Australian e-Journal for the Advancement of Mental Health (AeJAMH), Volume 8, Issue 2, 2009 ISSN: 1446-7984
Guest Editorial Mental health promotion, Australian policy, and housing for people with mental illness Sam Battams Discipline of Public Health, Flinders University, Adelaide, South Australia Keywords mental health promotion, public mental health, mental health policy, housing, social inclusion
Revisiting mental health promotion Mental health and wellbeing activity requires us to be visionary about the kind of society, communities and culture which promote mental health. It entails political questions such as ‘What living, working, community and neighbourhood environments are conducive to mental health?’ and ‘What kind of society and culture do we want to live in and create?’ Mental health promotion is not only political for the way in which it involves challenging existing structures, processes and values (Sainsbury, 2000), it is also a deeply personal issue as it warrants a closer examination of our societal and personal culture and values - the extent to which we promote a culture of co-operation, respect, tolerance, forgiveness, reconciliation, compassion, and the extent to which we value and actively support equity and human rights. In addition to maintaining a vision, mental health promotion initiatives must continue to build upon the growing evidence for a range of positive indicators for mental health, both at a community and individual level (Jané-Llopis, Barry, Hosman & Patel, 2005; World Health Organization: WHO, 2004). A growing focus has been on strengthening personal resilience, developing mental capital (Beddington, Cooper, Field et al., 2008; Foresight Mental Capital and Wellbeing Project, 2008), enhancing social capital and community integration, healthy Contact: Citation:
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settings approaches, addressing social determinants of health and mental health and macrolevel indicators which better account for human development factors (i.e., the Human Development Index, Gender Development Index and Gender Empowerment Index: WHO, 2004). Yet despite developing evidence and progress in mental health promotion activity over the last ten years (Walker & Verins, 2009), the challenges for mental health promotion are great. Firstly, whilst a key aim of mental health promotion activity is reducing inequity and the risk of mental disorders, evidence indicates that there is strong inequity within and across countries in terms of health outcomes, and in some cases growing inequity (Commission on Social Determinants of Health: CSDH, 2008). Some recent measures reflect growing inequity between Indigenous and non-Indigenous Australians (Australian Institute of Health and Welfare: AIHW, 2008b; Productivity Commission, 2009). Many mental health problems, illness and signs of mental distress are also increasing: depression is predicted to become the second leading cause of disability worldwide (Mathers & Loncar, 2006). In Australia, rates of hospitalisation as a result of self-injury were twice as high amongst young Aboriginal and Torres Strait Islander people in 2005-06, and between 1996-97 and 2005-06 had increased by 51% amongst young women (AIHW, 2008a).
Dr Sam Battams, Discipline of Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, 5001
[email protected] Battams, S. (2009). Mental health promotion, Australian policy, and housing for people with mental illness. Australian e-Journal for the Advancement of Mental Health, 8(2), www.auseinet.com/journal/vol8iss2/ battamseditorial.pdf Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet) www.auseinet.com/journal
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‘larger constellation’ of practitioners focused on treatment and the prevention of mental disorders. However, there are clear tensions for the mental illness sector, associated with social control and constraint supported by legislation (i.e., compulsory treatment orders), adopting mental health promotion goals of empowerment and structural change, especially when it has been noted that the institutional end of mental health services has become harsher and more focused on security and risk management in some countries such as Australia (Hazelton, 2005). Mental health promotion for people with mental illness needs to go beyond the recovery and rehabilitation workforce - and beyond the ‘treatment and maintenance’ sectors of the mental health promotion wheel (Barry, 2001) and foster responsibility within ‘other sectors’. Maintaining people who have been previously diagnosed with an illness (but may not be currently managed by public mental health services) in public housing, employment, and education should entail workforces in ‘other sectors’.
