Draft model for Nationally Coordinated Deaf Mental Health Services
The proposed model is based on the broad aims of the Blueprint 2 design, the NZ experience of running Deaf (cultural) Mental Health Services and NZ data on the epidemiology of mental illness and addictions in the NZ Deaf population and overseas research and practice around Deaf mental health and addiction services.
Blueprint II identified the need to ensure that “culturally specific models of care should continue to be developed as a choice and/or to complement mainstream services.” (p31). The Deaf community uses New Zealand Sign Language (NZSL) and most cannot communicate easily in English either written or spoken, leaving them frequently unable to access the communication when issues of mental illness and addictions are being addressed. About 10% of Deaf use a mental health or addiction service in any one year1, or around 300 people of which only 21 can get access to a Deaf Mental health service. This service which in 2003 had a full client case load, won a National Mental Health Award and was a finalist in NZ’s inaugural Health Innovation Awards has declined because of poor management, service downgrades and closure, and the lack of a national policy and vision for Deaf mental health and addiction services. Blueprint II1 recognises that the Deaf have complex needs that will require “integrating mental health and addiction and disability policy at a national level, and funding and service delivery at a local DHB level” (p29). Doing this will be a “good starting point to improve outcomes” (p30). This call for national policy coordination needs a coordinator with a good understanding of Deaf mental health and addiction issues to:
- bring together the relevant parties to create the policy framework in which services for the Deaf can operate
- ensure that all service agreements align with policy and operate within the framework set out
- report back to MoH and the Deaf community on the status of Deaf services
Regional Service Hubs
Evidence has been presented over the past decade on appropriate models for the delivery of cultural Deaf mental health and addiction services5, , , All these models point to the need for regional service hubs that allow for a sufficient aggregation of signing staff to create a stable and transdisciplinary service. Telehealth services play a major part in service outreach, particularly in providing prompt access to early intervention and assessment and good interpreter and therapist support to Deaf people living in isolated areas. Services generally aim to be comprehensive covering youth, community, acute, residential and old age sectors and moving into adjacent sectors such as intellectual disability and rest home care where signing therapeutic services for the Deaf are also needed. Greater collaboration between Deaf mental health and addiction services and general services offered to the Deaf community through organisations similar to Deaf Aotearoa (general support and fieldwork services) the Deaf Education Centres (support for Deaf children and their families) are also important. Much of the focus of these models is on supporting Deaf in the mental health, addiction, criminal justice and general health services they currently use through training of staff in these sectors in Deaf awareness, assessment and intervention support, and interpreter services. Special attention is also given to the residential services. Deaf people need to be in a signing community and that puts some constraints on independent living models.
The principles underpinning Blueprint II are very supportive of the model proposed above. Drawing from Te Kökiri: The Mental Health and Addiction Action Plan 2006–2015 , Blueprint II places a strong emphasis on the need to integrate funding, delivery systems and services starting with partial dismantling of the “ring fence” (p7) funding and “the integration of mental health and addiction services into the broader health system and across social services” (p9). This integration includes the justice, aged care and health promotion systems, and invites us to embrace a “stepped care, no wait” (p21) model that creates “holistic packages of care that bring together support across sectors and silos” (p20), and which “will need different funding, contracting and commissioning arrangements” (p21). This model addresses the issues faced by the Deaf community in trying to access a broad range of social services – there are a huge range of services and virtually none of them are accessible. Integrating as many of these services as possible and close collaboration with others makes great sense. As Blueprint II states:
“We need programs designed primarily for the whole or parts of the population in the context of everyday life, in settings where people live, study and work. They should be comprehensive, take into account the wider determinants of health, use a mix of skills, be collaborative in nature and long in duration” (p30).
In fact, Blueprint II recognises that certain areas of disability (in this case, aged care and dementia) encompass such complex needs that development of a “partnership approach that uses integrated, stepped care across home, primary, community and specialist services” (p29)is needed with respect to that disability. The Deaf are also acknowledged as a group with complex needs and the barriers of communication that they face provide a strong argument for integration based on, in the first instance, culture rather than some other aspect such geography, stage of life, or health or social service sector.
