The Changing Role of the Social Worker in the Mental Health System

ABSTRACT

The purpose of this paper is to discuss the role of the social work profession in the mental health service arena. It analyzes the changing mental health environment and the challenges facing social work. It stresses that the profession must adapt to the dramatic changes that have been taking place since the advent of deinstitutionalization and the need for community care for mentally ill persons.

Historical analysis of the social work profession shows that its involvement in the mental health field has started during the early stages of the development of the profession. Psychiatric social work has been considered a prestigious area of practice within the profession. Historically, social workers in the mental health field rarely challenged the dominance of the psychiatric profession. This position seems to have restrained social work from providing its full potential contribution to this field of practice and to the population it served.

Assessment of the continuing problems and current issues of the mental health system shows the potential central role of social work in this area. However, changes must take place in the practice of social workers in the mental health service system, as well as in the education and training of social workers. The paper discusses factors that facilitate or hinder the profession from appropriately adapting to the current service needs of the mentally ill persons, their families and communities, providing quality mental health and social services to this population and society as well.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Risk and liminality in mental health social work

From a socio-cultural standpoint, the concept of otherness is central to explaining the way risk is associated with certain social groups rather than others. In the mental health field, writers have frequently employed the concept of otherness to describe the ways in which mental health service users have been perceived, especially since the implementation of community care policies in the UK in the 1990s. Despite its popularity, few empirical studies have explored the concept of otherness and its use in explaining the risks associated with being mentally ill in any depth, and fewer still have done so in relation to professional practice. The present paper draws upon data from semi-structured interviews with 39 mental health social workers in order to explore the relevance of this concept in risk assessment. The paper employs the concept of liminal otherness as an analytic tool to explain how social workers assessed the risk of clients who were 'difficult to place' because of uncertainty about whether their behaviour was the result of their personality or their mental illness. It is concluded that liminality is relevant to understanding the following: the way in which some service users are found 'in-between' places in terms of service provision; the allocation of responsibility for the management of the risks they represent to social work as a liminal profession; and the symbolic importance of 'the street' as a liminal space within which forms of 'racial otherness' have become central to contemporary constructions of community care.     

Social work services for elderly persons with mental retardation: a case example

Elderly persons with mental retardation constitute a relatively small and often overlooked subgroup of our aged population. As their numbers continue to grow, it is likely that social workers in health care and social service agencies serving either the mentally retarded or the aged will increasingly encounter such older persons as clients. This paper presents a case study that illustrates some of the problems and issues that social workers in a variety of community-based and institutional-based agencies are likely to face in helping to provide for the health and residential care needs of members of this group.     

The effects of alcohol abuse among the new chronically mentally ill

In recent years, there has been a growing recognition of the high incidence of alcohol abuse among the new generation of chronically mentally ill. This article reports on a study that tracked a subgroup of the chronically mentally ill, those discharged from state psychiatric hospitals, through an entire community mental health aftercare system and its major auxiliary human service agencies. Those who were assessed by hospital discharge social workers as having a need for alcoholism services were found to be less likely to be referred for aftercare and to make contact with aftercare agencies post discharge; and for those with an alcoholism problem who do make contact, they generally received less service than those who did not have a need for alcoholism services. The professionals in both the mental health and alcoholism fields need to work together to better meet the needs of the chronically mentally ill with an alcohol problem.     

The Effects of Alcohol Abuse Among the New Chronically Mentally Ill

In recent years, there has been a growing recongition of the high incidence of alcohol abuse among the new generation of chronically mentally ill. This article reports on a study that tracked a subgroup of the chronically mentally ill, those discharged from state psychiatric hospitals, through an entire community mental health aftercare system and its major auxiliary human service agencies. Those who were assessed by hospital discharge social workers as having a need for alcoholism services were found to be less likely to be referred for aftercare and to make contact with aftercare agencies post discharge; and for those with an alcoholism problem who do make contact, they generally received less service than those who did not have a need for alcoholism services. The professionals in both the mental health and alcholism fields need to work together to better meet the needs of the chronically mentally ill with an alcohol problem.     

Brown versus New York: the Rashomon of delivering mental health services in the 1990s.

This article examines a case study of one homeless mentally ill woman in New York City to show the differing perspectives on mental illness among mental health consumers, family members, mental health professionals, and advocates. Different issues emerge, and different priorities for care become clear. The social worker as case manager must design intervention strategies based on these differing perspectives, a crucial challenge for the profession. This article reviews the current literature on case management and suggests a holistic approach that better meets the needs of mentally ill people, their family members, and the community.     

