RSS Feed for the unit Mental health practice: Bonnyrigg

Introduction

The Open University — Tue, 24 May 2011 13:08:46 GMT

This unit explores a number of issues relating to mental health practice. It starts by helping you define and understand the difference between mental health and mental illness. It also explores the discrimination that can arise when people experience some form of mental distress. You will look at how professionals working within the community can counter some of the effects of discrimination and stigma and contribute to the well-being of the wider community, as well as those who use their services directly.

This unit is an adapted extract from the Open University course Foundations for social work practice (K113)

Original Copyright © 2006 The Open University. Now made available within the Creative Commons framework under the CC Attribution – Non-commercial licence (see http://creativecommons.org/by-nc-sa/2.0/uk/).

Learning outcomes

The Open University — Tue, 24 May 2011 13:08:46 GMT

By the end of this unit you should be able to:

distinguish between mental health and mental illness;
give examples of how community resource centres can benefit the well being of individuals and communities in terms of mental health.

1.1 Introduction

The Open University — Tue, 24 May 2011 13:08:46 GMT

Like many subjects, mental health is complex. This is partly because the language used in discussions about mental health is diverse, can mean different things to different people, and can sometimes be misleading. For example, the term ‘mental health’ is usually used in discussions about just the opposite: ‘mental illness’! There are, however, good reasons for the confusion surrounding its language. One reason is that decisions about what constitutes ‘mental health’, ‘mental illness’, ‘mental disorder’ and so forth are difficult to make and so people often disagree about them. Another reason is that such decisions are also value-laden. For many people, being diagnosed with a mental illness such as schizophrenia or depression is a deeply stigmatising experience. In this section we explore some of the problems with defining mental health.

1.2 Boundaries between mental health and illness

The Open University — Tue, 24 May 2011 13:08:46 GMT

Activity 1: What is mental ‘health’?

0 hours 20 minutes

What do you think it means if someone is described as ‘mentally healthy’? Think of all the different ways of describing ‘mental health’ you can and write them out on one side of a sheet of paper. For example, you might think that ‘feeling happy’ is one of the characteristics of mental health. Next, on the other side of the paper, write down all the different ways of describing people when they are not mentally healthy. As you write this list, consider whether you think that not being ‘mentally healthy’ always means that a person is in some way ‘ill’. Where do you think the dividing line between ‘ill’ and ‘healthy’ is?

Discussion

Like our testers, your first list may have included some of the positive feelings people associate with mental health, such as feeling happy, content, calm or ‘stable’. Your second list might have included negative feelings, such as unhappiness, depression, confusion, distress, fear and anxiety, as well as some of the ‘symptoms’ associated with mental illness, such as ‘hearing voices’. However, you may also have noted that just having negative feelings does not in itself mean that someone can be described as ‘mentally ill’. Equally, you may have considered the idea that someone might feel perfectly well, but be considered mentally ill by those around them because of their behaviour. Furthermore, some of the so-called symptoms of mental illness are, in certain contexts, considered appropriate and ‘normal’. Hearing voices in a religious ceremony, for example, or during a seance, would not necessarily be regarded as out of place. This is what one of our testers said:

The cut-off point between being mentally ill and healthy is somewhat arbitrary as there is a continuum between, for example, being healthy and happy, and unhealthy and unhappy. Illness suggests treatment may or may not be required. I have a health condition which is treatable so I do not see that I am ‘ill’. I am indeed happy and cheerful so consider I am mentally healthy.

It's important to recognise that mental health issues affect everyone in that we all experience a degree of mental distress at some point in our lives, not least through bereavement or other major losses. However, it is also important to acknowledge that there are groups of people who have specific mental health needs at various times, who experience severe distress, and for whom labels can serve an important purpose. Labels such as a diagnosis can be important because they can help to secure access to services, treatment and support when needed.

Anyone who has experienced this illness (and it is an illness) will know what I mean when I say others have no idea how devastating it really is. Everyone suffers from some sort of ‘depression’ at one time or another, but to endure this lingering state for weeks or months on end is totally indescribable.
Read and Reynolds, 1996, p.35

Frequently, I am told that the drugs I take only suppress the illness without curing it. There is, they say, no cure for schizophrenia. And yet the state I am in at present is, I am convinced, as good as a cure. I have a nice home, a good job, no sleepless nights, no disastrous mood swings, no hallucinations, no confused or disordered thoughts.
Jameson, in Read and Reynolds, 1996, p.54

For these reasons, some mental health service users and carers actively prefer the label of ‘illness’, or specific labels such as schizophrenia or depression. In this unit, the use of the term mental illness is usually avoided because it implies that people can be categorised easily and their distress ‘treated’ in the same way as a physical illness, such as diabetes or heart disease. The notion of treatment in mental health is contentious because, while some service users have positive experiences, many others with serious needs have negative experiences of compulsory admission to hospital and treatments such as medication, particularly when they are forced to take them against their will. The issues of power and rights are therefore central to discussions about mental health and illness, as illustrated by this quote from one service user:

I was on [an] intensive ward and I really had bad treatment there, although I was getting the medications on time. One time, one nurse came in the evening and, you know, we have our smoking area where I was smoking, and the nurse tells me to go to my room, you know … And I say ‘I'm not feeling sleepy, I don't wanna sleep – I wanna relax, sit down and smoke, or watch the telly.’ And they said the telly time – the telly have to be switched off by 12 o'clock. I said: ‘Fine, I just wanna sit, I don't wanna go to my room’. He said ‘Go to your room – I'm not gonna say it again – if I say it that last time you're gonna get [an] injection’ … Well I was struggling with them but – you know what I mean – they pulled me down and gave me [an] injection.
Keating et al., 2002

Because there is disagreement about how to define mental health and illness, the figures which attempt to measure the numbers of people who experience mental health problems at any given time vary considerably. One of the most frequently quoted states that one in four adults in the UK will experience some form of mental health problem at some point in their lives. The next information literacy activity focuses on finding out more about how many people experience distress and/or illness.

