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The Individual, Health and Society: SWK 4220
Dr Ralph Hampson (Health)
Dr Noel Renouf (Mental Health)
Subject enquiries:
Off Campus Students
[email protected]
Workshop timetable
9.30
Social Work in Health Introduction
10.00
Health
12.30
Lunch
1.30
Mental Health
4.30
Summary and Close
SWK 4220 The Individual, Health and Society - Texts
Grbich, Carol (Ed) (2004)
Health in Australia : sociological concepts and issues (3rd ed.),
Prentice Hall.
Pritchard, Colin (2005)
Mental Health Social Work [electronic resource] London : Routledge.
Available via World Wide Web - access via Monash library (internet resource).
Unit guide refers to:
Meadows, Graham and Singh, Bruce (Eds) (2006)
Mental health in Australia : collaborative community practice (2nd ed.)
Oxford University Press, Melbourne.
Bloch, S and Singh, B (2006)
Foundations of Clinical Psychiatry (2nd ed)
Melbourne University Press, Melbourne
Recommended supplementary reading:
Alston, M and McKinnon, J (Eds) (2005)
Social Work: Fields of Practice - Second Edition.
Oxford University Press, Melbourne
- It provides a detailed analysis of social work practice.
Context
• Shift over time from public health issues
which were the concerns of the late 19th,
early 20th Centuries.
• Health is a major focus of Government policy
• Evidence that ill health is closely linked to low
income, unemployment, poor housing.
• Health system can be a safety net and/or it
can operate as a preventive/health promotion
project.
• Late 20th Century emphasis on: equity,
access, equality and participation
• Increasing focus on consumer involvement.
Principal feature of the Australian health
care system
• A private, for profit component (GPs,
pharmacists, dentists, private hospitals, private
specialists and alternative practitioners)
• A public component (community health centres,
maternal and child health, mental health,
hospital, HACC)
• A non-government, not-for-profit (FPA, welfare
services)
• A domestic component – carers at home
(Adapted from Owen and Lennie, 1992)
Australian HealthCare System
•
•
•
•
Medibank – Whitlam Government 1970s
Community Health Program – 1973
Medicare levy – 1.25% levy 1984
More recently -Increased focus on private
health insurance after a drop off in the number
of people taking out primary health insurance
• Introduction of the private health insurance
rebate by the Howard Liberal Government.
Key health policies and programs
• Commonwealth National Health Act
(1953) – universal health insurance
scheme & creation of the Pharmaceutical
Benefits Scheme
• Medibank 1975/Medicare 1984
• Council of Australian Governments
(1995)
Key health policies and programs –
community health
•
•
•
•
Community health program 1973
Local community involvement
Deinstitutionalisation
1980 Community health became a state
responsibility
• Is it marginal to the ‘main game’?
