Legal and Historical Context
Legal and Historical Context
This essay will consider key issues that relate to mental health problems in the practice of social work with adults in the United Kingdom. This will be demonstrated by firstly examining the legal and historical context of the mental health and the Mental Health Act (MHA). Secondly, an understanding of theories suitable for individual assessment and intervention process will be critically analysed. Finally, issues of diversity, collaboration and conflict encountered by Social Workers when working with individuals having mental health problems will be considered. The eighteenth century period signalled a change in the history of the treatment of people with mental health problems in the United Kingdom (Porter, 2003). This time was evidenced by the growth of asylums where individuals with mental health problems were detained and kept away from the society. Carbon (2011) states that, the asylums not only created new types of buildings to house people with mental health problems but also resulted in the establishment of new professionals who claimed expert knowledge in the care and control of people with mental illness. Jones (1993) argues that the improvement in the understanding of medical and social models of treatment at the beginning of the 20th century meant that the asylum numbers started dropping, and the mentally ill started to be treated within their communities (Pilgrim and Rogers, 1999).
According to Golightley (2011), another view for moving away from the asylums was that it was believed to be less costly to treat customers in the community than keeping them in hospitals. In addition, the impact of scandals and abuse in asylums also led to the deinstitutionalisation of care for the mentally ill (Fawcett, et al., 2012). Scull, (1979) cited in Pilgrim (2009), argues that deinstitulisation in Britain was a result of the introduction of welfare programmes which meant that it was economical to maintain patients outside hospitals. On the other hand, Warner (1989) argues that deinstitutionalisation was a result of the high demand of labour because of the after effects of World War II. Consequently the Percy Report, published in 1957 led on to the passing of the 1959 Mental Health Act (MHA), which laid an emphasis on treatment, and aimed at ending the asylum era (Karban, 2011). Equally the 1959 Act formed the basis of the MHA 1983 (Andrews, et al,. 1997). The MHA 1983 was established to improve mental health services (Department of Health (DoH), 1998). However, Karban (2011) suggests that it was influenced by a government program that was aimed at reducing risk and getting rid of dangerous individuals from the community.
The primary aim of the act was to involve a compulsory detention and treatment towards people with a mental disorder without their consent. This is necessary for treatment and care and safety for patients and the public. The MHA (1983) was amended in 2007 by the MHA (2007). The main striking amendments for the act were that of the definition of mental disorder, introduction of Approved Mental Health Professions (AMHPs), and community treatment orders (CTOs), (Bogg, 2010). The definition of mental disorder was loosely defined in MHA 1983, under the MHA 2007, definition relates to all forms of disorders. According to Hall and Ali (2009), the change resulted in lessening misperceptions as regards to eligibility for being detained under the Act. In addition, the new Act widened the criteria for inclusion of disorders that were not counted by the Act before. The role of an Approved Social Worker (ASW) was broadened to that of Approved Mental Health Professionals (AMHPs) and included professionals such as Social Workers and psychiatrists. On the other hand, Gregor (2010) states that the introduction of the AMHPs has triggered concerns amongst Social Workers and service users who valued the independent position of social work.
Bernecky and Huxley (2009) state that since social work is one of the minority professions in mental health services in the United Kingdom there is the likelihood that the social work perspectives will be gradually diminished as a result of interagency working in the new part of AMHPs. CTOs were introduced in 2008 as a result of the need to provide mental health treatment within the community following discharge from mandatory detention in hospitals (DOH, 2008). There were also initiated as a consequence of the failure of the deinstitutionalisation and an increased need in the community to, address issues of violence and burden of people with mental health problems (Barham, 1992). The administration of CTOs was meant to facilitate participation and reduce the number of admissions into mental health hospitals (Hannigan, 2003). The uptake of CTOs has been higher than expected as evidenced by an increase in 2011/2012 of 4220 individuals on CTOs (Dye, et al., 2012; DOH 2007). According to Archabeault, (2009) CTOs provide treatments in a less restrictive environment compared to institutional treatment which offers a compulsory element and is restrictive. According to the Mental Health Alliance (2006), ethical concerns have been raised in patients.
