Stage 1 - Beginnings
- Two parents Jim and Edna Mallow (all names and identities are
fictitious) and their son Bernie aged 21 - live in an isolated location
in a small, pre-war, run-down, detached three bedroomed house in
a rural part of Eastern England.
- They used to run a smallholding on their small plot of land a
mile from the nearest market town of Fenton. Jim became unable to
carry heavy loads after a back injury and gave up the business.
- Edna has always stayed at home, in her younger days working on
the smallholding. She has been primarily responsible for bringing
- Over the years, Edna has had many referrals for depression. The
doctor used to advise her to snap out of it. Latterly she has had
out-patient and in-patient treatment for depression.
- This case study begins where Edna goes to see their GP. She asks
for a prescription for her depression. She books an appointment
for Bernie. She persuades Bernie to visit the GP at the primary
- For the past 3 years, Bernie has been spending increasingly long
periods in his room listening to the radio and CDs on his headphones.
He also stays up all night playing computer games. According to
Edna, Bernie has been doing this for years. His school attendance
was good until the last year of A levels. He did well until then.
He was taking religious knowledge and English at A level and was
planning to go to university to study theology.
- A few months before the A level exams the parents started to
receive worrying messages from the Fenton sixth form college about
Bernie's failure to turn up at school. The school was not required
to inform the parents, but one of the staff knew Jim and Edna and
took an interest in Bernie's progress. He left home each day, but
failed to turn up, even though he left home on the bus each day
to go there. It turned out subsequently he spent the days wandering
round town, sitting in the park. One of the other pupils recalled
him going into the church.
- Bernie is unkempt, dirty and is becoming overweight. He has become
bullying and aggressive towards his parents, whenever they refuse
to wait on him with food and drink, while he stays in his room.
- The GP refers Bernie to the Community Mental Health team (CMHT).
(Note: Different types of CMHT operate in different ways. In this
team, discussion between the practitioners results in the decision
the social worker should take the lead, in view of her previous
experience of working with another family near the where the Mallow
family live.) The social worker from this team visits the home and
talks to Jim, Edna and, after some persuasion, Bernie.
- The social worker tries to talk to Jim. He is unforthcoming.
The social worker eventually gets Jim to talk about his life, by
taking a walk round the now overgrown smallholding and showing an
interest in the plants. It's like a dam bursting. He tells her his
life story. He's still grieving for his parents who died when he
was a teenager. He cries. He's mourning also the loss of the business.
He feels his life is over. Jim reveals he has convictions for violence.
He has served a prison sentence. He is not a Schedule 1 offender.
His offence was ABH against another woman, his fiancée at
the time, and was twenty years ago. He regrets this. He fears his
capacity to become violent when drunk. He won't admit to having
hit Edna, but admits he frightens her, and him, 'when I starts arguing
at her'. His view of Bernie is simply that he's lazy and needs 'a
good shaking' and 'to get off his backside and find a decent job'.
- The social worker goes back to Edna. She tells her she knows
the background of Jim. Edna now admits she is now doubly scared,
of her husband and of Bernie. She hasn't told anyone over the years
about Jim's violence towards her - she says he has hit her many
times - for fear of his reaction. She now says Bernie scares her
because of his 'becoming like his father'. She hasn't said anything,
though, for fear 'they'll take him away'. The few times she's tried
to approach Bernie in his room and ask him to emerge, he's threatened
her with violence. So now she acts like his housemaid, delivering
all his meals to him. he seldom emerges except to go to the toilet.
He goes for walks at night when the rest of the family have gone
to bed and the house is quiet.
- The social worker approaches Bernie. Bernie makes a passing comment
about missing Gran and wanting to talk to her some more, even though
she's dead. He calls Gran his 'other mum'. It emerges when his mother
used to be too busy with the smallholding, he went to live with
his gran for long periods.
- It emerges Bernie has had contact with a local church. He says
he's hoping in some way his religion will provide a route for him
not to lose contact with gran. He was close to her. She used to
visit the house regularly from her nearby rented house
- The social worker visits the priest, who has not seen Bernie
for a long time. It emerges Bernie has talked to the priest about
being bullied, being in debt and being frightened. His solution
is to stay at home. She talks to the priest at the church. It's
a gospel-based church. He has been hearing voices. He has talked
to the priest. He thought he was being called to take holy orders.
