12 Mental health Over the last few decades mental health has moved from an institution-based service setting to a community-based setting. Two Ministry of Health strategic papers (Ministry of Health 1994; Ministry of Health 1997) were developed to guide these developments, and they outlined a need for more, as well as better, mental health services. A detailed picture of how services would look if these strategies were completely implemented was developed in the Blueprint for Mental Health Services (Mental Health Commission 1998), and this document is guiding all current service development. These strategic developments have led to dramatic changes in workforce requirements for specialist and primary mental health services. Changes include a major increase in services 60 and a reorientation of the types of workforce required. The Blueprint describes a recovery approach to be used in all mental health services, which is defined as happening when people can live well in the presence or absence of symptoms of mental illness. All mental health workers are charged with using a recovery approach, which involves supporting full participation in society, protecting rights, and helping to create supportive environments, as well as more traditional clinical tasks of providing diagnosis and illness treatment services. Some mental health workers are also given the task of assessing and managing the risk of individuals doing harm to themselves or others using the Mental Health (Compulsory Assessment and Treatment) Act 1992 (Mental Health Act), which sets out a number of responsibilities for mental health workers. Approximately 1 percent 61 of people using mental health services are under the care of forensic mental health services, and less than onethird of these are hospital inpatients. Within the mental health sector there are a number of specialty services based on population groups or diagnostic groups, each requiring staff with particular knowledge and skills; for example, services for children and youth, mothers and babies, people who are profoundly deaf, older people, and people with alcohol and drug problems, dual diagnosis, 62 and head injuries. Staff working in forensic services also have additional training requirements. 12.1 The mental health workforce The workforce groups listed in Table 12.1 are all represented in the publicly funded mental health sector, although some are more commonly accessed in the private sector. Occupational therapists, social workers and health promoters have substantial roles to play in mental health, but are described and counted in other sections of this profile (but an estimate of the number that work specifically mental health is included in Table 12.1). 60 61 62 Funding for mental health services has increased by more than 100% since 1994. Over the period January to June 2001, an average of 790 people per month were in the care of forensic services, compared to an estimated 60,060 people using any mental health services. This term refers to two types of dual diagnosis: people who have a mental illness and an intellectual disability, and people who have a mental illness and substance abuse problem. 110 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
Table 12.1 shows that an estimated 8488 health practitioners work in mental health. This includes people working in the private sector and in educational institutions, but does not include the number of medical practitioners (such as MOSSs, registrars and house surgeons) who would also be working in hospital mental health services, or the number GPs providing some mental health services in a primary care setting. The data is based on APC surveys for the psychiatrist, nursing and registered psychologists workforces. For other groups, data are based on FTE contract numbers, the 1996 census, surveys or association membership. There appears to be a higher percentage (15.1 percent) of Mäori health practitioners in the mental health workforce than in most other sectors (Table 12.1). While ethnicity data are only available for five out of 10 workforce groups in this table, these groups are the larger groups in the sector. An initiative outlined by the Ministry of Health to develop the mental health workforce (Health Funding Authority 2000b) is to monitor mental health workforce numbers and skill levels. This project is currently being worked on by DHBNZ, and is expected to lead to improved data collection on the mental health workforce within the public sector. Table 12.1: Characteristics of the mental health workforce Workforce group Estimated number % Mäori % Pacific Per 100,000 population Source/date Alcohol and drug workers 785 23.5 4.1 21 Survey 96 Counsellors Mental health consumer and family workers 167 5 FTE (contract) 01 Mental health nurse 2889 12.0 3.2 76 APC 00 Mental health support workers 875 23 Completed training 01 Psychiatrists 1 274 7 APC 00 Psychotherapists 269 7.2 NZAP membership 01 Registered psychologists 2 1124 1.3 0.0 30 APC 00 Workforce group not included in this section, but which has a component in mental health Estimated number in mental health Social workers 3 2000 18 53 Census 1996 / membership details Occupational therapists 105 0.6 0.1 3 APC 00 Total 8488 15.1 3.2 223 Notes: 1 This table does not include the number of medical practitioners (such as MOSSs, registrars and house surgeons) who would also be working in hospital mental health services, or the number of GPS providing some mental health services in a primary care setting. 2 The number here includes all registered psychologists, not just clinical psychologists. 3 Rounded to the nearest 500. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 111
