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Mental health services have previously been heavily dominated by health service attitudes reinforced by medical models of explanation and beliefs, creating a division between the mentally ill and society. The dominance over biochemical approaches to mental health has so far presented little space for the expression of a more holistic alternative, (Tew, 2002).
Literature suggests that mental health services need to move beyond the bio chemical approach, which has created a division between the ‘normal’ and the ‘mentally ill’, by defining their ‘illness’ in terms of their ‘pathology’, (Bainbridge, 1999), into a practice which incorporates social work values underpinned by the social model of mental health.
‘2009 will be a significant year for mental health policy in England.’ (New Vision for Mental Health, 2008)
As the governments 10-year strategy for mental health, the ‘ National Service Framework’, is coming to an end significant policy changes are being made. Amendments which have been made to the Mental Health Act 1983 have radically changed mental health practice with changes in the roles and responsibilities of qualified mental health professionals, including introduction of two new roles: the responsible clinician (RC), formally the registered medical officer, (RMO) and approved mental health professional (AMHP), formally known as the Approved Social Worker (ASW). There has also been increased interest in social models and approaches to mental health, which is being supported through organisations such as, ‘The Social Perspectives Network’ (SPN), a network of people interested in how social factors contribute to people becoming distressed. (SPN, 2009).
With these changes in mind and plans for social care and health services to work together on a more integrated service delivery, the question is- where does this leave the role of social work practice in the future.
This literature review will focus on the changing approaches to mental health practice. Based on the literature provided it will examine why the medical model has dominated mental health practices in the past, and what the social model emphasises, focussing on psycho-social perspectives. It will place a critical perspective on the medical model and aim to show why increased emphasis on the social model may have encouraged a shift in policy and legislation, (amendments to the Mental Health Act 1983). It will also focus on how the social model can influence future social work practice.
‘Social work’s role in relation to psychiatry and the mental health system is particularly uncertain’. (Beresford, 2005).
As interventions within mental health are primarily medical model based, the role of social work within the multi disciplinary led service remains unclear. It has been noted that medical models have been the ‘driving force’, of policy and procedure within mental health. (Carpenter, 2002), and the dominant treatment paradigm in most mental health practices (Beecher, 2009). However in terms of social work, this model is detrimental to services users self worth and consequently conflicts with a number of social work values, (Carpenter, 2002).
The medical model is a perspective that is adopted by doctors and psychiatrists, suggesting that mental illness is rooted in our physiology and is treated as a ‘disease’ or ‘illness’, (Golightly, 2008) and although criticisms exist, it has been favoured by practitioners within the health care system, as a tool for aiding their practice (Boyle et al, 2006). It can be described as
‘The predominant Western approach to illness, the body being a complex mechanism, with illness understood in terms of causation and remediation, in contrast to holistic, and social models’, (Braye, 1992).
It is proposed by psychiatrists that ‘the ‘medical model’ is a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvements’. (Shal and Mountain, 2007). This model characteristically seeks to identify the problem by a ‘diagnosis’ then prescribe medication as a form of treatment to ‘eradicate’ or ‘rehabilitate’ the problem, (Kihlstrom, 2002), however critics state that this ‘diagnosis’ results in the service user becoming an illness rather than an individual. (Deegan, 1996).
Supporters of a more holistic approach would argue that the medial model is guilty of being ‘too restricted’ and ‘problem focused’, it also maintains the depersonalisation of the individual with mental ‘illness’, and their families, (McLean, 1990). In addiction it is too simplistic in taking into account the many variables that are in a persons environment (Ashford, et al, 2006), (which may be a cause of their ‘diagnosis’) focusing too often on their symptoms and deficits, not recognising or engaging with the whole environment (Rapp, 1998). It also ignores the individual’s or families experiences, (Barker et al, 2001), which could also have an affect to their behaviour; it is guilty of not seeing the situation holistically. (Beresford, 2005).
