Mental Disorders, Medications, and Clinical Social Work

Sonia Austrian

• Editorial: Columbia University Press
• Año: 2005
• ISBN:
  9780231529655
• Edición: 3
• Categoría: Ciencias sociales
• Categoría: Trabajo social

Written for social workers by a social worker, Mental Disorders, Medications, and Clinical Social Work discusses the etiology, epidemiology, assessment, and intervention planning for common mental disorders. Looking at disorders from an ecosystems perspective, Austrian goes beyond a linear classification approach and DSM-IV-TR categories and encourages social workers to analyze the internal and external environmental factors that contribute to a disorder's development. Austrian's discussion of effective intervention(s) for a particular client also stresses the importance of working with families in treating disorders.

In addition to information on new medications, biochemical data on the causes of disease, and diagnostic tests, the revised third edition discusses therapies such as motivational interviewing, cognitive-behavioral, interpersonal, and dialectic.

1

Introduction

SOCIAL WORK is a profession with its own mission, knowledge base, and repertoire of skills. It serves clients who present a broad spectrum of problems in a range of settings, and its activities include direct service, case management, advocacy, and program planning. Clinical social work has incorrectly been assumed to be synonymous with psychiatric social work. Clinical social work actually refers to direct, hands-on interventions with clients, individually, within families, or in groups, and encompasses all fields of social work practice. It is a mistake to think that social work services to people with mental disorders are rendered exclusively in mental health settings. Social workers in all settings encounter people who are affected by mental disorders. Affected clients include those suffering from mental disorders, their close friends, and their family members.

Contemporary social work training can be differentiated from training of other mental health professionals by its emphasis on assessing the whole person. As a result, the social worker can arrive at an understanding of what factors may have caused or contributed to the development of a mental disorder and what needs to be modified in the person and/or the environment to improve coping and mastery. Adhering to a psychosocial perspective distinguishes social workers from all other mental health disciplines (Meyer 1992). Social workers are not “nonmedical psychiatrists” or “psychotherapists,” but members of a profession who can make a unique contribution to helping people with mental disorders, among other problems.

Beginning in the 1970s, in response to the publishing of Harriett Bartlett’s seminal book The Common Base of Social Work Practice, social work scholars sought to identify common elements in social work practice that could be used as a foundation for a core knowledge base. There was recognition that knowledge of case phenomena and professional skills, rather than adherence to a methodology, should determine intervention. With this came a shift in the orientation of practice from the linear, causal approach, with its emphasis on specific methodology, to the more inclusive ecosystems perspective, with its emphasis on biopsychosocial assessment, which considered each case holistically, leading to a case-indicated choice of method.

Moving from a linear (medical/psychiatric) approach to the broader ecosystems perspective involved a change in terminology. In 1970 Meyer (1995) introduced the semantic and, of even more importance, epistemological change from study, diagnosis, and treatment, which viewed the clinician as the “authority,” to exploration, assessment, and intervention, which involved a joint effort on the part of the social worker and the client. The ecosystems perspective—a unifying conceptual construction—provides a framework for examining and understanding the complexity of a case, while focusing on the interaction and reciprocity between person and environment. Eco refers to the relationship of person to environment; systems refers to the interrelatedness, within a systematically defined boundary, of personal and institutional factors impinging on the client. The ecosystems perspective requires thorough assessment, consideration of interrelated phenomena, and intervention based on contextual considerations. The clinician needs to have a broad knowledge base, experience in evaluating interview content, an awareness of a range of possible interventions, an ability to listen, and the presence of a client (with the exception of most of those who are mandated) who can, and wants to, participate in the process. The clinician may also need to accept that the client may have some problems that are not amenable to intervention. This framework is not linked to any methodology, but represents the “what is,” not the “how to,” of a case (Meyer 1983, 1993).

The ecosystems perspective places primary responsibility for successful case intervention on the complex skill of assessment, which Meyer defines as

the thinking process that seeks out the meaning of case situations, puts the particular case in some order, and leads to appropriate interventions… . Assessment is the intellectual tool for understanding the client’s psychosocial situation, and for determining “what is the matter.”

(1993:2)

The process of assessment, as outlined by Meyer, uses a rigorous, defined method beginning with (1) exploration—listening to the client’s unique story and acquiring and organizing case data. Since it is not possible, nor relevant, to obtain a full history of the individual, efforts should be made to obtain salient and relevant information that will enhance understanding of the context and cause of problems in adaptation and coping. After the raw data have been gathered, the process moves to (2) inferential thinking, which involves reviewing the data to determine what they mean, whether they are consistent and logical and whether conclusions are derived from worker intuition and/or direct evidence from the data. The clinician makes decisions about how to use the data on the basis of professional knowledge of similar cases or classes of clients, theoretical orientation, and the type of setting and availability of resources. The next step is (3) evaluation, which involves assessment of client functioning, given the defined problem areas. This includes evaluating the strengths and weaknesses of the person in the environment. Although steps 2 and 3 primarily involve the worker, step (4) problem definition moves the process back to client and worker, for without mutual agreement about how to frame the problem, intervention may be seriously hampered. At this point, the “presenting request” may have been modified to the “presenting problem” by the first three steps. While the client may present many problems, what must be agreed on are the problem(s) and the context that will be the focus of the intervention. In addition, there must be recognition of what is “doable,” given the constraints of the case, managed care, and the setting. We strive to understand the “whole case,” yet we act on a part of it, thus we “think globally and act locally.” The final step is (5) intervention planning, based on the preceding four steps. Here the client and worker contract with respect to modality, time frame, and the need to focus on the defined problem; they also discuss the anticipated outcome. Thus, assessment, while grounded in professional knowledge and skill, is an individualized process that demands recognition of the uniqueness of person and situation. It is an ongoing process, with intervention subject to modification as new data emerge. A knowledge of cultural differences and perceptions of mental disorders is essential to providing a thorough assessment and good intervention planning.

