Jeremy Weinstein is a UKCP registered psychotherapist, qualifying in 1999.
Jeremy is an academic former social worker who now works in south London, offering counselling/psychotherapy and supervision and has a special interest in working with loss and bereavement, difference and discrimination and Family Constellations.
He has written and researched extensively in these and related areas. Jeremy’s route into gestalt psychotherapy was via social work, first as a practitioner, then lecturing at London South Bank University, from where he retired in 2007 as a Visiting Fellow.
SOCIAL WORK AND MENTAL HEALTH
Introduction: ‘No health without mental health’
Let’s start with the context. An estimated one in four of us will suffer from a mental health problem at one point in our lives. 43% of the 2.6 million people claiming long term disability benefits in 2012 have a mental or behavioural disorder. This huge level of suffering comes at a cost: emotional, social and also financial (£105 billion a year at present, a figure expected to double in the next twenty years).
These statistics come from the Coalition Government’s 2012 Strategy Paper ‘No Health Without Mental Health’, (hereafter NHWMH). The paper’s focus is on England but its authors recognise that the issues which it addresses resonate across the UK. It lists as ‘vulnerable groups’, children (with one in ten between the ages of 5 and 16 having a mental health problem which may persist into adult life), women with post natal depression (experienced by one in ten mothers) and prisoners, of whom 90% have a diagnosable mental health problem. NHWMH also acknowledges the risk factors for ‘many people from black and minority ethnic communities’. It uses the language of ‘social justice’ and ‘challenging stigma’ and (perhaps reflecting the influence of Wilkinson and Pickett’s seminal text The Spirit Level (2010)) acknowledges that ‘Social inequality of all kinds contributes to mental ill health’ (p.2).
NHWMH then links ‘mental health objectives’ to action points, whether ‘under way’, ‘new’ or ‘on-going’, and the named government department responsible for seeing the objective through to completion. One of the major strands in this strategy is IAPT (Improving Access to Psychological Therapies), with a further investment of £400 million for a New Labour initiative offering free, within the NHS, ‘a choice of psychological therapies’, although the choice is limited to NICE compliant, ‘evidence based’ approaches, i.e. cognitive behavioural therapy.
NHWMH pledges that, together, government and professionals will ‘give weight to both mental and physical health … our ambitious aim (is) to mainstream mental health in England’ (p.2). This has every appearance of a sustained campaign at the highest levels to reach a different understanding of ‘mental health’, progressive even in not viewing mental health as mysterious and ‘out there’ but central to the structures, and spirit, of society.
Nonetheless it represents the confusing, contested and often contradictory character of current discussions and debates around mental health. Thus while NHWMH recognises that the ‘incidence of mental health problems … can increase in times of economic and employment uncertainty’ (p. 7) this document emanates from a Conservative/Liberal Democratic government that is implementing policies and cuts which are directly and deliberately increasing these very uncertainties. Work capability assessments, for example, have been taken away from GPs and given to a private firm, Atos, on a contract worth £500 million. At the time of writing the government is in the process of replacing Disability Living Allowance with a much more draconian ‘Employment Support Allowance’ which will cut benefits, ignoring the grim irony of trying to get people into work at a time of rising unemployment. And despite the official message that ‘work is good for you’ a major report from the Chartered Institute of Personnel Development has identified workload-related stress as being the main reason for people visiting their GPs (CIPD, 2011).
One reason for such apparently contradictory policies is that is increasingly difficult even for right-wing governments to ignore the extent to which mental ill-health and distress is a creature of the system under which we live. As Wilkinson and Pickett have argued (2010), industrialised societies, like the UK, have levels of emotional distress, anxiety and physical illness which are directly related to levels of inequality. In a striking phrase, they conclude that ‘individual psychology and social inequality relate to each other like a lock and key’ (p. 33). James (2008) coined the term ‘affluenza’ for the virus that afflicts a system built on competition and inequality. Like Wilkinson and Pickett, he argues that socio-economic upheavals, industrialism and insecure working conditions, unbridled materialism, individualism celebrated as opposed to collectivism and unhappy personal relationships have left unprecedented numbers of people in deep emotional distress. It is, therefore, exceptional if you are not disturbed for this is not some accidental by-product of the system but rather it ‘actively encourages distress, feasting upon it’ (2008, p. 9). James’ description of this system as ‘selfish capitalism’ has echoes of the Tory Premier, Heath, who in 1973 sought to put the blame for a previous economic crisis on ‘the unacceptable face of capitalism’, while today’s Tory leader, Cameron does the same by talking about ‘crony capitalism’. I suggest we need no such qualifying phrases, we can begin to orientate ourselves as social workers by recognising that alienation, or estrangement – from self, others and the wider world – is the very essence of the capitalistic system (for an introductory discussion of Marx’s analysis of alienation see Swain, 2012).
MADNESS: ‘THE CONTOURS OF DISORDER’
Going beyond government strategy papers, we need to open ourselves to a fuller sense of the various competing and complementary ways that ‘mental health’/‘madness’ is constructed within society. This is important since ‘These are not abstract, intellectual questions … Our attitudes to madness will shape our responses to it in terms of both our everyday interactions and in the choice of therapies that are available’ (Leader, 2011, p. 2).
