Mental Health and Social Problems

A Social Work Perspective

Nina Rovinelli Heller, Alex Gitterman, Nina Rovinelli Heller, Alex Gitterman

• Publisher: Routledge
• Year: 2010
• eBook ISBN: 9781136892745
• Topic: Medicine
• Subtopic: Health Care Delivery

Mental Health and Social Problems is a textbook for social work students and practitioners. It explores the complicated relationship between mental conditions and societal issues as well as examining risk and protective factors for the prevalence, course, adaptation to and recovery from mental illness.

The introductory chapter presents bio-psycho-social and life-modeled approaches to helping individuals and families with mental illness. The book is divided into two parts. Part I addresses specific social problems, such as poverty, oppression, racism, war, violence, and homelessness, identifying the factors which contribute to vulnerabilities and risks for the development of mental health problems, including the barriers to accessing quality services. Part II presents the most current empirical findings and practice knowledge about prevalence, diagnosis, assessment, and intervention options for a range of common mental health problems – including personality conditions, eating conditions and affective conditions.

Focusing throughout upon mental health issues for children, adolescents, adults and older adults, each chapter includes case studies and web resources. This practical book is ideal for social work students who specialize in mental health.

1
Introduction to social problems and mental health/illness

Nina Rovinelli Heller and Alex Gitterman

The social work profession has a dual mission: “to enhance human well being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers (NASW), 2008). Individuals who struggle with ongoing mental health issues experience challenges in all spheres of functioning, on a daily basis. Daily life stressors and struggles can generate cumulative and chronic stress. In accordance with our profession’s mission, social work practitioners help clients to restore their optimal levels of overall functioning in various domains. Because a wide range of social and personal conditions and influences promote or mitigate mental health and illness, social workers must have a clear appreciation of the power of these social and personal conditions and influences. Social work practice theory emphasizes the importance of understanding the complex relationships between people and their environments and this represents one of the distinguishing features of our profession. One of the first ecologically based practice models, the Life Model of Social Work Practice (Germain & Gitterman, 1980) provides a theoretical and practice framework for understanding the transactional and bidirectional relationships between social and personal problems and mental health and illness. The model rests upon several key concepts, including the reciprocity of person-environment exchanges; adaptedness and adaptation; human habitat and niches; vulnerability, oppression and misuse of power; social and technological pollution; the life course conception of unique pathways in human development; the importance of considerations of historical, social and individual time; life stressors and related coping tasks; resilience; the interdependence of all phenomena and ecological feminism (Gitterman & Germain, 2008, pp. 1–2). These concepts are central to our understanding of the importance of a dual perspective when assessing individual and social vulnerabilities and resiliencies, while understanding the transactional effects of living in the world with a mental health condition.

This model serves us particularly well today. Our knowledge base regarding mental health has grown exponentially since the 1980s. As we understand more about the biological determinants (genetics, brain structures and functions) of many mental health conditions we are better positioned to develop preventive and remedial strategies that can ameliorate the suffering of our clients and their families. However, there are necessary cautions in our use of this knowledge; we risk making our understanding of the human condition of mental illness unidimensional. The social work profession’s strength in bringing together the understanding of biopsychosocial factors and their relationships to each other is critically important. We are increasingly familiar with the biological determinants of mental conditions and social workers with expertise in mental health have long contributed their understanding of psychological and environmental factors. Likewise, all social workers including micro and macro practitioners are aware of the impact of social forces and influences on our clients, their families and communities.

However, in many undergraduate and graduate schools of social work, we continue to teach mental health content as separate from other social work content, particularly from macro social issues. While we no longer tend to call these courses “Psychopathology” or “Abnormal Psychology for Social Workers,” the content is tilted toward the psychological and increasingly toward the biological. Lacasse and Gomory (2003), in a survey of what they described as “psychopathology syllabi” from 58 social work schools, found a nearly exclusive focus on biological psychiatry. Fortunately, we are beginning to include more content on mental health care disparities as we begin to identify that mental health issues both affect and manifest differently among various ethnic and racial groups. While this is an important advance, we think all of the historical and contemporary social influences and problems that impact the experience of living with a mental illness must be considered.

