Mental Health Work In The Community

Theory And Practice In Social Work And Community Psychiatric Nursing

Michael Sheppard

• Publisher: Routledge
• Year: 2004
• eBook ISBN: 9781135385781
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

A presentation of a comparative analysis of the work of mental health social workers and community psychiatric nurses, an issue of importance because of "community care" and also important as much of their work territory overlaps. The findings are more favourable to social workers.

Chapter 1
Introduction

The context for the practice of social work and community psychiatric nursing (CPN) as well as the development of community mental health centres (CMHC) is provided by the increasing emphasis since 1945 on community care of the mentally ill. To a large degree this arose from the development of psychotropic drugs in the 1950s, which revolutionized the control of major mental illness, such as schizophrenia, creating an atmosphere of therapeutic optimism. This was allied to a growing disenchantment with hospitals as an appropriate setting for managing mental illness, and the potential debilitating effect of institutional care (Goffman, 1961). The term ‘institutional neurosis’ described a process by which hospital regimes created individuals with characteristics such as submissiveness, apathy and a shuffling gait (Barton, 1959). Closely associated with this was the preferred notion of ‘normalization’: ‘The conviction that if people with handicaps are treated like everyone else, their handicaps will cease to be of importance to them and to society’ (Jones, 1988, p. 90). In political terms the focus for decarceration of patients was most evident in Powell’s well known speech as Minister of Health planning to halve the number of hospital beds in fifteen years (Powell, 1961), which was followed by the ‘Hospital Plan’, which envisaged the run down and eventual closure of existing hospitals and their replacement by short stay psychiatric units and community care facilities provided by local authorities (Ministry of Health, 1962). Figures for bed occupancy reflect the subsequent reduced emphasis on institutional care: average daily bed occupancy reduced from 118,800 in 1966 to 83,800 in 1976 and 61,500 in 1986 (Department of Health, 1988).

While reduced hospital care focused primarily on major mental illness, research has identified high levels of morbidity, primarily in minor mental illness, in general population surveys. The point prevalence of psychiatric disorder is somewhere between 90 and 200 per 1000 at risk, primarily constituting various combinations of depression and anxiety (Goldberg and Huxley, 1980). These disorders arise in a social context and rates, notably of depression, are about twice as high for women as men, and higher in urban than traditional rural contexts. (Brown and Harris, 1978; Brown et al., 1977). While Goldberg and Huxley (1980) assert community depression is generally less severe than that encountered in hospital, research by Brown and his colleagues (1985) indicates that, except for a small proportion of severely depressed, depression in the community is as severe as that in hospital. The implications of research were not simply the discovery of high levels of morbidity, but that much of it goes untreated.

The growing emphasis on care in the community was accompanied by the establishment of Social Services Departments in 1971, followed by National Health Service reorganization in 1974 with the associated organizational separation of social work from health professionals. Workers formerly concentrating on mental health, child care, elderly and handicapped work respectively, were brought together in one unified social work profession. The effect was to create two empires, one social work based in local authorities and the other, dominated by medicine, based in health authorities, Together with the other developments in community care, this generated a number of issues evident in subsequent policy documents. The first was interprofessional collaboration, recognized increasingly as a problem with organizational separation. The 1975 White Paper (DHSS, 1975a) advocated the attachment of social workers to primary care teams as well as their involvement in specialist multiprofessional psychiatric teams, the advantages of which were closer collaboration and the pooling of a variety of perspectives and skills. A later document (DHSS, 1978) charted the problematic nature of collaboration deriving from differences in organization, knowledge and status, and suggested joint work, bringing together different skills in the service of particular clients, as superior to individual work.

