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This study takes up the examination of social work practice in the area of mental health in the UK. It is based upon the experiences of the author in the course of her work as a Mental Health Professional in a multidisciplinary team in a community care setting.
Mental health issues, more specifically mental illnesses, have troubled humans from the dawn of human civilisation. The history and literature of all historical societies reveal numerous instances of mental disorders among people and the inevitably associated ostracism and discrimination faced by such people. Mental illnesses in the UK, till even some decades back were associated with abnormal, deviant and dangerous behaviour and thousands of people with different types of mental issues were housed in high security asylums against their will for years on end. Such blatant violations of fundamental human rights were carried out at the behest of the medical fraternity with the active support of the government, the judiciary, the legal system, enforcement agencies and society.
Social workers entered the area of mental health in the UK in the early decades of the 20th century and progressively increased their interaction and work with mentally ailing people. The involvement of social work practice in the area grew slowly until the 1960s but increased rapidly thereafter. Greater involvement of social work practice led to the development of psycho-social models for providing assistance to people with mental ailments and helped in changing societal perceptions towards such persons. The post Second World War period also witnessed a very substantial shift in governmental and medical approaches towards people with mental health disorders. The last full fledged asylum for housing the mentally ailing was closed down in ….
Medical disorders are now viewed to be strongly related to various social and economic conditions as also to phenomena like racism, oppression and discrimination. The overwhelming majority of people with mental health ailments are now treated in the community, in the midst of family and friends, and institutionalisation is resorted to only in extreme cases and that too for limited periods of time. Social work practice has become very relevant to the area of mental health. Qualified social workers like the author of the study, known as mental health professionals, work with medical professionals like doctors and psychiatrists and play active, even leading, roles in the assessment, planning, intervention and evaluation of people with mental health disorders.
This study takes up the case of Maya, a 68 year old Asian woman, who lives in East London. Maya is a first generation immigrant and has spent much of her life in an alien society. She suffers from depression and has been referred to the local social work authorities. Maya’s case is fully described in the appendix to this study and is thus not elaborated here.
The essay examines various aspects of Maya’s life and experiences in order to crystallise the various factors are contributing to her current mental difficulties. Special emphasis is given to the challenges faced by people suffering from depression and to the high incidence of depression among South Asian women. The study takes up the application of social work theory to practice, the role of oppression and discrimination in the development of mental ailments, the role of social workers in helping mentally ailing persons and the importance of adoption of anti-oppressive approaches in dealing with them. It also details the social services that are available to such service users and how such services can help Jaya.
Causes and Consequences of Depression
Maya has been intermittently suffering from depression for the last 27 years and has undergone medication and counselling on five occasions. She was specifically referred by her GP to the local social services department following an episode of some severity.
Crippling depression is one of the biggest reasons for misery in modern day Britain. It is a submerged problem of immense dimensions that is kept out of sight by family shame. The Psychiatric Morbidity Survey reveals that one in six of UK residents are liable to be diagnosed with depression. It would surprise many people to know that 40% of all physical and mental disabilities are caused by mental illness, even as 17% of such ailments are caused by depression alone. The incidence of depression among people is more than 3 times that of cardiac disease.
Psychologists agree that mental illness constitutes the most important predictor of human distress in the UK and is far more powerful than poverty or various other types of disability. With few forms of deprivation being worse than chronic depression, it is evident that social workers should give the highest priority to care for persons with depression and other mental health ailments.
Much of research on the causes of depression has necessarily being medical in nature. A number of medical studies reveal that depression can arise out of a range of factors like medical and physical disabilities, the death of loved people, social isolation, exclusion and loneliness, and abusive relationships, separation and divorce. Depression can also be initiated by economic and other types of stress, estrangement from family members, the compulsion to care for ailing family members and relocation.
Social work research on the other hand reveals that social phenomena like racism, discrimination and oppression can play significantly causal roles in the emergence of depression. Individuals from different religious, ethnic and cultural backgrounds have often been subjected to discrimination in the UK. The decades after the closure of the Second World War witnessed a large influx of people from erstwhile British colonies in Africa, Asia and the Caribbean into the UK. Such immigrants, many of whom came to the UK to escape from lives of poverty, hardship and violence in their home countries, were often subjected to various degrees of oppressive and discriminatory treatment, both in the workplace and in the community.
Such discriminatory treatment manifested itself in areas of employment, education and access to public facilities. Immigrants were treated differently and subjected to discrimination because of their lack of familiarity with the English language, their different physical appearances, religious traditions, cultural and social habits and their clothes. Such discrimination sometimes assumed distinctly undesirable dimensions like in the case of Christopher Clunis. A mentally disturbed person of African origin, Clunis murdered Jonathan Zito, a young white man, at a tube station in 1992.Whilst subsequent enquiries revealed that Clunis was mentally disturbed and he was subsequently institutionalised, the British media built up a picture of Clunis, (as a large, clumsy, unkempt and violent man), with strong overtones of racism. The numerous incidents of discrimination and ill treatment of persons of Asian origin in the USA after the September 11 attacks reveal racism and social discrimination to be a latent phenomenon that continues to work under the surface in societies and surfaces in response to different types of provocation and perceptions.
Immigrants and their families even today have much poorer levels of education, income, health and public participation than members of the mainstream white majority in the UK. Maya is a first generation immigrant who was uprooted from her familiar North Indian environment when she was still in her teens and thrust into alien surroundings; she was unfamiliar with the local language and found it extremely difficult to communicate with others. Her social life was perforce restricted to the local Indian community in east London, which itself was very small when she came to England. Her husband and children, who had to adjust to the local community and its demands and expectations in order to survive and enhance their life chances, would have in all likelihood faced numerous incidences of discrimination and oppression over the course of their lives.