Activity 2: How many people experience mental health problems?

1 hour 30 minutes

In this activity you will use the PROMPT criteria to find quality information about mental health from a number of websites. You will need to:

examine the PROMPT criteria which can be used to evaluate information;
find information about mental health and the number of people affected by mental health problems from a few organisations' websites;
use the PROMPT criteria to evaluate two of these websites.

You will work through the PROMPT criteria, a useful tool for evaluating the quality of information, using the printable PROMPT table linked below. You will use these criteria to evaluate at least two websites for organisations which support people affected by mental health problems. In looking at the websites you will also have the opportunity to find out more about mental health and the number of people affected by mental health problems.

Click 'View document' below to open the printable PROMPT criteria table.

View document

Visit two websites

Visit two of the following websites:
- Mental Health Specialist Library - National Library for Health
- MIND
- BBC Health: Mental Health
- Mental Health Foundation
- Rethink
Whilst you are looking at your chosen websites, find out as much information as you can about mental health and the number of people affected by mental health problems. Jot down any statistics you come across in the printable PROMPT table, linked above.
Note the different language used, with some organisations focusing on mental illness and others on the broader category of mental health problems.
Evaluate the chosen websites using the PROMPT criteria and complete the table provided.

Discussion

This activity has introduced you to the PROMPT criteria, a tool you can use for evaluating all types of information, whether print or electronic. Having worked through this exercise, you may have found it time consuming and complicated. We are not suggesting that you will need to work through it all in detail each time you have a piece of information to evaluate. As you become increasingly familiar with the questions in the checklist, you will find that you can scan things very quickly and identify their strengths and weaknesses. It is about developing a critical approach which just takes a bit of practice. Poor presentation of a website can have serious consequences, particularly if as a result you can't find the information you want. Did you use the search facilities on the websites you tried? Did you find any of the websites particularly relevant? As you surfed some of the sites you may have noticed the different language used, with some organisations focusing on mental illness and others on the broader category of mental health problems.

Objectivity is a very important evaluation criterion when you are looking at websites. Many websites are owned by people who are selling products or services or who are trying to influence public opinion. The provenance criteria will help you identify whether the owner of the site is likely to have a vested interest in what they are communicating. The method criterion is only for use with research reports and data collection. As you were looking for information on the number of people affected by mental health problems, could you tell how the statistics you found were gathered and how up to date they were? It is easy to assume that all information on the web will be up to date. However, this is often not the case, but it can be quite difficult to find out how often websites are updated. Hopefully, having bookmarked the sites you found particularly helpful, you will use these as an excellent way to keep up-to-date with developments in the mental health field.

1.3 Models of understanding in mental health

The Open University — Tue, 24 May 2011 13:08:46 GMT

Because mental health is such a complex area, it is important that the models of understanding which are applied to it are broader than the ‘biomedical’ one alone, which focuses simply on professional activity and on diagnoses and treatment. The box below provides a quick summary of the biomedical model.

The biomedical model

Health care is seen as medical care, and medical care is seen as:

a quest to conquer and cure disease;
focused on disease more than on the whole person;
concerned with what is normal and what is pathological and making judgements about the boundary between them;
a rational activity based on scientific knowledge that is secured through lengthy formal training.

The biomedical model has been the dominant model in mental health services because the dominant profession in these services has been psychiatry. Psychiatrists are medically trained and therefore tend to see the main purpose behind their work as the diagnosis and treatment of illness or disorder. However, the work of more and more mental health professionals, including psychiatrists, is influenced by much broader models of understanding mental health, particularly social models such as the one described in the box below.

The modern social model in mental health has the following key characteristics:

It is based on an understanding of the complexity of human health and well-being.
It emphasises the interaction of social factors with those of biology and microbiology in the construction of health and disease.
It addresses the inner and the outer worlds of individuals, groups and communities.
It embraces the experiences and supports the social networks of people who are vulnerable and frail.
It understands and works collaboratively within the institutions of civil society to promote the interests of individuals and communities and critique and challenge when these are detrimental to these interests.
It emphasises shared knowledge and shared territory with a range of disciplines and with service users and the general public.
It emphasises empowerment and capacity building at individual and community level and therefore tolerates and celebrates difference.
It places equal value on the expertise of service users, carers and the general public but will challenge attitudes and practices that are oppressive, judgemental and destructive.
It operationalises a critical understanding of the nature of power and hierarchy in the creation of health inequalities and social exclusion.
It is committed to the development of theory and practice and to the critical evaluation of process and outcome.
Duggan, Cooper and Foster, 2002

The social model of mental health places much greater emphasis on the role of networks and communities in maintaining the mental health of individuals. Social isolation is a common problem for people experiencing mental distress and some kinds of mental health services can make a vital contribution towards alleviating this isolation, thereby forming an essential part of the social networks of their service users. To highlight the importance of these issues, this unit next introduces the work of a community resource centre in Scotland which makes a significant contribution to the welfare of local people.

Activity 3: Evaluating reflective writing

1 hour 0 minutes

For this activity you need to evaluate a piece of reflective writing rather than complete any yourself. The five questions below should be used to complete this evaluation.

