Alternative now

" Writing about community based services is bedevilled with a Babel of labels, often sounding similar. This creates confusion: is the label synonymous with one clearly defined service model, or does it denote discrete sets of service components.[1]"

Prologue

I remember when the concept of “recovery” was first heard in the 1990s. It sounded so intuitively obvious as the purpose of evolving community-based mental health services. Then came deeply considered discussion and papers examining an epistomolgy of recovery, and “what it might look like” when achieved.

During this time, I found myself chatting with a very enthusiastic nurse over morning tea at a conference: “I’m so glad they’ve introduced the idea of “recovery”... at last we now have a word to describe what we’ve always done”.

Transforming the system

“Alternatives to...” provokes a similar level of (very grounded) excitement and anticipation within mental health services. In spite of their success (and there a numerous now – with evidence), they still seem to represent a measured “tipping of the hat” towards transformative consideration of a whole system.

Long not short term

In such an environment there is a real risk of these “alternatives” being seduced and comfortably absorbed into the status quo, filling gaps, becoming a further band-aid and crutch to system that is already on life support. The genesis, purpose and meaning of these alternatives risk being promoted as more novelty and highlight. (Milan Kundera reminded that “The struggle against power is the struggle of memory against forgetting.)[2]

In fact it is these so-called “alternatives”... that now need to be developed, regarded and accepted as the new standard...

Introduction

I had the opportunity in November to attend Te Hiringa Mahara / TheMHS forum exploring the state of crisis responses in Aotearoa New Zealand. Then, just seven days later, I joined the team at WALSH Trust as they celebrated 10 years of providing alternatives to inpatient care for new mums and their babies, He Kakano Ora (seeds of life).

It was sobering to appreciate that just 10 years ago I was privileged to be a member of the team that initiated this development; one that was to become a multi-award winning service – described by one of the clinical leads at Auckland DHB as “World-class.... realised through love and hard work.” In 2015, this was the first of its kind in the country; there was no one to copy!

In 2025 the service has clearly evolved, matured and gained confidence. A process that didn’t occur by accident, but though 100% commitment by a remarkable and dynamic team prepared to break new ground, the support of key partners and cliniciams with hosptial services, and the gift of trust by the 100s of new mums and their whānau who shaped the service by using it.

Why are alternatives to traditional “crisis responses” needed?

Fundamentally, traditional “crisis responses” tend to represent the last vestiges of institutional “care”. They rely on a limited number of “tools” complemented by extraordinary powers such as removal of a person’s liberty (through compulsory treatment), and restraints such as seclusion / “solitary confinement” (as has been more accurately described by the NZ Mental Health and Wellbeing Commission.)

Institutional approaches tend to be restrained to “one-size-fits-all” models of treatment. In recent years, “acute alternatives” such as crisis resolution teams, home treatment, and community-based facilities / homes and support have gained prominence as preferable options for many people experiencing more acute mental health challenges. These alternatives are often considered better than inpatient care because they can offer:

Reduced Disruption to Daily Life

Inpatient care can be highly disruptive, removing individuals from their familiar environments, routines, and support networks. Alternatives, such as home treatment and community-based crisis services, allow individuals to remain at or close to home, helping maintain family relationships, employment, paying the rent or mortgage, child care, and social connections. This continuity can facilitate recovery and reduce the anxiety that often accompanies hospital admission.

Enhanced Personal Autonomy and Empowerment

Community-based alternatives empower individuals to take an active role in their recovery. Rather than being passive recipients of care in an institutional setting, people can make decisions about their treatment, fostering a sense of autonomy and control over their lives – and hope. This approach can contribute to better mental health outcomes and greater satisfaction with care.

Reduced Stigma and Trauma

Being admitted to a mental health inpatient unit still carries significant stigma; it can also be am incredibly traumatic experience for some. Acute alternatives minimise exposure to institutional environments, helping to reduce the risk of additional psychological distress and the negative social consequences sometimes associated with inpatient care.

More Personalised and Flexible Care

Alternatives to inpatient care typically aim to provide more personalised and responsive support. Community-based teams can tailor interventions to the individual's specific needs and circumstances, offering flexible hours and services in familiar settings. This can lead to more effective de-escalation of crises and better long-term engagement with mental health services.

Cost-Effectiveness and Resource Allocation

Inpatient care is very, very expensive and resource-intensive. Community-based alternatives are far more cost-effective (approx. $300 per bed night, compared to $1,500-$2,000 per bed night in an inpatient unit), enabling mental health services to support more individuals with the same resources. This also allows an inpatient service to reserve beds for those whose needs indicate that this would be their better option.

Improved Outcomes and Satisfaction

Research shows that many people recover more quickly and experience better mental health outcomes when supported in their own communities. Acute alternatives often result in fewer repeat admissions, higher satisfaction with care, and improved quality of life.

The alternatives advantage

While inpatient care is an important option for those whose severe or complex needs, are best met in that environment, acute alternatives offer significant advantages for many individuals in crisis.:

Reducing disruption
Empowering people
Minimising stigma
Providing flexible, responsive, cost-effective care

these approaches represent a progressive shift in mental health support - focusing on recovery, dignity, and community integration.

What were some of the critical fundamentals behind He Kākano Ora?

Factors that brought good intentions to the reality of He Kākano Ora would include:

A Trust Board that had the courage to be guided by its “why”; its reason for being – rather than hesitantly deciding that such a venture was “too risky” or “...not what we do”, or “...the wrong time”. For WALSH Trust the project involved bulldozing some small offices, and committing over a $1 million to a purpose built home.
Critically, the Trust Board had the capacity, capability and confidence to arrive at and commit to a decision within the tight deadlines requiredThe connections and humility to be able to acknowledge where current expertise might be lacking or light, where and how the needed expertise could be engaged and drawn in.
A seasoned leadership team that got right in behind the project – on top of all their other work and commitments.
A commitment to holding the confidence that the organisation could deliver the contractually implied “gold standard” service, funded by what I would describe as a “corrugated iron standard” budget.
Building new relationships with hospital-based, clinical maternal service providers – in the development, design and on-going delivery of the new service.
Partnership and flexibility by the DHB funding and planning team around the establishment of the service – particularly while the building / construction work was taking place.