The Regional Service Hubs proposed are located in the three major centres of Deaf population. They are closely aligned with the Blueprint II principles and need to be considered in relation to “the new integrated mental health and addiction system where no one is turned away will move us well beyond the ‘3%’”(p19). Clearly the funding for this is not going to be new money, but the re-alignment of existing resources. Apart from the 2000 epidemiological survey and the numbers of Deaf accessing Deaf Mental Health services held by the MoH , there is no data currently collected on the broad use of mental health and addiction services. Bridgman et al (2000)10 showed that the chances of Deaf people having an interpreter present at a mental health consultation were low and the outcomes generally judged as poor by the clients of those services. Anecdotal evidence suggests that Deaf people in NZ are often misdiagnosed, undiagnosed, inappropriately treated and as a consequence end up in the criminal justice system. The key to development is in a transfer of resources from services that are poorly serving the Deaf into culturally centred signing services. The Blueprint asks for DHBs to “make the most effective use of the funding available, easily integrate services across primary, community and specialist care, and implement a stepped care model”. Because the Deaf population is small and concentrated in specific geographic locations, a number of DHBs will have to collaborate to create a sufficient resource for cultural services.
Key practice partners
While the goal of integration is the “coordination of services resulting in support that is seamless smooth and easy to navigate” 8(p46) this cannot be because all services for a community are provided through a single organisation or service model, even though a greater emphasis on this approach is helpful for the Deaf community. However, Deaf culture is not homogenous, different models work best in different places, and the Deaf want choices. Collaboration is an important theme that runs through Blueprint II, starting with the Treaty partnership. We recognise that about 20% of the Deaf population also identify as Maori, and that staffing of Deaf mental health and addiction services would need to reflect that mix to ensure equal access for both cultures . The Blueprint also recognises the significant role that “poverty, inadequate housing, low levels of education and unemployment” (p16) plays in forming and maintaining mental illness and addictions. Around half of the Deaf community are on some form of benefit , indicating high levels of poverty, and necessitating collaboration with “the social welfare, education and justice sectors” to address this issue. Both Deaf Aotearoa and the Deaf Education Centres who run networks of signing services throughout New Zealand would be senior partners in this area.
While Deaf mental health and addiction services need to be as comprehensive as possible, there will be areas that they are unable to independently support, particularly around remote locations and severe and complex needs. Collaboration with other community/specialist services using a transdisciplinary approach, telehealth and interpreting services; training for both the Deaf and the community/specialist services to enhance role sharing and exchange; and a “collaborative relapse prevention and wellness action recovery planning” would strengthen both areas of service and lead to an “early return to wellbeing and resiliency” for Deaf clients (p27).
Steps to the future
This model is presented as a discussion document, not as the only possible structure for mental health and addiction services for the Deaf community. For any model to succeed it will need strong advocates both from within the Deaf and hearing communities. There are features that we think, however, are critical for success. These services have to be cultural services that are driven by commitment to NZSL and Deaf community values. This can only happen if they are based around a hub of services that has sufficient staff to be a stable cultural community and the opportunity to build on success. Given this baseline some steps that could lead to the development of a comprehensive service are:
- create a national policy and framework for the delivery of mental health and addiction services to the Deaf community based on Blueprint II and a commitment to this service being a cultural service
- research the quantity and quality of mental health and addiction services Deaf people are currently receiving and how these could be coordinated or integrated to improve their accessibility and effectiveness
- extend the regional hub concept to the point where it can be trialled as a genuine model for Deaf mental health and addiction services. Such a model would require comprehensive regional outreach, telehealth, internal staff training, and Deaf awareness (external staff training) components as well as appropriate contractual arrangements with interpreting services and MOUs with key mental health and addiction services, and services currently supporting Deaf people on a regular basis (e.g. residential services) and the major Deaf agencies. Such a model could be built onto the existing Deaf Mental Health service in Auckland at relatively low cost and then extended into the hub model providing the necessary national coverage. Funding for research of the outcomes of the trial would also be needed.
We have attached a number of papers to this proposal. Deaf Community is a brief introduction to Deaf culture. David’s Story is a vignette that captures the damage done when services are in adequate. Reducing Risk in Deaf Mental Health is a background paper on the epidemiology of mental illness in the Deaf population and options for service development. Submission to the Mental Health Commission on resources needed for Deaf Mental Health Services updates the NZ context for Deaf mental health and addictions and provides information on recent overseas service models. The Submission to Blueprint II Consultation Process shows in detail how this proposal matches Blueprint II objectives.