Have relevant areas of knowledge, skills, values or processes been selected and discussed?
Does the answer show an understanding of the issues and arguments discussed in the course materials?
Does the answer indicate an ability to reflect upon practice learning through the integration of learning from a range of sources?
Is the writing clearly expressed?
Is the organisation of the answer clear and logical, with a clearly expressed, well-evidenced discussion?

Now, use these criteria assess the following piece of writing. For the purpose of this exercise you should correct any mistakes that you find and note any parts which you think are effective. If there are sections which you feel could be written better, then you may wish to suggest a rewording.

Discussion

I have written my comments in parentheses in the box below.

Looking back at my five questions:

Have relevant areas of knowledge, skills, values or processes been selected and discussed?

There is some good evidence of knowledge, but skills, values and processes need to be more explicit.
Does the answer show an understanding of the issues and arguments discussed in the course materials?

Yes – there are some good links.
Does the answer indicate an ability to reflect upon practice learning through the integration of learning from a range of sources?

There is some good reflection and evaluation, but some issues need further discussion.
Is the writing clearly expressed?

Yes.
Is the organisation of the answer clear and logical, with a clearly expressed, well-evidenced discussion?

Some improvements in evidence would be helpful, and a more explicit structure. An introductory paragraph outlining the areas of practice to be evaluated would be useful.

1.4 A community resource centre in action

The Open University — Tue, 24 May 2011 13:08:46 GMT

It is clear that the well-being of communities and the well-being of the individuals within them are intrinsically linked. The Orchard Centre is a community resource centre for people with mental health problems in Bonnyrigg in Midlothian, Scotland.

Figure 1 Services provided by the Orchard Centre

Bonnyrigg is the second largest town in Midlothian and it has a population of approximately 14,500.

Figure 2 Bonnyrigg

You can a see a list of the aims of the Orchard Centre in the box below.

The Orchard Centre aims to:

Provide support for those with enduring mental health problems.
Provide a secure, stimulating environment in which people can feel safe.
Provide a preventative, holistic service which helps people to meet their emotional, social, physical and spiritual needs.
Provide a range of creative and supportive services on an individual, group and community basis to assist people to meet their needs.
Provide a flexible and easily accessed service which is responsive and readily available.
Offer the opportunity to rebuild skills adversely affected by mental health problems.
Support people to live as normal a life as possible.
Promote positive mental health both within the centre and the wider community through education, participation, social interaction, inclusion and empowerment.
Offer respite and support to families and carers.
Contribute to the prevention of hospital admission.

(The Orchard Centre) ©

The Orchard Centre

Figure 3 The Orchard Centre

As you can see from this information, the Orchard Centre explicitly aims to operate beyond the boundaries of the building itself in order to promote positive mental health in the surrounding communities.

Activity 4: Introducing the work of the Orchard Centre

1 hour 0 minutes

Listen to the audio clip below, where Joan, project manager of the Orchard Centre and a qualified social worker, talks about the work of the centre and the values that underpin it. While you listen to the audio, make notes on the following questions. Use the pause button to stop the recording when you need to in order that you will have the necessary time to do this. You might find it helpful to listen to the recording through once before playing it again and making notes:

How do people get referred to the Orchard Centre?
What is one of the main anxieties for those who use the Orchard Centre?
You explored two ‘models’ of explanation for mental health in Section 1.3. Which of these models does the philosophy of the Orchard Centre most closely reflect, and why?
How does Joan explain the stigma that is sometimes associated with the Orchard Centre and its work?

Click play to listen to audio clip (6 minutes).

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Transcript

So far, you have only read and heard about the aims of the Orchard Centre ‘in theory’ or from staff who work there. But what about the people who actually use the service? What do they think? In the next activity you will hear about how service users from the centre experience the work that goes on there, and what their views are on a range of issues.

Activity 5: The Orchard Centre: service user perspectives

1 hour 0 minutes

Listen to the audio clips below, in which Loui, David, Linda and Willie discuss their experiences as users of the Orchard Centre. As in the last activity, try listening to the audio twice, the second time using the pause button to give you extra time to make notes as you listen.

There are five main topics discussed in the audio. To begin with, the four participants discuss their first impressions of the centre and the kinds of volunteer work they have become involved in. They then discuss how they feel the wider community in Bonnyrigg perceives the centre. Loui, David, Linda and Willie then discuss what is meant by a ‘crisis’ in mental health and what they think of crisis services. Following this, they talk about their experiences of the health professionals they have come into contact with, and how the Orchard Centre compares with being in hospital. Finally, there is a brief discussion about advocacy and the importance of having someone to speak up for you.

Click play to listen to audio clip (Part 1, 13 minutes).

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Transcript

Click play to listen to audio clip (Part 2, 14 minutes).

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Transcript

Once you have listened to the audio and made some notes, complete the following activity.

Look again at the aims of the Orchard Centre listed at the beginning of this section. Based on what you have heard from Loui, David, Linda and Willie, to what extent do you think the centre is meeting these aims? The best way of approaching this activity would be to take each of the aims of the centre in turn and provide an example from the audio to show how it is being met.

Discussion

You may have found the evidence on the audio was clearer for some of the aims than others. In any event, it should have become clear even from this brief insight into the experiences of those attending the Orchard Centre that it is meeting its aims to a very great extent.

In some ways, the work of the Orchard Centre can be seen as a form of community work. This is because one of its aims is to ‘promote positive mental health both within the centre and the wider community through education, participation, social interaction, inclusion and empowerment’. We turn now to one of the key concepts within this aim, and that is the concept of ‘empowerment’. You will be exploring this concept alongside advocacy, which is a key social work skill.

