When I began working at Rauaroha - Segar House - the Intensive Psychotherapy Service soon after moving to New Zealand, I felt deeply fortunate to have found such a position within the public mental health system. As a psychiatrist and psychotherapist grounded in psychoanalytic thinking, the work aligned closely with my beliefs about what genuine mental health healing entails. I saw in its model of care, a clear commitment to depth and to cultivating therapeutic relationships that allow clinicians to engage with and think about patients’ psychic pain in ways that foster transformation rather than merely manage symptoms. It felt and indeed was, a rare environment within a system increasingly shaped by throughput and brief interventions.  

Established in 1975, Rauaroha - Segar House was a tertiary-level, specialist psychotherapy service initially residential and later evolving into a day program, for people with complex histories, often including severe childhood traumas, longstanding depression, and chronic suicidality. The intensive program served a small number of highly complex clients at any one time with a small, specialised team, offering a combination of group and individual therapy. 

The program’s heart was its therapeutic community. In an era where loneliness, social withdrawal, and relational trauma were central to many patients’ difficulties, the simple fact of coming into a stable group, four days a week, mattered as much as any specific technique or therapeutic modality. People who had spent years feeling unsafe with others slowly experienced being seen, recognised, and held in mind by staff and peers. The day structure that included shared groups, morning starts, regular break, created continuity and rhythms that countered the fragmentation and isolation that so often accompanied long-standing attachment traumas and chronic suicidality. 

Clinically, Rauaroha - Segar House integrated several therapy modalities within a coherent, reflective frame. The intensive day program combined psychiatric care, individual psychotherapy, process groups focused on here-and-now relationships, dialectical behaviour therapy skills, mentalisation-based work, mindfulness, and creative therapies. Psychoanalytic and psychodynamic thinking provided a backdrop for understanding transference, countertransference, attachment, and enactments, while DBT and skills-based approaches offered concrete tools for emotion regulation and crisis survival. This integration meant we could respond flexibly: at times staying close to unconscious meaning and history, at other times concentrating on behavioural safety and practical change, continuously linking internal states with external realities. 

The team itself was central to the treatment. Our regular meetings functioned like a clinical “mind” that could hold multiple perspectives on a person whose life story, disintegrated psyche and erratic behaviours might otherwise feel overwhelming to a single clinician. We discussed countertransference, risk, progress, and impasses, drawing on psychodynamic, mentalizing, DBT, and systemic lenses at once. This meant ongoing labour of processing and integrating the split parts of the patients as well as the need to work through the inevitable splits within the team. Over 12–18 months, many clients moved from repeated self-harm, intense interpersonal crises, and chronic hospital use toward more stable relationships, study or work, and a renewed sense that life could be bearable and even meaningful. Patients described the program as “life-changing” and said there were no realistic alternatives available to them in the wider system either publicly or even privately. 

The abrupt announcement in mid-2025 of its closure, framed as a resource management decision in the context of low patient numbers and a shift toward briefer, more widely distributed therapies, landed heavily with both staff and clients. We tried to resist the decision as a team, suggesting practical changes to the service model and referral pathways. Our efforts were echoed by many mental health colleagues, unions, patients, and their families who publicly voiced concern that no comparable service of similar intensity or specialization existed for the people we supported. Their solidarity meant a great deal, reminding us that many others share our views. 

For many patients, it echoed previous abrupt endings and losses, stirring fears of being “alone again” with unbearable internal states and we found ourselves working explicitly with themes of mourning, repetition, and distrust. We were carrying the grief of the existing patients as well as the potential future patients that will not have the opportunity for the therapy at the level of care they need alongside our own sense of personal, professional, and ethical loss. 

Reflecting on this journey, this raises in me painful questions about how psychotherapeutic work can survive within contemporary public mental health systems. At its heart, therapy depends on time, trust, and the clinician’s capacity to work through the emotional pain of patients in ways that foster growth and transformation. Yet this kind of work can only flourish when clinicians themselves are contained by a supported and well-supervised team environment. It is especially required for teams working with complex patients, to actively cultivate reflective processes that will allow work with countertransference while maintaining emotional resilience. Without that, too often, the pressures of efficiency, risk management, and throughput push clinicians toward crisis response rather than deep, sustained care.  

This leads us to larger ethical and societal questions: how do we, as a community, define mental health? Is it merely the reduction of risk and the management of behaviours that disturb social order - or should it also include the nurturing of meaning, relationship, and psychological growth? Our funding priorities may ultimately reveal which definition we choose to stand by. 

Working at Rauaroha - Segar House gave form to what I knew about trauma being a disorder of attachment, symbolisation, and affect regulation. It created a stable therapeutic community that functioned as a holding environment in the Winnicottian sense, providing containment for unmanageable states of mind and allowing previously dissociated or split-off experiences to become thinkable within multiple relationships. Over time, I saw how an integrated frame, drawing on transference and countertransference, mentalisation, and skills-based work, could support structural change rather than just symptom reduction in people once labelled “too complex.” The programme’s closure was an institutional ending, but the psychotherapeutic principles it embodied, relational depth, attention to unconscious meaning, and the use of community as a corrective emotional experience for profound isolation, continue to organise how I conceptualise and wish to practise psychiatry.