Case Study, Working with Adults assignment (Mental Health).
This paper is a discussion of the social work issues in the case of Mary, a 44 year old woman with a history of compulsory admissions under the MHA 1983. Mary has been variously diagnosed with bipolar disorder, psychotic depression: she is considered to have a borderline personality disorder and alcohol dependency syndrome. She is currently prescribed anti-depressants and a four-weekly anti-psychotic depot injection. Her 24 year old son, Pete, has a substance misuse problem, and lives nearby. Apart from support arising out of her contact with social services, Mary has intermittent support from her sister, Sophie, a social care worker who lives in a nearby town.
The professional and clinical dilemmas implicit in Mary’s case are, arguably, highly indicative of wider problems in the diagnosis and care of the mentally ill . They are particularly relevant to the generic issues faced by social workers in many similar cases. Whilst it is obviously impossible to generalize, the fact remains that the type of care offered will ultimately depend upon the decisions made by the relevant professionals, a fact which brings into focus the complex system of checks and balances which has accumulated around mentally unwell clients and patients. As Golightly observes, ‘Mental health services are at a crucial stage of redevelopment which, by the time it is complete, will produce a service that is appropriate and responsive to service user needs.’ (Golightly 2008: p.2). Whilst this impetus is tangible and visible in various initiatives and policy changes, the fact remains that it ultimately depends upon a complex range of legislative, procedural and professional integrations, many of which remain very much a work in progress. Whilst this process is ongoing, it is up to practitioners themselves to mediate these processes in the interests of their vulnerable clients. Over and above this, it is important to retain an anti-discriminatory perspective, taking account of the preconceptions which may skew both analysis and practice in the case of certain issues. . As Thompson expresses it, truly anti-discriminatory practice must be ‘…part of a wider framework which reflects power and privilege differences and which hinge on social divisions. This brings us….to the point…namely: if you are not part of the solution, you must be part of the problem.’ (Thompson 2006: p.78)
1. Critically evaluate the impact of salient legislation and policy in your work with Mary.
The principle impact of salient legislation and policy in this case lays in the area of consent, and in particular the successive refinements to the processes through the client is adjudged to be either capable or incapable of determining the context in which their care should take place. Given that Mary has been compulsorily admitted under sections 2 and 3 of the Mental Health Act 1983 on five separate occasions in the last ten years, (the most recent only two years ago), it would seem that in her case the precedents militate against the obtaining of consent. As these episodes have also involved violence against both social work practitioners as police officers, any risk assessment would point to the fact of consent being unlikely, and appropriate contingencies being put in place as a matter of professional responsibility. The question is, do the intermediate consent arrangements introduced after 1983, and in particular the graduated approach to issues of consent which arise out of the Mental Capacity Act 2005 and the Mental Health (Amendments) Act 2007, offer practitioners – or Mary herself, a more positive trajectory?
As suggested above, official intervention has taken the form of a whole new tier of intermediate legislation (discussed more fully below) which fills a perceived vacuum, and provides a range of new protocols for the social work practitioner and other agencies. As Bogg puts it, ‘With the inception of partnership arrangements between health and social care came awareness that the regulatory frameworks that governed each sector needed to be aligned.’ (Bogg 2008: p.9). Parallel to this development was the transformation of the Approved Social Worker (ASW) role into that of the Approved Mental Health Professional (AMHP). Questions remain as to the precise reasoning behind this development, and whether its provenance lays entirely in the re-framing of practice, or other contingencies. As Bogg points out, ‘While the initial implementation of the Mental Health (Amendment) Act 2007 will be to convert existing ASW staff into AMHP’s the opportunity for nurses, occupational therapists and psychologists to become ANHP’s will be available from the latter half of 2008, and these groups will therefore need to consider what this will mean for their practice and their professional perspectives….One particular concern in relation to AW provision is that of an ageing workforce…the introduction of the AMPH enables other professions to take on the statutory role within mental health service provision, and potentially expands the availability and perspectives of the workforce.’ (Bogg 2008: p.116).