The dominance of the conventional, medical/professional standpoint is evident in NHWMH’s (2011) use of ‘mental health problem’ as an ‘umbrella term’ for all those ‘diagnosable mental illnesses and disorders, including personality disorder’ and which ‘may be more or less common, may be acute or longer lasting and may vary in severity’. NHWMH acknowledges that the very term ‘problem’ is problematic since it can ‘medicalise ways of thinking and feeling’ and so not allow consideration of ‘the many factors that can prevent people from reaching their full potential’ thus reinforcing stigma. The term is retained, nonetheless, because ‘there is no universally acceptable terminology that we can use as an alternative’ (p. 7). But framing it in terms of ‘illness’ brings it all back to biology and a reliance on ‘physical treatments … drugs, ECT or even brain surgery (as) the first, if not the only, course of action’ (Ferguson, 2000, p. 232). Emphasising medical symptoms and syndromes gives greater credence to diagnostic texts such as DSM1V (APA: 2005) and NHWMH (2011), especially in its support for the Improving Access to Psychological Therapies (IAPT) initiative. Given IAPT’s status as a flagship for both the present and previous governments it merits some closer study.
IAPT: A CASE STUDY
New Labour initiated IAPT with funding of £173 million for the first three years of a six year programme based in England. For this money the public is offered talking therapies free at the point of delivery within the NHS. These are ‘NICE compliant’ and ‘evidence based’, basically CBT (Cognitive Behavioural Therapy). By 2011, 70,000 people were recorded as having ‘recovered’ from illness (a 50% rate in my own area of Wandsworth in South London) and 14,000 moved off sick pay and benefits. This was successful enough for the government, in 2011, to commit a further £400 million to IAPT, extending the programme across England by 2015 and including older people, patients with long-term physical conditions and medically unexplained conditions, as wel as children and adolescents showing signs of anxiety and depression, conduct disorder and disruptive behaviour.
The ‘stepped care’ treatment model offers those with mild to moderate anxiety and depression ‘low intensity work’ such as guided self help including computerised programmes (cCBT), psycho-educational groups and telephone support. ‘High intensity’ is for those with moderate to severe depression and anxiety disorders, including panic disorder, post traumatic stress, obsessive compulsive disorders, social phobias and relationship issues. Interventions include 12 1-1 sessions.
In Wandsworth, a group working closely with BME groups, the Community Empowerment Network, seized the opportunity to raise the specific needs of the Bengali, Urdu, Tamil and Somali (BUTS) communities. In specially commissioned research (Roehampton University, undated) respondents reported their general lack of knowledge of mental health conditions, especially depression and anxiety, and a lack of trust in the interpreter services. It was also found that GPs needed to have improved cultural awareness. Based on these findings IAPT developed ‘mental health first aid’ training for the BUTS communities with NICE guidelines for anxiety and depression appearing in the relevant languages and IAPT workers provided with a glossary of terms that might be used within the communities. IAPT is also now offered in mosques, temples and the black churches as well as GP surgeries.
At first sight, this appears to be an imaginative, proactive approach to marginalised groups that also bears a resemblance to the original model of ‘community social work’ which pioneered surgeries away from the office and on local estates. There are, however, serious questions regarding the way it is being applied. The BUPS research, for example, had no discussion of the possible impact of racism in the lives, and mental health, of their respondents and the favoured talking therapy, CBT, is evidence- light in terms of working with black and minority ethnic groups. Randomised control trials (RCTs) measuring its effectiveness have failed to address race and ethnicity (Levinson, 2010, p. 184) and terms such as ‘cultural competence’ and ‘service user inclusion’ are the dominant phrases erasing the concepts like ‘racism’ and ‘feminism’ (p. 184). Tellingly, a literature search of ‘CBT’ and ‘diversity’, ‘cultural competence’ and ‘cultural sensitivity’ ‘produced no generic articles at all’ (p. 186). In one CBT text (Trower et al, 2009) the index has no entry for ‘race’, going straight from ‘questions, use of’ to ‘rational-emotive imagery’
Taking the scheme as a whole there is also a problem in the not- so- small print. 50% of people assessed by IAPT (and in my area this is mainly a telephone assessment) are then referred onto other agencies, although it is not clear how that decision not to treat is made and no record is kept as to whether people manage to find that further support or just give up. Once accepted, IAPT claims that ‘four in ten’ recover but a study of the figures show that that refers only to those who completed their CBT- based interventions. This, in turn, is only 9% of those initially referred. For example, 9% of potential patients declined treatment, 21% dropped out once the treatment had started, 12% were judged as unsuitable (McInnes, 2011, p.40).
Practitioners within the service are not always satisfied with their experience. One working for an independent body commissioned to provide IAPT reports how counsellors, after ‘a remarkably short acquaintance’, have ‘to assign each new patient to a preliminary diagnosis, selected from a drop-down menu of “disorders”’. In her view this tick box exercise can only be intended to meet funding requirements since the system is ‘not designed for counselling interventions and … is therefore unsuitable … either as a diagnostic tool or statistical device’ (Gibbons, 2012). Other warn of the rush to recruit workers for IAPT: ‘without the sensitivity achieved by a more thorough training, it (CBT) can prove to be destructive, and even dangerous’ (Hemmings, 2009. p. 44) while Lowenthal and House are anxious to ‘distinguish clearly between the state and policy-making uses to which CBT is being put’ contrasting this with ‘the sincere good faith of many CBT practitioners on the ground, who have a genuine, principled, and thoughtful commitment to their modality’ (2009, p. 290) .
CBT does have its place in social work and mental health along with other short term interventions such as task-centred or solution-focused work but my concern is with the way that they are increasingly presented as the only acceptable and evidence based approach. It is an approach which also dovetails into ‘positive psychology’, and it is hardly a coincidence that a major British advocate of positive psychology, Lord Richard Layard, was also a prime mover behind IAPT (see Ferguson, 2008). The emphasis is not on staying with and exploring the reasons for someone’s sadness or anger at what they confront but finding the quickest way to get them think and feel differently.