- The social worker speculates. It is important this speculation
arises in discussions between team members, as part of customary
working practice of the team. (See heading Team Working
- especially King (2001) below.) Bernie could be having psychotic
episodes. He could be chronically depressed. It could be the lack
of carers providing an adequate support for him to grieve and move
on in his life, he may have become withdrawn. Because of Edna and
Jim being locked into their own depressed stand-off of a relationship,
they are too preoccupied with their own lives to attend to the needs
of their son. This compounds the justification he sees for his withdrawal
to his bedroom.
A number of questions are generated by the process
of evidence based practice. These are, first, practice-linked (Key Questions)
and evidence-linked (Research Focused).
The practice-linked questions broadly follow the sequence
of the evidence-based approach, focusing in turn on theories and concepts,
needs, outcomes and services. In other words, they illustrate the ideal
process the social worker goes through of clarifying what the situation
is about, seeking information about the needs of the person receiving
services, identifying the level and intensity of the justification for
intervention and specifying the response, in terms of services provided.
This suggests three separate but linked questions, embedded in the practice
throughout this case:
- What did the social worker consider?
- What did the social worker decide?
- What did the social worker do?
Moving on, here are the key questions triggered by
this paragraph, bearing in mind this is a preliminary list, before the
social worker proceeds, largely focused on justifying proceeding further:
Values questions come first and arise from the social
worker's personal and professional beliefs and assumptions. These will
be threaded throughout the work the practitioner does with family members:
- What tensions exist between the views of Jim, Edna and Bernie?
- How can the differing perceptions of Jim, Edna and Bernie be
taken into account in attempting to work in an empowering way with
each of them?
- Is there an ethical dilemma about whether empowering work with
individual family members will lead to the break-up of this family
- What information is available from Bernie about his condition?
- What information can Jim and Edna give?
- What information can the GP, priest and other professionals provide?
- What are the practitioner's legal duties, powers and responsibilities?
- What are the agency's policies?
- Are any immediate risks to clients, carers and others apparent?
If so, what are they?
- What contribution can the social worker make, in the multi-disciplinary
team? The social worker may be able to contribute a less medicalised,
problem-based and a more user-driven perspective on Bernie's psychotic
- The social worker may ask 'What other approaches do we try first?'
The social worker may say 'I know this is a risky procedure. What
would make it less risky?'
- How can the social worker reduce the dominance of problem-based
aspects and encourage and empower family members by building on
strengths? Four questions follow from this:
- What strengths do the family members bring to their circumstances?
- How can the social worker reframe risks as opportunities?
- What risks are family members prepared to take for themselves?
- How can the practitioners help by sharing and holding some
of the risks?
- How does the social worker ensure the practice is according to
- values and ethical standards
- cultural, religious requirements
- agency Policy e.g. on Confidentiality
- National Occupational Standards
- Codes of Practice for Social Care Workers and Employers?
- What practice needs developing in order to avoid contravening
Vulnerable Adult policies (concerning Adult Protection)?
Research Focused Questions
We turn now to the kinds of evidence which will link
with, or back up (if we are fortunate) the thinking, decisions and actions
of the social worker about whether, and if so how, to proceed. You should
bear in mind the evidence based approach is just that, an approach,
not an answer. Research-mindedness is an attitude to cultivate. Just
as research findings often are complex and generate further questions
and debates, so practice cannot rely on them to justify decisions and
actions and close doors to further discussion and doubt. Research will
make those discussions better informed.
At this point, we need to recognise different sorts
of evidence relate to and are inherent in practice. Some relate to values,
others to concepts and knowledge and others to skills. They are all
research-based, and thus constitute the evidence justifying practice.
But the messiness and complexity of the situations social workers deal
with means there is no single piece of scientifically conducted research,
with proven results, which guarantees that doing the job this or that
way will produce the desired outcome.
- What possible explanations are there for Bernie's symptoms?
- What can research tell us about predisposition to violence?
