Options and Dilemmas Facing British Mental Health Social Work

Shulamit Ramon
Anglia Plytechnic University, Cambridge, UK

This chapter looks at the options and dilemmas facing British mental health social work in the 21^st century in the light of its past and present.

Mental health social work began in 1920, when the first social worker was appointed to the Tavistock clinic; the second such appointment took place in 1927, to the Jewish child guidance clinic in Hackney (Timms, 1964).

Traditionally social workers followed a psychosocial model of mental health and illness. This was reflected in their preference for a loose psychodynamic approach to mental illness, a strong belief in non-institutionalised and non-medicalised interventions of both psychological and social nature. They took for granted the connections between poverty, social deprivation and mental illness, and accepted by and large the critique put forward by the anti-psychiatry movement in the 60s and 70s of the 20^th century. Most MHSWs (mental health social workers) believed that users were over-medicated, and had doubts concerning the validity of psychiatric diagnosis. Their training would have introduced them to the writing of Boyle (1990) and Bentall (1990) on this issue.

Since the late 1980s, social workers have been influenced by the Social Role Valorisation approach and by the lessons to be learned from child abuse. However, these influences have insufficiently impacted on everyday work with adults, as distinct from the effect they had on working in the field of learning difficulties or with children.

Historically the social work perspective thus offered a contextualised and holistic approach to mental ill health. Most social workers today would not deny the value of medical input in the field of mental health, but would perceive it as a narrow and insufficient perspective. Until the 1980s social work contained a focus on individuals (casework), as well as on groups and communities (groupwork and community work), even if only few workers combined both approaches in their everyday practice.

Social work is clearly affected by political shifts. The ascendancy of the Conservative government to power in 1979 meant the destruction of community work as an integral part of social work. Similarly, the entry of Labour to power in 1997 is reflected in the re-establishment of community development approaches (though not within social work itself), and in symbolic facts such as the one that the social inclusion unit is headed by a social worker, as is Sure Start. At the same time a more punitive approach to offenders meant that training for the probation service has been taken out of social work education by the same government, continuing the wish of the previous one.

Since the second half of the 20^th century the following developments highlight the focus on a contextualised, holistic, psychosocial and empowering, non-biomedical, approach. They include:

• self-directed groupwork, which put together community development with empowerment principles (Mullender and Ward, 1991);
• networking and community care (Trevillion, 1992);
• paying attention to institutional abuse, child and elder abuse, and the strong connection between abuse and mental ill health (Stanley et al, 1999);
• anti-discrimination in its implications for ethnic minorities, disabled people, women and poor people has been a much more pronounced feature of training in social work than in any other helping profession;
• empowerment and participation (Beresford and Croft, 1993, Bray and Preston-Shoot, 1995).
• user involvement in policy making and in research (Barnes and Bowl, 2000, Ramon, 2002)

In terms of practice innovations, there is a long list of innovations initiated by social workers, such as:

1. Establishing attachment of social workers to primary care in a Kentish Town practice (1966). Social workers offered counselling and benefits advice. Although this attachment was judged as successful by social workers, service users, GPs and psychiatrists (Brewer and Lait, 1978), local authorities withdraw social workers from primary care in the early 80s, as this initiative was not regarded as obligatory.
2. Social workers and psychiatrists pioneered the Barnet Intensive Crisis Intervention Service, one of the few holistic services focused on minimising the use of hospitalisation to exist in the country for a long time (1974). While research evidence has amply demonstrated the effectiveness of this service, it did not become a beacon service to be followed, due to its non-biomedical stance. The contribution of social workers to initiating the service and to conceptualising about it (Mitchell, 1993) is hardly remembered or recognised.
3. Social workers at the Family Welfare Association in Tower Hamlet - influenced and supported by George Brown - initiated a project in which isolated mothers became members of groups led by local women in their homes in the early 70s. The organisation provided training, supervision, a budget for refreshments, and a very modest pay to the group leaders. The project was evaluated to be a success, but was discontinued when the political climate changed (Knight, 1978).
4. The Chesterfield Support Network, established by Derbyshire social services in 1982, offers a model of user-run large group and some satellite groups, as well as an individualised advisory service provided by social workers, based in an ordinary community centre used by more than twenty community groups (Hennelly, 1990).
5. The first user policy forum - the Camden Consortium - was established by Iris Nutting, then team leader of Camden social services in Friern hospital in North London (1984). A number of its members have become leaders of the British user movement.
6. Social workers have led the development of the renewed work in the field of domestic violence in the 90s.
7. Social workers have been leading the development of crisis card schemes and direct payments in Britain (Diggins, 2000, Maglijlic et al, 1999).
8. Social workers initiated and led the development of the Building Bridges project, attending to the needs of parents with mental illness and their children in different, and imaginative way (Diggins, 2000).