Maya’s domestic problems were also intensified because of her compulsion to stay with her husband’s parents, a tradition that is still widely followed by the Asian community in the UK.
Depression among Women from South Asian Communities in the UK
A number of social work surveys and studies indicate that the incidence of depression is significantly high in South Asian women. Whilst such women originate from a large and ethnically diverse area that comprises of India, Pakistan, Sri Lanka and Ceylon, many South Asian women suffer from similar causes for mental depression. Fenton and Carlsen, (2002) state that the main causes for depression amongst such populations are experiences of racism, family difficulties, financial problems, poor physical health and lack of employment. Women from these communities experience excessive mental pressure on account of community influence and reputation. Some of them have to cope with unsuitable marriages and unhappy relationships with their in-laws. Such circumstances create enormous difficulties and life challenges and moreover do not provide any avenues for escape. Some women have described how their families and the larger Indian community made them feel inadequate and repeatedly impressed upon them that they were failing in meeting their familial obligations. Such women also feel pressurised because of social isolation, lack of friends and acquaintances, inadequate education and stressful living conditions.
The case study reveals that Maya has often been subjected to stress because of her difficult and strained relationship with her mother in law. It is also evident that the option of setting up home independently was never explored by her husband. It needs to be noted that whilst joint family living is common in South Asian communities, it is also often economically necessary because of straitened financial conditions and the additional costs that are likely to be incurred if children opt to live separately from their parents.
Depression evidences itself in symptoms like change in eating and sleeping habits, lack of interest in normal daily activity, withdrawal from children, family and friends, overlooking of necessary activities at the home and outside and finally self destructive tendencies. Depressed people are prone to self harm and develop suicidal tendencies. Maya suffers from irregular sleeping habits, often sleeps late at night, gets up late in the mornings and is sometimes unable to cook for her family. She has reduced her interaction with outsiders and is becoming distant from her immediate family. She often suffers from headaches and cries for no reason. Such manifestations and symptoms constitute strong reasons for addressing depression in an elderly person like Maya.
Not treating depression can place her and other older people at increased risk for additional physical and mental health problems. The disinclination to get out of the house and exercise can increase her hypertension, lead to diabetes and faster deterioration of the heart, lungs, bones and muscles. It can also lead to deeper, debilitating depression.
Implications for Social Work Theory and Practice
Social work theory and practice is fundamentally concerned with the improvement of the social and economic circumstances of disadvantaged individuals and groups and the challenging of oppression and discrimination in all its forms. Systems theory in particular, whilst abstract in nature and not applied systematically, has helped social workers to move from linear and causative medical models to significantly greater multi-causal contexts for the understanding of human behaviour. General systems theory provides a conceptual scheme for realising the interactions among different variables, rather than by reducing behavioural explanations to one reason.
This is clearly evident in the area of mental health, where depression in people and their resultant behaviour is associated with a number of interacting social, biological and psychological factors. Systems theory requires social workers to examine the multiple systems in which people interact. Assessment of mentally ailing persons will for example require social workers to obtain information from different sources and place them in appropriate family and community contexts. Knowledge of social constructionism theory on the other hand enables social workers to realise how language has been used by medical experts and other dominant groups to build up images of the mentally disturbed as people who cannot look after themselves and their families and who need to be treated by medical “experts”.
Modern society’s perceptions about mental illnesses are significantly shaped by medical models, which state that medical ailments represent serious conditions that can make it hard for persons to sustain relationships and engage in employment. They can lead to self-destructive and even suicidal action (Walker, 2006, p 71-87).
Social constructionism theory states that such perceptions are built by purposely developed vocabularies of medical models, which are bursting with complex nomenclatures for mental ailments and fixed on deficits. Walker, (2006, P 72), argues that vocabularies of medical models, including that of mental illness, are social constructs, comprising of terms that detail deficits and view humans as objects for examination, diagnosis and treatment, much like machines. Such perceptions result in treatments that is focused on removal of symptoms and do not take account of actual client needs (Walker, 2006, p 71-87). Social constructionism can assist social workers in realising the disparaging chimeras that have been built by existing medical models about the mentally ill.
Social workers must also be informed by the theories of oppression and discrimination that condition and shape the behaviours of people, both the oppressors and the oppressed, towards poor, isolated and disadvantaged segments of society. Neil Thompson’s PCS theory of oppression (2001), states that oppressive and discriminatory attitudes in people are socialised over the course of their life by three strong influences, namely personal perceptions and cultural and structural influences. Personal perceptions about the mentally ill can arise through reading about such people, viewing them on cinema, thinking about them and other such associated activities. Cultural influences comprise of numerous cognitive inputs from school, friends, family and the larger community about the mentally ill and unstable. Structural influences arise from the various embedded factors in the larger environment like their lack of fitness for employment and their need to be bodily restricted. These PCS factors shape the minds of individuals and build up strong discriminatory attitudes that rest below the surface and are manifested in various ways. The media outrage over the Clunis incident and the construction of the person into a larger than life image of a socially dangerous person represents the way in which such discriminatory attitudes can often shape the behaviours and actions of people.
Chew-Graham et al (2002), state that whilst the incidence of depression among South Asian women is significantly higher than the national average, such women faced numerous barriers in accessing social services because of internal and external barriers. Whilst internal barriers occurred because of family structures and community pressures, external barriers happen because of their unfamiliarity with English, difficulty in communicating with local social services departments and the disinclination of social workers to come to their aid. Services thus tended to be accessed only at points of desperation if at all and increase the tendency of such women to engage in self destructive activities. Dominelli (2002), states that discriminatory attitudes are deeply embedded in the existing social work infrastructure and can be eliminated only if there is a genuine and widespread feeling among social workers to do so. The labelling theory states that the self identity of individuals is often determined by the terms that are used to describe them.
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