National Health Strategy 1990s
•
•
•
•
•
•
Needs of populations
Inequality
Efficiency
Cost effectiveness
Public engagement in debate
Rights and responsibilities
Health
Policy
• Universal access to basic health
care
• Services should be of a high
quality
• Financing of health care should
be equitable
• Services are delivered through a
mix of public and private system
• Accountability and efficiency
Levels of
Service
Delivery
PRIMARY SERVICES
General Practice (usually in Private Practice) and Primary
Health – Allied Health and Community Health
SECONDARY SERVICES
General Hospital Care - Private and Public
Specialist Services
TERTIARY SERVICES
Specialist Services e.g. nursing homes, transplant services,
mental health
Primary
health
care
• Multidisciplinary in nature
• Based community needs
• Integration of health, welfare, private, public, not for
profit – a partnership approach – tensions can emerge
• Social context
• Data traditionally not collected in a consistent manner
Funding
• 2004–05, the majority of spending in health was
funded by governments (68.2%)
– Australian Government contributing $39.8 billion
(45.6%)
– State, Territory and local governments contributing
$19.8 billion (22.6%)
– Non-government sector funded the remaining
$27.7 billion (31.8%)
Data from World Health Organisation (accessed 3 Aug, 2006) Figures are for 2004 unless indicated. Source: The world health report
2006
USA
Brunei
Japan
Singapore
China
Australia
India
Total population:
298,213,000
Total population:
374,000
Total population:
128,085,000
Total population:
4,326,000
Total population:
1,315,844,000
Total population:
20,155,000
Total population:
1,103,371,000
GDP per capita (Intl
$, 2004): 39,901
GDP per capita (Intl
$, 2004): 19,767
GDP per capita (Intl
$, 2004): 30,039
GDP per capita (Intl $,
2004): 28,848
GDP per capita (Intl
$, 2004): 5,581
GDP per capita (Intl
$, 2004): 31,454
GDP per capita
(Intl $, 2004):
1,830
Life expectancy at
birth m/f (years):
75.0/80.0
Life expectancy at
birth m/f (years):
76.0/78.0
Life expectancy at
birth m/f (years):
79.0/86.0
Life expectancy at
birth m/f (years):
77.0/82.0
Life expectancy at
birth m/f (years):
70.0/74.0
Life expectancy at
birth m/f (years):
78.0/83.0
Healthy life
expectancy at birth
m/f (years, 2002):
67.2/71.3
Healthy life
expectancy at birth
m/f (years, 2002):
65.1/65.5
Healthy life
expectancy at birth
m/f (years, 2002):
72.3/77.7
Healthy life
expectancy at birth
m/f (years, 2002):
68.8/71.3
Healthy life
expectancy at birth
m/f (years, 2002):
63.1/65.2
Healthy life
expectancy at birth
m/f (years, 2002):
70.9/74.3
Child mortality m/f
(per 1000): 8/7
Child mortality m/f
(per 1000): 10/8
Child mortality m/f
(per 1000): 4/3
Child mortality m/f
(per 1000): 4/3
Child mortality m/f
(per 1000): 27/36
Child mortality m/f
(per 1000): 6/5
Adult mortality m/f
(per 1000): 137/81
Adult mortality m/f
(per 1000): 107/81
Adult mortality m/f
(per 1000): 92/45
Adult mortality m/f
(per 1000): 92/51
Adult mortality m/f
(per 1000): 158/99
Adult mortality m/f
(per 1000): 86/50
Total health
expenditure per
capita (Intl $, 2003):
5,711
Total health
expenditure per
capita (Intl $, 2003):
681
Total health
expenditure per
capita (Intl $, 2003):
2,244
Total health
expenditure per capita
(Intl $, 2003): 1,156
Total health
expenditure per
capita (Intl $,
2003): 278
Total health
expenditure per
capita (Intl $, 2003):
2,874
Total health
expenditure as % of
GDP (2003): 5.6
Total health
expenditure as % of
GDP (2003): 9.5
Total health
expenditure as % of
GDP (2003): 15.2
Total health
expenditure as % of
GDP (2003): 3.5
Total health
expenditure as % of
GDP (2003): 7.9
Total health
expenditure as % of
GDP (2003): 4.5
Life expectancy
at birth m/f
(years):
61.0/63.0
Healthy life
expectancy at
birth m/f (years,
2002): 53.3/53.6
Child mortality
m/f (per 1000):
81/89
Adult mortality
m/f (per 1000):
275/202
Total health
expenditure per
capita (Intl $,
2003): 82
Total health
expenditure as %
of GDP (2003):
4.8
Challenges
facing
• Private and public mix
Health
• Prevention, early intervention and treatment
Services
• Pressure Medicare /PBS -costs
• Bulk billing declining
• Tensions between State and Federal Governments
• Ageing of the population
• Infrastructure/Technology
• shorter admissions, high costs, emphasis on throughput
• Power of hospitals – can they become self serving
organizations
• Dental health services
What changes to health care
services have you noticed
in your area in the past five
years?
What factors have brought about these
changes?
