In today’s paper is one of those events which happen if you have any form of community care for people who are actively psychotic. Any person who runs inpatient units (which I have done) will say that they cannot guarantee that such a tragedy will not happen on their unit, on their shift.
So my first reaction was “Thankfully not my unit” — then the inevitable guilt, because I do have sympathy for the family.
The family of attacker Jason Meradith Harvey, 39, are devastated about the assault, particularly since it was a family member who suffered 65 stitches and two skull fractures in the attack.
Harvey has been charged with the attempted murder of his brother-in-law, Mark Heighton, and an assault on his sister, Jo Heighton.
In the wake of the attack, Jo Heighton wrote to the Government asking when it would take action over Auckland District Health Board’s Te Whetu Tawera Unit.
The unit has been under considerable pressure for bed space and is cutting bed numbers.
Staff fear it will lead to patients being discharged too quickly to free up beds.
Harvey – a paranoid schizophrenic with substance abuse problems – had been discharged from Te Whetu Tawera five days before the attack. It was the third time he had been taken to the emergency mental health unit this year.
Harvey had also spent two extended periods at the Buchanan Rehabilitation Centre, a 40-bed mental health rehabilitation unit in Pt Chevalier.
via Mentally ill patient on a rampage – National – NZ Herald News.
One of the reasons I have sympathy for the family is that, like most people who work in mental health, I have been attacked. I have not been seriously injured — but people have tried to break my arm, punched me (a few episodes) and laid a bunch of complaints against me. The bruises fade. The compliants do not. And my experience is common.
Auckland’s central unit has had a series of incidents, There have been formal complaints to the centralised Health and disability commission that are publicly available. These are critical. There have been a series of high level reports but little action.
I trained in Auckland. I now work in Otago. There is a huge difference. We have some bed pressure — but we have around 45 — 50 (depending on Southland staffing) acute and 30 sub-acute beds for 400 000 people. Auckland is around 500 000 and has but 54 beds and shares all the sub-acute resources (which is two or three units of 15-20 beds each across the Northern Region which has 1.4 million people. In practise, these beds are not available.
This means that I have an ability to slow down the process of inpatient care. If something is not going well, if there is risk, if there is no adequate community care, at present* I can take a little more time.
Time is important. There are no gold tests for madness. I cannot point to a lesion on a MRI, or EEG, or blood test and reliably say that that it means anything. Moreover, the medications do not work all the time — in the first episodes they probably work about 80% of the time regardless of what is used, but it takes weeks to see a response. Longer term, 20% — 40% of people with schizophrenia don’t achieve clinical remission Sorting out what medications work, what support mechanisms work, and what rehabilitation is going to be appropriate and work for any one person and family is not magical. It takes time and talking.
And here beds matter. The hospital management, throughout the Western world, will not accept over crowding since it is linked with patient to patient violence. We have de-institutionalised. Less beds are seen as better. But too few beds means you shorten stays to the point where people are discharged still mad. You have become a sedation service. And… given that the average community worked in Auckland used to have 60 people on their lists (this may have improved) the one visit a week you can reasonably expect a district nurse to give the person who is mad may not be enough to contain them.
There are some solutions that have worked, historically, but they are not politically palatable.
- Resurrect the long term psychiatric hospital — aiming for around 1 bed for every twenty to forty thousand population. People who have ongoing histories of aggression and treatment resistant madness used to be managed in total institutions, where the structure of the supervised week contained them. This approach is still used in forensic wards, but that is after the crime is committed.
- Increase the Assertive Community Teams without removing the current community mental health teams. The law needs to change so such a team can remove all monies from the person who is mad, and so that they can be seen daily, or thrice daily (case loads of 10 -15 people per worker). There should not be a “waiting list” for this.
- Increase the number of acute beds to 1:7 500 population.
- Move from an inpatient specialist team which can be influenced by powerful people (Auckland’s unit used to have John Read, who is actively anti medication, as its head of psychology. I am unsure as to if he is still there). Instead, have the inpatient care supervised by the community psychiatrist — either from the assertive or ordinary team. As a rule, if someone needs admission, they need specialist follow-up.
- Listen to the families and caregivers. Listen to the nurses. Listen to the patient If they are scared, they are probably right.
Nothing on this list is new. What is lacking is the poltical will to admit that we have moved too far down a path of liberalism, that the ideology of recovery has reached its limits, and that the human need for shelter and emotional asylum remains.
Cutting beds does not work. Destroying mental health workers by repeated enquiries does not work. Giving the system the tools that allow them take the time to build working relationships with the mad has a better chance of working.