Therefore, the alliance did not welcome the introduction of CTOs. Brookes and Brindle (2010), state that CTOs were established to avoid recurring relapse and increase value, freedom and less control in patients’ lives. However, Khurmi and Curtice, (1998), argue that, patients are likely to face issues of stigma, discrimination and fail to exercise their rights in the community because of CTOs. The government introduced Care Program approach (CPA) policy in 1991 to help improve the management of people with mental disorders in the community in terms of risk management (DOH, 1990). According to Marshall (1996) the introduction of the CPA has been debated and its implementation inconsistent in various communities. The CPA has been transformed to be a primary cornerstone of the personalisation programme (DOH, 2007). The shift was towards the maximisation of service user’s choice, individual needs and needs of the service (Kingdon, 1997). CPA has been challenged for its failure to integrate and build upon case management models (Martin et al., 1999). According to Bindman, et al. (1999), the CPA has played a major role in facilitating service users care package, on the other hand, it has given way to coordinate care for people with mental health problems.
Practice and Theory
The medical model is one of the models of treatment in mental health. The model ascribes mental health problems to genetics, physiological and biological causes (Beresford, 2005). As a result, it attempts to treat the disorders or abnormalities of mental health by using procedures that are medically grounded such as psychotropic medication and Electroconvulsive (ECT) therapy (Gould, 2010). (Morley, 2003) supports the model for its objectivity, measurable observation and that it is based on the nature and biological science. The model offers formulations, terminology and explanations which can be universally understood by professionals in mental health. Professionals in mental health use the diagnostic and statistical manual of Mental Health (DSM) 1V and ICD10 to diagnose mental disorders (Read et al, 2004). Consequently, certain patterns of disease and the effectiveness of medication can be quantified. Sha and Mountain (2007) state that, treatment using drugs are more effective and even better when combined with psychological therapies.
However, McLeod, (2008) argues that some treatments such as ECT have severe side effects such as memory loss and are not always effective. In addition, anti-psychotic drugs and anti-depressives take a longer period to have a noticeable effect on symptoms. Sha, et al., (2007) states that the treatments under the medical model are paternalistic, cruel, and reductionist. Barker, et al. (2000) states that the medical model has helped in lessening the blame and stigma attached to families of people with schizophrenia towards contributing or causing the illness. On the contrary, (Johnson, 2000) argues that, families reported that they still feel marginalised by mental health professionals resulting in them being stigmatised because of the medical model. Szaz (1991) argues that there is a risk that focus is put on physical definitions and treatments, as a result, the main causes of psychological disorder such as stress, poverty and inequality are ignored. Furthermore, he argues that if the disorder has a physical cause then it should be classified as a physical illness. In contrast Szaz, suggests that disorders such as Epilepsy have a clear physical cause, however, low mood and hallucinations don’t show any physical cause.
This implies that such disorders should be referred to as “disorders of mind”, thus ruling out the medical model. The medical model emphasises that the diagnostic and formal classification of mental illness should be adequate. This view means that patients are placed in groups and will have common treatment methods sought for them (Beecher, 2009). Consequently The Schizophrenia Commission (2012), blames the prearrangement because it regards patients as cases and not as individuals who should be dealt with on an individual basis. The commission also comments that the diagnostic of schizophrenia is not clear as it covers a wide range of symptoms. Therefore, it has recommended The National Institute of Health and Research and the mental research Council to carry out research on causes and treatments of schizophrenia. This will help bring together psychological, social and biological perceptions. According to NICE guidelines, CBT may help individuals deal with the impact of symptoms and help keep them out of hospital.
