For my essay I have chosen to look at the role of a mental health social worker (MHSW). MHSWs may be incorporated into a multi-disciplinary community mental health team or they may work as part of a generic team and I have chosen to focus on the former. Many MHSWs although formally employed by a local authority are often permanently seconded by health and work in health and social care trusts that are partnerships between health and local authority employers. (Wilson, Ruch, Lymbery and Cooper, 2008). Community mental health teams (CMHTs) work to help people with complex mental health disorders such as schizophrenia and bipolar disorder. They provide day-to-day support that allows service users to remain in the community. The Care Programme Approach (CPA) used by CMHTs has been central to government policy since 1991. It was crucial to ensure that, following the closure of the old, long stay, hospitals, people with mental health problems received the care they needed, rather than lose contact with services and end up homeless or exploited. The Care Programme Approach (CPA) requires that everyone accepted for treatment or care by mental health services should have their needs assessed, a care plan to meet those needs, a named mental health worker and regular review of their needs and their care plan (Department of Health (DOH) 2010).
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A mental health social worker’s contribution to a CMHT ‘is ideally found in a combination of systematic, psychodynamic and broadly relationship-based skills and perspectives’ (Wilson, Ruch, Lymbery and Cooper, 2008:586). A MHSW performs roles that can be divided into three broad categories: advocacy role, direct change agent role and executive role (Beckett 2009). Very often these roles are performed simultaneously and this may cause conflict. Advocacy can be defined as ‘the exclusive and mutual representation of a client(s) or a cause in a forum, attempting to systematically influence decision making in an unjust or unresponsive system(s)’ (Schneider and Lester, 2001:65 cited in Beckett 2009:118). Advocacy is a very important role played by social workers especially as mental health service users are a group ‘marginalised in some way by society’ and it is ‘about redressing the balance and helping voices to be heard, which otherwise would have gone unheard’ (Beckett 2009:122). People with mental health problems experience discrimination in many areas of life. Social workers by virtue of their professional status possess a lot of power and need to be aware of this when they are trying to build a relationship with a service user group that has been effectively disempowered by society. As advocates social workers can use their power to challenge the oppression faced by mental health service users. A mental health social worker can act as either a ‘direct advocate’ or an ‘indirect advocate’. As a direct advocate they would speak on behalf of a service user. As part of a multi-disciplinary team social workers are expected to work with other professionals such as psychiatrists, nurses and occupational therapists. In recent years the primary agency responsibility for mental health work has shifted decisively towards the health sector and there are those that argue that ‘operating within the medicalized paradigm of practice reduces human potential to the confines of drugs and mental patient role reproducing programs, thus short-circuiting social development and reproducing the conditions of oppression’ (Rose and Black, 1985:58/9). This has had a big impact on social workers as difficulties arise from a clash in values of the medical model and social models of mental health care. In addition competing demands of the various professionals working in the team faced by limited resources may lead to further difficulty. A MHSW may have to advocate for a service user when dealing with other professionals and must be skilled in diplomacy and communication in order to achieve the best possible result for the service user when dealing with other professionals. As an indirect advocate a MHSW helps service users speak on their own behalf. Social workers are frequently in a position which makes it impossible for them to be truly independent and represent only the service users’ wishes. For example, when a social worker needs to act on behalf of more than one family member who have conflicting wishes or interests, when service user’s wishes conflict with the social worker’s assessment of what is in the best interests of the service user, and when conflict arises because social workers have a responsibility to manage public funds and prioritise limited resources and this may conflict with the service user’s wishes/needs. Advocacy skills are important to social workers, but they must also have the knowledge required to advise service users to find independent advocacy appropriate to their needs.
In the direct change agent role a MHSW through interaction with individual service users or groups of service users can work to bring about change. Bringing about change will require assessment of the service user’s needs and looking at ways in which their circumstances may be improved and this will involve significant skills in problem solving. Social workers in a CMHT may borrow from therapeutic/counseling techniques and ‘past’ or ‘present’ oriented approaches (Beckett 2009:47) such as psychodynamic and cognitive behavioural theories can be used to help the service users bring about change in their lives. ‘Mental health problems are intensely personal experiences for the person who is directly affected, but also for those close to them’ (Wilson, Ruch, Lymbery and Cooper 2008:566). Working with a service user to bring about change may involve working with carers and/or family members as a mediator to resolve conflict or as an educator. This can be very useful as service user problems can sometimes be linked to those around them and part of bringing about change would require change from them. Some of the skills required by a MHSW in a direct change agent role would be communication, negotiation and counseling.
