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By the end of the unit you will be able to:

• Demonstrate understanding of the basic values and principles underlying anti-mentalist practice.
   

• Critically appraise the major existing theories, models and treatment methods in this field.
   

• Critically evaluate the social model of mental health.
   

• Promote the users’ perspective in mental health services, showing awareness of how to manage areas of conflict.

Below is a list of learning objectives you will be working towards in order to demonstrate the module learning outcomes for each session. You can use it to evaluate your current understanding of Mental Health, and to help you decide how the module can contribute to your further learning.

The profile is for your general use only. It is not assessed by anyone else. However you may wish to use it in the early stages of your learning support workshops in planning with your peers and tutor the work the group will be concentrating on.

For each of the objectives listed below, please tick the box on the scale which most closely corresponds to your present knowledge. You can use this to determine in how much detail you will need to study each session. At the end of the unit you will find an identical list of objectives and the same scale. By completing this Learning

Review you can gauge how much your learning has developed and on which areas you still need to work.

This module aims to help students consider the role and perspective of social workers and to promote their distinct contribution to working in partnership with people with mental health problems and their families in the context of current legislation and policy.

This will involve exploring how definitions of mental health and responses to people with mental health problems have changed over time and how they vary between cultures. Students will acquire an understanding of medical, social and psychological models of mental ill health and critically evaluate them in the context of anti-discriminatory and anti-oppressive social work practice.

Throughout the module we will be identifying the range of stakeholders, including service users and carers, and their influence on the development of policy, legislation and practice. Current government policy and guidance will be described, raising issues of social inclusion and the tension between 'care and control'.

Social workers in the field of mental health are increasingly working in multi-disciplinary settings with a range of other professionals, who may or may not share their values, their understanding of mental health or their approach to working with people with mental health problems. Increasingly voices are raised in support of abandoning discrete professions and introducing generic mental health workers. We will consider the role of the social worker and their particular contribution to multi-disciplinary and multi-agency working, as well as exploring the dynamics of multi-disciplinary working.

Due to the dominance of the medical model, 'treatment' is frequently viewed in terms of physical interventions such as medication and ECT (electro-convulsive therapy). However, there is a wide range of psychological and social interventions which haven proven effective. The module will look at the availability of different treatments and interventions to service users and question the extent to which 'treatment' is evidence based.

Although the theme of service user and carer participation will be woven throughout the module, space will be given to examining the development of the user movement and to the responses of professionals to this 'challenge' to their power. We will also consider advocacy and question to what extent social workers can be effective advocates for service users with mental health problems.

Session One

Stakeholders and their influence

This session begins by introducing the concept of stakeholders e.g. mental health professionals, carers, service users, the pharmaceutical industry, the media etc, and asks students to identify what the 'interests' of these different stakeholders might be in defining and responding to mental health problems. We then consider how the influence of different interest groups impacts on the lives of people with mental health problems and go on to discuss the effect of stigma and discrimination on people with mental health problems. Following on from this there is a discussion of the 'double discrimination' experienced by people on the basis of race, gender, sexuality, age etc., and explore the implications for anti-discriminatory social work practice. We then describe the dominant psychiatric classification system and ask students to critically evaluate it from the perspective of anti-discriminatory practice.

In this session we begin by describing what we mean by a model of mental ill health. We then describe and evaluate the disease model, which is based on the belief that mental health problems have a biological basis. Although this is frequently referred to as the medical model, we suggest it is a separate model. The session then addresses a number of psychological approaches:

the psychodynamic model, which looks to childhood experience to explain the source of mental health problems;

the behavioural model, which focuses on behaviour rather than symptoms.

the cognitive model, which locates the genesis of mental health problems on patterns of maladaptive thinking

We then consider the social model of mental ill health, which is concerned with the influence of life events and social circumstances on the development of mental health problems. The social model is not only concerned with the influence of social factors on mental ill health but also with the construct of illness, so we will describe and discuss social construct theory and the influence of labelling in maintaining mental ill health.

Having looked at a variety of models we will return to our contention that the medical model is different from the disease model and discuss the nature of the professional/service user relationship which underpins it.

We will critically evaluate these models in terms of research evidence and of social work values. The session will then question whether any one model can successfully explain the complexities of mental ill health. We then describe the stress-vulnerability model, which acknowledges the influence of biological, psychological and social factors in the development of mental ill health as an example of a more integrated model.

