Within my assignment I will demonstrate my understanding of mental health and the direct correlation to my professional practice. I will clearly define and critically evaluate two of the dominant perspectives which are significant in mental health theory and practice, the biomedical and the social causation perspective. By explaining my practice with regards to the case scenario 1 – Ahmed, I will substantiate my understanding of both perspectives, examining the advantages and disadvantages of each by considering how I might undertake and assessment and how I might address issues identified from the case scenario including the impact of discrimination and the importance of anti oppressive practice. I will evidence my knowledge and understanding of relevant issues including reflecting the perspective of the individual, by drawing up an intervention plan, including identifying clearly my understanding of the legal framework within which I would practice.
Issues of mental health are approached from a variety of different perspectives and using a variety of different terminologies. Many have the greatest confidence in scientific or biological approaches, whilst others prefer more holistic or social approaches.
The biomedical medical model of mental health has been dominant simply because the dominant profession is 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 (Rogers and Pilgrim,2005).The simplistic view of cause and effect whilst beneficial if you have broken your leg or have diabetes, is not the same for mental illness. There are organic brain diseases or illnesses such as epilepsy and huntingdon’s chorea which may manifest in symptoms often associated with mental illness (Rethink,2007) and therefore it is vital that the possibility of underlying physical causes are examined. The bio medical model utilises ideas of a single underlying cause and therefore treatment of the cause will lead to a return to the pre existing state(Wade and Hallingan,2004).Another assumption is of a normal existing state, and therefore an ability to measure evidence of abnormality thus concluding with a diagnosis. Traditional bio medical models focus on the pathology of the illness rather than understanding the illness whether it is biological, social or psychological.
Criticism of the biomedical model is that it is a simplistic model in a very complex arena. Reductionist explanations of mental health reduce mental health issues to the smallest possible factors, simplistic but clearly flawed (Crossley,2006). One of the most predominant arguments is the involvement of environmental factors in shaping our behaviour. A person’s environment can shape their behaviour and this is a constant process. An individual may be born with certain genes but environmental factors such as society and a person’s family can shape further behaviour (Nettleton, 2006). In reducing a concept to its component parts and simplest terms many important aspects are overlooked. Individual factors are hard to explain under reductionism, because reductionist explanations generalise behaviour. Each individual is unique and responds differently. A reductionist explanation would be genetics, but the same behaviour in two people could be caused by separate environmental and biological factors and therefore limiting the reductionist explanation (Crossley,2006). Reductionist explanations can be useful, by reducing complicated concepts to their component parts but sometimes this offers a simple solution to an otherwise more complicated problem. For example giving anti-depressants to someone who is depressed may seem like the most favourable solution, but this may overlook the real problem such as bereavement, financial or work problems.
Iatrogenesis is another arena that is problematic for the bio medical model. Iatrogenisis is often associated with adverse effects resulting from medical interventions (Heller et al, 1996) but can and is viewed as the direct result of the intervention which impedes a person’s recovery, and therefore could include psychiatry which is the predominant force in the bio medical model. Labelling with regards to mental health diagnosis is another criticism of the bio medical model. Scheff (1999) understands mental illness as a result of societal labelling. Simplistic put, society has views on what is socially norm and acceptable, any deviation from these norms, results in a label of mental illness.
The social causation model suggests links between social disadvantage and mental health problems. These social disadvantages are prevelant in many areas – education, health, employment, income and social inclusion. Poverty and social class have been determined as the two significant factors of social causation and the link to mental illness (Murali and Oyebode, 2004). Lynch et al (1997) found people living with financial difficulties on a long-term basis, were much more likely to suffer from clinical depression than those who did not. Studies into mental health suggest there are stressors associated with low status and this creates an environment for increased risk of developing mental health problems. Payne(1999) in the 1999 PSE study provides evidence that people who live with various aspects of poverty, deprivation, unemployment and social exclusion are more likely to have mental health problems, although the relationship between poor mental health and these aspects are complex. I will examine employment in more detail.
Research shows that less than 40% of employers would consider employing a person with a mental health issue (Rethink, 2009).Consequently the prejudice and discrimination people face as a result of a mental health diagnosis presents problems in itself. In 2002/ 2003The Citizens Advice Bureau conducted research regarding social exclusion and mental health and their results were stark. 60% of people with mental health problems gave up work as a result of discrimination, prejudice and stigma. 61% per cent of male adults with a psychiatric disorder are in full-time or part-time employment. Whereas the figure is 75% of men with no psychiatric disorder (Mind,2010b). If an individual has maintained a job or found employment then if they are affected by relapses this again impacts financially. With these statistics in mind it is clear to see that many who experience mental health issues will also be affected by economic hardship. Living on state benefits and sometimes less, as a result of an inflexible benefit system, can also result in a vicious circle of deprivation and poverty in all aspects of their lives, not only economic but in health, social activity and participation.