2. Critically explore the issue of consent and capacity with reference to Mental Capacity Act 2005
The facts of Mary’s mental health and her current emotional state would seem to suggest that obtaining consent from her would seem unlikely at present. It may be argued that the Mental Capacity Act 2005, and the provisions of the subsequent Mental Health Act 2007, represent the government’s cumulative response to converging concerns about individual liberty and the functioning of the human services with regard to mental health. As the government itself states, ‘The main purpose of the legislation is to ensure that people with serious mental disorders which threaten their safety or the safety of the public can be treated irrespective of their consent where it is necessary to prevent them from harming themselves or others.’ (Golightly 2008: p.48)
They also encapsulate the dilemmas which beset government and jurisprudence in this sphere, and the hegemony of the European Commission of Human Rights over human rights law in general. In other words, the British government is not the master of its own fate with regard to the decision to deprive a client – or patient – of their liberty on the grounds of mental incapacity. The clearest evidence of this is the apparently intermediate status of the 2005 Act, which, although enshrined in UK law, awaits its substantive validation through other processes, as Golightly indicates. ‘Section 50 of the MHA has amended the MCA 2005 to provide safeguards for those incapable people over 18 years of age that are deprived of their liberty. The government hopes this will meet the requirements of the ECHR although we will have to wait until it is tested in the courts.’ (Golightly 2008: p.50).
Putting aside this extended validation process, it remains to critically assess the allied issues of consent and capacity as they are dealt with in the 2005 Act. In the first instance, it may be helpful to understand the function of this legislation through its framing and provenance. The really novel and significant contribution of the 2005 – and subsequent refinement in the 2007 Act – arguably lays in the Deprivation of Liberty test and procedures, within which set out in Section 50 of the 2007 statute. Under this, if no authorization has been obtained under the DoLs, a deprivation of liberty can only be lawful through the satisfaction of two possible preconditions. Firstly, such an arrangement must be the subject of an order made by the court of protection under s.16(2) of the Mental Capacity Act. Subsequently, an application must have been made to the court under which such a deprivation of liberty is considered necessary in the meantime – either to save the person’s life, or prevent a serious deterioration in their condition. (Golightly 2008: p.50). These refinements were prompted by the case of an autistic man (HL) held ‘informally’ by the Bournewood Trust, a situation which gave rise to the hearing of HL v. United Kingdom. As Golighty reports, this situation was unlawful, because ‘…the common law of necessity is too vague and has too few effective safeguards to comply with articles 5(1) and 5(4) of the ECHR. Thus, HL was de facto detained and the DoLs represent the government’s attempt to remedy the problem that (the) Bournewood case highlighted.’ (Golighlty 2008: p.49).
In effect then the 2005 MCA was designed to add definition to the informal and often legally flawed protocols, which social workers and other professional had evolved in the around the 1983 Mental Health Act. After 2005 a new tier was added to the hierarchy of actions to which these agencies had recourse: informal or voluntary admission under s.131: admission under the Deprivation of Liberty Procedures in the amended Mental Capacity Act 2005, or ultimately, compulsory detention under part 2 or part 3 of the Mental Health Act 1983. (Golightly 2008: p.48). The 2005 Act also initiated other safeguards, such as the system of Independent Mental Capacity Advocates (IMCA’s): for the first time, potentially vulnerable clients without the support of relatives or friends have a statutory right to an appointed, i.e. ‘non-instructed’ advocate. (Golightly 2008: p.51). This, it was intended, would furnish the client with both continuity of objective advice and a pastoral perspective, which might otherwise be deemed lacking in the system of legal and clinical checks and balances devised for their care.