- Practitioners must ensure compliance with the requirement that
every person referred through mental health resources and services
must have a risk assessment. What can research tell us about the
risk factors and how to manage them in order to protect Bernie,
members of his family and members of the public?
- What can research tell us about the factors predisposing Edna
- How can work with Bernie proceed?
- What work with Jim and Edna will enable them to improve their
A prerequisite for effective mental health practice
is a high standard of multi-disciplinary and multi-professional teamwork.
This cannot be taken for granted. Research informing good practice is
a good source of practice guidance. Two examples are given here from
different kinds of community-based teams:
1. Community Mental Health Teams (CMHT):
King (2001) reports on research into the processes
by which a multi-disciplinary mental health team works with people with
mental health problems. A key finding is the importance of harmonising
different team members' perceptions of severe mental illness, so as
to gate-keep and maintain good practice.
King, Charles (2001) 'Severe Mental Illness: Managing
the Boundary of a Community Mental Health Team' Journal of Mental
Health 10, 1, pp. 75-86
2. Community Rehabilitation Teams (CRT):
Ryrie, Doherty, Bertram and Wrigley (2001) have carried
out an evaluation of a CRT. They show how tensions arise in the team,
as members set out to optimise levels of people's independent functioning
and promote their social integration, using everyday resources in the
community. These tensions arise in such areas of practice as the collaborative
support practitioners on the one hand which is essential to team functioning,
and on the other hand the dominant culture of psychiatric services based
on individualised key working or case management.
Iain, Doherty, Ingrid, Bertram, Mark and Wrigley, Marieke (2001) 'An
Evaluation of A Community Rehabilitation Team' Journal of Mental
Health, 10, 6, pp. 645-55
Standards of Service
The Mental Health National Service Framework standards
are crucial throughout the process of working with a person with mental
health problems. These are found in Department of Health (1999a) National
Service Framework for Mental Health: Modern Standards and Service Models
London, Stationery Office
Approved Social Worker
Services for people with mental health problems are
provided through the Mental Health Trust, a joint provision by four
local Health Trusts. Approved Social Workers are employed by social
services departments to fulfil statutory responsibilities under the
Mental Health Act 1983.
An Approved Social Worker is a social worker appointed
under the responsibilities of local authority social services, to discharge
the provisions of the Mental Health Act 1983 s. 114(1). The ASW must
be competent in dealing with a person with a mental disorder (s. 114(2).
The ASW has a duty under s. 13(2) to interview in
a suitable manner.
- What does suitable mean? It means following the Code of Practice:
- not conducting the interview through a closed door;
- taking account of cultural differences;
- taking account of language needs;
- ensuring the interview is carried out in the least oppressive
Reading on mental disorder:
Bean, Philip (2001) Mental Disorder and Community
Safety, Basingstoke, Palgrave
Mental Health Act 1983
Section 135 The ASW, under s. 135 can apply to a JP
for a warrant to search a house and remove. But this is only if the
criteria are met and the person is 'ill-treated', 'neglected' or unable
to care for himself or herself living alone, or is 'kept otherwise than
under proper control'.
Section 136 enables a police officer to enter 'a place
to which the public have access' in a serious situation, i.e. where
the person appears to be suffering from mental disorder, or is in immediate
need of care or control. In these circumstances, the officer is empowered
to remove the person to a place of safety. Normally this is taken to
mean a psychiatric hospital. But the police officer cannot enter the
home on this basis, only premises deemed to be a public place or an
Models of mental illness and mental health
There is no single approach to explaining and responding
to mental health problems. Views and approaches differ widely. The fields
of mental health and psychiatric practice are littered with debates
We can identify four main strands of thinking and
practice. These were identified in the 1970s by the psychiatrist Anthony
Clare (Clare, [2nd edition], 1980) and his general analysis still is
- Organic and biological approaches. Psychiatry and mental health
practice in the health sector has been dominated by this cluster
of medicalising approaches to mental health work which have grown
up over the past two centuries. Practitioners emphasise genetic
and physiological factors leading to preferences on the part of
(medically led) practitioners for physical treatments such as drugs
(most common), electro-convulsive therapy (ECT) (more rarely) and
psycho-surgery (extremely rare).