The social causation model defined within the social model needs to be understood by practitioners as it acknowledges the experiences of individuals, as well as being the springboard for challenging the socio political environment which contributes to social problems, which in turn impact on an individual’s mental health. This is fundamental for practitioners as one of the key roles of social workers is to challenge and champion social and political change (Horner,2006).According to Rogers and Pilgrim (2006) race, gender and age are all areas of disadvantage than can be investigated via social causation. This would support the findings of several studies which highlight the relationship between some of the identified areas and poor mental health. Examples to illustrate these links are, Irish men have three times higher psychiatric admission rates than the general population (Fitzptrick, 2005); women are more likely to be treated for mental health problems than men (Mental Health Foundation, no date) and in research by Beecham et al (2008) it was identified that fewer than 10% of older people with clinical depression were referred to specialist mental health services compared with about 50% of younger adults. These stark differentials question the basis of these statistical differences and one explanation is social causation.
In recent years there has been a shift in Mental Health legislation. Although the Mental Health Act 1983 remains the primary legislation, there has been the addition of the Mental Capacity Act 2005 which provides a legal framework to protect individuals who lack, or may lack capacity. The Mental Health Act 2007 amended the MHA 1983 and the MCA 2005. Along with these amendments to legislation there has also been a radical shift in policy documents from central Government. These policy shifts demonstrate the need to understand mental health in a more holistic context. The emphasis is shifting from purely medical perspectives with a recognition of how the social perspective has an impact on a person’s mental health well being. A plethora of policies from government such as Tackling Health Inequalities (DOH, 2001); Working Together – UK Action Plan on Social Inclusion(DWP, 2008) and Child Poverty Review(H.M. Treasury,2004) have been designed to tackle social inequalities such as health, income, work and education as well as a recognition for the need for more person centred approaches to delivering services. This does not detract from the clear message from legislation that risk and public safety are of paramount importance. The debates about care or control and rights versus risk are ever present particularly with high profile cases such as Christopher Clunis and Michael Stone were pivotal in the changes to the Mental Health Act in 2007. The Mental Health Alliance (2006) maintain that legislative reforms which enables individuals to access services within the mental health arena when they need it, as opposed to imposing treatment, would be a more viable option and address the issue of risk in a more proactive way.
The Mental Health Act 1983 still remains the overarching legislation regarding mental health in the England today and is the only piece of legislation that permits the detention of an individual before they have committed an offence and purely on the basis that they might pose a threat to themselves or others(Golightly,2008).The changes in 2007 allowed for approved mental health professionals rather than the traditional approved social workers. One could argue that if this is eradication of the social worker role and the move to further medicalise mental health (as the approved mental health professional can be health background rather than social care).
The Mental Capacity Act 2005 might be viewed by some as contradicting the Mental Health Act 1983. After all a person suspected of having a mental illness may fulfil the section 3 test of capacity under the Act, and under the principles of the act is able to make unwise decisions, but the Act makes no stipulation regarding these unwise decisions. Clearly committing a criminal offence is an unwise decision and a person committing the offence could clearly know and understand their action and face consequences laid down under criminal justice legislation. Under the Mental Health Act a person is not required to have committed an offence to be detained, a suspicion of possible harm to self or others is enough to warrant a section 2 assessment for involuntary admission. This arena has been addressed with and the Mental Capacity Act 2005 amendment to the Mental Health Act 1983 whereby an individual cannot refuse treatment if that treatment is deemed necessary under the conditions of the Mental Health Act in that the MHA effectively overrides the MCA if the person is or deemed to be mentally ill. This is a contradiction regarding any other forms of medical treatment for a physical condition such as treatment for cancer or radical surgery(if a person meets the capacity assessment criteria), a person can refuse treatment for any other physical health condition but not for mental illness as a person can be detained to compulsory treat.
New Horizons is a cross government programme which was launched in 2000 which identified not only the need of improved mental health services but the recognition the importance of maintaining good mental health and well being for everyone and covers childhood to old age (DOH,2009). It clearly recognises the impact of social factors aiming to address social inequalities identifying health, education and employment as important factors in an individual’s well being and the impact on mental health.
The Mental Health Act 1983 is the primary legislation which covers the assessment, detention, treatment and rights of people with a mental health condition. Following the psychiatric model the practitioner would need to make an assessment of Ahmed’s functioning identify the signs and symptoms which he is exhibiting – for Ahmed these would be his day to day functioning – he has rent arrears, utilities have been cut off; personal care – evidence suggests he lives on takeaways; social functioning – he is a loner and he goes into the town centre shouting apparently aggressive; thoughts – he appears to be having delusions that his mother is not his real mother, and possibly hallucinations – evidenced with him shouting, but not directed at anyone. The psychiatric model uses judgements of “normal” which are not objective, but on agreed standards of normal within a cultural and social context (Esyenck,1994 and Giddens,1997). But the question has to be who is the predominant force in that society and how does this impact on individuals from differing cultural backgrounds in the teat of normality. Although the case study has not specified Ahmed’s cultural background it is an area which needs due consideration.