12.1.1 Key issues 63 The number of national agencies with a role in mental health workforce development Due to rapid growth and change in this sector, and the current severe workforce shortages, mental health is one of a small number of areas in health where there are substantial workforce development initiatives under way, and where responsibilities for developing the workforce are shared by a number of central agencies. A programme for spending on workforce development is managed by the Mental Health Directorate of the Ministry of Health, guided by Tuutahitia te Wero, Mental Health Workforce Development Plan 2000 2005. This includes funding DHBNZ to deliver a number of projects in priority areas, as well as more general information gathering, tracking and planning work. The Mental Health Commission, established in 1996, has three terms of reference, one of which is to work with the sector to strengthen the mental health workforce. The Commission has a number of work programmes aimed at improving the capacity of the workforce to deliver a recovery approach in all services. Some confusion is expressed by the sector about the boundaries and responsibilities of these national agencies with regard to workforce development, and concerns are also raised about possible duplication of work. In 1999 the National Mental Health Workforce Development Co-ordinating Committee identified key problems for the mental health workforce (Mental Health Commission 1999). These included: lack of co-ordination in workforce development insufficient numbers of staff with certain skills unsatisfactory skill mixes inappropriate attitudes and values inappropriate training to deal with a changed delivery environment recruitment and retention difficulties. Shortages There are serious international problems with recruitment and retention as well as absolute shortages of mental health workers identified by the World Health Organization (WHO 2001). In New Zealand there are specific problems, such as insufficient skilled Mäori and Pacific mental health workers, and an overall shortage in some geographical areas and specialist areas. For example, there are major shortages in the child and youth mental health specialty area, especially of the highly skilled workforce, with a critical under-supply of child and adolescent psychiatrists. 63 Sources include submissions from the Mental Health Commission, ALAC, and the Mental Health Support Work Advisory Group. 112 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
Training for Mäori Despite progress, there continues to be substantial under-representation of Mäori in the mental health workforce, particularly in the clinically trained workforce. However, there have been several education developments that seek to address this issue. Te Rau Puawai, Workforce 100 is an initiative by Massey University aimed at increasing the professional Mäori mental health workforce by providing bursaries to Mäori who want to study in mental health-related areas, with support during their study provided by a co-ordinator and a structured mentoring programme. The aim is to increase the professional Mäori mental health workforce by 100 by the year 2003. Te Rau Puawai is expecting 50 graduates at the end of 2001. Te Wananga o Raukawa has run a one-year advanced extra-mural training programme in oranga hinengaro (mental health) since 1998. This is funded by the CTA as an NZQA course aimed at raising the skills of Mäori who have a health qualification to develop the specific knowledge and skills required in the specialty field of mental health care to Mäori. The programme is rooted in tikanga Mäori. Waikato Institute of Technology is now offering a postgraduate diploma in Mäori mental health nursing. Pacific workforce More Pacific people need to be recruited into the mental health workforce at all levels and in all occupations (Mental Health Commission 2001a). Significant effort is needed to increase the percentage of Pacific mental health workers with appropriate health qualifications and cultural knowledge. It is suggested that the role of matua 64 should be recognised as an integral part of mental health services for Pacific peoples. Data issues There is a serious lack of reliable demographic information about many of the occupational groups in mental health. This is being addressed by a DHBNZ project. Competencies As set out in the Blueprint For Mental Health Services (Mental Health Commission 1998), cultural change requiring a new set of competencies is expected across the entire sector as it transforms from an institutional approach to a community-based approach. This creates demand for training to re-orientate the workforce as well as modifications to existing training and education curricula. The Mental Health Commission has produced some recovery competencies (Mental Health Commission 2001b) that are expected of all mental health workers. This document is designed to be used by training and service providers. 64 Matua has a similar meaning to elder in English. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 113
Standards The new Mental Health Standards developed in 1997, and reviewed and republished by Standards New Zealand in 2001, have required significant changes by services and increased demands on workers. Of particular note is the requirement to involve service users at all levels of service delivery, including funding and policy making. This has created a new workforce group 65 that requires more collegial and structural support than is currently achieved, and which challenges many services and practitioners in those services. Generic mental health worker There is a reported need to strengthen the workforce in the mental health sector by developing a generic mental health worker. This has been done to some degree through the development of the role and training provision of the mental health support worker. A graduate generic mental health programme has also recently been set up at the Auckland University Department of Psychological Medicine. However, there is concern that this move to genericise the mental health workforce must not be at the cost of the clinical skills and expertise that professional groups bring to the workplace: The threat of a generic workforce that sidesteps health professionals remains an underlying tension in the mental health sector and has an impact on the development of [mental health professionals] (Walsh 2002). A model of core competencies, advanced core competencies and specialist skills based on current and future roles for people working in the mental health service was developed by the National Mental Health Workforce Development Co-ordinating Committee. This was not accepted by some professional groups. The recovery competencies (Mental Health Commission 2001b) have generally achieved more support within the sector. Alcohol and drug competencies for the generalist health workforce As noted in the National Alcohol Strategy (ALAC 2001): To maximise the potential that exists in the prevention and management of alcohol-related harm, education and training should... be broadly based. Involvement in alcohol intervention cannot be expected and will not be realised, or effective unless a wide range of professionals acquire appropriate knowledge and skills. Despite the call for increased alcohol and drug training for health workers, little has been achieved. ALAC reports that significant barriers include the lack of adequate resourcing in this area, and limited recognition of its importance by the members of the different workforces, those responsible for their training, and those who fund training. 65 People employed in this group have a variety of different job titles in different provider services, including: consumer adviser, consumer advocate and consumer consultant. 114 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
