The community as a whole needs a rethink on the way alcohol and drugs are used to address the mental health crisis gripping Whanganui.
That's the message coming from managers at the Whanganui District Health Board dealing with an overpopulated mental health unit.
The Te Awhina unit is funded to have 12 patients but in the last year has regularly housed close to 20. In August that number reached 23.
There had also been 20 assaults of staff over that year and to deal with the bed crisis staff were getting patients to sleep on mattresses on floors and couches.
The DHB's acting medical director of Mental Health and Addiction Services, Dr Jo Stephen-Tastard, said they were getting more admissions and patients' stays were getting longer.
"We think that this is about some quite complex factors and that those factors require a whole-of-community response in order to understand," she said.
"They've been discussed at a national level with all of our colleagues in Wellington coming up to look at the data to say 'what is this that is causing people to not recover in the ways that they would have done 15-20 years ago?'
"What is it about the kind of illnesses ... we're seeing that make their recovery that much more complex?"
Dr Stephen-Tastard said an example of a 'whole-of-community response' would be for everyone to think about how they used alcohol and "designer" drugs - which she said were prevalent in Whanganui.
"We don't know what the effects of those are on developing brains but what we're beginning to see is that they aren't good.
"If there was one thing that we did as a community to change the shape of mental health in the future ... we need to look very hard at the way in which we're using alcohol, the way in which people are accessing alcohol and also at these designer substances and what they're doing to people.
"Both in real time now but also the next generation who are in the womb. I think we've got a problem and we need to address that urgently."
Housing and making sure a patient returned to an adequate home was also a major issue often lumped on the DHB to try solve.
"We have people who are served with eviction notices for example and then they find themselves whilst they're in hospital suddenly without accommodation and then that adds to the difficulties that we then have to come up with solutions to.
"For mental health consumers they are often the least able to negotiate, to find for example the money for a bond," Dr Stephen-Tastard said.
"They also are the people who don't easily get a good reference.
"When they do get accommodation they often struggle to maintain it. They struggle to do things like mowing the lawns. They struggle to maintain good relationships with neighbours.
"We can find that they are prejudiced when it comes to tenancy because landlords may find ways of excluding them."
Dr Stephen-Tastard wanted to see more single-tenant accommodation. She also said there needed to be more robust housing - "unfortunately some of our people are not particularly caring of doors and walls and things like that".
Whanganui DHB chief executive Russell Simpson reiterated Dr Stephen Tastard's concerns.
"The issue we have here around homelessness and displacement is creating a huge demand on services where traditionally those demands wouldn't be there.
"So we're seeing residents in our community that are being forced out of accommodation because of affordability issues and that ultimately will have an impact on their health and mental wellness."
The DHB's associate director of nursing in mental health is Jeff Hammond.
He said the unit did actually get its numbers down to 12 patients at one stage about three weeks ago, but only for a few hours.
"The staff have really sort of pulled together. They're a tight team. Remarkable how they've remained happy and are passionate about what they do but I just worry about how long they can keep it up for. So we need to get our numbers down to what we're funded for [12 beds] and what the building's designed for."
Why not just increase the number of beds?
"The answer lies in the community - not in creating more beds. It lies in the community and how we interact with other community agencies and how the community responds and their attitude towards the mentally ill. That's where their answer is, and not within the unit.
"The inpatient unit has a limited therapeutic value. It's good for people for a short period of time. It's not a good place to complete your recovery from mental illness being around other acutely mentally unwell people.
"That's the best place to complete your recovery ... in your own bed, in your own house and certainly out in the community. Getting back on the horse, getting back to work and being amongst family and friends."
His boss agreed.
"We have 62,000 beds in our community," Russell Simpson said.
"The best bed for a person is their own one. All the statistics would demonstrate that an inpatient admission is not in the best outcome for a person, particularly with a chronic condition."
He also called on families and friends to keep an eye on their people and to try not let them fall into such a state they had to be admitted to places like Te Awhina.
"As a District Health Board we need the community's help and we need to make sure there's that self-responsibility for one's individual self and also the family and the whanau.
"They have a huge role to play in someone's wellness. If we can all collectively use our wisdom and channel it in a way that protects an individual from any of the potential issues with alcohol and drug then we would welcome the intervention from those families at an earlier stage rather than letting it escalate and requiring the reliance on many of our other services which are for the acutely unwell.
"The only way we can address these current concerns is to work collectively as a community and that community requires our 62,000 residents to play a part in that as well."