HPFT Social Work Conference July 2013
“Work with mentally ill people was really a sectioning service … It was very strongly oriented in working mentally ill people towards compulsory admissions and there was little in the way of prevention, little in the way of after-care … the predominantly male MWOs saw their job as controlling and catching ‘mad’ people … they didn’t see their task as curative, rehabilitative or therapeutic care. The general view was that a lot of it was man’s work.”
Rolph et al (2003) drawing on the perspective of a
Mental Welfare Officer in 1968
“It is doubtful whether psychiatric social workers would be willing to undertake the work and it is certain that many would consider that if they came to be associated with the duty of securing the compulsory removal of the mentally sick (which is the essential function of the authorised officer) it would seriously interfere with their primary function of assisting patients to solve their family relationship and other social problems. It may be that this final act of taking away the patient's liberty ought not to involve one who is so vitally and intimately concerned with the treatment of the patient, but should be the duty of someone with a more independent and impartial approach to the problem.”
(Daley 1949)
- To understand the ways in which workers are currently helping young people recovering from psychosis to generate and mobilise social capital
- To develop a social capital intervention model that can be used to frame social work and social care practice
- To evaluate effectiveness and cost-effectiveness of the Connecting People intervention model with adults with mental health problems (below and above 65 years of age) and adults with learning disabilities
- To evaluate the implementation of the intervention model in health and social care agencies
- To gather data in preparation for an RCT
- Intervention model has been adapted for use with adults with learning disabilities and older adults with mental health problems
- Scoping study identified about 18 agencies who are willing and able to implement intervention in the three social care user groups
- 2/3 day intervention training provided to 16 agencies
- 140 new referrals are interviewed at baseline and 9-month follow-up
- Outcomes being measured:
- Social participation (SCOPE, Huxley et al 2012)
- Well-being (WEMWBS, Tennant et al 2007)
- Access to social capital (RG-UK, Webber & Huxley 2007)
- Process evaluation - interviews with service users, workers and managers
- Economic evaluation to measure cost-effectiveness
- Hypothesis to be tested = better fidelity to intervention model will improve outcomes
- Increase focus on social interventions
- Defining, articulating and evidencing
- Decrease reliance on statutory functions as a defining characteristic of MHSW
- Engage with discourses in mental health services to enhance social perspectives in policy decisions - particularly recovery agendas
- Explore creative opportunities with user-led social enterprise and co-produced services in the third sector
- Reduce bureaucracy associated with personal budgets to unlock the potential for creative person-centred care planning
- Consider using asset based approaches and community development models to develop recovery communities
- Challenge service models based on medical paradigms (but PbR care clusters...?)
- Shall we advocate for a return to community social work?
- A third way between becoming therapists or being defined by policy
Where have we come from?
Mental Welfare Officers
- Worked for local authorities and provided community care with very little resources at their disposal
- Lacked professional status and recognition
- Performed statutory functions under Mental Health Act 1959
- Predominantly male
Psychiatric social workers
- Largely based in psychiatric hospitals, but were involved in after-care of discharged patients
- Focus of work was therapeutic, drawing on their psychodynamic training
- Higher professional status than MWOs, but fewer in number
- Predominantly female
Where are we now?
2012 survey
2012 national survey of Approved Mental Health Professionals (n=504, 96% of whom were social workers)
- 55% do not feel valued by their employer
- 40% do not wish to continue as an AMHP or are unsure about doing so
- Only 6% met threshold for burn out on the Maslach Burnout Inventory (Maslach and Jackson 1986), but they were all social workers
- 44% met threshold for common mental disorder (depression and anxiety)
(Hudson & Webber 2012)
2002 survey
Mental health social work
Typology of attitudes about MHSW from interviews with senior mental health social work managers / professional leads (n=50) in London in 2001-2 (McCrae et al 2005)
why?
Traditional
Eclectic
Variables associated with having a common mental disorder, after controlling for confounding factors:
- Younger age
- Larger caseloads
- Higher emotional exhaustion (MBI)
- Higher depersonalisation (MBI)
- Lower personal accomplishment (MBI)
- Feeling less happy about non-AMHP duties
- Not feeling valued by employer
- Feeling unsure about continuing as an AMHP
Interestingly, workload associated with AMHP duties is not associated with common mental disorder
enthusiastic about multidisciplinary teamwork and reducing role demarcation, but keen to preserve the diversity of professional contributions
a traditional view of social work, advocacy and empowerment from a sociological stance, maintaining a local authority base and links to other fields of social work
National survey of mental health social workers (including Approved Social Workers) found high levels of stress, burnout and common mental disorder
- ASWs were more burnt out than mental health social workers without statutory duties and 52% met threshold for probable common mental disorder (Evans et al 2005)
- Mental health social workers had higher rates of common mental disorder than psychiatrists (47% vs. 25%) and were more burnt out (Evans et al 2006).