Secondly, government and particularly the ‘health sector’ is clearly only part of mental health promotion, as it goes beyond government, sectors, systems and services. It involves addressing inequity through social determinants of health and mental health; that is, building positive social capital, economic participation and good working conditions, early childhood development, education, democratic systems, freedom from discrimination, freedom of selfdetermination, a human rights framework, addressing stigma, and culture (see CSDH, 2008). A range of government sectors clearly have an important role to play in terms of policies and strategies to support mental health, such as positive parenting programs, work-life balance policies and practices, developing more democratic organisations and structures, addressing negative school, workplace and sporting cultures, addressing racism, violence and discrimination, and ‘social inclusion’ strategies. However, intersectoral activity is difficult to achieve, especially across levels of government, and was considered one of the most difficult aspects of previous mental health plans (Steering Committee for the Evaluation of the Second National Mental Health Plan, 2003).
Fourthly, although at an international level mental health promotion has gained momentum across the past 10 years (Walker & Verins, 2009), mental health promotion seems to have recently slipped from the national political agenda in Australia. Australia has previously been considered an international leader in mental health promotion (Barry, 2007; Parham, 2008) but has more recently focused on ‘downstream’ treatment outcomes (Parham, 2008). In addition, the prevention focus in Australia has become physical health and individual behaviours - what we ‘eat, smoke and drink’ - overweight and obesity, tobacco and alcohol (National Preventative Health Taskforce, 2008). The relationship between mental and physical health and the way health behaviours are shaped by social conditions has taken a backseat. The physical health of people with a chronic mental illness, who have amongst the worst health of any group, is also lost in this focus. Conversely, the mortality rates of people with mental illness are equal to the general population residing in developing countries, and the overall mortality rate of people with mental illness from preventable causes is 2.5 times that of the general population (Lawrence & Coghlan, 2002; Lawrence, Holman & Jablensky, 2001).
Thirdly, there is still debate about the mental health promotion workforce and expressed need for capacity building in this area. Questions have arisen as to the delineation between health promotion and mental health promotion, and the scope of mental health promotion. Conversely, while it is often said that mental health promotion is ‘everybody’s business’, it is easily overlooked in curriculum, workforce development and policy agendas. Two kinds of workforces have been suggested: a dedicated mental health promotion specialist workforce working across settings, and a wider workforce from across sectors (Barry, 2007). As in ‘health in all policies’ approaches (Kickbusch, 2008), we need a ‘mental health promotion lens’ on policies from across a range of sectors, and highly skilled advocates with the skills to work across sectors. The mental health promotion workforce has also been associated with recovery and rehabilitation for people who have experienced mental illness. Mittelmark (2005) refers to a ‘small constellation’ of practitioners focused on whole of population positive mental health, and a much 2
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Policy is rates of suicide, although the WHO (2004, p. 33) has previously cautioned against using suicide as an indicator of psychological distress, as it may help to conceal the ‘more prevalent and potentially more modifiable morbidity of self-inflicted injury’. We are thus potentially missing the alarming increase in selfinjury amongst young women, and the much higher self-injury rates amongst young Aboriginal people (AIHW, 2008a).
Recent policy initiatives in Australia In March of this year, the National Mental Health Policy 2008 (Australian Health Ministers: AHM, 2009) was released. This followed the Council of Australian Governments (COAG, 2006) National Action Plan on Mental Health 2006-2011, which focused on outcomes for people with mental illness. The latter ensued from the political momentum for mental health in 2005, associated with national inquiries such as the Palmer inquiry into the wrongful detention of Cornelia Rau (Commonwealth of Australia, 2005) and the national Senate Select Committee on Mental Health (2006). The new National Mental Health Policy appears to incorporate some of the mental health promotion aims of the previous National Action Plan for Promotion, Prevention, and Early Intervention for Mental Health (Commonwealth Department of Health and Aged Care: CDHAC, 2000), as well as some of the initial aims of the National Mental Health Policy (AHM, 1992). In this respect, the United Kingdom concept of ‘public mental health’ has been promoted, which incorporates mental health promotion and takes a population focus to reducing risks and increasing protective factors for mental health (Department of Health, 2009; Friedli, 2005).
