Mental Health Social Work Observed

Mike Fisher, Clive Newton, Eric Sainsbury

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000438116
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Despite extensive changes in the organisation of social and psychiatric services, there had been no study of mental health social work in the UK since the early 1960s. There was, however, no shortage of 'received wisdom' about the perceived failure of social work to provide a service to the mentally disordered. Originally published in 1984, it was to provide some basic information about the practice of social work in this field that the study was conducted on which Mental Health Social Work Observed is based.

The authors looked at both long-term work and emergency work in which the use of compulsory powers was requested. In addition to the views of social workers, the opinions of psychiatrists, family practitioners and of the clients themselves were sought in order to gain a full picture of social work in practice. Through their thorough immersion in the field of study and through their experience of social work and of mental health issues, the authors were able to provide a sympathetic and lucid account of the difficulties of mental health social work and of the thorny issue of interprofessional relationships which will ring true to the practitioner.

They produced recommendations relevant to social work practice at the time and this book would be found useful to social workers and their managers, to psychiatrists, family practitioners, psychiatric nurses and clinical psychologists. Of particular relevance to the then current changes in the role of the social worker under the new mental health legislation is the authors' study of mental health emergency work, culminating in a recommended code of practice.

Chapter 1 INTRODUCTION

The Background to the Study

Social work with people suffering mental ill-health has received very little attention; the last major study in Britain was conducted almost two decades ago (Rehin & Martin, 1968) soon after the implementation of the Mental Health Act (1959) and well before the reorganisation of the local authority personal social services. There have been some attempts to provide social workers with a working knowledge of psychiatry, particularly of its diagnostic categories (e.g. Munro & McCulloch, 1969; McCulloch & Prins, 1975), and some attention has been given to the uncertain role of social workers acting as Mental Welfare Officers (MWOs) under the Mental Health Act (e.g. Olsen, 1976 and Oram, 1978). But little attention has been paid to the preventive and/or therapeutic contributions which social workers are able or expected to make within a policy of ‘community care’ for the mentally ill.

On the other hand, there is no shortage of ‘received wisdom’ about the quality and quantity of ‘mental health social work’ currently undertaken. Some psychiatrists have been highly critical of what they perceive as a deterioration in the quality of social work service since the reorganisation in 1971. This reorganisation, it is claimed, resulted in a loss, through dilution, of the specialised skills of MWOs consequent upon their incorporation into unified social services departments. Many social workers share the view that the standards of social work service to the mentally ill are poor, but tend to be disparaging about the role of the pre-1971 MWOs, seeing them largely as psychiatric menials with little professional skill, power or independence.

It was within this context of general disquiet about the contribution of social workers in the mental health field, together with widely divergent views about the causes of inadequate service and an almost total absence of hard data, that the Mental Health Research Liaison Group of the DHSS promoted the present study as part of a continuing debate leading, amongst other things, to the recent legislative review.

Aims and Objectives

The underlying purpose of the study was essentially to look for ways of improving the quality of social work support provided by community-based social workers to individuals suffering mental ill-health and to their families. It was hoped that the study would result in some concrete suggestions for improvement rather than simply a lengthy description of a complex (and possibly unsatisfactory) situation.

It was acknowledged (and recent events can only serve to confirm this impression) that no substantial increase in funds was likely to be available to local authority social services in general, or for this client group in particular, within the foreseeable future. Suggestions for improvement would, therefore, need to be made largely within the limitations of existing resources.

It was further agreed to limit the study to the adult mentally ill. In spite of the statutory and administrative overlap between services to the mentally ill and to the mentally handicapped, there can be little dispute that the needs of these two groups and the services available to them are dissimilar and incapable of a unified research approach. Services for the mentally ill aged under 18 are complicated by the wide responsibilities placed upon local authorities for the care and education of children and young persons and it was agreed to exclude them for this reason.

Social work with the mentally ill can take place in a wide variety of settings including various types of residential and day-care establishments and hospitals. Because of manpower constraints it was decided to confine the study to the work carried out by community-based area teams and to limit examination of these other settings to their functions as resources to area-team social workers.

