This essay discusses a case study, and the most appropriate social work interventions to address the needs of the client. Daryl’s stable life situation has been severely disrupted by mental health issues, and he seems unable to cope with life outside hospital. Daryl’s situation is discussed in terms of relevant theoretical perspectives. The next sections looks at the most appropriate approaches to social work interventions to support Daryl, and at specific provisions available in the Kirklees and wider area. Constraints, particularly financial, on agency action are discussed, as well as relevant legislation and guidelines nationally.
The following essay considers a case study, and the most appropriate social work interventions to address the needs of the client. Daryl’s stable life situation has been severely disrupted by mental health issues, and he seems unable to cope with life outside hospital. Daryl’s situation is discussed in terms of relevant theoretical perspectives. The next sections look at the most appropriate approaches to social work interventions to support Daryl, and at specific provisions available in the Kirklees and wider area. Constraints, particularly financial, on agency action are discussed.
The case study concerns Daryl, who suffers from manic depression. Prior to the advent of this mental condition, Daryl had a stable, responsible job, and a family (a wife and two children). Manic depression, in common with other mental illnesses, can have a devastating effect upon a sufferer’s life, with families falling apart and lost jobs, particularly if the illness is not recognised as such and symptoms viewed as personality traits or lapses of judgement (DePaulo and Horvitz 2002). The impact of his illness upon Daryl’s life has been severe: his wife is now divorcing him, and his daughter did not visit him in hospital. The symptoms of manic depression are varied, although generally include swings between periods of elation and depression (Jovinelly 2001). The term ‘manic depression’ is colloquial: the condition is more properly referred to as ‘bipolar disorder’. While 72% of those who suffer manic phases also suffer episodes of depression, the existence of depression is not necessary for a diagnosis of bipolar disorder. It has been estimated that between 0.7 and 1.6% of the population suffer the condition (Russell and Jarvis 2003). Daryl’s symptoms include paranoia: he feels as if he is being watched and talked about when he is walking in the park, for example. As well as paranoid thoughts, he also suffers hallucinations and mood swings. This is typical of the disorder: other symptoms may include impaired judgement, impulsive behaviours and increased sexual appetite (Russell and Jarvis 2003).
Daryl’s case has been affected by budget cuts. Mental health services throughout the UK have been subject to such cuts, with a claim that over 50,000 NHS jobs will be lost over the next five years, a loss which will disproportionally impact the most vulnerable in need of mental health care (Channel 4 2011 [online]). The psychiatrist who is in charge of Daryl’s care has to decide whether he should leave the psychiatric hospital where he currently stays, or be discharged so he can go home. Once discharged, he will be under the care of a psychiatric team. There is an argument that he would be better off in the community, where a dedicated community mental health team including community psychiatric nurses, clinical psychologists and a key worker would be available to help Daryl (The Royal College of Psychiatrists 2011). Some claim that community-based mental health care reduces stigmatisation of the mentally ill, and allows a patient to feel supported by his family (Hunt 2008), however, this approach has been widely criticised. Indeed, some claim that the main advantage of care in the community is cost: it is cheaper to treat a patient based at home with a mental health team than it is to keep him or her in hospital. In addition, and in practice, community services lack sufficient funding to provide the level of care patients need, and there is evidence that the level of suicide for mental patients outside hospital is higher than those who are institutionalised (Kirkby 2000).
