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Good Social Work Practice with Adolescents in the Field of MentalHealth

Social work’s role as the dominant provider of mental healthservices is rooted in history and well-established in the contemporary socialservices landscape. It has been estimated that social workers invest more thanhalf their time in dealing with mental health issues (Howard et al., 1996).Constituting over sixty percent of the mental health workforce, social workersprovide more community-based mental health services than any other professionalgroups. Also, social work has more candidates in preparation for this growtharea than does any other discipline. It is the largest field of practice andthe most-chosen focus of study among social work graduate students (Proctor,2004).

The heaviest consumers of social work services also are the most probablevictims of mental illness. The clientele of certain service delivery settings,including homeless shelters, child welfare, out-of-home placement and long-termcare, settings in which social workers predominate, are among the most at riskfor psychiatric disorders and the least likely to gain access to appropriatecare. This highlights the tremendous potential of social service professionalsto reach and to treat individuals with mental health problems.

Adolescents are far from immune to these findings. For example, psychiatricimpairment rates for youths in the child welfare system have been estimated atbetween 35-to-50 percent, closely matched by the 30-to-50 percent ratings ofjuveniles in the criminal justice system (Proctor, 2004). Walker (2003)pointed out that one of the few undisputed risk factors for mental illness inadults is unaddressed or inadequately treated psychiatric problems in youths. Thecost of failure to respond effectively to the mental health problems of adolescentsincludes lifetimes of potential productivity lost to consequences such as drugabuse, homelessness and suicide.

The following discussion applies relevant theory and research to thequestion of good social work practice with adolescents suffering psychiatricdisorders. A touchstone for good practice can be found in Mowbray and Holter’s(2002) charge to social work practitioners and researchers that their effortson behalf of the mentally ill should produce:

Increased integration within the community (aswith other disability groups);

Decreased stigma and discrimination;

Increased utilization of effective treatmentoptions;

Equitable access to effective, appropriatetreatment.

Adapting LeCroy’s (1992) outline, practices in the broad areas ofassessment, treatment and service delivery are considered.

Assessment Practices

It generally is agreed that assessment methodologies developed foruse with adults lack efficacy for assessing adolescents. Partly due to youths’higher level of dependency on the environment, a ‘person-in-environment’perspective is a recommended starting point (LeCroy, 1992). In order toaddress the question of how the individual’s and the family’s coping skillsinteract with the quality of the environment, the social worker must weighresources and support, the barriers and opportunities, the risks and protectivefactors present in that environment.

Wakefield et al. (1999) pointed out the pivotal role of a socialworker’s attributions in the assessment of adolescent antisocial behavior. Thecomplex web of logic and experience, evidence and intuition, theory and belief,involved in the assessment process is reflected in this study. The researchquestion was two-fold: (1) whether social workers correctly distinguish betweena psychiatric disorder and non-disorder (as defined in DSM-IV) given contextualcues supporting one or the other attribution, and (2) whether judgments bearingon prognosis and appropriate treatment follow these attributions. Finding positivesupport for both questions, the authors called for a focus on this criticaldiscriminate attribution in social work training programs.

In working with adolescents, the desirability of a broad-basedassessment, across environments, informants and factors affecting copingability and stress, requires the social worker to possess skills in casemanagement and clinical areas. Research by Elze (2002) highlighted the effectsof the wider social context on adolescent functioning. In this study, sheexamined risk factors for mental health in a sample of self-identified gay,lesbian and bisexual youths. Unlike most research involving this population,her enquiry included the role of factors unrelated to sexual orientation. Shefound that most of the variance in mental health status was accounted for bysocioeconomic level, familial mental health, family functioning and otheridentified life stressors. From a practice perspective, this researchreinforces the importance of assessing a client’s overall psychosocialfunctioning, as related to and beyond the limits of the presenting problem.

Objective, empirically-based assessment instruments, designed forthe adolescent population, are needed to increase the reliability of thispractice. Most of the instruments in use with adolescent clients today aremodified adult or child-specific protocols, such as the Child BehaviorChecklist or the structured life events interview (LeCroy, 1992). An extremeexample of the caution required in using adapted instruments was presented byElls (2005). The context of this critique was the courts’ need for assessmentsof psychopathic tendencies in juvenile offenders as a basis for jurisdictionwaiver decisions. Ells reported on assessments using the Hare PsychopathyChecklist: Youth Version (PCL:YV), derived from an instrument developed foradults. She found the tool subject to ethnic bias, developmental bias and alack of predictive value due to unfounded generalizations from research andexperience with adults. She warned that the introduction of psychopathyassessments in juvenile jurisdiction waiver decisions is premature anddangerously unreliable. Overall, good practice in adolescent assessmentcertainly would benefit from objective, evidence-based protocols, honedespecially for this population group.

These are some of the implications for good social work practice inthe mental health assessment of adolescents.

Treatment Practices

To establish that treatment can be effective with children and adolescents,LeCroy (1992, p. 227) reported the results of two meta-analyses, demonstratingthat average outcomes for those who received treatment were 71-to-79 percentbetter than an untreated control group. In order to establish good practice,however, the social worker must know which treatment approaches are likely toproduce what effects for the adolescent and significant others.

The breadth of focus required for assessment is echoed in goodtreatment practice recommendations for working with psychologically impairedadolescents. The keynote appears to be a conceptualization of problems asconstellations of interrelated systems, yielding treatment goals inclusive ofthe family, peer group and community, toward the underpinning of long-termadjustment for the client.

This view of good practice is common across theoreticalperspectives. For example, from a social ecological point-of-view, Ungar(2002) left the more mechanistic systems models behind and reflected on the diversity-embracingnew ecology, with community as the central concept in treatment.

Steven Walker, whether expounding on community-based applications ofthe psychosocial model (2003) or considering treatment practice from apostmodern perspective (2001), emphasized the necessity for an integrated (ordeconstructed) model of treatment practice, inclusive of a broad panorama ofoptions. Noting that flexible, creative solutions are required by adolescentswith psychological problems, Walker (2003) discussed the United Kingdom’sfour-tier model for mental health services to children and adolescents as anopportunityfor intellectual agility on the part of social workers (p. 683).

Barth’s (2003) dissertation on the treatment of college studentswith eating disorders is an interesting example of this eclectic approach totheory and treatment. She made a point of focusing on the entiresocial/medical context of a client, then drawing treatment implications fromany number of theoretical models that fit this context, includingpsychoanalytic, psychosocial and postmodern perspectives. Given the length ofthe usual battle with eating disorders, this assessment treatment assessmentcycle repeats throughout the life of the case, opening new opportunities foreffective intervention at every turn.

As with assessment, research is essential for informing goodtreatment practice. The research of Colarossi and Eccles (2003), for example,offered evidence that support from significant others is not a unidimensionalconstruct. They examined the differential effects of support provided byparents, teachers and peers on adolescent depression and self-esteem. Nonfamilialsources of support were found to be more efficacious for improving self-esteem,while depression responded to all support offered, regardless of source. Theresults obtained suggest the need to selectively promote support from varioussources, as opposed to a broad or unfocused social network tactic.

In service of good treatment practice, LeCroy (1992) lists a numberof promising approaches (p. 227) that social workers should include in theirtreatment options toolkit. These include behavioral treatment (or competencytraining) for antisocial problems, functional family therapy, parent-managementtraining, home-based treatment, training in social skills and problem solving,psychopharmacology and psychotherapy or IPT-A (interpersonal psychotherapy foradolescents).

These are examples of some good social work practice guidelines formental health treatment of adolescents, derived, to a large extent, from theoryand research. Putting assessment decisions and treatment choices into actionis the role of service delivery systems.

Practices Related to Service Delivery

Considering systems of service delivery prompts the realizationthat, in terms of good practice, social workers must be proficient in an arrayof interventions beyond the confines of direst treatment. In order tocoordinate multiple services and monitor systems of care, critical casemanagement competencies are required. The significance of a well-coordinatedsystem of care must be salient for every social worker involved in servicedelivery.

One of the most difficult decisions in this arena is when to utilizesubstitute care. Inpatient or residential treatment, foster care, respitecare, partial hospitalization and day treatment, define points along thissubstitute care continuum. Especially in light of research on the importance ofsocial support and of home and community-based treatment, moving the adolescentinto a substitute care setting seems particularly invasive.

Research studies and reports can help inform the decision to utilizepsychiatric inpatient treatment. For example, Pottick et al. (1999) helped tountangle the many variables affecting adolescent length of stay in thesefacilities. Looking at factors that influence the occurrence and timing ofdischarge, they found that facility type was significant. Stays in generalhospitals with psychiatric services were much shorter than in public or privatepsychiatric hospitals or multi-service mental health centers. Also, insurancewas a factor; privately-insured youths stayed longer than did publicly-fundedor uninsured adolescents. Having a previous hospitalization predicted a longerstay, as did the diagnosis of conduct disorder (versus depression). Althoughthis research does not speak to the quality of care, and given that moreoutcomes research is needed, the awareness of contingencies disclosed by thisstudy can aid a social worker in forming valid expectations and making aninformed decision for the client.

Romansky et al. (2003) looked at factors influencing readmission to psychiatrichospital care for children and adolescents who were in the child welfaresystem. Their findings highlighted the significance of enabling factorspresent for these children, including living arrangement, geographic region andpost-hospitalization services. The focus must be on community-based servicesto prevent readmission for these adolescents.

On a similar note, a review of the research on inpatient treatmentin child and adolescent psychiatry (Blanz & Schmidt, 2000) cautiouslyconcluded that hospitalization can be beneficial given that effective treatmentand discharge planning are included. These researchers pointed to acontinuum-of-care model as crucial in facilitating integration/coordinationbetween inpatient interventions and aftercare services.

While research such as this can aid the social worker in making thedifficult inpatient care decisions, there are myriad other placementconsiderations that should rely on good practice to advantage adolescents inneed of mental health care. The keynote for good practice remains choosing theleast restrictive, appropriate environment. To make this choice for a givenadolescent, the social worker must be familiar with the placement optionsavailable and the treatment philosophy of each program, as well as the uniqueconfiguration of problem dimensions particular to that client.

LeCroy (1992) suggested that social work should try to developobjective tools to assist in meeting the good practice guidelines for mentalhealth placement decisions. He offered the Arizona Decision Making Tree (p.228) as a potential model for such a tool. This tool is used for theassignment of juvenile offenders to five levels of care, varying inrestrictiveness and program components.

At best, a fine balance in judgment is required to match a givenadolescent, at a specific point in time, with a certain treatment setting,providing the best therapeutic approach for the client’s particularconstellation of problems. A control problem versus learning disabilities isonly one example of how varied and far-ranging the mix of relevant factors canbe.

At times, there may be a need for a more restrictive setting as afunction of risk factors in the home/community environment. A study by Ruffoloand colleagues (2004) addressed such a situation. To inform the design of moreeffective mental health intervention (and prevention) programs, they examinedthe risk and resiliency factors for groups of delinquent, diverted andhigh-risk adolescent girls. All these girls were either involved in thejuvenile justice system, or at risk of involvement, and were receivingresidential services in either a home or community-based, open or closedsetting. Girls in the closed residential setting (the most restrictive) reportedhigher levels of depression, family discord, sexual abuse, negative lifeevents, involvement in special education programs, and more delinquent andnegative coping behaviors. In other words, the girls with the greatest riskfactors present in their home and community were placed in the most restrictivesetting. The authors concluded that these placement decisions reflected anappropriate appraisal of the level of need.

These are a few of the factors available to guide the development ofgood social work practice in the coordination of service delivery systems.

Conclusion

This paper reviewed a portion of the theory and researchcontributing to good social work practice standards in the area of adolescentmental health. While accomplishments in this area are commendable, muchremains to be done.

More well-designed and well-controlled research is needed to weighthe effectiveness of adolescent service models, especially with regard tolong-term outcomes. As effective systems of care are identified, they must be developedinto practice guidelines and supported by policy and funding.

Social workers are challenged to work for increased, improved,accessible services for adolescents, to educate the community and mobilizestakeholders, to develop and to implement effective strategies for preventionand intervention.

References

Barth,F.D. (2003). Separate but not alone: Separation-individuation issues incollege students with eating disorders. Clinical Social Work Journal,31(2), pp. 139-153.

Blanz,B. & Schmidt, M.H. (2000). Preconditions and outcome of inpatienttreatment in child and adolescent psychiatry. Journal of Child Psychologyand Psychiatry, 41(6), pp. 703-712.

Colarossi,L.G. & Eccles, J.S. (2003). Differential effects of support providers onadolescents’ mental health. Social Work Research, 27(1), pp. 19-30.

Ells,L. (2005). Juvenile psychopathy: The hollow promise of prediction. ColumbiaLaw Review, 105(1), pp. 158-208.

Elze,D.E. (2002). Risk factors for internalizing and externalizing problems amonggay, lesbian, and bisexual adolescents. Social Work Research, 26(2),pp. 89-99.

Howard,K.I., Cornille, T.A., Lyons, J.S., Vessey, J.T., Lueger, R.J., & Saunders,S. (1996). Patterns of mental health service utilization. Archives ofGeneral Psychiatry, 53, pp. 696-703.

