**13. Mental health response to disaster and trauma informed care**

Some of the earliest written records in human history from Sumeria in 2000BC record the anguish and suffering of the population following the destruction of Nippur (Kinzie & Goetz 1996). In more modern times, there has been increasing recognition in a more rigorous scientific manner on the significant psychological and psychiatric sequelae resulting from people affected by disasters (Norris et al 2002)

This increased recognition has also occurred in the co-incident context of political recognition of high public expectation in respect to the quality of services that government in the developed world provides to it's citizens involved in a disaster. As an example of this the British Foreign Secretary, Jack Straw, on the anniversary of the 2004 tsunami, apologised to British families caught up in the disaster who had not received adequate support, commenting that British citizens have "very high expectations of what the British government can deliver and fair enough" (Eyre 2008). This co-incident context is of significant concern given projected estimations that in Australia, 65% of men and 50% of women may be exposed to a traumatic event during their lifetime (Forbes et al 2007) and with the current prevalence for PTSD being 1.3%, or 20,000 cases per year (ibid).

In recent years, there also has been increased identification of the effect of historical trauma as a subjective experiencing and remembering of events in the mind of an individual or the life of a community, passed from adults to children in cyclic processes and how this intergenerational trauma can lead to the breakdown of a functional society (Atkinson et al 2010). In this context, Professor Helen Milroy (pers comm) also describes the phenomenon of "Malignant Grief" as an end result of persistent intergenerational trauma and stress experienced in Australian Indigenous communities. Professor Milroy defines Malignant Grief as a process of irresolvable, collective and cumulative grief that affects Australian Indigenous individuals and communities. The grief causes individuals and communities to lose function, become progressively worse and ultimately leads to death. Professor Milroy further comments that the grief has invasive properties, spreading throughout the body and that many of Australia's Indigenous people die of this grief.

Enhanced clinician skills for clinicians to assist people affected by disaster and trauma as the need arises can be incorporated into organisational development within mental health services (Guscott et al 2007). On occasion, specific programs may need to be developed to address mass population trauma such as the one organised by the Peking Institute of Mental Health to assist clinicians and volunteers working with the Chinese population effected by the Sichuan earthquake in 2008 (Parker et al 2009). In addition, enhanced education resources devoted to the appropriate response of mental health clinicians to those affected by disaster (Ursano et al 2007) can guide appropriate economic and managerial responses by governments and health organizations.

#### **14. Housing**

Homelessness amongst people affected by severe mental illness is a continuing concern. In a recent series of nationwide meetings to discuss mental health policy and service provision in Australia, the lack of appropriate housing for the mentally ill was a consistent and significant theme in the discussions amongst a wide group of stakeholders (R Irving pers comm.). It has been estimated that 46% of homeless people in the United States may have a mental illness (O'Hara 2007) with another review estimating prevalence rates of psychosis at around 10 to 13% and a prevalence of affective disorders at around 20 to 40 % in homeless people (Schanzer et al 2007) Homelessness is also associated with higher rates of readmission to inpatient units along with longer inpatient stays (ibid). Additionally, homelessness is linked with excess mortality and particularly so with homeless people who abuse substances (Morrison 2009). Poverty, disabling health, behavioural issues co morbid substance abuse, competition for available public housing stock along with complex processes in applying for such stock all limit the opportunity for the mentally ill to access appropriate housing (O'Hara 2007). In addition, conventional categorical funding streams, bureaucratic program requirements, narrow administrative approaches to resource allocation and management and staff skills not geared to supporting the mentally ill in normal housing have been thought to have limited successful involvement by mental health services in this area (ibid).

It has also been noted that housing is a significant aspect of the recovery for people affected by severe mental illness with the concept of a "home" providing "roots, identity, security, belonging and a place of emotional wellbeing" (The PLoS Medicine Editors 2008). The "home" concepts that appear to be valued by the mentally ill are considered to be markers of ontological security: namely constancy, daily routines, privacy and a secure base for identity construction (Padgett 2007). It appears that different levels of housing support may be appropriate in this regard with supervised housing being more appropriate for people with severe disability from mental illness with a graduation to independent housing in the context of recovery (Tsai et al 2010).