However, Rethink has noted that access to CBT services is limited as evidenced by few people being offered CBT. Service users who participated in a study that was done by McGrath, et al. (2007) argue that the medication has prevented therapeutic prospects to deal with their emotions. As a result, many mental health organisations are advocating a departure from medical to the recovery model approach to treatment (Ralph et al., 2002). Over more, this view has been challenged through a study by Barnes (2010) whereby it was concluded that a stigma as a result of mental health may also be traced to the social model, not only from the medical model. Sayce (2000) criticises the medical model for focusing on the person’s problems such as depression, whilst ignoring the importance life events such as death, divorce, loss of employment and disability. Ashford et al. (2006) further highlights that issues of culture and diversity are also ignored by the model.
In addition, Maclean and Harrison (2011) asserts that the model is inconsistent with the partnership working as it does not take into account individual’s views for treatments. In contrast to the medical model, the social model sees the causes of mental health problems as a result of social and environmental factors. According to Tyrer (2013), social factors linked to class and social roles are the main causes of mental health problems. On the other hand, Tew (2011) notes that life events may also trigger mental health problems. According to Cooper and Sylph (1973) cited in Tyrer and Steinberg (2013), such events are more pronounced in patients with mental disorders than in matched control subjects. Bebbington et al. (2004: 222) Indicates that life events such as sexual abuse, being bullied, being taken into care, violence in the home have resulted in the high incidence of psychosis in later stages of life. According to McAuley and Young, (2006), care leavers have higher chances of developing mental health problems than any other groups.
This is mainly due to the effect of traumatic events such as abuse, neglect or domestic violence experienced in the hands of those with power (Plumb, 2005). Life events such as loss due to bereavement, employment, status maybe overcome by going through the process of grieving. However, when the loss experience is associated with isolation and dependence, Brown and Harris (2011) suggests that individuals may feel deprived. It is a feeling of losing something special, as a result; anger establishes within, making it difficult to move on, therefore, increasing chances of mental health problems such as depression. According to Beresford et al, (2010), the social model does not have an idea of what constitutes a psychiatric illness because it views individuals from a society set up, compared to other models that look into internal explanations of mental disorders. Tew (2011) states that, when using the social model, behaviour and all symptoms are taken into consideration in the context from the society they come from. As a result, boundary lines between what is normal and abnormal can be determined by the model (Duggan et al, 2002).
In contrast to other models, a wider view of mental disorders is considered by the social model (Beresford, 2004). The other models such as medical, study the patient closely but in isolation whilst, in the social model, looks at both the patient, the doctor and the system that individuals associate with (Bhugra and Leff, 1992). The social systems theory provides a framework for assessing the clients systems such as, family, how the system is influenced and affected by other systems within the environment. Consequently the results of the assessments will help the Social Worker to intervene at the most appropriate system. In mental health Polak, (1971) cited in Davies (2013), proposes a more realistic approach in which the social systems are seen to be naturally unstable, prone to external stressors and likely to cultivate tensions and conflicts. However, on the other hand, some social systems such as families may provide support. Tew (2011) states that such social systems maybe sources of abuse and oppression to individuals with mental health problems. In addition, he highlights that poor relationships, inequalities and conflicts within the system maybe a further trigger to their mental health problems.
As a result, Social Workers strive to engage with such systems in order to necessitate a change within the system so that it remains supportive and flexible by using approaches such as task centred and solution focused (de Shazer, 2005). The systems theory allows Social Workers to take a holistic approach of individuals with mental health problems during assessments. Gitterman, (2009), further suggest that this will allow the Social Workers to look deeper and understand the various causes of problems and therefore base their interventions on the needs of the clients, not theirs. However, some Social Workers are not able to carry out accurate assessments of systems that affect the clients because of limited information. In such situations, Payne (1991) suggests that the theory will not be able to guide the Social Workers of where or when to intervene within the system. Gitterman and Germain (2008) suggest that working collaboratively with service users might help overcome the situation.