3. Provide a critical overview of protection and risk issues in this situation.
From a legislative perspective, the problem is that some of the most alarming evidence is circumstantial, is derived from third parties, and may in fact be apocryphal. For example, neighbours have been reporting disturbances at erratic and unsociable hours, but this at best represents a general indication or suggestion that Mary’s mental health may be entering a difficult phase, or even deteriorating. It cannot, unilaterally, support anything approaching an admissions procedure: given that her son Pete, (who himself has a history of substance misuse), is apparently at her flat frequently, it is not necessarily the case that Mary is herself the cause of these ‘disturbances’. Conversely, it is quite possible that disagreements between Mary and Pete are the cause of the disturbance. However, given that they are both frequently in an altered state of mind, either due to mental health issues or either alcohol or substance misuse, the likelihood of being able to make an objectively worthwhile assessment based purely on investigation of this situation does not seem strong.
4. Critically discuss the role of inter-professional collaboration and practice in relation to Mary’s situation.
According to the information supplied in the case study, those in contact with Mary currently comprise her social worker, the consultant psychiatrist, and the CPN assigned to her.
From the information available, it seems that there is significant dissonance within the multi-agency effort to assess and plan for Mary’s needs. Principle amongst these is the position of the Consultant Psychologist, who has expressed doubts as to her diagnosis as mentally ill, and requested that she is transferred to the substance misuse service. He has further stated that a home visit – although requested by the care coordinator – is unnecessary, and that Mary should be ‘offered’ inpatient detoxification. This may prove to be either a major stumbling block, or, at the very least, a significant determining factor in the direction of Mary’s care. As Golightly points out, ‘Consultants will point out that they have clinical responsibility for the individual and hence medical-legal responsibility. This has been further compounded with the emergence of nurse prescribers.’ (Golightly 2008: p.139). At present, it is debatable whether or not the consultant’s hegemony would be operable in the context of a tripartite formal assessment under part two or three of the 1983 Act. There is, however, a sense in which his current intransigence may eventually produce a repetition of Mary’s earlier compulsory admissions, if it contributes to a lack of action in respect of her current difficulties. As Bogg points out, ‘…the professionals involved need to identify with and own the team’s purpose and goals if there is to be effective multi-disciplinary cooperation.’ (Bogg 2008: p.35)
5. Drawing on a range of theories and approaches critically demonstrate the evidence base for your work with Mary and Pete.
There are several principle theoretical frameworks which may be deemed applicable in the case of Mary and Pete. It is important here to recognize and retain the link between the theoretical base, the evidence base, and the pertinent policy framework. Given that the multi agency effort incorporates both social and clinical practitioners, the two theoretical models which should be applied are the social, the medical, the biopsychosocial, and the recovery. In this part of the discussion we will consider the case of Mary and Pete discretely within each variant.
As Bogg observes, the social model ‘…places the emphasis of the condition on the consequence of the mental distress or disorder…instead of looking at symptoms and disorders as an entity in themselves…the social model focuses on the social consequences and how to improve the quality of life and wider responses the individual is facing.’ (Bogg 2008: p.44). From this position, it has to be recognised that the evidence base currently held is inconclusive in respect of the precise course of action which might benefit Mary’s condition. This is principally due to the subjective and fragmentary nature of such evidence: although, overall, it combines to present her situation as alarming, in fact the total of such evidence may be more than the real sum of its component parts. In other words, the specificity of each apparently negative social interaction – at Mary’s workplace, with neighbours, friends or relatives – needs to be looked at in more detail before an accurate, overall picture can be agreed upon. Meanwhile, the medical model, again defined by Boggs, is, in its psychiatric sense, ‘…ordinarily a reference to the biological model. This rests on two principles: first, that mental disorder is a brain disorder, and second, that all mental events are neurological events. {Bogg 2008: p.45). The controversies thrown up in the space between the social and medical models have in turn produced more graduated approaches in the biopsychosocial and recovery models.
