Transcript (Download) - Faculty of Medicine, Nursing and Health Sciences

The Individual, Health and Society: SWK 4420
Associate Professor Rosemary Sheehan & Dr Ralph Hampson
Subject enquiries:
[email protected]
[email protected]
Workshop timetable
9.30
Social Work in Health Introduction
10.00
Mental Health
12.30
Lunch
1.30
Health
3.15
Summary and Close
SWK 4420 The Individual, Health and Society - Texts
Grbich, Carol (Ed) (2004)
Health in Australia : sociological concepts and issues (3rd ed.),
Prentice Hall.
Pritchard, Colin (2005)
Mental Health Social Work [electronic resource] London : Routledge.
Available via World Wide Web - access via Monash library (internet resource).
Unit guide refers to:
Meadows, Graham and Singh, Bruce (Eds) (2006)
Mental health in Australia : collaborative community practice (2nd ed.)
Oxford University Press, Melbourne.
Bloch, S and Singh, B (2006)
Foundations of Clinical Psychiatry (2nd ed)
Melbourne University Press, Melbourne
Recommended supplementary reading:
Alston, M and McKinnon, J (Eds) (2005)
Social Work: Fields of Practice - Second Edition.
Oxford University Press, Melbourne
- It provides a detailed analysis of social work practice.
Context
• Shift over time from public health issues
which were the concerns of the late 19th,
early 20th Centuries.
• Health is a major focus of Government policy
• Evidence that ill health is closely linked to low
income, unemployment, poor housing.
• Health system can be a safety net and/or it
can operate as a preventive/health promotion
project.
• Late 20th Century emphasis on: equity,
access, equality and participation
• Increasing focus on consumer involvement.
Principal feature of the Australian health
care system
• A private, for profit component (GPs,
pharmacists, dentists, private hospitals, private
specialists and alternative practitioners)
• A public component (community health centres,
maternal and child health, mental health,
hospital, HACC)
• A non-government, not-for-profit (FPA, welfare
services)
• A domestic component – carers at home
(Adapted from Owen and Lennie, 1992)
Australian HealthCare System
•
•
•
•
Medibank – Whitlam Government 1970s
Community Health Program – 1973
Medicare levy – 1.25% levy 1984
More recently -Increased focus on private
health insurance after a drop off in the number
of people taking out primary health insurance
• Introduction of the private health insurance
rebate by the Howard Liberal Government.
Key health policies and programs
• Commonwealth National Health Act
(1953) – universal health insurance
scheme & creation of the Pharmaceutical
Benefits Scheme
• Medibank 1975/Medicare 1984
• Council of Australian Governments
(1995)
Key health policies and programs –
community health
•
•
•
•
Community health program 1973
Local community involvement
Deinstitutionalisation
1980 Community health became a state
responsibility
• Is it marginal to the ‘main game’?
National Health Strategy 1990s
•
•
•
•
•
•
Needs of populations
Inequality
Efficiency
Cost effectiveness
Public engagement in debate
Rights and responsibilities
Health
Policy
• Universal access to basic health
care
• Services should be of a high
quality
• Financing of health care should
be equitable
• Services are delivered through a
mix of public and private system
• Accountability and efficiency
Levels of
Service
Delivery
PRIMARY SERVICES
General Practice (usually in Private Practice) and Primary
Health – Allied Health and Community Health
SECONDARY SERVICES
General Hospital Care - Private and Public
Specialist Services
TERTIARY SERVICES
Specialist Services e.g. nursing homes, transplant services,
mental health
Primary
health
care
• Multidisciplinary in nature
• Based community needs
• Integration of health, welfare, private, public, not for
profit – a partnership approach – tensions can emerge
• Social context
• Data traditionally not collected in a consistent manner
Funding
• 2004–05, the majority of spending in health was
funded by governments (68.2%)
– Australian Government contributing $39.8 billion
(45.6%)
– State, Territory and local governments contributing
$19.8 billion (22.6%)
– Non-government sector funded the remaining
$27.7 billion (31.8%)
Data from World Health Organisation (accessed 3 Aug, 2006) Figures are for 2004 unless indicated. Source: The world health report
2006
USA
Brunei
Japan
Singapore
China
Australia
India
Total population:
298,213,000
Total population:
374,000
Total population:
128,085,000
Total population:
4,326,000
Total population:
1,315,844,000
Total population:
20,155,000
Total population:
1,103,371,000
GDP per capita (Intl
$, 2004): 39,901
GDP per capita (Intl
$, 2004): 19,767
GDP per capita (Intl
$, 2004): 30,039
GDP per capita (Intl $,
2004): 28,848
GDP per capita (Intl
$, 2004): 5,581
GDP per capita (Intl
$, 2004): 31,454
GDP per capita
(Intl $, 2004):
1,830
Life expectancy at
birth m/f (years):
75.0/80.0
Life expectancy at
birth m/f (years):
76.0/78.0
Life expectancy at
birth m/f (years):
79.0/86.0
Life expectancy at
birth m/f (years):
77.0/82.0
Life expectancy at
birth m/f (years):
70.0/74.0
Life expectancy at
birth m/f (years):
78.0/83.0
Healthy life
expectancy at birth
m/f (years, 2002):
67.2/71.3
Healthy life
expectancy at birth
m/f (years, 2002):
65.1/65.5
Healthy life
expectancy at birth
m/f (years, 2002):
72.3/77.7
Healthy life
expectancy at birth
m/f (years, 2002):
68.8/71.3
Healthy life
expectancy at birth
m/f (years, 2002):
63.1/65.2
Healthy life
expectancy at birth
m/f (years, 2002):
70.9/74.3
Child mortality m/f
(per 1000): 8/7
Child mortality m/f
(per 1000): 10/8
Child mortality m/f
(per 1000): 4/3
Child mortality m/f
(per 1000): 4/3
Child mortality m/f
(per 1000): 27/36
Child mortality m/f
(per 1000): 6/5
Adult mortality m/f
(per 1000): 137/81
Adult mortality m/f
(per 1000): 107/81
Adult mortality m/f
(per 1000): 92/45
Adult mortality m/f
(per 1000): 92/51
Adult mortality m/f
(per 1000): 158/99
Adult mortality m/f
(per 1000): 86/50
Total health
expenditure per
capita (Intl $, 2003):
5,711
Total health
expenditure per
capita (Intl $, 2003):
681
Total health
expenditure per
capita (Intl $, 2003):
2,244
Total health
expenditure per capita
(Intl $, 2003): 1,156
Total health
expenditure per
capita (Intl $,
2003): 278
Total health
expenditure per
capita (Intl $, 2003):
2,874
Total health
expenditure as % of
GDP (2003): 5.6
Total health
expenditure as % of
GDP (2003): 9.5
Total health
expenditure as % of
GDP (2003): 15.2
Total health
expenditure as % of
GDP (2003): 3.5
Total health
expenditure as % of
GDP (2003): 7.9
Total health
expenditure as % of
GDP (2003): 4.5
Life expectancy
at birth m/f
(years):
61.0/63.0
Healthy life
expectancy at
birth m/f (years,
2002): 53.3/53.6
Child mortality
m/f (per 1000):
81/89
Adult mortality
m/f (per 1000):
275/202
Total health
expenditure per
capita (Intl $,
2003): 82
Total health
expenditure as %
of GDP (2003):
4.8
Challenges
facing
• Private and publicmix
Health
• Prevention, early intervention and treatment
Services
• Pressure Medicare /PBS -costs
• Bulk billing declining
• Tensions between State and Federal Governments
• Ageing of the population
• Infrastructure/Technology
• shorter admissions, high costs, emphasis on throughput
• Power of hospitals – can they become self serving
organizations
• Dental health services
What changes to health care
services have you noticed
in your area in the past five
years?
What factors have brought about these
changes?
• Concern about increasing costs
• Clinical Governance, risk and safety
issues
• Demographic changes
• Public/Private split
• Increasing consumer expectations
• Legal issues and medical insurance
What is
health?
Health is shaped by:
• Attitudes, beliefs and values
• Sex, age, religion and socio-cultural groupings
• History, knowledge and dominant understandings
about health and illness
• Professional versus consumer experiences
Definitions
of Health
•
World Health Organization (WHO): “a complete state
of physical, mental and social well-being, and not merely
the absence of disease or infirmity.”
•
Bircher: “a dynamic state of well-being characterized by a
physical and mental potential, which satisfies the demands
of life commensurate with age, culture, and personal
responsibility.”
•
Saracchi: “a condition of well being, free of disease or
infirmity, and a basic and universal human right.”