Finally we focus on the research of Marius Romme and Sandra Escher into 'hearing voices', as an example of how research can influence practice.

Session three begins with an historical overview of mental health policy and legislation to demonstrate the range of imperatives influencing service response at any point in time. We will trace the development of different theories of the causes of mental ill health and the increasing legitimacy of a disease model under the influence of the medical profession. We will describe the development of policy from segregation to hospital closure and community care, noting the continuing tension between "care and control".

We will trace the debate about care in the in the community, from the aspirations of the 1950's to the introduction of the Community Care Act 1990 and the Care Programme Approach for people with mental health problems. We will see how public concern following a number of homicides committed by people with mental health problems influenced consequent policy development.

We will then focus on current policy directions as set out in the government's policy statement, "Modernising Mental Health Services, Safe, Sound and Supportive" and the standards described in the Mental Health National Service Framework. The government guidance Modernising the Care Programme Approach, which updates the original Care Programme Approach guidance of 1991, provides the framework for the delivery of mental health services to individuals and their carers. We will evaluate the guidance and discuss the implications for practice. We will highlight its emphasis on prevention, social inclusion, service user and carer involvement and risk.

We will then outline the major provisions and themes of the Mental Health Act 1983, including the role of the ASW and consider the proposals in the White Paper, Reforming the Mental Health Act.

Risk assessment and risk management are central to both the Care Programme Approach and to assessment under the Mental Health Act 1983. We will discuss the political, organisational and personal influences on risk assessment practice, which can lead to defensive practice, and suggest risk management as a constructive alternative.

Mental health social workers now work predominantly in multi-disciplinary teams, so we will begin this session by tracing the development of community mental health teams from the start of the hospital closure process to the present development of specialist criminal justice, assertive outreach and crisis teams.

We will revisit the current policy promoting ever closer working between agencies and disciplines and look at the implications for Local authority mental health social work. We will then explore team development and the organisational and professional issues, which influence team dynamics and effectiveness. The session will address the different understandings of mental health problems, different value bases, different training and different perceptions of status held by different disciplines within teams. We will discuss whether these differences widen perspectives of the team and contribute to offering choice, or whether they can be a source of conflict which effectively narrows choice to service users, depending on the perspective of their allocated worker. Given current discussions on the creation of generic mental health workers we will examine the role of social workers and explore whether they have a distinct contribution to make to mental health work.

In this session we will focus firstly on the range of treatments and interventions in mental health and explore their perceived advantages and disadvantages. The session will describe physical, psychological, social and alternative treatments and interventions. We will critically evaluate them in terms of equality of access, appropriate choice and research evidence. This will lead us to consider how social  workers can intervene effectively with people with mental health problems. We will then focus on Social Role Valorisation, an approach which strives to counteract the effects of labelling on devalued individuals and to enable them to take a full part in the community as valued people. It is underpinned by the values of respect, self - determination and empowerment. We will explore the implications of this approach for practice.

On the theme of empowerment we will then look at the development of the service user movement and its influence on policy and services, and the education and training of mental health professionals. Government guidance now stresses the importance of service user participation. We will consider whether in practice this is a meaningful development or a tokenistic gesture. Finally the session will describe the different forms of advocacy and question if and when social workers can act as effective advocates for service users.

The power of language to categorise people is especially apparent in relation to mental health and disorder. There is ongoing debate about the appropriateness of different terms to describe the behaviour, thoughts and feelings experienced by people with 'mental health problems'. Throughout the module we use the terms 'mental health' and 'people with mental health problems', in an attempt to avoid negative stereotyping (e.g. he/she is mentally ill) and denying the reality of the experience (e.g. mental distress). I use the term service users, as this is the term used (on the whole) by the user movement and by Social Services Departments.

The exposition in the main body of the text will draw on a variety of sources, including theories and models of mental ill health, legislation, government policy and guidance, social work theory and research findings.

The activities you will be asked to complete are intended to enable you to develop your understanding of mental health, by inviting you to reflect on a range of issues which may be new to you. They will help you to develop self-awareness by inviting you to relate your own experience to the issues being explored. Even if you have not had the opportunity to work in a specialist mental health setting, mental health issues cross all client groups and it is probable that you will have encountered a child, an adult with a learning disability or an older person experiencing mental health problems.