• Concern about increasing costs
• Clinical Governance, risk and safety
issues
• Demographic changes
• Public/Private split
• Increasing consumer expectations
• Legal issues and medical insurance
What is
health?
Health is shaped by:
• Attitudes, beliefs and values
• Sex, age, religion and socio-cultural groupings
• History, knowledge and dominant understandings
about health and illness
• Professional versus consumer experiences
Definitions
of Health
•
World Health Organization (WHO): “a complete state
of physical, mental and social well-being, and not merely
the absence of disease or infirmity.”
•
Bircher: “a dynamic state of well-being characterized by a
physical and mental potential, which satisfies the demands
of life commensurate with age, culture, and personal
responsibility.”
•
Saracchi: “a condition of well being, free of disease or
infirmity, and a basic and universal human right.”
•
Australian Aboriginal people: “…Health does not just
mean the physical well-being of the individual but refers to
the social, emotional, spiritual and cultural well-being of
the whole community.” This is a whole of life view and
includes the cyclical concept of life-death-life.
http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/
WHO
definition of
‘Health’ –
critical
appraisal
•
WHO definition of health is utopian, inflexible, and
unrealistic, and that including the word “complete” in
the definition makes it highly unlikely that anyone
would be healthy for a reasonable period of time
•
‘a state of complete physical mental and social wellbeing’ corresponds more to happiness than to health
•
words ‘health’ and ‘happiness’ designate distinct life
experiences, whose relationship is neither fixed nor
constant
•
Failure to distinguish happiness from health implies that
any disturbance in happiness, however minimal, may
come to be perceived as a health problem.
http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/
Assumptions
about health
and illness
• People can choose to be sick or well?
• Encouraged to express ‘dis-ease’ through the
physical
• Changes over time: childbirth, children’s
hospitals, homosexuality, sexual abuse,
mental illness
Sociological lens –
Sociology
of health
– social patterns – age, sex, race, class,
culture, geography, community profiles
– processes – interest groups, beliefs and
history
– social relationships – power
Risk
factors
•
•
•
•
•
•
Diet
Environment
Occupational health
Stress
Unemployment
Poverty
Role of
social work
• Interrelationship between health and human
functioning
• Individuals, families, groups and communities
can have health concerns
• Social workers are both professionals and
consumers of health services
• Person in environment
Social
Workers
bring to
Health
•
•
•
•
•
•
•
•
Systemic thinking
Political awareness and critical thinking
Ethics
Practice skills – assessments and
interventions
Human development
Social theory
Macro and micro awareness
Passion and idealism
Typical
Health
seeking
• First port of call is the GP
• Beliefs, gender, family history, tolerance of
pain e.g. men, pap smears
• Language/Culture
• Labeling of illness – blame and sympathy
What does
this mean
for social
work?
• Health is political
• Social workers are part of the system and
‘outside’ it at the same time
• Resources, access and information
• Social activist and/or ‘keeper of the peace’.
History
- Social
Work
• 1905 Massachusetts General Hospital
• Australia – growth in the health field – Hospital Almoners
• Understanding our history - is this important?
• Psychosocial approach
– Family domestic and social situations
– Complying with medical treatment
– Hospital and the wider community
• Home visits – a lost art perhaps?
1960s
1970s
1990s
•
•
•
•
•
Influence of psychoanalytic traditions
Social investigation
Diagnosis and treatment
Caseworker, therapist – splits in the profession
Genericism versus Specialism
•
•
•
•
•
•
•
Civil Rights movement
Feminism
Rights movements
Anti-psychiatry – encounter groups, humanism
“Radical social work” – structuralism
Community health
Community development
•
•
•
•
•
•
Targeted benefits
Economic rationalism
Effectiveness
Evidence based practice
Accountability
Competition
Theoretical
frameworks
•
•
•
•
•
•
•
•
•
Bio-psycho-social
Psycho-analytical
Ego psychology
Systems theory
Behaviourism
Feminist
Strengths based
Solution focused
Others?