The executive role deals with the practical side of being a mental health social worker. As a care co-coordinator the MHSW would be the first point of contact between the service user and various professionals involved in their care. A social worker acting in this role should be able to explain to the service user how different services are responding to their different needs, while at the same time relaying any of the service user’s concerns to the appropriate professionals. Part of the executive role includes the social worker acting as a control agent. This role ‘regulates and enforces boundaries of behaviour in order to protect vulnerable people either from being harmed themselves or from harming others’ (Beckett 2009: 12). Under the Mental Health Act (MHA) 1983 Approved Mental Health Practitioners (AMHPs) have a ‘statutory role in arranging compulsory admission to hospital’ (Brammer 2010: 446). This role creates an ethical dilemma for the MHSW as they are expected to balance the rights and welfare of the individual against public welfare and this may mean compulsory detention for assessment or treatment. AMHPs work closely with medical practitioners who are required to first recommend compulsory detention for assessment or treatment, ultimately the final decision lies with the AMHP. The AMHP must also consult the service user’s nearest relative (Family member, spouse, civil partner, or someone who has resided with the service user for five years) before an application for treatment or guardianship is made (Brammer 2010:448/9). The role of control agent poses an ethical dilemma as the social worker ‘ sees herself as facing a choice between two equally unwelcome alternatives, which may involve a conflict of moral values’ (Banks 2010:13).
A MHSW can apply various theoretical perspectives in their area of work. I have chosen to briefly explain the person-centred approach, cognitive behavioural therapy and the strengths perspective. Following this I will describe in detail how the strengths perspective can be applied in a CMHT.
The origins of the person-centred approach can be traced back to Carl Rogers in the 1950s and 60s. Rogers placed immense value on the therapeutic relationship and identified six conditions ‘”necessary” and “sufficient” for therapeutic change to occur’ (Dykes 2010:114/5). These conditions are psychological contact between client and therapist; client’s state of incongruence; therapist’s congruency or integration in the relationship; the therapist’s unconditional positive regard for the client; the therapist’s empathic understanding of the client and communication of empathic understanding; and positive regard achieved to a minimal degree. To use this approach successfully social workers do not ‘claim to have superior expertise to their client and they do not claim to be able to explain or interpret their clients to themselves, they simply help their clients to draw on their own expertise and their own problem-solving capacity’ (Beckett 2009: 66). This approach empowers service users and gives them confidence to come up with their own solutions. In this process the helper grows personally while helping the service user to do the same. In order to help the service user the social worker needs to ‘already being the place where the client needs to get in order to deal with his own problems in his own way’ (Beckett 2009: 69). This approach comes with some difficulties as social workers can be expected to play different roles at the same time. When a social worker acts as a control agent it is virtually impossible to offer the “acceptance” that the approach requires. The social worker cannot just accept the ‘client’s world’ without ‘evaluating and judging’ especially when there is risk of harm to the service user or others. In some situations it is also possible that a social worker may have to disclose information revealed by a service user to other professionals or agencies. A social worker cannot just accept what a service user has divulged and may be required to act on the information whether or not the service user wants them to. This may not foster the type of trusting therapeutic relationship that Rogers envisioned.
Present day cognitive-behavioural therapy represents an evolutionary merging of behaviour therapy and cognitive therapy (Dykes 2010). It is an approach supported by the National Institute for Clinical Excellence (NICE), the body set up to review the effectiveness of clinical treatments for the National Health Service (Wilson, Ruch, Lymbery and Cooper 2008). It is the method of choice in mental health services due to empirical evidence of its effectiveness and its overall cost-effectiveness as it can be offered on a short term basis. The underlying theory of the cognitive-behavioural approach is that behaviour and mood are largely the result of the cognitive processes with which we interpret the environment that surrounds us. From his early research Aaron Beck realised the need for theory that ‘drew together meaning and behaviour in both normal and abnormal emotions’ (Salkovskis 2010:146). Beck’s cognitive theory of emotion is integral to the understanding of mental health problems from a cognitive-behavioural perspective. The cognitive theory of emotion suggests that it is the meanings that individuals take from a situation that create emotional responses. If the meaning is negative, the emotional response will be negative and vice versa. Particular emotions are typically linked to particular meanings. For example anxiety and fear are usually linked to personal threat and danger (physical, social or role-related)These meanings are not always conscious and may require a social worker to carefully question an individual so that they can be identified, therefore communication and counselling skills would be essential. The cognitive theory identifies that normal emotions become disordered when an individual continually takes certain meanings out of situations with persistant negative responses. A practitioner using the cognitive-behavioural approach offers, a safe environment, acceptance and congruence, actively challenging self-destructive and negative thought processes that may be destructive. The practitioner seeks to facilitate the client’s own understanding of their behaviour and feelings and thus effect a change of view of the way in which they see the world and how it impacts on them. Seeking to alter irrational into rational beliefs, which are less likely to result in poorly adapted behaviour and disorders such as depression. It is very important for the practitioner to assist the individual in making clear both the problems they want help with and the goals they want to work towards.
