Mental Health Social Work in Context

Nick Gould

• Publisher: Routledge
• Year: 2022
• Print ISBN: 9781032019901
• eBook ISBN: 9781000590036
• Edition: 3
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

This new edition of Mental Health Social Work in Context continues to be an authoritative, evidence-based introduction to a core area of the social work curriculum.

Grounded in the social models of mental health particularly relevant to qualifying social workers, but also intended to familiarise students with social aspects of medical perspectives, this core text helps to prepare students for practice and to develop their knowledge around:

• promoting the social inclusion of people with mental health problems;

• the changing context of multidisciplinary mental health services;

• an integrated evidence base for practice; and

• working with people with mental health problems across the life course.

Including new material on proposed reforms to mental health and mental capacity legislation, this book also contains major revisions that focus on the statutory and policy contexts of social work practice as well as ongoing changes in the organisational frameworks for the delivery of services and implications for the social work role.

This fully updated third edition is an essential textbook for all social work students taking undergraduate and postgraduate qualifying degrees, and it will also be invaluable for practitioners undertaking post-qualifying awards in mental health social work.

1PERSPECTIVES ON MENTAL HEALTH

DOI: 10.4324/9781003181323-2

INTRODUCTION

Consider the following three scenarios:

Brian is a man in his late 70s who was widowed five years ago and now lives alone in the rural community where he has resided all his life. He worked as a farm labourer, and the care of his home and other domestic affairs were managed by his late wife. He has no children or extended family. Neighbours contact social services to report that Brian has been wandering in the village, inappropriately clothed for the weather, and asking people what day of the week it is.

Poppy is a lone parent who originates from Eritrea and now lives with her two teenage children in a house rented from the local authority. Twelve months ago she began complaining to the police that an unknown person was breaking into her house when she was out and moving her belongings, but the police could find no evidence to substantiate this claim. Poppy has now been referred by her GP to the local Community Mental Health Team, as she complained to her doctor that she could not sleep and attributed this to unidentified persons shouting abusive comments about her at night. When the team social worker visits Poppy’s house, she finds that windows and doors are barricaded and the whole family is sleeping in a downstairs room for protection against unknown aggressors.

David is a man in his early 20s who has lived with his parents since dropping out of university during his first year of studies, citing that he had lost interest in his subject as his reason for doing this and stating that he would find a job. He has never secured employment, and he now spends all of his time in his bedroom where he also takes his meals. David’s parents report that he spends all day writing in notebooks or staring into space.

All of these situations are not atypical of those that a social worker might be called on to assess and possibly follow up, either alone or with others as part of a multidisciplinary team approach. Each situation contains ambiguities and uncertainties that could be indicative of the presence of a mental health problem, the consequence of social circumstances, or a combination of factors. It may even transpire that the person concerned does not consider that they have a problem; the difficulty may be the attitudes of those who define the person’s behaviour as problematic.

Whatever the particular circumstances behind these scenarios, the thesis behind this book is that, in order to practise effectively, social workers need an understanding of the social factors that impact on mental health. Furthermore, because social workers increasingly practise in contexts in which they work alongside members of other professions, they also need an appreciation of the various frameworks that inform their decision-making – be they medical, psychological, or legal perspectives. They also need to be responsive to perspectives that are based on the philosophy that the best understanding comes from those who themselves have mental health problems and use services, the ‘experts by experience’.

Though it may try the patience of the reader who wishes to press on with learning about specific mental health conditions – perhaps schizophrenia or dementia – because of the contested nature of mental health, we must first spend some time considering the wider frameworks and approaches that will shape our understanding and therefore our practice. The approach taken by this book is not, however, that mental health problems are entirely constructed by language and its meaning and context, a perspective that is sometimes described as ‘social constructivism’ (Burr 1995). Nor, on the other hand, does this book advocate biological determinism: the assumption that all mental health problems are ultimately physiological and that consigns social workers to being the ‘handmaidens’ of psychiatrists. The position taken here is one that is sometimes described by the label of ‘pragmatism’ – not as in the lay definition that anything will do as long as it works but in the more technical, philosophical sense that we have to work with the best evidence that we currently have – namely, that all knowledge should be considered as provisional and subject to review as mental health becomes better understood.

This pragmatic perspective is combined with critical realism: the view that a mental disorder is something that has an external reality and can be detected and measured, that it exists within social contexts, and that social workers have a responsibility to be both critical and proactive about its inequitable and discriminatory consequences. Tew seems to be expressing a similar position in an article about social perspectives and social work education:

Rather than taking the extreme position that ‘mental illness’ does not exist, a social model need not rule out the possibility that some people may have greater innate vulnerabilities to particular experiences due to medical, nutritional, genetic, or other factors. However, over and above any biological predisposing factors, evidence suggests that a variety of social factors may play a major role in contributing to longer-term vulnerability to breakdown or distress.

(Tew 2002)

THE SCALE OF THE PROBLEM

Mental ill health, despite the stigmatisation it can produce, is everyone’s business. At any point in time, around 16% of the population in Britain is experiencing a common mental health disorder such as depression (Beddington et al. 2008). Around 4% will be living with a severe mental disorder such as schizophrenia or bipolar affective disorder. In the region of 885,000 people are currently experiencing dementia in the UK (at a cost of £34.7 billion a year at 2015 prices), which will rise to over 1 million by 2030 (Wittenburg et al. 2019). Although there is some variation in diagnostic rates between countries, for instance, prevalence rates for depression of 4% in Shanghai and 26% in the United States reflect cultural and service differences, it is increasingly being recognised that mental ill health is a major factor in the global experience of ill health and disability (Rehm and Shield 2019; Whiteford et al. 2013). Measuring the so-called ‘global burden of disease’ in terms of years lived with disability (YLDs), Rehm and Shield (2019) found that mental disorders and substance abuse comprised 7% of the global burden of disease and were the leading cause of years lived with disability worldwide at 19%, which was more than cardiovascular disease, common infectious disease, cancer, and diabetes combined. To indicate the trajectory of the challenge for policymakers, the burden of mental and substance use disorders increased by 37.6% between 1990 and 2010, which for most disorders was driven by population growth and ageing (Whiteford et al. 2013).