It's worth noting that all the above reflect attributes that are certainly not uncommon within the non-government, community-based sector in New Zealand. Internationally, this sector is virtually unique to the New Zealand mental health sector “landscape”, having been developing since the late 1980s. It can now be justifiably regarded as a tāonga – a treasure that is still potent with its full potential yet to be realised.

The New Zealand NGO sector is in fact evidence of Dr. Arthur Evans’ (Director, DBHIDS, Philadephia) assertion that: “…inherent in every community is the wisdom to solve its own problems.”[3]

How it came to be

I have been separated from this service for nearly two years now. My brief visit in November was a lovely reminder (for me) of He Kākano Ora’s most valuable and enveloping quality: it’s just a nice place to be and hang out”! This is a rare quality; hard to produce – even harder to sustain! When I look back on how it developed, evolved and “became”, some core principles stand out for me:

Foster recovery, confidence, relationships and re-discovery: the service would be less reliant upon assessment and treatment, instead offering intentional, focused support in nurturing mum’s needs to physically and psychologically recover into being the parent she needed to become.
Nurture and maintain a culture that focuses on offering hospitality to guests: Prioritise how we welcome mums (ie. as if she were staying at a hotel; chocolates on the pillow, a goody bag…[4]), kindness and service - complemented by a broad range of options and choices led by “mum”., not just traditional risk led generic reactions to safety.
Personalise the recovery process: Cater to individual mum's needs, history, time and space in their life, relationships, aspirations… recognising that each is unique and on “their journey” – making sense of this along the way.
Focus on staff development, growth and achievement: Invest in recruiting, retaining, and continuously training high-quality people (better people make better professionals) who can engage and partner mums rather than just “treat” or “look after them”.
Create a thriving, warm, safe and life-enriching "ecosystem": Build a supportive and collaborative service culture that fosters a sense of safety, interdependence, confidence, potential and respect – for mums and staff!.
Adopt an organic farming metaphor: View health and wellbeing as the by-product of a living system that needs to be fed and nurtured, focusing on the conditions for growth (like soil health) - rather than just the output (exit / discharge).
Encourage partnerships: Foster collaboration between the service and other community resources, agencies and organisations.

Culture critical

While each of these principles were important, while staff development was important, it was the culture of the service (ie. what it “felt like” to be there) that was absolutely critical. This was where the “rubber hit the road”. To deliver the service that we envisaged, we employed a mix of specialists who were able and willing to be generalists. Thus at times you might find the Manager and / or nurse cleaning the bathrooms while a support worker was deep in conversation supporting a mum in baby-craft.

What we did in practice

There remains a very strong and creative team culture that drives service provision and the outcomes achieved.

We did not allow this to become a “crisis service” with just a traditional limited array of “crisis tools” available.
We avoided the sense of fear and “crisis anticipation” for both staff and mums. (It was a psychiatrist at the forum who observed that “fear” can, and has played, a powerful role in shaping crisis services.)[5]

A further and quite essential element of the service was that we could also provide home-based support after mum had exited the house. In fact we came to understand this option as having the most powerful impact.

This was about a new mum being supported to integrate this new role in to her life, in “her place”, familiar surroundings, relationships and routines. And this actually showed itself as being one of the more welcomed and effective options the maternal service offered – and again with hindsight, an outcome that shouldn’t have surprised anyone!

Epilogue

At the Te Hiringa Mahara / TheMHS forum, we heard that there are some really good things going on in the mental health sector, but it is arguably happening in-spite of a rigidly dominant culture that narrowly defines how we understand and respond to poor mental health - not because of it.

Current flaw

Current policies are based in mechanistic conceptions of health, as if addressing poor mental health was an industrial process. Surely no one would argue that it is in fact a deeply personal, human one.

Community-based, alternative approaches, (typically services that are labelled “Alternative to…”) have, under careful curation, emerged in the last 25 years or so.

They now have history, experience and maturity.
The services they offer are very personalised – meeting broad and diverse needs.
They are responsive to, and engaged with the communities they serve; a critical and important dynamic.

In fact in 2025, the irony of the label "Alternative to…" should not at all be lost. It is the “alternative” that should now be the standard. A response that recognises the uniqueness of each person and supports their "whole being" to support their recovery for life in a world that can be volatile, uncertain, complex, and ambiguous.

The Minister of Health recently announced a $61.6 million funding package to improve acute crisis services in New Zealand. This includes the creation two new 10-bed peer-led acute alternative services. A development that should be applauded, encouraged – and dramatically expanded.

My closing caveat would be that we begin to lose the language of “alternatives” and start enacting the language of transformation and “replacement”.

Notes:

[1] Home Treatment for Acute Mental Disorders, David S. Heath, 2005

[2] The Book of Laughter and Forgetting , Milan Kundera 1979

[3] Arthur C. Evans (2016) Keynote presentation: “Beyond the black box: The transformation to a population health approach. TheMHS Annual Conference, Auckland

[4] There was some concern expressed about how we might be wasting money on such indulgences. In fact our commitment to being an engaged community citizen meant that some of these “indulgences” (eg. cosmetic samples...) were sponsored by businesses.

[5] Which does cause one to wonder the extent this been an influence on our high use of seclusion during inpatient treatment?

[6] The report of the Government Inquiry into Mental Health and Addcition. 2018

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