LeCroy,C.W. (1992). Enhancing the delivery of effective mental health services tochildren. Social Work, 37(3), pp. 225-231.

Mowbray,C.T. & Holter, M.C. (2002). Mental health and mental illness: Out of thecloset? Social Science Review, 76(1), pp. 135-179.

Pottick, K.J., Hansell, S.,Miller, J.E., & Davis, D.M. (1999). Factors associated with inpatient length of stay forchildren and adolescents with serious mental illness. Social Work Research,23(4), pp. 213-224.

Proctor, E. (2004). Researchto inform mental health practice: Social work’s contributions. Social WorkResearch, 28(4), pp. 195-197.

Romansky, J.B., Lyons, J.S.,Lehner, R.K., & West, C.M. (2003). Factors related to psychiatric hospitalreadmission among children and adolescents in state custody. PsychiatricServices, 54(3), pp. 356-362.

Ruffolo, M.C., Sarri, R.,& Goodkind, S. (2004). Study of delinquent, diverted, and high-riskadolescent girls: Implications for mental health intervention. Social WorkResearch, 28(4), pp. 237-244.

Ungar, M. (2002). A deeper,more social ecological social work practice. Social Science Review,76(3), pp. 480-497.

Wakefield, J.C., Kirk, S.A.,Pottick, K.J., & Hsieh, D. (1999). Disorder attribution and clinical judgment in theassessment of adolescent antisocial behavior. Social Work Research, 23(4),pp. 227-238.

Walker, S. (2001). Tracingthe contours of postmodern social work. British Journal of Social Work,31, pp. 29-39.

Walker, S. (2003). Socialwork and child mental health: Psychosocial principles in community practice. BritishJournal of Social Work, 33(5), pp. 673-687.

Constance Ballew

All over the world the issue of mental health is a rampantly growing problem. With budget cuts both statewide and federally since the 1980’s by President Ronald Reagan, our country has had to create more cost efficient ways to meet the needs of our mental health crisis. Because of these budget cuts the need for more mental health services has grown and our county has responded to the outcry from those with mental health issues. Tulare County has come up with a way to help meet these needs locally through the Mental Health Services Act (MHSA), which was voted for in November 2004 and became effective January 2005. From August 2009 to October 20011 MHSA has helped over 16,000 Tulare county residents with mental health issues. This is possible because of a 1% tax surcharge on those who make $1 million or more per year. Mental health groups in Tulare County treat a broad spectrum of problems. From Bipolar Disorder and depression to schizophrenia, there are support groups to help clients deal with the difficulties associated with mental illness (HHSA, 2012).

In California the rate mental illness vary from county to county. Over all the rate of those with mental health issues in California are 16.3% that equals to about 4 million Californians. This percentage is a scarce comparison to that of all Americans who need mental health services. These figures which are 20-28% are alarming. Mental health affects everyone, even those who don’t have mental illness are affected by the mental health crisis in our county and country. Mental illness does not choose its victims by color, race, gender or age. Mental illness also does not prefer certain social or economic status. (Lund, 2001)

Before 1956 many patients were not open to the idea of group therapy, almost two thirds of the patients in fact. And of those who entered group therapy 15% dropped out within the first 5 weeks of therapy. It is also shown in the study done by DeSchill that patients who had already received individual counseling did not increase their likely hood of staying in group counseling over those who had not. (DeSchill, 2014)

The creation of mental health groups came from the need for more patients to be seen at a more economic and less time consuming. This is due to the introduction of Managed care into the mental health care system. Managed care has brought some limitations into treatment of mental illness as well as other groups. These are that managed care will pay for a certain amount of group sessions. There is a price cap on some of the sessions and therapist are often limited to the quantity and quality of care they provide group members.

The Goal of mental health groups is to help people cope with the disabilities they face in life. It is this such support that helps many people around the U.S. live their lives in more fruitful ways than they would if they did not had the support of the mental health support groups. Mental health support groups provide an end to isolation. The isolation that people suffer who have mental health issues is debilitating and leads to early death rates for the mentally ill. According to Marla Szalavitz, in a study done by researchers at University College London, 6,500 people over the age of 52 where studied. The most isolated of those had a 26% higher chance of earlier death than those who were not isolated. Mental health groups have a valuable role in the part of treating those with mental illness, not just mentally but also physically (Szalavitz, 2013).

The group members would be screened prior to entering the group. This is to ensure safety within the group and also to allow the maximum effectiveness for the group. The screening process would be done by a physician who would then refer the member to our group. This would help the therapist to focus on the members in the group who are able to do work and participate in their own change process.

The roles of the members in a group are important to study. Each member role help to establish a flow for the dynamic and solidifies norms. The challenges of the leaders in a mental health group can be somewhat different from a leader in other groups. This is because the dynamic could change more often than that of other groups due to the challenges that face those with mental illness.

The treatment models used to treat mental illness in group therapy according to Sara Battista, groups can be psychodynamic, cognitive behavioral psychotherapy and psychosocial. The purpose and goal of a mental health group is dependent on the type of model used. In psychosocial groups, the goal is to sustain a balance of norms in the clients life, change if it happens is slow and not expected with the psychosocial model of treatment. In a Cognitive behavioral model led group, the leader is an example for the group. The group is made of people with the same sorts of issues who seek the same goal. Psychodynamic groups focus on the role each member has had in their families or in society and now have in the group. (Battista, 2013)

In addition to the generalization of the treatments used to treat mental health issues, there are more in depth tools used in groups for the treatment of mental illness. Depression for people who have a mild or moderate level has been treated with cognitive behavioral along with interpersonal psychotherapies. While patients who have a disorder such as schizophrenia have been shown to benefit from cognitive behavioral psychotherapy. (Lehman et al, 2004)

Psychoanalytic groups or psychodynamic groups settings usually have anywhere from 5 to 10 people. In this type of setting there is a gender heterogeneity and the ages are usually within the same developmental stages. This is also a group which is cost effective and would benefit the members in financial hardship. The meetings are generally and 1 ? long or longer depending on the group. This type of group would meet a couple of two to three time per a week. This model is used because of its effectiveness to deal with group issues such as resistance and transference. Because of the heterogeneity in the group, members are able to work out other emotional reactions they might have opposed to that of a homogeneous group. Group members use their interactions with each other to help them work out problems in their lives. There is a sense of self-awareness that is gained by this type of therapy in group and the individual is able to do work more efficiently than on his own (DeSchill, 1974).

Cognitive Behavioral Therapy used in group sessions is cost and time efficient. This type of therapy helps the group members to focus on life issues such as relationships, matters of their health and are aims to help correct dysfunctional issues with the clients. The goals for this type of group would be to help the group members realize that they can have more choices than the ones that have had in the past. Also to replace faulty behavior with healthy emotions and behaviors. This group would be a smaller group of about 5-10 people and also heterogeneous. This group would most likely meet about twice a week for about 2 hours to help promote the necessary change needed in the group (Cowdry, 2012).

Psychosocial group settings are settings in which the group members talk out their problems, this is an effective type of treatment for people who have various type of mental health disorders. The setting would also be gender heterogeneous and include different ethnic backgrounds. The cultural differences in the group may prove to be an issue of resistance but if the therapist is trained with a multicultural background it can be a learning experience for the rest of the group. This group much like the two previous types of groups I have mentioned would be smaller groups and would meet more frequently to help the process of change. (Cowdry, 2012)

The group duration is ongoing for those with more serious mental health issues and can be more time limited for those with anxiety or depression issues. Since the goals for the groups are different. The duration would also be different. Meaning that people with schizophrenia will need a group with a longer duration, maybe 2 years while someone suffering from anxiety and depression may only need 16-18. This is because for those with serious issues the goals are more about maintaining their lives and with anxiety or depression it is to help produce change.

The goals of each group would be depending on the degree of mental health issues in which the members have. For instance, the goals for group members who are more seriously mentally ill would more tailored to adapting or maintaining mental and physical health and not towards a cure or getting better. While the goals for groups that are for depression and anxiety are focused on cognitive and the behavioral changes for members. It is also focused on helping the group members see more positive ways to manage stress and coping skills to manage negative thoughts. (Corey et al, 2014).

Group rules for mental health members should be clear and easy to understand. They should set limits on behaviors and encourage the members to share. Rules should also help to ensure safety and confidentiality within the group. Rules would be as follows; please allow people to finish sharing before speaking. Respect others thoughts and feelings. Please keep what has been shared in group inside group. Please share any thoughts or concerns you may have in group.

The tools that can be used in the forming stage of the group can be activities used to create safety and trust. This would be for the first few sessions of the group. The next few sessions would be activities to confront resistance in the group so that the members can get through to the second stage of tuckmans model which is storming. Then a few team building exercises to help the group cohesion and encourage the norming stage. The next few sessions would be based on tools to increase performing within the members and the final stage and for the last few weeks group members and therapist would be focused on the ending of the group-termination. This final stage would be to help the member talk about any issues that they feel haven’t been addressed and also deal with the closing of the group. These last sessions will also be used to go over what has been learned by the group members, what they will do after group and help them with crisis plans.

There are some ways in which a group can be evaluated to see if it has been an effective form of treatment. One way is to ask the clients to complete a pre group and post group questionnaire. This would ask questions asking the group member to rate their feelings toward themselves, their mental illness, their current abilities to function inside and outside of the group and also would ask them how willing they are to join the group. The post group questionnaire would also ask the client to rate their feelings based on how they felt after receiving the treatment in group. Another way to evaluate the effectiveness of the group would be to ask the group members to share with each other how they feel in group during the first few sessions about the effectiveness. This would be charted. The therapist can also ask members to come to a meeting after termination of the group in which they are asked their thoughts and feelings again about their time in the group. This would also be charted. The comparisons used in the feeling checks before and after group can help the group leader determine the effectiveness of the group. A therapist can also evaluate the effectiveness of the group by research. The therapist can study how many people need more help, how many terminate early and for what reasons and also what changes need to be made to enhance the effectiveness (Corey et al, 2014).

In doing this research, I found that mental health groups are a vital part of treating those with mental health issues. At times people feel alone, with group such as mental health treatment groups, members don’t have to feel alone and can relate to each other.

References

Battista, S. (2013) New Trends in Mental Health Treatment, National Alliance on Mental Illness, Retrieved From http://www.nami.org/Template.cfm?Section=Top_Story&template=/contentmanagement/contentdisplay.cfm&ContentID=158934

Corey et al, (2014) Theories and Techniques of Group Counseling, Groups Process and Practice, Ninth Edition, Brooks/Cole, Cengage Learning

Cowdry, R (2012) Treatments and Services, National Alliance on Mental Illness, Retrieved From http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&Template=/ContentManagement/ContentDisplay.cfm&ContentID=10510

DeSchill, S (1974) Introduction to Psychoanalytic Group Psychotherapy Part 1, The Challenge for Group Psychotherapy, Retrieved From http://americanmentalhealthfoundation.org/books/introduction-to-psychoanalytic-group-psychotherapy-part-1/

Health and Human Services Agency (2012) Tulare County Mental Health Services Act, Five Year Report, HHSA, Retrieved From http://hhsawebdocs.tchhsa.org/questys.cmx.hhsawebdocs/File.ashx?id=2819&v=1&x=pdf

Lehman et al. (2004) Evidence-Based Mental Health Treatments and Services: Examples to Inform Public Policy, Millbank Memorial Fund Retrieved From http://www.milbank.org/uploads/documents/2004lehman/2004lehman.html

Lund, L. E. (2001) Mental Health Care in California Counties: Perceived Need and Barriers to Access, Center for Health Statistics, Retrieved From http://www.cdph.ca.gov/pubsforms/Pubs/OHIRmentalhealthCareCA2001.pdf

Szalavitz, M. (2013) Social Isolation, Not just feeling Lonely May Shorten Lives, Time, Retrieved from http://healthland.time.com/2013/03/26/social-isolation-not-just-feeling-lonely-may-shorten-lives/

Mental distress/disorder as a function of the society we live in: implications for the practice of mental health social work in terms of gender and race
Introduction

Mental illness/disorder/distress is a rather ambiguous umbrella term for describing a wide range of diverse disorders of the mind. According to the Oxford Medical Dictionary, mental illness is “a disorder of one or more of the functions of the mind (such as emotion, perception, memory, or thought), which causes suffering to the patient or others” (Oxford Medical Dictionary, 2007). The global burden of mental illness was estimated at 12.3% at the beginning of the millennium and is expected to rise even further in the next decade (Murray and Lopez, 1997; Patel et al, 2006).

Critical perspectives that refute the biological definitions of mental illness started to arise in the 1960s. Szasz (1961) and other critical theorists have continually challenged the classification of normal and abnormal behavioural categories, and focused instead on the role of social factors on the development of mental illness (Martin, 2003). Key among these factors are gender, race and ethnicity, sexual preference, age and class.

Apart from several medical theories that explain the aetiology of mental illness with neurological chemical imbalances, the actual causes of such psychological disorders are largely unknown. However, as outlined above, there are myriad known factors that trigger or prompt such mental impairment. Work stress and work-related psychosocial conditions, for example, plays an important role in self-reported mental health (Kopp M et al, 2008).

