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Introduction Beginnings Making sense of the information Deciding what to do Reviewing the plan

Stage 2 - Making sense of the information

Case Information

  • The social worker has information from the GP about Edna going to the GP but has no information about the GP's response, beyond prescribing anti-depressants.
  • So far, the social worker has formed the view the family situation is complex. It would be a mistake to over-medicalise the responses to Edna and Bernie. Edna is entitled to an assessment as carer.
  • Bernie may have a mental illness. But he needs empowering, by adopting a service user perspective.
  • There may be an issue about poverty in this family. The questions for the practitioner include: What do you know about poverty? How should you respond to indications of poverty in the family? Is there a Welfare Rights Department in your agency? Is there a local CAB office? These will help people complete relevant benefits forms.
  • In this regard, how should the somewhat marginal situation of Jim in the family be acknowledged and his needs tackled?
  • Jim is in the background in this family at present. But his anger and potential for aggression require attention.
  • More insight into Bernie's experiences emerges. Bernie has a longstanding fear of being taken from home and put in an institution. He recalls going to gran's when his mother was taken to a mental hospital. It was a long time ago but he cries when he tells the social worker.
  • Bernie lets the information slip that till last year his aunt, Daisy, Edna's sister lived with them. The social worker draws information from Jim about this. Edna won't speak about it. Bernie's aunt is resident at Harrow House subject to Section 117 of the Mental Health Act 1983. This requires the local authority to provide aftercare services for people formerly detained under Sections 3, 37, 45a, 47, 48 until they no longer need it. Bernie's aunt is on the Care Programme Approach (CPA) register.
  • Depending on decisions reached by those working with the family, there may be work done by three different workers, with Edna as carer and Jim and Bernie as clients. This implies three individual care coordinators, coming together with one worker who care coordinates the whole family. This would be complex to manage. From experience, the social worker knows it will be necessary to monitor family dynamics as work with individuals proceeds. Bernie's aunt also will have a care coordinator. Each person will have a risk plan, a crisis and contingency plan completed.
  • The priest visits Bernie. The priest's view of Bernie's situation complicates the assessment process. He suggests Bernie is not having psychotic episodes but is having religious experiences. In the view of the priest, Bernie is in danger of being stigmatised and therefore marginalised and excluded.
  • The situation with Bernie is at an impasse. Medication to control his perceived onset of a psychotic illness (possibly) would require his cooperation. Without this, unless on health or safety grounds he was deemed sectionable under the Mental health Act 1983 to prevent deterioration in his health as well as an immediate risk, treatment couldn't be enforced. Bernie is perceived by Jim and Edna as dangerous.

Key Questions

Values-based Questions

  • How can the social worker identify his own values and beliefs regarding mental health work and the risks of violence by clients and maintain best practice in the interests of Bernie and other family members?
  • How can the mutually conflicting goals of empowering Bernie and supporting other family members be managed?

Practice-driven Questions

  • How can the social worker advocate for change in relatives' negative stereotyping of Bernie?
  • How can the social worker move beyond Bernie's unwillingness to accept treatment, without compulsory powers to impose medication on him?
  • What supports in the community are available to enable Bernie's feelings of loss, loneliness and his associated anxieties to be tackled?
  • How can the social worker incorporate the concept of risk in practice so as to empower rather than restrict Bernie?
  • Could there be genetic risk factors? What is the diagnosis of Daisy's condition? What symptoms did she display? Were there similarities with Bernie's symptoms? Was she hearing voices?

Research Focused Questions

Knowledge Questions

  • What does the social worker know about the risks to family members?
  • What does the social worker know about the protective factors?
  • What is the balance between risk factors and protective factors?

Skills-related Questions

  • How can the social worker best use the different perspectives on practice to enable a holistic assessment which best informs objective practice and the formulation of an appropriate plan?
  • How can the social worker
    • encourage Bernie to be assessed, so as to screen him physically,
    • eliminate organic causes,
    • understand his emotions and thoughts, including his spiritual beliefs and
    • enable his symptoms i.e. hearing voices, to be better understood?
  • How can the social worker help other family members realise Bernie does not need coercive treatment and is unlikely to be more prone to aggressive or violent behaviour than if he did not have his present symptoms?
  • What theories advance understanding of Bernie's anxieties and sense of loss and how can he be empowered to move beyond these?
  • How can work with Edna and Jim enable them to move forward?

Relevant Knowledge

The assessment process and the person-centred approach

The social worker set out to gain as full an understanding as possible of the past and present situation of Bernie. In order to achieve this, the social worker attempted to observe Bernie's behaviour, speak to him and take careful note of his responses, trying to avoid prejudging and making presumptions.