2 Social work skills: empowerment and advocacy

The Open University — Tue, 24 May 2011 13:08:46 GMT

Qualified social workers are expected to have the necessary skills to empower service users to participate in assessments and decision making and also to ensure that service users have access to advocacy services if they are unable to represent their own views. The requirement for these skills can be found in the key role ‘Support, representation and advocacy’. Both empowerment and advocacy are concerned with power and the ways in which it is distributed between people. Empowerment and advocacy are also concepts which can be difficult to define, as pointed out in the quotation below:

Empowerment and advocacy are both concerned with a shift of power or emphasis towards meeting the needs and rights of people who otherwise would be marginalised or oppressed. Beyond this generalisation, the concepts of empowerment and advocacy are not simple and as such are almost impossible to define. Where the term ‘empowerment’ is used it often covers a whole range of activities from consulting with service users to involvement in service planning.
Leadbetter, 2002, p.201

Empowerment lies at the very heart of what social work is all about, as demonstrated not only by its place in the key roles for social work, but also by the term's appearance in the definition of social work, as agreed by the International Association of Schools of Social Work (IASSW) and the International Federation of Social Work in 2001:

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 points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.
IASSW, 2001 (emphasis added)

However, while the term ‘empowerment’ is used frequently in social care and social work, there is seldom any detailed explanation of what empowerment actually means and how it can be achieved. In fact, some social workers would argue that empowerment is simply a ‘buzz-word’ that has become popular but which means very little in practice. Others would argue that it is not really possible for people to become ‘empowered’ and that the concept belies the true relationship between professionals and service users, where professionals basically still hold most of the power and are only prepared to share it under certain conditions. How can you measure something like ‘power’ anyway? And is it always possible to tell if someone has more power than somebody else? A major feature of the focus on empowerment in mental health services is the emphasis on service user involvement in services. This involvement can happen at many different levels, as you have seen from the experiences of service users at the Orchard Centre.

A good attempt at a clear definition of empowerment is as follows:

Empowerment aims to use specific strategies to reduce, eliminate, combat and reverse negative valuations by powerful groups in society affecting certain individuals and social groups.
Payne, 1997

Given the evidence of the discrimination experienced by many mental health service users – something you will be exploring in Section 3 – it is easy to see why empowerment should be an important goal for mental health practitioners. But what does good practice in relation to empowerment look like? Barnes and Walker identify one of the principles that should govern good practice as follows: ‘empowerment should enable personal development as well as increasing influence over services’ (1996, p.381). When service providers seek to involve service users, they often do so in order to gain feedback so that they can make changes and improvements to their services. What this principle asserts is that approaches to involvement should also be designed so that service users are personally empowered by the experience. In other words, there should be a two-way, rather than a one-way benefit. A good example of where things can go wrong in terms of involvement is when service users feel that their views have not been listened to or taken seriously, which can have the effect of making people feel disempowered rather than empowered.

If you refer back to your notes from Activity 5, you will see that advocacy was discussed by the service users from the Orchard Centre. One of the most powerful points about advocacy was made in the audio by Willie, who said:

I am actually quite bewildered that it has taken so long for advocacy to take the profile that it has taken on now. I don't see it as being a good idea: it is crucial. How do you expect somebody with a serious mental health issue – where maybe your brain is pickling in cider at the time – to put across clearly what you need? You need somebody that speaks to you, for you, when you are like that. It is essential.

So the essence of advocacy is the notion of someone who speaks for service users and represents their views. Beyond this essentially simple way of seeing advocacy, there are a number of different forms that it can take, as shown in the box below.

Self-advocacy seeks to empower service users to speak up for themselves by expressing their own needs and representing their own interests. This process can enable the service users to regain some control and power over their experience. Many advocacy projects have an explicit goal of consciousness-raising and power sharing for service users (Conlon and Lindow, 1994).
Peer advocacy is a process whereby one person advocates for another who has experienced, or is experiencing, similar difficulties or discrimination. Survivors of the mental health system may be more acceptable advocates for mental health users by being able to show empathy and understanding (Atkinson, 1999).
Citizen advocacy is usually a one-to-one and long-term partnership between a trained unpaid ‘citizen advocate’ and a service user (Brandon, 2001).
Professional or paid advocacy involves a trained paid worker responding to an identified problem, event or change in someone's life. The advocate's support is time-limited (Barnes, 2000).
Quoted in Rai-Atkins et al., 2002, p.5

This list of different forms of advocacy illustrates that it will frequently not be the social worker themselves who can act as an advocate. In fact, although social workers are expected to have the skills required to advocate on behalf of service users, they are frequently in a position which makes it impossible for them to be truly independent and represent only the service users' wishes. This can occur for many reasons, such as when:

They need to act on behalf of more than one family member who have conflicting wishes or interests.
The service user's wishes conflict with the social worker's assessment of what is in the best interests of the service user.
The wishes and needs of the service user are in conflict with the resources available to the social worker, who also has a responsibility to manage public funds and prioritise limited resources.

Consequently, although social workers need the skills of an advocate, they also need the knowledge of how to advise service users to find an independent advocate appropriate to their needs.

Given the discrimination experienced by many mental health service users and the racism experienced by many black mental health service users, advocacy has been seen as having a central role in ‘empowering’ people. The next section takes a closer look at stigma and discrimination and how these can be addressed.

3.1 Understanding stigma

The Open University — Tue, 24 May 2011 13:08:46 GMT

In the first half of Section 3, the focus is on the nature of the stigmatisation and discrimination which can be experienced by people with mental health problems. The section then turns to consider racism in mental health services and the impact this has on black service users.