A further issue relates to medical and non-medical approaches, which the White Paper (DHSS, 1975a) considered partly competing and partly complementary. Hence, the belief in the importance of biochemical factors and the efficacy of drug treatment was contrasted with approaches stressing underlying social, psychological and environmental causes of mental illness, particularly neurotic problems. The alternative to competing positions was an eclectic approach incorporating biological, psychological and social elements. The competing positions tend to emphasize to different degrees ‘medical’ and ‘non-medical’ approaches. A third, associated, issue relates to prevention. Primary prevention was considered in broad terms of reducing individuals’ exposure to social circumstances likely to place their mental health at risk. Concern was expressed about early recognition, assessment and support for those caring for the mentally ill, involving not just professionals but employers, managers and planners (DHSS, 1975a). A fourth issue related to the target group. The Social Services Committee (Short, 1985) contrasted the concern with decarcerated patients with the non-hospitalized mentally ill in the community. They commented on the ‘almost obsessive concentration’ in public policy on the former group, and suggested the balance should be redressed by a greater involvement with the latter. To a considerable degree this entailed a change in the balance of emphasis: from major mental illness, predominantly associated with hospitalization, to minor mental illness, predominating in the community. Throughout, there has been a concern that political and financial commitment to community care has been more rhetorical than practical, and concerns have been expressed that community care should not be viewed as a cheap option (Short, 1985; Audit Commission, 1986). These concerns have not been dispelled with the publication of the White Paper (Department of Health, 1989) giving primary responsibility, as suggested in previous reports, to local authorities (Jones, 1988).

Community Mental Health Centres (CMHCs)

CMHCs represent an important response to the development of care in the community. Echlin (1988, p. 2) comments that

Judging from the evidence of the rapid expansion of CMHCs in Britain in recent years, planners are increasingly turning to CMHCs as their favoured method for moving mental health provision out of hospital.

The first centre was opened in 1977, since when there has been an exponential growth: by 1987, 122 centres existed or had planned funding, and 155 were at the unfunded planning stage (Craig et al., 1990). Most authorities possessed, or planned, CMHCs (Sayce, 1987). The inspiration came largely from American (and Italian) experience, where CMHCs arose within the Civil Rights movement of the 1960s, but subsequently suffered both political and service delivery problems (Jones, 1988). However, unlike their American counterparts, British CMHCs have no mandated services: their development stemmed rather from enthusiasm and commitment. There is, however, no simple definition of a CMHC. Sayce (1989) comments that the CMHC has become something of a buzzword, reflecting the belief that, even if an authority did not have one, they nonetheless should. But a cursory glance at British developments shows a bewildering variety: mental health advice centres, mental health resource centres, day centres, community mental health teams as well as those avoiding explicit reference to mental health in their title (hoping to reduce stigma) (Sayce, 1988).

Echlin (1988) identifies two models. The first is a base or building in the community for a multidisciplinary team serving a prescribed catchment area. Others see a central base as a barrier to service provision and work instead peripatetically in different settings such as community centres, church halls and health centres. Dick (1985) also identifies two models as approaches to managing psychiatric morbidity. The first is a service acting as a ‘funnel’, passing most work to local resources (e.g. primary health care, social services) and only maintains that which cannot otherwise be managed. The second is a specialist service providing particular styles of treatment: however if the particular skills available do not match client needs, the client cannot be helped. It is service driven rather than client need led. Sayce (1987) identifies three approaches: first, as an entry point for most of the locality’s mental health referrals to a devolved psychiatric service; second, a sessional model offering counselling and/or group work; third, a community development model, with an emphasis on initiating formal and informal networks of care.

Although models may differ, there are common characteristics for which CMHCs strive. Accessibility is the first (Peck and Joyce, 1985). This contains a number of elements: potential clients should have direct access to the service rather than requiring intermediate referral by professionals (‘walk-in service’); the service response should be as speedy as possible; the premises should be geographically easily available, either being local or on major transport routes; and stigma should be reduced (encouraging referral) by using non-stigmatizing (ordinary) buildings and service titles. Second, CMHCs tend to emphasize psychosocial rather than medical (biophysical) methods of intervention. This involves an emphasis on social and familial dimensions, and a greater available range of therapies and intervention provided in a coordinated way which would be unavailable (without attachments) in GP services. Third, multidisciplinary teamwork is emphasized. For some, this involves greater equality, rather than medical leadership, between involved professions. It certainly emphasizes greater cooperation and collaboration between mental health workers. Most centres are based around CPNs and social workers, and some advocate the development of generic mental health professionals, because of apparently overlapping skills and consequent ‘role blurring’ (Peck and Joyce, 1985; Jones, 1988) which, it is argued, makes demarcation by professional group obsolete. Fourth, comprehensiveness is often emphasized. In part this relates to multidisciplinary teams offering various skills, and it may be more accurate to describe CMHCs as part of a comprehensive service (Sayce, 1989). Finally community links are often considered important. This can involve links with other agencies, such as ‘outposting’ to general practice (Grey et al., 1988). It can also involve taking seriously consumers’ views of the service, through, for example, consumer studies, or even consumer participation in the planning and development of CMHCs.