Other evidence suggests that social causative factors, such as unemployment, unstable family circumstances, substance misuse and poor education are more likely to explain a persons behaviour rather than any medical diagnosis, (Taylor and Gunn, 1999).
Although it has been noted that the medical model has been the more favourable approach in reinforcing policy and service provision we cannot say that the medical model, on its own, is a sufficient basis to underpin policy and practice in mental health, (Carpenter, 2002). As also argued by Tew, (2002), research which has been based on longitudinal surveys shows that advances in medical treatments have resulted in inconsistent recovery rates-so we cannot say that the medical model is a sufficient tool to base practices on.
This raises the subject of the social model, how does this model differ, what does the model emphasise? The following literature will aim to identify the key principles in answer to these questions.
It has been established that the medical model sees the service user as an individual with a problem, rather than an individual within an environment, which holds causable factors. Literature suggests however that the social model takes a more ecological approach, (Littlejohn, 2004). So what is different about the social model and how can it change perceptions in psychiatry?
According to Ramon (2001) the social model fits well within the holistic approach of social work and is the underlying rationale for mental health social work. Tyrer and Steinberg (2003) express that,
All social models in psychiatry have the same fundamental premise. They regard the wider influence of social forces as more important than other influences as causes or precipitants of mental illness (Tyrer and Steinberg, 2003. p87).
The social model embraces the impact that social causative factors and psychological factors can have on a person’s life. (Duggan, 2002) especially the impact it can have on their health. It considers that individuals suffering from socio-economic disadvantages (such as social exclusion and poverty) can impact their health both physically and mentally, and are more likely to suffer as a result of this.
Duggan (2002) supports the social model and identifies clear key characteristics, which the social model emphasizes. The impact of social factors on individuals who are vulnerable and the importance of maintaining social networks and support systems. Unlike the medical model, the social model considers the inner and the outer worlds of individuals, emphasising empowerment and capacity building at individual and community level and places equal value on the expertise of service users, carers and the general public, (Tew, 2002). Duggan goes further and explains the model in more depth,
‘The model allows practitioners the chance to see mental distress as a reaction to a range of social circumstances (past and present) that may be experienced. In this sense, it may often link with issues of powerlessness and loss’, (Duggan, 2002).
Smith explains his view on the social model as apposed to the medical model and argues,
Behaviours defined as symptoms and disorders are best understood as creative responses to difficult personal and social histories, rooted in a person’s experience of oppression. (Smith, 1999. p.31).
The social model emphasises key characteristics, which can be identified in social work values, those of service user empowerment, self-determination and environment role in personal experience (Carpenter, 2002).
The general orientation of social work values are helpful in attaining a more holistic approach, in that they promote a more user-centred social work practice and combine a commitment to work with individuals and the environment which surrounds them, (Tew, 2002). Therefore the values that are at the heart of social work practice sit more comfortably with what the social model emphasises.
Both the medical and social models have been discussed, highlighting what each model emphasises, the literature has aimed to underline why a shift in policy and legislation may have taken place. The following literature will now look at the implications for social work.
Farone (2006) also argues that social work with its ecological perspective is well suited to address the complexities in mental health practice. So how can social work effectively intervene within mental health services?
In a study published by Rethink, (Martyn, 2002) involving 48 people with a schizophrenic diagnosis (a common mental disorder), they identified themes in support areas which service users perceived as being effective in their situations – access to paid and voluntary work, support with relationships with family and friends, counselling and psychotherapy and education on health living, a similar research also concluded these were important, see Macdonald and Sheldon, (1997).
These support areas embrace solutions beyond those recommended by medical diagnosis alone.
Employment plays a key role in tackling social exclusion (a common social cause of onset mental disorder) it also provides the service user in helping building self-esteem as well as increasing social capital and standard of living. (New Vision for Mental Health, 2008). Loss of employment can consequently have adverse effects potentially creating strain on mental health.