12.2 Alcohol and drug workers Alcohol and drug workers identify, assess and plan appropriate interventions for drug and alcohol related problems. They work therapeutically with individuals, groups (including family and whänau), wider communities and significant networks to reduce harms associated with drug and alcohol abuse. They also assist other health and social service workers to deal effectively with those who are experiencing problems related to alcohol and drug use. Some mental health workers and drug and alcohol workers specialise in dual diagnosis, 66 and deliver services to people who have both a mental illness and problems with drugs or alcohol. 12.2.1 Capacity A survey undertaken in 1996 (Hannifan and Gruys 1996) estimated a total paid workforce of 785 alcohol and drug workers. 67 The number includes managers, as the researchers found that managers also had clinical roles. ALAC reports that it is appropriate to assume this approximate number was still valid in 2001. While community FTEs have increased in some areas, many residential services and other services have since closed. A more recent survey in 1998 (Sellman et al 1999) of a random sample of 217 alcohol and drug workers provides some ethnicity data. It found that 23.5 percent of alcohol and drug workers are Mäori and 4.1 percent are Pacific people. 12.2.2 Education and training Specific training available for alcohol and drug workers is relatively new and is still developing. Specialised training for alcohol and drug workers currently available is given in Table 12.2. Table 12.2: Training for alcohol and drug workers available in New Zealand Undergraduate Manukau Institute of Technology Te Wananga o Raukawa Heke Matauranga Mauriora Wellington Institute of Technology (Weltec) Bachelor of Alcohol and Drug Studies Advanced Certificate in Alcohol and Drug Studies Diploma in Alcohol and Drug Studies Graduate and postgraduate Manukau Institute of Technology Graduate Certificate in Addiction Process Studies L6 (Note: this course was not run in 2001 due to insufficient students and may not run in 2002) University of Otago Postgraduate Certificate in Health Sciences (Alcohol, Drugs and Addiction) Postgraduate Diploma in Health Sciences (Alcohol, Drugs and Addiction) Auckland University Postgraduate Certificate in Health Sciences (Alcohol and Drug Studies) Postgraduate Diploma in Health Sciences (Alcohol and Drug Studies). Massey University Postgraduate level paper on Alcohol and Drugs 66 67 In this circumstance dual diagnosis refers to people who have a mental illness and an alcohol and drug abuse problem. This included people in paid employment in needle exchange services, kaupapa Mäori services, non-statutory residential services, statutory alcohol and drug services, and other direct personal alcohol and drug services. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 115
12.2.3 Specific regulation and interest groups There is no current regulation for alcohol and drug workers. 12.2.4 Key issues 68 Accreditation Currently there is no requirement for people working in the alcohol treatment field to be accredited. There is no measure of consistency in the nature or standard of practice provided by alcohol and drug workers. Steps are being taken to rectify this. The Alcohol and Drug Treatment Workforce Development Advisory Group, convened by the Alcohol Advisory Council of NZ (ALAC) in 1998, has developed a set of competencies (ALAC 2001) as a means to establish a more professional field and enhance the quality of service. The Advisory Group is currently using these competencies to develop a credentialling system. Leadership There is no official body, such as a professional association, that considers the needs or represents the interests of the treatment workforce. The Advisory Group has at least partially addressed this deficit. It is investigating the feasibility of establishing a formal practitioner association for alcohol and drug workers. Another subsidiary of ALAC is Te Röpu Mäori (a Mäori alcohol and drug workforce group). Skill match, education and training Currently a major gap exists between the level of education and training considered desirable, and the level of qualifications held. Moving Forward (Ministry of Health 1997) requires that by 2002 50 percent of all contracted alcohol and drug services that employ clinical staff will include staff members with postgraduate specialty training in drug and alcohol treatment. A survey of the alcohol and drug treatment workforce in 1998 (Sellman et al 1999) found that only 3.3 percent held a postgraduate qualification directly related to their work. An earlier survey (Hanifan and Gruys 1996) of the treatment workforce found that approximately 38 percent of the workforce had achieved less than a tertiary qualification, yet, as noted by the authors, the skill and knowledge of alcohol and drug staff are expected to be at an advanced degree of expertise and professionalism. Opportunities for alcohol and drug education and training have increased over the last five years, except for those wanting training delivered from a kaupapa Mäori or Pacific perspective. ALAC has identified a number of barriers to accessing education and training, including: financial constraints work pressures, such as difficulty releasing staff to undertake training geographical barriers 68 Sources include submissions from the Mental Health Commission and ALAC. 116 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
