Mental Health Illness: Good Social Work Practice
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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.
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.
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.
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.
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