Mental Health and Later Life

Delivering an Holistic Model for Practice

John Keady, Sue Watts

• Publisher: Routledge
• Year: 2010
• eBook ISBN: 9781136922312
• Topic: Medicine
• Subtopic: Health Care Delivery

The mental health needs of older people are all too often overlooked or put down to the inevitable consequences of ageing. This textbook will make it much easier for health, social care and third sector workers to identify, treat and support the needs of this population.

The book takes an interdisciplinary team approach and sets the scene by looking at different practice contexts in the United Kingdom and the increasingly important role played by social care in addressing the mental health needs of older people. A number of more clinically focused chapters then cover:

• mental health promotion
• anxiety and depression
• ageing and psychosis
• alcohol and dual diagnosis
• dementia
• later life liaison services
• complex and enduring mood disorders.

Each clinical chapter makes use of extended and detailed case studies which illuminate the team's role in the assessment-intervention-evaluation cycle and ensure the text's application to practice. Service user and family perspectives are drawn on throughout and current practice exemplars outlined. The final chapter distils key messages from the book and sets a number of key challenges.

Mental Health and Later Life highlights the rewards and complexity of working with older people with mental health needs and their families. It is invaluable reading for all those learning about, or working with, this population.

Part 1
Setting the scene

1
Between participation and practice

Inclusive user involvement and the role of practitioners

Richard Ward with contributions from the Scottish Dementia
Working Group and Lindsay River, Ex-Director of Polari

Key messages

• Inclusive measures are vital to user involvement in order to avoid replicating existing inequalities in access to health and service care.

• Practitioners have an important role to play in strengthening user participation and can work together with users to tackle exclusion and discrimination against particular groups and communities.

• Adopting a social model of mental health within the involvement process can assist in tackling the structural barriers to the participation of service users.

• Taking account of the biographies of service users supports a better understanding of the cumulative impact of exclusion and discrimination upon their involvement in user networks.

• Making relations of power explicit within user involvement initiatives can support the development of empowering practice and help in the recognition of differences between service users.

Introduction

The participation of service users in the structures and processes of the welfare state is now widespread, although still far from systemic. User involvement has evolved politically from something tolerated at the margins of health and social care to an undertaking now required of both health and local authorities (Department of Health 2006, 2007, Dialog 2007). This shift reflects broader social and political changes as forms of democracy and citizenship become more localised and diffuse and the grand narratives of twentieth-century politics fade from view. As with much recent rights-based policy, participation has been introduced as an administrative duty on providers and straddles different cultures and disciplines within health and social care. It has the potential both to unify the provision of services and erode long-standing divisions between differing professional groups and the individuals they support. Yet, participation of service users is one of the least well evidenced reforms to recent policy (Campbell 2001), especially in terms of its outcomes (Carr 2004), and little detail is known about who gets involved or how (Bochel et al. 2008).

This chapter addresses three key questions:

1 What role can practitioners play in strengthening participation?

2 Why is inclusivity important to user involvement?

3 How can inclusive forms of participation best be achieved?

The discussion focuses on the challenge of developing inclusive forms of user involvement. Without inclusive measures there are few guarantees that participatory mechanisms will necessarily avoid the exclusions and inequalities that currently prevail in health and social care. Practitioners have a vital role to play in this process through enabling individual users and by ensuring the involvement process reflects diversity and supports difference. A case is made for looking beyond the way services define users according to presenting needs, to consider instead the significance of a broader social and biographical context as a basis for involvement. The idea of a uniform category of service user is questioned through reference to two case studies of user involvement with groups that have historically been excluded from the planning and provision of mental health services.

Practice supporting participation

Within the existing literature there are (at least) three ways in which user involvement has been portrayed:

• As a conceptual clash (Carr 2007) between a top-down set of policies and a so-called bottom-up social movement.

• As a spectrum of involvement activities where there is an emphasis on the heterogeneity of approaches and methods (Nolan et al. 2007a, 2007b).

• As one element on a spectrum of actions in which users are engaged (Campbell 2001).

Beyond these characterisations are a host of more sceptical standpoints, with emphasis placed on participation as a hegemonic system or technology by which policy-makers and service providers seek to legitimate their own interests (Harrison and Mort 1998, Carey 2009). Despite such an array of perspectives there has been a tendency to neglect the role of the practitioner, with limited thought given to where health and social care practice fits into the involvement agenda. Indeed, little evidence currently exists of the opportunities for practitioners to reflect on what user involvement means to them – either collectively or as individuals. Only recently have calls been made for the training and education received by practitioners to include skills associated with supporting user participation (e.g. Barker and Rolfe 2004, Postle and Beresford 2007).

Instead, two increasingly well-documented forces have been argued to drive user participation in the welfare system. One such force consists of often well networked, vocal and co-ordinated user movements. In mental health, this movement has worked to challenge entrenched beliefs, for example drawing attention to the socially located and constructed dimension to mental health difficulties while placing emphasis upon social attitudes to mental illness, stigma and other adverse conditions. Such emphases imply the need for a broader social agenda for mental health rather than individualised medical responses. By contrast, a consumerist doctrine in policy has promoted involvement as a route to improving services but has presented few challenges to existing structures or relations. In the context of this tension between top down policy and grass roots campaigning, where does the practitioner figure?