‘DO NOT ADJUST YOUR MIND, THERE IS A FAULT IN REALITY’
A quite different perspective rejects the ‘strict clinical justification’ for mental illness, arguing instead that ‘all societies judge some people mad’ as ‘part of the business of marking out the different, deviant, and perhaps dangerous…. demarcating self from other, as in the polarized distinctions we draw between Insiders and Outsiders’ and this includes such areas as race, gender and sexuality (Porter, 2002 p.6). Porter argues that ‘The construction of such ‘them-and-us’ oppositions reinforces our fragile sense of self-identity and self-worth through the pathologization of pariahs … Setting the sick apart sustains the fantasy that we are whole’ (pp 63/63). This is an interesting echo of the more baldly put Paris ’68 slogan, ‘do not adjust your mind, there is a fault with reality’.
Within this perspective it is interesting to note how, rather than trying to understand actions that disturb and distress, we turn instead to variations of the phrase ‘mad’. Bush described Gaddafi as ‘a mad dog’, rioters in England in the summer of 2011 were attacked as ‘mad’ and ‘feral’, with the violence routinely described as ‘mindless’. Anders Breivik, who killed 69 of his fellow Norwegians, was quickly diagnosed with any variety of disorders but the developmental psychologist Baron-Cohen(2011) questioned this rush to judgement, seeing no evidence of mental illness in Breivik’s written rationale for his actions. Baron-Cohen leaves us reflecting whether we find it more comforting to dismiss Breivik as mentally ill rather than rational within a racist ideology, as a one-off rather than part of a wider political neo-Nazi movement.
‘Madness’ certainly generates strong feelings; indeed Laurence subtitled his enquiry into the experience of the mentally ill ‘How fear drives the mental health system’ (2003) and talks of the ‘growth in coercion’, giving as an example the campaign for Community Treatment Orders (pp. 35- 71 and see discussion below).
That fear has continued, and probably worsened, in the recent period. In one survey, Mind (2007) found that 71% of respondents described being victimised in their communities as a consequence of their mental health history. Recent incapacity benefits reforms have added to the problem. . ‘Thousands of people with mental health problems … (are) being wrongly assessed as “fit to work” (Mind website, downloaded 03.12.11) while the terms like “scrounger”, “cheat” and “skiver” … (have been) used in 18% of (newspaper) articles about disability benefit fraud in 2010/11 compared to 12% in 2004/5’ (Slorach, 2011, p. 6). Birrell (2011) refers to the ‘demonisation of the disabled’, with individuals attacked, verbally and physically, both out on the streets and in their own homes. Although directed against anyone recognisably disabled, ‘Amongst those feeling the coldest chill of this new mood of intolerance’, the ‘easy scapegoats in the age of austerity’, are those with mental health problems ‘already so often victims of bullying and hate crimes’ (p. 42).
‘DANGEROUSNESS’: FROM MORAL PANIC TO PUBLIC POLICY
While the evidence shows that people with mental health problems are far more likely to be victims of crime and violence rather than perpetrators, a very different picture is presented in the popular press. Here, ‘dangerousness’ has been turned on its head and it is the mentally ill who are the threat. When ‘care in the community’ emptied the big asylum hospitals, ex in-patients became increasingly visible, and the most conspicuous groups were those portrayed as the most ‘dangerous’. This became a moral panic of the highest order in 1993 when Christopher Clunis killed a complete stranger, Jonathon Zito, in a random knife attack and suddenly it became self-evident that the mentally ill were roaming free, refusing their medication and beyond the control of mental health professionals. This was despite the exceptional nature of such attacks. One study of 408 homicide convictions found that just 12% of the assailants had been in contact with mental health services over the previous twelve months. Contrasted to this, in the same period, over one thousand people with mental health problems committed suicide (Manchester University research carried out for the DoH, reported in the Guardian, 12.12.97.).
Nonetheless the result was a contradictory and tense compromise: the mentally ill were demonised by the very policies that were presented as being for their protection. Talk of the importance of understanding, promoting independence, prompt treatment and collaboration between health and social services went side by side with threats to section those considered ‘non compliant’. Community Treatment Orders, fitting into the already established patterns of ‘discipline and surveillance’ (Jordan, 2000, p. 117), set the tone for all patients/service users and ignored any serious consideration of the actual experience of community care. This included the impact of market forces and reliance on hostels that were part of the private and voluntary sector with staff often under qualified and under paid.
USER SELF ORGANISATION: ‘HUGS NOT DRUGS’
Although the contradictory nature of the legislation tended to act against the interests of service users this was not always the case. Reflecting the consumerism of the Major government of the early 1990s, legislation and guidance argued for service users, and carers, to be fully involved in the planning and delivery of care (see discussion in Leiba, 2003), and some took full, and perhaps unexpected, advantage of this.
There have always been individuals who, through self support and solidarity, have challenged the stigma and shame of their ‘mental illness’. The Mental Patients Union and the anti-psychiatry movement in the early 1970s were strands of this struggle and something of the spirit survived through the grim days of Thatcherism. Then, in the late 1980s and 1990s, the community care reforms ‘contributed to official acceptance and encouragement of user organisations’ (Kemp, 2010, p. 25). Ferguson’s (2000) research of Scottish organisations, variously calling themselves ‘advocacy groups’, ‘users forums’ and ‘survivors groups’, illustrates the breadth of their campaigns: protesting psychosurgery, the loss of the mobility component of the Disabled Living Allowance and the cuts in general. Methods ranged from letter writing, to MPs and the press, conferences and demonstrations. Opposition to Compulsory Treatment Orders included one ‘good humoured and colourful’ demonstration in August 2002, called by the Critical Mental Health Forum and bringing together service users, relatives, mental health workers and academics. Their banners carried slogans such as ‘hugs not drugs’, ‘respect choice, not compulsion’ and ‘detention without trial’. (www.psychminded.co.uk/news/news2002)
One sustained and sophisticated campaign was against the threatened closure of the emergency clinic at the Maudesley Hospital in south London and the case study of this campaign is instructive (see Weinstein, J(enny)/Southwark MIND, 2010).