Hurricane Katrina provides one sobering example of the importance of understanding the importance and utility of this bidirectionality between social problems and mental health conditions. We are all familiar with the difficulties in the FEMA (Federal Emergency Management Agency) response to the hurricane victims, particularly those who lacked the economic resources to flee the city before the hurricane or to resettle quickly afterwards. Many of the victims initially “housed” at the Civic Center were residents of the Ninth Ward, a predominantly African American neighborhood. While we tend to believe that natural disasters affect people without regard to race or class, this is not so (Prilleltensky, 2003). Nor is this a new observation; Spriggs (2006) reminds us of the Titanic, where discrepant safety planning resulted in lifeboats for first class passengers and none for those in steerage. In the case of Hurricane Katrina, Voorhees, Vick, and Perkins (2007) note that,

it was poverty which primarily determined who lived in the most vulnerable, low-lying neighborhoods (that flooded first and emptied last), who was uninsured, who was unable to escape the storm and flood (and thus who lived and died), who had fewer choices in relocating, and who did not have the resources to return and rebuild.

(Voorhees et al., 2007, p. 417)

Logan (2006) reported that indeed, preexisting disparities of race and class existed; the damaged areas were 45.8 percent African American and 29.9 percent lived under the poverty line. These represent much higher percentages than those living in the nearby, undamaged areas. These disparities put this vulnerable population at further heightened risk for many deleterious personal and social outcomes, one of which may be the mental health sequelae in the post-natural disaster period. The very issues, which place a person at greater risk for developing a particular mental condition, affect the course, outcome and experience of the illness.

In one of the first comprehensive studies of indicators of mental health conditions among the hurricane survivors, Kessler et al. (2008) used existing baseline date (pre-hurricane) from the National Comorbidity Survey Replication Study (NCRS) and did follow-up studies with survivors at 5–8 months post-hurricane and again a year later. They found that during that time, post-traumatic stress disorder (PTSD), serious mental illness, suicidal ideation, and suicide plans all increased significantly in the one-year interval. This finding is in contrast to prior ones related to natural disasters, in which post-disaster mental health problems tend to decrease with time. While the initial results suggested that adverse effects were weakly related to sociodemographic variables, one variable, low family income, consistently and significantly predicted increased prevalence of severe mental illness, PTSD and suicidal ideation. These results may not fully reflect the disparities in the incidence of post-Katrina mental health conditions because the authors note that the original (pre-hurricane) survey may have left the most marginalized segments of the population underrepresented (for example those who were unreachable by phone). Clearly, experiencing the effects of a natural disaster is not good for anyone; however, we do know that certain disadvantaged populations are at higher risk for the disaster itself, and hence for the complicated after effects. The social work response to the incidence of mental health problems in this population must consider interventions at all levels, in addition to the direct practice provisions of a range of mental health interventions and services. At the same time, we need to pay attention to the social issues and inequities, which create, promote and maintain elevated risk for a number of variables.

Consider the following practice example:

Jonya is a 16-year-old African American female who presented to a community health clinic in Houston. She was a resident of the Ninth Ward in New Orleans when Hurricane Katrina struck. She was home alone at the time of the storm; though she heard warnings to evacuate, her boyfriend told her “it would be fine.” She had lived there with her mother, who was at the time tending to her own mother, who had recently been admitted to a nursing home in the next county. After spending seven days in the Civic Center without sufficient food or water, she was evacuated to Houston. She had no contact with her family during this time; when she left New Orleans she did not know whether her mother, grandmother or boyfriend had survived. Once in Houston, she lived in a makeshift shelter where her already precarious mental health deteriorated. By the time she came to the clinic, she had not spoken in several weeks. She sat quietly in the office. The social worker sat with her. She nodded her agreement, however, to come back in the following day. Over the course of the next several sessions, during which she mostly sat silent, she began to report that she was having nightmares daily and even at times when “I don’t even think I was asleep.” She also reported that prior to the disaster, she had been seeing a counselor at the public clinic, because her mother was concerned that she continually washed her hands (often until they bled), worried about germs, and frequently complained that she was dying and that “people were after me.” These symptoms had begun six months prior to the hurricane and her mother had voiced her concerns that “you are just like your paternal grandmother; she was crazy and had to go away – no one ever saw her again.” When Jonya began to talk about her experience in the immediate aftermath of the hurricane, she surprised the social worker by going on a tirade about the “black people” behaving so badly. When the social worker asked her to elaborate, Jonya described the media images and commentary that she saw on the television at the shelter. Like much of the rest of the country, she saw images of black men who were described as “looting” stores alongside images of white people, described as “securing supplies” (Voorhees et al., 2007). In her vulnerable state, Jonya began to internalize the racism inherent in that news commentary and began to express shame about herself and the people in her community. This resulted in a strong resistance to accepting any of the concrete services, which she badly needed. She then added that she “didn’t like” the Civic Center and began to talk about having felt very vulnerable and frightened there – “It was dirty; I’ll never be clean again.”

If we consider only the “facts” of symptoms, we might conclude that Jonya has a preexisting condition, which has been exacerbated by her ordeal. We might consider a panic disorder, obsessive compulsive disorder, post-traumatic stress disorder, selective mutism. We would also note that there was a possibility of the history of schizophrenia or another psychotic condition on the paternal side (grandmother was “crazy”, sent away, and never to be seen again). However, we would also need to consider Jonya in terms of her developmental stage, her gender, her race, the stigma her mother associated with her grandmother’s psychiatric history, her lack of financial resources, the trauma of the disaster, her vulnerability to internalized racism, and the revictimizing experience of the delayed federal response to the disaster. We would also note that in spite of all of this, by the second or third session, Jonya was able to confide in the worker, accept services and begin to put together a coherent narrative of her harrowing experience. While Jonya might well need additional interventions, including medication evaluation, the ecological perspective and life modeled practice remind us of the interdependence of many factors as well as the resiliency of human beings under acute stress.

The experience of Hurricane Katrina is extreme but illustrates the “perfect storm” of natural, personal, social and political phenomena. We are also increasingly aware of the deleterious and complex effects of war, poverty, immigration status, oppression, racism, sexism, and all forms of violence, upon the well-being of individuals, families and communities. These pernicious influences disproportionately affect the most vulnerable (by temperament, health status or social status) among us.

Social workers tend to emphasize either the “mental health” side or the “social problems/ social justice” side of the equation. However, in doing so, we lose a great deal, the profession loses, and most importantly, our clients lose. We risk losing our appreciation of the complexity of the human condition and the ways in which the environment and social forces have the capacity to either ameliorate or advance an individual’s experience with mental health and illness. We also risk assigning blame to individuals for their struggles, without considering the impact of pervasive damaging social influences. This book is a realization of our attempts to bring together both sides of our social work mission as it is reflected in our knowledge base, our practice skills and our professional values. As social workers we carry a responsibility and charge to attend to people who are suffering, triumphing, and living with both the multiple effects of mental illness and the social problems, which influence them.

Social workers and mental health

In 1985, the New York Times reported that there was a “quiet revolution” in the provision of therapeutic mental health services with “social workers vaulting into a leading role” (Goleman, 1985, p. 1). Today, social workers are the primary providers of mental health servic...

Table of contents

• Contents
• Contributors
• Preface
• Acknowledgements
• 1 Introduction to social problems and mental health/illness
• Part I Social problems and mental health/illness
• Part II Mental health conditions
• Index