Yet MHSWs, in line with the rest of social work, has taken an anti-intellectual stance, and viewed educators and researchers as "theorists", perceived as divorced from practice by practitioners. Knowledge and use of research continues to be relatively low among practitioners, though the establishment of SCIE (Social Care Institute for Excellence) at the end of 2001 signifies an attempt to disseminate research and give research a higher profile than before within social care. Educators would argue that their role is to ensure that students need to be prepared for the best available practice as well as for improving it, rather than for the run of the mill workplace. A similar tension exists in nursing.

However, all of these initiatives have been overshadowed by the focus on Approved Social Work in mental health, a role legislated through the 1983 Amendments to the Mental Health Act. The role requires assessing the need for compulsory admission for mental illness and following-up such an admission, while looking for the least restrictive alternatives to hospitalisation, and working closely with family members in certain circumstances. It enables social workers an autonomous position vis a vis other assessors, notably psychiatrists and GPs (Barnes, Bowl, Newton and Fisher, 1990).

From the legislator's perspective social workers replaced relatives in this highly complex role, and were expected to offer a psychosocial perspective to balance the biomedical model brought in by the psychiatrists and GPs. Carrying out such an assessment at the point of intense crisis calls for well developed skills of assessment, thorough knowledge of the law, mental health and community resources, as well as sensitivity to approach users and their family members.

However, several obstacles to meeting the requirements of the role have emerged. These include:

• The tools necessary for psychosocial work - as distinct from psychosocial assessment - were not put there in the first place. The development of less restrictive alternative settings in which people could be looked after in a mental health crisis has been patchy and unsatisfactory in the country as a whole, thus disabling ASWs from fulfilling their obligation in this regard.
• The increasing focus on risk assessment since the early 1990s has led to a further erosion of the psychosocial dimension in the assessment process. This has meant that only risk avoidance has been focused upon, at the expense of risk taking. The ever-present tension within social work between care and control has been tilted significantly in ASW work towards the control end of the range.
• The lack of sufficient numbers of MHSWs, coupled with the legal obligation of local authorities to provide ASW cover, had led to curtailing most of the work which was not directly legislated for in the Mental Health Act, such as:

1. family work;
2. group work;
3. work with people who had mild mental health problems;
4. any type of preventive work.

Social workers wishing to continue the above areas of work in a significant way had to battle with their managers, find alternative sources of funding which would free them from ASW rota for a while, move to part-time work as ASW while working elsewhere on what they believed to be essential psychosocial mental health work, or move to work in the voluntary sector.

Although social workers were initially doubtful about becoming ASWs due to its clear controlling (and potentially coercive) aspect, the role has brought them prestige, higher pay, and enabled them to oppose recommendations for compulsory admission when in disagreement with psychiatrists and GPs (Barnes et al, 1990). All of this is seductive for a profession often treated as an outsider by the rest of the mental health system.

To become an ASW social workers have to undertake a sixty days training programme, followed by five days updating training per year. Performance is assessed by practice teachers and through written assignments.

This needs to be compared to the two days mandatory training for psychiatrists, and ten days for GPs. ASW training is provided by a consortium, some of which are linked to universities and some are not, regulated and monitored by the Central Council of Education and Training in Social Work (CCETSW) until 2002. From 2002 The CCETSW has been replaced by regional training boards (TOPPS), and a General Council of Social Care (GCSC) has become responsible for the registration of social care staff, including social workers.

Training is offered as a mixture of lectures, seminars and supervised practice, in which one hundred and twenty competencies have to be mastered. Yet crucial elements are often missing from this package, such as actively searching for the least restrictive alternative to hospitalisation, methods of working with the Nearest Relative and other family members and friends, advocacy and user empowerment. By now all ASW courses involve service users and carers as trainers, and some also involve them as learners. Likewise, most mental health training modules on the basic qualification for social work engage users and relatives in the training, and place students for supervised fieldwork in user-run organisations. This type of involvement - which can be tokenistic at times, but does not have to be so - is yet to happen in other mental health professions.

For a long time, especially since the first Thatcher government in 1979, social work has been treated as a marginalised professional group within mental health, in part due to its location within local authorities, and in part due to its liberal, "soft" message. This is reflected in the role allocated to it within major policy initiatives such as:

• psychiatric hospitals closure;
• community mental health teams;

Social workers have been the only professional group to be committed to care in the community since the 50s (Ramon, 1985) Although more knowledgeable about communities and care in the community than other mental health profession, they were largely excluded from having an active role in the hospitals closure and resettlement programme, due to the wish of the health sector to retain control of this programme. In some cases social workers felt scapegoated by other staff in the hospitals during the closure process, in retribution for their support of the closure (Ramon, 1992).

