Chief Executive Karen Orsborn opinion piece on coercive practices

In early June we provided an article on coercive practices to the New Zealand Herald for consideration as part of its Great Minds campaign on mental health. The article, by our Chief Executive Karen Orsborn, pointed out that coercive practices continue in Aotearoa despite evidence they have no therapeutic value, and called for investment that will provide the choice of services needed to enhance safety for all.

Karen Orsborn: Time to end coercive practices in mental health care


People in Aotearoa New Zealand experiencing significant mental distress continue to be subject to coercion despite evidence there is no therapeutic value in such practices.

The Mental Health and Wellbeing Commission wants investment that will provide the choice of services needed to enhance everyone's safety, end coercive practices and support whānau to safely navigate through significant distress.

The Commission urges the Government to be bold in work under way to transform mental health law, and to invest in culturally appropriate, community-based acute services to provide genuine choice for people and whānau, alongside the option of inpatient care. People with personal experience of mental distress want options for getting through crises at home or in welcoming, warm, home-like settings.

We are already seeing great examples of innovative services for people experiencing high levels of distress, such as peer-led acute services, after-hours drop-in spaces, whānau-led wānanga, and crisis co-response teams involving paramedics, mental health clinicians, peers and police staff.

Over the past 10 years, such services have demonstrated that they can support people safely, and that people's levels of distress decrease when they are aided by people with lived experience who are trained in intentional peer support. Furthermore, a warm, home-like setting often has a positive calming effect and levels of distress, and risk, are often reduced when people are able to receive services, care and support in these environments. It is our strong view that such services should be available across the country.

We don't need to wait for new legislation to see care approached differently and coercive practices reduced.

Coercive practices include: community treatment orders, where a person may be medicated without consent and have their freedom of movement curtailed; and inpatient treatment orders, where a person must remain in an inpatient mental health unit and may be subjected to unconsented treatment and/or solitary confinement, where a person is restricted, alone, in an area or room that they cannot leave.

Such practices are enabled by outdated mental health law, a lack of recognition of people's expertise to manage their own distress, and a lack of safe, accessible community-based options for acute care and crisis support. It is concerning that there is a persistently higher application of mental health law to Māori.

For many people, the experience of compulsory treatment is forceful and traumatising. There is no evidence that it is effective, and in fact it can be counter-productive in terms of treatment outcomes. He Ara Oranga, the 2018 Inquiry into mental health and addiction, called for a repeal and replacement of the Mental Health (Compulsory Assessment and Treatment) Act 1992, to "reflect modern approaches to human rights, supported decision-making and informed consent".

All people accessing health and disability services have the right to make an informed choice and give informed consent to treatment, to the extent possible with their decision-making skills at the time. Our current mental health law overrides that right and discriminates on the basis of disability, breaching our country's obligations under the United Nations Convention on the Rights of Persons with Disabilities.

It's important to acknowledge that mental health and addiction services are stretched, and staff often don't have the time or options to work with people and whānau to find safe and mutually agreeable solutions to distress before it becomes acute. Incorporating skilled peer workers and using evidence-based alternatives to coercion like the Six Core Strategies and the World Health Organisation's Quality Rights Initiative will help change practice. Providing alternative options for acute care will further reduce the need for coercion.

Recent Mental Health and Wellbeing Commission reports found that the number of people subject to a community treatment order has increased by 10 per cent between 2016 and 2020.

Of particular concern, despite a reduction in the use of solitary confinement in some district health boards (DHBs), others are still showing high use of this practice.

Māori in particular are faring poorly in the current system. In 2020 Māori were 4.1 times more likely than non-Māori (excluding Pacific people) to be subject to a community treatment order, 3.5 times more likely to be subject to an inpatient treatment order, and 5.4 times more likely to be subjected to solitary confinement in adult inpatient services than non-Māori.

Change is happening in pockets.

Zero seclusion: Safety and Dignity for All is a joint project between the Health Quality & Safety Commission, Te Pou, and DHBs (soon to be Health New Zealand). It aims to reduce solitary confinement (seclusion) rates in all acute mental health units across Aotearoa New Zealand by 50 per cent by 1 June 2022, contributing towards the ultimate goal of zero seclusion.

The project supports DHBs to find alternatives to solitary confinement for people who are experiencing distress. Many DHBs across the country have succeeded in finding alternatives. Auckland, Waitematā, Whanganui, South Canterbury, and West Coast DHBs have all had a reduction in solitary confinement (seclusion) rates and, at times, have reached and sustained zero seclusion.

Encouragingly, data from the first half of 2021 show solitary confinement rates (the number of people confined for every 1000 people admitted to inpatient mental health facilities) have decreased, and this decrease has been greater for Māori.

At this time of transition to Health New Zealand and the Māori Health Authority, it is imperative that transforming the mental health and addiction system remains a priority and is not lost in the stresses of transition. We commend the 2019 Wellbeing Budget $1.9 billion cross-agency investment in mental wellbeing, and the additional Budget 2022 investment of $100 million for mental health, including community acute options and crisis services.

Ending coercion and transforming our mental health and addiction system is important for the mental health and wellbeing of everyone in Aotearoa New Zealand. There is an opportunity now to make changes to services that will uphold people's dignity and human rights, develop and support the workforce and help rebuild trust in the mental health system for people who experience significant distress.

Everyone involved has something to offer to achieve this transformation, and we all must work together. Nāu te rourou, nāku te rourou, ka ora ai te iwi. With your food basket and my food basket the people will thrive.

Karen Orsborn is the chief executive for the Mental Health and Wellbeing Commission.

A copy of the article can be read on the New Zealand Herald website