New Zealand Rehabilitation Association, Inc.

This month’s interview is with Alison Masters – a psychiatrist in the Early Intervention Service for Mental Health Services at Capital & Coast District Health Board (CCDHB).

What is the Early Intervention Service (EIS)?

We are contracted to provide assessment, treatment and rehabilitation for people with first episode psychoses.  At CCDHB there are a number of specialist teams in the mental health service including a maternal mental health service, a personality disorder service, a mental health and intellectual disabilities service and a dual diagnosis service for people with alcohol and drug addictions.  All our services are slightly different but we were set up under similar contracts.  In fact EIS is ten years old this December!

Is there much overlap between all those services?

Not really because we are all quite specialised.  That being said, psychotic disorders occur in every part of society so for example we have patients who are pregnant so we often utilise some expertise from maternal mental health.  We also have a small number of clients who have intellectual disabilities and we have heaps of clients with alcohol and drug issues.

Do you travel around a lot for your job?

We are a speciality regional service so we cover the whole of Capital Coast DHB and Hutt Valley DHB regions.  Our base is in Thornden (Central City Wellington) but some days we can be in Wainuiomata then at Kapiti.

How many people might you see one day?

Well, I try not to do too much travelling because it’s not particularly efficient. I try to save the travel for people who just wont be seen otherwise – or if they are in the acute phase and maybe at home.  Mostly I try to do more clinic based work.  Usually for days when I’m doing clinics I might see seven or eight people – something like that.

People referred to our service need to be between 13 and 25 years of age, living in the wider Wellington area, and have or be suspected of having their first episode of a psychotic disorder – so if someone has had a year or two of treatment with another service then we don’t pick them up even if they are in our age group.

What’s the advantage of providing specialist early intervention services for psychosis?

Young adults with psychotic illness represent a small but important cohort. It’s said that there are about 15 cases of first onset psychosis per 100,000 people per year – although there is some suggestion that in New Zealand the incidence might be higher: more like 30 cases per 100,000 per year.  There is a lot of evidence showing that early detection is vital for good outcomes. The duration of untreated psychosis is quite strongly linked with important health outcomes including the level of disability someone ends up with, the cost of care for the next ten years, the number of relapses, the family burden, and other social consequences such as how much a young people disconnects with other aspects of their life. So we have a really low threshold for assessment.  In that way we are probably quite different from other parts of the mental health sector which often use high thresholds as a way of gate-keeping.

What is a low threshold for assessment exactly?

It’s like if there is a suspicion of someone having psychosis we will see them, whereas some of the other services require a diagnosis before a person is seen. Our message to referrers – to GPs and youth agencies etc. – is if in doubt refer to us because we’re funded to take the time needed to engage with a young person.  A GP can’t spend four hours on an initial assessment for example, and then a few more hours per week trying to get that person onboard with the service, whereas we’re specifically funded to do that.  Also on the surface there isn’t necessary a clear distinction between a teenager who’s troubled and doing badly versus a teenager who might have a psychotic illness.  They may look the same. They may be isolated in their room, smoking dope, and may even appear quite depressed – but kind of differentiating what’s behind that is a little harder.  So as I’ve said one of the key parts of our role is early detection.

What other types of intervention do you provide?

The second part of our work is what is often called ‘assertive case management’. The evidence seems to suggest that for case management to work best case managers need to have low case loads, provide very close follow up and a lot more direct involvement in care; not just in the brokerage of services.  Our case managers provide close monitoring of a person’s mental state; going into people’s home to meet with their families, engaging with families, telling them what’s going on, and providing lots and lots of what we call ‘psycho-education’. Case managers support people through the crisis, settling the situation down and often work with medical staff around whether the meds are working, whether the person is getting side-effects etc. Then after that phase it’s really about seeing what the young person wants to do – what problems had existed before and what they want to do now.  Some of the people might have already dropped out of school and dropped out of education so they want help getting back into that – they want help getting a job and so on. We also link in with lots of community-based mental health support and intervention groups.

How long do you follow people for?

Two years.

Two years is a long period for an acute service from the perspective of a physical rehabilitation service!

Right! There’s a guy in England called Max Birchwood who coined the term the ‘critical period’ referring to the first five years during the stormy period of the illness – and it looks like often the level of disability and other features of the illness are set during that time.  This is another argument therefore for working very intensively during this time. While there is a still research to be done here, it looks as if this is a cost effective approach to long term management of psychotic disabilities.  In fact we have argued that we should be working with people for more than two years.  We think it should be more like three to four years and in reality we tend to keep people for up to three years if it is indicated – but if the service is under pressure, we do tend up our discharge rates, if that makes sense.

What are the some of the differences between mental heath and physical rehabilitation?

One aspect relates to the simply the differences between physical impairment and psychiatric impairments.  If someone remains hearing a voice for instance it’s always much harder to work out how best to accommodate for that. For example, in vocational settings what kind of environment is going to allow someone with a mental illness to work optimally?  A person in a wheelchair might need a ramp or altered toilet area, whereas with mental illness those sorts of strategies are a little less clear.  Studies have shown however that if you put people in with good support, good understanding and a lack of discrimination, they can sustain work quite well. 

The other issue is that the people in our service often have a history of not doing so well prior to the onset of psychotic illness – so often we are perhaps more involved in habilitation rather than rehabilitation.  In other words, these people are not losing function; they never really quite got there with their function in the first place.

From an outside perspective it seems that the disability movement has had a more profound impact on the delivery of mental health services – I may be wrong here, but what’s your take on that?

I think it is very true.  I think the disability movement in mental health has become very powerful.  The Ministry of Health standards for mental health require every service to have a consumer advisor – which is quite amazing really.  We also have a youth consumer advisor who sits in our clinical team meeting every week and participates in clinical discussion for every client.

The mental health consumers have a fairly loud political voice in comparison to a decade or so ago.  Things clearly happen more easily if you have got those consumer groups onside than if you try to work against them.  They are organised and funded.  Some of this of course comes out of the fact that they were so marginalised and so voiceless in the past – and not just politically.  Many felt marginalised in the relationship they had with the doctors and nurses they saw, whereas with physical disability, at an individual level, a lot of the consumers could still argue at their case.  They weren’t locked up or had all their rights as a citizen removed because they had a stroke or something – but if you had mental illness, that’s kind of what happened to you in the 1960’s.  As a consequence of that, the consumers have perhaps become more politicised.

 Finally, do you have soapbox issue you would like to share?

One of my main ones is just that rehabilitation should be the focus in mental health from the first moment we see someone.  I’m sure this is true in physical rehabilitation as well.  We shouldn’t wait until they have a severe chronic disabling illness that robs them of so much before we think, oh, this person needs rehabilitation.  Of course, when I talk about rehabilitation, I mean a whole philosophical approach focusing on a person’s life, not just their illness or a specific service.  I think if we have that focus from the beginning we are much more likely to do something that give people what they want and therefore they will be more likely to keep coming to see us.

 Thank-you very much for you time!