The strengths perspective originates in North America from the works of Saleebey, Rapp, Weick and others. They advocated for professionals to challenge key concepts in biomedical and psychiatric discourses that focussed on deficits. The ideas behind the strengths perspective are an effort to correct a strained and often destructive prominence of what is absent, wrong and abnormal. Practicing from this perspective does not ask social workers to ignore the real problems that impact people and their sense of future possibility as in ‘the lexicon of strengths, it is as wrong to deny the possible as it is to deny the problem’ (Saleeby, 1996:297). The strengths perspective is strongly aligned with solution-focussed and empowerment approaches. Features of the strengths perspective are consistent with the empowerment approach as the aim for both is to build service user confidence in their own abilities. The empowerment perspective ‘can be seen as a bridge between the strengths perspective and anti-oppressive approaches in that it combines core elements of both practice perspectives’ (Healey, 2005:157) The perspective draws on theoretical knowledge and empirical research in social sciences and social work. The perspective assumes that all people have strengths, are resilient, have the ability to determine what is best for them and that professionals tend to focus on the clients’ problems and deficits and shy away from collaborative partnerships with service users because they want to protect their professional power (Healey 2005). The key practice principles of the strengths perspective are adopting an optimistic attitude, focussing primarily on assets, partnership with the service user, working towards long-term empowerment of service users, and creating community.
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According to Rapp (1998) mental health workers must have a belief in people and the capacity to better their lives and that the ‘practice perspective must reek of “can do” in every stage of the helping process’ (Rapp, 1998:54). The strengths perspective embodies social work values of respect and service user self-determination (Healey 2005). Optimism is essential if a social worker is to build on the service user’s strengths and ‘social workers have a professional duty to assume a positive and optimistic attitude towards service users’ (Healey 2005: 158). A MHSW will need to acknowledge their client’s strengths and respect the direction in which clients want to apply them. This may require a MHSW to challenge themselves and others to question approaches that focus on the problem or deficit that the service user has. Instead the MHSW would look for strengths that the service user possesses and focus on these as ‘we can build only on strengths, not on deficits’ (Healy 2005:159). It is also important to focus on the strengths of the service users families and community as inherent in the perspective is the belief that all people, families and communities possess strengths that can be called on to improve the quality of their life. The social worker must be able to convey their belief in the service user and vital to this would be their use of language. Instead of referring to a service user as a schizophrenic, they would be referred to as a person with schizophrenia (Healy 2005). Separating the service user from the problem that has brought them to the agency is an integral part of the approach. Listening and identifying strengths and resourcefulness that a service user has is an important part of the strengths perspective. A social worker must be able to listen to a client’s account of a situation and identify the service users’ capacity to make positive changes. For example, when dealing with a service user that suffers from severe anxiety the social worker can help the service user to identify periods when they are not anxious. Service users then realise that they are not in a permanent state of anxiety and identify what it is that helps then remain in a state of non-anxiety. Client goals and visions then become the base for intervention plans.
The strengths approach requires that the service user and social worker have a collaborative partnership and this is consistent with social work values. Working in partnership increases the likelihood of a positive outcome as the service user is involved from start to finish. A MHSW would have to use their listening skills and it would be essential for the partnership that the service user feels that their views are being listened to. It would be important for the MHSW to ‘create opportunities for the alienated and distressed to seize some control over their lives and the decisions that are critical to their lives’ (Rappaport cited in Healey 2005: 163/4). Empowering service users to make changes would be a key role for a MHSW.
The strengths perspective demands that workers regard their practice from a different viewpoint. Service users and those who surround them need to be seen for their capacities, abilities, competencies, ideas, values, and hopes, however affected they are by situation and oppression. There are those that criticise the approach because it ignores real problems, however, the perspective does not downplay or ignore real problems. Problems are what bring the service user to the agency and they are compelled to talk about them. They need opportunities to express themselves, and recount the barriers to their expression and value. How a MHSW would relate to these problems is pivotal in the strengths perspective.
Social work is a diverse role that requires many varying skills. These skills are used to support members of society who have been marginalised and disempowered and social workers attempt to correct these inequalities in the many different agencies that they work. In order to make decisions social workers require a firm understanding of theory and their ability to use the appropriate theories for a given situation or to be able to select different principles from varying theories and use them in combination for the benefit of the service user is equally important.
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