There are discussions regarding psychiatry as being “colour blind” and “culture blind”. Fernando(2002) examines the rationale for these concepts in relation to hearing voices, and explains perhaps cultural stereotypes which do not consider multi cultural dimensions are responsible. Fernando(2002) draws upon the studies relating to high proportions of British African Caribbean men being labelled as aggressive, perhaps due to the appearance or interpretation of symptoms leading others to define the symptoms within the mental health arena (Nazroo and King, 2002). Fernando (2002) expounds further by explaining this could also be related to society norms. The norms are dictated by the predominant forces within society. When individuals do not conform to social norms they are subject to sanctions in order to ensure conformity – this is evident within the legal justice system a person commits a crime a punishment a fine or community service order or prison sentence is served. The parallels for mental health could be seen that if a person does not conform then admission to hospital, intervention and treatment may be viewed as the sanctions to deviating from those perceived norms. Risk management is a highly politicised area with the primary objective in the political arena to manage risk, whilst improved outcomes for individuals appears to be in secondary (Holloway,1996). Holloway(1996) goes on to say in order to understand and therefore manage the risk then as a practitioner you need a very detailed understanding of the individual. Good practice regarding risk management is about a clear foundation for the decision and an expectation for the proposed outcome, as well as provision for change if the intended outcome does not occur (Petch,2001).
A discussion with Ahmed regarding voluntary admission for assessment and treatment would be deemed appropriate given the assessment. The Mental Health Act 1983 clearly states in section 131 that voluntary admission should always be used if the person is willing. Should Ahmed resist treatment and admission to hospital then it would be necessary to address the need for detention under section 2 of the act. This provision is made with the agreement of 2 doctors ideally one who knows Ahmed perhaps his GP, and an approved mental health professional (AMHP). Under the Mental Health Act 1983 section 2 allows involuntary admission to hospital for assessment and treatment. Under section 2 Ahmed does not have the right to refuse treatment. Once Ahmed is admitted to hospital then assessment for a diagnosis would be paramount.
The two diagnostic and classification tools used in modern psychiatry are the DSM IV codes and ICD 10 codes (Bolton, 2008). Although there are differences in these codes, the premise for these codes and outcomes are the same. These codes represent the bio medical model, the reduction of the illness to signs and symptoms to which a psychiatrist can determine a diagnosis and treatment based on that diagnosis. Whilst this may be useful for organic brain disorders for the majority of mental health problems where there is no definitive biological condition, the diagnosis simply reflects the individual’s reflections on how they think and feel. The treatment plan would be developed based on the assessment outcome (diagnosis). Often treatment ranges are limited with a high emphasis on drug interventions, where the primary objective is to stabilise Ahmed’s mental health condition in an effort to return him to a functional state. This medicalised response and the use of drugs could be viewed as a means of social control (Rogers and Pilgrim, 2005).
By drawing on the theory of social causation this would enable me to support Ahmed to analyse the issues he is facing in a non judgemental way. Oppression and discrimination is observed in the lives of people from marginalised groups (Dalrymple and Burke,1995) and as practitioners we have an obligation to challenge discrimination and oppression. Personal experiences are clearly associated with social, cultural, political and economic divisions and therefore understanding these areas in context to the individual is vital in understanding and challenging the oppression and discrimination they may encounter (Adams et al, 2002). The stigma attached from having mental health problems cannot be underestimated. Research by the Department of Health – Attitudes to Mental Illness in 2007 showed that whilst many of the negative pre conceived ideas and beliefs held by society about people with a mental health illness were diminishing, but the changes year on year were not significant. This may be due to education and understanding of mental illness and the understanding of the effects of discrimination and stigma. The Time to Change Programme (2008) is by its own admission, nationally and globally the most ambitious plan to stamp out discrimination faced by people with mental illness. Stigma poses a threat to all aspects of an individual’s life if diagnosed with a mental illness, they contribute to social isolation, distress and difficulties gaining and maintaining employment. In a survey by Crisp and Gelder (2000) discovered there were consistent themes of perceptions of people who had a mental illness. Some views were common amongst the several diagnoses, namely they were difficult to talk to and they were unpredictable to assumptions of being dangerous.