Literature suggests that the family is an important source of support for services users with mental illness, and social work should seek to maximize and sustain this support (Reinaires and Vieta, 2004). The social model does acknowledge that this imperative to any service users mental health as it is a central aspect of social inclusion and plays a critical part in recovery. Social work can in turn help seek and sustain employment (Beresford, 2005).
However as acknowledged by a leading mental health organisation,
‘Employment is an area where people with mental health problems experience extensive discrimination and disadvantage and be a source of damaging stress that causes mental ill health. (Mind, 2009).
This is an important factor which social work can effectively intervene with, to tackle discrimination and support service users through sustaining work placements, to remain included. Social inclusion remains a large factor in maintaining mental health as research suggests the social model can contribute to social workers challenging social exclusion (Tew, 2002). Huxley et al (2003) identified the difficulties services users face in sustaining and preserving social contacts and social networks, especially when suffering from mental disorders.
In addition Corry et al (2004) also found that people with mental health problems who live in more isolated rural areas with limited access to services are likely to find it more difficult to develop and preserve supportive social contacts and networks. Social work role then is support service users in accessing and day centres, and promote relationships between people who use services, encouraging group work, which can lead to challenging marginalisation and discrimination, and in turn educate the user.
A psychological factor underpinned by the social model that is overlooked by the medical model is the importance of family support, without this service the user could be at risk of mental health deterioration. (Huxley et al, 2005). Research suggests that maintaining network relationships between family and services can have significant impact on mental health. It is suggested that a social work role here would be to support the network relationships, (Germain and Gitterman, 1996). However as acknowledged by Jack (2000), relationships can be both supportive and stressful and therefore necessary to examine the nature of the relationships to understand whether they were liable to assist or weaken functioning.
Direct payments, personal budgets and individual budgets are at the centre of the government’s aim of personalising adult social care services around the needs of users. They involve direct cash payments given to service users to purchase care services, which they have been assessed as needing, and are intended to give users greater choice in their care. Direct payments allow the user to employ people or commission services for themselves and take on all the responsibilities of an employer. (Community Care, 2009)
However research conducted by the Health Care Commission (2007) reported that direct payments for people with mental health problems are under-used. Social work role here would be to advocate on behalf of the service user, working in partnership and facilitating empowerment to increase access to direct payments as suggested by Spandler and Vick, (2005) who conducted a study into the usage of Direct Payments.
The subject of social work with a mental health practice is a wide area of discussion. Unfortunately, the coverage of research studies evaluating social work contributions to mental health practice is erratic and many areas of practice remain under-researched.
There remains a gap in the research capturing the perceptions of service users from marginalized groups, in particular views of women with severe mental disorders or those from linguistic minorities. It is important that social work develops a greater understanding within these fields to understand their situations holistically and in turn result in better access to services, which fundamentally underpins the social model of practice. With the growing interest of the social model within mental health to actively ensure the best service delivery these issues of equality and diversity need to be analysed.
There also remained a gap in research of service users with dual diagnosis, with the majority of the research having been undertaken in the United States. It should be stressed that due to medical research overshadowing social research in dual diagnosis and with a growing amount of service users falling within this area, more research is needed from a social care perspective.
There is also the growing concern as the integration of health and social care services evolves in the mental health; social workers role will become even more vague. Social work practitioners feel that their values, based on a social model, will be controlled by health professions values, which in turn will adopt a more medical model perspective. This concern has become more apparent with the replacement of the ASW by the AMHP.
Due to this replacement, and the loss of a professional group, which had a clear identity, the replacement, AMHPs will need support to remain independent and develop a common approach, which underpins the social model of practice. As the AMHP’s could potentially be from a health care background, it is the social workers role to ensure this overlap with other professions, continues to focus on the service user as an ‘individual’, based on the social model of mental disorder, as appose to a ‘anti social’ medical based model.
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