Social Work and Community Psychiatric Nursing

Although social work has a history going back to the nineteenth century, it dates back in its modern form to 1971. Prior to this, with the establishment of Social Services Departments, social work was fragmented into separate groups, and Mental Welfare Officers (MWOs) were local authority based, while Psychiatric Social Workers (PSWs) were hospital based. MWOs were incorporated into the new departments in 1971, followed in 1974 by PSWs, with NHS reorganization. Removal from medical oversight and incorporating PSWs into the professional mainstream might be considered beneficial. However, other ‘immediate consequences were well nigh catastrophic’ (Hargreaves, 1979, p. 77). Although Seebohm did not condemn specialization, the word ‘generic’ (referring to skills or knowledge common to different aspects of work) was misused, and redefined as ‘generalist’ with the ‘unrealistic expectation that all social workers should be professionally competent in dealing with every kind of human problem and need’ (Sainsbury, 1977, p. 77). This had various effects on mental health work. To a considerable extent this meant the loss of previously available specialist mental health skills. Hargreaves (1979, p. 77) calculated there was a reduction of a third in social work person-hours devoted specifically to mental health between 1967 and 1976. He set this against an increase of 35 per cent in the number of psychiatric nurses during the same period. Together with the loss of specialist skills, the interprofessional relationship between doctors and social workers generally worsened. Psychiatrists and PSWs/MWOs had formerly had close professional relationships based on a high degree of specialization and common concerns, which were disrupted by reorganization. This loss was frequently accompanied by drifting apart and disillusionment. Third, mental health was given a relatively low priority by the new departments, which were increasingly dominated—particularly with child abuse deaths—by child care. The recent White Paper (Department of Health, 1989) comments on the still small fraction of SSD budgets devoted to mental health.

Although this era was dominated by a generalist orientation, many ex-MWOs maintained an interest in mental health work and were able to continue with this as an aspect of their caseload (Howe, 1986). More recently widespread reorganization by individual SSDs has led to increases in specialist interests, with a realization that expertise in all aspects of social work is unrealistic. Reorganization has occurred either at a department wide level, with changes associated with central policy, or on a ‘bottom up’ basis where changes, occurring at area team level, are decided by the area teams themselves. This has taken three forms: structural changes in teams involving specialist subgroups, a growth in the number of individual specialist mental health posts, and bias in individual workers’ caseloads, whereby 75 per cent of cases involve a particular client group (Challis and Fairlie, 1986, 1987). From a position of virtual abandonment of mental health posts following the 1971 reorganization, there has been a drift back to more specialist work in more recent years, and the growth of specialism has been marked in mental health. This process is likely to be emphasized with the effects of changes presaged in the 1989 White Paper.

Community psychiatric nursing is a relatively recent development. According to Hunter (1974) the first recorded service began at Warlingham Park Hospital, Croydon, and services began at Moorhaven, Devon in 1985. The impetus for a community service arose, according to Hunter, from informal contacts with patients’ relatives and the influx of ex-service personnel with extensive life experiences outside the mental hospital. They were subject to haphazard development, and by 1966, forty-two hospitals used nursing staff in community work. The remarkable growth of CPN services followed local government reorganization and the emphasis on generalist social work. This appears not to be coincidental. The Community Psychiatric Nursing Association (CPNA) representatives giving evidence to the Social Services Committee (Short, 1985) commented that, with the loss of specialist expertise and the resulting gaps in social work provision, CPNs moved into a vacuum created by ‘the genericism (sic) of social work’. This may not have been the only factor: it is noticeable that the growth in the number of CPNs occurred contemporaneous with the decline in the number of hospital beds, reflecting an increased emphasis on community care.