Furthermore, gender is generally accepted as a significant risk factor for the development of mental distress. The World Health Organization acknowledges that a large majority of common mental health diseases are more frequently reported in the female gender than in their male counterparts. As an example – common psychological disorders such as depression and anxiety are predominant in women. Conversely, there are other disorders of the mind that are more common in men. These include, but are not limited to, substance misuse (including alcohol dependence) and antisocial personality disorder (The World Health Organization). Nevertheless, there are no reported differences in the incidence of some severe mental disorders, like schizophrenia, in men and women. In addition to the gender-related differences documented in the incidence of these disorders, there have also been reported differences in terms of the epidemiology and severity – age of onset, symptom frequency, social adjustment, prognosis and trajectory of the illness.

The World Health Organization proffers possible explanation for the observed differences between genders – men and women have differential withstanding power over socioeconomic determinants of their mental health, social position, status and treatment in society and their susceptibility and exposure to specific mental health risks (The World Health Organization).

Similarly, race could also be a determining factor for the development of mental illness. In addition, mental illness in some races, e.g. black and minority ethnic (BME) groups can be further exacerbated by alleged discrepancies in the mental health services available to this potentially vulnerable groups of patients (Ferns P, 2008). A possibly rational explanation for the reason behind any disparities in mental health across diverse races could be the societal differences that are inherent to various cultural backgrounds.

The main objective of this paper is to analyse the social factors that can prompt mental distress, especially in women and people from BME populations, and to rationalise how these factors may actually pathologise the discourse of mental health.

Mental Illness in Women

The natural subordinate role of women and gender stereotypes in most societies makes them prone to disorders of the mind. Psychoanalytic theories believe that patriarchy-based communities are associated with a higher rate of mental illness in women (Olfman S, 1994). These supremacy-governed organisations in which men are largely in control leave women with a consistent feeling of repression, which could culminate in mental distress. Indeed, in some extreme societies, women with more independent views who express anger or dissatisfaction with the standard patriarchal social structure are often seen as having psychological problems (Martin, 2003).

According to The World Health Organization, gender-specific roles, negative life occurrences and stressors can adversely affect mental health. Clearly the impact of the latter factors (i.e. life experiences and stressors) is in no way exclusive to the female gender. However, it is the nature of some events that are sometimes commonplace in women’s lives that could account for the documented gender-related differences. Risk factors for mental illness that mainly affect women include women-targeted violence, financial difficulties, inequality at work and in the society, burdensome responsibility, pregnancy-related issues, oppression, discrimination, and abuse. There is a linear correlation between the frequency and severity of such social factors and the frequency and severity of female mental health problems. Adverse life events that initiate a sense of loss, inferiority, or entrapment can also predict depression (The World Health Organization).

Furthermore, in a domino-effect way some female factors can also lead to mental illness, not just in the individual concerned, but also in subsequent generations and/ or interacting family and friends. For example – maternal depression has been shown to be associated with failure of children to strive in the community, which in turn could culminate in delays in the developmental process and subsequent psychological or psychiatric problems (Patel et al, 2004).

In the past three decades, the debate of women and mental health illness and their treatment in mental health services has been quite controversial (Martin J, 2003). From a social constructionist point of view, it is believed that some women are wrongly labelled as ‘mentally ill’ merely because they do not accept certain (usually unfair and unfounded) gender-related stereotypical placement in the society. In this often-cited and somewhat controversial book chapter by Jennifer Martin (Mental health: rethinking practices with women) she expresses great concern for the biological explanations of mental health which have the tendency to lay undue emphasis on the female reproductive biology that supposedly leads to a predisposition to mental illness. Such sexist notions tend to disproportionately highlight female conditions such as pre-menstrual tension, post-natal depression and menopause, in a bid to foster the notion that women are at higher risk of developing mental distress (Martin J, 2003).

Instead of this allegedly short-sighted approach to the medicalisation of mental health in women, feminist theorists focus on female mental illness as a function of the lives they are made to live within patriarchal, and often oppressive, societies. Women are disadvantaged – both socially and psychologically – by these unreasonably subservient role expectations (Martin J, 2003).

Mental Illness and Race

The United Kingdom (UK) is a home to a very diverse and multicultural population, and BME communities make up approximately 7.8% of the total UK population (Fernando S, 2005). There are innate differences in the presentation, management and outcome of mental illness between the different races and ethnic groups (Cochrane R and Sashidharan S, 1996; Coid J et al, 2002; Bhui K et al, 2003).

In a recent policy report for the UK Government Office of Science, Jenkins R et al, (2008) explained that while some mental disorders appear to be more common in the BME populations, others are not. In addition, incidence rates of different mental disorders also vary among different ethnic groups within the BME populations. For example, depression is increasingly common in the Irish and Black Caribbeans, but not necessarily in the Indian, Pakistani and Bangladeshi sub-populations (Jenkins R et al, 2008). In the UK, the risk of suicide also varies by gender as well as ethnicity, with Asian men and Black Carribeans having lower rates than the general UK population, and Asian women having higher rates. Similarly, the incidence of psychoses is not uniformly elevated in all BME groups – the highest incidence is seen in Black Caribbean and Black African groups in the UK, (4 – 10 times the normal rates seen in the White British group) (Jenkins R et al, 2008).

In a retrospective case-control study of a representative sample of more than 22,000 deceased individuals, Kung et al (2005) highlighted important disparities in mental health disorders, such as substance misuse, depressive symptoms and mental health service utilisation as possible determinants of suicidal behaviours and/ or attempts. Also, clear associations have been demonstrated between racism and the higher rates of mental illness among BME groups (McKenzie K, 2004). The rising incidence of suicides in some developing countries, as seen with Indian farmers, South American indigenes, alcohol-related deaths in Eastern Europe, and young women in rural China, can be partly attributed to economic and social change in these nations (Sundar M, 1999; Phillips M et al, 1999).

Pre-, peri- and post-migratory experiences can be major stressor determinants for the development of mental health illness (Jenkins R et al, 2008). Therefore, in order to understand the differences in these populations, it is of utmost importance to gain some insight into their cultural backgrounds and the happenings in their countries of origin all of which could be determinants of mental health.

There is a direct relationship between social change and mental health and, in the recent past, many developing countries have undergone incomparable, fast-paced social and economic changes. As Patel et al (2006) have pointed out, such economic upheavals commonly go hand-in-hand with ruraliˆ­urban migration and disruptive social and economic networks. Furthermore, it is noteworthy that The World Health Organization has acknowledged that such changes can cause sudden disruptive changes to social factors, such as income and employment, which can directly affect individuals and ultimately lead to an increased rate of mental disorders.

Also Alean Al-Krenawi of the Ben-Gurion University of the Negev has extensively explored how exposure to political violence has influenced the mental health of Palestinian and Israeli teenagers (Al-Krenawi A, 2005). Al-Krenawi goes on to emphasise that the concept of mental health in the Arab world is a multi-faceted one and is often shaped not only by the socio-cultural-political aspects of the society, but also by the spiritual and religious beliefs.

In addition, the perception of racial discrimination has been identified as a significant contributory factor to poor mental and overall health in BME groups – even more important that the contribution of socio-economic factors (Jenkins R et al, 2008). It is disheartening to note that institutionalised and/ or constitutional racism is rife in the conceptual systems that are employed in the provision of mental health services (Wade J, 1993; Timimi S, 2005).

Implications for the Practice of Mental Health Social Work

In general, people suffering from mental illnesses receive substandard treatment from medical practitioners both in the emergency room and in general treatment, and insurance coverage policies are usually unequal compared with their mentally balanced counterparts (McNulty J, 2004).

For BME populations, especially Black and Asians, access and utilisation of mental health services are very different from those recorded for White people (Lloyd P and Moodley P, 1992; Bhui K, 1997). Exploring the pathway to care in mental health services, Bhui K and Bhugra D (2002) highlight that the most common point of access to mental health services for some BME groups is through the criminal justice system, instead of their general practitioner, as would be the case in their White counterparts.

Major areas in which institutional racism is rife in the provision of mental health services to BME patients include mental health policy, diagnosis and treatment (Wade J, 1993). For example, Black patients with mental illness are more likely to be treated among forensic, psychiatric and detained populations (Coid J et al, 2002; Bhui K et al, 2003) and are also disproportionately treated with antipsychotic medication than psychotherapy (McKenzie K et al, 2001). Having said this, it is important to differentiate between racial bias and the consideration of racial and ethnic differences. In fact, ignoring these essential differences could actually be seen as a different type of bias (Snowden L, 2003).

Already, members of the BME population face prejudice and discrimination; this is doubled when there is the additional burden of mental illness, and is one of the major reasons why some of these patients choose not to seek adequate treatment (Gary F, 2005). As such, stigma arising from racism can be a significant barrier to treatment and well-being, and interventions to prevent this should be prioritised. It is therefore also of utmost importance that institutional racism be eliminated.

As far back as 1977, Rack described some of the practical problems that arise in providing mental health care in a multicultural society. These include, but are not limited to: language, diagnostic differences, treatment expectations and acceptability. Some effort has been made to address some of these problems in England, by the development of projects for minority ethnic communities both within the statutory mental health services and in non-governmental sector (Fernando S, 2005). In addition, overcoming language barriers should help in eliminating racial and ethnic disparities towards achieving equal access and quality mental health care for all (Snowden L et al, 2007).

The World Health Organization also draws attention to similar bias against the female gender in the treatment of mental disorders. Doctors are generally more likely to diagnose depression in women than in men, even with patients that present with similar symptoms and Diagnostic and Statistical Manual of Mental Disorders (DSM) scores. Probably as a result of this bias, doctors are also more likely to prescribe mood-altering psychotropic drugs to women.

Considering that immigrants and women separately face challenges with the provision of mental health care, it is expected that immigrant women would have even more setbacks, owing to their double risk status. Using Kleinman’s explanatory model, O’Mahony J and Donnelly T (2007) found that this unfortunate patient group face many obstacles due to cultural differences, social stigma spiritual and religious beliefs and practices, and unfamiliarity with Western medicine. However, the study did also highlight some positive influences of immigrant women’s cultural backgrounds, which could be harnessed in the management of these patients.

To effectively target and treat the diverse population that commonly present with mental illness in the UK, it is necessary to promote interculturalisation, i.e. “the adaptation of mental health services to suit patients from different cultures” (De Jong J and Van Ommeren M, 2005). Hollar M (2001) has developed an outline for the use of cultural formulations in psychiatric diagnosis, and advocates for the inclusion of the legacy of slavery and the history of racism to help understand the current healthcare crisis, especially in the Black population.

Conclusion

As we have discussed extensively in this paper, females and patients of BME origin are commonly disadvantaged in the treatment of mental illnesses. Mental healthcare professionals need to eliminate all bias in the treatment of these patients, while at the same time, taking into consideration their inherent differences to ensure that mental health services provided are personalised to suit the individual patient.

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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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Rowland, N., and Gross, S., (2003), Evidence-Based Counselling and Psychological Therapies, Brunner-Routledge, Hove.

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Thompson, N., (1998), Promoting Equality: Challenging discrimination and oppression in the human services, MacMillan, Basingstoke.

Thompson, N., (2000), Understanding Social Work, London, Macmillan Press.

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Watson, F., Burrows, H., and Player, C., (eds), (2002), Integrating Theory and Practice in Social Work Education, Jessica Kingsley, London.

Weale, A., (1978), Equality and Social Policy, Routledge and Kegan Paul, London

In this report I will discuss Mental health and community care, I will look at the historical context of community care taking into consideration policies and that stemmed it and competing ideological perspectives that that has impacted on it. I will further look at its benefits and shortfalls since its implementation taking into accounts the impact of the 1990 NHS Community Care Act and current reforms. Finally I will discuss the process of poverty and social exclusion which affects some of these people who have been discharged home as a result.

History of Community Care and Objectives

Dobson (1998) stated that Care in the community represented the major political change in mental healthcare in the history of the National Health Service (NHS)

It was the result both of social changes and political expediency and a movement away from the isolation of the mentally ill in old Victorian asylums towards their integration into the community (Goffman 1961).

The aim was to “normalise” the mentally ill and to remove the stigma of a condition that is said to afflict one in four of the British population at some time in their lives.

The main push towards community care as we know it today came in the 1950s and 1960s, an era which saw a sea change in attitude towards the treatment of the mentally ill and a rise in the patients’ rights movement, tied to civil rights campaigns.

The 1959 Mental Health Act abolished the distinction between psychiatric and other hospitals and encouraged the development of community care.

According to Goffman, (1961) historically, people who were designated as having a mental illness lived in confined institutional environments for years and had limited expectations for returning to the community.

Community care is used to describe the various services available to help individuals manage their physical and mental health problems in the community which is the British policy for deinstitutionalisation. Duane (2003) defined deinstitutionalisation as process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with mental disorder or developmental disability. These services include, for example, nursing or social work support, home help, day centres, counselling and supported accommodation.

The Department of Health expresses the need to promote the development of a personal health plan of individuals, based on who they are, what they want and what their circumstances are.

According to DoH, ‘Health is linked to the way people live their lives and the opportunities available to choose health in the communities where they live’. There have been major improvements in health and life expectancy over the last century and on the most basic measures, people are living longer than ever before (DoH report, 2005).