The latest draft Fourth National Mental Health Plan refers to social determinants such as housing, education and employment for people with mental illness, within a ‘recovery’ approach. However, there appear to be greater ‘whole of government’ opportunities through social inclusion strategies for people with mental illness, which have become a focus as they have in the United Kingdom (Friedli, 2005). For example, South Australia’s Social Inclusion Board developed the latest mental health policy, Stepping Up (Social Inclusion Board, 2007), and the Australian Social Inclusion Board (2009) has as a priority the employment of people with disabilities and mental illness, which has led to the National Mental Health and Disability Employment Strategy (Australian Government, 2008). Homelessness has also become a priority for both state and national social inclusion boards. In December 2008 the Australian government released its national homelessness policy, The Road Home (The White Paper), where it confirmed two broad COAG goals of halving homelessness and offering supported accommodation to all rough sleepers (Homelessness Taskforce, 2008). Within this policy, mental health issues are recognised as being a cause of homelessness, with a third of clients of the Supported Accommodation Assistance Programs (SAAP) and the homeless in inner city areas being mentally ill. The policy also introduces a ‘no exits into homelessness’ from mental health facilities stance (Homelessness Taskforce, 2008).
However, as can be seen from the aims of the latest National Mental Health Policy, the focus is largely back onto mental illness, as confirmed by the ensuing draft Fourth National Mental Health Plan (Fourth National Mental Health Plan Working Group, 2009) which says little about whole of population mental health promotion. Missing from the current National Mental Health Policy and associated draft plan is the life course perspective of mental health promotion, a population group focus, healthy settings approaches, and a range of positive indicators for mental health found in previous and current mental health promotion strategies in Australia and the United Kingdom (e.g., CDHAC, 2000; Department of Health, 2009; National Mental Health Development Unit, 2005; Victorian Health Promotion Foundation, 2005). Currently there are no such population level indicators for mental health promotion included within the draft mental health plan. When it comes to ‘negative indicators’, one indicator in the latest National Mental Health
Mental health promotion, citizenship rights, and people with mental illness People with mental illness should be considered an important group for mental health promotion activity, due to their relationship to social determinants such as housing, employment and access to health services. In my recent research 3
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collaboration was part of bureaucratic and professional cultures. In order to facilitate coordination across sectors, intersectoral policy and planning processes, cross-sectoral policy networks, high level intersectoral structures, common accountability mechanisms (e.g., housing stability), and the engagement of leaders within and across sectors are required.
(Battams, 2008), I closely considered the issue of housing outcomes for people with a severe mental illness. As part of this research, national policy trends across the health and housing sectors (2000-2005) were examined, with a number of policy factors considered unconducive to people with mental illness achieving housing outcomes. The research also considered the South Australian 2000-2005 mental health reform period as a case study. The following main themes were identified: •
Increased privatisation across sectors consistent with neo-liberalism and new forms of government (Dean, 1999); that is, dwindling public housing resources and a lack of significant investment at a national level for supported accommodation for people with psychiatric disability. Investment in a national program where housing is coordinated with disability support and clinical services would prevent piecemeal, short-term approaches and discrepancies across states. Supported housing models utilising existing public housing were considered desirable (rather than separate ‘within mental health sector’ programs), as the majority of mental health service users already resided in public housing, and cross-sectoral strategies could help to address particular issues arising within the housing sector (e.g., ‘disruptive tenants’ and stigma for people with mental illness in public housing). Also recommended were programs that separated tenancy management and support, incorporated joint workforce development across sectors, and provided housing close to community resources and family and friendship networks.