The aims of the study can be broadly defined as follows:

1. To identify the adult mentally ill amongst the clientele of social services area offices,
2. To examine how social workers attempt to meet the needs of this client group,
3. To discover from social workers, other professionals and the clients themselves, their opinions about the adequacy of present services and their suggestions for change, and
4. To make recommendations about possible improvements in services and how these might be achieved.

Many questions remain unanswered, but we hope that we have made some contribution to clarifying the state of social work practice and the issues needing resolution. There can be no doubt that the resources available for the community care of the mentally ill are inadequate; but we are also convinced, in the light of our work, that significant improvements can be made to the quality of service even within the constraints of present resources. A number of recommendations to this end are included in our final chapters.

The research was carried out in a Shire county in England hereafter referred to as the County. We chose to work with three area teams which would reflect the diverse nature of the County:

1. ‘City team’ covers a quadrant of a city. It includes most of the decaying inner-city area where ethnic minorities are concentrated, together with substantial areas of council housing and of prosperous suburbia.
2. ‘Town team’ covers two industrial towns and two villages.
3. ‘Rural team’ covers three small market towns, together with a large, mainly pastoral, rural area.

The two years of the research project were divided into three parts:

1. The first four months were devoted to negotiations with the three area teams (in order to receive informed consent to participation in the study) and to the design of research instruments. The time available did not allow for adequate piloting of the research tools, but we received valuable assistance from a ‘Project Group’, consisting of two social workers from each of the three areas, who helped us to make our approach and methods relevant to the work undertaken by their teams and appropriate to local conditions.
2. The next twelve months were spent in the collection of information concurrently in the three areas. New referrals and existing cases were monitored; clients, social workers and other professionals were interviewed; and a considerable amount of time was given to observing the work and procedures of the teams and to informal discussions with staff-members.
3. The final eight months (later extended to twelve months) were used to analyse and write up the information collected, to draw conclusions, and to formulate recommendations.

Definition of a ‘Mental Health Case’

The first major problem to be faced in planning the research was the definition of cases to be included in the study. It had been agreed with the DHSS at an early stage that we should not limit our attention to those cases involving formal psychiatric assessment. We knew that in many cases there would be prior medical involvement; but we were also aware that the acquisition of a psychiatric diagnosis may be a haphazard process, and that many people who might come to the notice of social services, even with quite severe mental health problems, would not necessarily have undergone this process.

It was also apparent that we could not rely on the departmental classification of ‘Mentally Ill’ cases to include all those which might be of interest to us. In the County at the time of the study the classification ‘Mentally Ill’ was a residual category: i.e., cases were classified in this way only if they did not contain elements possessing a higher priority classification, such as ‘Child Care’ or ‘Elderly’.

It was therefore necessary to produce our own definition of a ‘mental health case’. This brought us into the contentious area of the nature of mental illness, an issue in which we did not want to become embroiled. Thus, our definition of a ‘mental health case’ is not intended as a definition of mental illness per se but is simply an heuristic device for the selection of cases for the study. We are aware that our definition includes certain individuals who some would say were not mentally ill, while it excludes others who might be described as mentally ill. We cannot hope to please everyone by our definition, but we hope that it is sufficiently acceptable for our study to be considered to have a reasonably firm foundation.

In formulating a definition we knew that we would be dependent on social workers to make judgements about their own cases and, for this reason, decided to avoid the use of psychiatric terminology in favour of language which focused on those aspects of problems which directly concern the activities of the personal social services. To this end, we based our definition on two concepts: ‘mental state’ and ‘social functioning’. Only those cases were included where impaired social functioning was accompanied by impaired mental state, and where the impairment of social functioning could not be wholly attributed to circumstances other than impaired mental state. To clarify the use of this definition we divided the impairment of both ‘mental state’ and ‘social functioning’ into a number of headings as shown on facing page.

It was not necessary to the inclusion of cases in the study for impairment to be present in all the listed sub-categories; but impairment needed to be present in at least one of the categories on each side of the table.