The ‘stigma’ of mental illness and distress refers to the idea that such experiences are a disgrace or an embarrassment, not only to the person concerned, but also to those around them. To be mentally distressed can sometimes be regarded as a sign of personal weakness or failing, something of a personal flaw. Mental illness is also often regarded as something from which people can never fully recover, and which therefore leaves them ‘tainted’, particularly when someone is diagnosed with an illness such as schizophrenia (Barham, 1997). The first activity in this section provides an opportunity to start thinking about how stigma might be defined by relating it to a media story surrounding the former world heavyweight champion boxer, Frank Bruno.

Activity 6: What's in a name?

0 hours 30 minutes

Spend five minutes writing down all the different words you can think of that are used to describe people who are mentally ill or distressed. Include in your list words that might be considered offensive.

Next, read the two articles about Frank Bruno, linked below. Why do you think there was such an outcry about the original Sun newspaper article? What do you think this story tells us about attitudes towards mental health in the UK?

Article 1: Public condems ‘bonkers’ press coverage

View document

Article 2: The Sun: no longer bonkers?

View document

Discussion

A comment from one tester was:

This article gave a negative view, the use of language was insensitive and portrayed a false image of [mental health service users]; it reinforced the misconceptions around mental health.

A survey by See Me Scotland (2004) found that the stigma associated with mental health issues had prevented 43 per cent of people applying for jobs because of their fear that they would be perceived negatively. Fifty-seven per cent of people in the same survey had actually concealed their history of mental distress when applying for posts.

The decision to conceal such information is perhaps hardly surprising, given the evidence that disclosure of mental health issues does indeed create problems. One survey by the National Schizophrenia Fellowship Scotland found that, whilst 15 per cent of the general public living in Scottish communities had been subjected to some form of harassment, a much higher proportion – 41 per cent – of people with mental health problems had experienced such harassment (See Me Scotland, 2004). This suggests that the ‘care’ in ‘community care’ is not experienced by all groups equally.

Stigma results in many people feeling that they need to keep their difficulties secret from others. This affects all of us because of the evidence that so many people will experience some form of mental distress at some point in their lives. According to a major survey carried out by the Scottish Executive into public attitudes to mental health:

more than two thirds of the large sample interviewed said that someone close to them had been diagnosed with a mental health problem at some point – the most common diagnosis being depression;
over a quarter had themselves been diagnosed with a mental health problem;
a third of those who had been diagnosed with a mental health problem had experienced negative attitudes from other people;
half of all the respondents said that if they developed a mental health problem they would not want anybody to know.
Scottish Executive Social Research, 2002

So, mental health issues and the stigma associated with them are relevant for everyone. In England, the Social Exclusion Unit of the government has conducted an investigation into the experiences of people with a mental illness (Social Exclusion Unit, 2004). The report produced by the unit outlines a sustained programme to improve public awareness of mental health issues and challenge discrimination. Ministers have also agreed that they should analyse complaints made against the media regarding their coverage of mental health issues, and also advise people as to how they can complain about programmes which stigmatise those with mental health problems. This is especially important because the media is by far the biggest source of information about mental health issues for the general public. These reports acknowledge the close link between the feelings of stigmatisation, which are often experienced by people with mental health problems, and discrimination.

Activity 7: Discrimination and mental health

0 hours 20 minutes

Make a list of the different ways that people who experience mental distress might encounter discrimination. You might want to draw upon your own personal experience or that of those close to you, or you might consider your professional experience with people who have used mental health services. As you create your list, think about why you think this kind of discrimination occurs.

Discussion

Your list is likely to have included some or all of the following areas, and you may well have thought of others:

People who have experienced mental distress may be less likely to have the same access as other people to employment opportunities.
They may be less likely to get promoted at work.
They might be considered unsuitable tenants when seeking housing.
People with a history of mental illness or distress may receive less favourable treatment in terms of accessing resources and services, such as insurance, mortgages and other financial arrangements.
They can experience difficulty when seeking treatment for physical health problems.
Young people with mental health problems can be discriminated against in terms of educational opportunities, such as gaining a place at university.
People with mental health problems can be wrongly assumed to pose a risk of violence to others.

When you considered the possible reasons for this kind of discrimination, you may well have included the fear and misunderstanding that surrounds mental illness and the negative attitudes that are often associated with it.

Evidence from surveys conducted in Scotland and elsewhere in the UK confirms that discrimination against people with mental health problems is indeed a serious problem. At the most extreme end of the scale, a survey by See Me Scotland (2004) found that 16 per cent of people with direct experience of mental health problems had been physically abused or intimidated at work, and 21 per cent had been verbally abused. In the vast majority of these cases, it was managers who were responsible. Thirty per cent of people in the survey felt that they had been turned down for employment because of their mental health problem. People who already experience discrimination on grounds such as race face an even greater risk that they will not receive equal rights when they experience mental illness, not only in terms of employment opportunities but also within mental health services themselves. Not only do these findings have important moral and ethical implications in terms of the rights of the individuals concerned, there are also important social and economic implications arising from them.

The ‘see me’ research shows that many people who have experienced mental ill-health do not enjoy equal rights in the workplace. People's attitudes and lack of awareness are at the root of the problem. Losing skilled and experienced individuals from the workforce is the last thing most employers want at a time when organisations across Scotland are struggling to recruit and retain staff.

My bosses spent 12 months trying to force me to leave and the only contact they made with me was to tell me my absence was costing money, it was too far to come and see me face to face and that I shouldn't have applied for the promotion to manager.
See Me Scotland, 2004

Evidence on discrimination against people with mental health needs, particularly in the workplace, has not gone unchallenged. See Me Scotland is running a series of publicity campaigns together with employer organisations to publish the results of its findings and to raise awareness of the problem. Also of great concern are the particular kinds of discrimination faced by black service users, who experience racism as well as discrimination because of their mental health needs.