Operating a member-employing therapeutic business as part of an alternative mental health center

The promises of deinstitutionalization have not been kept for unemployed chronically mentally ill people. This article describes an innovative community support program--a nonprofit therapeutic member-run business. Rainbow Services provides opportunities for adults with chronic mental health problems to learn marketable job skills and necessary social skills through participation in various work settings. On-site job training, vocational education, socialization, and job counseling are offered. Thirteen years of business success demonstrate that chronically mentally ill people can function productively in the community. The features of the business are related to beliefs and values familiar to early settlement house workers and social activists and support social work's claim to leadership in working with this population.     

Assessing the service needs of the discharged psychiatric patient

In recent years the chronically mentally ill have come to be regarded as a heterogeneous population with a diversity and multiplicity of needs. Social workers assessed a cohort of psychiatric patients being discharged from two state hospitals in terms of their postdischarge service needs. The findings confirmed that these patients needed not only basic mental health services of chemotherapy and counseling but also social rehabilitative services and specialized services such as substance abuse counseling. The data have been utilized by agencies and state and county governmental entities to document the need for new programs and to reorder service priorities. To start a planning process, recommendations on the study findings are being distributed to mental health and human service agencies and family coalitions on a communitywide basis.     

Labor market conditions and employment of the mentally ill

BACKGROUND: The mental health services literature includes assertions that workers with mental illness are at earlier risk of unemployment than other workers when the economy contracts. This possibility is important for several reasons. One is that such a phenomenon would support the argument that the lives of mentally ill persons are made unnecessarily stressful by the stigma of mental illness. Another is that the phenomenon could distort comparisons of the effectiveness of programs designed to prepare persons with severe mental illness for work. Despite its importance, the assertion that severely mentally ill workers are at early risk of unemployment has never been empirically tested. AIMS OF THE STUDY: We aim to test the hypothesis that unemployment among persons with severe mental illness (SMI) increases before job loss among other workers. METHODS: We test the hypothesis by applying Granger causality methods to time-series data collected in two communities in the United States (i.e., Concord and Manchester, NH) over 131 weeks beginning on 12 May 1991. RESULTS: We find no relationship between job loss in the labor market and the likelihood that persons with SMI will be unemployed. DISCUSSION: We speculate that persons with SMI participate in the secondary labor market and that their employment status is unlikely to be well described by data gathered in the primary labor market. This implies that widely available measures of labor market status, which are designed to describe the primary labor market, cannot be used to improve the evaluation of programs intended to prepare the mentally ill for work. We also discuss the possibility that persons with SMI may have needs that are better met by the secondary than by the primary labor market. CONCLUSIONS: The intuition that workers with severe mental illness are affected earlier than other workers by labor market contraction may not be correct. We infer that persons with severe mental illness may participate in the secondary labor market about which we know relatively little. We cannot, therefore, easily adjust program evaluations to disentangle intervention effects from those, if any, of the labor market.     

Field Instruction in a Psychiatric Setting

New biological findings, major shifts in family intervention models, the failure of the deinstitutionlization movement to provide humane quality care for the mentally ill and shrinking community-based resources all suggest the need for vigorous social work leadership in the metal health field of practice. Such leadership can only emerge from a social work student body sparked to engage in, grapple with and reframe mental health practice for the future. The field instruction relationship nurtures this spark. This chapter will highlight the challenges and obstacles to teaching in the current psychiatric climate.     

Deinstitutionalization: A microcosmic perspective

Changes have taken place in caring for chronic patients due to deinstitutionalization, and these changes have affected the services rendered by the community mental health centers. Statistical data on dehospitalized patients treated in a community mental health center located in the South Central Bronx are examined to determine trends in service utilization by these patients. Demographic characteristics of this population are also examined. Issues surounding treatment and rehabilitation of chronic mentally ill patients are critically explored and recommendations for changes in the care of the chronically mentally ill patient are offered.     

Families of chronically mentally ill people: siblings speak to social workers

Twenty siblings of chronically mentally ill people discussed their emotional responses to the mental illness of their brother or sister. The findings were drawn from a study that was part of the author's practice experience as a social worker in a community mental health setting. The findings also paralleled the author's life experiences as a sibling of a chronically mentally ill person. Sibling emotional responses were categorized into grief and loss phases of denial, anger, bargaining, depression, relief/respite, and acceptance. Siblings believed that their expressions of grief and loss were impaired by characteristics of mental illness and by mixed messages from the mental health system. The siblings recommended inclusion of siblings in client treatment; support and education for siblings; clear communication between social worker and family; a social worker focus on family strengths; and, most of all, effective client intervention. The sibling perspective points out the salient need for social workers to use their ecological, person-in-environment training to facilitate healthier family support networks for chronically mentally ill people.     