Strengths perspective may be used to support individuals with mental health problems such as Schizophrenia in realising their strengths and improving their self-esteem. Saleeby (2009) states that strengths can be any personal or environment factors that result in growth and development of life. On the other hand, Rapp (1998), suggests that strengths can stem from individuals and the community where they live. Sullivan and Fisher (1994) describe environment and community as essential targets for change when helping individuals to achieve their strengths. Strengths perspectives integrate basic principles of empowerment (Payne, 2005). Weick, et al., (1989) argue that Social Workers who are empowerment minded discover power from clients as they are able to identify their own strengths and solutions. Empowerment is, therefore, valued for helping individuals with mental health problems to gain control over their lives during recovery (Adams, 2008). Moreover, the approach challenges service providers and Social Workers to reflect on their powers and attitudes as helping professionals to avoid disempowering service users (Healy, 2005).
The strengths perspective is significant to task centred approaches as well as the main feature in a solution focused therapies (Davies, 2013; Marsh and Doel, 2005). Consequently it may be used with other interventional methods such as motivational interviewing when attempting to change a client’s specific behaviour with mental health problems (Howe, 2009). Eichler et al. (2006), state that Social work may holistically assess the clients systems, to determine if there is structural discrimination or oppression problems contributing to the client’s failure in achieving their strengths.
Holmes and Saleeby (1993) suggest that, individual’s ability to go through life changes may be crippled if Social Workers or any agent focuses on pathology and deficits of service users. (De Jong and Miller (1995) also highlights that the approach ignores the reality of clients’ problems as it ignores the weaknesses. Kisthard, (2009) notes that strengths perspectives are inconsistent with the social work core principles, such as the obligation of carrying out risk assessments on people with mental health problems in the community under the CPA. In such context, Saleeby, (2009), suggests that the main focus on client’s strengths is not feasible and may worsen some clients’ susceptibility to harm others or themselves. As discussed above systems theory, strengths perspectives with other approaches such as AOP, ADP and evidence based practice maybe used as a tool box for practice. According to Trevithick (2007), choice of theories and models vary according to the situation, hence the need to consider an application of theories on an individual basis.
Diversity, Collaboration and Conflict
According to the Disability Rights commission (2007), inequality, stigma and discrimination have had a large impact on people with mental health problems. According to Sheppard, (2002) there is a positive relationship between mental distress and poverty. This perception was supported by an analysis of Social exclusion Survey conducted in 1999 where more than half of the respondents to the survey were poor and had mental health problems. Payne (2000) argued people with mental health problems are deprived in the labour market and, as a result, are exposed to more poverty, and ill health. This is highlighted by (Sayce, 2000) who suggested that by helping the deprived minority in gaining employment may help people with mental health problems. The Citizens Advice Bureau (2007) notes that the stigma and discrimination towards people with mental health problems are one of the leading barriers to employment. In addition, Sainsbury, et al. (2008) noted that service users who are at work are reluctant to inform their employers of their situation because of fear of being stigmatised and discriminated.
Gilbert (2003) suggests that Social Workers may also support service users by representing them in mental health tribunals on employment issues. Social Workers may have the opportunity to work along with service users so as to promote social inclusion and mobilise resources from voluntary organisations. Individuals from ethnic minorities are most likely to be diagnosed with mental health problems (Fernando, 2010). Greene, et al. (2008) states that black patients are four times more likely to be detained under the MHA (2007) and more than nine times likely to be admitted in hospitals. They have also got longer lengths of admission and treated on high security wards (Care Quality Commission, 2009). This is as a result of delays in seeking and receiving treatment early, misdiagnosis and discrimination (Fawcett, et al., 2012). Besides, (King, et al. 2005) and (Fearon, et al. 2006) highlight that a psychosis is more common with people from African Caribbean and Africa origin. However, they noted that the high rates are not found in their countries of origin.
