Social_Work_with_Mental_Health_Service_Users

This essay aims to critically examine the provision of mental health social work. In order to do this it will consider the processes, procedures and organisational implications of working within mental health. Within this, the role of the Approved Mental Health Professional will be discussed. The essay aims to demonstrate an understanding of how mental health law impacts upon service users and will identify specific areas of potential oppression particularly in relation to black and ethnic minorities and women. The Mental Act 1983 defines mental disorder as ‘…any disorder or disability of the mind’. Mental illness was not defined within the Act. The World Health Organisations constitution states that ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (pg 6). The difference between these definitions is that mental health is described as more than the absence of mental disorders or disabilities. Mental health is therefore an essential part of health (Adams et al, 2009). Historically people with mental health problems were placed in institutions away from the rest of society. This was a result of the 1845 Lunacy Act which required counties to provide asylums to detain ‘lunatics, idiots and persons of unsound mind’ (Green, 2011). Furthermore a Mind (2010) report said that the growth of these asylums was fuelled by funding arrangements which paid a subsidy to Poor Law authorities of up to 25 per cent of the cost of supporting 'pauper lunatics' in asylums (pg 3) . This was the first government financing of any health or social care service. By 1923 The Maudsley Hospital had opened in London. It was the first psychiatric hospital to operate outside the restrictions of the Lunacy Act. The National Health Service was established in 1948, the same year The National Assistance Act 1948 stated that ‘it shall be the duty of every local authority to provide residential accommodation for persons who, by reason of age, illness, disability or any other circumstances, are in need of care and attention which is not otherwise available to them'. This, together with the introduction of welfare benefits, encouraged the beginning of the move from institutional to community-based care. A Mind (2010) report said that the main intention of de-institutionalisation was to increase the freedom of those with mental health problems by promoting the principle of the least restrictive alternative. These laws were superseded by the Mental Health Act 1959. Medical professionals held a significant amount of power within the Act. The Act was not clear in giving specific functions to ‘Mental Welfare Officers’ as social workers within mental health were known (Green, 2011). Barber et al (2009) purport that the Mental Health Act 1959 took a ‘welfarist approach’ in that it may be necessary to intervene against someone’s will where they are considered to be suffering from a mental disorder, in order to protect the patient or others. Social work, especially in relation to mental health, has a profound effect upon peoples lives, as Smith (2008) reports it is constantly challenged by the need to make decisions and carry out interventions which can have a fundamental impact on the lives of service users. Such as the compulsory detention of people in hospital. The Mental Health Act 1983 according to Brayne and Carr (2008) was implemented following the consolidation of the Mental Health Act 1959 which was amended in 1982. The Act applies to people living in both England and Wales. It covers the ‘reception, care and treatment of mentally disordered persons’ (MHA, 1983). The Mental Health Act 1983 provides the legislation by which people suffering from a mental disorder can be detained in hospital and have their disorder assessed or treated against their wishes. Although as the GSCC (2008) state many situations that social workers find themselves in can be unpredictable which require skilled professional judgements. Additionally Adams et al (2009) purport that social work is a moral activity involving the exercise of power within complex frameworks. Green (2011) states that the 1983 Mental Health Act recognised the significance of social factors within mental illness. Prior to the introduction of a specialist practitioner, the social worker working with a family was not deemed to be of equal standing to the medical professional. As was in the Mental Health Act 1959, the medical professional was seen in terms of status, as the higher ranking. The Mental Health Act 1983 brought about powers and duties which were invested in a new role, the Approved Social Worker (Wilson et al, pg 588). Collins (2006) states that the Approved Social Worker had overall responsibility for co-ordinating the assessment of a person who may require admission to hospital. The Mental Health Act 1983 was primarily concerned with hospital based treatment however following a number of high profile cases involving mentally ill patients within the community including the 1992 killing of Jonathan Zito by Christopher Clunis there was concern that the law was not providing adequate protection to those suffering from mental disorders or to those affected by their actions. The Mental Health Act 2007 brought about amendments to the 1983 Act which broadened the definition of ‘mental disorder’ to include an even wider group of people (Barber et al, 2009). One of the main changes made in the amended act was the role of The Approved Social Worker which was replaced by the Approved Mental Health Professional (AMHP). Whereas an Approved Social Worker was a qualified social worker with additional training the AMHP may be a registered social worker, nurse, occupational therapist or psychologist who is suitably qualified and has undertaken additional training (Wilson et al, 2008). The AMHP must be approved by the Local Authority to undertake their role. Alongside the Mental Health Act 1983 and 2007 is the Mental Health Act Code of Practice which ‘provides guidance to registered medical practitioners, approved clinicians, managers and staff at hospitals and Approved Mental Health Professionals on how they should undertake duties within the Act’ (DoH, 2008, pg 8). In accordance with s.2 of the Mental Health Act 1983 written recommendations from two registered medical practitioners are required in order for compulsory admission to hospital for assessment one of whom where possible should know the patient. The role of the AMHP is to carry out