•
A lack of intersectoral linkages, including within bilateral1 agreements, and poor access for people with mental illness to government programs in ‘other sectors’. Separate bilateral agreements sometimes led to competing programs guidelines and goals of public servants. Other factors influencing intersectoral collaboration included: changes in government leading to turnover in staff, state level structures and processes for collaboration, the extent of within and crosssectoral integration in policy networks (including NGOs), and the extent to which 4
•
A social view of health and disability, which emphasised the determinants of health and disability, was not always reflected in policies. The notion of recovery was quite individualistic in its definition and whilst the National Action Plan (CDHAC, 2000) considered settings for mental health promotion which included housing, these were listed as aged and disability settings and temporary accommodation, rather than intersectoral strategies to maintain people in public housing (where the majority of people with a mental illness reside). The strong ‘medical discourse’ on health and disability shaping policy initiatives within the mental health sector (state level) tended to overlook social determinants and the impetus for intersectoral collaboration. Public forums and policy debates where experts from across sectors could interact with people with psychiatric disability and carers could bring opportunities to debate important issues - such as ideal housing models and their implications for intersectoral collaboration, competing discourses on disability and associated policy solutions, and the connection between policy problems such as ‘disruptive tenants’, ‘hospital emergency department demand’ and ‘supported housing shortages’.
•
Changing definitions of the 'rights' of people with a psychiatric disability have been reflected across national mental health policy. Across iterations of the first three national mental health plans, there has been a change from a focus on broad civil rights (such as the right to housing), to promoting rights in health care policy, planning and treatment settings. Additionally, when it comes to intersectoral linkages, the focus in the third plan was upon policy and services integration, rather than meaningful community participation to develop policy
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also mentions the importance of ‘integrated programs’ across mental health and housing sectors. However, it is unclear if any of these policies (or affordable housing strategies) will specifically provide for supported accommodation resources for people with a mental illness at a national level.
and resources in non-health sectors (AHM, 2003). With Australia being signatory to the recent UN Convention on the Rights of Persons with Disabilities (United Nations, 2008), the rights of people with mental illness should be fully reflected in mental health policy, including the right to physical health. •
•
We currently need a ‘public mental health action plan’ with clear strategies, targets, and resources for implementation. The sorts of indicators that might be considered include rates of community, social and emotional wellbeing (not simply the prevalence of mental illness), social capital (civic engagement, family and friendship networks), economic participation, work-life balance policies, and equity in health. Where once Australia was considered a leader in mental health promotion, we could now take the lead from the United Kingdom and Scotland, which now have comprehensive ‘public mental health’ policies with a range of population level strategies and indicators for mental health and wellbeing (National Mental Health Development Unit 2005; Scottish Government, 2009).
Tension in the way carers are perceived in national policy. The definition of ‘carer as resource’ is apparent throughout the national mental health policies, and at the same time, carers are represented as needing resources to support their central caring role. Conversely, there is growing evidence on the poor health of carers, particularly carers’ poor mental health and lower levels of wellbeing (Australian Institute of Family Studies, 2006 cited in Edwards, 2009; Ballard, Eastwood, Gahir & Wilcock, 1996; Cummins, Hughes & Tomyn, 2007; Hirst 2004; Wilson & Menon, 2004; Wooff, Schneider, Carpenter & Brandon, 2003). Consideration of the rights of family carers, and addressing privacy issues to assist with their involvement in service level programs is important for both carers and carerecipients.
Note 1. Bi-lateral agreements refer to agreements between the Australian Commonwealth and State/Territory governments regarding the funding and provision of services; for example, Commonwealth State Housing Agreement and Commonwealth State Territory Disability Agreement.
Stigma reduction strategies have been mentioned since the inception of the National Mental Health Strategy. My research highlighted the importance of tackling community stigma, particularly that expressed through the media and in ‘other sectors’, as it had the capacity to influence public debate and ultimately policy decisions. Suggested strategies for tackling community stigma included engaging the support of community leaders, developing relationships with the media (continuing stigma watch campaigns), involving people with mental illness and carers in policy forums, and working with neighbourhoods when introducing housing initiatives.
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The recent National Mental Health Policy and The Road Home acknowledge the importance of housing to people with mental illness and their over-representation amongst homeless populations, with the former recognising the importance of long stay accommodation options. The draft Fourth National Mental Health Plan
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