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The Individual, Health and Society: SWK 4420 Associate Professor Rosemary Sheehan & Dr Ralph Hampson Subject enquiries: rosemary.sheehan@med.monash.edu.au ralph.hampson@med.monash.edu.au. Workshop timetable. SWK 4420 The Individual, Health and Society - Texts. Grbich, Carol (Ed) (2004)

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slide1

The Individual, Health and Society: SWK 4420

Associate Professor Rosemary Sheehan & Dr Ralph Hampson

Subject enquiries:

rosemary.sheehan@med.monash.edu.au

ralph.hampson@med.monash.edu.au

swk 4420 the individual health and society texts
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

slide4
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
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
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
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
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
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
National Health Strategy 1990s
  • Needs of populations
  • Inequality
  • Efficiency
  • Cost effectiveness
  • Public engagement in debate
  • Rights and responsibilities
health policy
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

Levels of Service Delivery
primary health care
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
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%)
challenges facing health services
Challenges facing Health Services
  • Private and publicmix
  • Prevention, early intervention and treatment
  • 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 factors have brought about these changes
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
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
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’ – 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 well-being’ 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
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
sociology of health
Sociology of health

Sociological lens –

  • social patterns – age, sex, race, class, culture, geography, community profiles
  • processes – interest groups, beliefs and history
  • social relationships – power
risk factors
Risk factors
  • Diet
  • Environment
  • Occupational health
  • Stress
  • Unemployment
  • Poverty
role of social work
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
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
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
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
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
1960s
  • Influence of psychoanalytic traditions
  • Social investigation
  • Diagnosis and treatment
  • Caseworker, therapist – splits in the profession
  • Genericism versus Specialism

1970s

  • Civil Rights movement
  • Feminism
  • Rights movements
  • Anti-psychiatry – encounter groups, humanism
  • “Radical social work” – structuralism
  • Community health
  • Community development

1990s

  • Targeted benefits
  • Economic rationalism
  • Effectiveness
  • Evidence based practice
  • Accountability
  • Competition
theoretical frameworks
Theoretical frameworks
  • Bio-psycho-social
  • Psycho-analytical
  • Ego psychology
  • Systems theory
  • Behaviourism
  • Feminist
  • Strengths based
  • Solution focused
  • Others?
issues and practice
Issues and Practice
  • Shorter length of stay
  • Family support
  • Short term nature – crisis
  • Discharge planning – ‘bed blockers’
  • Person in ‘environment’
  • Counselling
  • Advocacy
  • Community linkages
  • Financial, accommodation, benefits
  • Team work
crisis intervention
Crisis intervention

Constructive

Relative homeostasis

Destructive

group work
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
MultidisciplinaryInterdisciplinary
  • 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
Allied Health

Psychology ?

Taken from Austin Health promotion – The Well Wisher

Olivia Newton John Cancer Center Appeal Spring 2007

rural remote challenges
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 multi systemic approach ams
Advanced Multi-Systemic 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
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
Meaning of health and illness
  • People experience illness differently
  • Lens’ – for example
    • Culture
    • Class
    • Gender
    • Age
    • Sexuality
immigration gbrich 2004
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
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
‘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
Refugee Health
  • 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?

New perspectives on migrant and refugee health (Gbrich, 2004:119)

gender health gbrich 2004 ch6
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
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
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
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
slide49
Indigenous health …

DVD – Bringing Them Home

trauma

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
Characteristics
  • 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
  • Types of Trauma(Aldwin, 1993)
trauma models of understanding
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
309.81   DSM-IV Criteria for Posttraumatic Stress Disorder
  • 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]

Prevalence

risk protective factors harms 2005 115
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
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 intervention56
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
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
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 maltreatment59
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
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
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 old71
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 old72
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
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
Understanding Ageing
  • 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

What is ageism?

ageing reforms
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
social work roles
Social work roles
  • Acute hospitals
  • Rehab
  • Residential Care
  • Grandparents as parents
  • Community health services
  • Community support
  • Community development
slide80

Disability

  • DisAbility
some facts
Some facts …
  • 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?

Meaning

defining 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
Chronic illness …

www.chronicillness.org.au

defining chronic illness
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
Stereotypes
  • Dependent
  • Passive
  • Non-compliance – blame
  • Expensive

Walker, C (1999) Health Issues, V59, pp 10-13

predictability
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 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
  • Individual medical model
  • Welfare or policy model
  • Socio-political model

(Bowles, 2005)

Understanding

individual medical model
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
Welfare or Policy 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

Socio-Political Model

legislation
Legislation
  • Intellectual Disability Persons Act
  • Disability Discrimination Act 1992
  • Disability Services Act
  • Equal Opportunity Legislation
  • DHS State Plan
  • HACC & Disability Standards
  • 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.