an assessment or to decide if to make the application for admission to hospital for assessment. Smith (2005) states that an assessment of social circumstances should be considered alongside a medical diagnosis when balancing the risks in a service user's perceived needs and vulnerabilities. The Code of Practice advises that the patient should be given the opportunity to speak to the AMHP alone. An effective assessment should be carried out collaboratively, as Adams et al (2009) state a partnership approach can recognise an individuals’ right to autonomy, safety, inclusion and having their voice heard ‘without denying power differentials’ (page 217). The Code of Practice also states that where possible the examination should be carried out jointly with the medical practitioner. This can however cause difficulty as some medical practitioners can be reluctant to await the arrival of the AMHP. A further issue that can be apparent is the reluctance of some AMHP’s to challenge the recommendations made by medical professionals. Although both professionals are meant to be working together it is still the medical v the social model. The General Social Care Council and the Code of practice both state that the least restrictive principle should always be adhered to; as Smith (2005) states the primary task of an approved social worker is to consider whether any "less restrictive alternative" to hospital admission is possible or desirable. s.3 of the Mental Health Act 1983 is for compulsory admission to hospital for treatment for up to six months. Again written recommendations from two medical practitioners are required before the AMHP complete an assessment. Wilson et al (2008) state that although it is the job of the psychiatrist to determine whether the person being assessed is suffering from a mental disorder both the AMHP and psychiatrist must agree to an admission before it can happen. This therefore means that there is always a psychosocial as well as a psychiatric aspect to the decisions being made. It is crucial that the AMHP ensure that in any admission to hospital the paperwork that accompanies the admission is completed correctly. The issue of forced treatment potentially violates a person's right to respect for his or her private life under Article 8 of the European Convention on Human Rights. Mind (2010) state however that this right is not an absolute one and treatment which your doctor says is 'therapeutically necessary' will not violate Article 8, unless you can show that the harm to you from receiving the treatment significantly outweighs the benefit the psychiatrist claims you will get from it. This can be very difficult for the patient to clarify. Smith (2005) however states that mental health social workers have for some time held responsibility for making crucial judgements about risk where the rights of service users are balanced against those of the wider family. The consequences of these judgments may involve compulsory detention (Ball & McDonald, 2002). One of the key concepts of the 1959 and 1983 legislation is that compulsory treatment is for the benefit of the patient. If the condition can not be treated, the patient should not be detained (Wilson et al, 2008). Brayne and Carr (2008) however report that the concept has been ‘watered down’ so that a patient can be detained if appropriate treatment is available, even if it ‘can not be shown that it will benefit the patient’. Adams et al (2009) report that the majority of detained patients stay in hospital for a short period of time, though some may be detained for several years. On average, patients detained under Section 2 stay in hospital for two weeks. The average stay for those detained under Section 3 is a year. An important duty as defined in s.26 of the Mental Health Act 1983, which the AMHP must carry out in any assessment is to identify the ‘Nearest Relative’. Davies et al (2008) report that the Mental Health Act 1983 gives a patient’s nearest relative some rights and powers in relation to detention, discharge and being informed or consulted when certain actions have been taken under the Act or when these are being proposed. The Mental Health Alliance purport that one of the most common areas where mistakes are made by AMHP‘s is the issue of who is identified as the nearest relative. Brayne and Carr (2008) list the order in which the nearest relative is identified these being; - spouse or civil partner - Cohabitee of six months standing - son or daughter - parent - brother or sister - grandparent - grandchild - uncle or aunt - niece or nephew - any other person who has lived with the patient for at least five years Hewitt (2007) reports that the role of the nearest relative is to compensate for the loss of a persons principle rights. This however is not always the case as the Mental Health Alliance state ‘the nearest relative will not necessarily be the person identified by the patient as their next of kin, and the patient has little control over who will be seen in law as the nearest relative. He or she may be someone the patient dislikes and does not want involved in their life, let alone decisions about hospitalisation – and the patient has no power to apply for the displacement of an unsuitable nearest relative’ (Mental Health Alliance, pg 3). Due to the complexity of the role of the nearest relative the Mental Health Alliance wrote a Bill to the House of Lords requesting that the patient be added to the list of people who are able to ‘displace’ the nearest relative as they may not always have the persons best interests in mind. The Code of Practice requires that if the AMHP’s decision is made not to admit a person to hospital then this should be supported by an alternative framework of care and be recorded on the patients medical notes. When an assessment has been completed by an AMHP whereby an application is not made s.47 of the NHS Community Care Act 1990 can be used to assess the patient to put in a package of care to support (Collins, 2006) The assessment should take place within a reasonable time of social services finding out that a the patient may require community care services (Mind, 2010). The social model versus the medical model has been a contentious issue for some time. Walton (1999) cited in Adams et al (2002) state that the Mental Health Act 1983 provides the legislation for intervention but is does not assist the social worker as it is embedded with the psychiatry model of illness and medical