Stage 2 - Making sense of the 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
- 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
- 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.
- 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
- How can the mutually conflicting goals of empowering Bernie and
supporting other family members be managed?
- 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
- What supports in the community are available to enable Bernie's
feelings of loss, loneliness and his associated anxieties to be
- 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
- 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?
- 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
- 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
- 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?
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
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
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
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
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
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
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.
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
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.
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
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
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.