If politicians and policymakers still are not persuaded by the magnitude of these challenges, the economic analyses of the costs of mental disorders are likely to focus their minds. A study for the European Union calculated that the total cost of mental disorders is over 4% of gross national product (GNP) (OECD 2018). The indirect costs due to lack of productivity resulting from exclusion from the labour market increase this figure even further: a study in the UK estimated that the annual cost of mental distress to the national economy was around £70 billion and that 40% of new claims for disability benefits each year were for forms of mental disorder, the highest level in the rich, developed world (OECD 2014). Without committing us to a narrowly utilitarian view of this, that is, defining something as a problem simply because it is costly for the wider economy, these figures do provide some kind of proxy for the amount of distress and disruption that is caused in the lives of individuals by mental health problems.

This chapter provides a brief historical overview of the emergence of community-based care for people with mental health problems; it reviews the arguments for and against adopting a medical perspective on the experience of mental distress and then considers a range of perspectives that contribute to contemporary understandings of mental disorders, including the biopsychosocial model, social capital, the disability movement, and recovery perspectives. Finally, it draws together the core aspects of the ‘new’ social models.

FROM THE ASYLUM TO COMMUNITY CARE

Even within the working lifetime of many current mental health social workers, the dominant paradigm for the delivery of mental health care has changed dramatically. Research by Huxley et al. (2003) has shown that the mental health social work workforce is predominantly middle aged. Older practitioners may well have developed their interest and expertise in mental health when the dominant mode of intervention for people with a mental health problem was inpatient treatment (often long term) in a large hospital, probably a ‘county asylum’ first built in the mid-nineteenth century. The publicity surrounding scandals of patient abuse (Butler and Drakeford 2005), the escalating costs of maintaining large hospitals (Scull 1977), the availability of powerful tranquillising drugs to suppress symptoms (Rose 2007), and an intellectual climate of radicalism in the 1960s combined to challenge the dominant form of inpatient care, what Foucault had likened to the segregation of lepers in the Middle Ages (Foucault 1961).

At that time ‘anti-psychiatry’ was in the ascendancy, a broad umbrella term for a range of intellectual influences, including social constructionism and labelling theory, the Palo Alto school of systems theory, and, not least, R.D. Laing’s beguiling cocktail of existentialism, psychedelia, and (briefly) Marxist dialectic (Gould 2005). For a period in the late 1960s and early 1970s, it seemed that these influences would synthesise into an irresistible defeat of the dominant medical approach to treating mental distress (Cummins 2017). In fact, apart from some exceptions such as Psichiatria Democratica in Italy (a radical alliance of political activists and psychiatrists whose agitation led to legislation in 1978 to close all Italian public mental hospitals) (Donnelly 1992), this was no more triumphant than the student and worker protests of the same period were in overthrowing the capitalist order. As various commentators have pointed out, anti-psychiatry was more potent as a rallying point for cultural disaffection than it was as a serious response to the complexities of the lives of people who were mentally distressed (Sedgwick 1982; Miller and Rose 1986).

The closure of the county asylums and the transfer of care to services in the community have a more mundane rationale than the attention of the counterculture. One credible perspective is that, since the end of the Second World War, we have seen the progressive dismantling of the workhouse system which had provided shelter for people with a range of disabilities and social problems (Fawcett and Karban 2005). From the 1960s, the closure of long-stay provisions for a range of service users accelerated for a variety of fiscal, humanitarian, and professional reasons already mentioned. This process accelerated in the 1980s, with health services looking to the private sector to alleviate the through-care problems of patients stuck in expensive hospital placements. Local authorities similarly were looking to non-statutory alternatives in order to meet demand for services, and all of this was against the background of a conservative political orthodoxy that promoted the rolling back of the state and individual self-help.

These piecemeal developments were given policy coherence by the 1986 Audit Commission report ‘Making a Reality of Community Care’ (1986), which identified the wastefulness of the system and pointed to the possibilities for coordinated, non-institutional care arrangements that could potentially be delivered by adopting the US-developed model of case management. This led to the so-called Griffith report of 1988 and eventually the 1989 White Paper ‘Caring for People’ (Department of Health 1989), which created the organisational architecture for care in the community that was given statutory force by the National Health Service Community Care Act (1990). Despite continuous processes of reform of the internal structure and workings of health and social services, this legislation created the fundamental fram...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Introduction
• Chapter 1 Perspectives on mental health
• Chapter 2 Developing socially inclusive practice
• Chapter 3 The social work role in mental health services
• Chapter 4 Working with children and adolescents
• Chapter 5 Mental health social work with adults: Mood disorders and post-traumatic stress disorder
• Chapter 6 Mental health social work with adults: Psychoses and personality disorders
• Chapter 7 Mental health social work with older people
• Chapter 8 Risk and dangerousness
• Chapter 9 Contemporary mental health social work: Challenges and opportunities
• Bibliography
• Index