insufficient inducement low salary scales relative to other professions and a lack of career opportunities reduce the attractiveness of investing in training lack of education and training opportunities that integrate cultural and clinical perspectives and practices. Retention Retention of staff has been cited as a problem. This appears to be mainly a consequence of low pay and limited career opportunities. ALAC reports that remuneration, career structures and access to training need urgent attention. Need for increased capacity There has been a 107 percent increase in the number of FTEs for adult community alcohol and drug services since 1998. 69 However, the total number of FTEs in this sector still falls short of the Blueprint benchmark of 19.75 per 100,000 population. 70 To reach the benchmark levels (as is current government policy), funding will be required for another 195 FTEs. Such shortfalls place stress on services and their workforces and adversely affect their ability to deliver quality interventions. ALAC reports that, particularly in some parts of the country, the effect of an under-resourced workforce in terms of FTEs could mean at worst no services and at best reduced availability. 12.3 Counsellors Counsellors help people deal with their feelings and responses, and assist their clients to decide on actions they can take to solve problems. They may specialise in relationship counselling, grief and loss, drug addiction or family problems. Counsellors are mainly based in the private sector rather than being employed by mental health services or primary health care service organisations. However, mental health clients occasionally receive public funding via ACC or the social welfare system for counselling services. Counsellors come from a wide range of training backgrounds and they provide services in many public sector organisations, including education, justice and health. 12.3.1 Capacity According to census data, 2349 people were employed as counsellors in 1996, and 73 percent were female. However, few of these would have been employed in a health service capacity, so the numbers are not included in the summary tables. There is no other demographic information available about this group. 69 70 Blueprint output tables prepared by the Mental Health Directorate for the Ministry of Health September 2001, showing FTEs contracted at June 2001, indicate that there were 567 community FTE alcohol and drug workers in adult services. This is a 107% increase from the 262 FTEs cited in the Blueprint in 1998. These numbers do not include residential treatment and support services. Including dual diagnosis services. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 117
12.3.2 Education and training A wide range of courses are available in counselling. Training for a two-year National Diploma in Social Services (Counselling) includes bicultural studies, counselling theory, self-awareness and supervised practical work. This course sometimes complements other training in a discipline such as teaching, social work or nursing. Table 12.3: Counsellor training available in New Zealand Two-year Diploma in Counselling Bachelor degrees Graduate and postgraduate Offered by the following institutions: Bethlehem Institute of Education (Tauranga) Bible College of NZ (Henderson) Christchurch Polytechnic Institute of Technology EIT Hawke s Bay Lifeway College (Warkworth) Manukau Institute of Technology Nelson Marlborough Institute of Technology Otago Polytechnic UCOL Universal College of Learning Waikato Institute of Technology Wellington Institute of Technology UNITEC Institute of Technology Bachelor of Social Practice (Counselling) Wellington Institute of Technology Bachelor of Counselling UNITEC Institute of Technology Graduate Diploma in Counselling University of Waikato Master of Counselling University of Waikato Master of Counselling Postgraduate Diploma in Counselling Nelson Marlborough Institute of Technology Offers a diploma in Applied Counselling with Psychotherapeutic Studies for Psychiatrists See also training for Psychotherapists 12.3.3 Specific regulation and interest groups There is no regulatory body for this group. Regulation is achieved through the rules of service providers or funding agencies. ACC require certain standards and training requirements to be met before they will list individual counsellors as eligible for client-based funding. Counsellors need to complete counselling training through a recognised programme. The minimum requirement for most provider organisations is the two-year National Diploma in Social Services (Counselling). There is a New Zealand Association of Counsellors, which represents the interests of counsellors. 12.3.4 Key issues 71 Primary health care funding paths Access to publicly funded counselling services for clients referred by a GP is limited. Access to funded services can only be achieved through referral to a secondary mental health service, or ACC, which is often not appropriate or necessary. There are also issues around equitable access by mental health service users to counselling services. Often mental health services do not make provision for counselling, and their clients can only access it through ACC or social welfare funding, which has certain requirements not met by all clients. There are also reports of people being denied mental health services on the basis that they receive ACC counselling, or vice versa. 71 Source: Submission from the Mental Health Commission. 118 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