In 2004, the plan to close the clinic caused immediate protest since this was a place where people in crisis could turn, 24/7, for support and services, seeing the clinic as ‘a place of safety and security … an accessible haven where they felt known and understood’ (p. 150). The health authority’s response was a Review Group to look at the breadth of emergency services and it decided to draw up various proposals with the PCT (Primary Care Trust) and the health authority agreeing that a local ‘Users’ Campaign Group’ could develop their own plan. This group came to the view that a new clinic should stay at the Maudesley since this was a familiar, central and trusted venue, but argued for a ‘social model’ including counselling, not a medical/treatment approach. The official answer was that it was too expensive and it was not even included as an option for consideration in the resulting consultative paper. In response service users, through Mind, organised their own stakeholder consultation, held demonstrations, put on a ‘Bonkers Festival’, raised questions in Parliament and won a review by the secretary of state. Nonetheless the PCT ‘rubber stamped the closure … simply adding “we note users have concerns”’ (p. 151).
The case study concludes that while service users see that there is a framework for involving them in decision making processes, such efforts can appear as “empty rhetoric” … sound bites that do not result in any real change in the service user experience on the ground’ (p. 152).
One example of the complexity of the relationship between what service users campaign for and what they achieve is highlighted by ‘the personalisation agenda’ where ‘personal budgets’ returns us to the theme of the role of the market and its impact on both service users and social workers/care managers. Significantly the demand for ‘personalisation’ arose from service user resentment that what they were offered by professionals came in ‘a one size fits all’ model rather than being individually shaped by and negotiated with the individual seeking support. But campaigners saw individual budgets as an option for service users whereas the government now has plans to impose this model, by April 2013, on those considered eligible however unwanted or inappropriate. The process of turning ‘client’ into ‘service user’ into ‘consumer/customer’ offers losses as well as gains.
Service user mobilisations against the cuts and Atos continue, including the Black Triangle group (www.blacktrianglecampaign.org) and the Hardest Hit campaigns (www.disabiltyalliance.org/hardesthit.htm). Meanwhile UK Uncut has organised joint actions with DPAC (Disabled People Against the Cuts), a move potentially of great significance since it directly challenges the ‘marking off as other’ tendencies, of the mentally ill from the disabled and of the disabled from the wider anti-capitalist movement.
RECOGNISING THE SUBJECTIVE AND THE OBJECTIVE WORLDS: ‘A FIGHT ON TWO FRONTS’
Within these contested arenas we need as social workers to locate and own a model of mental health that acknowledges the importance of accurate diagnosis but is not over reliant or dependent on medical models. We are more than a collection of symptoms, we are each shaped by a (his)story unique to her/himself and this our psychological self is mediated by outside events. Kovel (1991) describes this as ‘the contours of disorder’ where there is ‘a battle in the subjective world’ and the ‘objective, external world’, (emphasis in the original)… a fight … carried out simultaneously on two fronts – between the person and his world and within the person’ (p. 37).
Personal life has to be grounded in social existence … (the individual) … has defined himself and is defined by others by class, race and occupational identity. These memberships give form and structure to more intimate concerns … What he is becomes defined by the integral of his private and public worlds’ (p. 30).
This returns us to our earlier discussion, the acknowledgement of the Marxist term, alienation, which is an estrangement from self, others and the wider world and profoundly shaped by the political system within which we struggle to survive. This feels like an approach we can work with but before we see how it can be better understood and translated into action we must turn to a more specific exploration of how social work is caught up in debates that are not always of our own making.
DISENTANGLING THE ROLE OF SOCIAL WORK
Returning to Porter’s depiction of the history of madness, that ‘fantasy that we (society as a whole) are whole’ and the ‘polarized distinctions between Insiders and Outsiders’, we can see social workers as ‘the Outsiders’. Indeed this complex, contradictory and uncomfortable position we hold within the wider society was built into our role from the very onset of the welfare state. As Cooper and Lousada (2005) describe it, the Beveridge Report was shaped by the chaos of the Second World War and reflected the hope that ‘the giants’ of Idleness, Ignorance, Want, Squalor and Disease (within which was subsumed ‘mental health’) could be given over to rational and expert professionals. This would allow the wider society not to have to confront the messiness, uncertainty, challenge and risk which social workers face every day, including the dis-ease of ‘mental disease.’ The result, in Simpkin’s (1979) phrase which has stood the test of time, is that we have ‘a peculiar and privileged position in the state system, not unlike the court jester we are licensed to criticise, we are the institutionalised conscience of society. Social work faces both ways, to client and to society’ (p. 41). And we might add, ‘and to colleagues in other disciplines’, especially in the area of mental health. We find ourselves having to mediate all those competing and complementary ideas that ‘society’ has about ‘madness’.
NOW YOU SEE US, NOW YOU DON’T
Positively, today’s practitioners and students can draw on a wide range of texts, many of which claim and outline a clear and central role for social work. Pritchard (2006) sees ‘evidence based practice’, the phrase of the moment, as the core of social work although this is a hostage to fortune. We saw in the earlier discussion of IAPT how narrow and medicalised is the definition of ‘evidence’. Others take an explicitly ‘critical’ and radical perspective (Bailey, 2002, Keeping, 2008, O’Gara, 2008) or describe working with mental health as an opportunity to ‘transform’ social work (Bainbridge, 1999, Golightly, 2004).
