Prepared by Mary O’Hagan for PeerZone and ActionStation
The Problem
Big Psychiatry (our medical-led mental health and addiction system) was created around 200 years ago in an historical moment that established the construction of madness as an illness. The new profession led a medicalised, institutional and coercive system, where even the best intentions led to routine harm and poor outcomes.
Despite the closure of the old psychiatric hospitals and the addition of some community support services, Big Psychiatry still sits at the hub of our mental health and addiction system, where it shapes the world view and draws on most of the available resources. Its medical lens and expensive, narrow interventions focus on symptom reduction and short-term risk rather than holistic wellbeing and long-term outcomes. Big Psychiatry has also contributed to colonisation through imposing an alien system on a disproportionately large number of Māori.
New Zealand led the world by taking the first significant steps in the transformation from Big Psychiatry to Big Community (a multi-sector, community-led wellbeing system) in the 1990s and 2000s, through the closure of the large psychiatric hospitals and growth in community support services.
However, in the last decade a crisis has developed from persisting inequality, loss of leadership, lack of investment in Big Community and a complex, inflexible and fragmented system. There is widespread public concern about levels of distress and suicide, especially among Māori and youth. Many people cannot access help until they are in a deep crisis. People who use services are poorly served, with increasing rates of coercion, traumatising crisis interventions and a paucity of comprehensive responses.
More of the same will not fix the problem.
What is Big Psychiatry and Big Community?
| Big Psychiatry | Big Community |
|---|---|
| Mental disorder is viewed primarily as a health deficit. | Mental distress is viewed as a recoverable social, psychological, spiritual or health disruption. |
| A mental health system with a health entry point led by medicine. | A wellbeing system with multiple entry points led by multiple sectors and communities. |
| Most resources are used for psychiatric treatments, clinics and hospitals. | Resources are used for a broad menu of comprehensive community-based responses. |
| Employs predominantly medical and allied professionals. | Employs a mix of peer, cultural and traditional professional workforces. |
| Has a legacy of paternalism and human rights breaches. | Has a commitment to partnerships at all levels and to human rights. |
| Focused on compliance, symptom reduction and short-term risk management. | Focused on equity of access, building strengths and improving long term life and health outcomes. |
| Responds to people at risk with coercion and locked environments. | Responds to people at risk with compassion and intensive support. |
| A colonising medical system that excludes other world views. | A bi-cultural system that embraces many world views. |
What is Big Psychiatry and Big Community?
BIG PSYCHIATRY
- Mental disorder is viewed primarily as a health deficit.
- A mental health system with a health entry point led by medicine.
- Most resources are used for psychiatric treatments, clinics and hospitals.
- Employs predominantly medical and allied professionals.
- Has a legacy of paternalism and human rights breaches.
- Focused on compliance, symptom reduction and short-term risk management.
- Responds to people at risk with coercion and locked environments.
- A colonising medical system that excludes other world views.
BIG COMMUNITY
- Mental distress is viewed as a recoverable social, psychological, spiritual or health disruption.
- A wellbeing system with multiple entry points led by multiple sectors and communities.
- Resources are used for a broad menu of comprehensive community-based responses.
- Employs a mix of peer, cultural and traditional professional workforces.
- Has a commitment to partnerships at all levels and to human rights.
- Focused on equity or access, building strengths and improving long term life and health outcomes.
- Responds to people at risk with compassion and intensive support.
- A bi-cultural system that embraces many world views.