Rogers A and Pilgrim D (2001) stated that the ideological commitment to community care was associated with vague idea of achieving an ideal society, prior to it being effected as a practical reality. Similarly Titmuss in the 1960s suggested that the notion of community care invented ‘a sense of warmth and human kindness, essentially personal and comforting’ Titmuss (1968). This early positive view emphasised the idea of leaving the disabling environment of the institution behind and ushering in the enabling possibilities of ordinary living.

According to Bulmer (1989), the first use of community care was in the part of mental health, as understanding developed of the negative consequences of institutionalizing mental patients in hospitals, and to discharge the ex-patients and mental handicap hospitals, and to discharge the ex-patients into the community, where they would live in hostel-type accommodation or in their own homes and be cared for by a mixture of professional and personal carers, particularly in day centres and by nursing staff on the one hand and by members of their own families on the other.

Community care in the past has always been a mixed economy, financed by both the state and by user charges and provided by voluntary sector organization, commercial, for-profit organization, the state and the family. Alan Walker (1982, 1989) and Roy Parker (1990) have specifically addressed the problem of defining community care and have pointed out that it has been very easy for one person’s community care to be another’s institutional care. Community care has been a mixture of policies. To the health service any provision outside the NHS equals community care, therefore institution run by local authorities constitute community care.

The mixed economy of community care during the 1960s left wing academics, notably Peter Townsend (1962), made moving request for the deinstitutionalization of elderly and mentally ill people, whereas Titmuss (1968) has already sounded a note of caution when he referred to the way in which the term community care conjured up a sense of warmth and human kindness. All this assumed the main provider of community care to be the state.

In some ways, the idea of community care in mental health ran counter to the dominate trend within the NHS after 1948, which until recently, was centralised and hospital-dominated.

Bulmer (1989) similarly emphasised that in recent years community care has broad meaning including the goal of providing comprehensive outreach, day and residential services and support for ordinary facilities within the locality. In principal at least community care now extends to social inclusion and the promotion of assess to facilities used by other people living in the community and the right and responsibility of participation in local community acitivties.

According to Pilgrim (2001) when the Labour government came to power in 1997, it announced the need for rapid reform of mental health services based on the impression or evidence that care in the community has failed. In 1998, the Health Secretary, Frank Dobson, stated that discharging people from institutions has brought benefits to some. But it has left many vulnerable patients to try and cope on their own. Others have been left to become a danger to themselves and a nuisance to others. A small but significant minority have become a danger to the public as well as themselves.’ Mind, along with many others, disagreed with the statement that community care had failed.

These were based on concerns about control of risky behaviour which led to the spokes enquiry following the killing of a social worker (Isablel Shwartz) in 1984 by patient Sharon Campbell in Bexley Hospital. These were some of the limitations of care discovered and led to recommendation about post-discharge case management DHSS (1998). The report similarly noted the lack of any requirement on the part of services to identify vulnerable patients or provide individualised care plans, and for agencies with responsibilities for mental health to work together.

The inquiry into the care of Christopher Clunis was also another reason why the community care needed a reform.

Rogers and Pilgrim (2001) explained that inquiry examined the manner in which services failed to respond adequately to Christopher Clunis, a young black man With a diagnosis of paranoid schizophrenia who stabbed a stranger (Jonathan Zito) at Finsbury Park underground station. This highlighted a number of problems why the Labour government called for the reform of the community care policy because of the inadequate support for in the community with severe mental health problems.

In 1999 The Government published the National Service Framework [NSF] for mental health modern standards and service models for England. The NSF spelled out national standards for mental health services, what they aimed to achieve, how they should be developed and delivered, and how performance would be measured in every part of the country.(DoH

Community care is the support by informal and formal carers of the elderly, the disabled and the mentally disordered groups in the community who are usually in their own homes rather than in institutions.

According to Bulmer(1989)the ideas with which community care came about is due to the mixture of sociological propositions about the nature of modern community life, including personal ties between relative, friends, and neighbours.

The Griffiths Report: ‘Community Care: Agenda for Action’

Margaret Thatcher invited Sir Roy Griffiths to produce a report on the problems of the NHS. This report was influenced by the ideology of managerialism. That is it was influenced by the idea that problems could be solved by ‘management’. According to the report, Griffiths firmly believed that many of the problems facing the Welfare State were caused by the lack of strong effective leadership and management. Because of this previous work, which was greatly admired by the Prime Minister, Griffiths was asked to examine the whole system of community care.

In 1988 he produced a report or a Green Paper called ‘Community Care: Agenda for Action’, also known as The Griffiths Report.

Griffiths intended this plan to sort out the mess in ‘no-man’s land’. That is the grey area between health and social services. This area included the long term or continuing care of dependent groups such as older people, disabled and the mentally ill.

Basically he was saying that community care was not working because no one wanted to accept the responsibility for community care.

Community Care: Agenda for Action made six key recommendations for action:

Minister of State for Community Care to ensure implementation of the policy – it required ministerial authority.

Local Authorities should have key role in community care. i.e. Social Work / Services departments rather than Health have responsibility for long term and continuing care. Health Boards to have responsibility for primary and acute care.

Specific grant from central government to fund development of community care.

Specified what Social Service Departments should do: assess care needs of locality, set up mechanisms to assess care needs of individuals, on basis of needs – design ‘flexible packages of care’ to meet these needs

Promote the use of the Independent sector: this was to be achieved by social work departments collaborating with and making maximum use of the voluntary and private sector of welfare.

Social Services should be responsible for registration and inspection of all residential homes whether run by private organisations or the local authority.

The majority of long term care was already being provided by Social Services, but Griffiths’ idea was to put community nursing staff under the control of local authority rather than Health Boards. This never actually happened. The Griffiths Report on Community Care seemed to back local government whereas, the health board reforms in the same period, actually strengthened central government control. rewor

According to the Mind, In 1989 the government published its response to the Griffiths Report in the White Paper Caring for People. It set out a framework for changes to community care, which included a new funding structure for social care. This would mark the beginning of the purchaser/provider split whereby social services departments were encouraged to purchase services provided by the independent sector. The report promoted the development of domiciliary, day care and respite services to enable people to live as independently as possible in their own homes. Other objectives included quality initiatives around assessment of need and case management. Carers’ needs were addressed by prioritising practical support initiatives for them. The next decade saw a dramatic increase in the number of voluntary and private sector service providers.

The impact of the community care reforms

The community care reforms outlined in the 1990 Act have been in operation since April 1993 Glennester, (1996).They have been evaluated but no clear conclusions have been reached. A number of authors have been highly critical of the reforms. Hadley and Clough (1996) claim the reforms ‘have created care in chaos’ (Hadley and Clough 1996) They claim the reforms have been inefficient, unresponsive, offering no choice or equity. Other authors however, are not quite so pessimistic.

Means and Smith (1998) claim that the reforms:

introduced a system that is no better than the previous more bureaucratic systems of resource allocation

were an excellent idea, but received little understanding or commitment from social services as the lead agency in community care

the enthusiasm of local authorities was undermined by vested professional interests, or the service legacy of the last forty years

health services and social services workers have not worked well together and there have been few ‘multidisciplinary’ assessments carried out

in reality little collaboration took place except at senior management level

the reforms have been undermined by chronic underfunding by central government

the voluntary sector was the main beneficiary of this attempt to develop a “mixed economy of care”

The Care Programme Approach (CPA )

According to Rogers and Pilgrim (2001) there was a light with the introduction of the Care Programme Approach in 2001. It introduced an attempt to improve and standardise the delivery of community care services. The CPA set out a practice framework for health authorities in England, giving guidance on how they should fulfil their duties as laid out in the National Health Service (NHS) and Community Care Act 1990. The programme contained four key elements namely,

Arrangement for assessing the health and social needs of recipients of specialist mental health services,

The regular use of care plan that identified which provider was responsible for different aspects of a person’s care

Key worker who would monitor and co-ordinate care for the individual

Regular review and if appropriate changes to the care plan.

Through the introduction of the CPA, patients identified at risk have been required to be kept on supervision register (DH, 1995). The idea was that all patients in contact with services would be subject to CPA but that some require greater scrutiny and service input. Pilgrim et al stated that the Labour government inherited this method in 1997 and continued to endorse it as the mainstay of good quality community-based management for people with mental health disorder, despite the concept of community care being problematic by health ministers and controversial cases such as that of Christopher Clunis.

Social inclusion

Social exclusion occurs when, marginalised by society, people are not able play a full and equal part in their community. Many people who experience mental distress experience stigma and discrimination, and live in poverty. They may find it hard to find adequate housing or access employment. The net result is that people can become seriously isolated and excluded from social and working life.

Following the publication of the Social Exclusion Unit’s (SEU) report into mental health and social exclusion, the National Institute for Mental Health in England (NIMHE) have been charged with implementing the 27 action points listed in the SEU report. NIMHE are working on a number of policy areas including employment, education, social networks, housing and homelessness, direct payments, income and benefits.’ (DoH 1998)

1.0 Introduction

This report will explore on mental health and community care within the historical view of community care and the impact of ideological perspectives that have influenced it. It will further analyse the benefits and shortfalls since its implementation, taking into account the impact of the 1990 NHS Community Care Act and current reforms will be considered. Again, the effects of poverty and social exclusion for those accessing community Care will be discussed. The author will further consider key aspects of mental health and the gradual transition from insitutionalisation to deinstitutionalisation (community care) since the early 1950s will be discussed. Recommendations shall be made regarding, especially, how the mental health system (including community care) could be improved.

HISTORY

In the pre-medieval period people believed that mental illness was a result of the possession of the human body (patient) by evil spirits. In order to get these perceived evil spirits out they drilled holes in the skull of such people. Andreasen (2001) tries to give credence to this by mentioning that scientists have found fossils of drilled skulls that are about 10,000 years old. During the middle ages a belief in Europe was that witchcraft was the reason for mental illness. As a punishment such people with mental illness were killed by burning, hanging or drowning. Some were put in government institutions called poorhouses. By the 1500s many European nations had built special institutions to separate the mentally ill from the rest of society. One of the most famous of such institutions was the St. Mary of Bethlehem in London which was built in 1247 and declared a hospital exclusively for the insane by 1547 It is widely known widely known as Bedlam. According to Butcher et al (2009), inmates suffered from unsanitary conditions, beatings and other harsh treatment. This included violent patients being used for shows display shows for the public to pay and watch, while gentler patients were sent to beg for charity on the streets.

A lot has changed in the United Kingdom especially with the relative improvement in the mental health institutions or hospitals and also with the emphasis on community care since the 1950s. In fact some see care in community, usually referred to as community care in as a replacement for hospitalization and any other form of institutionalization of people with mental ill health. However, these historical perspectives of mental illness can stick in people’s minds, and can still cause stigma today. Goffman(1961)

Community Care

Skidmore (1997) describes community care to be the various services available to help individuals manage their physical and mental health problems in the community with dignity and independence in order to avoid social isolation. Similarly, Clough and Hadley (1996) explained that community care can be means of providing the right level of intervention and support to enable people to attain utmost autonomy and control over their own lives. The author notes that in order for these to be achieved, it will require support by formal and informal carers input

The development of community mental health care has evolved over a period of years as opposed to institutional care. Goffman (1961) stated that social and political changes influenced the movement away from isolation of mentally ill in old Victorian asylums towards their integration into the community. Currently, there are various services that have been put in place to support people who have mental health problems and are leaving in the community. These services includes (Sainsbury centre of mental health 2003)

HISTORY

Community care has historically always been financed through a mixed economy financed by both the state and by user’s charges, and provided by voluntary sector organisations, commercial profit organisations, the state and the family (Lewis. J). Social scientist have made an association with informal care to family member participation. Informal care has historically been the origins of the present day community care. The origins of the term community care appear too traced back to the Royal Commission on Mental Health and Mental deficiency (1957) which notes ‘The Development of Community Care’ (Bulmar 1987). However community care has a ‘multiple meaning’ (Bulmar 1987) and historical official use failed to distinguish these differences.

problem as it is a product in part of at least, the impact of political process and policy development.

According to Levites et al (2007), Social exclusion is a difficult and multi-dimensional process which involves the lack or denial of resources, rights, goods and services, and the inability to participate in the normal relationships and activities, available to the majority of people in a society, whether in economic, social, cultural or political arenas. Similarly, Townsend (1979) defines poverty as “the absence or inadequacy of those diets, amenities, standards, services and activities which are common or customary in society”. I will argue from the above definition that, social exclusion and poverty are linked. Pierson (2009) argues that government likes to use the term to hide poverty. Barker (2003) stated that in recent years the government has launched a range of initiatives to help tackle social exclusion and reduce inequalities which has specific objectives relating to education health, employment, crime prevention and wider social well being. These initiatives include the need for communities to put into action; supportive and innovative approaches in order to promote local involvement to support people with mental health problems, as this will minimize exclusion. The structure of care in the community (in relation with mental health) can lead to poverty because many people who experience mental distress, experience stigma and discrimination as well. These issues may make it hard for them to find adequate housing or access employment. As a result, people can become seriously isolated and excluded from society. If this also includes being excluded from working life, then this may lead to poverty. Social Exclusion Unit (2004).