12.4 Clinical psychologists Clinical psychologists who have undertaken training in a professional training programme have the skills to deliver the following services: psychological assessment and formulation interventions with complex problems psychological testing diagnosis of mental disorder training, support and supervision design, implementation and evaluation of evidence-based interventions development and evaluation of new methods and approaches applied research development of health policy. At an individual and client level clinical psychologists assess behavioural and mental health problems. They assess the current emotional and lifestyle problems of clients, their social and family histories, and examine how feelings, actions, beliefs and culture interact to shape the person s experience and difficulties. They interview and observe clients, including children, adults, couples, families and communities. Clinical psychologists give psychometric and neuropsychological tests to identify problems and to measure clients skills and abilities. They develop and implement individual treatment plans or group therapy treatment plans (for some problems) to address clients psychological difficulties. 12.4.1 Capacity APCs were purchased by 1124 registered psychologists in 2000 (Table 12.4). However, not all of these are clinical psychologists and not all work in a health capacity. Of those who responded to the APC survey, 29 percent (326) worked for a DHB, 31.8 percent (339) worked in private practice (many of whom would be delivering services related to mental health), and another 1.6 percent worked in the community for a voluntary agency. Table 12.4: Characteristics of registered psychologists Number with an APC Number who responded to survey % Male % Female % Mäori % Pacific % Working in private practice 1990 768 552 44 56 1991 1 0 2000 1124 667 38.1 61.9 1.3 0 31.8 % change (number) 46.4 27 62 86 Source: APC surveys. The response rate for the 2000 survey was only 59.3%. 12.4.2 Education and training After completing an undergraduate degree in psychology, a three-year (minimum) postgraduate diploma at one of six postgraduate clinical psychology training programmes is required to gain a specialist clinical psychology qualification. The person will then hold either a master s degree or a doctorate, and a postgraduate diploma in clinical psychology. Consequently, a registered The New Zealand Health Workforce: A stocktake of capacity and issues 2001 119
psychologist with specialist professional training in clinical psychology will have participated in a minimum of six years training. Table 12.5: Clinical psychologist training available in New Zealand Postgraduate Auckland University of Technology Postgraduate Diploma in Clinical Psychology Massey University Postgraduate Diploma in Clinical Psychology University of Canterbury Postgraduate Diploma in Clinical Psychology University of Otago Postgraduate Diploma in Clinical Psychology University of Waikato Postgraduate Diploma in Psychology (Clinical) Victoria University of Wellington Postgraduate Diploma in Clinical Psychology 12.4.3 Specific regulation and interest groups Clinical psychologists must be registered with the New Zealand Psychologists Board. The New Zealand Psychological Society and the New Zealand College of Clinical Psychologists also represent the interests of clinical psychologists. 12.4.4 Key issues 72 Clinical psychology career paths in mental health services There is a lack of psychologists employed within the mental health sector, partly because of a shortage and difficulties recruiting this workforce. For clinical psychologists, remuneration available in private practice is often far better than in the public health system. Students may be drawn to other areas of psychology, such as industrial or organisational. It is also suggested that the lack of clinical psychologists in mental health services is partly due to a historical lack of valuing this profession. Training Clinical psychology programmes have always been funded by Vote: Education rather than the CTA. This has led to very few places being available each year, and an extremely stringent competitive selection process. There does not appear to be a shortage of applicants for training courses, but there is only a small supply of psychologists coming through the education system. 72 Source includes submissions from the New Zealand Psychologists Board. 120 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
Primary health care Currently clinical psychologists in the health system are accessible via secondary services or privately. A shift of the balance to primary health care-based funding for psychologists would allow GPs to refer people to psychologists and jointly manage mental health problems, without entering the expensive and often unnecessary secondary mental health system. Continuing professional development Historically, continuing professional development for clinical psychologists in the health workforce has been fragmented, with post-qualification training and education typically being obtained in an ad hoc fashion and with minimal funding allocated (Hahn 2001). Currently no specific funding is available for ongoing education and training needs of clinical psychologists. 12.5 Mental health consumer workers and family workers This workforce group has developed in New Zealand over the last five years alongside similar international developments. Growth of this group has occurred in all DHB mental health services in response to requirements in the New Zealand Mental Health Standards. The current group mainly consists of people who were previously working in a voluntary role as service user advocates, and in some cases family advocates, or as part of a collective offering peer support options for mental health service users. There has been increasing recognition that consumer workers and better family liaison are essential in maintaining an effective service, and there is evidence that peer support activities improve the outcomes for service users. Consumer workers and a smaller number of family workers are employed in a number of different capacities within DHB and non-government mental health service providers. In many cases consumer workers are part of the service management team and responsible for ensuring a service-user perspective is employed in service management processes. 12.5.1 Capacity According to contracting records, there were 167 FTE consumer and family workers funded in July 2001, 73 up from 30 consumer worker FTEs and 33 family worker FTEs in 1998. Many consumer and family workers are part time, so the overall number of workers is likely to be substantially higher. 12.5.2 Specific regulation and interest groups A large number of local and regional mental health consumer organisations are involved in advocacy or offering peer support services. These organisations have an interest in participating in, and ensuring the quality of, the work undertaken by consumer workers employed by mental health services. National consumer groups include Balance (a national network for people with bi-polar affective disorder), GROW (a self-help group), and the National Advisory Group for the Like Minds, Like Mine campaign. The national and local SF groups (mainly known as Schizophrenia Fellowship or sometimes as Supporting Families) provide a voice for family 73 FTE contract numbers are derived from Blueprint output tables prepared by the Mental Health Directorate of the Ministry of Health, September 2001, showing FTEs contracted at 30 June 2001. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 121