3.2 Racism in mental health services

The Open University — Tue, 24 May 2011 13:08:46 GMT

Research has shown that people from particular minority ethnic groups are over-represented in some psychiatric diagnostic categories compared with others. One of the most hotly debated issues concerns what appears to be the relatively high number of African-Caribbean men who receive a diagnosis of schizophrenia, compared with white or other minority ethnic groups. Given what you have seen about the difficulties in defining mental health and illness, it will be no surprise to learn that the diagnosis of schizophrenia is problematic in general. However, just as worrying is the over-representation of African-Caribbean men in terms of the kinds of services they are likely to receive once they become mentally distressed. They are more likely than other groups to be forced into services against their wishes, for example through compulsory admissions to hospital. Once in hospital, they are more likely to be physically restrained by staff and to receive particularly high doses of powerful medication. A tragic example of such experiences was the death of David ‘Rocky’ Bennett whilst under restraint in hospital in 1998.

(Recommendations, The Independent Inquiry into the Death of David Bennett, Norfolk, Suffolk and Cambridgeshire Strategic Health Authority) ©

Recommendations, The Independent Inquiry into the Death of David Bennett, Norfolk, Suffolk and Cambridgeshire Strategic Health Authority

Figure 4 Inquiry report into Rocky Bennett

The following quote is an extract from the strongly critical statement made by the official panel of inquiry into Rocky's death.

There have been many conferences, consultations and papers written during the last twenty years about the problems that the mental health services face. Some of these have dealt with the problems experienced by the Black and Minority Ethnic communities. Time and again regrets at the existing state of affairs have been expressed. Time and again promises of improvement have been made. While it would be unfair to say that nothing has happened, it is true to say that not very much and certainly not enough has happened. Unless there are sufficient resources and sustained management, which is both dedicated and committed, these problems cannot be solved. At present people from the Black and Minority Ethnic communities, who are involved in the mental health services, are not getting the service they are entitled to. Putting it bluntly, this is a disgrace. The NHS is national. Final responsibility lies fairly and squarely with the Department of Health. Other institutions may advise and may contribute to what should be done. But, individually or collectively, they have little power to require that changes be made. We are told that the Department of Health is determined to carry out the necessary improvements. We very much hope that this time they will. But, in view of the history we reserve judgment about whether this time these good intentions will be translated into action and that that action will be sufficient to cure this festering abscess, which is at present a blot upon the good name of the NHS.
(Blofeld, 2003)

The fact that black and minority ethnic people generally have a much poorer experience of mental health services than their White counterparts has been endorsed in a report from the National Institute for Mental Health in England (NIMHE) called Inside Out: Improving Mental Health Services for Black and Minority Ethnic Communities in England. In its statement of underlying values and principles, NIMHE highlighted the following:

We must begin by acknowledging the problems of mental health care as it is experienced by Black and Minority Ethnic groups:
that there is an over-emphasis on institutional and coercive models of care;
that professional and organisational requirements are given priority over individual needs and rights;
that institutional racism exists within mental health care.
To change this it is essential to place progressive community based mental health at the centre of service development and delivery. Those who use mental health services are identified, first and foremost, as citizens with mental health needs, which are understood as located in a social and cultural context.
Department of Health, 2002, p.7

In terms of explaining some of the negative patterns in the way services operate, one powerful argument presented in some studies is that black people are less likely than their white counterparts to seek support voluntarily from services. Because many black people have such poor experiences of mainstream services, they are less likely to seek and benefit from support during the early stages of their experience of mental distress, for example, through their GP. When they do eventually come into contact with mental health services, they are therefore more likely to do so because they have become very distressed. Consequently, there are ‘circles of fear’ in operation, where mutual distrust has built up between many black and minority ethnic service users and the mainstream services that are supposed to meet their needs (Keating et al., 2002).

As you can see from the statement from NIMHE above, community-based mental health now occupies a central place in terms of achieving change. An indepth analysis of the general role of communities and social networks is outside the scope of this unit. Instead we are going to look more closely at the role of social workers in multidisciplinary teams in community-based mental health services.

4.1 Mental health specialists

The Open University — Tue, 24 May 2011 13:08:46 GMT

Social workers are often regarded as the chief proponents of the social model of mental health. Because of the value-base of social work, they are also often seen as being in a strong position to challenge inequality and address the consequences of stigma and discrimination in mental health. In this section you will see how other professionals are increasingly expected to emphasise similar goals in The Ten Essential Shared Capabilities for mental health professionals.

As well as the need for all social workers to have knowledge and skills in mental health, some social workers choose to specialise further so that they acquire a more in-depth level of knowledge about mental health/illness and can take on more specialised roles within mental health services. One good example of a specialised role is that of Mental Health Officer in Scotland (known as Approved Social Worker in England and Wales at the time of writing). Mental Health Officers are qualified professionals employed by a local authority who have undertaken specialist training under appropriate legislation. This training enables them to have substantial powers alongside other professionals, for example to assess someone with a view to making an application for admission to hospital. While these statutory powers are clearly a very important part of the role undertaken by many social workers who specialise in mental health, they make up only a tiny part of what these social workers do on a day-to-day basis.

The roles that mental health social workers undertake have changed considerably over the past twenty years, particularly since the implementation of the NHS and Community Care Act 1990. This Act resulted in an increase in the range of settings in which people with mental health problems are to be found. In simple terms, Community Care legislation resulted in a rapid shift from an emphasis on hospital-based care to care in community-based services such as day hospitals and day centres, supported accommodation, and user-led drop-in services. The graph below provides a graphic illustration of these trends in Scotland and gives you a good idea of the speed and extent of the changes.