Usual Mental Health Professional Team

There is now a range of more specialist community mental health teams (CMHTs) in the United Kingdom (UK) these includes: Home treatment, Crisis intervention, Early Intervention, First episode psychosis, ABT (assessment and brief treatment), Continuing care, Rehabilitation, Assertive Outreach and Forensic services. These teams are as a reform to government policy to promote community care. They work with people with mental health problems by helping them to become independent, working with them to develop their strengths, working together to resolve problems and many other supports that enables the promotion of wellbeing. A typical mental health professional team include the psychiatrists who prescribe medication, the psychologists who administer and interpret psychological tests, the psychiatric nurses who administer prescription medication and give injections, and the social workers who have specialized knowledge in assessing and planning treatment (Suppes and Wells, 2000).

Conclusion/Recommendations

The gradual transition from institutionalisation to community care since the 1950s is certainly not unhealthy. It only would yield no positive results if, borrowing the words of Skidmore (1994), people with mental health problem are not just decanted into the community without an identification of the informal carers.

Social exclusion is a major concern in promoting recovery for those experiencing mental health problems and if not tackled on time will discourage and lead to relapse for those who have experienced or facing these difficulties. Promoting social inclusion will usually includes promoting equal opportunities for those who are excluded and experiencing discrimination so I can therefore say there is a clear link between promoting social inclusion and promoting equality and diversity to alleviate poverty. I also believe that the Mental health practice which is currently driven by the National Service Framework which aims at reducing discrimination and social exclusion to improve mental health of the population should be supported by mental health professionals to build social inclusion into clinical practice by including in the care plans of users their aspirations for work, education, relationship and other chosen journeys of ‘recovery’.

The following recommendations are worthy of consideration in the bid to improve the current mental health system in the United Kingdom.

Research concerning how institutional and community care can be improved

Reduction of stigma against people with mental illness since that can jeopardize their speedy recovery whilst in the community.

Involvement of informal carers in decision-making regarding treatment of patients

Attend to the health needs of informal carers

Informal carers should be trained on how best they can take care of patients.

The British government should invest more in community care especially with the needs of patients in communities.

Deinstitutionalization should be done more gradually and carefully especially in the case of people with chronic mental illness.

Poverty is generally understood to mean a condition in which people are deprived in some way, such that they lack the basic requirements for sustaining well-being, and ultimately, life. These basic requirements are understood as such things as food, water, shelter (as may be understood, for example, in a developing country context) or access to education or political power (as might be understood, for example, in the context of a developed nation). Poverty is an absolute within itself, as people are termed to be in poverty, but poverty can also be understood in relative terms, when, for example, poverty of different resources is considered: poverty of education is obviously not as fundamental a level of poverty as poverty of food, for example, as, obviously, without food, a person would die, but a person can manage to live without education, even if this would mean a life of continuing poverty, through lack of opportunity.

Poverty can be measured in many different ways, and indeed, there are many indicators of poverty, which are used to assess year-on-year changes in poverty. Obviously, as with definitions of poverty, measurements of poverty are relative, with different measures being used in developed vs. developing nations, for example, or between nations of the developed, or developing, world. In general, one overall measure of poverty which has gained ground in recent years is the income inequality scale, which shows that income inequality has, recently, worldwide, become less of a problem, with the world becoming more equitable in terms of income levels across the world’s nations. This does not belittle the problems of poverty, however, as poverty is still a major issue that the world has yet to deal with in a satisfactory manner.

As with the definitions and measurement of poverty, the causes of poverty are many and varied, with environmental and geographical factors creating poverty in many developing countries, and with disease and lack of natural resources also causing poverty in these regions. Indeed, it is difficult to attribute one cause to poverty in any situation, especially poverty in developing countries. In developed nations, however, poverty is perhaps best understood as a product of society’s failure to act to avoid the situation, and, as such, policies are in place to prevent poverty in these situations^[1]. It is a moot point, however, amongst politicians, social workers and philanthropists as to how far policies can actually prevent poverty, and, indeed, some people suggest that current policies do not go far enough to act to prevent poverty.

The effects of poverty are, again, many and varied, with poverty leading, ultimately, to death, in many developing nations, and with poverty leading to lack of opportunity and social exclusion in developed nations. In developed nations, policies are in place to avoid such poverty, such as subsidised housing, education and health care^[2], although these are not always effective, as we have seen, leading to undesirable effects, such as crime (Jones, 2001; Muncie, 2004). It is hypothesised, for example, that in extreme poverty situations, people turn to crime in order to provide basic necessities, and this has been supported by much original research on the subject (see Muncie, 2004).

The next section of the paper will look at levels of poverty in the UK, and following this, the paper will then proceed to assess poverty in the UK from a Marxist viewpoint. Poverty in the UK is still at shockingly high levels, with the problem seeming, on the face of it, to be mainly caused by low pay levels; indeed, it is suggested by recent research that in low-income households, both members of the family need to work in order for the family to earn enough to cover basic expenses^[3], and that, of these low income families, many are at a disadvantage in terms of receiving health care and the achievement of minimum educational standards. It seems, also, that this trend, rather than decreasing, is actually increasing, with the number of families claiming children’s tax credits increasing year-on-year and the proportion of workers classed as ‘low paid’ increasing year-on-year^[4].

It is shocking, therefore, to see that much of the UK, and a large proportion of the children living in the UK, live in poverty. This is despite the fact that policies have been in place for many decades to try to curtail, and avoid altogether, the issue of poverty. As we have seen, however, these policies are often not effective, and can take years to come to fruition, by which time a new generation of infants have grown up in poverty, leading to what is known as ‘the poverty trap’. We have seen, therefore, how successive UK governments have attempted to deal with the issue of poverty: by creating policies to deal with each ‘strand’ of poverty individually, and not attacking the whole problem of poverty as a whole.

This leads on to thinking about how Marxists understand poverty, which is essentially in a more holistic, if idealistic, manner. Marxists do not make any distinction between class, poverty and disadvantage; for Marxists, members of any class, they argue, can fall into poverty through unemployment, for example, and that, as such, ‘the poor’ can be best be viewed as part of a continuum from those in society who have a lot of material wealth to those who do not. This definition using the idea of a continuum, however, stands in direct contrast to the situation of class inequality which, obviously, Marxists attempt to fight against by their calls for equality in society, for all.

Perhaps the issue of poverty can be best understood in terms of the dependency theory of Marxists: this theory suggest, essentially, that lifting the poor out of poverty is not enough, they need to be given tools to be able to sustain themselves out of poverty. True Marxists would add that this can never be achieved under a capitalist system, as this system is built to achieve successes at the expense of the failure of others; as such, poverty is a consequence of the capitalist system, and something which Marxists fight against, in their search for equality, or, rather, in terms of poverty, in their quest for a situation in which underdevelopment is not an option.

Assessing poverty in terms of a purely socio-political approach as we have done, and then within the framework of Marxism as we have also attempted, provides two different frameworks with which to understand the issue of poverty. One framework aims to treat poverty as something that can be solved by implementing policies and by watching those policies take effect, the other attempts to understand poverty as a societal achievement, which can only be solved by changing the very foundations of society.

Social workers are some of societies most valuable professionals, who, in concert with families, teachers, and the police can put children, and families, back on track before they reach an irreversible moment in which damage has been done which cannot be corrected. Children are valuable members of society, and it is the responsibility of all society to look after them: perhaps this is what Marx was implying when he talked of societal equality. Children deserve equality of opportunity, in terms of access to basic requirements, and, above these, to health care and education and information provision. Without these basic requirements, without basic care, children live in poverty. It is a travesty that in this day and age there are many children who live in poverty in the UK, but with the approach outlined here applied on a daily basis by social workers, it is hoped that poverty will soon be a thing of the past, at least in the UK.

References

Best, S. (2005) Understanding Social Divisions, London, Sage

Cree, V. E. (2000) Sociology for Social Workers and Probation Officers, London, Routledge.

Dominelli, L. (1997) Sociology for Social Work, London, MacMillan

Glennerster, H. et al. (2004). One hundred years of poverty and policy. Joseph Rowntree Foundation.

Iceland, J. (2003). Poverty in America. A Handbook of the University of California Press.

Jones, S. (2001) Criminology, Trowbridge, Cromwell Press

Layder, D. (2005) Understanding Social Theory, London, Sage

Muncie, J. (2004) Youth and Crime, 2nd edition, London, Sage,

Ritzer, G. (2000) Sociological Theory, London, McGraw-Hill

1

These effects have a negative bearing on children and mothers since they affect self-confidence and ability to meet life goals. Separation, substance abuse, mental disorders and divorce are effects which adversely affect children’s development stages (Johnson & Ferraro, 2004). Abused children may replicate abuse as adults, which lengthen the violence cycle. This paper will discuss family violence in Canada including marital rape. Statistics which reveal extent of abuse will be disclosed and various dynamics of abuse discussed, including relevant laws. Since family violence is normalized, processes of normalizing the vice will be evaluated. Brief recommendations on how abuse can be discouraged will be discussed, with a summary given at the end.

Statistics

There are more than five hundred shelters for children and women in abusive households in Canada (Gannon, 2006). Newfoundland and Labrador, New Brunswick, Prince Edward Island and Manitoba have among the highest number of shelters. In 2007 over 40,000 cases of domestic violence were reported to law enforcers. This comprised over 11% of the overall crime in Canada, which is a significant proportion. In addition to this, over 80% of victims were female, which shows that wives bear the brunt of violence in households. In most cases, assault was reported in family violence, with stalking, criminal harassment and threats being other forms of abuse committed. In over 80% of abuse cases, people familiar to victims performed abuse. More than 40% of women are also reported to have experienced marital rape.

Law enforcers were also blamed for abuse, with over fifty thousand cases involving youth and children being committed by them (Wallace, 2009). Amongst adults, law enforcers reportedly abused over 1900 people, with this representing a third of abuse cases amongst adults (Gannon, 2006). Generally, these statistics reveal that both law enforcers and the public are responsible for abuse. Children and women suffer the largest proportion of abuse, with this being performed by men they are in relationships with. Domestic abuse comprises over 10% of the overall crime committed which reveals the severity of the issue. It is imperative that abuse is analyzed in further detail and prevention measures developed to stem this rising crime.

Canadian rape laws

Initially, rape was regarded as an offense in common law. Common law is borrowed from England and it initially treated rape as abduction. It was regarded as an offense greater to fathers or husbands than to female victims. Marital rape was unheard of during this period and was not considered criminal. The society then, also marginalized women and their testimony alone could not prove evidence of rape. Their previous sexual conduct was heavily relied on in proving rape. However, this crime was unreported despite its rampancy. In 1983, weaknesses in existing laws led to changes which redefined nature and punishment for rape. There needed to be stricter punishment and higher convictions to encourage women to report rape. Changes included abolishing analysis of previous sexual history of victims, repealing of corroboration laws and redefining of rape to assault. Further legislation changes in 1992 outlined the shield on use of historical sex lives of victims in questioning their credibility.

Reasons for domestic abuse
Power and domination

The quest for power contributes highly to cases of domestic violence. Some people need to dominate others to feel they have power. These people use oppression and abuse as tools to attain power. Physical abuse enables them to make victims powerless over them. Economic abuse ensures that victims are dependent and cannot escape abuse. Mental disorders, low esteem or stress may drive offenders who use violence to attain power. Such abuse may be reversed through medication and therapy with support from family (Babcock et. al., 2004).

Drug abuse

When people use drugs, they may be unaware of consequences of actions. They are unable to reason rationally and may resort to abuse. People who live with drug abusers suffer most from effects of drugs including increasing irritability, delusions, stress and other effects (Dutton, 2006). These may lead to domestic violence and can be treated through medication and therapeutic interventions.

Socialization process

Research reveals that children who undergo abuse when young may replicate the abuse as adults (Kitzmann et. al., 2003). Abused children have higher chances of practicing family violence as adults compared to those not abused. This is explained by the sociological theory where children practice things imparted on them during the sociological process. When they are abused, they may view it as part of socialization and they may commit the same to their families as adults.

Normalization of family violence

The widespread nature of family violence has created a perception of normalization, where violence against women is “acceptable” by society. Normalization of violence is seen in low reporting rates of violence at home. In Canada, over 50% of cases of violence in family settings are unreported, according to research. Since family violence is widespread, there are emerging trends where batterers are offered sympathy at the expense of victims. This trend began in the 1980s in US where intervention and support programs for batterers were created. These programs rationalize domestic violence and perceive batters as victims. The society is thus sympathetic to abusers and they become tolerable to certain degrees.

In some cases, victims view themselves as having provoked abusers, hence rationalizing the crime. Since batterers are close family members, victims may also avoid reporting battery due to consequences on family units, especially if they are dependent on the batterer (Ellsberg et. al., 2001). Others fear societal perception of the abuse especially if it leads to divorce. They see it as shame and allow violence to be perpetuated against them. This gives the abuser leeway to commit abuse and normalization of abuse occurs as a result. Victims view it as normal and learn to live with violence.