treatment. Primarily medical support is given to patients as this can be far more cost effective than psychosocial models such as counselling or cognitive behavioural therapy. In most serious case reviews that have taken place a lack of joined working has been criticised heavily. Action plans and recommendations have been put in place in attempts to co-locate and support joined up working, yet two frameworks are still being worked to. The correlation between physical exercise and mental health has been researched for numerous years. The phrase a healthy body leads to a healthy mind has been debated within these research papers. Within Callaghan (2004) it is suggested that exercise is beneficial for mental health; it reduces anxiety, depression, and negative mood, and improves self-esteem and cognitive functioning. Faulkner (2005) argues that there is evidence to suggest that exercise may be a neglected intervention in mental health care stating that ‘exercise is seldom recognised by mainstream mental health services as an effective intervention in the care and treatment of mental health problems’ (Faulkner, 2005, pg 326) A number of studies have shown that, in their lifetime, nearly half of the population will suffer some kind of psychological or psychiatric disorder (Jones, 2002). Research by the Office for National Statistics shows that 20 per cent of women between the ages of 16 to 65 have 'significant mental health problems', as compared with 14 per cent of men between these ages. Mind (2003) similarly state that statistically, women are more likely than men to experience mental and emotional distress. However, for schizophrenia, the onset of illness is, on average later in women and women are more likely to make a full recovery. Gender differences in mental health have been widely debated, and a number of explanations are commonly given. Jones (2002) recognises that in general women are more likely to admit to mental health problems and seek help than men. There is also the consideration that in the majority of cultures, it is the woman who typically bears the major impact of care in the family, not only of the children, but also of the elderly relatives, and this can produce constant levels of stress, which again, is recognised as a major trigger for ‘psychological morbidity’ (Davies, 1994). However it could be due to the general perception within the gender stereotype. It is more ‘socially acceptable’ for a man to have an alcohol problem. Women are expected to be more emotional than men, and the male stereotype of being ‘unflinching in the face of adversity’ (Bandarage, 1997). The differing representations of racial and ethnic groups within Britain today is not evenly distributed (Wilson et al, 2008). Both past and recent research suggests that some groups particularly Black Caribbean, Black African and other Black groups are over-represented in psychiatric hospitals. The number of young African Caribbean men being diagnosed with schizophrenia is very high, with some studies reporting between two to eight times higher rates of diagnosis compared to the white population (Mind, 2003). Further, research by Community Care (2011) into Article 14 of the Human Rights Act, which states all have a right to equal and fair treatment without discrimination, is a long way from being a reality in many of the UK‘s secure hospitals. Black Mental Health UK (2008) indicate that more African Caribbean and other Black people with psychosis are being admitted to hospital for treatment because of the way they initially find themselves in contact with the mental health services. Evidence suggests that they are more likely to have been in contact with the police or other forensic services prior to admission. Similarly, Grant (2003) cited in Wilson et al (2008) records that this happens despite the fact that they are less likely than White people to show evidence of self harm and are no more likely to be aggressive to others before admission to a mental health hospital. Mental health social work is shaped by policy that promotes service user involvement but considers the importance of public safety (Adams et al, 2009). Social work happens in settings where disadvantage and discrimination are commonly experienced and yet the GSCC (2008) code of practice sets out that social work practice is obliged to engage with power imbalances in this respect. The consequence for service users can be a loss of control of over key aspect of their lives. Smith (2005) finds that social workers can often hold power over service users in the form of expertise and authority and yet they are expected to promote empowerment and autonomy for the service user. Mistreatment and oppression can be a common occurrence for people who are diagnosed with mental health difficulties. The experience of being diagnosed or labelled as having mental health problems is not only used as a means to explain a persons difficulties, but also as a means of control (Adams et al, 2009). There can be a fear of people who have been diagnosed with mental health problems. That fear is compounded by the media where people diagnosed are portrayed violently and negatively. This can contribute to the stigma and discrimination that people with mental health problems experience on a daily basis. This essay has identified that mental health social work is extremely complex, the loss of rights that accompanies compulsory admissions is not to be taken lightly. A thorough assessment of a persons rights versus risk has to be taken into consideration and must be fully accountable. The gender differences within society are reflected in the gender differences in health generally. The woman, in the majority of cultures is expected to assume a number of different roles each with their own pressures. Being a carer is common and can be cause of stress. This can contribute towards mental ill-health. The disproportionate number of racial and ethnic groups represented within secure hospitals has also been explored. As has the number of diagnosed cases of schizophrenia within young black men. Autonomy is essential within social work however within mental health social work and the legislative constraints worked within it could be argued ‘to what extent are we free to make a choice and what limits us' Bibliography Adams T. & Clarke C.L. (eds.) (1999) Dementia Care: Developing Partnerships in Practice Balliere Tindall, London. 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