•
Australian Aboriginal people: “…Health does not just
mean the physical well-being of the individual but refers to
the social, emotional, spiritual and cultural well-being of
the whole community.” This is a whole of life view and
includes the cyclical concept of life-death-life.
http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/
WHO
definition of
‘Health’ –
critical
appraisal
•
WHO definition of health is utopian, inflexible, and
unrealistic, and that including the word “complete” in
the definition makes it highly unlikely that anyone
would be healthy for a reasonable period of time
•
‘a state of complete physical mental and social wellbeing’ corresponds more to happiness than to health
•
words ‘health’ and ‘happiness’ designate distinct life
experiences, whose relationship is neither fixed nor
constant
•
Failure to distinguish happiness from health implies that
any disturbance in happiness, however minimal, may
come to be perceived as a health problem.
http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/
Assumptions
about health
and illness
• People can choose to be sick or well?
• Encouraged to express ‘dis-ease’ through the
physical
• Changes over time: childbirth, children’s
hospitals, homosexuality, sexual abuse,
mental illness
Sociological lens –
Sociology
of health
– social patterns – age, sex, race, class,
culture, geography, community profiles
– processes – interest groups, beliefs and
history
– social relationships – power
Risk
factors
•
•
•
•
•
•
Diet
Environment
Occupational health
Stress
Unemployment
Poverty
Role of
social work
• Interrelationship between health and human
functioning
• Individuals, families, groups and communities
can have health concerns
• Social workers are both professionals and
consumers of health services
Social
Workers
bring to
Health
•
•
•
•
•
•
•
•
Systemic thinking
Political awareness and critical thinking
Ethics
Practice skills – assessments and
interventions
Human development
Social theory
Macro and micro awareness
Passion and idealism
Typical
Health
seeking
• First port of call is the GP
• Beliefs, gender, family history, tolerance of
pain e.g. men, pap smears
• Language/Culture
• Labeling of illness – blame and sympathy
What does
this mean
for social
work?
• Health is political
• Social workers are part of the system and
‘outside’ it at the same time
• Resources, access and information
• Social activist and/or ‘keeper of the peace’.
History
- Social
Work
• 1905 Massachusetts General Hospital
• Australia – growth in the health field – Hospital Almoners
• Understanding our history - is this important?
• Psychosocial approach
– Family domestic and social situations
– Complying with medical treatment
– Hospital and the wider community
• Home visits – a lost art perhaps?
1960s
1970s
1990s
•
•
•
•
•
Influence of psychoanalytic traditions
Social investigation
Diagnosis and treatment
Caseworker, therapist – splits in the profession
Genericism versus Specialism
•
•
•
•
•
•
•
Civil Rights movement
Feminism
Rights movements
Anti-psychiatry – encounter groups, humanism
“Radical social work” – structuralism
Community health
Community development
•
•
•
•
•
•
Targeted benefits
Economic rationalism
Effectiveness
Evidence based practice
Accountability
Competition
Theoretical
frameworks
•
•
•
•
•
•
•
•
•
Bio-psycho-social
Psycho-analytical
Ego psychology
Systems theory
Behaviourism
Feminist
Strengths based
Solution focused
Others?
Issues
and
Practice
• Shorter length of stay
• Counselling
• Family support
• Advocacy
• Short term nature –
crisis
• Community linkages
• Discharge planning –
‘bed blockers’
• Financial,
accommodation,
benefits
• Person in
‘environment’
• Team work
Crisis
intervention
Constructive
Relative
homeostasis
Destructive
Group
Work
•
•
•
•
•
•
•
Bereavement Service – Royal Children’s Hospital
Stroke Support Group
Incest survivors group
Children of parents with a mental illness
Parenting skills
Siblings of children with cancer
Transplant Support
Multidisciplinary
Interdisciplinary
•
•
•
•
•
•
Allied health profession
Ownership of the patient
Sharing of roles
Emergence of case management
Sharing of roles with others
Negotiating boundaries and roles
Allied Health
Psychology ?
Taken from Austin Health promotion – The Well Wisher
Olivia Newton John Cancer Center Appeal Spring 2007
Rural &
remote –
challenges
•
•
•
•
•
•
Being a member of the same community
Dual and multiple roles
Lack of anonymity
Confidentiality and privacy
Personal safety
Supervision and debriefing
Advanced
MultiSystemic
Approach
(AMS)
•
•
•
•
•
Biological Dimension – the ‘mind-body’ connection
Psychological/Emotional Dimension
Family Dimension
Religious/Spiritual/Experiential Dimension
Social Environmental – community, culture, class,
social/relational, legal history, community resources
• Macro dimension – e.g. policies, legislation,
oppression, poverty, homophobia, sexism
[Ref: Johnson, L J; Grant, G (2005) Medical Social Work Pearson, New York]
Case
examples
•
•
•
•
•
Mark, a baby, is born with spina bifida. You have been
asked to work with the parents re: the diagnosis.
What are some of the areas you may cover in your work
with the family?
Mrs Smith comes into hospital has a diagnosis of cancer
which will require radiation and chemotherapy
Referred to social work as she is depressed and does not
want to have treatment, says “she would rather die.”
What would you do?
Meaning of
health and
illness
• People experience illness differently
• Lens’ – for example
–
–
–
–
–
Culture
Class
Gender
Age
Sexuality
Immigration
(Gbrich,2004)
• Immigration program post WW2
• Waves of immigrants:
– Britain and Northern Europe
– Southern Europe
– 1973 White Australia Policy abandoned
– Asia
– Skilled migration/Family
– Refugees – Humanitarian
• Assimilation
• Multiculturalism
• Cultural Pluralism
Overseas
Born Health
Status
(AIHW, 2006)
• Australia has one of the largest proportions of
immigrant populations in the world
• 24% of the total population (4.75 million people) in
2004 estimated to have been born overseas
• More than half of these—one in eight Australians—
were born in a non-English-speaking country
• Research has found that most migrants enjoy
health that is at least as good, if not better, than
that of the Australian-born population.
• Immigrant populations often have lower death
and hospitalisation rates, as well as lower rates
of disability and lifestyle-related risk factors
(Ref: AIHW: Singh & de Looper 2002)
‘healthy
migrant
effect’
(AIHW, 2006)
Believed to result from two main factors:
• a self-selection process which includes persons who
are willing and economically able to migrate and
excludes those who are sick or disabled; and a
• government selection process which involves certain
eligibility criteria based on health, education,
language and job skills (Hyman, 2001)
but
• As length of residence in a destination country
increases, the health status of immigrants—as gauged
by health behaviours and by morbidity and death rates—
tends to converge towards that of the native-born
population.
Refugee
Health
New
perspectives
on migrant
and refugee
health
(Gbrich,
2004:119)
• Refugees, asylum seekers and detainees share similar
life experiences
• Experience higher rates of unemployment and welfare
dependency than other migrants
• Health and trauma – imprisonment, sexual assault,
torture
• Witnessing of death in refugee camps – disease etc
• Loss and Grief
• Understanding health within a global framework
• Holistic approach to health
• Social capital and well being
• Preventing disease, promoting health and prolonging life
• Shift away from ‘othering’ of the migrant
• Paradigm shift?
Gender &
Health
(Gbrich, 2004,
Ch6)
• Life Expectancy – women have outpaced men but
gap is narrowing
– 1920-22 Male 59.1:Female 63.3
– 1950-62 Male 67.9:Female 74.1
– 2000
Male 76.6:Female 82.1
• Why do men die younger?
– Violent behaviour
– Aggression
– Excessive alcohol use
– Dangerous driving
– Smoking
– Quality of relationships
Gender &
Health
(Gbrich, 2004,
Ch 6)
• Social Model of Health
• Holistic approach
• Health Service Utilisation:
– Women access health services more than men
– Women’s health issues associated with
reproduction
– Medicalisation of women’s health
– Men’s health – legal problems, being a lad –
growth in the issue of men’s health
Explaining
gender
differences
• Fixed roles and expectations
– mediated by age and responsibilities – dual
responsibilities of women and increased
burden
• Sex role socialisation
– masculinity and femininity – stoicism of men,
women more likely to report medical – no
evidence
• Clinician bias
• Critical and feminist theory
– ‘messiness’ of women’s health
Blinkers – what are some you can think of?
Social
Class
• Class analysis – social conflict – used to explain social
health inequalities
• Social stratification – focuses on social consensus – used to
describe social health inequalities using socioeconomic
status
• Consistent pattern – death rates go up as socio-economic
status goes down
• Physical, psychological and social dimensions of illness all
show that illness rates go up as socioeconomic status goes
down (Smoking? [The Age, 190209])
• Conflict Theory – the physical work environment and the
way work is organised lead to higher levels of illness for
working class
• Consensus – it’s not what they do at work – it’s what they
do outside of work that causes the problems –
consumption/risk taking
Indigenous health …
DVD – Bringing Them Home
Trauma
Trauma refers to situations where a person is confronted with
situations that exceed and overwhelm their coping capacity.