Weak laws governing violence also normalize violence since victims will not report abuse if there are few and light convictions. In addition to this, barriers to reporting, investigating and prosecuting abusers may lead to normalization of abuse. The laws governing rape in Canada in 1980s can illustrate this phenomenon. As was discussed, the society marginalized women, and their testimony alone could not prove evidence of rape. Their previous sexual conduct was also heavily relied on in proving rape. In addition to this, marital rape was unheard of. Weaknesses in such laws discouraged reporting of rape, and this normalized the crime. When changes were realized in 1983, reporting rates increased and rape cases decreased.

Weaknesses and strengths of research sources

There are different research used and these have diverse weaknesses and strengths. Most works used are journals and books which are scholarly in nature. Scholarly works are credible information sources since they are written by professionals in diverse fields. These works are sourced from the Internet, which is readily available and cheap, which is a strength of these sources. They also cover diverse topics and give various dimensions on topics discussed, which makes them accurate and credible. However, weaknesses include inability to corroborate information gathered due to difficulty in tracing the authors. This may create ambiguity or inaccuracy in research done. Duplication of error is another weakness which arises from use of inaccurate scholarly works. If works used are inaccurate, the research findings will be erroneous. Finally, these works may be outdated which makes research inaccurate.

Conclusion

Various aspects of family violence and marital rape have been evaluated. Marital rape and domestic violence is rampant, with 40,000 cases of domestic violence being reported to law Canadian enforcers in 2007. This comprised over 11% of the overall crime in Canada. Various reasons for violence including socialization process, power and domination and drug abuse have been advanced as reasons for abuse. However, there is no rational reason for commission of violence. Recent trends have also revealed normalization of violence in the current society. Weak laws, fear by victims and societal perceptions are to blame for normalization of abuse. This is dangerous for society as it encourages commission of crime. The statistical evidence also shows that law enforcers also practice abuse, and this is intolerable in society. This paper used scholarly works and books, and these are valid sources. The evidence provided is therefore accurate and several measures which discourage abuse should be taken. Some of these will be discussed in recommendations provided below;

Recommendations on reducing family violence
Legislation

Legislation plays a crucial role in acting as deterrent to crime. Many people cannot commit crime due to fear of repercussions. In tackling domestic abuse, a similar approach is effective since harsh repercussions will deter offenders. The Canadian parliament should develop harsher legislation to deal with marital rape and domestic abuse since it is a significant societal problem. This will reduce instances of abuse through long sentences to abusers.

Rehabilitation

Although Canada has over five hundred rehabilitation shelters for abuse victims, this figure is still inadequate (Taylor-Butts, 2007). More shelters for abuse victims should be constructed and stocked with necessary facilities and staff to help victims. This will enable victims to achieve their life potential through pursuance of individual dreams and goals.

Public education

According to Hamel and Nicholls (2007), education is very effective in reducing abuse. The public should be educated at individual, society and family levels on domestic abuse. Abuse signs and cooperation with law enforcers will help eradicate this vice. In addition, shelters for victims should be publicized to ensure victims seek justice. Education on abuse will prevent the normalization of abuse in families.

Interpersonal skills, majority of the managers chose interpersonal skills as their greatest strength. Managers must have a good communication skill in dealing with their stakeholders. In Catherine Lodge, our manager has effective communication skills in dealing with the entire situation with regards to resident’s needs if it is being met, staff, and resident’s families.

A good company wouldn’t have a very strong foundation without a team that helps in problem-solving. Care workers must be careful in recognising a problem by assessment, know the possible cause and effect, and plan for the procedure thoroughly. Team work will set in, as the person who recognises the problem will report to the team, to assess, collect all the data, and to plan the best action. Communication is still there as they are following a process of solving a problem, and in decision-making. (http://www.jstor.org/discover/10.2307/2629217?uid=3738032&uid=2129&uid=2&uid=70&uid=4&sid=21101226337883)

The aim of the policy is to ensure that the effective channels of communication are established, supported and maintained. It believes that the communication of good information promotes quality care, offers client’s assistance in making informed choices and plays a vital role in motivating and supporting staff.

aˆ?To enable us to fulfil our statutory responsibilities to provide information.

aˆ? To communicate effectively with staff about ongoing issues, policies and procedures.

aˆ? To provide opportunities to consult with staff and for them to express their

Views and offer ideas and suggestions.

aˆ? To communicate effectively with client’s and their representatives.

aˆ? To promote the quality of service that we provide to our clients.

Technology is moving so fast nowadays that we have many electronic aids to help us communicate. For example, smart phones can used to make calls, send text messages and emails; can used to make video call where you can see the person on the other line, can leave a voice message if it’s not available.

There are many factors that affect communication. They are:

aˆ? Sensory deprivation – when someone cannot receive or pass information because of visual and hearing disabilities.

aˆ? Foreign language – when someone has different accent, different pronunciations, and/or uses sign language that the other person does not speak, or understand.

aˆ? Jargon – Using of medical terminology to a patients, service users, and family members that they may not understand, it is better to explain things according to the level of their understanding because understanding the facts can make something appear less scary.

aˆ? Slang – when a care worker uses a language that is not everyone uses, or familiar with.

Cultural differences – there are some things that has the same meaning but could mean different in two cultures. For example, keeping an eye contact whilst communicating is seen as being respectful, and being truthful, but for some culture like in East Asia for them it is a sign of being rude and defiant.

aˆ? Distress – everyone can experience distress, this can be difficult for them to clearly understand what is being said due to lack of focus.

aˆ? Emotional difficulties – every one of us has emotional difficulties at times and can make us upset. The negative effect is not to hear or understand clearly what the other person is is telling you and can lead to misunderstanding.

aˆ? Health issues – when the person is ill, he/she cannot be an effective communicator, especially service users that suffering from Parkinson’s disease or Multiple Sclerosis affect an individual’s ability to communicate properly, care worker should be trained and aware on how to work with these people.

Communication Audit it is a method use to identify the Strengths and Weakness of your current and external communications.

Organisations recognise the benefit of keeping their customers, clients, investors, partners and/or members aware of happening with in their organisation. The techniques they choose are varied, ranging from the “tried and true “e.g. e-mailings, and website postings, variant of high technology tools. Placing a suggestions box at the front door gives the resident’s family to write their comments and suggestions anonymously or they can name their names, and/or they can even go straight to the managers, seniors for their comments. Making quarter year survey that requires family member of clients to answer a questionnaire, and they are free to add their comments.

When Stakeholders reach out: developing and implementing a promotion plan We go into developing a promotion plan. We offer steps and examples. From there we look at what a communication plan entails. Emerging from this we look at relating to the media. We highlight the importance of identifying key messages and who your target audience is for different promotion work. Finally, we offer lots of suggestions for nervous speechmakers.

Promoting your organisation: when people reach in: A large part of an organisation’s work happens through telephone contact and with visitors coming to your office. If you put people off with a negative attitude when people phone in or visit, you will probably end up having an organisational image not to your liking. So, we look at promoting your organisation’s image in this context. We give ideas about your reception area, how you receive people, handling phone calls and e-mails. And we end off looking at how you can monitor and evaluate your organisat ion.

Task 2 – Report

Catherine Lodge is a residential care home that aims to provide continuous professional care to all its residents within a safe, friendly and relaxed environment. It caters up to 39 elderly residents providing each individual with a personal form of service derived from a carefully formulated care plan that meets their needs. This is provided both in short and long term basis depending on each individual. Since each resident has specific needs that range from physical, psychological, social or spiritual needs on a 24 hour basis it requires a certain level of personnel to facilitate this.

“Show me the money!” Well, that’s what financial data do. They show you the money. They show you where a company’s money came from, where it went, and where it is now.

There are four main financial data. They are: (1) balance sheets; (2) income statements; (3) cash flow statements; and (4) statements of shareholders’ equity. Balance sheets show what a company owns and what it owes at a fixed point in time. Income statements show how much money a company made and spent over a period of time. Cash flow statements show the exchange of money between a company and the outside world also over a period of time. The fourth financial statement, called a “statement of shareholders’ equity,” shows changes in the interests of the company’s shareholders over time.

A balance sheet provides detailed information of company’s asset, liabilities and shareholders’ equity.

Assets are things that company owns that have value. They can either be sold or used by the company to provide services that can also be sold. It also includes physical property of the residents that can/can’t be touched but nevertheless exist and have value.

Liabilities are amounts of money that a company owes to others e.g. all kinds of obligations like borrowed money from a bank, payroll a company owes to its employees, environmental costs, taxes owed, and obligations to provide good quality of services.

Shareholders’ equity or capital

Income statements is a report that shows how much revenue a company earned over a specific period, it also shows the company’s net earnings and losses.

Cash flow statement report a company’s inflows and outflows of cash. This is important because a company needs to have enough cash on hand to pay its expenses and purchase assets. While an income statement can tell you whether a company made a profit, a cash flow statement can tell you whether the company generated cash. It shows the net increase or decrease in cash for a period.

In Residential home, we have enough staff to work in the morning, in the afternoon and at night. We have a monthly staff meeting to raise our concern at work, problems with our colleagues, and suggestions on resident/s care plan, and we also have a separate Senior Carers meeting, the Manager/Owner and the Deputy Manager always presents the Carers the needs of good communication, and team work. We have supervision every 3 months, the manager is giving feedback to identify our strengths and weaknesses, and if they think the staff needs to be trained, and appraisal every 6 months in which we rate ourselves, and the Deputy Manager is rating the staff as well in our performance, we can voice out our own opinion, about the job, colleagues and if we are getting support from the Managers. The company also provided us mandatory training, manuals, booklets, presentation from the lecturer and a questionnaire that we need to answer at the end of the training. Catherine Lodge has a seasonal newsletter where they introduce new staff member, residents who celebrated their birthday, and about the achievements of the company.

A good communication skill is very important, specially working in care settings. Working with vulnerable adults requires more understanding, must have different techniques and strategies use in supporting communication between the individual with specific communication needs. Good communication with vulnerable adult is essential. This includes identifying behaviour triggers, by means of visual prompts and speaking in short, clear sentences. I considered that the social workers used verbal and non-verbal forms of communications and applied the principles of active listening. Some people with disabilities are not able to use speech as their principle means of communication. They may however be able to use an alternative method of communication such as symbols and symbolic languages. It is vital to recognise that symbols are different from pictures. Pictures generally convey a lot of information at once but their focus is often unclear. Symbols, on the other hand, are often designed to convey a particular meaning. Symbols or symbolic languages can be applied to signify many aspects of verbal communication. Symbols can be presented through visual, auditory and/or tactile media and can take the form of gestures, photos, manual signs, printed words, objects, ‘reproduced’ spoken words or Braille. Symbols help understanding which can increase involvement, choice and confidence. It helps support creativity and self expressions. Using mobile phones at work is strictly prohibited, as it may interfere in whatever the carer is doing or it may cause accident e.g if the Carer is feeding, doing morning care. Some residents may have challenging behaviour that sometimes affects the carer itself, they best react in a calm, quiet environment, Carer must consider the Residents preference, cultural difference, language and environment, assumptions, judging, noise, and distraction.

The use of technology helps the care workers by having an easy access by just typing the resident’s name all his/her information daily report will come out in one click, comparison graph of residential’s weight incomparable from past to present will easily available in one click, not unlike if it is just written and filled you have to search for it and check the book where you filed it. Make work a lot easy, report will neat and tidy, because it is easy to edit if you accidentally misspelled.

Disadvantage of it is if the computer got virus and/or the system got hacked all the information will wipe out, that will give an extra work for the manager, care workers, and andmin.

Code of Practice sets out the minimum standards and guidelines for hygiene, fire building safety, and the level of care required , which aims at ensuring that residents in the homes receive services of acceptable standards that are of benefit to them physically, emotionally and socially. (http://www.swd.gov.hk/doc/downsecdoc/code_rchpd.pdf)I will assess the workplace strategies, policies and procedures that should be in place to ensure good practice in relation to all forms of communication in health and social care setting. The health and social care industry mainly focuses on the heart of care. Since it involves people, communication takes a very important role. Effective communication is not only significant to the health care professionals in ensuring the improvement of clients’ quality of life by addressing their needs. It is also the client’s and support systems’ right in the promotion of their equality and diversity as people.

Workplace strategies, policies, and procedures for good practice in communication focus on ensuring privacy, and confidentiality, disclosure, protection of individuals, rights and responsibilities, and equal opportunities. Moreover, a practice on disciplinary procedures, complaints policy, and flexible working also benefit the entire health care team. If all these flow efficiently, there will be no hindrance in the system of communication. For example, one of our residents had a GP appointment and I escorted her. When we arrived in the GP surgery, the receptionist asks the residents loudly for the reason that I am in the GP surgery in which other patients can hear, there is a break in the policy of ensuring privacy. Whenever I start expressing my concerns at her pace, then I will definitely not have my privacy. It establishes a barrier between us personally and professionally. As a patient, I might start complaining with regards to her action.

Effective communication is a key factor in success may it be in work or association. It is always a part of personal and professional progress. Therefore, to master communication skills and techniques is a very important area to develop in each individual. In the given scenario its implication is to render a quality health care service which benefits the service providers and the service users.