Generic
subscribed to an inter-disciplinary model, overcoming assumed and statutory role boundaries where appropriate, and working towards a generic mental health practitioner
What does this mean for mental health social work?
What is social work?
MHSW has become subsumed within a bureau-medicalised mental health service and its distinctive contribution is in question (Nathan & Webber 2010)
We argue that its unique contribution means:
- Putting service users at the centre of the profession’s practice and giving them a voice in relation to the dominating institutions in which they live
- Working within dominant institutions (ie mental health services) but taking a position to challenge them alongside service users
- Dual identification with institutions and service users (co-production)
“The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.”
(IFSW Code of Ethics)
Why?
Depression guidelines:
- Stepped care
- Drug treatment
- Psychological therapies
- Social interventions - befriending
Long hours
Schizophrenia guidelines:
- Family interventions
- Social skills training
- Vocational rehabilitation
- Mostly about drugs and psychological therapies
High job demands
“Until social work can assert the value of its unique contribution, its impact on policy and practice will remain weak, and the prospects for a more socially based model in integrated services may be undermined. A lack of evidence as to what mental health social workers actually achieve may hasten their demise.” (McCrae et al 2005)
Low decision latitude
Where we are today...
Not feeling valued
- Mental health social work is largely defined by statutory functions – MHA Act, personalisation, safeguarding etc
- Statutory functions can be given and taken away
- We have not fully exploited our therapeutic potential
- Evidence base for mental health services is defined by psychiatry and psychology through the dominant paradigm of the randomised controlled trial
- We need to provide better evidence about what we do well to influence NICE guidelines, local authorities and mental health services
- We should define mental health social work ourselves
Objections to randomised controlled trials of social interventions in the UK
- Oversimplify causation
- Cannot test complex interventions
- Ignore the role of theory in understanding effectiveness
- Inappropriate where ‘blinding’ is impossible
- Politically unacceptable
- Too expensive
- Unethical because of withholding intervention from control group and experimental research is exploitative
- Good alternatives to RCTs exist
(Oakley et al 2003)
Current position of mental health social work
Connecting People Study aims:
Increasing access to social capital
- Social capital = resources available within social networks
- Inequality in access to social capital because of smaller networks
- Social capital can assist the process of recovery from a mental health problem (Webber 2011)
- Care Bill (2013) emphasizes importance of drawing upon an individual's networks in meeting their care needs
- Personalisation & government MH strategy highlight importance of building community capacity
Connecting People study (1)
Combinative ethnography of social care practice
- Semi-structured interviews, observations of practice and focus groups
- Exploratory, not evaluative
Setting
- NHS mental health services (mental health professionals and support time & recovery workers in early intervention in psychosis teams, social inclusion and recovery services)
- Housing support (supported housing & floating support workers)
- Third sector (social enterprises, voluntary organisations)
Sample
- 150 workers, service users, managers, commissioners
Connecting People study
Untapping our potential
Intervention training feedback
Intervention training reflections
“We are doing this already” – model articulates practice
- “It’s nice to see that we’re doing a good job!”
- “You’re not telling me anything new”
Level of engagement
“In choosing to participate in the study, I felt that it dovetailed very well with the move towards self-directed support and would help social care colleagues to be able to use a model which would guide and inform their practice. I was particularly attracted to the partnership approach to work with clients as this also linked into the recovery model in mental health.
I feel that the intervention helps to enable social workers to identify what they are able to offer in the field of mental health, particularly in relation to developing and enhancing individuals’ circles of support and looking to link in with community resources”
Griff Jones, Social Care Lead, Derby City Council
“There is no way we can implement this” – barriers are predominant
- “We cannot move away from a medical model”
- “Our service users are too unwell, do not want to connect or do not want to change”
- “There are no resources to implement this way of working”
Training was provided to a large variety of different groups:
- Social care workers (professionally unqualified)
- Social workers
- Occupational therapists
- Mental health nurses
Experienced workers can be trained in new approaches, but:
- Must integrate workers’ expertise into the process
- Must provide the ‘big picture’ and show where the training fits in
Training needs to be engaging and fun, but relevant to practice
Sceptical workers can be convinced of its value, unless they decide it’s not for them
Thank you!
"Lets try something new” – open to new ideas
- “We’ll ask our manager to consider setting up a new drop-in”
- “I’m going to see if x and y want to meet up”