Issues
and
Practice
• Shorter length of stay
• Counselling
• Family support
• Advocacy
• Short term nature –
crisis
• Community linkages
• Discharge planning –
‘bed blockers’
• Financial,
accommodation,
benefits
• Person in
‘environment’
• Team work
Crisis
intervention
Constructive
Relative
homeostasis
Destructive
Group
Work
•
•
•
•
•
•
•
Bereavement Service – Royal Children’s Hospital
Stroke Support Group
Incest survivors group
Children of parents with a mental illness
Parenting skills
Siblings of children with cancer
Transplant Support
Multidisciplinary
Interdisciplinary
•
•
•
•
•
•
Allied health profession
Ownership of the patient
Sharing of roles
Emergence of case management
Sharing of roles with others
Negotiating boundaries and roles
Allied Health
Psychology ?
Taken from Austin Health promotion – The Well Wisher
Olivia Newton John Cancer Center Appeal Spring 2007
Rural &
remote –
challenges
•
•
•
•
•
•
Being a member of the same community
Dual and multiple roles
Lack of anonymity
Confidentiality and privacy
Personal safety
Supervision and debriefing
Advanced
MultiSystemic
Approach
(AMS)
•
•
•
•
•
Biological Dimension – the ‘mind-body’ connection
Psychological/Emotional Dimension
Family Dimension
Religious/Spiritual/Experiential Dimension
Social Environmental – community, culture, class,
social/relational, legal history, community resources
• Macro dimension – e.g. policies, legislation,
oppression, poverty, homophobia, sexism
[Ref: Johnson, L J; Grant, G (2005) Medical Social Work Pearson, New York]
Case
examples
•
•
•
•
•
Mark, a baby, is born with spina bifida. You have been
asked to work with the parents re: the diagnosis.
What are some of the areas you may cover in your work
with the family?
Mrs Smith comes into hospital has a diagnosis of cancer
which will require radiation and chemotherapy
Referred to social work as she is depressed and does not
want to have treatment, says “she would rather die.”
What would you do?
Meaning of
health and
illness
• People experience illness differently
• Lens’ – for example
–
–
–
–
–
Culture
Class
Gender
Age
Sexuality
Immigration
(Gbrich,2004)
• Immigration program post WW2
• Waves of immigrants:
– Britain and Northern Europe
– Southern Europe
– 1973 White Australia Policy abandoned
– Asia
– Skilled migration/Family
– Refugees – Humanitarian
• Assimilation
• Multiculturalism
• Cultural Pluralism
Overseas
Born Health
Status
(AIHW, 2006)
• Australia has one of the largest proportions of
immigrant populations in the world
• 24% of the total population (4.75 million people) in
2004 estimated to have been born overseas
• More than half of these—one in eight Australians—
were born in a non-English-speaking country
• Research has found that most migrants enjoy
health that is at least as good, if not better, than
that of the Australian-born population.
• Immigrant populations often have lower death
and hospitalisation rates, as well as lower rates
of disability and lifestyle-related risk factors
(Ref: AIHW: Singh & de Looper 2002)
‘healthy
migrant
effect’
(AIHW, 2006)
Believed to result from two main factors:
• a self-selection process which includes persons who
are willing and economically able to migrate and
excludes those who are sick or disabled; and a
• government selection process which involves certain
eligibility criteria based on health, education,
language and job skills (Hyman, 2001)
but
• As length of residence in a destination country
increases, the health status of immigrants—as gauged
by health behaviours and by morbidity and death rates—
tends to converge towards that of the native-born
population.
Refugee
Health
New
perspectives
on migrant
and refugee
health
(Gbrich,
2004:119)
• Refugees, asylum seekers and detainees share similar
life experiences
• Experience higher rates of unemployment and welfare
dependency than other migrants
• Health and trauma – imprisonment, sexual assault,
torture
• Witnessing of death in refugee camps – disease etc
• Loss and Grief
• Understanding health within a global framework
• Holistic approach to health
• Social capital and well being
• Preventing disease, promoting health and prolonging life
• Shift away from ‘othering’ of the migrant
• Paradigm shift?