Apart from the humanitarian aspects of the provision of a "home" to enhance recovery for people affected by severe mental illness, there also appear to be economic benefits generally with potential savings from repeated and lengthy hospital admissions that should encourage further strategies in this area.

#### **15. Governance**

232 Health Management – Different Approaches and Solutions

Some of the earliest written records in human history from Sumeria in 2000BC record the anguish and suffering of the population following the destruction of Nippur (Kinzie & Goetz 1996). In more modern times, there has been increasing recognition in a more rigorous scientific manner on the significant psychological and psychiatric sequelae resulting from

This increased recognition has also occurred in the co-incident context of political recognition of high public expectation in respect to the quality of services that government in the developed world provides to it's citizens involved in a disaster. As an example of this the British Foreign Secretary, Jack Straw, on the anniversary of the 2004 tsunami, apologised to British families caught up in the disaster who had not received adequate support, commenting that British citizens have "very high expectations of what the British government can deliver and fair enough" (Eyre 2008). This co-incident context is of significant concern given projected estimations that in Australia, 65% of men and 50% of women may be exposed to a traumatic event during their lifetime (Forbes et al 2007) and

In recent years, there also has been increased identification of the effect of historical trauma as a subjective experiencing and remembering of events in the mind of an individual or the life of a community, passed from adults to children in cyclic processes and how this intergenerational trauma can lead to the breakdown of a functional society (Atkinson et al 2010). In this context, Professor Helen Milroy (pers comm) also describes the phenomenon of "Malignant Grief" as an end result of persistent intergenerational trauma and stress experienced in Australian Indigenous communities. Professor Milroy defines Malignant Grief as a process of irresolvable, collective and cumulative grief that affects Australian Indigenous individuals and communities. The grief causes individuals and communities to lose function, become progressively worse and ultimately leads to death. Professor Milroy further comments that the grief has invasive properties, spreading throughout the body and

Enhanced clinician skills for clinicians to assist people affected by disaster and trauma as the need arises can be incorporated into organisational development within mental health services (Guscott et al 2007). On occasion, specific programs may need to be developed to address mass population trauma such as the one organised by the Peking Institute of Mental Health to assist clinicians and volunteers working with the Chinese population effected by the Sichuan earthquake in 2008 (Parker et al 2009). In addition, enhanced education resources devoted to the appropriate response of mental health clinicians to those affected by disaster (Ursano et al 2007) can guide appropriate economic and managerial responses by

Homelessness amongst people affected by severe mental illness is a continuing concern. In a recent series of nationwide meetings to discuss mental health policy and service provision in Australia, the lack of appropriate housing for the mentally ill was a consistent and significant theme in the discussions amongst a wide group of stakeholders (R Irving pers comm.). It has been estimated that 46% of homeless people in the United States may have a mental illness (O'Hara 2007) with another review estimating prevalence rates of psychosis at around 10 to

**13. Mental health response to disaster and trauma informed care** 

with the current prevalence for PTSD being 1.3%, or 20,000 cases per year (ibid).

that many of Australia's Indigenous people die of this grief.

governments and health organizations.

**14. Housing** 

people affected by disasters (Norris et al 2002)

The development of effective governance processes to enable the mental health of a population should be the major concern of any government and health authority. Effective governance processes should have a continuing "flow on" effect over many years with demonstrated benefit for people affected by severe mental illness, their families and communities. Mulvale et al (2007) point to the way that historical factors can mitigate against good governance in developing a modern mental health system that reflects recovery principles. Alternatively, O'Connor and Paton (2008) elaborate key aspects of a modern clinical governance framework (safety of patients and staff, consumer and family focus and participation, a skilled and valued workforce, incidents as learning opportunities, continuous improvement of clinical care, structures of accountability) and the ways that such aspects can be supported at various levels of a health system in the developed world. Governance systems should also be underpinned by strong ethical principles in respect to the appropriate treatment for people affected by mental illness. A good example of such ethical principles is the Code of Ethics produced by the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2010).