Consequently they indicate that, it is not being black that increases the rates of psychosis but “being black in Britain”. Stereotyping such as “big, black and scary”, mainly through the media has resulted in BME mental health service users being further discriminated and stigmatised (Rogers and Pilgrim, 2003). This was evidenced in the case of a black man Christopher Clunis (diagnosed with Schizophrenia) who killed Jonathan Zito (a stranger) in 1992 (Bogg, 2010). Keating, et al. (2002) noted that the stereotyping views that were raised by the media concerning Christopher and black people had a significant impact on mental health services provision to the BMEs. Besides, the Ritchie Report 1994, found that Christopher’s assessment and management of his care were poor because of his ethnicity. (Ritchie, et, al 1994).This incident also indicates how service users may face double discrimination. In this case having schizophrenia and being black resulted in a negative response from the media and the public. Social workers may make use of Thompson’s Personal, Cultural and Structural (PCS) model, to understand discrimination and oppressive practices. The Social Worker may assess and understand how the three levels interact within a system for individuals and challenge using anti-oppressive and anti-discriminatory practises. (Bogg, 2010). Gender is a significant determinant of mental health problems.
Disorders such as depression are more common in women than men due to social and biological factors (Piccinelli and Homen, 1997). Women are mainly affected by negative life events such as violence, low income inequality and sexual violence. According to WHO, (1997) women are the mostly affected compared to men. Concerns on parenting capabilities have also been raised by the medical and maternity services on pregnant women with mental health problems (Falcov, 1996). They have been labelled as incapable parents who cannot look after their new born babies by the medical staff (Somers, 2007). To help women with mental health problems in Britain, mothers and baby units were created in hospitals so that those with post natal depression would have access to treatment whilst living with their babies in hospitals (Downey and Cayne, 1990). In addition, there are educational classes set up in hospitals to provide Therefore Social Workers may help by signposting service users to such classes. According to Rethink people with mental health problems face lethal discrimination.
This is discrimination which causes death. It results in patients dying earlier than the rest of the population. Bailey (2013) notes that individuals with serious illnesses such as schizophrenia die 20 years earlier than the entire population. Campion and Checinski (2013) argue that the deaths for people with mental health problems may be avoided. As a result, NICE (2005) guidelines state that, mental health professionals should be in a position to encourage and make offerings for quitting smoking to those with schizophrenia. In addition, General practitioners are also required to carry out physical health checks on patients with mental illness and act upon them. Social workers may help by encouraging mental health patients to attend their GP appointments. Weinstein, et al, (2003) proposes that Social workers may also work collaboratively with other agencies to warrant an effective and timely intervention for individuals whose mental health needs cannot be met in primary health care. Research briefing from SCIE conducted by Crome, et al (2009) highlights that substance misuse has led to the worsening of psychiatric problems. Jukes and Mc Laughlin (2005) further highlight that such individuals, with dual diagnosis are less likely to respond to treatment very well.
As a result, they experience negative effects on their treatments with higher amounts of hospitalisation, detention, homelessness, poverty and high risk of suicide (DoH 2009). Furthermore, service users with dual diagnoses such as mental health problems and substance misuse are more vulnerable to suicide attempts and self-harming. (The National Treatment Agency for Substance Misuse, 2001). According to Rethink the present safeguarding system has failed adults with mental health problems. This was happening despite the introduction of Health No Secrets Guidance in 2000 that made it a mandate for local authorities to put in place policies and codes of practice for multi-agency safeguarding. Safeguarding principles are applied in Local authorities through defining the process of how referrals should be made and to whom. It is advisable that the AMHPs need to be alert of such processes and all safeguarding processes so that they may help in identifying any diverts from proper safeguarding procedures. If they are any diversions, the Social Worker may do whistleblowing to alert responsible departments for safeguarding with any issue.