Gender &
Health
(Gbrich, 2004,
Ch6)
• Life Expectancy – women have outpaced men but
gap is narrowing
– 1920-22 Male 59.1:Female 63.3
– 1950-62 Male 67.9:Female 74.1
– 2000
Male 76.6:Female 82.1
• Why do men die younger?
– Violent behaviour
– Aggression
– Excessive alcohol use
– Dangerous driving
– Smoking
– Quality of relationships
Gender &
Health
(Gbrich, 2004,
Ch 6)
• Social Model of Health
• Holistic approach
• Health Service Utilisation:
– Women access health services more than men
– Women’s health issues associated with
reproduction
– Medicalisation of women’s health
– Men’s health – legal problems, being a lad –
growth in the issue of men’s health
Explaining
gender
differences
• Fixed roles and expectations
– mediated by age and responsibilities – dual
responsibilities of women and increased
burden
• Sex role socialisation
– masculinity and femininity – stoicism of men,
women more likely to report medical – no
evidence
• Clinician bias
• Critical and feminist theory
– ‘messiness’ of women’s health
Blinkers – what are some you can think of?
Social
Class
• Class analysis – social conflict – used to explain social
health inequalities
• Social stratification – focuses on social consensus – used to
describe social health inequalities using socioeconomic
status
• Consistent pattern – death rates go up as socio-economic
status goes down
• Physical, psychological and social dimensions of illness all
show that illness rates go up as socioeconomic status goes
down (Smoking? [The Age, 190209])
• Conflict Theory – the physical work environment and the
way work is organised lead to higher levels of illness for
working class
• Consensus – it’s not what they do at work – it’s what they
do outside of work that causes the problems –
consumption/risk taking
Indigenous health …
DVD – Bringing Them Home
Trauma
Trauma refers to situations where a person is confronted with
situations that exceed and overwhelm their coping capacity.
These situations threaten the physical and psychological
integrity of the person and cause an intense reaction of horror.
Typically there is a significant impact on at least immediate
functioning, if not long term, involving distress and disturbance
and, for some, disorder.
Harms,L (2005) Understanding Human Development: A
Multidisciplinary Approach, OUP, 146
Characteristics
Types of
Trauma
(Aldwin, 1993)
• Sudden and unexpected events, leaving the
individual unable to prepare psychologically for the
event
• Events which are out of one’s control
• Unfamiliar events so the individual cannot draw on
past experience in order to cope
• Can create long lasting problems
[Tedischi & Calhoun (1995)]
• Natural and technological – e.g. nuclear, bushfires
• Wars and related atrocities
• Individual traumas
– Individual acts of violence, abuse
– Car accidents, ABI, disability
– Sudden deaths/Infectious diseases – cancer, AIDS/HIV
Trauma:
Models of
Understanding
•
•
•
•
•
•
Trauma can be ‘political’ – silenced
Lunacy – weak gene pool – linked to eugenics
‘Shell shock’ – troops WW1/WW2 – now PTSD
Talking models of helping
Treatment – holocaust survivors – soldiers
PTSD – DSM IV – 1980
– Transient response – 2 days to 4 weeks
– PTSD can be:
> Acute (less than three months)
> Chronic (symptoms last for more than 3 months)
> Delayed onset (more than 6 months after the event) e.g.
Vietnam Veteran’s; stolen generation
• A ‘Problematic’ term?
• Neurological responses to trauma
309.81
DSM-IV
Criteria for
Posttraumatic
Stress
Disorder
Prevalence
A. The person has been exposed to a traumatic event
in which both of the following have been present:
•
(1) the person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others
•
(2) the person's response involved intense fear,
helplessness, or horror.