These situations threaten the physical and psychological
integrity of the person and cause an intense reaction of horror.
Typically there is a significant impact on at least immediate
functioning, if not long term, involving distress and disturbance
and, for some, disorder.
Harms,L (2005) Understanding Human Development: A
Multidisciplinary Approach, OUP, 146
Characteristics
Types of
Trauma
(Aldwin, 1993)
• Sudden and unexpected events, leaving the
individual unable to prepare psychologically for the
event
• Events which are out of one’s control
• Unfamiliar events so the individual cannot draw on
past experience in order to cope
• Can create long lasting problems
[Tedischi & Calhoun (1995)]
• Natural and technological – e.g. nuclear, bushfires
• Wars and related atrocities
• Individual traumas
– Individual acts of violence, abuse
– Car accidents, ABI, disability
– Sudden deaths/Infectious diseases – cancer, AIDS/HIV
Trauma:
Models of
Understanding
•
•
•
•
•
•
Trauma can be ‘political’ – silenced
Lunacy – weak gene pool – linked to eugenics
‘Shell shock’ – troops WW1/WW2 – now PTSD
Talking models of helping
Treatment – holocaust survivors – soldiers
PTSD – DSM IV – 1980
– Transient response – 2 days to 4 weeks
– PTSD can be:
> Acute (less than three months)
> Chronic (symptoms last for more than 3 months)
> Delayed onset (more than 6 months after the event) e.g.
Vietnam Veteran’s; stolen generation
• A ‘Problematic’ term?
• Neurological responses to trauma
309.81
DSM-IV
Criteria for
Posttraumatic
Stress
Disorder
Prevalence
A. The person has been exposed to a traumatic event
in which both of the following have been present:
•
(1) the person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
•
(2) the person's response involved intense fear,
helplessness, or horror.
•
Note: In children, this may be expressed instead by disorganized or agitated
behavior.
• 2.3% of the male population
• 4.2% of the female population
[Meadows & Singh, 2001:124]
Risk &
Protective
Factors (Harms,
2005:115)
•
•
•
•
•
•
•
•
Developmental stage of the individual
Gender (violence)
Socioeconomic position
Culture
Traumatic event
Type of trauma
Blame and personal responsibility
Personality of the individual
• “… the subjective construction of the event thus
becomes of critical importance.”
• The role of hope
• Recovery environment
Core tasks –
Critical
Incident
Stress
Management
(Harms,2004:169)
• Defusing
• Formal debriefing (2-3 hours)
– Establishing facts
– Behaviours
– Thoughts and feelings about the event
– Educational and preventive focus
• Education – short and long terms responses;
coping strategies
• Counseling – typically a longer term response
• Referral
Crisis
Intervention
Assessment – here and now focus – avoid dealing
with long term issues – safety and security
Planning – concentrate on the immediate – “This
turns the crisis from an unstructured, frightening
and bewildering situation into something
manageable”(p40).
Intervention – calmness, listening, in touch with self –
use of resources and systems – advocacy –
awareness of culture, hope and confidence
Termination – clarify what will happen next – write it
down
[Truswell, S et al (1988) In the Eye of the Storm: Crisis
Intervention in Hospital Aust Social Work, March,
V41,No1:38-43]
Refugee
survivors of
torture and
trauma
• Confronted by trauma and the depth of human
cruelty
• Social justice and valuing the rights of all
people
– Confronting the issues of torture and
trauma
– Migration and resettlement issues – loss
and grief
– Lifestyle, personality and family issues
Child
Maltreatment
• Physical, sexual and emotional abuse, neglect
• Long term effects:
– Re-victimization in later life
– Mental health problems
– Self harm & suicidal behaviours
– Sexual difficulties - intimacy
Child Maltreatment
• Change from family/private issue to
criminalisation
• Harming children is not OK
• State has a role to play
• Social work role – prevention,
interventions with children, family, child
welfare etc.
• The wider safety net – neglect – housing,
income support, education, physical
health etc.
AIDS/HIV
•
•
•
•
•
Diagnosis
First diagnosed in 1982
Death to long term chronic illness
Impact on the gay and lesbian community
Changes over time – from central health issue – Grim
Reaper – to ?
• Positive Counselling Service – Bouverie Clinic
–
–
–
–
–
–
–
–
–
Recognise the ‘family’ however presented
Listen
Show and feel compassion, respect, interest and understanding
Do not take an authoritarian stance
Hold the belief that clients can manage their lives
Raise issues that are difficult for our clients to raise
Comfort – use touch when appropriate
Share information and transparent
Avoid pathologising families
Growing old
• Most older Australians are neither frail nor in need of long
term care.
• Around 20 per cent of people aged 70 years and over use
Government-funded care services: about 8 per cent live in
nursing homes and hostels; and around 12 per cent receive
community care services.
• There are many more women than men in the oldest age
groups and more women than men live alone at older ages:
– women comprise almost 70 per cent of people aged 85
years or more;
– around 38 per cent of women and 30 per cent of men
aged 80 years and over live alone.
Growing old
• Likelihood of needing residential care increases as people
get older and is higher for women than men — at 80 a
woman has a 59% probability of entering a nursing home
during her remaining lifetime compared to 39% for a man.
• Most who need care receive some support from informal
carers, that is, family, friends and neighbours. In 1998, the
ABS estimated that there were 201,000 primary carers of
people aged 65 years and over.
• The incidence of dementia increases with age:
– about 5% of people over the age of 65 and 20% over
the age of 80 have some form of dementia;
– the number of people with dementia is expected to
increase from 148,000 in 1999 to 258,000 people in
2021 and 450,000 in 2041.
Growing old
• Depression is often under-diagnosed in older people.
• Significant proportion of older Australians are from
culturally and linguistically diverse backgrounds.
• Aboriginal and Torres Strait Islander people have
poorer health status than non-indigenous Australians
across all age groups.
Costs
• In 1999–2000 the Commonwealth Government will spend
over $5 billion on residential aged care, home and
community care , respite and support for carers.
• Public and private spending on health has been around
8.2 to 8.4% of Gross Domestic Product from 1991–1998.
• Expenditure on health needs of people aged 65 years and
over accounts for 24% of medical services, 31% of
pharmaceutical services and 35% acute hospital services.
Understanding
Ageing
What is
ageism?
• Physical changes
• Psychosocial changes
–
–
–
–
–
•
•
•
•
Disengagement theory (Cummings and Henry, 1961)
Activity theory
Continuity theory
Multidimensional approach – person, time and environment
Life Course perspective
Stereotyping
‘closed minded, demented, deaf, slow, unfit and ugly’
Advertising
There are many ways to be old – not homogenous
Ageing
Reforms
•
•
•
•
•
•
•
•
Market based reform agenda
Means testing of aged pensions
Reforms to the Superannuation system
Means testing or targeting of a range of health and
welfare services
Increased competition in the sector
Increasing reliance on ‘user pays’
As ‘user pays” increases the ‘grateful elderly will
disappear”
Focus on community based services
Intergenerational
tensions
Social work roles
•
•
•
•
•
•
•
Acute hospitals
Rehab
Residential Care
Grandparents as parents
Community health services
Community support
Community development
• Disability
• DisAbility
Images …
http://www.pwd.org.au/
Some facts
…
Meaning
•
•
•
•
1998 – 3.6 million people reported a disability
Largest proportion of people over 65
Ageing of the population – likely to be an increase
Main disabilities – sensory, intellectual and psychiatric
(AIHW, 2000, 2003)
•
•
•
•
What does disability mean to you?
What does chronic illness mean to you?
What experience do you have?
How do you think our community reacts to disability?
Defining
disability
• May 2001 the WHO adopted a multi-dimensional
definition
• International Classification of Functioning, Disability
and Health (ICF)
• WHO definition highlights:
– Importance of environment, social and political in
defining disability
– Problems within people’s bodies – impairments
– Dynamic interaction between health conditions,
environment and social factors (WHO, 2001; Bowles,
2005)
Chronic illness …
www.chronicillness.org.au
Defining
chronic
illness
• Chronic illness is “usually defined as a medical condition
lasting at least six months”.
• Usually has an impact on the quality of life
• Examples: asthma, arthritis, depression, heart disease,
neurological, MS … (Baum, 2002)
• Chronic Illness Alliance – consumer body – 2005
• “an illness that is permanent or lasts a long time. It may get
slowly worse over time. It may lead to death, or it may
finally go away. It may cause permanent changes to the
body. It will certainly affect the person’s quality of life.”
Stereotypes
•
•
•
•
Dependent
Passive
Non-compliance – blame
Expensive
Walker, C (1999) Health Issues, V59, pp 10-13
Predictability …
When I was diagnosed with breast cancer, I got my
affairs in order and left money in my will to care for
the cat. Well the cat’s dead; I’ve stopped cleaning
out of my cupboards and I wish I hadn’t given away
my Zeppelin collection.