The word ‘impairment’ was chosen because of the implication it carries of a reduction below previous levels: we did not wish social workers to pre-suppose and to apply any absolute standards of ‘normality’. Clearly all aspects of social functioning and mental state are contextual, and are dependent on a wide range of factors: age, sex, intelligence, subcultural value systems, etc. We wished social workers to assess impairment in the context of individual clients’ normal levels of functioning and we included the following direction in our instructions to them:

When you are using these guidelines, we would like you to assess the client’s impairment using standards from his social environment and bearing in mind his previous mental state and social functioning. We hope in this way to avoid the imposition of the worker’s standards. As a general principle, we intend that the worker should assume behaviour to be normal until convinced it is not. If you are in any doubt, leave the case out of the study or ask the research workers.

I MENTAL STATE	II SOCIAL FUNCTIONING
Impaired Perception of Reality - includes significant distortions of reality or persistent misapprehensions, feelings of persecution, fears, hallucinations, etc.	Economic - includes difficulties in maintaining paid employment, housework and child care; impaired capacity to carry out a social role consistently or at a previous level of responsibility or efficiency.
Inappropriate Feelings - includes depression, anxiety, apathy, aggressiveness, euphoria etc. which are inappropriate by reason of their depth, duration or setting.	Interpersonal - persistent difficulties in Immediate family relationships (spouse, children, other coresident relatives) Wider social relationships (other relatives, neighbours, friends, workmates). Personal Care - includes self-neglectful and self-destructive behaviour.

Finally, in our instructions, we included three hypothetical examples which we considered might be helpful to social workers in deciding where to draw the borderline between cases which would be appropriately included in the study and those which would not:

1. A mother gives birth to a Down’s Syndrome child. In this situation her distress and feelings of guilt are not unusual and it would be expected that for some time her social functioning would be affected. Given realistic long term support and information, however, the mother is likely to be able to provide her child with as normal an upbringing as possible. This case would not come into our study.
   But if the mother found it so difficult to adjust that she began to deny that her child actually was abnormal, she may for example show unjustified anger at her child’s inability to keep pace with children of the same age. In our terms this mother’s perception of reality would be distorted and her social functioning (as a mother) impaired. This case would then be included in our study.
2. A man made redundant from his job as a skilled fitter at the age of 45 calls into the office requesting financial advice. Apart from his financial problems, he is angry at the way he has been treated and at having to ask for help. Given the right advice, however, he may manage to get the financial help to which he is entitled. This case would not come into our study.
   He may, however, experience redundancy as a personal failure and so find no way of retaining his self-respect. His feelings of worthlessness may grow to the point where he is unable to do anything towards sorting out the family’s problems. Referral to Social Services may follow and this case would be included in our study.
3. Social services have a supervision order on a 15-year-old girl following a series of petty thefts. She comes from a large family where the father is unemployed and where the mother is at the end of her tether. The social worker’s primary responsibility is towards the girl and so the case is classified as ‘Child Care’. While impaired social functioning may be present in several members of this family, the case is not included in the study.
   However, as work progresses the social worker recognises that the mother has become increasingly distressed at her inability to care for her children to the point where she is so low that she can do little around the house. The mother’s impairment would be a reason to include this case in our study.

Again, we wish to emphasise that these examples were not intended to constitute a definition of the borderline between ‘mental illness’ and ‘mental health’ (if any such sharp distinctions may be said to exist). They were merely intended to identify situations where there had been a change in a person’s perceptions or mood which was ‘inappropriate’ (by reason of its depth, duration or setting) to the context in which it arose, and which was of sufficient magnitude to reduce significantly his or her previous levels of social functioning. In the body of this book, we will frequently refer to these clients as ‘mentally ill’ or as ‘having mental health problems’; but these phrases should be interpreted as nothing more than a convenient shorthand. Not surprisingly, perhaps, the guidance provided to social workers did not prove adequate to determining all borderline cases, and a considerable number were discussed between social workers and the research team before decisions were taken on their inclusion in the study.

As a result,...

Table of contents

• Cover
• Half-Title Page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Acknowledgements
• 1 Introduction
• 2 The Social Workers and their Teams
• 3 Working with the Health Services
• 4 The Clients in the Study
• 5 Receiving Social Work
• 6 Providing Social Work
• 7 Four Case Studies
• 8 The Use of Compulsory Powers
• 9 Improving the Service
• Appendix: Referral and Review Forms
• DHSS Mental Health Social Work Study Referral Form Coding Instructions
• DHSS Mental Health Social Work Study Review Form Coding Instructions
• References
• Index