Plugging Holes with People: How NZ's Mental Health System Fails Everyone
From the diary of a Clinical Psychologist
Dear Diary,
I heard a new perspective in a conversation with a health practitioner from another team today. I was explaining the impact of the constant clinician turnover on our surviving team members. A never-ending problem in many mental health services in NZ. It is hard to work on the ground in an unstable team. It is hard to do a good job with the patients who are on my caseload and also support the team members who are leaving. The clinicians leaving are struggling to transition severe, complex and high-risk clients. Within the team there are no clinicians with capacity to pick them up safely. Discharging these patients with a referral to another (under-resourced) team is often a necessary but unsafe "solution."
There are many patients every day who are discharged from one team and referred to another. Some patients seem to spend more time in referral-limbo than they do with a clinician. Unfortunately, many (but not all) of the clinicians who survive the job as a Health Practitioner are more skilled at this perpetual referral game than they are at working with patients to help them improve their functioning and reduce distress.
Anyway, I was telling my friend about my concerns and she said “they’re like rats on a leaky ship, although, it was leaking 10 years ago, now it’s sinking.” So I swallowed my initial reaction, which was to protest that obviously my colleagues and I weren’t rats, and I asked her to elaborate. She said that all the rats start in the bowels of the ship, water is flowing throw gaping holes and the rats have three options:
1. They can focus on swimming to see how long they can last. These are the clinicians who prefer to maintain their focus on the patient-facing work and try to find ways to keep doing that, even while the ship is sinking around them. The coping strategies people develop to do this are not always helpful, for them or their patients. Compassion fatigue and burn-out is common.
2. They can try to climb over each other to get to higher ground. These are the people trying to climb the ranks of management or create positions for themselves away from the patient-facing positions at the front line. Ambition, self-preservation, or hopeful big-picture thinking? Personal reasons for taking this approach are easily understandable in this broken system. The end result is a bloated bureaucracy and empty positions on the front lines.
3. They can leap off the ship and make a swim for it. These are the clinicians’ leaving services in droves for greener pastures. Private practice, another country, a different career, or another service with better working conditions, more stability and more realistic expectations. Often skilled clinicians with integrity and genuine care leave their positions with various feelings to process and understand over time. Loss, disillusionment, survivor’s guilt, shame, anger, failure and more.
While unkind, I can see a truth in this "rats on a sinking ship" analogy, and as such, I haven't been able to shake it off. Even when the government bureaucrats feed us propaganda to positively reframe the situation here in New Zealand.
Clinicians in many services who are engaged in patient-facing work at the front end are in many ways set-up for failure. The service and the clinicians are drowning in patients. Each individual clinician spread so thin that they cannot possibly do what they were trained to with many of their patients, let alone all of them. It’s no wonder most “resilient” health practitioners focus on tick boxing KPIs instead of providing quality and individualized care.
I’ve been trying not to drown in the bottom of the ship for 5 years. What kind of rat am I?
Modern-Day-Me Reflection.
Turns out I was the first kind of rat for a while and then I became the third kind. A decision I do not regret.
And now, I'm watching the current Minister of Mental Health, Matt Doocey, focus all our attention on what he tells us is the main solution for their sinking ship problem.
He tells us he was a frontline worker.... before he started climbing.... alllllllll the way to the top of the mast.
He tells us, he is fixing a big workforce supply issue at the front end. He’s found a potential supply of fresh baby rats from the university psychology programs. All they need to do is give them a title, “Associate Psychologists" he calls them in the media. The title is usually given to people with extensive training and experience, these baby rats will not have that training, how will they swim? Intern Psychologists for example, have far more training and experience, than the new "Associate Psychologists” will. Which title sounds better? This title and job description should attract lots of unsuspecting students.
And now they are working out how to better lock these newly minted and underprepared baby rats in the bowels of the ship. The ship will still be sinking and the well-trained and experienced Psychologists will have to help them swim – while also trying not to drown themselves of course. How long can that last? This seems like a cruel and ridiculous solution to me.
More importantly, it's a huge distraction from the most obvious solutions:
1. There is already a huge number of highly trained and experienced psychologists working in New Zealand who they could be employing to do the front-line patient facing work.
2. They need to build a new ship, their one is sinking and more baby rats won't stop that.