By sharp contrast, NHWMH (2011) contains not a single reference to social work. There are fleeting mentions of adult care and the role of local authorities but the main focus is firmly on health and hospitals. Nor is this an unfortunate omission. Within the wider legislation, the very term ‘social worker’ has been eased out (in England, though not in Scotland). There are now ‘care managers’ and the title ‘Approved Social Worker’ was changed (in a 2007 amendment to the 1983 Mental Health Act) to Approved Mental Health Practitioner, to allow, as it says on the tin, the work to be extended beyond the remit of social workers ( although few other professionals seem willing to take on the role).
Returning to NHWMH, social workers are not even mentioned when the document recognises the impact of ‘the early years’ on later mental health, stressing the importance of working with children and families. It refers only to needing to increase the number of Health Visitors and Family Nurses and establish more Sure Start children’s centres. This reminds us of Jordan’s (2000) warning, when Sure Start was introduced alongside a raft of other neo-liberal reforms of welfare, that while the language of social work was being used, the profession itself was side lined having become ‘part of the problem …(we were) familiar, faded and slightly discredited … in the background – the dog that didn’t bark amid all the frantic activity’ (pp 14-15).
The newly launched College of Social Work is quick to raise concerns that focussing on personalisation/personal budgets has contributed to the devaluing and downgrading of social workers. They take hope, however, in the promise of the Care Services minister, Paul Burstow, that the government is ‘committed to protecting the role of social workers in adult care’ (Press statement, CSW, 03.02.12) It remains to be seen how far the White Paper on Adult Social Care (pending at the time of writing) actually delivers on this and whether the planned appointment of a Chief Social Worker comes anywhere near to changing the mood.
And the key question is: does this matter or are we being over- protective of the title? Perhaps ‘the dog’ is not barking because there is no need for alarm; perhaps social workers have made for themselves a crucial role in this area of work bringing into multidisciplinary teams their own perspectives of the social model, service user involvement and anti-discriminatory practice, their own approaches of ‘the recovery model’. The next section will explore some of these questions partly through reflecting on my own experience of mental health social work over four decades.
A LITTLE BIT OF HISTORY : MY LIFE AS ‘A MENTAL VISITOR’
I first came to social work in the early 1970s immediately following the reorganisations recommended by the 1968 Seebohm report. The old professional divisions were abolished allowing the emergence of a unified and community based profession. Consequently, in the same teams, sharing the common title of ‘social worker’ and carrying generic case loads, were the ex Child Care Officers, Welfare Workers and Psychiatric Social Workers. This latter group was seen as very conservative and professionally self-contained and ‘Case Con’, the radical social work magazine, had much fun satirising, none too subtly, the Freudian influences of the PSWs and identified instead with the antipsychiatry movement. The Autumn 1973 edition (number 13) carried a statement from the Mental Patients Union which condemned ‘the entire practice of psychiatry as oppressive politics masquerading as medicine… psychiatrists collude with and support an inegalitarian society’ and damned policies such as sectioning, forced medication and behaviour therapy. This was part of the anti-psychiatry movement represented by writers like Laing as well as in fiction and film, classically Ken Kesey’s ‘One Flew Over the Cuckoo’s Nest’ (1962/2003).
On the first day of my first job, in a very recently established community social work office, I was given a mental health warrant. It was assumed that because my professional training included a two week placement in a therapeutic community and a law exam with questions about the Mental Health Act I, after a day spent visiting older people wanting meals on wheels and rescuing adolescents from police cells, was then eligible to go home, take emergency night duty calls and make decisions on whether someone should be sectioned. It was not only me whom this combination of roles and title confused. On one occasion, I was in the High Court giving my opinion on the psychiatric state of a mother whose child, I was arguing, needed to be in care. I was being sharply challenged by the mother’s barrister when the judge interrupted him with the comment: ‘I think we need to listen carefully to the evidence of the mental visitor’ !
MEDICALISED SOCIAL WORK AND THE MARKET ECONOMY
Forty years on much has changed. The old specialisms that Seebohm had challenged and abolished have returned and now we have specialisms within the specialisms: not just ‘mental health workers’ but workers based in community mental health teams entitled ‘home treatment’, ‘recovery’, ‘assertive community outreach’, ‘crisis intervention’ and ‘dual diagnosis’ (working with mental health problems and drug/alcohol dependencies). Now practitioners responsible for assessing, and possibly sectioning, individuals have to undergo extensive further training to become ‘approved’ as a ‘mental health practitioner’. Given this it is ironic to recall the excitement back in the 1970s that the new Seebohm Departments represented social workers being ‘rewarded with their own state agency … no longer was medicine the lead profession’ (Jones, 2011, p.27). We have now turned full circle and the medicalisation of mental health has drawn social work deep into its logic and ideology. A recent text aimed at ‘transforming social work practice’, for example, opens with the statement that ‘the medical model … is the dominant approach to work with service users’ although the writer goes on to add his belief that social workers can influence the practice with ‘a more socially orientated approach’ (Gologhtly, 2006, p. x).
Before addressing the skills and values of social workers we need to step back and identify some other past markers in the development of our work. Perhaps the most important was the closure of the big mental hospitals. This signified the introduction of the term ‘care management’, which further opened social work to the challenge of working alongside medical staff within the NHS with key workers developing co-ordinated frameworks of assessment and setting up and reviewing care plans. This signalled a major shift for all the professionals involved but clear thinking was not helped by the sheer numbers of long stay patients and the complexity, and cost, of their needs. Various commentators (Jordan, 2000, Leiba, 2003) review the documented concerns about statutory agencies not responding effectively, the degree to which old attitudes and distortions persisted, the staff demoralisation reflected in a blame culture and rivalries within the different staff groups. This may be an unduly pessimistic view, neglecting the opportunities that existed within the legislation that social workers were able to use. Leiba (2003) argues that although social workers felt there was ‘a threat’ to their ‘culture and values … other professionals appreciated that the social workers strive for the democratic values in social work to facilitate creative discussion … They shared the social workers discomfort with the medical model and valued their critical perspective on mental health’ (pp 165-166).