Moreover, provisions in the Mental Capacity Act (2005) have provided a useful framework for making decisions on behalf of individuals who do not have the mental capacity to make decisions for themselves. Social Workers may intervene by ensuring that proper procedures have been put in place and followed before an individual has been considered to lack capacity. The Human Rights Act (HRA) 1998 provides guidance for protecting vulnerable people such as adults with mental health problems under Article 3, 8 and 14. The articles ensure that the core principles of human rights are maintained such as dignity, autonomy, equality of life and respect (HRA, 1998). In contrast to the HRA, CQC also helps in identifying risks to the quality and safety of vulnerable individuals such as those with mental health problems. They ensure that the poor quality care is eliminated; services are person centred, and their (service users) rights are protected. Social Workers working in mental health should ensure that the Mental Health Act (MHA 2007) is applied appropriately and safeguarding those who need to be protected under the auspices of the Act. Single key working and working as a coordinator using a person centred approach will help to understand issues of power and abuse so that they can be minimised or eliminated.
To challenge cases of abuse Michael (2010), suggests that Social Workers need to report culprits to the department safeguarding of Vulnerable Adults (SOVA) and police. The implication will be that they will have a criminal record, and they will be barred from working with any vulnerable adults. Alternatively, Social Workers may follow company procedures for whistleblowing or if, uncomfortable, report to the CQC any incidences of abuse. NICE (2005) also offers guidelines to be followed by staff when they work with patients who are violent and can be a risk to themselves, others or team. There is provision of ways for calming people and use of tranquillisers. In hospitals patients may be put under special observations or isolated if they are violent or suicidal. The role of the Social worker will be to ensure that individuals affected, and their families are informed and given reasons for taking such an action and ensuring that risk assessments are done plans put in place. The BBC news revealed that the mental health services are going down because of cuts on spending and reduction of welfare services to patients (Buchanan, 2013). In addition whilst referrals to hospitals are increasing by at least 16%, on the other hand the government is reducing funds for the CMHTs.
According to MIND, beds totalling 1500 for mental health patients have been closed, and NHS Trust hospitals are offering limited beds (www.mind.uk). As a result, patients have ended up being put in police cells instead of being admitted in proper psychiatric units because of the shortage of beds (McNicoll, 2013). Patients admitted to hospitals have also raised concerns of being subjected to institutional racism because of their mental health status (Mckenzie and Bhulk 2007). Social Workers may work in collaboration with service users, carers, housing, employment and other professionals. It is, therefore, necessary to make the multi-agency work and relevant to the situation. Structured policy documents such as National Service Framework for Mental health (DoH 1999) and National Health Service and community care Act (DoH 1990a) make provision for collaborative working in mental health practice. The MHA 1983 and the CPA necessitate the need for collaboration between users, carer’s health and social care (DoH 1990b). Green paper that details the role of the voluntary sector in multi-agency when working with CMHTs was developed to facilitate collaborative work in mental health sector (DoH, 1997).
Challenges to achieve collaborative work in mental health are issues on confidentiality, communication, limited resources, power roles and tension (Kings Fund, 1997).Sectioning of adults under the MHA and use of CTOs has brought conflict between service users and professionals. Because some patients have complained that it has been done against their will and it is inhuman (Sha and Joels,2006) According to Secker and Hill, (2001), some agencies have failed to provide information on risk issues concerning service user because of confidentiality. This may lead to serious health and safety problems; consequently staffs end up working without enough support systems (Westein, et al., 2003). Therefore, Sharples et al. (2002) suggests that carers and service users need to have discussions with multi agency professionals and make arrangements about the extent of information sharing. According to Peck and Norman (1999), social work practice is threatened because the community mental health teams are dominated by health workers whose approach is medically based.
According to Higgins, et al. (1994) different professional knowledge such as social care and health professions might show that one group is more superior to another. This may result in conflict and resentment. Freeman, Miller and Ross (2000) suggest that joint training and joint Interprofessional learning may help overcome challenges of collaborative working in mental health. In conclusion, the essay has provided a discussion on mental health problems as one of the current issues affecting adults. It has shown how mental health legislation and policies have been established and changed in order to offer and meet the needs of service users. Several treatment models such as medical and social are available when treating mental health problems. Social Workers also make use of various theories and models for their practice to assess and intervene when helping service users. Social workers need to be aware of diversity, and conflict issues when working collaboratively with multiagency or service users.