Walker, C (1999:10-13)
Diagnostic
tools categorical
• Diagnostic and Statistical Manual of Mental Disorders
• International statistical classification of diseases and
related health problems (ICD)
• Burden of disease
• Quality of life
Understanding
• Individual medical model
• Welfare or policy model
• Socio-political model
(Bowles, 2005)
Individual
medical
model
• Viewed as victims
• Expert help to recover
• Not recover – exempted from ‘normal social’ roles –
employment, marriage, sex, raising families
• Treated like children
• Biomedical problem
• Charity/welfare approach
• Social work under the medical model has generally been
restricted to a role that is secondary to medical intervention
(Bowles, 2005:54)
• Acceptance, counseling, family support and financial
accommodation
Welfare or
Policy Model
•
•
•
•
•
•
SocioPolitical
Model
•
•
•
•
Focus on rehabilitation
Grew out of post WW2 – rehabilitation for veterans
Clients not patients
Holistic
Multidisciplinary
Independent living, social groups, sexuality, self
esteem and assertiveness
• Welfare payments
• Disability advocacy – social justice
• Year of the Disabled
Human rights approach
Effects of the environment in creating disability
Social construction DisAbility
Structural change - advocacy
Legislation
•
•
•
•
•
•
State Disability
Plan - Vision
• By 2012, Victoria will be a stronger and more
inclusive community – a place where diversity is
embraced and celebrated, and where everyone has
the same opportunities to participate in the life of the
community, and the same responsibilities towards
society as all other citizens of Victoria.
Intellectual Disability Persons Act
Disability Discrimination Act 1992
Disability Services Act
Equal Opportunity Legislation
DHS State Plan
HACC & Disability Standards
Acceptance
Integration
• School support programs
• Community housing
• Employment programs
Cultural
Differences
• Attitudes vary across cultural groups
• Rural/metropolitan
• Family reactions:
– Punishment
– Gift from God
– Non medical beliefs
ABS Data
•
•
•
•
•
•
•
•
•
Intellectual
Psychiatric
Sensory/Speech
Acquired Brain Injury (ABI)
Physical
Profound
Severe
Moderate
Mild
AIHW
Definition
• Disability is conceptualised as a multi-dimensional
experience
• Effects on organs or hody parts
• Effects on activities
• Effects on participation
• Facilitate participation
• Physical and social environmental factors
Core
activities
• Self care – bathing, showering, dressing, eating, using the
toilet, and bladder or bowel movement
• Mobility – getting into or out of a bed or chair, moving
around at home and going to or getting around a place away
from home
• Communication – understanding and being understood by
others (strangers, family and friends)
Carers
• 1998 – 57% of the people with a disability needed
assistance with ADLs
• Carers – unpaid
• Issues – financial security, income support, workforce
participation, flexibility (Carers Australia, 2005)
• Carers provide unpaid care and support to family
members or friends who have a chronic or acute
condition, mental illness, disability, or who are frail
aged.
Social
Policy
Social
Work
Practice
•
•
•
•
Institutional to community based services
Discrimination
Advocacy
Power of legislative change
•
•
•
•
Human rights
Dignity
Social Justice
Individualised care packages rather than one size
fits all
Child with a
disability
•
•
•
•
•
•
•
Trauma and shock
Loss and grief
Marital stress
Integration
Tiredness
Life stage adjustments
Transitions – loss and grief
Case
•
•
•
•
•
•
•
•
•
3 days old baby girl
ICU
Requires cardiac surgery
SW asked to see family
Father 26/Mother 23 – both teachers
Live in rural area
1st child
What might the issues be?
What might you say if asked?
– Is she going to die?
– Have you got children of your own?
– Why did this happen to us?
loss and grief
•
•
•
•
•
•
•
•
Separation
Divorce
Moving House
Changing Schools
Unemployment
Chronic illness
Death of a dream
Death
On Death
and Dying
• Elizabeth Kubler-Ross identified five stages that a dying
patient experiences when informed of their terminal
prognosis.
– Denial (this isn't happening to me!)
– Anger (why is this happening to me?)
– Bargaining (I promise I'll be a better person if...)
– Depression (I don't care anymore)
– Acceptance (I'm ready for whatever comes)
• Not prescriptive
Worden (1987)
Complexity
• Face the reality of the loss
• Experience the pain of grief
• Adjust to an environment in which the deceased is
missing
• Emotionally relocate the deceased and move on with life
• Developmentally with every stage of the life course
there are losses and gains
• Mourning/Grieving of men and women
• Family grief – felt differently
• Disenfranchised grief –not recognised e.g. gay &lesbian
• Minimisation of the impact due to age elderly/children
• Role of hope – rebuilding and relearning
lifespan … loss
and grief
• What are the issues?
– Babies
– Children
– Teenagers
– Young Adults
– Middle Age
– Later Age
– Old Age
CASE STUDY
• Clive is 27 years old and has just been
diagnosed with leukaemia. What impact
might the diagnosis have on him?
• Social work role?
• What drugs have you or do you do?
History
Influences
on
changing
attitudes
• All societies use drugs
• Alcohol – central to life in Europe – safer than water – high
calories – helped people cope with work – festivals
• Alcohol also used therapeutically – build strength, digestion
and as an anaesthetic
• Ambivalent views – drunkenness
• 16th/17th Centuries increasing social concern about
drunkenness
•
•
•
•
•
•
•
Religious
Increased availability
Commercialisation
Transport/Stronger fortified wines – allowed storage
Public ale houses
Food changes
Conspicuous consumption
suffer
Understanding • Moral Model: moral weakness of the user – should th
legal, physical and psychological consequences (19 C)
drug use
• Pharmacological Model: drugs dangerous – focus on
abstinence – the power of the actual drug. Humans victims
of the drug – temperance /prohibition
• Disease Model: disease beyond the control of the
individual – develop alcoholism – treatment abstinence
• Spiritual Model: e.g. AA
• Educational Model: knowledge is power
• Public Health Model: person, drug and environment
• Harm minimisation
Types of
drug use
• Experimental – single or short term use – curiosity, new
experience, risk taking – harm reduction and education
• Social Recreational – controlled use of the substance in
prescribed circumstances – harm reduction and education
• Circumstantial use: exam, long distance driving, soldier in
combat, bereavement – harm reduction, education, medical,
counseling
• Intensive use – daily use, bordering on dependence –
medical, counseling, specialist care
• Compulsive Use – persistent, frequent high doses which
produces psychological and physiological dependence medical, counseling, specialist care, prison
•
•
•
•
•
Tobacco – most harmful recreational drug in terms of costs – 1976 advertising
banned on TV and radio
1988-1994 – sale of cigarettes to children illegal
Warnings, restrictions on promotion and sponsorship
Passive smoking – latest frontier
Paradox of tax revenue
VicHealth – public health model
Alcohol
•
•
•
•
•
•
High usage in Australia
One in five admissions to hospital alcohol related (Baum, 2002:40)
Personal choice – legal substance
Harm minimisation
Education
Industry self regulation
Illicit
drugs
•
1980-1990s – moderate approach – harm minimisation – health problem
rather than a criminal problem
Shift under the Howard Government – debate that illegal trade makes it difficult
for people to seek help - ties with crime and corruption
Ongoing debate
Policies &
programs tobacco
•
•
•
Harm
minimisation
•
•
•
•
•
Drug use will continue to be part of society
Eradication is impossible and maybe counterproductive
People make choices
Focus on the harm it causes rather than on the use itself
Choice
•
•
Supply reduction – legislation and law enforcement
Demand reduction – health promotion, education, alternatives to
drug use, treatment programs
Harm reduction – information about safe usage – e.g. needle
exchange, low-risk driving, safe injecting rooms, methadone,
warnings on labels
Harm minimisation – flexible approach, non judgmental, focuses
on client engagement, focus on individual and community
•
•
Previous
policy
• Tough on drugs
• Parents and families talking with their children –
“I believe that the best drug prevention program in the world is a
responsible parent sitting down with their children and talking with
them about drugs.” PM John Howard
• Ignores structural issues – assumes all children have
responsible parents and all parents share one view. Poverty,
stress etc.
• Importance of political agenda – evidence based research.
What does
this mean
for social
workers?
• Likely that many people you work with will use
alcohol and other drugs – across the life span
• Indigenous communities
• Links with violence
• Harm minimization
• What works?
• Public health but what happens in the meantime
• Range of interventions – self help, insight, groups,
medical, behavioural, dual diagnosis
What is
Evidence
Based
Practice?
Rubbin & Babbie
(2008)
What makes
an evidence
based
practitioner?