(The balance of care for people with mental heath problems, 1980–2002; Scottish Community Care Statistics (2002). Scottish Executive. Crown copyright material is reproduced under Class Licence Number C01W0000065 with the permission of the Controller of HMSO and the Queen’s Printer for Scotland) ©

The balance of care for people with mental heath problems, 1980–2002; Scottish Community Care Statistics (2002). Scottish Executive. Crown copyright material is reproduced under Class Licence Number C01W0000065 with the permission of the Controller of HMSO and the Queen’s Printer for Scotland.

Figure 5 The balance of care for people with mental heath problems, 1980–2002

For most social workers who specialise in mental health, their work now centres on assessing the needs of service users, formulating care plans to meet these needs, and either directly providing appropriate help and support or ensuring that it is provided by others. These tasks are normally carried out within the context of a multidisciplinary team, in which social workers work closely alongside other professionals. Known in mental health services as the Community Mental Health Team (CMHT), these groups of professionals are at the forefront of the delivery of services in the community for people who have been diagnosed with a mental illness and/or assessed as having specific mental health needs. CMHTs are expected to perform the following main functions:

advise other professionals such as GPs on the management of mental health problems;
provide care and treatment for those with mental health problems which are likely to be resolved within a certain timescale (‘time-limited’ disorders);
provide care and treatment for those with more complex and enduring mental health needs.
Department of Health, 2002

The exact way that CMHTs are organised and managed, and the kinds of professionals that work in them, vary quite widely. However, generally speaking, you could expect a CMHT to include the following kinds of professionals or some combination of them:

social workers
support workers (including ‘STR’ workers: Support, Time and Recovery)
community psychiatric nurses
psychiatrists
mental health officers / approved social workers
occupational therapists
clinical psychologists
team manager
students.

Activity 8: Understanding professional roles

0 hours 45 minutes

Do you know what each of the professionals listed above actually does and the qualifications or background they have? This activity helps to ensure you fill any gaps in your knowledge or refresh the knowledge you already have. Spend some time looking up definitions of the occupations above, either in books by setting aside some time in a library, or via the internet if you prefer. You may well have come across relevant information for this activity from Activity 2. In any event, make sure you have basic knowledge about each of these occupations.

Discussion

One of the distinctions that can be made between the different professionals listed above is between those who have received medical training and those who have not. This is particularly important when bearing in mind the discussion about models of understanding in mental health in Section 1.3. Traditionally, the biomedical model of understanding mental health is associated with psychiatry and nursing, while social models have been linked with social work and other social care workers. This distinction has been used to explain much of the conflict which takes place between members of inter-disciplinary teams, particularly social workers and psychiatrists (Miller, Freeman and Ross, 2001).

4.2 Essential shared capabilities for mental health

The Open University — Tue, 24 May 2011 13:08:46 GMT

While professional groups will be expected to retain their distinctive roles to some extent, the demand for change is increasingly strong. Professionals are increasingly expected to focus on the range of elements of good practice which they share, many of which have been historically associated with social work. One important example of the demand for change in this direction can be found in the introduction in England of The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce (National Institute for Mental Health in England and Sainsbury Centre for Mental Health, 2004). You can see a summary of the ten capabilities in the following box.

The ten essential shared capabilities for mental health practice

Working in Partnership. Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks. Working positively with any tensions created by conflicts of interest or aspiration that may arise between the partners in care.

Respecting Diversity. Working in partnership with service users, carers, families and colleagues to provide care and interventions that not only make a positive difference but also do so in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality.

Practising Ethically. Recognising the rights and aspirations of service users and their families, acknowledging power differentials and minimising them whenever possible. Providing treatment and care that is accountable to service users and carers within the boundaries prescribed by national (professional), legal and local codes of ethical practice.

Challenging Inequality. Addressing the causes and consequences of stigma, discrimination, social inequality and exclusion on service users, carers and mental health services. Creating, developing or maintaining valued social roles for people in the communities they come from.

Promoting Recovery. Working in partnership to provide care and treatment that enables service users and carers to tackle mental health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any mental health problem.

Identifying People's Needs and Strengths. Working in partnership to gather information to agree health and social care needs in the context of the preferred lifestyle and aspirations of service users, their families, carers and friends.

Providing Service User Centred Care. Negotiating achievable and meaningful goals; primarily from the perspective of service users and their families. Influencing and seeking the means to achieve these goals and clarifying the responsibilities of the people who will provide any help that is needed, including systematically evaluating outcomes and achievements.

Making a Difference. Facilitating access to and delivering the best quality, evidence-based, value-based health and social care interventions to meet the needs and aspirations of service users and their families and carers.

Promoting Safety and Positive Risk Taking. Empowering the person to decide the level of risk they are prepared to take with their health and safety. This includes working with the tension between promoting safety and positive risk taking, including assessing and dealing with possible risks for service users, carers, family members, and the wider public.

Personal Development and Learning. Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one's self and colleagues through supervision, appraisal and reflective practice.

Department of Health (2004), The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce. Crown copyright material is reproduced under Class Licence Number C01W0000065 with the permission of the Controller of HMSO and the Queen’s Printer for Scotland.