- Psychotherapeutic approaches. These are based on the belief in
the power of the helping relationship between the practitioner and
the client. Practitioners emphasise patients benefiting through
the therapeutic processes engendered by that relationship.
- Sociotherapeutic approaches. The main emphasis of these is on
the social functioning and social capacities and skills of the patient.
Practitioners focus on the demands made on the patient by society
and help to improve his or her ability to cope with these demands
of everyday living. The sociotherapeutic model does not diagnose
the individual as sick. It focuses on the wider network of factors
giving rise to the mental health problem. The social work relationship
that informed the social worker’s practice is based on a person-centred
approach (Rogers, 1961; 1965).
- Service user approaches. Since the 1970s, patients and ex-patients
have organised and protested from the last quarter of the twentieth
century. Survivors Speak Out is the best known ex-patients' group
in the UK. Advocacy and self-advocacy have grown from being part
of the radical fringe of anti-psychiatric movements to occupy the
mainstream of social work. David Brandon's work provides a highly
readable introduction to the field of advocacy (Brandon, 1995).
Advocacy, self-advocacy and survivors' groups are instances of the
broad-based movement by people receiving mental health services
to propose a normalising, non-medical, approach. This operates on
the basis that all people are susceptible to mental health problems.
These result from the conditions, including stresses, of everyday
The implications of these user-led perspectives are that self-advocacy
and self-help are more appropriate than professionally-led work
with people with mental health problems.
The implications of the fourth approach are important.
Social workers need:
- to have the assertiveness to challenge, when appropriate, the
medical model of mental illness and mental health practice.
- to ensure people receiving services and carers, have the confidence
to challenge practice.
Morgan's (1994) book on community mental health practice contains
an important chapter (ch. 9, pp. 186-212) on advocacy and user empowerment
in community mental health.
Other reading on user perspectives on mental health:
Marian (2001) Taking over the Asylum: Empowerment and Mental Health,
Read, Jim and Reynolds (1996) (eds) Speaking our Minds: An Anthology,
A key collection of short and memorable pieces of writing by a wide
variety of people who have first-hand experience of mental distress.
Diana (2001) Users' Voices: The Perspectives of Mental Health Service
Users on Community and Hospital Care, London, Sainsbury Centre
for Mental Health
Anne, Pilgrim, David and Lacey, Ron (1993) Experiencing Psychiatry:
Users' Views of Services, Basingstoke, Macmillan with MIND
Mental illness, Stigmatisation and Social Exclusion
The apparent incidence of mental health problems is gender-linked.
However, men may be less predisposed than women to admit to symptoms
and seek mental health or medical help. Barnes and Staple point out
twice as many women as men suffer from depression (Barnes
and Maple, 1992).
The over-representation of women in particular types
of mental health problems, especially depression, has been researched
widely and subjected to critical comment by feminist writers (Prior,
1999, pp. 42-7).
People with mental illnesses tend to be stigmatised
and excluded from many key aspects of society.
Social exclusion has been recognised as a particular
problem for people with mental health problems, even before it was acknowledged
in Government policy (Sayce,
People, often women, who have been sectioned for depression
are excluded from certain categories of work, because this remains on
the medical records. Women with mental health problems experience multiple
discriminations (Rogers and Pilgrim, 2001, p. 200).
Other reading on discrimination, exclusion, gender
and mental health:
Dora (2000) (ed) Women and Mental Health, London, Routledge
Prior, Pauline (1999) Gender and Mental Health, Basingstoke,
Liz (2000) From Psychiatric Patient to Citizen: Overcoming Discrimination
and Social Exclusion, Basingstoke, Macmillan
Assessment in social work, according to Hughes (1995)
goes far beyond merely collecting information and data. It involves
a range of observational, communication, interpersonal, cognitive and
analytic skills (Hughes, 1995, p. 69). The relationship between the
practitioner and users or carers is crucial, since assessment is about
understanding their circumstances. Hughes devotes chapter 5 of her book
on community care to examining the processes and skills involved in
assessment (pp. 66-92).
Hughes, Beverley (1995) Older People and Community Care, Buckingham,
Open University Press