Daryl himself, despite not realising that he was going to stay in hospital (it ‘just seemed to happen’) would now rather be in hospital, although has been moved on to a community care programme. He feels safe there, and doubts that there are the resources outside to support him. This reluctance to leave the institution was noted as early as 1971, when Wallace notes that “a sizeable body of patients (perhaps 40% or more) do not want to leave the mental hospital” (Wallace 1971, p. 22). Daryl feels safe in hospital, and since starting the community based programme visits the hospital every day, although he is not admitted. On one occasion he went to the ward and demanded to be admitted, getting very agitated and angry, and insulting the staff. The mental healthcare team are collectively worried that this is slowing the pace of his recovery, as he has few incentives to get up in the morning, and the focus upon the hospital gives him a daily motivation. Lack of motivation is a common feature of severe mental illness, and can mean treatment is more difficult, as patients are unmotivated to persist with courses of treatment (Villena 2007). Daryl also reports feelings of loneliness and isolation. Loneliness / isolation can both exacerbate or cause mental conditions (Glicken 2009) and be a function of such conditions (Kahn and Fawcett 2008). Daryl’s isolation has been noted by his mental health team, who have tried to engage him and empower him to structure is day more, through accessing clubs and drop-in centres, but Daryl is not interested. He feels negative about any change in his mental state or that his feelings can be alleviated. However, he has progressed regarding his attitudes to the hospital, now understanding that it is a place for treatment, not his ‘home’. There have also been some signs of progression and gradual improvement, backed by feedback from the team who encourage him and show he is able to cope.
There are a number of social work approaches which might help Daryl live more positively with his mental condition. In particular, taking an anti-oppressive practice, building Daryl’s sense of empowerment and taking a social investment approach seem important. To some extent, a radical perspective with a structural critique focussed upon challenging inequalities in society also seems necessary. Social work practices which embrace cognitive-behavioural therapies might also be helpful. Anti-oppressive practice means being explicitly and critically aware of the way in which power and authority work to construct social divisions for example in areas of gender, class and race (Burke and Harrison 1998). Within mental health, there is a need to be aware of, and challenge, stereotypes about mental illness, both at the level of the institutions and individuals Daryl comes up against, but also negative views about mental illness that Daryl has internalised. The service provider also needs to be aware of negative stereotypes that he or she may have internalised concerning mental illness (Tew 2005).
Daryl clearly feels little sense of empowerment. While widely used, ‘empowerment’ is a much-debated term in social work theory, with a lack of consensus over precise definitions, claims that the term is paradoxical, and some lack of clarity over practical applications. However, despite these issues, there is general agreement that clients benefit from taking on more power over their circumstances, developing awareness of the impact of their actions, taking responsibility for their lives, and feeling more confident and able to bring about positive outcomes (Gould 2009). How, in practice, is Daryl to gain this sense of empowerment he lacks? One way is to ensure that Daryl is supported when dealing with the numerous institutions and formal bodies he encounters, and to be given support in finding out about, and attending, day-care facilities which will combat his isolation. The framework of the recovery model could also be used: this emphasises the likelihood of recovery from the illness, and suggests helping clients to develop self-motivated coping strategies to deal with episodes, rather than reliance upon authority figures (Gould 2009). Self-determination is central, and client participation is also encouraged. Practically, this means, for example, formulating plans of action and clear goals with the client in partnership, education about the condition, and training in ways to deal with acute episodes (Atwal and Jones 2009).
Another approach which might be of use is the ‘social investment’ approach. Rather than a case-study focus with an emphasis upon individual therapies, this approach works to improve social inclusion for mentally ill people “working with them to overcome the experiences of isolation and stigma that are often the most debilitating effects of mental illness” (Midgely and Conley 2010 p. 71). This approach has been influential in the United States, and in parts of Europe. It places mental health care in the wider political concept, stressing that investing in mental health can lead to economic progress for society as a whole. The concept emerged in the 90’s as part of a wider discussion of ways to modernise the welfare state in Europe and make them more sustainable, and involves better preparing individuals to cope with social risks over their lifetime, rather than repairing damage which is done (Policy Network et al 2011). The social investment model has been elaborated for the social work context, for example by Mayadas and Elliot (2000), linking the micro and macro level of practice. Social investment and economic investment address the macro level, tackling problems by spending money on infrastructure and bringing the marginalised into the wider community. At the same time interventions at the micro level can make families more sustainable and empower individuals (Healy and Link 2011). It can be asked, however, whether this is really a new approach, or rather a recontexualising 70’s radical approaches which focussed upon changing the system, as much as the individual (Norman and Ryrie 2004).
