Faces of Public Health: Q&A with Thomas Bornemann, The Carter Center

Apr 4, 2014, 12:50 PM

Behavioral health was a frequent topic at this year’s Preparedness Summit in Atlanta for both presenters and attendees, who focus on helping people cope with stress during a disaster as well as on mental health conditions which can be exacerbated by the stress of an emergency. Thomas Bornemann, EdD, has been the director of mental health programs at the Carter Center in Atlanta since 2002. The Carter Center is the philanthropic foundation of former president Jimmy Carter and his wife, and focuses primarily on peace and health initiatives globally and in the United States.

NewPublicHealth spoke with Bornemann about the Center’s mental health programs and challenges that lie ahead. We spoke with Bornemann several days before the shooting this week at Fort Hood.

NewPublicHealth: What are the key mental health projects underway at the Carter Center?

Thomas Bornemann: We’re involved in a number of issues at the local level, national level and globally. One of our major global programs is a program in Liberia, West Africa, where we’ve been working on scaling up services in this post-conflict, low-income country. We are in our fourth year of five, and we’re providing three services: We’re training mental health workers because their mental health system was decimated after the war; we have helped them develop a national mental health policy plan and a national mental health law that will go to the legislature for approval this year we hope; and we’ve been working on the issues of stigma and discrimination against people with mental illnesses and helping to develop support for family caregivers who provide the lion’s share of the care.

In the United States we’ve been working for years on Mrs. Carter’s number one healthy policy priority, which has been the implementation of mental health parity legislation which passed in 2008. The U.S. Department of Health and Human Services has been working on final regulations since then which spell out the terms and conditions of parity. We’ve been working on monitoring that through the years, and we were very proud that in November Secretary Kathleen Sebelius came here to announce the release of the regulations out of respect for Mrs. Carter’s long commitment to parity legislation. We’ll continue to monitor the parity efforts as they become implemented through the Affordable Care Act.

Locally, we’ve been in a civil rights lawsuit that was filed against the State of Georgia for civil rights violations in our state hospitals, where there were more than 130 suspicious or unexplained deaths over a five or six year period. We helped organize stakeholders and have been working quite collaboratively the state, the department of behavioral health and development disabilities and with the Justice Department on implementing the terms and conditions of that settlement agreement.

We also have a journalism fellowship program that’s a signature program for Mrs. Carter.

We bring in six American journalists who are competitively awarded fellowships. It’s a paid fellowship and we also provide them with as much technical assistance as they may need. Completed projects have included a series on the mental health needs of returning veterans and the closing of a state mental health hospital that has since been replaced with new facilities that are much more modern and in other ways appropriate for proper care.

A reporter for the Dallas Morning News wrote a piece on homelessness in Dallas, and as a result the County Commission allocated $10 million for homeless services in their county. So the work we’re funding can have a very direct impact on the community and often a very positive one.

NPH: Looking globally first, why do you think stigma remains an issue with regard to mental health?

Bornemann: Certainly, lack of knowledge is a problem. There’s no doubt about that, and there are a lot of mythologies about mental illness and they differ from country to country and within countries. The lack of information and stigma varies quite a bit, but one common denominator we feel, in terms of an intervention for stigma, is a public policy intervention. For example, we have some evidence that when there is an increase in the budget for providing mental health services stigma seems to go down, and what that suggests is that providing the services legitimizes those conditions as real and important health conditions and that, more importantly, they deserve public support, including financial support.

There is also a fair amount of evidence that one of the most effective anti-stigma tools or strategies is to get to know someone with a mental illness. When people begin to realize that it may be that person that lives next door to you that you have coffee with two or three times a week and you find out by happenstance or whatever that he or she may have major depression that they’re being treated for, and you realize well, wow, I know this person and they may have their struggles, but I like them, I believe in them and I believe their situation deserves concern. It takes it from that really big macro level right down to the very interpersonal level that when you know somebody who’s struggling with it, lessens the stigma.

NPH: What have we learned from treating people globally following conflicts that might be beneficial for how we help returning veterans?

Bornemann: I think, unfortunately, we learn a lot during wars. And I say unfortunately because we’re forced to take a look at what happens to people when they’re exposed to extraordinary stress over time, and that certainly has been the case for service personnel who served in Iraq and Afghanistan. I think that a number of things can be very beneficial on their return, though the returning veterans can have very different circumstances and levels of support when they get back. Career service men and women will go back to their bases and have a built-in support network. Not that it’s going to be easy on them, but they will live often within a community that understands it and has been through it and can relate to one another about it without having to say a whole lot of words. They know the challenges faced by people who have been in war.

The National Guard and Reserve Corps have been heavily deployed during these wars and that’s an area the Carter Center is looking at carefully. We devoted one of our annual symposiums on mental health policy to it. They don’t necessarily go back to the same kind of support network that career service personnel have and they’re often on their own in their communities and with their families, and I think one of the real key lessons that we’re learning out of these wars is that these are family issues, these are not simply the warrior’s issue. The warrior’s issue becomes a family issue, and it’s not just spouses; it impacts the children and parents as well. We forget sometimes that a lot of parents are responsible for some of the follow-up care of their adult children who served. So it is a family constellation issue.

The good news is we’re seeing some practices emerging around the country that are taking this issue seriously and are looking like they’re going to sustain their interest over time, which is what we’re going to need to do. This war is producing, as each war does, unique kinds of clusters of injuries, and what we’re seeing out of this war with so many concussive kinds of injuries are a lot of brain involvement, whether traumatic brain injuries or other types of brain involvement that are serious and need close attention, and multiple levels of response. Certainly the Veterans Administration and other formal authorities need to step up to the plate.

We owe these men and women and we’ve got to keep our debt, and we didn’t do that in the last war so we need to do that on this one. So we’ve got to hold government accountable to do what they’re supposed to do and the best I can tell, they are attempting to meet their obligations, but we’ve got to stay on them and I think a vigilance about that is really important.

Veteran support organizations that recognize the role and service of the family are really important. I can’t emphasize that enough. That support system is really, really pivotal, and making and reestablishing those ties after deployment is not easy. It’s very difficult and often fraught with risk of breakups and other kinds of bad consequences, so I think a lot of attention needs to be paid to that.

The other thing that I would take a look at is to realize that most of these men and women are pretty strong. They’ve been through some really difficult experiences, but they have a lot of strength, and we need to help them raise that to their conscious awareness so that they are reminded of their own strength and allowed to build on those strengths no matter what has happened to them, even if there are some deficits as a result of their war experiences. They’ve been through things that other people can’t imagine, and helping them kind of reconcile that I think is a task for all of us as community members.

NPH: During the Preparedness Summit meeting this week in Atlanta, helping vulnerable populations, and in particular people with mental illness after a crisis has been a frequent session topic. What does the public health infrastructure need to be mindful of in particular when addressing this population during preparation for and recovery from a disaster?

Bornemann: It is really important that mental health professionals are part of the disaster preparedness apparatus. To make sure at the state and local level, and certainly at the national level, that mental health is a core part of whatever team is put together, and particularly in the planning process so that you know where your mental health assets are in any state or local community. That’s really vital, and if you’re a part of the apparatus of the planning process, then you know neighborhoods and you know vulnerabilities and the social demographics of a neighborhood, all of which can be vital. When a big tornado comes through and rips through neighborhoods, you’d like to know who has been living there and has been impacted and what were their conditions are because that may help you really learn how to respond to their needs more effectively. So it starts with making sure that competent mental health professionals who are skilled in disaster response are core members of your larger team.

This commentary originally appeared on the RWJF New Public Health blog.