The following chapters will suggest questions that are useful, within the above framework, in assessing the presence of a particular mental disorder. Social workers should be familiar with such tools as the Ego Assessment (Goldstein 1984), which will help guide realistic intervention planning, and the Mental Status Examination (MacKinnon and Yudofsky 1988). Ego Assessment does not follow a prescribed format but is based on knowledge of ego functions. It seeks to evaluate past and present areas of ego strengths and ego deficits. Whether used formally or informally, it should almost always be part of an assessment. The formal Mental Status Examination is rarely used by social workers. Some or all the general areas will, however, be covered in a psychosocial assessment. These include

1. General description: appearance, motor behavior, speech, and attitude

2. Emotions: mood, range of affects, appropriateness

3. Perceptual disturbances: hallucinations and illusions, depersonalization, and derealization

4. Thought disturbances: process, content, distortions, delusions, capacity for abstract thinking, preoccupations, intelligence

5. Memory: remote, recent, immediate

6. Sensorial: level of consciousness, orientation

7. Impulse control

8. Judgment

9. Insight

10. Reliability

Certain exercises may be employed as part of the Mental Status Examination if there is a need to further assess suspected areas of difficulties including memory, orientation, and judgment.

It is the author’s contention that the Diagnostic and Statistical Manual of Mental Disorders is antithetical to the social work tradition of valuing the uniqueness of individuals and their situations and to the assessment process that is at the core of the ecosystems perspective. Assessment involves individualizing treatment for a client and recognizing the client’s uniqueness, while classification systems such as the DSM look for group phenomena and rely on generalizations, highlighting similarities and overlooking differences, and disregarding context, it makes it impossible to consider strengths, capabilities, knowledge, and survival skills as well as environmental and cultural resources (Saleebey 2001:184). Although DSM-IV-TR acknowledges that people with mental disorders are heterogeneous and that no category is “a completely discrete entity with absolute boundaries” (xxxi), it still establishes criteria with defining features. The term diagnosis implies an initial effort to narrow case data to fit a diagnostic category, while assessment recognizes the client’s individuality, defines that person’s problem within its unique context, and arrives at a personalized intervention. Relying primarily on the DSM-IV-TR might actually impede intervention, because the categories provide no clues to what interventions in the environment may be essential, or at the very least, important to enable better adaptation and coping. As psychiatry moves more and more toward a biochemical explanation of many mental disorders, with the intervention often medication, it may further avoid consideration of the environment, and, as any social worker knows, lifting a mood or modifying bizarre behavior is important, but the person may still exist in the context of an environment that, without change, may not provide the needed support, resources, and structure to promote better coping and adaptation.

Although psychiatry has moved from referring to a person as “depressive” to describing that individual as “a person with depression,” the emphasis is on a list of exclusionary criteria rather than consideration of what in the person’s environment is causing or exacerbating the symptoms. Dumont (1987), in his forthright criticism of DSM-III-R, emphasizes that by omitting conditions of life and considering only “the qualities of a human being,” the person is only an “object.” He refers to the theoretical bias as favoring “narrow-minded, white, middle-class parameters of individual pathology” (10), thus making it difficult to be used effectively by professionals serving primarily the poor and minority populations. While DSM-IV-TR (American Psychiatric Association 2000) offers a list of psychosocial and environmental problems to be used on Axis IV, it suggests using those present in the past year or those occurring prior to that only if they “clearly contribute to the mental disorder or have become a focus of treatment, for example, combat experiences leading to posttraumatic stress disorder” (31), not fully recognizing the complexity, chronicity, and insidiousness of many environmental problems experienced by social work clients. It should also be noted that use of Axis IV, psychosocial and environmental problems, and Axis V, global assessment of functioning, is optional, although both would be considered essential to a rigorous psychosocial assessment. For example, according to DSM-IV-TR, a person could be considered as having dysthymia, a chronically depressed mood for at least two years (380), and intervention planned without the clinician’s being aware of stressors, such as a history of unemployment, single parenthood, many losses, or a chronic medical condition. There is little or no attempt to view the person and the symptoms in a context, or to individualize the case, a requirement for good social work practice. DSM-IV-TR infers that the problem rests within the person (or possibly the environment) and it does not acknowledge that the two rarely can be considered separately. It should be added, in fairness, that the lack of individualization of a case also occurs in areas of practice other than mental health, such as the use of diagnosis-related groups (DRGs) in medical settings and uniform case records (UCRs) in child welfare settings. The result of depending on criteria such as DSM-IV-TR can be that several clients, with widely differing life circumstances or experiences, may receive the same diagnosis. The development of classifications may facilitate accurate communication across disciplines, but classification can interfere with full understanding o...