• Practitioners make practice decisions using the best
available research evidence
• Synthesis of scientific knowledge and practice
expertise
• Evaluation of outcomes of decisions
• E.g. new client you might:
– Identify diagnostic tools – assessment
– Treatment plan developed in light of the best research
evidence
– Same for policy development
• Critical thinking rather than authority based practice
• To do this need to find the evidence – ongoing
lifelong part of practice
• Evidence can be inconclusive, not there etc. the
important thing is that you seek it out
• Needs to be client centred research
Ethics and
BioEthics
•
What are ethics?
– A system of moral principles by which human proposals may be
judged good or bad, right or wrong
– The rules of conduct recognised in respect of a particular class of
human actions; for example medical ethics
– Moral principles of an individual
(Macquarie Dictionary, 1991)
Ethics and
Social
Work
• Values
– personal values
– social work profession’s values
– employer’s values
– underlying values of policies and programs
– underlying values of our political system
Code of Ethics
AASW
http://www.aasw.asn.au/adobe/about/AASW_Code_of_Ethics-2004.pdf
What are
your ethics?
Case Study
•
•
•
•
•
•
•
Euthanasia
Conflict with employing agency
Mental health
Child Protection
Family dynamics
Termination
Sexuality
A mother brings her 9 year old child to the child and
adolescent clinic because of behavioural problems. The
child’s parents are divorced but retain joint custody of
the child. The child needs help. The mother says the
father would object if he knew the child was coming to
the clinic. Should you tell the father about your contact
with the child?
Social work in health: foundation principles
• What does illness mean?
• The impact of illness
• Psychological consequences of illness
• Where does social work fit in?
Case study
Kim (42 years) and Mary (39 years) live
with their two children, Henry (15 years)
and Crystal (10 years) in a Housing Trust
apartment. Kim’s mother Mrs Lim (68
years) lives there with them. Kim is
devastated as he has been diagnosed
with cancer. Mary has been referred to
the hospital social worker because she
wants to understand how to help her
husband and children and she would like
to know what the options are.
Social Work
Practice in
Health Care
• Assessment is key response
• Who will be affected by the change of
circumstances?
• Systems and intersections:
• Who do you ask?
• What do you observe?
• What methods does social work
use?
• What is the social work role?
Case study – assignments
MENTAL HEALTH AND
SOCIAL WORK
• Chronic illness leads to long-term adjustments in
Psychological
living
consequences • Illness and limitations
of illness
• Impact on roles, relationships, leisure, work, finances,
housing etc.
• Individual factors: self-esteem, identity
• Re-configuration of normality, e.g. birth of child with
disability
• Re-configure relationships – changes in significances
• Power and authority
• Unrealistic optimism
• Family issues are significant
• Psychodynamic issues
• Individual functioning
What is mental
health and
mental illness?
• Mental health is described as well-being, when the
individual can cope with the normal stresses of life, is
aware of their own abilities and can contribute to his or
her community.
• Mental illness means there is impaired functioning
associated with distress, symptoms and diagnosable
mental health disorders, such as depression and
schizophrenia
• The mental condition of the individual is determined by
a multiplicity of factors including biological, individual,
family and social, economic and environmental.
• Mental Health is a specialty that requires social
workers to extend their knowledge of developmental
theories, truama theories, attachment theory,
behavioural theories as well as systems theory. In
addition to this, social workers will require a working
knowledge of the Diagnostic classification of mental
disorders as found in the DSM IV
Social
Work Role
• Are usually employed as part of a multi-disciplinary team required to contribute a social work perspective to this
team.
• Some of the contributions of social workers are:
complex case management skills, information on child
protection, a holistic and systemic view of ‘the problem’,
discharge planning skills, advocacy and networking skills
etc.
• Social workers need to be able to do the following:
–
–
–
–
provide a social work perspective to the multi-disciplinary team
undertake a Mental State Examination
carry out a Risk Assessment
present treatment options
Mental State
Examination
• Appearance - dress, grooming, posture, gait, voice, gender,
•
•
•
•
•
expression, odours, coordination, etc.
Perception - alertness, orientation to time and space, memory,
auditory and visual hallucinations, illusions, accuracy, etc.
Thinking Processes - content, main themes, general
knowledge, dreams, fantasies, wishes, obsessions, delusions,
coherence, disturbance in flow, abstract reasoning, defence
mechanisms, language, fluency, comprehension, insight and
judgement, objectivity, etc.
Affect - Emotional tone of interview, range, variation, intensity,
appropriateness to content, awareness and control of feelings,
congruence.
Behaviour and activity - i.e. themes, goal directed,
persistence, concentration, reaction to stimuli, ageappropriateness, etc.
Attitude to self and others - view of self, ideals and
aspirations, goals, body image, sexual identity, self esteem,
feelings of belonging or alienation, trust in self and others.
Risk
Assessment
(1)
• Involves determining whether a person is at
risk of harm to self or others.
• In completing a risk assessment, one needs to
establish with the patient/client :
– if they have ever considered harming
themselves or others.
– If yes, then what plans do they have and do
they have access to/or means to complete this
plan?
– One needs to establish how long this has been
their plan and if any attempts have been made
to date to carry it out and what were the
consequences.
– Furthermore, have they informed anyone else
about it or sought help.
– Also, establish whether they in fact wish to
seek help and how or from whom.
Risk
assessment
(2)
• If the person is clearly indicating a wish to harm
self or others, then establish a contract with
them i.e., a guarantee of safety.
• If the patient is unable to guarantee safety, then
steps need to be taken to ensure their safety
which may be to have them admitted to an
inpatient service. This may entail that they be
certified if they are unable to give consent and
are deemed to be mentally ill.
• At times it may be sufficient to contact next of
kin and ensure that the patient returns home in
the care of someone who can keep them safe.
Case
Sanjay has recurring bouts of depression which
need treatment with anti-depressants. He has in the
past said he “wants to end it all”.
As his social worker you see him and he tells you
he has stoped his medication to use herbal mixtures
which is more usual in his culture.
He asks you what you think and asks you not
repeat this conversation. Should you respect his
wishes?
Write down what your responses would be and
what the issues are.
Treatment
• In looking at treatment options, social workers
often develop skills in methods such as family
therapy, group therapy and individual therapies
such as psychotherapy.
• Treatment is often designed to suit the individual
or family and is aimed at responding specifically
to the problem presented and its source, e.g. if
the problem is a direct response to conflict
between family members, then a family therapy
approach may be needed in order to address
family dynamics.
• In addition to treatment, the social worker may
provide secondary consultation to schools and
other organisations on the mental health aspects
that impact on the individual or family.
Case
• As a school social worker you have been asked to
speak to a 14 year old girl to discuss mental health
problems she has talked about with her teacher.
• Write down what factors you think are crucial to help
build a good relationship with her.
• What ideas do you come up with?
Case
study
• Providing a suitable setting that is welcoming, private,
safe, secure, has few distractions, comfortable seating,
materials to write with
• Plan the session
• Set boundaries about what you can discuss and what
won’t be discussed
• Keep an open mind to gather information from the young
person
• Listen and reflect as you get a full picture of the young
person's life and their analysis of the situation
• Empathy and intuition, to understand what is going on for
the young person and how they assess their situation
• Safety, be sure the door of the room is open, or another
colleague close by.
social work
competencies
•
•
•
•
•
•
•
•
Knowledge of mental health problems and disorders
Contemporary approaches to treatment, rehabilitation and
recovery, including: early intervention, relapse prevention,
rehabilitation and recovery.
Assessing and helping people with mental health problems,
particularly through understanding the social context and
consequences of mental ill-health.
Knowledge of interventions used by other mental health
professionals
The nature of mental health services, both public and private,
for children and adolescents, adults, and older people, and
psychiatric disability rehabilitation and support services.
Knowledge about income support, supported housing and
employment services for people with mental ill-health.
How to support consumers and carers, acknowledging the
lived experience of consumers and of families and other
carers, including the impact of stigma, and how this should
shape social work practice.
Being aware of the moral and legal rights of consumers,
families and other carers.
social work
competencies
• Knowledge about mental health policy and legislative
context
• Been familiar with national and local state mental health
policies and their relevance to social work practice.
• Being aware of the influence of age, gender, cultural
and ethnicity factors
• Understanding differences in mental health problems
across the life span, and between men and women.
• Being aware of cultural and ethnic issues.
• Multidisciplinary practice
• Practice Skills
• Caring for yourself!
Why is
social work
concerned
about
mental
health?
• Emotional problems significant reason for GP
consultations
• The psychological dimension to client problems
• Implications and consequences of mental illness
• Normalisation of mental health problems
• Distress of mental illness
• Link between social environment and mental
health
What is mental
health?
What is mental
illness?
Mental health is the embodiment of social,
emotional and spiritual wellbeing. Mental health
provides individuals with the vitality necessary for
active living, to achieve goals and to interact with
one another in ways that are respectful and just.