The social worker regarded it as crucial to meet and talk with other family members. Hitherto, no practitioner had considered the family unit in detail. The social worker speculated as to whether previously, healthcare professionals, GP district nurse, had worked with individuals, pursuing a clinical approach within the medical model of mental illness.

The social worker was working in a multi-professional, multi-disciplinary way, alongside healthcare practitioners, nurses, doctors, psychiatrists. She adopted a social model. She met Jim. She talked in depth to Edna.

It emerged the marriage has not been happy, for years. Edna won't complain about it but Jim has been violent. They have slept separately since soon after Bernie was born.
Edna tries to keep drink out of the house. When Jim drinks he is most aggressive towards her.

Her father died in her infancy. Her own mother lived in this same house and brought her up. Jim worked for her father. He moved in when his own parents died. She admits she never loved him but his offer to marry her seemed like the practical thing to do at the time.
The social worker locates the problems of Edna's depression in the marriage and in her isolation, not just with problems of coping with Bernie.

Carer Assessment and Support

The Carers (Recognition and Services) Act 1995 gives carers the right to an assessment. The Carers and Disabled Children Act 2000 extends this right to all caring situations. It requires the local authority to meet carers' needs by providing services.

Contradictions inherent in two aspects of mental health law and principles and standards of practice - intervention and empowerment.

The Mental Health Act 1983 confers on local authorities and social workers as their agents legal duties and powers to protect the public from people by compulsorily admitting them to mental hospitals where necessary. (Section 2 enables a person to be detained for assessment and/or treatment for up to 28 days.) Simultaneously, the Act provides for the protection of the rights of those people with mental health problems, preserving a measure of their dignity and self-respect.

Section 131 encourages non-compulsory admission to hospital.

At the same time, though, the Act states the nearest relative does not have to give consent for informal admission to hospital. Whilst the person is free to leave if admission is informal, if admitted under a Section of the Mental Health Act 1983, the person cannot leave unless granted leave conditions. If the person leaves without this, they are judged to have absconded and the police have powers to return them to the hospital.

The social worker has a duty to protect the person from self-harm and the community from harm by that person. The social worker may have to act oppressively against the rights of that person, rather than in an empowering way.

Dilemmas arising from multiple accountabilities and the duty to carry out a single assessment

The modernising agenda and NSF reinforced by local policy in the area covered by this fictional case study, require all trusts and CPA to develop single assessment. This implies shared documentation across hospital and community, disciplines and professions plus one set of documentation only with different rights of access.

The social worker set out to establish a relationship of trust with Bernie and his parents. But her responsibility was constrained by her multiple accountabilities, to Bernie as client, to his parents as carers, to his mother as a woman experiencing depression, to her line manager, to her employing organisation and to colleagues in social work and in healthcare professions. She also felt loyalty towards her personal values and professionalism.
These different strands of accountability in some ways blended. After all, the principles of teamworking and policies of confidentiality within the team, encourage the practitioner to share information within the team.

But in other ways, these different accountabilities were in conflict. In particular, the social worker could not distance herself from her legal duties. She could not provide the assessment which would be shared with other practitioners in healthcare and social services and at the same time act as advocate for Bernie and his parents. The social worker was in the position of power. No matter how much empathy or friendliness she showed towards family members, her relationship with them was professional rather than that of friend.

At the same time, the social worker was aware she needed the full cooperation of family members in order to carry out the assessment. She was reliant on information they supplied to give insight into their circumstances and to corroborate information gathered from other sources.

Managing other people's perceptions of risk

It was difficult to maintain a non-directive, person-centred approach and simultaneously pay due regard to the perception of other family members that they needed protection from Bernie. It seemed to them as though Bernie could act aggressively. Would he become violent? Were other family members, particularly his mother, vulnerable to emotional abuse as they tried to care for him?

The social worker continually encountered other family members stating they were at risk from Bernie's aggression. However, there was no evidence Bernie had ever acted aggressively. If he had, or if there were other grounds to regard this as a significant risk, the social worker would be obliged to carry out an objective risk assessment.

Spirituality, Mental Health and Mental Health Problems

There is a debate over spirituality, mental health and psychiatry. Some radical and critical psychiatrists have highlighted this since the 1970s.

The community mental health team and the priest have a dialogue.

Bernie's story has some validity. There is a debate about whether his symptoms have been a couple of psychotic episodes or whether his hallucinations are religious experiences which have some validity.

Separation and consequent separation anxiety

The experience of loss may leave a person with an anxiety about attachment, or over-dependency. The earlier in life the loss, the more marked this may be. Separation from a parent or another parental figure may be particularly traumatic.