These debates were being acted on and acted out within the ‘mixed economy of care’. Radicals had always warned about ‘the commodification of welfare’ but now ‘the market’ was explicitly part of the equation with the growth of small, commercially driven hostels often marked by ‘fewer facilities or opportunities for individual autonomy … (and) a lack of imaginative, creative provision and stimulating therapeutic or care environments’ (Jordan, 2000, p. 116). They would also often be staffed by under qualified workers leaving both them and the residents vulnerable.
MANAGERIALISM – AND FEEDING THE FEAR OF FEELING
We have seen the argument that ‘fear drives’ the mental health system and social workers are not immune from this. Community Treatment Orders have justified all the warnings of the critics: NHWMH comments that their use has been ‘much greater than predicted’ and this is alongside, in 2009/10, an increase in detentions under the Mental Health Act (2011, p.25).
A report from the Care Quality Commission (Guardian, 15.03.11) fleshes out these figures. Between 2008/9 and 2009/10 there was a 75% increase in the number of people sectioned and nearly 40% of all NHS psychiatric patients are there under legal duress. 6,200 Community Treatment Orders have been served, 10 times the number expected, and Mind gives statistics of 30% imposed on individuals with no history of not cooperating with medication. This is one example, then, of the tension between different aspects of the social work role.
And if social workers are to manage the tensions between ‘support v surveillance’ (Weinstein, 2008, p. 72) they need support to be built into the organisation. Cooper and Lousada (2005), however, describe how as social workers confront ‘the messiness, uncertainty, challenge and risk’ of their work this is within increasingly centralized and regularised organisations of welfare. These have ‘become puzzling, contradictory and uncomfortable’ places where there is a ‘fear of feeling’ (p. 3). The price of suppressing these feelings is high. Coyle et al (2005) identified burnout in mental health social workers as a result of, among other factors, conflict and ambiguity in their roles, lack of social support and the pressure of fulfilling statutory responsibilities. Carpenter et al (2003) found that, compared to their health professional colleagues, social workers in multidisciplinary community mental health teams ‘had poorer perceptions of team functioning and experienced higher levels of role conflict’ and the paper concludes by recommending that ‘support and supervision’ was needed to ‘ensure a social work contribution’ (p. 1081). Gould (2005) argues that in the integration of health and social care services ‘mental health social workers are disadvantaged … because they cannot identify the knowledge base for their practice’ (p. 109). In another mental health setting social workers described their stress and low job satisfaction caused by the demands of the paper work, covering for vacant posts, role confusion and the constant changes of reorganisations. They reported feeling not valued and ‘vulnerable’ because they felt ‘out of sympathy’ with both their employers and the wider society. ASWs had the greater dissatisfaction. Most startling of all perhaps, and reminding us of that saying often blutacked to office walls, ‘You don’t have to be mad to work here but it helps’, is that 55% recorded stress levels high enough to indicate a probable mental disorder (Huxley et al, 2005).
A CASE EXAMPLE: GEORGE HAUNTED BY TWO DEATHS IN A FORTNIGHT
The experiences of ‘George’ (Weinstein, 2008), brings this into sharp relief. He is an ASW who was caught up in the deaths of two service users within a fortnight. One was a young black woman who George had helped section and who then died on the ward from an undiagnosed medical condition. George was obviously upset by this and wanting support to explore what he, and others, could have done differently. Instead the subsequent Serious Untoward Incident Panel left him enormously stressed. It was conducted by senior managers as ‘a little inquiry’ and who were anxious about the attention this death was receiving and possible accusations of institutional racism. The other death, of an older woman whom George had decided not to admit but who had then died later that day in her own home, caused no comparable concern to the organisation. Nonetheless it haunted George who asked himself how far he had put her solitude and confusion down to ageist assumptions about what was ‘normal’ for old people. If he had acted differently, he asks himself, seeing beyond the ‘mental health’ label, might he have got her the medical help she needed? But George had to work this out on his own for in his agency, ‘a Victorian organisation (with) a Victorian bureaucracy (where) there’s no supervision although (that is) the policy … People go through stages of getting burnt out … we’re like the sponge of society’. He is sad and disillusioned as he recalls his energy, when starting in social work, ‘to make things better’ and he wonders what this younger self would say to the George who now spends so much time dashing into crisis situations with the police and psychiatrists in tow’ (p. 164).
THE SKILLS, THEORIES AND ETHOS OF SOCIAL WORKERS: ‘THAT’S HOW THE LIGHT GETS IN’.
I make no apologies for the grimness of this previous section: we need to be honest about the difficulties if we are to find a way through them, both for the benefit of our service users and ourselves in a profession worth fighting for. We need also to be self-critical concerning our theories and our practice so that we can follow the appeal to ‘ring the bells that still can ring/forget your perfect offering/There is a crack in everything/That’s how the light gets in’ (Cohen, p. 179).
There are several places where we might start. We have heard the appreciation of our ‘more socially orientated approach’ (Golightly 2006, p. x) while Leiba, not himself a social worker, comments how other professionals in multi-disciplinary teams appreciate how we ‘strive for the democratic values in social work to facilitate creative discussion … They shared the social workers discomfort with the medical model and valued their critical perspective on mental health’ (2003 pp 165-166) Bailey (2002) builds on this, encouraging social workers to recognise the importance of multidisciplinary realities and not to be defensive but to take on ‘an activist’ role, moving from an ‘operational doing to’ to a ‘human being with’ approach with the emphasis, then, on the quality of the worker-service user relationship (p. 177).
