Mental Health in Aotearoa New Zealand: Rising to the Challenge of the Fourth Wave?

The mental health system in New Zealand has undergone major transformation in the past few decades. Although these changes have followed similar events occurring overseas, the manner of the changes and the impact on the health system are unique to New Zealand. Professor Mason Durie (Mental Health Commission, 2012a) characterises the evolution of the mental health system as a number of waves; the first wave lasting more than a century treated people with mental illness in large psychiatric institutions away from the sight of the community, with psychiatry having unquestioned authority. The second wave saw the shift towards deinstitutionalisation and the closure of the large psychiatric hospitals. From being out-of-sight and now sited within the community, the care of the mentally unwell was placed on a society that was largely unprepared and apprehensive. The turmoil that eventuated proved to be a watershed in the evolution of the third wave of mental health services and continues as the existing model we have today. The emerging literature is now shifting away from the traditional paradigm of mental disorders to one of wellness that is maintained throughout the lifespan. The Mental Health Commission in their Blueprint II (2012b, p. 10) viewed this progression as a "new wave", or as the fourth wave. Durie (Mental Health Commission, 2012a, p. 7) succinctly defined this fourth wave as: "In contrast [to the previous stages] the fourth stage may not be about disorders at all but about dysfunctional relationships, maladaptive attitudes and behaviours, exaggerated responses to life crises, emotional and cognitive symptoms associated with poor physical health, and a failure to adapt to changing times and circumstances". The currents of change in mental health care Second wave (1960s-1980s): Transition from deinstitutionalisation to community care Internationally, the late 1950s saw rapid changes towards deinstitutionalisation from large psychiatric hospitals into the care of the community for people suffering mental illness (O'Brien & Kydd, 2013). It was not until 1969 that New Zealand legally ratified the move towards a community-based mental health system of care. There was an increasing awareness of the negative impact of involuntary hospitalisation and the loss of liberty faced by those committed to psychiatric care. Furthermore, the fiscal sustainability of long-term institutional care was threatened, particularly after the prohibition of peonage (Brunton, 2013). However, discharged patients were frequently readmitted back into psychiatric hospitals after a briefperiod in the community (Mason, Ryan, & Bennett, 1988). As Brunton (2003) astutely noted, deinstitutionalisation was largely concerned with the "de-hospitalisation" of patients from psychiatric institutions, while "deinstitutionalisation", in the form of the long-term effects of institutionalisation, received little attention. The tragic failures of deinstitutionalisation highlighted in the Mason reports (Mason et al., 1988; Mason, Johnson, & Crowe, 1996) prompted the New Zealand government to develop a strategy for a community-based mental health service (Ministry of Health, 1994). It was also the beginning of an investment by the New Zealand government to ring-fence funding from the general health funds towards the mental health system. Based on the Tolkein report (Andrews, 1991), the focus of the community mental health initiative was to treat the most severely unwell people, identified as 3% of the total population. Contrasting with the dominant psychiatric institutionalised model of care, its intent was to shift away from an illness model to that of a recovery model; defined as "when people can live well in the presence or absence of their mental illness" (Mental Health Commission, 1998, p. 1). New Zealand was the first country to articulate the principles of a recovery model of mental health care that was eventually taken up by other countries, such as England, Scotland, and the United States of America (NGOiT, 2012). …