It is difficult to identify the exact growth in CPN numbers, although while they were hardly mentioned in the 1975 White Paper Better Services for the Mentally Ill (DHSS, 1975a) they were considered important in the 1985 Short Report, reflecting their much higher profile. By 1980 there were 1667 CPNs employed nationally, a figure which rose to 2758 (a 66 per cent increase) by 1985 (CPNA, 1985b). However, while the 1985 ratio of CPN:population was 1:23,800, the CPNA aim was for 1:10,000, indicating further developments, ‘warmly welcomed’ by the Short Report (1985). However, the overall figure concealed considerable variations in CPN provision between different regions. Parnell (1978) noted considerable variation also in the organization of services, reflected in the 1985 National Survey. Thus while the majority of CPNs worked in general psychiatry teams, 29 per cent worked in a specialist capacity, the majority with the elderly. Furthermore, their organizational base varied: the largest group (though declining relative to others) were based in psychiatric hospitals (37 per cent) while others, each comprising between 16 and 19 per cent of CPNs, were based in DGH psychiatric units, health centres and ‘other’ bases (CPNA, 1985b).

Role

Social work, as the better established occupation has a role, the core of which is well established, although it has developed over time. Although recognized as largely determined by the profession, their role has nonetheless been outlined in official documents. The Ottan Report (DHSS, 1975b) identified various elements to health social workers’ role: the assessment of social factors contributing to diagnosis; providing advice on social factors and approaches contributing to treatment; assessing social factors affecting discharge from hospital; and provision of, if necessary, long term after care support. Additionally in the primary health setting the role advocated included therapeutic work with individuals, families or groups; mobilizing practical resources and liaison with outside agencies; educating the team on social factors in health care; and specialist consultant to social services staff. The White Paper (DHSS, 1975a) discussed the social work role specifically in relation to mental health, identifying three main areas. First, they should have a working knowledge of symptoms, treatment, cause and prognosis of an individual’s illness. Second, therapeutic work with individuals and families involves developing and maintaining a consistent relationship with the individual, knowing the ways the family may be affected, being aware of their particular family relationships and offering psychological and practical support to them. Third, they identify the use and mobilization of support services and outside agencies, such as primary health care, social security, housing, social services, and the ability to judge not just what is viable but also apply professional skill in considering what is best for each client.

Subsequent developments have expanded upon this traditional social work role. The Barclay Report (National Institute for Social Work [NISW], 1982), a semi-official document, advocated the development of community social work. Beyond concerns with individuals and families, this advocated the use and development of social networks, involving a partnership between social services, informal carers and voluntary agencies. Its focus is upon actual or potential links which exist or could be fostered between those with similar concerns. Two broad categories are identified: the first involves a focus on locality in which particular interests are related to geographical area, while the second is distinguished by a shared concern or problem, e.g. the needs of particular client groups. The report identified the need for social workers to increase their capacity to negotiate and bargain, to act as individual and group advocates, and recognize and use communities of interest between different people. This of course involved roles general to social work rather than specific to mental health. More recently the 1989 White Paper has outlined a further role, that of case manager, likely to be taken on primarily, but not entirely, by social workers. Where complex needs exist (e.g. chronic mental health problems) case managers may ensure that individuals’ needs are regularly reviewed, act as assessor of care needs, plan and secure delivery of care, monitor the care provided and review client needs. Case management will be linked to budgetary responsibility and occur in the context of a range of resources. Finally, social work contains the specialist role of Approved Social Worker, primarily involving assessment for compulsory admission, unique to the profession, which has been discussed in detail elsewhere (Sheppard, 1990).

To a considerable degree, the role ascribed to themselves by CPNs overlaps with that of social workers. There are, however, no descriptions of the CPN’s role in official documents (which social workers have), and there is some lack of professional clarity. The Short Report (1985) stated that ‘it is in need of self discipline and definition’ commenting that not just health managers, but many CPNs are uncertain about their role (vol 1, para 193). Early statements of the CPN role were relatively limited, reflecting a ‘medical handmaid’ service: the provision of basic nursing care (medically supervised),supervision of prescribed medication, consultant to non-psychiatric nurses, keeping close contact with PSWs and other agencies...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Preface
• Chapter 1: Introduction
• Chapter 2: Theoretical Foundations
• Chapter 3: Agency Work
• Chapter 4: Brief Intervention
• Chapter 5: Extended Intervention
• Chapter 6: Practice Foundations: Interpersonal Relations
• Chapter 7: Clients’ and Workers’ Views of Intervention
• Chapter 8: Client Perceptions: Brief Intervention
• Chapter 9: Client Perceptions: Extended Intervention
• Chapter 10: Conclusions
• Appendix 1: Methodology
• Appendix 2: Research Questionnaires
• Bibliography