New working cultures

The only part of an organisation that many service users come into contact with is their individual worker or service team. Much rides on the quality of this encounter, and the extent to which the parties are able to develop a relationship in which professional expertise is put at the disposal of the service user’s agenda.

(Braye 2000: 24)

The integration of health and social care creates new contexts and cultures for practice. Different professions are finding their working practices open to scrutiny as they seek to articulate and share their skills whilst establishing routes to collaborative working. In this context, Barker and Rolfe (2004) have called for the reframing of the nurse’s role through a rights-based approach. They argue that mental health nurses are increasingly working in ‘multi-disciplinary and community-based settings where they are both more exposed to social approaches and more able to take forward social approaches in their own work’ (p. 366). Similarly, Carr (2004) has recommended that ‘frontline practitioners could be usefully engaged in user participation strategies and benefit from a user-led training focusing on the practice and principles of user participation’ (p. 273).

The move toward integrated health and social care provision has brought professional differences to the surface that have implications for user involvement. The rather more clearly set out and hierarchised knowledge-base in health has been perceived as dis-advantaging social care workers (Gould 2006), whose working knowledge is often more tacit, context-specific and consequently more difficult to articulate or aggregate (Pawson et al. 2003). Yet the skills associated with social care approaches have been argued to lie at the heart of a move toward strengthening user involvement and the enabling of service users (e.g. Postle, Wright and Beresford 2005). This shift involves the recasting of the practitioner from the role of expert, defining user needs and deciding on their behalf how best to respond to that of a facilitator, working in partnership with users.

In respect to working with older service users, Thompson and Thompson (2001) describe this as a shift from a care of the elderly model to one of empowering practice. Integral to this is the need to challenge the effects of ageism and how they shape relations between practitioners and users, and the development of more collaborative forms of working that aid user decision-making and greater levels of involvement in the welfare system. The authors highlight three key features of practice necessary to this partnership style of working:

1 Interpersonal and problem-solving skills that raise confidence and self-esteem and challenge the effects of ageism.

2 An understanding of services, resources and other opportunities available to users.

3 The capacity to analyse complex social and personal circumstances and help identify ways of moving forward.

(Thompson and Thompson 2001: 66)

Why is inclusivity important to user involvement?

A compelling argument for user participation is that service users possess insights into their own needs, and a situated understanding of the services they access to meet those needs, which is otherwise inaccessible to providers (Beresford and Croft 2001). Within mental health provision, evidence of the incorporation of situated knowledge is beginning to emerge, signalled by a growing concern to ascertain user-defined criteria and outcomes as a means to develop more tailored forms of care and support (e.g. Perry and Gilbody 2009). The challenge for such participatory approaches lies in how well they are able to take account of difference and avoid creating normative categories of service users.

All users are not equally well placed to participate, and face barriers to involvement that are comparable to those when accessing services. Yet there is limited commentary on how individuals are recruited or engaged by participation mechanisms. A review by Tait and Lester (2005) found that most mental health user groups are small, poorly funded and non-representative of minority groups or communities; while Webb (2008) has observed that where service user groups are active they are usually self-selecting and their forms of accounting to a wider public are often uncertain. In short, little is known about the patterns of exclusion that currently define and mark out the participation process within health and social care. Forbes and Sashidharan (1997) succinctly summarise this dilemma in the following way: ‘A uniform notion of users implied by the current model, such as mental health users, older users or users with a disability is made possible only by ignoring the heterogeneity of users’ (p. 492).

Forbes and Sashidharan (1997) also highlight a series of reasons for looking beyond the category of service user – summarised below:

• Users do not have a uniform relationship to services.

• Needs differ, as do experiences of a service.

• Broader social divisions shape access to and experiences of a service.

• Notions of need and risk are also shaped by a wider social context.

• Inequalities and divisions can be reinforced by services (for example, the higher levels of custodial and coercive forms of intervention employed with Afro-Caribbean mental health service users).

Such considerations highlight why there is a need for inclusivity in user involvement mechanisms, and underline the role played by health and social care in constructing the identities of service users while also upholding differences between them, both within and beyond service provision. An example that has particular relevance to mental health services for older people is the relationship between medicine and homosexuality.

The significance of a biographical context: older lesbian, gay and bisexual (LGB) mental health services users

Work conducted with older LGB people underlines the significance of taking into account a biographical context when such individuals access mental health services as well as in the development of participation mechanisms with older service users. At earlier points in their lives older gay, lesbian and bisexual service users were viewed and treated by psychiatrists and other medical practitioners as mentally disordered, a view supported by a longstanding concern within medicine to identify the cause of homosexuality. Only relatively recently was homosexuality removed from psychiatric diagnostic manuals. For older LGB service users such experiences ...

Table of contents

• Dedication
• Contents
• Illustrations
• Contributors
• Foreword
• Acknowledgements
• Glossary
• Introduction
• Part 1 Setting the scene
• Part 2 Clinical contexts
• Part 3 A way forward
• Index