(VicHealth 1999)
A psychiatric disorder is a psychological
“syndrome” (or pattern) that is associated with
distress (unpleasant symptoms) or dysfunction
(impairment in one or more important areas of
functioning) or with an increased risk of death, pain
or disability. (Bloch and Singh 2004)
What is mental • Impaired pyschosocial or cognitive functioning due to
illness?
disturbances in biological, chemical, psychological,
genetic or social processes.
• Variable in duration, severity and prognosis
• Major forms of psychological disorder include mood
disorder, psychosis, personality disorder, organic
disorder and anxiety disorder
(Baker: The Social Work Dictionary, NASW, 1995)
Mental Health Act (Victoria) 1986
• A person appears to be suffering from a mental illness
ifs/he has recently exhibited symptoms which indicate a
disturbance of mental functioning which constitutes an
identifiable syndrome or are symptoms of a disturbance
of thought, mood, volition, perception orientation or
memory which are present to such a degree as to be
considered pathological
What shapes
definitions?
•
•
•
•
•
•
•
Ideas about causes
What is normal vs abnormal
Community perceptions
Normal vs abnormal
Social factors
Moral/ethical views
Individual as economic unit.
Influences
on mental
health
• Biological: biochemistry and physiology and
their influence on mental illness. Some
individuals are born with a predisposition to
illness, or inherent factors that predispose
them to illness.
• Psychological: influences from individual's
childhood development, family experiences
and relationships with others.
• Sociological/sociocultural: the societal and
sociocultural context and the individual's
current life circumstances. View that, to some
extent, mental illness and mental health are
socially constructed.
Influences
on mental
health
• Developmental: mentally healthy individual
achieves life stage transitions successfully.
• Cognitive development : the interplay between
experience and processing information, whether or
not the individual experiences their environment in
positive or negative terms, influences thinking
about self and their place in the world.
– For example, the child with severe separation
anxiety when (s)he begins school may develop into
an anxious personality.
• Personality Development: Early life experiences
together with heredity, family and social
environment factors shape the individual's view of
themselves and the world. Attachment . Family
style and gender attitudes. Immediate environment
significant to personality development: parenting
style, relationships with siblings, school
experiences etc.
Influences
on mental
health
• Social causes:
– Age, gender, socio-economic status, marital status
as well emotional support networks and life events
affect mental health.
– Beliefs about those who deviate from ‘normal’
behaviours, for example, Salem ‘witches’
• Social Disorganisation:
– Individuals who cannot meet the demands of daily
living, who cannot cope with societal values and
ideals, become mentally ill
– Factors such as stress, social isolation, population,
mobility, migration, family breakdown are
contributors to social disorganisation and therefore
to mental illness.
• Social structure theorists see mental illness as
deviation from social norms.
Influences
on mental
health
•
How individuals adapt to changes in their milieu affects their
personality development.
•
Personal Deviance:
– Behaviour at variance from certain desired social
constructs such as personal responsibility, sobriety,
employment, stable housing etc.
– Robert Merton’s “strain theory”
– The “personal morality” issue
– Assumption that there is general agreement in society
about what is normal and abnormal, that the abnormal is
undesirable and one strives to revert it to “normal”.
•
Family Interaction:
– Confused interactions in families create intellectual and
emotional confusion in the individual who then becomes
mentally ill to “escape”.
– R.D. Laing- the relationship between family “messages”
and mental health.
Influences
on mental
health
•
Learning Theory/Motivation:
– Individuals acquire appropriate or inappropriate
behaviours: mental illness is a series of “maladaptive”
behaviours which need to be “unlearnt”
– Skinner’s theories about learned behaviour
– Martin Seligman's theory of learned helplessness.
Models
Approaches
• Biomedical model defines mental illness as a
disease, rather like epilepsy, diabetes, multiple
sclerosis, with clear symptoms and specific
treatments: breakdown occurs in the
individual’s biological functioning and medical
treatment is prescribed.
• The cause of mental illness is physiological, be
it genetic inheritance, brain injury, severe
infection (for example, encephalitis),
atherosclerosis, dementia.
• Illness explained in biological terms leads to
treatment that is medically oriented; depending
on severity there may or may not be the
possibility of cure or change in the individual’s
condition.
Models
Approaches
• Lifestyle model places importance on life
experiences, environment of the individual and how
the individual adapts to the demands of their milieu.
• This includes sociocultural factors, family, and
prevailing social attitudes about acceptable
behaviour and the amount of deviance tolerated in
society.
• Problems that contravene “accepted standards” may be defined in terms of “mental illness”.
• Familial model understands that it is family
interaction which shapes behaviour, develops the
self, and defines how the individual reacts to the
outside world.
• The significance of abnormal behaviour is viewed
within the context of the family.
Models
Approaches
• Social Models:
– Mental illness defined as a metaphor for problems in
living.
– Mental illness understood within the social context - it
is seen as a “defective strategy” for dealing with life’s
problems, a deviation from accepted social, legal and
moral norms.
– Enormous variation in understanding mental health
and illness, that behaviour acceptable in one historical
period or social context may not be acceptable in
another.
– Creates difficulties negotiating the differences and
boundaries between cultures within society.
Models
Approaches
• Psychodynamic Perspective:
– Emotions have a central place in human behaviour
– Unconscious and conscious mental activity motivates
human behaviour
– Early childhood experiences are central to emotions,
and problems
– Pressure of individual and external demands
– Ego defence mechanisms
How real
is mental
illness?
• What is considered normal in terms of human conduct
and emotions and what is considered abnormal.
• Historically a close relationship between medicine and
psychiatry
• The biological basis to much mental illness is well
accepted
• Greater acknowledgment of the relationship between
health and environment, of the biopsychosocial model.
• Some writers suggest psychiatry is an instrument of
society which labels certain people as having a mental
illness in order to control them (Bloch and Singh 2004).
• The sociological model of psychiatric disorder rejects the
relationship between mental illness and medicine as well
as disputing the existence of mental illness as it is
generally understood
•
Alternative
models of
mental
illness
•
•
•
•
•
•
Thomas Szasz: mental illness a “metaphor”, a way of dealing
with life problems
The psychiatrist the interpreter of social norms
Stigma attached to mental illness
Thomas Scheff: mental illness arises from violation of social
norms
“Labelling” described by Karl Menninger: it obscures the
individual’s problems. Particular concerns about the
classification of behaviours as “neurosis”, “psychosis”,
“paranoia” etc.
Irving Goffman focused on how people are defined, socially, as
“different” and how these definitions become rigid allowing the
person little option for change. His concerns about
institutionalisation lent weight to the “de-institutionalisation”
movement.
These and other writers- R.D. Laing and David Cooper- argue
that "mad" behaviours may be understood as stratagems
individuals use to protect themselves from real or perceived
threats.
•
Alternative
models of
mental
illness
•
•
•
•
R.D. Laing- Schizophrenia may have validity and meaning
when viewed according to the individual's particular social and
psychological experiences.
The power of family dynamics to manoeuvre the individual into
schizophrenic behaviour. The “double-bind” messages that
create internal confusion for the individual and make it
impossible to meet family demands: "schizophrenegenic”
process.
The irrational behaviour, the hallucinations and delusions of
the schizophrenic person are therefore perceived as their
responses to family dynamics.
David Cooper also argued that “madness” was not in the
individual but in the person’s system of relationships.
Family therapy- problems in the system of relationships, within
the individual’s milieu which lead one member to become the
“identified patient”, the bearer of the family pain, fear, sadness
etc.
Impact of
these
views
• The view that all mental illness is a social construction can
overlook the suffering imparted by mental illness
• Impact on families who believe that are responsible for the
schizophrenia.
• Society fears the abnormal and wants to control aberrant
behaviour.
• Is treatment system for mental illness is merely society’s
way of dealing with deviance?
• Social work must be mindful of what is the behaviour which
has led to public attention. Whom does it concern, how
does it affect the individual and others around him/her. Is
such behaviour eccentricity or mental illness, is it
temporary or permanent? Does it need to change for the
individual to cope with daily living?
• The consequences of not offering assistance may be more,
rather than less, severe for the individual and their family.
Normalisation and
De-institutionalistion
• The de-insitutionalisation discourse follows the
historical response to mental illness when
sufferers were sent away from the town to live.
• Over time the unwanted people were then
placed in poor houses, asylums or gaols.
• Thus was an institutional system with a captive
population, the motivation for which sometimes
stemmed from kindness, sometimes from fear of
the different or the inexplicable.
• This institutional response remained the
dominant approach to problems posed by the
mentally ill, to those with permanent disabilities,
until the 1960’s.
• The institution and the community were seen as
two separate, and distinct entities: provision of
services to, thinking about the ‘disabled’, a group
seen as separate from the community.
Reform
• Reform of the institutional system brought a new way of
thinking about the mentally ill or persons with permanent
disability.