members of people with mental illness and have an interest in supporting family liaison workers where they are employed. Consumer workers employed in DHB mental health services have formed a National Association of Hospital and Health Service Consumer Advisors (NAHHSCA). 12.5.3 Key issues 74 Consistency People employed as consumer workers have a variety of different job titles in different provider services, including consumer adviser, consumer advocate, clinical adviser and consumer consultant. There is an equally diverse range of job descriptions and working conditions, along with a lack of consistency between and within job descriptions. Workforce support and training As a new workforce group with no specific training and high expectations from their constituency, mental health consumer workers need an opportunity to share ideas and develop consistent work expectations. The Mental Health Support Workers Advisory Group (described section 12.7) is planning to review and help address the training needs for consumer workers (for example, advocacy, advisory roles, policy and leadership). Clarity about the value of the role Many mental health service workers and managers are not yet clear about the value of the consumer and family worker role. This can lead to a difficult working environment and underutilisation of the services the consumer worker can provide to improve a mental health service. 12.6 Mental health nurses A mental health nurse provides treatment, care and support for people with emotional, mental and behavioural problems. Mental health nurses are increasingly working in a community setting, but the majority work in hospital inpatient or outpatient settings. They are skilled in the specialised use of communication, counselling, psychopharmacology, applying speciality knowledge in the provision of clinical assessment, monitoring, therapeutic interventions, treatment, and referral to other health professionals. They work with individuals, groups and their families in a variety of settings, providing primary health care, health maintenance, acute care and care of people with long-term mental distress and/or illness. Some mental health nurses have special responsibilities under the Mental Health Act 1992 as duly authorised officers. 74 Source: Submission from Mental Health Commission. 122 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
12.6.1 Capacity There were 2889 mental health nurses recorded in the 2000 APC survey, comprising 8.8 percent of the total active nursing population. Of the mental health nurses, 348 were Mäori (12.0 percent) and 92 Pacific people (3.2 percent). 12.6.2 Education and training To work in mental health, the majority of recent nursing graduates or those re-entering the mental health workforce undergo a 10-month new graduate programme funded by the CTA. Advanced mental health nursing training is also available for experienced mental health nurses. Table 12.6: Mental health nurse training available in New Zealand Postgraduate and graduate Diplomas and certificates Single units and short courses Auckland University of Technology Graduate Diploma in Child Mental Health Auckland Healthcare Postgraduate Certificate in Health Sciences (Mental Health Nursing) University of Otago Master of Health Science (Mental Health) Postgraduate Diploma in Health Science (Mental Health) Postgraduate Diploma in Health Science (Alcohol/Drugs/Addiction) Postgraduate Certificate in Health Sciences (Mental Health Nursing + specialty) Postgraduate Certificate in Health Sciences (Child and Adolescent Mental Health) Postgraduate Certificate in Health Sciences (Forensic Mental Health) Postgraduate Certificate in Health Sciences (Alcohol/Drugs/Addiction) Manukau Institute of Technology Graduate Certificate in Specialty Nursing (Mental Health) Otago Polytechnic New Graduate Certificate in Mental Health Nursing Whitireia Community Polytechnic Graduate Diploma of Psychiatric Mental Health Nursing Practice NZ Postgraduate Certificate in Forensic Psychiatric Care Victoria University Postgraduate Certificate Advanced Nursing (Mental Health) Massey University Postgraduate Certificate in Nursing (Mental Health) University of Auckland Postgraduate Certificate in Health Sciences (Mental Health Nursing) Nelson Marlborough Institute of Technology Diploma in Applied Counselling with Psychotherapeutic Studies The Open Polytechnic of NZ Diploma in Applied Mental Health UNITEC Institute of Technology NZ Certificate in Forensic Psychiatric Care University of Otago Certificate in Community Psychiatric Care UNITEC Institute of Technology Special Needs Programme: Understanding Mental Illness (Short Course) The New Zealand Health Workforce: A stocktake of capacity and issues 2001 123
12.6.3 Specific regulation and interest groups Mental health nurses need to have registration as a comprehensive nurse, psychiatric nurse or general and obstetric nurse. There is an Australian and New Zealand College of Mental Health Nurses, which sets standards, advises on competencies and represents the interests of mental health nurses. There is also a mental health nurses section in the New Zealand Nurses Organisation. 12.6.4 Key issues Several DHBs report difficulties recruiting and retaining mental health nurses. 12.7 Mental health support workers Mental health support workers are widely employed throughout the country in mainstream mental health, kaupapa Mäori, general rehabilitation, home-based and mobile community support services. The mental health support workforce is mainly employed in the non-government support services sector. These workers provide support and deliver rehabilitation services or programmes that facilitate the recovery process for people experiencing serious mental or emotional distress. There is a growing need for this community-based workforce to work with people and family/whänau in their regular life activities (work, housing, learning, relationships and health). 