Social workers involved in resettlement work have been portrayed by the media as callous and stupid (Wallace, 1985).

Social workers looked forward to community mental health teams collaboration, but also with trepidation to being led by psychiatrists and losing their autonomy in the process. The current co-existence of social workers with CPNs, where leadership of the joint teams alternates, with psychiatrists being marginalised, makes social workers happier.

The verdict is out as to whether collaboration has in fact improved, especially between social workers and health workers, and whether these teams simply pander to "the lowest common denominator", namely the medical model (Galvin and McCarthy, 1994, Onyett and Ford, 1996).

It is also unclear as to whether the mergers of mental health NHS trusts with Social Services teams as from April 2001 have changed much the character of the collaboration. Judging from the Northern Ireland experience of unified health and social care services, social workers stand to lose in autonomy, with no visible gains to either MHSWs or to service users (Campbell, 1998). Will the likely disappearance of social services departments as we know them in the next five years will curtail further the professional autonomy of social workers?

The transfer of the overall responsibility for care management from social workers to psychiatrists in 1995, even though the first group has had a lot more experience of care management, highlighted further the marginality of MHSWs.

BASW has a relatively active special interest group on mental health, responding regularly to policy proposals and sending representatives to various collaborative bodies (e.g. the Mental Health Alliance).

However, unlike its stance in the 70s and 80s, most of its activities have not been proactive, and the group represents only a minority in this branch of the profession. BASW as a whole suffers from falling membership.

Despite its justified credentials for being pro-users, the BASW mental health special interest group not rebeled against the government's draconian policy towards people with anti-social personality disorder. Social workers based in forensic settings have created their own special interest group, reflecting the view that their interests and concerns are apart from the rest of MHSW.

Only one director of social services (but no frontline social worker) was a member of the Experts Committee advising the govenrment on desirable changes in the 1983 Mental Health Act. She has campaigned vigorously for the recommendations of the committee.

The recent focus on mental health promotion and prevention in the context of social inclusion (see Standard 1 of the National Service Frameowrk for Mental Health, 1999) - in which psychosocial factors have a more prominent place - is yet to make its impact on MHSWs or on their policy advisory groups.

The Experts Committee (the Richardson committee, 2000) recommended that not only social workers will carry out the work currently performed by ASWs.

This recommendation has been met with concern and opposition among MHSWs. Some of these sentiments have to do with fears of loss of power and prestige; some with acknowledging that no other profession has the training necessary for providing a psychosocial perspective necessary within compulsory admission work.

I share the second concern, as the largest group of professionals in mental health services - nurses - would need a lot more than sixty days to adopt the knowledge, attitudes and values necessary for applying a psychosocial approach. Nurses would need to be trained by social workers and shadow them in their daily work if indeed they were to follow a psychosocial approach in their assessments.

However, MHSWs should seriously consider that not having the sole responsibility for ASW work would free social workers to use their knowledge and skills more broadly in working with users and their families. This would be more beneficial to users, relatives, social workers, and mental health services in general, as it will bring a psychosocial perspective to the fore. It would constitute one step towards the active reduction of the dominance of the biomedical model in these services by promoting a competing, yet complimentary, model of values, theory and practice.

Existing models of practice of MHSW have been insufficiently influenced by newer and more promising directions of conceptual and practice developments of psychosocial approaches, which include:

• although the strengths approach was developed within social work in the early 90s and most social work students would have been taught something about it, it is not applied in everyday practice (Rapp, 1992);
• the strengths approach is closely related to the focus on social capital and capacity building (Wilkinson, 1996), yet both concepts are hardly explored in MHSW (or in social work in general and throughout the mental health system) and rarely applied in its practice;
• the social disability approach has convincingly argued that disability per se is not a sufficient barrier to having a valued place in society or leading a life of good quality. The able-bodied have created a society which prevents the acceptance of those disabled (Oliver, 1995). The systematic application of this model to mental ill health is yet to happen.
• The strong focus in social work theory and in social work education on structural barriers to the participation of service users as valued citizens has insufficiently permeated MHSW practice, even though it pioneered such participation.

The re-construction of the psychosocial approach needs to take these areas into consideration.

Given this background, MHSWs need to ask where their unique contribution to the field of mental health lies; and how the re-building of a comprehensive psychosocial approach spanning theory, policy, practice and research can be enhanced.