Criticism aside, a social investment approach would involve lobbying for better provision of mental health care services and investment in preventative treatments, but would also involve working with Daryl to empower him to realise he is capable of more than he currently realises, as described above. It might also involve work with the family. It is clear that there are issues both with the way Daryl views his family, and the extent to which they feel able to support him. New ‘integrated treatment’ approaches to social work emphasise the importance of, where possible, including a client’s family in treatment programmes, perhaps with family therapy in addition to CBT or other therapy for the client, and drug treatment (Pritchard 2006). Even where families are reluctant to engage with family therapy, or it is not appropriate, psycho-education can help prognosis by involving a client’s family more directly. Psycho-education covers helping the family understand the condition from which the client suffers, including the symptoms and events which might trigger them. It also offers the possibility of earlier interventions if families can recognise symptoms (Pritchard 2006). By involving his family through education, Daryl’s manic phases might be better managed.
While the above describes options for Daryl’s care in an ideal world, in the real world options are limited by budget, what is available locally, and government constraints on agency action. Kirklees council are explicitly committed to ensuring the best possible deal for people with mental health problems, and believe that mental health services should be ‘mainstreamed’, that is, the council aim to “improve social inclusion, employment opportunities and educational achievement” for those with mental health concerns (Kirklees Primary Care Trust 2008). However, since this document was written, the global recession has led to cuts in funding to many local councils. The BBC reported in February 2011 that Kirklees council, based in Huddersfield, is scaling back adult social care in order to make savings following government cuts to local authority grants, with an aim of saving £80 million by 2014 (BBC 2011 [online]). This is likely to mean that council-funded services are less available. However, at the time of writing, there are a number of independent local groups which might be beneficial to Daryl, particularly given the sense of isolation he feels. ‘Support To Recovery’, based in Huddersfield, works across Kirklees’ residents with mental health problems, providing both one-to-one support (to help Daryl work through his feelings) and also self-help workshops and drop-in services. They provide out of hours support, which might be helpful to Daryl in weekends and evenings. Other support services locally available include ‘Bartonians’, a lunch club for elders and people with mental health problems. Because Daryl has mentioned isolation as an issue, services offering social groups might be particularly useful, including the ‘Pathways’ day centre, offering activities to build confidence and sense of empowerment, and the St. Anne’s Befriending Scheme in North Kirklees, through which people with mental health issues are provided a volunteer ‘befriender’ to offer support (Kirklees Council [online] 2011). Research has suggested that creative arts may be beneficial as part of treatment for mental illness (Miles 2010), and there are a number of provisions within Kirklees to address this, including ‘Bead Therapy’, in Batley and Diva, targeted at people with mental ill-health and providing services to encourage creativity (Kirklees Council [online] 2011). Daryl might benefit from attending these providers, assuming he enjoys creative activity.
The above has discussed a case study concerning Daryl’s experience of mental illness and release into the community. The essay discusses the options which would benefit Daryl, in terms of his needs and current theoretical perspectives. It also discusses what is available to Daryl in terms of his location, constraints on spending and locally available services.
Elliott, D and Mayadas, N S (2000) ‘International Perspectives on Social Work Practice’, in P Allen-Meares and C Garvin (eds.) The Handbook of Social Work Direct Practice, Sage, Thousand Oaks, CA, pp. 633-650.
Glicken, M D (2009) Evidence-based counseling and psychotherapy for an aging population, Academic Press, Burlington, USA.
Gould, N (2009) Mental Health Social Work in Context, Taylor & Francis, Abingdon Oxon.
Healy, L M and Link, R J (2011) Handbook of International Social Work: Human Rights, Development, and the Global Profession, Oxford University Press, Oxon.
Jovinelly, J (2001) Coping with bipolar disorder and manic-depressive illness, Rosen Publishing Group, New York.
Kahn, A P (2008) The encyclopedia of mental health (3rd edn.), Infobase Publishing.
Midgley, J and Conley, A (2010) Social work and social development: theories and skills for developmental social work, Oxford University Press, Oxford.
Policy Network / Wiardi Beckman Stichting / Foundation for Progressive European Studies (2011) ‘Social Progress in the 21st Century: Social investment, labour market reform and intergenerational inequality’, Policy Network, the Wiardi Beckman Stichting and the Foundation for Progressive European Studies (FEPS).
Wallace, S E (1971) Total Institutions, Transaction Publishers.
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