Data Protection is designed for person responsible for safeguarding the confidentiality of information and of the person giving his or her own information. One of its purposes is to safeguard “the fundamental rights of individuals”.

This act governs the right storage and processing of personal data held in manual records and on computers. Under this act, the rights of the individual are protected by forcing organisations to follow proper and sound practices, known as data principles (DPP). Reporting and recording of information is a vital form of communication needed to ensure the safety of vulnerable adults. Parts of a carer’s daily routine should include making notes in a care file, as well as using communication books, forms and documents. Make sure that the writing is legible and clear, that is signed and dated, and that where necessary copies are made.

http://transparency.dh.gov.uk/dataprotection/information-charter/

Health and Safety inspections are an important monitoring tool to help ensure that workplace hazards are controlled and that risk to employees and others are eliminated or minimised. Inspections should be carried out regularly. Carers must inspect the equipment/s before using it, report and record all faulty equipment/s to the Manager e.g. heating, lightning, and ventilation. Charter is for anyone who has dealings with the Department of Health whether through correspondence, involvement in public policy consultations or if for any other reason we hold personal information about the resident.

Communication and listening gives clues to a better understanding of an individual’s preferences and wishes. Gathering information about an individual will lead to creative and supportive ways of providing care. Carers must exercised active listening and having the ability to empathise with the residents by paraphrasing what the others saying to her and understand it. So that, she will increased the trust and gain more information from the individuals. Communication itself is influenced by individual’s values and culture. Carers should always make sure of eye contact; focus on what they are saying and acknowledged what is being said to her by paraphrasing or nodding her head. Carers must also use different technique to enhance their social culture, beliefs and values. Like for instances, I usually greets and chat with the individuals by smiling , Carers must apply the sense of touch in her communication. I believes that by means of touch can be a very positive form of communication in that it can provide comfort and re-assurance when someone is distressed making them feel safe and secure, it can also be a signed of love, respect and affection to somebody or it may calm someone who is agitated. In this case carers show that they met the desires of the human beings to their client which are love, purpose and self expression.

Carers should be warm and caring in nature and she has the ability to connect well with others. Fine qualities and having a good communication skill plays important role in the delivery of care in whatever ethnicity, sex, education or social care they may be.

Saving face is saving your credibility, dignity and ethics by means of being honest, getting out of the situation by means of good explanation.

Theories of Organisational communication

Attraction- selection attrition framework; In Attraction, everyone is different, people are differently attracted to a career for different reasons, this could be their passion, helping and/or looking after people could make them happy and fulfilled, even if they just want to try different job, and this is depending on their personality to choose the organization they want. In Selection, in organization the Manager chooses who she thinks will qualified for the job, with the same interest, goals, and personal reasons. Attrition, this is the complete opposite of attraction, where the people who didn’t qualify, or found that they are not happy with the organization, management, job tend to leave, only those people who have the same ideas, interest, fits in the job chose to stay. A very good example is in the residential home I used to work, I’d chose that residential home to apply because of a good reputation. The manager hired me because she thinks have got the qualification they are looking for, and I can contribute to the organization. I and the other lady started working as a Induction carer, 3 days after the manager talked to me, and told me my colleagues are happy working with me and I can start working as a regular carer, working on my own. The sad part was, the new lady didn’t appear two days after.

http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Public%20Relations,%20Advertising,%20Marketing%20and%20Consumer%20Behavior/Attraction-Selection-Attrition_Framework(ASA).doc/

There are many types of organizational communication. Individuals communicate with peers, superiors, and subordinates within the organization. Managers manage through communication. Employee communication departments attempt to inform and/or secure “cooperation”; from employees. Labour relations specialists deal with labour unions. Formal and informal communication takes place between departments and role occupants throughout the organization. Public relations specialists communicate to external audiences about the organization in general,and advertising departments communicate to consumers about the organization’s products and services. Change agents; and other organizational representatives communicate with clients and community representatives. Finally, organizations communicate with other organizations which generally share common problems or values. In groupthink or team work, a manager or team leader should be sensitive, open to accept suggestions from your subordinates in order to meet the target goal. Working in groups are building blocks for meeting organization goals. Managers should also consider ways to develop leadership in team members. Training for versatility in leadership styles through workshops could encourage this growth. Encouraging self-growth through concept of motivation.

It is very important to have an effective communication at shift turnover; Care workers should give this a high priority. Shift turnover should be included in the safety-critical topics supervised and audited periodically by management. They should identify its importance in policy and procedures, assign responsibilities and set minimum standards. A description of how to conduct an effective handover should be available so individuals can assess and improve their own practice. High risk handovers needing extra attention should be flagged up.

The importance of effective communication skills during shift handover and throughout other work activities suggests this attribute should be amongst the selection criteria for key posts. Furthermore, opportunities should be available for existing staff to develop their communication skills if required.

To be able to motivate a care worker is to identify his strengths and weaknesses, and by giving him feedback. Being open to accept negative feedback is the key for being productive by improving, and being eager to learn, and update skills. Team work and good communication with one another will make each other’s work easy.

Task 3 – Interpersonal communication

How the use of ICT in health and social care benefits service users? The Information Communication Technology aims to the efficiency of the health care services. This means to b a better outcome for the same or a lesser use of resources. ICT also helps and empowers the health and social care staff, it improves positive patient’s experiences and facilities research and development relevant to health and social care, the legal consideration in the use of ICT is the Health and Safety. How the ICT supports and enhances the activities of care workers and care organisations? As aforementioned, the ICT supports and enhances health and social care activities of care workers and care organisations. It is through administrative, financial, clinical, infrastructure applications, etc. That the needs of staff are met; and there is a high regard innovation in business administration, efficiency and quality of service. It also helps in meeting requirement of other agencies, accountability, and audit. For example, the use of a computer screen is an indication of a patient’s arrival makes the work of the receptionist lighter and easier. Imagine if there was no such thing then the receptionist will have to entertain every person coming in a queue. She will not have enough have time to do other things.

Working with vulnerable adult, Professionals must shows different techniques and strategies used in supporting communication between the individual with specific communication needs. Good communication with people with vulnerable adult is essential. This includes identifying behaviour triggers, by means of visual prompts and speaking in short, clear sentences. I considered that the carers must use verbal and non-verbal forms of communications and applied the principles of active listening. Some people with disabilities are not able to use speech as their principle means of communication. They may however be able to use an alternative method of communication such as symbols and body language. It is vital to recognise that symbols are different from pictures. Pictures generally convey a lot of information at once but their focus is often unclear. Symbols, on the other hand, are often designed to convey a particular meaning. Symbols or body language can be applied to signify many aspects of verbal communication. Symbols can be presented through visual, auditory and/or tactile media and can take the form of gestures, photos, manual signs, printed words, objects, ‘reproduced’ spoken words or Braille. Symbols help understanding which can increase involvement, choice and confidence; it helps support creativity and self expressions.

Theories of Interpersonal Communication

Uncertainty reduction model People have an urge or need to reduce uncertainty about individuals that they find attractive and this motivates them to communicate In Social network theory closeness develops if people proceed in gradual and orderly fashion from superficial to more intimate levels of exchange. People consciously and deliberately weigh the costs and rewards associated with a relationship and seek relationships that reward them and avoid those that are costly. People connect with others because they believe that rewards or positive outcomes will result. Expectancy value model People believe according to their expectations, and evaluation. The behaviours they perform in response to their beliefs and values are undertaken to achieve some end. However, although expectancy-value theory can be used to explain central concepts in uses and gratifications research, there are other factors that influence the process. Attribution theory is significantly driven by motivational drives, looking at how the person constructs the meaning of an event based on the person’s motives to find cause on person’s surroundings.

Personal development planning is the lifelong process of nurturing, shaping, and updating person’s knowledge. It is about allowing individuals to improve and develop in line with the industry in which they engage or aspire to engage. It is about widening or broadening their knowledge and skills in order that they will continue to have a place in the flatter structures of today’s organisations.

The benefits of personal development planning are that it provides a schedule to work to motivate the individual and suggests a framework for monitoring and evaluating achievements. A good example is If you are currently working as a first line manager or senior administrator and aspire to the position of your manager, you may need to acquire new skills or develop your lower level skills to a higher level in, for example, budgeting, managing people, performance review, report writing and chairing meetings. You would need to planhow you are going to acquire these skills and over what time frame. Personal development planning can also be the basis for: Assessing where you want to be and how you can get there ,keeping skills up-to-date through meetings, trainings, reading the record book of the residents, updating it via computer, particularly in IT and technical areas, Continuous learning, gaining satisfaction from achievements through feedback from colleagues and management whether it is formal or informal, Building up transferable skills, such as time management, adaptability to change, self-awareness, and supporting future employability. You have to set yourself a SMART objective; they must be attainable, viable and realistic time-frame.

A good example of SMART objective is;

Within the next 12 months (time-bound), I will devise and implement a system (specific) which will enable the team to communicate more effectively with each other (achievable and realistic) through monthly group meetings and three-monthly one-to-one meetings (measurable).

Introduction

Most women and men are at a disadvantage in areas of job and trainings, wages and salaries, and are constrained to certain occupations based on their age, colour, disability, sex, ethnicity, without reference to their capabilities and skills. Today, in some developed countries for example, women workers still earn up less than male colleagues performing the same work. According to the Equal Employment Opportunity law, workers have the fundamental human right to be free from discrimination, can choose their employment freely without bias and have the ability to develop their potentials to the fullest. Workers benefit from equality policies through training, equal wages, and overall quality of the workforce.

The aim of this essay is to explore the multifaceted problems of unequal treatment of workers as a result of diversity and gender discrimination between men and women at work (the labour market). The study will also attempt to highlight the advantages and disadvantages of diversity and equal opportunity at work, and also proffer solutions for the reduction and subsequent eradication of gender discrimination. To the society at large, bringing equality to the workplace has major financial benefits, and if employers practise equality they would have access to a pool of well organised and diverse workforce. ILO (International Labour Organisation) practices equality as a tool to eliminate discrimination at work and in the society, they also apply gender mainstreaming strategies in the field of labour.

Benefits of workplace diversity

Employees from diverse backgrounds bring individual talents and experiences into the application of work. A diverse workforce of skills, experiences, languages, cultural understanding allows a company to operate globally in providing service to customers and having a variety of viewpoints, and also improving an organization’s success and competitiveness as well as increased “efficiency and effectiveness” (Sharron and Maeve, 2007, p.157).

Diversity and equality are linked to HR practices, therefore HR professionals have a key role in the implementing of fair and favourable working conditions for employees, and this indeed is a key challenge. Managing diversity helps to control differences by creating a productive working environment in which everyone, “feels valued” (Tom and Adrian, 2009, p.346), talents are fully utilised and organisational goals are met. The CIPD definition of diversity is, “valuing everyone as an individual, valuing people as employees, customers and clients” (CIPD, 2007). However, it is also applied to social groups thereby raising awareness of ethnic and cultural diversity. We live in a multi-cultural society where contributions from different cultures are made to society and culture. Diversity should focus on the positive rather than the negative.

Equality opportunity and gender mainstreaming

Equality can be defined as combined efforts, equal participation and shared responsibilities involving both sexes in decision making, implementation of policies aimed at maximizing potential production of goods and services. The fruits of these efforts should also be shared equally and both sexes should be given opportunities to exercise their rights. Equal opportunity approaches are aimed only at the disadvantaged and therefore potentially create problems in organisations by constantly targeting the disadvantaged rather than making efforts to ensure that the organisation naturally encourages equality of opportunity for all and sundry. There are six social groups listed in the Equality and Human Rights Commission Literature, the body that regulates and monitors the UK’s equality legislation, which are gender, age, disability, ethnicity, religion and sexual orientation. These social groups are protected by law, therefore staff and customers have the legal right to be treated fairly and equally (Kirton, G and Greene, A, 2005).

Article VII of the 1964 Civil Rights Act, bans any type of discrimination based on any social group. In addition, 1963 Equal Pay Act prohibits organizations from formulating gender-based pay discrimination regarding workers who perform same work under similar conditions. Article VII of the 1964 Civil Rights as well set up the USA Equal Employment Opportunity Commission (EEOC), the commission started working in 1965 and has a duty of enforcing the federal acts which disallows workplace discrimination. The focus of Employment Opportunity is underpinned by the notion of social justice or the right to be treated fairly.

The following are selected relevant ILO instruments on Equality:

Equal Remuneration Convention, 1951 (No. 100) This fundamental convention requires equal remuneration for all workers (men and women) for equal measure of work in ratifying countries.

Discrimination (Employment and Occupation) Convention, 1958 (No.111) This fundamental convention requires ratifying nations to declare and pursue practices of equality of opportunity and treatment in respect of employment and occupation, with a view to eliminating any distinction, exclusion or preference made on the basis of race, colour, sex, religion, political opinion, national extraction or social origin.

Workers with Family Responsibilities Convention, 1981 (No. 156)

The convention requires ratifying states to make it a goal of national policy to enable working men and women with family responsibilities to exercise their right without being subject to discrimination and, as much as possible, without conflict between their employment and family responsibilities. The convention also requires governments to take into account of the needs of the workers in community planning and to develop or promote community services, public or private, such as childcare and family services and facilities.

