting out fires all day.”
In the first published paper from her acute inpatient unit research, Jenkin and her co-authors found there was a lack of agreement on unit purpose. Most staff she interviewed said keeping people safe was the primary purpose, not recovery. The units were seen as short-term, crisis intervention centres where people were stabilised, largely through observation, monitoring and medication.
“Many staff deemed people to be too unwell to engage in therapies on the ward, and recovery was considered to be something that would happen back in the ‘community’,” the paper said.
Jude, the woman who received care in the mothers and babies unit, has had previous inpatient experiences in Christchurch and Wellington in the past three decades. She was critical of the environment in the units overall, saying they felt stark, cold and clinical.
“I feel they’re designed and set up as a holding pen rather than a therapeutic space where people go for respite and recovery. And it’s very much to move people through as fast as they can.”
“In an acute environment, I think they just want to get you talking and walking correctly and then out the door because there’s more people that need to come in."
Patients also placed a high priority on safety, Jenkin found, but thought the main function should be to provide much-needed respite from mental distress. Sleep and medication were key, but they also wanted meaningful activities. Many complained about a lack of activities on the ward and the limited range of therapies on offer, apart from medication.
In an interview with Newsroom, Jenkin said many of the inpatients she spoke with appeared to be heavily medicated. They enjoyed talking to her, she said, because it gave them something to do.
“Service users talked about their needs for care not being met in an atmosphere of paternalism and boredom. They were really bored in these places.”
Madeline Reid, who received care in an Auckland inpatient unit for worsening depression and suicidal ideation last year, said there was a range of activities promoted on a whiteboard in the unit. The problem was, aside from a daily walk, they rarely took place.
“There was a hearing voices group support. Did that happen? No. Would that have been helpful? Yes.”
It was the first time Reid had been in an inpatient unit, and she was surprised at the lack of psychological support. After she was discharged, the 26-year-old said she was on a high dose of medication for months without proper follow-up care.
“There was no counselling. They’re very reliant on medication, and I think they over-medicate.”
Ombudsman reports published since 2018 included criticisms of a number of inpatient units for failing to provide adequate, meaningful activities or therapeutic programmes. In September 2018, inspectors visited Whakatane inpatient unit Te Toki Maurere. The occupational therapist had left in January 2018 and had not been replaced. “The provision of purposeful activities and therapeutic programmes for patients remains poor,” Chief Ombudsman Peter Boshier said.
Bay of Plenty District Health Board mental health business leader Jen Boryer said the position had still not been filled, more than three years later, although it was due to be re-advertised. An occupational therapy assistant and cultural workers supported activities on the unit, she said.
Janet*, who has had several stays at the main Christchurch acute inpatient unit at Hillmorton Hospital, said while there were activities like daily walks and art therapy, there was no talking therapy and the nurses were too busy and not trained to provide it.
“That’s the thing I think is a real problem that isn’t there; they don’t have someone coming in and saying ‘Let’s sit down, tell me what is going on for you at the moment’.”
Patients just wanted someone to talk to, Jenkin said.
“Some nurses did talk to service users, but then other nurses would say ‘That’s not our job, we’re not here to chat to them’.”
Some inpatient units like Tiaho Mai, the new facility at Middlemore Hospital, do have dedicated clinical psychologists. However, Dr Paul Skirrow, the executive advisor to the New Zealand College of Clinical Psychologists, said for many inpatient services, hiring a psychologist was last on the list. New Zealand had a shortage of psychologists and the inpatient environment was a challenging place, making it difficult to recruit.
The churn of people through mental health units made it difficult to provide structured therapy, Skirrow said, but it was a time when psychologists could assess people and figure out what they might need going forward. They could also provide group therapy sessions and work with people to teach them cognitive strategies.
“This is a chance to make a start with people who may never have spoken to somebody."
Medication was helpful and necessary for many people, but Skirrow believed it was important to also offer access to talking therapies.
“At the minute, it's like only having a hammer when you really need a saw. You don't have any choice.”
Newsroom asked the ministry if inpatient units should have dedicated psychologists. Gutschlag said DBHs organised their workforce in different ways to meet the needs of their communities. Some, for example, had psychologists working in other areas who could also work with inpatients as required.
Garrick, of the NZNO, said mental health nurses would be well-placed to deliver talking therapy, both in inpatient units and the community. The NZNO had pushed for more training to achieve this, she said.
“We have suggested that there be a specific training pathway for people to work in talking therapies rather than this biomedical focus on medication, and that's not that medication isn't important for some people, but it seems to be the only service that's available.”
Gutschlag said the ministry provided funding for health professionals to take post graduate qualifications in cognitive behaviour therapy (CBT). Several DHBs ran training programmes to build talking therapy capacity, she said.
Almost every service user spoken to by Newsroom said talking therapy would have improved their inpatient stay. “A hundred percent yes,” said Janet.
“In an acute environment, I think they just want to get you talking and walking correctly and then out the door because there’s more people that need to come in.
“So medicate you and see you later — let the outpatient department figure it out.”
*Jude and Janet are not their real names. Newsroom has agreed to use pseudonyms to protect their identity. Want to share your inpatient experience? Email oli.lewis720@gmail.com
This project was funded by Nōku te Ao Like Minds, with support from the Mental Health Foundation
All contributing artists are part of the Ōtautahi Creative Spaces creativity community, in Christchurch
Where to get help:
1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor
Lifeline – 0800 543 354 or (09) 5222 999 within Auckland
Samaritans – 0800 726 666
Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)
thelowdown.co.nz – or email team@thelowdown.co.nz or free text 5626
Anxiety New Zealand - 0800 ANXIETY (0800 269 4389)
Supporting Families in Mental Illness - 0800 732 825