Completing a Community Care Assessment in accordance with the NHS and Community Care Act 1990 would be necessary in order to identify Ahmed’s needs and how those needs would be best provided for. The assessment would include information from Ahmed as well as significant others where applicable and determine need on a short and / or long term basis (Sharkey, 2007). The assessment does not detract from the need of some immediate intervention, to work directly with Ahmed to address some of the immediate issues such as his rent arrears (which would immediately reduce the threat of eviction) and getting his utility services back in place. Acute and crisis services and intervention were designed to offer support in a less restrictive and stigmatising way than traditional formal of intervention such as compulsory admission (Golightly,2008).
Crisis intervention is a model of intervention which ideally prevents the situation from deteriorating further and builds on existing resources and strengths in order to improve the situation (Ferguson,2008). This could assist Ahmed’s mental health and well being as well as his environment and other social factors i.e. relationship with mum and neighbours. The intervention allows a recent Cochrane review found that home care crisis treatment, coupled with an ongoing home care package, was a viable alternative to hospital admission for crisis intervention for people with serious mental illnesses and probably more cost effective (Joy at al, 2006).
Working directly with Ahmed using a task centred approach would be ideal as it is a very practical based approach. The work is “time limited, structured and problem focused”(Parker and Bradley, 2007, p.93). An example for Ahmed might be:
Outcome : Pay off rent arrears so no longer in debt.
Rationale: this would immediately reduce the risk of eviction as well as encouraging Ahmed to take responsibility for his situation in a supportive and empowering way.
Agree a payment plan with Ahmed that is manageable within current budget (?10 every 2 weeks)
Once plan agreed Ahmed to visit housing provider to agree payment plan and request an update every month on arrears.
Pick up benefits every 2 weeks, on a Tuesday, and immediately pay 2 weeks rent at paypoint in post offices along with agreed ?10 arrears and obtain receipt.
For the purpose of this assignment I have listed some of the actions which could be identified in order to support Ahmed.
Pay off rent arrears.
Benefits assessment to ensure Ahmed is claiming his benefit entitlement.
Tenancy support worker in order to support with tenancy related issues such as rent, utilities and maintaining a tenancy agreement.
Support worker to assist with increasing his contact and reduce social isolation. This could be simply going out for a coffee or some other activity which Ahmed identified.
To explore if Ahmed has concerns regarding psychiatry, and his reluctance to meet with the psychiatrist – this is vital it may simply be he forgot about the appointment or further issues regarding his concept of psychiatry.
To work with Ahmed to explore his thoughts regarding his mother and assess the foundation for his thoughts that she is not his mother.
To gain understanding on any other significant relationships in the past (there is mention in the case study of children) and the possibility of re-connection with his children and wider family connections.
Re-connection with community – whether this would be utilising self help groups, classes which may hold a particular interest or active engagement in community/ voluntary projects – to build self esteem and confidence and develop a sense of purpose and engagement.
Explore training / employment options
To support Ahmed to begin a life story book or consider psychology intervention. To offer support to examine Ahmed’s current strategies of coping recognising his abilities through the strength model and supporting him to identify any patterns and how to deal with them.
To develop a contract for future work in order to be clear of professional boundaries and expectations from both parties and how intervention might look in the future should this be required.
Should the circumstances not improve or continue to deteriorate then there is a possibility of seeking hospital admission either, voluntarily or in accordance with the Mental Health Act 1983.
More people than ever are being detained in hospital under compulsory orders. Admissions to hospital under the Mental Health Act 1983 have risen by nearly 30% in the past decade in England. According to a report from three national mental health charities, Rethink, Sane and the Zito Trust, this figure is a worrying reflection of the care for people with mental illness (Kmietowicz, 2004). A sobering thought for any professional. As a practitioner I have learnt that causes of mental health issues are often complex and can involve a combination of biological vulnerability, environmental factors, social stressors, social networks, supports and relationships, psychological orientations and learned behaviour. Coppock and Hopton (2000) state: “each perspective on mental distress and therapeutic intervention has its own internal logic”(p.175) and stress the importance of recognising the alternatives, otherwise, practitioners are in danger of becoming a rigid in their practice, not work in a person centred way. Having a critical perspective and understanding of the variety of theoretical perspectives and approaches regarding mental health is beneficial. It is clear that these perspectives whether biomedical or social have added to our understanding of mental health. The relative merits of the various perspectives are constantly argued, most characteristically by pointing out the limitations of the differing perspectives. Such critiques can be productive but are only a step in a larger task to develop broader perspectives that can be productively incorporate the different useful insights reached from each of a variety of different points of view.
A person centred approach to mental health would seem the optimum approach when examining mental health issues. It recognises the uniqueness of individuals and accounts for all the possible variables and their interactions from social causation, stress vulnerability, gender etc. which would enable practitioners to examine issues within a broader holistic context, instead of rigid simplistic processes of bio medical model (Freeth, 2007).
Word Count : 4007