The ten shared capabilities now form the basis for the education and training for all mental health professionals in England and Wales, regardless of their occupational group or discipline. Such a trend towards an emphasis on shared capabilities between professions is to be found throughout the UK. Therefore, they form the foundations for practice in relation to mental health for your training as a social worker. Notice how similar these capabilities are to what is regarded as good practice in social work. For some commentators, this kind of development represents a threat to the very survival of social work in mental health services because it begs the question, if all professionals are practising in ways which have traditionally been associated with social work, why do we still need social workers? As two social work academics have put it:

If it is to survive, mental health social work will need to define and communicate what is unique and valuable in its contribution to mental health services […]
Stanley and Manthorpe, 2001, p.96

The changes in policy and legislation that are taking place in the twenty-first century mean that the contribution made by social work as a profession, and by individual social workers within CMHTs and other settings, is as important now as it has ever been. Most importantly though, social workers will need to find ways to articulate to others what is valuable about what we do, something we have not been very good at in the past, as the quotation above suggests.

5 Conclusion

The Open University — Tue, 24 May 2011 13:08:46 GMT

This unit has picked up on a number of key themes relating to mental health practice. For example, you have considered the effects of discrimination that can arise when people experience some form of mental distress. It has also highlighted the stigma that is frequently experienced by mental health service users and the way this stigma can act as a barrier to receiving appropriate support, resulting in people becoming increasingly isolated and even more disadvantaged. The unit has also explored how community-based resources and the professionals working within them can counter some of the effects of discrimination and stigma and contribute to the well-being of the wider community, as well as those who use their services directly.

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References

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Barham, P. (1997) Closing the Asylum: The Mental Patient in Modern Society, London, Penguin.

Barnes, M. and Walker, A. (1996) ‘Consumerism versus Empowerment: a principled approach to the involvement of older service users’, Policy and Politics, 24 (4) pp.375–93.

Blofeld, J. (2003) Independent Inquiry into the Death of David Bennett, Cambridge, Norfolk, Suffolk and Cambridgeshire Strategic Health Authority.

Brown, A. (1992) Groupwork, Aldershot, Arena.

Cosis Brown, H. (1998) Social Work and Sexuality: Working with Lesbians and Gay Men, London, Macmillan.

Coulshed, V. and Orme, J. (1998) Social Work Practice, Basingstoke, BASW and Palgrave.

Department of Health (1998) Quality Protects: Framework for Action Plans, London, HMSO.

Department of Health (2002) Mental Health Policy Implementation Guide: Community Mental Health Teams, London, Department of Health.

Duggan, M., Cooper, A. and Foster, J. (2002) Modernising the Social Model in Mental Health: A Discussion Paper, London, SPN and TOPPS.

Goldberg, D.P. and Huxley, P.J. (1992) Common Mental Disorders: A Biosocial Model, London, Routledge.

International Association of Schools of Social Work (IASSW) (2001) ‘International Definition of Social Work’. Available from: , accessed 24 June 2008.

Jackson, S. and Martin, P.Y. (1998) ‘Surviving the care system: education and resilience’, Journal of Adolescence, 21, pp.569–83.

Jameson, R. (1996) ‘Challenging Loss of Power’ in Read, J. and Reynolds, J. (eds) Speaking Our Minds: An Anthology of Personal Experiences of Mental Distress and its Consequences, Basingstoke, Palgrave.

Keating, F., Robertson, D., McCulloch, A. and Francis, E. (2002) Breaking the Circles of Fear: A Review of the Relationship Between Mental Health Services and African and Caribbean Communities, London, Sainsbury Centre for Mental Health.

Leadbetter, M. (2002) ‘Empowerment and Advocacy’ in Adams, R., Dominelli, L. and Payne, M. (eds) Social Work: Themes, Issues and Critical Debates, Basingstoke, Palgrave in association with the Open University.

Miller, C., Freeman, M. and Ross, N. (2001) Interprofessional Practice in Health and Social Care: Challenging the Shared Learning Agenda, London, Arnold.

Payne, M. (1997) Modern Social Work Theory, Basingstoke, Palgrave/Macmillan.

Rai-Atkins, A., Ali Jama, A., Wright, N., Scott, V., Perring, C., Craig, G. and Katbamna, S. (2002) Best Practice in Mental Health: Advocacy for African, Caribbean and South Asian Communities, Bristol, The Policy Press and Joseph Rowntree Foundation.

Read, J. and Reynolds, J. (eds) (1996) Speaking Our Minds: An Anthology of Personal Experiences of Mental Distress and its Consequences, Basingstoke, Palgrave.

Scottish Executive Social Research (2002) Well? What do you think? A National Scottish Survey of Public Attitudes to Mental Health, Well Being and Mental Health Problems, Edinburgh, Scottish Executive.

Social Exclusion Unit (2004, June) Mental Health and Social Exclusion, Social Exclusion Unit Report Summary, Wetherby, ODPM Publications.

Social Exclusion Unit (2004) Action on Mental Health: A guide to promoting social inclusion, Wetherby, ODPM Publications.

Stanley, N. and Manthorpe, J. (2001) ‘Reading mental health inquiries’, Journal of Social Work, 1, pp.77–99.

Acknowledgements

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Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 Licence

Grateful acknowledgement is made to the following for permission:

Text

Section 4.2: Department of Health (2004), The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce. Crown copyright material is reproduced under Class Licence Number C01W0000065 with the permission of the Controller of HMSO and the Queen’s Printer for Scotland.

Figures

Figure 3 The Orchard Centre;

Figure 4 Recommendations, The Independent Inquiry into the Death of David Bennett, Norfolk, Suffolk and Cambridgeshire Strategic Health Authority;

Figure 5 The balance of care for people with mental heath problems, 1980–2002, Scottish Community Care Statistics (2002). Scottish Executive. Crown copyright material is reproduced under Class Licence Number C01W0000065 with the permission of the Controller of HMSO and the Queen’s Printer for Scotland.

Audio Materials

Unit image

The Orchard Centre

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