Implicit in this is the need to locate and own a model of mental health and I have argued the potential of Kovel’s ‘contours of disorder’ where there is ‘a battle in the subjective world’ and the ‘objective, external world’, (emphasis in the original)… a fight … carried out simultaneously on two fronts – between the person and his world and within the person’ (p. 37).
This resonates with perspectives developed within social work. Focusing on mental health specifically, ‘the biopsychosocial model’ with the medical view where ‘bio relates to changes at the biochemical level of brain functioning’, ‘psycho, to patterns of thinking, feeling and perceiving that becomes manifest in the capacity for judgement and reality testing’ while ‘social emphasises personal relationships and experiences including those of oppression, discrimination and disadvantage’ (emphasis in the original) (Bailey, 2002 p. 173). This relates well to the social work ‘PCS’ model (Thompson, 2001) which invites us to see every service user in the light of the interrelated factors of ‘P’, which stands for the personal and the psychological, ‘C’ which allows for the cultural/ community/codes of belief and ‘S’ which is the structural. We need, however, another ‘P’ for ‘political’ to help see how inequality and poverty is built into, rather than a by-product, of the neo-liberalism of modern capitalism. This analysis first helps us relate to the individual situation we confront and, secondly, to find the courage and the strategies to challenge the system.
A CASE EXAMPLE. ‘PETER’.
To see what this might look like in practice let us go construct a scenario of the most challenging of situations: at 4 am on a Saturday morning we are called to a house in the inner city where a middle aged African-Caribbean, ‘Peter’, with a history of schizophrenia, has again been playing his music loud into the early hours and shouting. Neighbours also report that his flat is so neglected it is attracting rats. Peter admits that he has stopped his medication and the shouting and music help drown out the voices which are giving him ‘nothing but grief … they are doing my head in’.
For the social worker/AMHP this is a difficult and tense situation. Peter is male and black and memories of Jonathon Zito’s death back in 1992 (see earlier discussion on ‘dangerousness’), conflate ‘race’ and ‘mentally illness’ to signal danger and difference. You have not met Peter before, nor has the GP on emergency call out, the police are alerted to the situation and neighbours are gathering at their doors and you feel the pressure mounting to simply sign off the forms to get Peter into hospital as quickly as possible. And it may be that this is what has to happen. Just because statutory powers can be used carelessly or callously it does not mean that authority should not be used when people are at risk. In an earlier example, as a ‘mental visitor’ I could justify to myself going to court to seek to remove a child from his mother. It may be that Peter does, for his safety and long term sanity, need some asylum, in the sense of respite from his present intense and unendurable distress (see Keeping, 2008, who argues that her sectioning a service user protected that individual, ‘both physically and emotionally’ (p. 78) and was done in the spirit of ‘best critical practice’).
Returning to Peter, however, a hospital admission may not be necessary. Our immediate response is inevitably, given the circumstances, ‘bio’: checking the signs and symptoms shaped by his long standing diagnosis of schizophrenia. In addition, however, we need space to think, to get a full medical assessment that goes beyond his mental state to include his general health, how far it has been exacerbated by the poverty he lives in. We need to review his medication, not just insist that he takes it or else.
More important, however, is that we then move on from this purely medical orientation and allow the ‘P’, the psychological and personal, to see Peter as more than the label, to appreciate his journey into, through and hopefully beyond his mental illness. In a fuller exploration of Peter’s story (Weinstein, 2008) the distress is linked back to the sudden death of his father when he, Peter, was an adolescent and his first enforced spell in hospital followed shortly afterwards. What then emerges is how he then experiences a whole series of, if not actual bereavements, then other quite profound losses: his family of origin, a child by an estranged partner, meaningful work, a comfortable home, his ‘sanity’. He had once hoped to achieve fame as a musician but can now only play other peoples’ music. He has his ‘voices’ but these are taken as a pathological symptom although recent work by ‘hearing voices’ groups suggest that they can, in fact, be clues to an understanding of a person’s place in the world, and ‘the voices’ are ‘one aspect of one’s life, not the sole confirmation of madness’ (Lawrence, 2003, pp.134-8).
Social workers can draw on a range of approaches to help them gain the trust of Peter and allow his story to emerge. Keeping, the mental health social worker cited above, stresses the centrality of ‘close, empathic attention’ to the service user’s story (2008, p. 71) and Payne (2005) reminds us how self actualisation and self fulfilment are part of our professional objectives. Empathy, congruence, genuineness and unconditional positive regard serve as ‘attributes of the worker in successful practice’ (p. 182). Parton and O’Byrne (2000) develop this into ‘narrative knowing’, challenging social workers to stop being ‘organisational functionaries’ with little time to ‘enter other worlds of meaning in order to offer help’ (2000:2). Instead they emphasise the need to enter a client’s story, cutting across our pre-judgments and preoccupations with preconceived theories. Aymer (2000) sees ‘narrative work’ as a focus for anti-discriminatory practice allowing a voice to those otherwise silenced or marginalised by the majority who are now free to speak out. In this same spirit is ‘the recovery model’ which is not about ‘cure’ or being ‘symptom free’, although this is perhaps what Peter yearns for, but about living as full a life as possible with the problems, indeed the problems become valued as part of the experience. NHWMH (2011, p. 16) takes Anthony’s definition of ‘recovery’ meaning ‘a deeply personal, unique process … a way of living a satisfying, hopeful and contributing life … the development of new meaning and purpose’ (1993, p.11). This is explored further by Cordle et al (2011) with users sharing how their creativity in, for example, poetry and film and there is the potential for Peter to re-engage with his creativity in music. Weinstein J(enny) (2010) on service users finding recovery through teaching social work and health care students or involvement in campaigns (see above).