In the case of Mary and Pete, with all of its implications regarding possible and actual substance dependence and misuse, the recovery model seems to offer the most realistic mean of empowerment. Given Mary’s history of psychotic diagnosis, the medical model obviously cannot be discounted, and will continue to represent a significant part of hr care. As Bogg observes, with acknowledgements to insights derived from Mahler and Tavano, recovery can offer ‘…both a conceptual framework for understanding mental illness and a system of care to provide supports and opportunities for personal development….while individuals may not be able to have full control over their symptoms, they can have full control over their lives…’ (Bogg 2008: p.48) As in all similar cases, whilst the policy base provides an inter-disciplinary and multi-agency framework within which to organize care packages, the theoretical base may vary according to perspective employed. However, the evidence base in Mary’s case strongly suggests that a holistic approach may gradually enable her to make her own choices about regaining control over her own life. It also has to be considered that at some point, the case worker may have to share their considerations of Mary’s case with the relevant ASW/AMHP, whose expertise and training may be helpful. As prior observes, ‘…there is a concentration of specialist training in this one area. This concentration on some staff throws into sharp relief the lack of training opportunities available to others.’ (Prior, 1992: p.108)
6. Critically analyse and take into account the causes and impact of inequality and discrimination on Mary and Pete.
There are, it may be argued, many possible sources of discrimination and inequality which may have impacted upon Mary and Pete. Some of these, taking into account the social model, are implicit in the structure of contemporary society: perhaps inevitably, some of these same factors feature in the practice of the human services. The situation in which Mary and Pete currently find themselves in relation to social services is, arguably, highly indicative of the transformations which have been required of the profession, and of the residual tensions implied by such transformations. Such tensions can be illustrated by comparing two intra-social work perspectives: one proposing a ‘Third-Way’ or ‘tough love’ approach to social issues, the other favouring a less sanguine, more interventionist position.
The first of these approaches can be summed up in the position of Ferguson, who argues that ‘…we now live in a post-traditional order where processes of individualization have resulted in the self becoming a reflexive project. Identities are now…constructed by individuals themselves, rather than inherited and this has given rise to a new agenda of life politics. While it should not replace a concern with emancipatory politics and life chances, I am arguing that life politics needs to be at the centre of how social work is understood and practised today.’ (Ferguson, 2001: p.42). For those opposed to this position however, the idea of ‘life politics’ does not adequately replace earlier ideas of ‘life chances’, or the way in which these are systematically denied to certain individuals. For adherents of this position, an approach which addresses this problem should lay at the core of effective social work practice. As Thompson indicates, ‘…a social work practice which does not take account of oppression, and the discrimination which gives rise to it, cannot be seen as good practice, no matter how high its standards may be in other respects.’ (Thompson 2006: p.15). For some observers, similar concerns are raised by the idea that the empowerment of the individual can shape a holistic approach to their care, rehabilitation and support. As Adams points out, ‘…the difficulty with the empowerment paradigm is that its contemporary forms have all fed off anti-sexist, anti-racist, anti-disablist, and other critical, anti-oppressive movements, whereas its historical roots lie partly in traditions of mid-Victorian self-help which tend to reflect the dominant social values of that time. Whereas in theory, self-help is a neutral concept, in practice…it was wielded by the…middle classes to extol their own virtues.’ (Adams 2003: p.18). Essentially then, such disagreements may be related back to the question as to whether the contemporary transformation of the profession, as one implicitly focused on official targets and competencies, is the model best adapted for the care of clients, or whether a more problematical relationship would be better. As Jones expresses it, ‘…social work must always be a difficult and troublesome activity irrespective of the government in power and the prevailing orthodoxies.’ (Jones, 1997: p.62)
At a clinical level, the possible diagnosis of Mary as having one of a range of different problems may have profound implications for the way in which she is treated, both within the social care and health systems, and society itself. In a sense this is a technical question which relates back to the discussion of multi-agency cooperation, and touches on the question of diagnosis and a hierarchy of needs. As Bogg points out, ‘The criticism of diagnostic categories (such as the stigma created by giving an individual a specific label) is not dispelled or underestimated…and a diagnosis can hold as much detriment as it can benefit…’ (Bogg 2008: p.46). Ultimately, the restoration of her depot injection regime may be the trigger which decides the course of her care in the immediate future.
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