• Considered important to maintain individuals in the
community.
• Belief that institutionalisation may still serve a useful purpose:
for the severely socially disabled; for those who have no care
givers or supportive networks; for those who need specialist
services and professionals who understand the physiology
and treatment of disability and mental illness.
• Institutionalisation as a response to those who find deinstitutionalisation too complex, too problematic, who have no
independent living skills, who may become ‘transinstitutionalised’:
Radical
Mental
Health
Social
Work
• Help offered to clients must meet their definition of need
• Communication patterns and mental illness
• Therapy vs surveillance and control
Mental Health
Continuum
• Healthy>Unhappy/Anxious> Miserable/Withdrawn>
Mental health problem or “illness”
• Ideas about mental health and mental illness, and
causes, range from view that an emotional, or
psychiatric, illness, is like any other illness and so is
treated as a physical illness, to being seta apart.
• Mental health and mental illness are on a continuum,
according to events internal and external in their
lives.
Classification
of
psychological
disorder
• Certain behaviours/feeling are signals for mental
health problems.
• The common classification of mental illnesses (from
the DSMIV or the “Diagnostic and Statistical Manual
of Mental Disorders”) is:
1. Affective Disorders
2. Anxiety and Somatoform Disorders
3. Schizophrenic Disorders including Psychotic
Disorder
4. Personality Disorders
5. Organic Disorder (for example, Alzheimer’s Disease)
Assessment
• The DSM IV provides a framework for
treatment/rehabilitation and for prediciting likely
outcomes for the individual and their family.
• Assessment of any individual’s problem however must
be in their own environment, relate to their individual
personality and be mindful of sociocultural,
development, and historical factors.
• Problem signs are signals for assistance and
understanding rather than answers in themselves.
• The mental state examination is the assessment tool to
determine the severity and nature of an individual's
problems and whether the individual is a risk to
themselves or to others.
The
healthdisorder
continu
um
• Most emotional problems can be resolved with
or without professional assistance. Individuals
move along a “mood continuum”
• Everyone has the capacity to be depressed,
or anxious.
• These “neurotic traits” are extensions or
exaggerations of “normal” behaviour.
• When these traits, or behaviours, interfere
with individual functioning, they are
problematic and indicate what has been
termed in the past "a nervous disorder" or
"neurosis".
• This includes anxiety states (which include
phobia, obsessive compulsive disorder, panic
disorder), depression, post-traumatic stress
disorder and physical disorders that have a
psychological origin.
Indicators of
neurosis
•
•
•
•
•
First, decreased efficiency in social functioning and
disturbances in interpersonal relationships;
Second, behaviour patterns are “self-defeating” or
maladaptive life patterns. Intensity and duration of
behaviour are key factors in assessing behaviour as
problematic and in need of attention and possibly
professional assistance.
Third, assessment must take into account the individual’s
own personality, life situation and general social situation.
Fourth, with anxiety and depression (excluding psychotic
depression) and the other states mentioned above, the
individual has insight into their situation The individual with
a psychotic disorder does not have this insight, and their
detachment from reality renders them unable to see
themselves and their behaviour relative to others.
Fifth, non-sufferers can identify, more likely to be
sympathetic they may have experienced elements of these
behaviours themselves, or can see that - given certain
circumstances - it could happen to them.
Neuroses
•
•
•
•
•
•
•
Anxiety States
Obsessive Compulsive Disorder
Reactive Depression
PTSD
Social phobia
Eating disorders
Panic disorder
Anxiety
• Anxiety is a normal experience
• Moderate or high levels of anxiety can increase alertness and
performance in particular situations
• People who experience continuous or recurring fears, or
episodes of intense fear can feel powerless to manage their
symptoms and their lives can become severely restricted.
• Anxiety disorders affect 12% of Australians at some time in
their lives. The increasing demands and stress of everyday
life means that anxiety has become a problem in our society.
• Stress related mental health issues, such as anxiety disorders
and depression represent a growing area of need in mental
health resources
• Unrelated or unrecognised anxiety disorders can lead to
secondary conditions such as agoraphobia, depression,
alcohol and drug abuse, or tragically in some cases, suicide.
Anxiety
• Generalised anxiety- chronic anxiety, individual deals with a
large number of worries, and finds it difficult to exercise much
control over these worries
• Panic disorder- a panic attack is a sudden episode of intense
fear that can occur ‘out of the blue’ or in response to being in
certain situations
• Social anxiety-the individual feels embarrassed or humiliated
in situations where they feel exposed to the scrutiny of others.
• Agoraphobia-fear of being in a situation that may cause a
panic attack
• Obsessive-Compulsive Disorder (OCD)
• Post Traumatic Stress Disorder (PTSD)
• Specific Phobia
• Separation Anxiety
Origin of
Anxiety
• Chemical imbalance in the brain may be involved
in the development of an anxiety disorder
• Uncertain whether this imbalance is the cause or
result of the disorder
• The DSM IV suggests a genetic pre-disposition as
panic attacks can quite often be traced through
families.
• Behaviourists suggest disorders are a learned
behaviour
• Psycho-analysis suggests anxiety stems from
unresolved issues from the past
• A disorder can occur when panic attacks and/or
anxiety symptoms are not successfully managed.
ObsessiveCompulsive
Disorder
• Obsession- intrusive thoughts that occur despite
individual not wanting them to.
• Compulsion-response to the thoughtsirresistible urges to perform acts or rituals to
ward off anxiety the thoughts generate
• Co-morbid disorder common
• Social and occupational impairment.
• Impact on family
Anorexia
Bulimia
• Anorexia- a condition in which a person refuses to eat
sufficient food to maintain a minimum weight for age and
height
• Consequences of wasting away has serious effects on many
body systems and may result in death
• Weight loss of 25% is one criterion for diagnosis of anorexia
• Tending to start in early teens, 1 in 100 Australian
schoolgirls have anorexia nervosa
• Bulimia is an eating disorder marked by cycles of binge
eating of excessive quantities of food, followed by purging
using vomiting, laxatives or diuretics
• The person with bulimia is rarely grossly underweight
• The purging can seriously damage health
• Bulimia tends to start in late teens and older age groups
• Estimated to affect about 6% of Australian women
Social
Phobias
• An anxiety disorder where the sufferer fears being
negatively judges or evaluated by others and
therefore they are afraid of doing something to
embarrass or humiliate themselves in public
• Social phobia is common and is thought to affect 1
in 10 people at some time in their lives
• Approximately 3% people are thought to have
social phobia at any one time
What is
Psychosis?
• Psychosis is a severe dysfunction in mood, behaviour,
relationships, roles.
• Psychosis is a significant mental health problem, it can
lead to bizarre and perhaps, life-threatening behaviour.
• Behaviour that is intense in action and in mood, insight
is absent.
• The behaviour does not “fit” within the continuum of
usual or appropriate behaviour for that person and that
community. People who have a psychiatric disorder
often become marginalised - they may have difficulties
within work, health, accommodation, inter-personal
relationships -and present to social workers for
assistance.
• Functional vs Organic psychosis
Indicators
of
psychosis
• Psychosis – conditions that affect the mind, where here
is loss of contact with reality producing a psychotic
episode
• Confused thinking
• Hallucinations
• Changed feelings and behaviours
• Delusions
• Psychosis occurs in 3 phases: prodrome, acute and
recovery
Types of
psychosis
Psychoses most encountered by social work:
•
•
•
•
•
•
•
Schizophrenia
Bi-polar disorder
Organic disorders
Depressive psychosis
Drug-induced psychosis
NB. Munchausen’s Disorder (Factitious Disorder)
Folie-a-Deux
Intervention
•
•
•
•
•
•
•
Assessment
Medication
Therapy
Practical assistance
Hospital
Involuntary treatment
Mental State Examination
Schizophrenia
• An abnormal condition of mind that drastically
changes thinking, feeling, dealing with the
world, confused reality, difficulty coping with
normal demands of life
– Causes: biochemical
trauma. Stress
parenting factors
family history
– Features: Delusions
Hallucinations
Illogical thinking
Social isolation
Loss
Bi-polar
Disorder
• Affective psychosis- abnormality of mood
• Lability
• Mania- severe persistent elevation of mood
characterised by excessive mental and physical
activity, lack of insight into consequences of
behaviour. Individual may believe can perform
amazing feats.
• Episodes of significant depression-mood changes,
sleep effects, agitation, guilt and worthlessness,
obsessions/compulsions, rumination (preoccupation
with past, hypochondriasis), hallucinations/delusional
development (may hear voices to commit suicide).
Forms of
psychosis
• Organic psychosis-psychotic symptoms appear as
part of a head injury or a physical illness that disrupts
brain functioning e.g brain tumour, ABI, dementia
• Memory problems and confusion usually present,
perhaps also mood changes
• Depressive psychosis-severe depression with
psychotic symptoms, without mania.