Bowlby refers particularly to the impact on young women of losing their mother through death before ten years old (Bowlby 1969, 1973).

Howe (1995) considers theories and research on attachment and loss. He points out (Howe, 1995 p. 139) a child experiencing loss or rejection may become compulsively self-reliant, thus avoiding the source of further possible hurt.

In Bernie's family, it is possible that, over and above these factors, the similarities in the situation of Daisy and Bernie may indicate a genetic link predisposing Bernie to manifest his stress psychotically, through symptoms of hearing voices.

Coping with loss

There are multiple losses in this family. Different family members are responding to losses in different ways.
Caroline Currer (2001) examines different models of bereavement and ways social care workers may work with people through the grieving process.

Dealing with conflicts of interest

Sometimes, family members' perspectives, opinions and circumstances conflict with each other. It may be impracticable to try to change these. The most that can be attempted is for work to be done to achieve increased mutual understanding.

Managing dilemmas of practice

By definition, dilemmas are insoluble. It is mistaken to seek a solution to a dilemma. The most practicable approach is for the practitioner to work to manage the dilemma or contradiction, holding it and dealing with the mutually conflicting attitudes and feelings of family members as they arise. Family members may need to be equipped to cope with these, rather than given false hope that they will be reconciled or differences disappear.

Managing Risk

Risk needs to be regarded as problematic if service users' as well as carers' best interests are to be met.

Nigel Parton (1998; 2001) has examined critically current practice based on the concept of risk. Schedules of degrees of risk create the impression of scientific precision; risk tends to have negative connotations; individual practitioners as well as organistaions can be held responsible and blamed if an accident happens. The consequence is that practice tends to be defensive and negative rather than positive and creative.

An emphasis on risk assessment and risk management in practice may create the impression of certainty where none exists.

The report of the inquiry into the death of Jonathan Newby, volunteer worker, on 9 October 1993 in Oxford, made recommendations that better training should be provided for residential staff in this field (Davies, Lingham, Prior and Sims, 1995p. 151-2)
Stanley, N. and Manthorpe, J. 2001 'Reading Mental Health Inquiries: Messages for Social Work' Journal of Social Work, 1(1) pp. 77-99

The (Louis Appleby) Confidential Report into Homicides and Suicides recommends all staff in mental health work receive risk training over prescribed periods, such as every two to three years.

Terence O'Sullivan (1999) offers a framework for social workers dealing with difficult decisions.

Mental Health Resources

A local organisation called Respite offers community outreach services. This consists of individual support on an intensive basis to start with, for a person suffering from mental illness. The focus is on helping and supporting in daily tasks of housekeeping and going out of the home shopping and interacting with other people. The outreach support service normally would become less intensive and involve one visit by the worker every week or fortnight.

A voluntary organisation, MIND Out, runs a volunteer scheme. A befriender is available from this, to visit Bernie once a week. A meeting at a local youth centre is organised through the Community Mental Health team.

Care Programme Approach

The CPA register includes patients discharged from mental hospitals and people who need continuing care in order to live in the community and not be readmitted to hospital.

Multi-disciplinary teams use care coordinators (formerly key workers) and care managers (formerly case managers) to implement care plans. The National Service Framework emphasises the importance of maintaining standards of care planning in the CPA. The CPA is intended not only for people with more serious mental health problems, but anyone with mental health problems which are severe and enduring.

Joint approaches involving health and social services lead to community psychiatric nurses (CPNs) and social workers operating as care managers. A care coordinator is appointed to monitor care and ensure regular reviews.

Under the CPA, all people receive risk assessments and crisis and contingency plans dealing with triggers to ill health and risk and action plans to be followed if these occur.

If Bernie's aunt was high risk she could be discharged under Section 117. This would increase the duty of the local authority to monitor her case after her discharge.

Aftercare services for psychiatric patients are provided under the Mental Health Act 1983. Supervision is provided under Section 25 of this Act. Bernie's aunt would not be placed on a Section 25 supervision, because this can only be implemented while a person is on a 'treatment' Section of the Mental Health Act 1983, i.e. Section 3, 37, 45a, 47 or 48.

Under the aftercare arrangements under this Act, Daisy could be obliged to live in a specified location and attend a given facility for treatment. However, she could decline the treatment when she attends.

Person-centred approach

Sarah Banks discusses a range of codes of professional values for social workers in different countries and comments that the humanistic perspective founded on respect for persons as a basic value of social work (Banks, 2001, p. 77). Her book is a clear, concise exploration of relationships between personal values, statements of professional ethics and practice.

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