12.7.1 Capacity There has been rapid growth of this workforce group over the last four years, with training beginning in 1997. According to the Mental Health Support Worker Advisory Group (MHSWAG), at the end of 2001, a minimum of 875 people had completed the National Certificate in Mental Health Support Work since the course was first established. This gives an indication of the number of active mental health support workers because the training is funded for employed support workers only. Contracting records show that there were 786 FTE community mental health support workers funded in July 2001. 75 It is not clear how many were working in hospital or residential settings. There is no information about the demographic make up. However, like the alcohol and drug workforce, anecdotal evidence suggests a higher percentage of Mäori workers than tends to be found in other health workforce groups. 12.7.2 Education and training The National Certificate in Mental Health Support Work was developed on the NZQA framework level 4 for community mental health support workers in 1997. It is offered by 22 providers, including those listed in Table 12.7. 75 FTE contract numbers are derived from Blueprint output tables prepared by the Mental Health Directorate of the Ministry of Health, September 2001, showing FTEs contracted at 30 June 2001. 124 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
Table 12.7: Providers offering mental health support worker training in New Zealand Mental health support worker training providers Auckland University of Technology Blueprint Centre for Learning Christchurch Polytechnic Institute of Technology EIT Hawke s Bay Manukau Institute of Technology NETCOR NZ Institute of Training in Social Services Nelson Marlborough Institute of Technology Northland Polytechnic Otago Polytechnic Southern Institute of Technology Tairawhiti Polytechnic Western Institute of Technology at Taranaki The Open Polytechnic of NZ UCOL Universal College of Learning UNITEC Institute of Technology Waiariki Institute of Technology Rotorua Waikato Institution of Technology Whitireia Community Polytechnic 12.7.3 Specific regulation and interest groups The key function of the Mental Health Support Worker Advisory Group (MHSWAG), previously known as the Standards Implementation Body, is to advise the Board of the NZQA in the area of mental health standards development and national qualifications. MHSWAG represents the mental health support work sector during the accreditation process for education providers. 12.7.4 Key issues 76 Increased demand There is a recognised need for an increase of over 600 support workers to meet the increased service needs outlined in the Blueprint. 76 Source: Submission to HWAC from NETCOR. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 125
Mental Health Support Workers Advisory Group (MHSWAG) Key strategic activities for the MHSWAG include: enhancing the ability of the mental health support workforce (including Mäori and Pacific peoples) to play a role in the future mental health workforce meeting training needs of consumers (for example, advocacy, advisory roles, policy and leadership) providing direction for the development of additional mental health workforce qualifications, such as unit standards and a Diploma in Mental Health Support work assisting the national co-ordination of mental health workforce planning and development. The MHSWAG is currently completing a review of the unit standards, and changes to both the standards and the qualifications are likely. They are also asking the sector to identify which standards are best taught in the classroom, workplace, or combination of these. NETCOR The New Zealand Education and Tourism Corporation (NETCOR) is contracted to administer a National Training Grant for applicants enrolled in the National Certificate in Mental Health Support Work. NETCOR liases with 22 education providers and 495 mental health service providers to fulfil this role. There were 600 applicants funded in 2001. NETCOR also has a brokerage role in the Midland area to meet the training needs of 62 mainstream mental health service providers and 45 kaupapa Mäori mental health services. NETCOR s contract was set up as a pilot, and it is unclear what will happen to the information and expertise developed once the pilot finishes in June 2002. Mäori provider organisations It is suggested by NETCOR that specific funding be provided to enable establishment of a programme that meets the training needs of Mäori provider organisations (a national Mäori qualification in mental health support work). This is believed to be necessary to develop the kaupapa Mäori workforce. Work-based pathways for training and qualifications To encourage people to enter this workforce and to retain their skills in the mental health sector, there needs to be some facility for career development building on the National Certificate in Mental Health Support Work. 126 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
12.8 Psychiatrists Psychiatry is a branch of medicine specialising in the prevention and treatment of mental disorder, and the promotion of mental health in the community. By virtue of their specialist training, psychiatrists bring a comprehensive and integrated bio-psychosocial approach to the diagnosis, assessment, treatment and prevention of psychiatric disorder for people with emotional, behavioural and cognitive mental health problems. Psychiatrists work with clients and their families, and primary health care practitioners, to work out the best options for managing recovery and minimising distress. They prescribe and administer medication, psychotherapy, and other treatment and rehabilitation programmes, and many psychiatrists have responsibilities under the Mental Health (Compulsory Assessment and Treatment) Act 1992. 12.8.1 Capacity There were 291 active vocationally registered psychiatrists reported as practising in New Zealand as of March 2000. This is an increase of 58 percent since 1990, when there were 184 psychiatrists. Currently across New Zealand the ratio is one psychiatrist for every 13,058 population (approximately 7.5 per 100,000), though in some rural regions the ratio is 1:24,000. There were 164 trainees (153 FTEs) in CTA-funded training posts in 2001, plus an additional number of non-cta-funded trainees. While the ratio of psychiatrists per head of population has been steadily improving, it remains well under that recommended by the WHO of 1:10,000. 