Going to ‘C’ of the Thompson model, we see that behind the promise of ‘care in the community’ is actually an experience for many of a ‘community’ that is ‘fragmented’ with a ‘psychological proletariat, living and (rarely) working in a social universe noticeably short on sympathy and empathy’ (Hoggett, 1993, p. 206). Hearing Voices groups, music workshops or other opportunities within the voluntary, or third sector, can help people contact a more rewarding community and culture and here also is the S’, or social/ structural for Peter has become locked into the structural inequalities of bad housing, unemployment and poverty, all the indicators recognised by the government, in NHWMH as well as authors such as Wilkinson and Pickett (2010) and James (2008) as heightening mental distress but which has then been worsened by that same government’s viscous austerity programme so this brings us back to the ‘P’ which is a political understanding.
How this relates to anti-discriminatory practice is that we need here both a professional and a political commitment. Certainly NHWMH (2011) recognises the special vulnerability of the BME communities and IAPT, in at least one area, has reached out to groups that might otherwise be marginalised. This recognition is welcomed although it could hardly be otherwise given the mountain of evidence relating to how discrimination gets played out within the mental health system, how ‘minority group members are … less served by preventative services, more often routed to punitive, custodial sentences and are more frequently ignored’ (Raiff and Shore 1993, p. 66). One response to this has been the term ‘cultural competency’ which argues for the social worker to see what differences belong with wider cultural expectations and the strengths this may bring in the face of adversity. The emphasis on ‘culture’ and ‘ethnicity’, however, ‘neutralises the language of discrimination’ (Sewell, 2009, p.21) while Desai and Bevan (2002) advocate for a wider dimension which recognises the impact of racism on the individual’s sense of self esteem and identity. Following this, Pilgrim (1997) cites Greenslade’s (1992) use of Fanon’s concept of ‘Black Skin/White Mask’ (1970) to inform his work with the Irish connecting psychological stress and colonialism. The suppression of a language and a history and enforced mass emigration results in an ‘existential uncertainty … compounded by continued social dislocation… and physical proximity to, and economic reliance on, the ex-colonial power’ (Pilgrim, p. 76)
Anti-discriminatory practice relates not just to BME communities. There is a long standing debate about how psychiatry views gender /women, how it has reflected and helped shape how women should and should not behave (for examples of the UK experience see Barnes and Maple, 1992, Perelberg and Miller, 1990 and Pilgrim, 1997) and Mind campaign (1992) on the stereotypes that effect mental health diagnoses, especially depression. Penketh (2011) links this to the politics of gender, where ‘care in the community’ often means women looking after their parents, their partner and their children and sexism is ‘a structuring principle of social policy and welfare provision’ (p. 47). It is encouraging, then, when social workers are seen challenging the disproportionate numbers of women that GPs referred for compulsory admission (Sheppard, 1991).
If women are more often diagnosed with a mental illness but are less likely to be hospitalised it is the opposite for men who are not only more often sectioned but also make up the prison population, where NHWMH recognises that 90% have a diagnosable mental health problem. Suicide rates for men have doubled in the recent period (Mind, 2007).
SOME TENTATIVE CONCLUSIONS – GIVING US AND OUR SERVICE USERS ‘ROOM TO BREATHE’.
The Manifesto issued by SWAN, the Social Work Action Group (Jones et al, 2007) calls on us, as part of ‘a new engaged practice’, to find ways ‘to bridge public issues and private pain’. And perhaps the need for this, and the difficulties, is never clearer than in our work in mental health.
These are tough times. We have seen, first and foremost, the dangers for service users, offered false promises by governments as they become ‘the easy scapegoats in the age of austerity’ (Birrell, 2011, p.42). As social workers, we offer often unrecorded encouragement and support to innumerable service users and carers and we do so often against all the odds. In the face of the pressures of the managerialism, marketisation and medicalisation which marks mental health social work we need to keep saying out loud what we know and what we are seeing. We need to follow the advice to be ‘activists’ and political within our profession, our multidisciplinary teams and the wider communities. We take what is on offer and push for the next step. When governments issue policy documents we agree and argue for their implementation. When there is talk of ‘inequalities and poverty’ we can reframe this as ‘class’, as a determinant of life chances and an analysis of how and why neo-liberalism has arisen in modern capitalism, and also as an agent of change. We will support service users, even when, or especially when, they are opposing cuts and here we have the inspiring examples of groups such as the Black Triangle. We practice ‘cultural competence’ and go on to name institutional racism (and sexism, disablism, ageism and homophobia) where and when it occurs. We do not limit ourselves, and our service users, to the medical dimension of mental health but seek to integrate the social and political aspects of how the system makes us mad.
If this feels too big a step for you personally to take then the default position is to remind ourselves of the theories and skills that we have as social workers. In the example of Peter we identified a humanistic rather than just a medical response to his distress. There was the potential for his story to be honoured and an understanding reached on the way that stigma and racism had brought him to that crisis. And in that process, through what we call narrative approaches or the recovery model or work with Hearing Voices or music groups, that story could help him out of his situation rather than keeping him locked into it.
I recently saw some feedback from a young woman who thanked her worker for giving her ‘room to breathe’. Now we may want more for our service users, and ourselves. We may hope for ‘room to survive and thrive’ but in difficult times ‘room to breathe’ is no bad thing. So we are the ‘quiet revolutionaries’ (McLeod, 1998, p. 240) fighting for every moment we can seize with service users to hear their story, to work with them to see some meaning in their lives. We have to seek not easy answers but to ask difficult questions, to stay with the pain and struggle and righteous anger of those who have been expropriated and, where and if and when, help ourselves and those we work with to recognise they can work within society and see that another life is possible, as is another world.
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