Social work and health restructuring in Canada and Finland

The health care systems in Canada and Finland are currently in the process of restructuring. Responsibility for care has increasingly shifted to ill persons themselves and to their families and friends. Reduced hospital stays, service privatization and user fees have been implemented to some degree in both countries. These changes are reverberating throughout Finnish and Canadian societies, affecting not only users of health care but also the labour force in health workplaces. Health social workers, at the front line with clients, have experienced new issues which have impacted on their practice with ill persons and their families. In an environment of health care restructuring, they have needed to draw upon their repertoires of knowledge, skills and community networks in order to respond. At the same time, social workers noted that there is a leaner package of health and social service benefits to support patients and families. Social workers have tried to adapt and find new opportunities to practice social work in the changed environment. This small study, initially conducted as a pilot for a larger study, compared the experiences of social workers in Canada and Finland and the perceived impacts of health restructuring on their clients. The findings, seen within the context of changing societal and institutional environments, can help us to better understand some of the impacts of health restructuring on social work and social workers in hospitals and local health centres. Indirectly and directly, these changes also affect clients in the health care system, those whose needs remain uppermost in the delivery of social work services.     

Continuing Education in Ethical Decision Making Using Case Studies From Medical Social Work

Medical social workers have needs for training in ethics that is specific to dilemmas that arise while providing service to patients who are very ill, mentally compromised, or in a terminal condition. A social work department developed a continuing education training to educate social workers in bioethics related to determining decisional capacity and understanding standards of ethical decision making. Case studies are used to illustrate ethical conflicts and the role of social workers in resolving them. The benefits of case study training are discussed.     

Developing community-based program alternatives for the seriously and persistently mentally ill elderly

The deinstitutionalization movement in the United States has traditionally neglected the rehabilitation potential of the seriously mentally ill elderly. With the proliferation of the elderly population, unique programs and community-based settings must be created and expanded to meet the mental health needs of this population in a cost-effective and humane manner. The mental health continuum presented is a model composed of programs that target the seriously mentally ill elderly in a variety of community placements including residential treatment facilities, nursing homes, retirement homes, and permanent housing.     

Living with the mentally ill: Effects on the health and functioning of other household members

Based on data from the National Health Interview Survey Mental Health Supplement, 1989 (NCHS, 1991), this article compares health outcomes for respondents living with someone who is mentally ill (N = 776) with a randomly selected subsample of respondents not living with someone identified as mentally ill (N = 716). When other predictors of health are controlled, sharing a household with a mentally ill person is associated with poorer self-reported physical health, increased risk of reporting some activity limitation, and increased service utilization—both greater risk of hospitalization or visiting a physician, and a greater number of days hospitalized and number of physician visits among those utilizing these services. The severity and duration of mental illness have little effect across health outcome measures. Impaired health and increased utilization of medical care among persons living with someone who is mentally ill suggest hidden costs to individuals, to families of the mentally ill, and to the service system.     

Risks to mental health patients discharged into the community

The advances in pharmacological and psychosocial treatments in the 1950s and 1960s facilitated the movement of care for increasing numbers of mentally ill people from the institutions to the community. This represented a radical change in mental health strategy and practice and has brought with it new sets of risks. Due to inherent stigmatisation and some well publicised cases of violence and murder, there is a perceived risk to the public from community-based mentally ill people. The findings of many studies have illustrated this and have led to the isolation and rejection of large numbers of people who have mental health problems. This has increased the risk to mentally ill people of victimisation and harassment from members of the public. Kelly and McKenna (1997) have shown that this takes many forms and occurs within and outside the home. Most worrying these latter risks can increase the former where some mentally ill people carry weapons to protect themselves. This in turn can increase public fear and raise stigmatisation. Furthermore, the lack of support and belonging can increase the risk of self-harm among the mentally ill. A more general risk is that for many deinstitutionalisation simply means transinstitutionalisation where incarceration in large mental hospitals is being replaced by incarceration within community based houses and flats. To assuage these risks mentally ill people still require social support and protection. The asylum the place may have disappeared but asylum the function is still required.     

Home health care for the elderly.

Home health services must be expanded and must include ongoing social work services. In addition to the provision of direct service, social workers are encouraged to advocate for quality home health services, to develop effective techniques for providing social services to home-care patients, to incorporate these techniques into social work education, and to become involved in the education of their medical colleagues. In this way, the home health field can begin to fulfill its goals by providing patients with quality care in the home setting, thus allowing them to remain independent and at the same time meeting their health and social needs.     

The APA model law and three legal issues in mental health

The needs of nondangerous mentally ill persons, the right of patients to refuse treatment, and professionals' duty to warn about the potential for dangerous behavior are important and controversial legal issues. The author considers the difficulties social workers have in implementing the principles and discusses the likely effects of the American Psychiatric Association's proposed model law on mental health services, particularly in the context of inadequate community care resources.