In an economic sense, it appears that the key objective of any governance system for mental health would be to maximise the potential of people affected by mental illness in respect to their human value and their contribution to their community and society in general. Porter (2010a) argues that any value in an individual's health status is measured by outputs rather than inputs and depends on actual patient outcomes, not the volume of services delivered.

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 235

The previous chapter has briefly outlined eight potential "mental health pillars of wisdom" that should be a strategic focus in any mental health funding formula to emphasise Recovery. The formula can obviously be adjusted to local economic social and cultural needs but provides a more comprehensive vision of a future for the provision of mental health. The "pillars" are also useful entities to attach specific funding priorities as well as

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**16. Conclusion** 

**17. References** 

74.

40: 51-54

benchmarks to assess achievement in each area.

Porter further notes that such outcomes should involve survival, functional status, sustainability of outcome and "others". Eriksson (2011) comments on a number of preconditions to enhance individual social capital, a significant component of human value, which then results in enhanced health. These are a Macro Structure (Social and Political conditions, Income distribution) and Social Network Characteristics ( Internalised Norms, Group Solidarity and Reciprocity) that lead to enhanced social support, social influence, social control, social participation and material resources) which lead to health benefits such as access to support, health enhancing behaviours, increased status and rewards, enhanced cognitive skills, belongingness and meaning of predicament along with improved access to health services and job opportunities. Eriksson (ibid) reports that trust and reciprocity are essential cognitive features of such collective and individual social capital and that these appear to be core elements for creating a health supporting environment, one of the five action areas for health promotion defined by the Ottawa charter. It could, therefore be argued that elements of the above should underpin any governance to enhance mental health.

Other key aspects of governance as outlined by O'Connor and Paton above is the development of appropriate mental health legislation and mental health service policies to protect patients, their carers and the community and comparative surveillance of such developments. The Mental Health Atlas (World Health Organisation 2005) reports and compares the presence in and population coverage of mental health legislation and mental health service policies in a range of world regions. The Atlas similarly reports on workforce for mental health. However, statistics do not necessarily supply the full picture of emerging trends. An example is the significant potential decline in numbers of mental health nursing workforce in Australia. Changes to nurse education in the 1980's along with the changing nature of work in psychiatric nursing appear to have significantly reduced the entry of young people into the profession. As a result, there may be major problems replacing the current workforce as they retire, leading to a severe workforce shortage in about a decade.

Mental health consumer employment within mental health services is an emerging and welcome development with consumer assisted services enhancing consumer outcomes with improved social functioning and reduced symptom severity and hospitalization (Nestor & Galletly 2008). However, it is essential that such consumer consultants be supported with training in addition to appropriate pay and conditions (ibid). The value of the role of family and carers in the management of people affected by severe mental illness is also being increasing recognised (Parker et al 2010).

The increasing use of outcome measures to assess disability and recovery as well as benchmarking where mental health services are gauged against each other and a number of key performance indicators (Coombs et al 2011) is another emerging mechanism in governance that needs to be considered. Porter (2010b) goes on to suggest a revised tier of hierarchies that is appropriate to assessing health outcomes. Tier One is whether the patient's health status is achieved or retained. Tier Two is the process of recovery of the patient and involves the time taken to achieve recovery and best attainable function in addition to the "disutility" of the care process (complications of treatment such as missed diagnoses and the ability to work whilst undergoing treatment). Tier Three involves the sustainability of the treatment process itself as well as any new health problems related to treatment. Such work encourages different ways of viewing different aspects of recovery in mental health and may allow a more accurate estimation of the economic basis of mental health management.