Given approximately one in five people will seek help for a mental health problem at some time in their life, it is possible that some of the activities may touch on aspects of your life or that of someone close to you, and this may cause you distress. If this happens, please seek out someone you can trust to talk things over with. You might like to consider now who this person may be.

You may be tempted to skip the activities – try not to as they can be valuable in ways you might not anticipate at first sight. They give you the opportunity to bring your own experience to the learning process. I would suggest you keep a booklet in which to write your responses, as this is an effective way of collecting your thoughts, highlighting gaps in your understanding and helping you to retain information. This will form a valuable resource for you to draw on in completing the module assignment.

The workshops will provide an opportunity to share your learning with the tutor and other students. Each workshop will relate to a particular session. Please prepare for them to enable you to make the most of the opportunity. As you work through each session, you may wish to make notes of particular issues you want  clarified or to discuss further. After the workshop you may also wish to record insights in your booklet.

SESSION ONE - Stakeholders and Their Influence

• Identify stakeholders in mental health (people or groups with an interest in defining and /or responding to people with mental health problems) and describe their influence.
   

• Describe how different stakeholders influence perceptions of mental ill health and how we respond to people with mental health problems.
   

• Identify how your own understanding of mental health has developed
   

• Describe the effects of stigma and discrimination on people with mental health problems.
   

• Describe how groups already subject to discrimination may be doubly discriminated against in the mental health system.
   

• Describe the dominant western psychiatric system of classification and critically evaluate it in terms of anti-oppressive practice.

"Mental illness" is not a static concept. Definitions of it and therefore responses to it change over time. If social workers are to respond to the needs of people labelled as "mentally ill", then we need to understand how definitions (what is "mental illness2) and responses (policy and practice) are influenced by changing ideologies, political imperatives and the power of different groups to influence perceptions. We will introduce the concept of stakeholders to help us make sense of these different and changing influences.

We will explore how our own attitudes and understandings have been formed, before going on to consider the particular impact of the media and how it may influence public perception of mental ill health. Certain sections of the media appear to propagate negative, stereotypical views of mental ill health. We will look at how this contributes to the stigmatisation of people with mental health problems leading to discrimination and social exclusion.

Groups already discriminated against on the grounds of race, gender, culture and sexuality, may be seen to be doubly discriminated against by the mental health system. We will consider the impact of stereotypical views of these groups in defining and responding to mental health problems and how the experience of discrimination may contribute to the development and maintenance of mental health problems.

We will consider whether the western system of classifying mental ill health can adequately describe or explain the experiences of mental ill health in all communities.

At different times a number of different groups will have an interest in defining and responding to mental ill health. These groups may be defined as stakeholders.

In her novel "Regeneration", Pat Barker describes the treatment of victims of shell shock (now referred to as post traumatic stress disorder) during the First World War and their subsequent return to the front, through the eyes of the army psychoanalyst, Rivers:

"Normally a cure implies that the patient will no longer engage in behaviour that is clearly self destructive. But in present circumstances, recovery meant the resumption of activities that were not merely self destructive but positively suicidal."

(Barker, 1991, page 238)

This apparently contradictory statement points to the fact that, the army and the government had an interest in "curing" mental distress in order to return soldiers to the front to continue the war.

Williamson defines interests:

"Interests are to do with advantage and detriment to individuals and groups. Interests…are something in which a stake is held; a personal or group resource to protect or enhance power. Everyone has interests in resources like influence, power, time, money, knowledge, the way situations involving themselves are defined."

(Williamson in Rogers and Pilgrim, 1996, page 1)

The following activity asks you to consider the implications of this.

As social workers an awareness of our own views and value positions is vital in our work with service users. Let us therefore explore our own attitudes to mental ill health.

We have already demonstrated that mental ill health is a contested concept. According to Shulamit Ramon and Monica Savio:

"Research on media responses to other controversial issues ….indicates that the media invariably engages in myth-making in its attempts to give clarity to phenomena which are unclear and carry ambiguous elements."

(Ramon (Ed.) 2000, page 210),

Let us examine the nature and consequences of media influence.

In ancient Greece the term stigma referred originally to signs, cut or burned into the body, to advertise and expose something unusual or bad about the moral status of the bearer. Although people with mental health problems do not bear stigmata, they are marked out in society as "other" and are socially excluded from participating in a range of activities and institutions.

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