• Drug-induced psychosis- associated with withdrawal
from alcohol/drugs
Factitious
Disorder
• Munchausen’s syndrome
• Individual who presents with imagined or
manipulated symptoms
• Demand surgery/drug treatment
• Features: family disorganisation, emotional
immaturity, no insight, masochistic, poor
interpersonal relationships, mind-body dissociation
• No effective treatment
Factitious
Disorder by
Proxy
• Parent invents or induces illness in a child
(seizures/poison, suffocation, asthma)
• Parent persistently brings child to doctor with story of
illness which may not neatly fit recognisable condition
• Parent with personality disorder, history of self harm,
alcohol/drug misuse
• Child abuse-refer to child protection, risk to child, failure
to thrive
• Parent (usually mother only person who witnesses
illness)
Folie-a-deux
• Folie a deux- a paranoid delusional system develops in
a person as a result of a close relationship with another
person who has an established and similar delusional
system.
• Usually seen in two people who are members of the
same family, a dominant partner with fixed delusions
who appears to induce similar delusions in a
dependent or suggestible partner.
• The two or more individuals concerned live in close
proximity and may be socially or physically isolated and
have little interaction with other people.
• The delusions of the second person quickly weaken if
the two are separated
Case
example
• Enoch and Ball's 'Uncommon Psychiatric
Syndromes' (2001, p181):
Margaret and her husband Michael, both aged
34 years, suffered from folie à deux as they
both shared similar persecutory delusions.
They believed certain persons were entering
their house, spreading dust and fluff and
"wearing down their shoes".
Both had, in addition, other symptoms
supporting a diagnosis of paranoid psychosis
which could be made independently in either
case.
Implications
for social
work
• Well supported people with significant mental illness can
lead satisfying lives appropriately (for example, Winston
Churchill and Spike Milligan had bipolar disorder).
• Families need great support when a member has a
severe mental illness, for example, people who have a
clinical mania can go without sleep for days on end, are
on a constant “up” - an extremely elevated mood,
engage in frenetic activity and might perhaps go into
great debt.
• Those who are depressed, or hear voices, or have
delusions, have little energy, are very tired yet sleep
poorly, have little sense of well-being, and may have
thoughts of suicide.
Implications
for social
work
• In these situations medication is important to help with
sleep, regain energy, raise the mood level to prevent
suicide. The delusions, or false beliefs, that accompany
much of psychotic disorder create great difficulty. Those
who are paranoid, or grandiose (having special powers),
or morbidly jealous, for example, add to the difficulty
individuals and families experience.
• Families who have a member experiencing an affective
(mood) disorder face difficulties: schizophrenia and
related disorders are highly stigmatised, frighten families
and the affected individual.
• It is important to offer families management strategies
and information as to what they can/cannot expect from
their family member, and what treatment options are
best.
Understanding
suicide
• Reasons people suicide are broad.
• Suicide evokes often quite powerful feelings in
others, and is accompanied by overwhelmingly
powerful feelings, of desolation, helplessness, selfpunishment or other-punishment. Those left behind
may experience fear, distress, anger, blame and the
agony of not knowing why this has happened.
• Suicide may come from profound emotional pain or
depression, or great anger, with feelings of anger
internalised. The anger may be directed at others,
who are left behind to deal with other people’s
reactions, grief and blame.
• A person feeling hopeless may see suicide as an
escape from the disorder they feel. Not all those who
attempt suicide wish it to be successful, but to signal
their despair.
• Motives for suicide are complex but generally we
see an absence of hope for the future, helplessness,
and urgency, a belief there is no way out from real or
perceived problems.
Why do
people
commit
suicide?
• Suicide in young people in Victoria is the most frequent
cause of death in young males, closely followed by motor
vehicle accidents.
• Sociologists like Fromm (1956), Durkheim see alienation
as strong cause: what refers to as "anomie", extreme
alienation of the self from society, from the destruction of
traditional social bonds, and highly urbanised,
technologically-oriented communities lacking supportive
local networks and tight family identity. Boredom and
monotony frustrate people’s attempts to meet their
personal and social needs.
Why do
people
commit
suicide?
• The inquiry into Aboriginal Deaths in Custody found the
same sense of isolation and social exclusion.
• Suicide often masked as an accident, statistics are
inexact, but young men are committing suicide in alarming
proportions.
• A positive correlation between substance abuse and
suicide; mental illness and suicide (the risk of suicide is
high in severe depression, in schizophrenia).
• People without a sense of “connectedness”, isolated from
others, more likely to commit suicide than those who have
family responsibility, supportive relationships, community
life.
• Often those intending to commit suicide give a warning of
some kind and it is important for social workers to assess
this risk of suicide.
Suicide
attempts
• Suicide attempts generally considered:
– a message for help, or
– designed to provoke a reaction from a significant other(s)
• Careful psychosocial assessment of the individual involves:
–
–
–
–
–
–
circumstances of attept
motivation of individual to deal with their problems
what happened and how (that is, the attempt)
why the decision to attempt suicide? (the last straw)
did the individual expect to die?
what reaction has there been to the attempt and, from whom?
• What does still being alive mean to the person - what plans
do they have for the future?
• The degree of risk and the likelihood of being rescued
important in assessment of seriousness of a suicide
attempt. This is important for understanding what the
individual hoped would happen, and what prospects for
change there might be.
Suicide
Factors
Recognised trigger factors:
• Family breakdown
• Poor self-image
• Pressure to achieve
• Physical and sexual abuse
• Money problems
• Unemployment
Legacy of
suicideimpact on
others
• Individuality of response
• People’s reactions to the death, to those left behind vary
widely and are not predictable
• Professionals also vary in how they deal with those left
behind, ranging from sympathy, to being judgemental, to
not mentioning the death
• Lack of support
• Few formal or familiar structures in place to assist those left
• Those not directly affected may find it difficult to identify
with the nature of the loss and associated feelings
experienced by survivors
• No accepted social norms for suicide survivors
• Uncertainty of survivors and those around them about
feelings, how to relate to others, how to explain death
• Mourning period: how long is ‘normal’, what is ‘normal’?
Legacy of
suicideimpact on
others
• Suicide- a very different grief
• Grief associated with other losses tend to have accepted
processes attached to them
• Language- how to disclose the nature of the individual’s
death to others
• Outsiders find it hard to identify with the nature of the loss
• Irrevocability of the impact of suicide
• ‘Short-term solution brings permanent change’, distress that
is individual’s choice
• ‘No going back’ aspect – difficult to explain when not known
precisely why, no time for discussion orgoodbyes
• Loneliness and isolation of survivors
Legacy of • Child survivors
suicide• How to respond to children left behind: how much to
impact on
disclose?
others
• Trauma vs honesty
• Children need open and honest discussion
• Truthful accounts
• Be mindful children may feel responsible
• Be alert to behaviour changes- anger, shame, hurt, low selfesteem
• Stigma
• How others view those left behind
• Viewed as responsible for another’s actions
• Anger at victim, at unleashed hurt, at shame, sense of failure
• Stress in other relationships
• Vulnerability and need for support
Social Work
responses
•
•
•
•
•
Assess underlying problems
Is there a psychiatric disorder?
Implement interventions that reduce ongoing stresses
Introduce social support
Liaise with family, relevant health professionals, support
agencies
Compulsory
treatment
• The issue of compulsory treatment arises in mental
health work and social workers may be asked to:
• assess the severity of a mental health problem,
• the person’s/family’s resources for coping,
• the risk of harm and/or deterioration,
• why this particular problem is occurring at this
point in time.
• If the risk of deterioration, of injury to the self or others
is high, and, perhaps, unrecognised by the individual.
• If there is significant risk then admission to hospital
may be appropriate. Not every mentally ill person is
prepared to be admitted voluntarily and it is in this
situation that involuntary admission takes place.
Rights and
responsibilities
• Essential social work practitioners ensure:
– correct assessment takes place,
– the individual’s rights are protected (do they require
legal representation, do they know what is happening
to them, what treatment is planned etc.).
– Consider referral to Community visitors, the Mental
Health Review Board, the Public Advocate, the
Ombudsman.
• The mental health legislation, albeit with some
variations, is found in most States and Territories of
Australia.
Legislation
and mental
health
• The Mental Health Act (Victoria) 1986 states people are
not mentally ill if they express particular political opinions,
religious beliefs, or sexual preferences, or if they are
intellectually disabled, sexually promiscuous, substance
abusing, or an anti-social personality.
• Involuntary admission takes place when:
(a) the person appears to be mentally ill;
(b) the person requires immediate in-patient psychiatric
treatment;
(c) the person’s health or safety is at risk, or members of the
public require protection from this person;
(d) the person cannot receive adequate treatment in a less
restrictive way.