Diversity in the workplace is responsible for and sensitive to the different types of individual who make up an organisation (Sharron and Maeve, 2007, p.159). Organisations need to study the cultures, people and societies they work in, so they can understand and provide for the diverse needs of their customers/consumers. When organisations ‘manage diversity’ properly, they get excellent results from employees and meet the varying needs of their customers, which is recognised as a factor in business excellence. International Business Machines (IBM) has a long-standing commitment to equality to ensure everyone is allowed to compete on an equal basis. Workforce diversity at IBM ‘excludes no one and serves as the bridge between the workplace and the marketplace’.

The main issue for diversity management is that managers need to empower all staff to realize their full potential. Companies like Microsoft have had as much as 90% of their market value represented by intellectual capital, human talent, reputation, and leadership. The ability to attract and retain diverse talented people rates more highly, therefore the Government is driving initiatives to encourage diversity and persuade business that there are real advantages to be gained from embracing diversity in the workplace. Diversity focuses on improving opportunities for all staff, respecting and valuing people as they are, rather than expecting them to conform to a stereotype. The global nature of business markets can be seen as a driving force for diversity initiatives. If a company’s business is international, its staff must be able to work across cultures, speak the customer’s language and address any barriers that might exist. A Company’s reason for adopting diversity policies are;

1. It is the right thing to do,

2. It is in compliance with equal opportunities and anti antidiscrimination laws and

3. It generates financial benefits that exceed implementation costs (Rebecca, 2005).

British Telecom’s (BT) recognises that it is crucial for its staff to reflect the diversity of its customers and is able to meet their ever-changing needs. It has introduced a number of initiatives to ensure that more women are recruited and progress in their careers with the company. Diversity policies are used by companies to gain access to talent. BT reports that equal opportunities and diversity policies have resulted in the company attracting 37% of female graduate applicants. By creating a working environment where all employees feel included, valued and rewarded on the basis of their talents and skills, companies increase employee morale leading to improvement in the quality and motivation of the workforce which in turn leads to an improved company performance.

Effects of gender discrimination in the work place

Learning about sex-roles takes place among men and women during the early phases of their lives, and this can translate itself into an attitude that creates difficulties later in work life, (Larwood and Wood, 1979). A lot of people would concur that these issues and discrimination of women is improper and unlawful and should not be tolerated. Nonetheless, many women have continued to be discriminated in their workplace.

As rational people, employers seek to put the right person for the right jobs e.g. when the work demands public relations, appearing on advertisements, employers prefer attractive women as marketers to sell their products. For technical, manual and production work however; they prefer to hire a man, (Tom and Adrian, 2009, p.351). Some employers believe that the cost of employing women is higher and that the productivity of female workers is low due to truncated and intermittent breaks for child bearing and rearing. Women for example are questioned if the family responsibilities could hamper their performance at work and at times questioned about their competency. These beliefs pose particular challenges in decision to employ women at work. The choice of an individual to accept work in a particular occupation or an employer’s choice to employ either mainly men or mainly women, are decisions influenced by learned cultural and social values that often discriminate against women (and sometimes against men). The “preference” is largely determined by learned, gender-related factors which stereotype occupations as “male” and “female”.

Occupational segregation by sex and Stereotyping

The resultant segregation of occupations by sex places a limitation on what jobs male and female can do. The early stereotyping of certain occupations as ‘male’ and ‘female’ is one factor that influences the subject choices of children and adults (Archer, 1992). Miller and Hayward (1992) examined children’s perceptions of who should, and who actually does, perform a range of jobs. Both Miller and Budd (1999) and Miller and Hayward (1992) found that individuals’ preferences remained largely restricted to those jobs that were viewed as gender-congruent (i.e. in keeping with stereotypes about the jobs that are appropriate for their own sex). Boys gave significantly higher preference ratings than girls for nine masculine occupations (airplane pilot, air traffic controller, architect, carpenter, fire fighter, lorry driver, police-officer, scientist and TV repairer). Conversely, girls gave higher preference ratings for seven feminine occupations (dancer, hairdresser, librarian, nursery school teacher, secretary, school teacher and shop assistant).

In the UK, research conducted for the Department for Education and Skills (DFES) indicated that parental attitude was one factor which influenced the decisions of young people regarding whether to remain in education or training, or to leave (Payne, 1998). In the USA, Farmer, Wardrop, Anderson and Risinger (1995) have identified parental support as a key factor influencing subject choice. Firstly, the mother’s attitude is a key factor in developing the child’s own view of the importance of the subject itself; this then influences the development of favourable attitudes towards the occupational area. Secondly, the child’s perception of the extent to which their mother believes in the importance of doing well has a positive influence on the child’s belief that their success is dependent upon their own efforts, which in turn impacts on their achievement and thereafter on their attitudes (Miller, Lietz and Kotte, 2002). Parental aspirations are usually viewed as an important influence on career decisions in general (Erikson and Jonsson, 1996). Schoon and Parsons (2002), also using a path modelling approach has shown that high parental aspirations are strongly correlated with high aspirations in their children and with good academic achievement.

Stereotyping against women at work is either due to employers’ attitude or to what women bring into the labour market in terms of qualification, family demands and feminine differentials.

Cultural restrictions

Cultural restrictions contribute to the establishment of what is acceptable work and how some countries signify sexual differences for certain occupations. In Moslem countries, ‘Purdah’ (kirton, G and Greene, A, 2005) effectively forbids women interacting with unknown men in public, as a result, many Muslim women are strongly discouraged from taking sales jobs except in shops where the customers are all women.

Women are usually stereotyped to their traditional and cultural roles of child bearing, rearing and home-keepers and are usually disadvantaged in preferences for occupations and promotion. In societies where women are at a disadvantage by sex segregation, parents tend to give their daughters less education than the male thereby adversely affecting the future generation of women and limiting them to the traditional ‘female Occupations’ (teaching, child-care, nursing, catering). Until recently, Nigerian parents believed that it was a waste to invest in the girl-child because they would eventually end up in the ‘kitchen’ and were therefore not given formal education but were groomed to attract suitors. Several women are constrained to ‘female jobs’ in certain sectors either through custom or through the prejudice and discrimination of employers. Some other factors like early marriages affect the education of the female, the role of the woman as “helper” and not the “breadwinner” also impedes their aspiration for higher challenges. Many women are unable to improve themselves educationally after marriage and childbearing.

Glass ceiling

Masculine stereotype play a role in determining the occupations which become typically “male occupations” (engineer, police officer, construction worker, security guard) and of course the “breadwinner. There are fewer men in “female occupations” and when men move into typically female areas of work, there is no equivalent ‘glass ceiling’ – in fact, the opposite almost seems to apply. Examples of areas in which women constitute the majority of the workforce are education and health. In secondary schools, women hold the majority of teaching positions in schools, yet men constitute the majority of head teachers (68 per cent) Source: Department for Education and Skills (DfES) (2003e), Statistics of Education: School Workforce in England. Male nurses were found to have poorer qualifications at both pre-registration and post-registration levels, yet to advance more quickly into senior posts, the average time for male nurse to reach a senior post was 8.4 years, compared with 14.5 years for a female nurse who took no career breaks (Davies and Rosser, 1986). Similarly, male nurses were twice as likely to be found in higher grade nursing posts, although females had better post-basic qualifications (Finlayson and Nazroo, 1998).

Women also feel there is relatively poor career progression in male dominated occupations, in terms of pay and status but UBS Investment Bank has a group called ‘Raising the Bar’ which looks at the glass ceiling and whether women are treated differently and how they progress in their careers. Women find it difficult to break through this ceiling because of the ways in which they are viewed by the society and the individual organization (Stephen Linstead, Liz fulop and Simon Lilley, 2004) as being emotional, irrational, less committed, under-educated and not strong enough to earn top managerial positions. This creates vertical segregation where men predominate in top ranked positions of the organisations. Also because women sometimes prefer to work part time with flexible working conditions, it is therefore difficult to reach senior management positions. However, the role of women in society is radically changing in most countries and even in Nigeria. Vast numbers of women are beginning to work full-time and to aspire to climb the same “organisational ladders” as their male counterparts (Davidson and Cooper, 1984). Women are attaining higher levels of education and they are competing favourably with the men especially in occupations which were formerly reserved for the men.

Female – Male pay differentials

Income inequalities between men and women from all backgrounds still persists, despite the equal opportunities legislation as women’s annual salaries are 25 per cent lower than men’s even when overtime and bonuses are taken into account (Sharon and Maeve, 2007, p.163). Women are making progress, but it is still relatively slow, Sean O’ Grady (2007), states that “women working part-time earn 38 per cent less than their men counterparts working part-time as well. Even full-time female employees earn 17 per cent less than men”. Hence, it makes it difficult to find women at the top of any business, political career or even the law.

It is true that the pay gap among women and men is becoming much smaller than it used to be, even though there are still restrictions for women in top managerial positions and politics. Women are more confident because they are enlightened and have role models like Margaret Beckett who became the first U.K female foreign minister, Dora Bakoyannis the first women ever appointed to a senior cabinet position in Greece, Nigeria’s Ngozi Okonjo-Iweala the finance minister to foreign affairs. More women are willing to stand up to the law, even if men are still reluctant to give up power to women as a result of the ‘Masculine’ perception (it’s a man’s world).

Child bearing and family responsibilities

The debate on work and family life still tends to be focused on working mothers (Esther and Katherine, 1988). Mothers make significant changes to their working lives to accommodate their family and just a small minority of fathers make major changes that enable them to be more involved in family life (Suzanne, John and Melissa, 2006). Many employers view pregnant women as someone who is about to leave them hanging for a couple of month, instead of seeing them as professionals who are competent and can perform. Some employers deny pregnant women the opportunity to advance in their careers by assigning them menial jobs since they feel that they cannot handle challenging problems. These are just attitudes which do not have any basis. For example, it is believed that women typically leave their careers following the birth of children often in their thirties, some women may return after a period of maternity leave or after early years of child rearing, many do not return at all. Some reasons for not returning are work-life balance issues such as, wanting extended maternity leave, part-time working not being possible for some jobs and the cost of children.

Organisations have the feeling that the society is fast moving and when maternity break is taken, technology moves on to such an extent that it is difficult for returners to keep up and a lot of re-training would be required when they return. Therefore, when the women return, companies may have progressed and maybe their previous job has changed to such an extent they have to trade places or move out. Some organisations therefore offer flexible working hours for women who indicate that they would like greater flexibility at work. Flexibility has its own loop holes; it could lead to career death in terms of promotional opportunities (Jerry and kathleen, 2004). Women choose such career comfort in order to balance work with their family life responsibilities.

Recommendations to curb gender and diversity discrimination in the workplace
Gender Discrimination

The use of gender equality mainstreaming strategy will enhance the management of gender diversities in the workplace; it will address the specific and often different needs of women and men. Targeted interventions should be taken which is aimed to overcome sex discrimination, empower women in the world of work and advocate equitable sharing of care responsibilities between both sexes. This approach will help to prevent gender-blind interventions that perpetuate inequality, by ensuring that both women and men benefit equally from management policies. The use of “good practices” as well as ILO strategies and tools such as the Action Plan on Gender Equality are encouraged in promoting gender equality in the workplace. Gender Audits could also be carried out at intervals.

Research and publications, training courses on upgrading mainstreaming skills, and mobilizing gender network should be encouraged in the workplace. Women workers should be given assistance in getting organised and being represented in various sectors especially sectors where they form the minority. There should be a Human Resources specialist to oversee and support the Managing Gender Policy.

Diversity Discrimination

In the area of Diversity, to attract and retain staff from diverse backgrounds, companies may need to revise existing employment contracts, benefits packages and working conditions to accommodate measures, such as flexible working programmes, maternity/paternity benefits and leave, and childcare schemes. Companies should set up some form of monitoring and reporting processes, by warding off change resistance with the inclusion of every employee in formulating and executing diversity initiatives in the workplace. Leaders and managers within organizations must show commitment by introducing diversity policies amongst organisational functions. The overall participation and the cooperation of management as well as training are essential to the success of an organization’s plan.

Conclusion – Gender, Diversity and Equal opportunity

In this essay, findings indicate that gender should be managed in organisations in such a way as to minimise any differences between the employment chances available to men and those available to women. Equal opportunity should aim at allowing women the same level of access to and participation within every level and area of the organisation. As employees gain the benefits of increased equal opportunity for men and women in the workplace, all family members gain from an easing of the strain of juggling work and caring responsibilities and some children will gain the social and development benefits of quality childcare facilities. There is also the danger of promoting such case because equality of opportunity may not be seen as a case of social justice but that of organisational self interest.

The benefits of diversity in the work place has its challenges which workers have to put up with, such challenges include prejudices, cultural and language barriers that employees bring into the lime light of work. Such challenges need to be overcome for diversity programs to succeed. There are always employees who will refuse to accept change and the fact that the workplace is changing as a result of the diverse nature of workers. The preconception of following “the rules” outlooks new ideas and hinders progress. “The profits of a globalized economy are more fairly distributed in a society with equality, leading to greater social stability and broader public support for further economic development”, (ILO, 1996-2010).