•
Note: In children, this may be expressed instead by disorganized or agitated
behavior.
• 2.3% of the male population
• 4.2% of the female population
[Meadows & Singh, 2001:124]
Risk &
Protective
Factors (Harms,
2005:115)
•
•
•
•
•
•
•
•
Developmental stage of the individual
Gender (violence)
Socioeconomic position
Culture
Traumatic event
Type of trauma
Blame and personal responsibility
Personality of the individual
• “… the subjective construction of the event thus
becomes of critical importance.”
• The role of hope
• Recovery environment
Core tasks –
Critical
Incident
Stress
Management
(Harms,2004:169)
• Defusing
• Formal debriefing (2-3 hours)
– Establishing facts
– Behaviours
– Thoughts and feelings about the event
– Educational and preventive focus
• Education – short and long terms responses;
coping strategies
• Counseling – typically a longer term response
• Referral
Crisis
Intervention
Assessment – here and now focus – avoid dealing
with long term issues – safety and security
Planning – concentrate on the immediate – “This
turns the crisis from an unstructured, frightening
and bewildering situation into something
manageable”(p40).
Intervention – calmness, listening, in touch with self –
use of resources and systems – advocacy –
awareness of culture, hope and confidence
Termination – clarify what will happen next – write it
down
[Truswell, S et al (1988) In the Eye of the Storm: Crisis
Intervention in Hospital Aust Social Work, March,
V41,No1:38-43]
Refugee
survivors of
torture and
trauma
• Confronted by trauma and the depth of human
cruelty
• Social justice and valuing the rights of all
people
– Confronting the issues of torture and
trauma
– Migration and resettlement issues – loss
and grief
– Lifestyle, personality and family issues
Child
Maltreatment
• Physical, sexual and emotional abuse, neglect
• Long term effects:
– Re-victimization in later life
– Mental health problems
– Self harm & suicidal behaviours
– Sexual difficulties - intimacy
Child Maltreatment
• Change from family/private issue to
criminalisation
• Harming children is not OK
• State has a role to play
• Social work role – prevention,
interventions with children, family, child
welfare etc.
• The wider safety net – neglect – housing,
income support, education, physical
health etc.
AIDS/HIV
•
•
•
•
•
Diagnosis
First diagnosed in 1982
Death to long term chronic illness
Impact on the gay and lesbian community
Changes over time – from central health issue – Grim
Reaper – to ?
• Positive Counselling Service – Bouverie Clinic
–
–
–
–
–
–
–
–
–
Recognise the ‘family’ however presented
Listen
Show and feel compassion, respect, interest and understanding
Do not take an authoritarian stance
Hold the belief that clients can manage their lives
Raise issues that are difficult for our clients to raise
Comfort – use touch when appropriate
Share information and transparent
Avoid pathologising families
Growing old
• Most older Australians are neither frail nor in need of long
term care.
• Around 20 per cent of people aged 70 years and over use
Government-funded care services: about 8 per cent live in
nursing homes and hostels; and around 12 per cent receive
community care services.
• There are many more women than men in the oldest age
groups and more women than men live alone at older ages:
– women comprise almost 70 per cent of people aged 85
years or more;
– around 38 per cent of women and 30 per cent of men
aged 80 years and over live alone.
Growing old
• Likelihood of needing residential care increases as people
get older and is higher for women than men — at 80 a
woman has a 59% probability of entering a nursing home
during her remaining lifetime compared to 39% for a man.
• Most who need care receive some support from informal
carers, that is, family, friends and neighbours. In 1998, the
ABS estimated that there were 201,000 primary carers of
people aged 65 years and over.
• The incidence of dementia increases with age:
– about 5% of people over the age of 65 and 20% over
the age of 80 have some form of dementia;
– the number of people with dementia is expected to
increase from 148,000 in 1999 to 258,000 people in
2021 and 450,000 in 2041.
Growing old
• Depression is often under-diagnosed in older people.