Renewed evidence indicates that it is the quality of the interaction between the individual and the social context which is crucial for their well being (Glouberman, 2001, Duggan, 2002). This re-emphasies the importance of holding to the connections between the psychological and the social, rather than opting for the recent fashion which discards the "psycho" in favour of the "social".

The above indicates that MHSW has a lot to offer to the re-construction of such an approach, but only if this comes with a thorough re-appraisal of the past, moving away from defensive positions, finding allies to work with in this process, and not to wait for others to take the initiative.

To summarise, for most of the period between 1983 and 2000 mental health social workers with adults have been engaged in the process of compulsory admission, risk assessment, care management and now the Care Programme Approach (CPA), ensuring that users obtain their benefits in a system that has not become simpler or easier to work with, some counselling and some joint work with their colleagues in child protection.

Those working in child & family consultation services focused mostly on child protection issues, the arrest and prevention of abuse.

Domestic violence - an area of major innovation led by social workers - has not been part of the agenda of MHSWs; nor have employment and education become part of everyday work with clients.

Most MHSWs are not currently engaged in any user-led activity, group work or community work; the same applies to preventive work, including such work with mothers who suffer from mental illness, even though this group represents a major component of their caseload.

The involvement in legal work - in mental health as in child protection - brought a clear focus and social-professional recognition to mental health social work. The question is at what cost, and whether this is where MHSWs would like to remain in the 21st century.

It seems to me that in terms of the values social work stands for, where its contribution can be most useful for the clients and our society, as well as enabling greater professional satisfaction, MHSW would need to broaden its mandate and move beyond the role of the ASW to more full-scale psychosocial practice.

A number of changes which have taken place towards the end of the 20^th century have brought the psychosocial approach to mental health to the fore. These include:

• the closure of most of our psychiatric hospital and the resettlement of the long stay patients in the community
• the focus of mental health services work has shifted from cure to care
• greater, and more focused, recognition of the limitations of the medical approach in the field of mental health (Breggin, 1985)
• social exclusion and inclusion are socially and politically accepted as essential parameters which impact on service users (if not among the majority of mental health professionals)
• the work carried out by nurses and social workers is becoming more similar in several aspects
• users are more heard and some are more involved in providing an input into service planning, training and research; as well as in running alternative services (Barnes and Bowl, 2000, Sedley, 2000, Ramon, Castillo and Morant, 2001);
• carers have a formal right to being assessed for their own needs and their views are more taken into account by professionals; they have a stronger voice and are more provided with support groups and educational opportunities;
• a much greater emphasis on creating educational and employment opportunities for service users can be observed (Perkins, 1997);
• more and better developed advocacy, direct payment, user and carer networking schemes have become available to service users and carers.

While these shifts have highlighted the need for a solid psychosocial approach, MHSW alongside the other stakeholders in mental health need to consider the following questions:

1. Has the role of the ASW provided what it was supposed to offer?
2. What has been the cost to users, carers, social workers and other members of the multidisicplinary team of the focus of MHSW on ASW work?
3. What should be the re-formulated psychosocial approach, one which takes into account the changes outlined above in values, concepts, issues, and modes of practice?
4. How are we going to achieve a mental health system impacted by psychosocial approaches, including the identification of the barriers and opportunities on the way to this achievement?

To undertake the rethinking MHSWs would need to become:

• more confident of the importance of their contribution and clearer about their current uniqueness in focusing on both the social and the psychological aspects of mental health,
• more updated in their knowledge of the past and the present,
• incorporate the contribution of social workers in areas which are not currently perceived as part of mental health but where the case for their inclusion could be powerfully made need to become part of mental health - such as the work on domestic violence and community work;
• learn and use elements of work currently carried out by other professions or sectors (for example the cognitive therapies, which should be also part of the strategies available to social workers and their clients).
• make use of the knowledge and experience re empowerment accummulated by service users and carers.
• critically examine the relationships between care and control in the work of MHSWs.
• create new alliances across the multi-professional range and with users and carers for the purpose of building a revised, viable, psychosocial approach.

Knowledge of policies and legislation is indispensable in this process, as is the knowledge of conceptual developments, new research methodologies, research findings, knowledge of how organisations change and how practitioners can use such changes positively as well as have a real influence on them in partnership with service users and carers (Ramon, 2000).

This component has been neglected in MHSW (and in social work in general) due to the mixture of a marked anti-intellectual stance and competencies-focused position taken by both employers and practitioners, and for which social work - and its users - are paying the price.

All of the above has considerable implications for training mental health social workers, a topic which deserves a separate text.

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