State Disability Plan - Vision

acceptance integration
AcceptanceIntegration
  • School support programs
  • Community housing
  • Employment programs
  • Attitudes vary across cultural groups
  • Rural/metropolitan
  • Family reactions:
    • Punishment
    • Gift from God
    • Non medical beliefs

Cultural Differences

slide95

ABS Data

  • Intellectual
  • Psychiatric
  • Sensory/Speech
  • Acquired Brain Injury (ABI)
  • Physical
  • Profound
  • Severe
  • Moderate
  • Mild
aihw definition
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
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
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 Policy
  • 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

Social Work Practice

child with a disability
Child with a disability
  • Trauma and shock
  • Loss and grief
  • Marital stress
  • Integration
  • Tiredness
  • Life stage adjustments
  • Transitions – loss and grief
slide101
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
loss and grief
  • Separation
  • Divorce
  • Moving House
  • Changing Schools
  • Unemployment
  • Chronic illness
  • Death of a dream
  • Death
slide103

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
Worden (1987)
  • 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

Complexity

lifespan loss and grief
lifespan … loss and grief
  • What are the issues?
    • Babies
    • Children
    • Teenagers
    • Young Adults
    • Middle Age
    • Later Age
    • Old Age
case study
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?
history
History
  • 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

Influences on changing attitudes

understanding drug use
Understanding drug use
  • Moral Model: moral weakness of the user – should suffer legal, physical and psychological consequences (19th C)
  • 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
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
policies programs tobacco
Policies & programs - tobacco
  • 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
  • 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
  • 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

Alcohol

Illicit drugs

harm minimisation
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
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
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 is Evidence Based Practice?Rubbin & Babbie (2008)
  • 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

What makes an evidence based practitioner?

ethics and bioethics
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)

  • Values
    • personal values
    • social work profession’s values
    • employer’s values
    • underlying values of policies and programs
    • underlying values of our political system

Ethics and Social Work

code of ethics aasw
Code of Ethics AASW
  • http://www.aasw.asn.au/adobe/about/AASW_Code_of_Ethics-2004.pdf

http://www.aasw.asn.au/adobe/about/AASW_Code_of_Ethics-2004.pdf

what are your ethics
What are your ethics?
  • 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?

Case Study

social work in health foundation principles
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 study120
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
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?
psychological consequences of illness
Psychological consequences of illness
  • Chronic illness leads to long-term adjustments in living
  • Illness and limitations
  • 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
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
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
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, age- appropriateness, 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
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
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.
slide130
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
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.
slide132
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 study133
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
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 competencies135
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
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 health?

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 illness?

what is mental illness
What is mental illness?
  • Impaired pyschosocial or cognitive functioning due to 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
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
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 health141
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 health142
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 health143
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 health144
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
ModelsApproaches
  • Biomedicalmodel 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 approaches146
ModelsApproaches
  • 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”.
  • Familialmodel 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 approaches147
ModelsApproaches
  • 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 approaches148
ModelsApproaches
  • 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
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
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 illness151
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
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
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
  • 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 de-institutionalisation too complex, too problematic, who have no independent living skills, who may become ‘trans-institutionalised’:
radical mental health social work
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
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
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
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 health disorder continuum
The health-disorder continuum
  • 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
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
Neuroses
  • Anxiety States
  • Obsessive Compulsive Disorder
  • Reactive Depression
  • PTSD
  • Social phobia
  • Eating disorders
  • Panic disorder
anxiety
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.
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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
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.
obsessive compulsive disorder
Obsessive-Compulsive Disorder
  • Obsession- intrusive thoughts that occur despite individual not wanting them to.
  • Compulsion-response to the thoughts- irresistible 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
Anorexia
  • 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

Bulimia

social phobias
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
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
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
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
Intervention
  • Assessment
  • Medication
  • Therapy
  • Practical assistance
  • Hospital
  • Involuntary treatment
  • Mental State Examination
schizophrenia
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
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
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
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
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
  • 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
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
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.
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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
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, self-punishment 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
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.
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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
  • 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
Suicide Factors

Recognised trigger factors:

  • Family breakdown
  • Poor self-image
  • Pressure to achieve
  • Physical and sexual abuse
  • Money problems
  • Unemployment
legacy of suicide impact on others
Legacy of suicide-impact 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’?
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Legacy of suicide-impact 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
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Legacy of suicide-impact on others
  • Child survivors
  • How to respond to children left behind: how much to disclose?
  • 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 self-esteem
  • 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
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
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
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
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.