12.8.2 Education and training After obtaining the Bachelor of Medicine and a Bachelor of Surgery (MBChB) basic medical qualification, aspiring psychiatrists must complete at least two years as a hospital medical officer (house surgeon), and a five-year postgraduate psychiatry course to become a specialist psychiatrist. In New Zealand, specialist training for medical practitioners to qualify as psychiatrists is conducted by the Royal Australian and New Zealand College of Psychiatrists (RANZCP). During the minimum of five years training, psychiatric registrars work under supervision in hospitals and community clinics. They gain wide experience in dealing with the full range of psychiatric problems, including those of children and families, adults and older people. Advanced training programme in child and adolescent psychiatry Training in child and adolescent psychiatry is based on an apprenticeship model. Each training programme has a director of training, a training committee and a number of accredited supervisors. There are formal academic components to each training programme. An accredited training in child and adolescent psychiatry requires the satisfactory completion of a minimum period equivalent to one year full time. 12.8.3 Specific regulation and interest groups Psychiatrists need to have current registration as a medical practitioner, and vocational registration as a psychiatrist with the Medical Council of New Zealand. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 127
12.8.4 Key issues 77 Distribution of the mental health workforce Total psychiatrist numbers have increased over the years, but many choose to remain in urban areas because of: better peer support opportunities for teaching and research the opportunity to work in sub-specialty services less arduous on-call commitments than would be the case in a provincial setting. Training The CTA funds all eligible psychiatry trainees. However, mental health services will in the short term continue to depend on recruiting psychiatrists from overseas. Shortages A global shortage is indicated in The World Health Report 2001 published by the World Health Organisation (WHO 2001), which identifies a lack of specialists and health workers with knowledge and skills to treat mental and behavioural disorders as an important barrier to providing care in developing countries. WHO recommends 10 psychiatrists per 100,000 citizens, but many countries, including New Zealand, are below that number. 12.9 Psychotherapists Psychotherapists use particular therapeutic disciplines and attitudes of inquiry to help people in mental or emotional distress. Psychotherapy s concern, in the broadest sense, is assisting individuals, couples and groups to see, think, feel or act differently. Psychotherapy is a collaborative process between the client and the psychotherapist, based on the client s active participation. While the immediate aim of psychotherapy may be to relieve discomfort or distress, psychotherapy has the longer-range goal of changing the patterns of thinking, feeling and acting, as well as learning new, more effective and satisfying ways of living. 78 12.9.1 Capacity The New Zealand Association of Psychotherapists (NZAP) reports rapid growth in the number of psychotherapists over recent years. In 2001 the NZAP had 204 members and 67 applicant members. There are also an unknown number of psychotherapists who are not members of NZAP. 77 78 Source: Submission from Clinical Training Agency. Source: New Zealand Association of Psychotherapists. 128 The New Zealand Health Workforce: A stocktake of capacity and issues 2001
12.9.2 Education and training Those entering the psychotherapy profession can undertake specific training in psychotherapy following prior training and experience in related fields, such as clinical psychology, psychiatry, social work, education or nursing. However, in recent decades, a growing proportion of those entering this profession do so as their first professional training. This can be correlated with the rapid rise of psychotherapy training now available in New Zealand. Psychotherapists are educated in a variety of settings, including: tertiary institutions private institutes that have been recognised by NZQA accreditation (these include institutes such as the Gestalt Institute based in Christchurch, and the New Zealand Institute for Psychosynthesis based in Auckland) individual learning programmes undertaken under the auspices of a senior psychotherapist. With the rapid rise of other forms of training this apprentice model is comparatively rare. However, it remains a possible pathway into the profession. An essential component of the education of those intending to become psychotherapists is for them to engage in their own personal psychotherapy. The NZAP requires its members to have undertaken personal psychotherapy at least as intensive, in terms of frequency and duration, as the form of psychotherapy in which they specialise. Table 12.8: Psychotherapy training available in New Zealand Undergraduate Postgraduate and graduate Postgraduate medical Auckland University of Technology Diploma in Psychotherapy (Adult Psychotherapy) Eastern Institute of Technology Diploma in Psychotherapy (Adult Psychotherapy) Auckland University of Technology Graduate Diploma in Clinical Child Psychotherapy Master of Health Science (Adult Psychotherapy) University of Otago Master of Health Sciences (Child Psychotherapy) Postgraduate Diploma in Child Psychotherapy Study in Child Psychotherapy Nelson Marlborough Institute of Technology Offers a Diploma in Applied Counselling with Psychotherapeutic Studies for Psychiatrists 12.9.3 Specific regulation and interest groups At present psychotherapy in this country is a self-monitoring profession. The NZAP has been responsible for setting the standards of the profession since 1947 through a code of practice, a code of ethics and the evolution of thorough admission procedures. Each member of the NZAP is required to be in regular supervision with a competent colleague who monitors and critiques the member s work. NZAP has introduced APCs to its membership and keeps a register of its members. The New Zealand Health Workforce: A stocktake of capacity and issues 2001 129