• Significant proportion of older Australians are from
culturally and linguistically diverse backgrounds.
• Aboriginal and Torres Strait Islander people have
poorer health status than non-indigenous Australians
across all age groups.
Costs
• In 1999–2000 the Commonwealth Government will spend
over $5 billion on residential aged care, home and
community care , respite and support for carers.
• Public and private spending on health has been around
8.2 to 8.4% of Gross Domestic Product from 1991–1998.
• Expenditure on health needs of people aged 65 years and
over accounts for 24% of medical services, 31% of
pharmaceutical services and 35% acute hospital services.
Understanding
Ageing
What is
ageism?
• Physical changes
• Psychosocial changes
–
–
–
–
–
•
•
•
•
Disengagement theory (Cummings and Henry, 1961)
Activity theory
Continuity theory
Multidimensional approach – person, time and environment
Life Course perspective
Stereotyping
‘closed minded, demented, deaf, slow, unfit and ugly’
Advertising
There are many ways to be old – not homogenous
Ageing
Reforms
•
•
•
•
•
•
•
•
Market based reform agenda
Means testing of aged pensions
Reforms to the Superannuation system
Means testing or targeting of a range of health and
welfare services
Increased competition in the sector
Increasing reliance on ‘user pays’
As ‘user pays” increases the ‘grateful elderly will
disappear”
Focus on community based services
Intergenerational
tensions
Social work roles
•
•
•
•
•
•
•
Acute hospitals
Rehab
Residential Care
Grandparents as parents
Community health services
Community support
Community development
• Disability
• DisAbility
Images …
http://www.pwd.org.au/
Some facts
…
Meaning
•
•
•
•
1998 – 3.6 million people reported a disability
Largest proportion of people over 65
Ageing of the population – likely to be an increase
Main disabilities – sensory, intellectual and psychiatric
(AIHW, 2000, 2003)
•
•
•
•
What does disability mean to you?
What does chronic illness mean to you?
What experience do you have?
How do you think our community reacts to disability?
Defining
disability
• May 2001 the WHO adopted a multi-dimensional
definition
• International Classification of Functioning, Disability
and Health (ICF)
• WHO definition highlights:
– Importance of environment, social and political in
defining disability
– Problems within people’s bodies – impairments
– Dynamic interaction between health conditions,
environment and social factors (WHO, 2001; Bowles,
2005)
Chronic illness …
www.chronicillness.org.au
Defining
chronic
illness
• Chronic illness is “usually defined as a medical condition
lasting at least six months”.
• Usually has an impact on the quality of life
• Examples: asthma, arthritis, depression, heart disease,
neurological, MS … (Baum, 2002)
• Chronic Illness Alliance – consumer body – 2005
• “an illness that is permanent or lasts a long time. It may get
slowly worse over time. It may lead to death, or it may
finally go away. It may cause permanent changes to the
body. It will certainly affect the person’s quality of life.”
Stereotypes
•
•
•
•
Dependent
Passive
Non-compliance – blame
Expensive
Walker, C (1999) Health Issues, V59, pp 10-13
Predictability …
When I was diagnosed with breast cancer, I got my
affairs in order and left money in my will to care for
the cat. Well the cat’s dead; I’ve stopped cleaning
out of my cupboards and I wish I hadn’t given away
my Zeppelin collection.
Walker, C (1999:10-13)
Diagnostic
tools categorical
• Diagnostic and Statistical Manual of Mental Disorders
• International statistical classification of diseases and
related health problems (ICD)
• Burden of disease
• Quality of life
Understanding
• Individual medical model
• Welfare or policy model
• Socio-political model
(Bowles, 2005)
Individual
medical
model
• Viewed as victims
• Expert help to recover
• Not recover – exempted from ‘normal social’ roles –
employment, marriage, sex, raising families
• Treated like children
• Biomedical problem
• Charity/welfare approach
• Social work under the medical model has generally been
restricted to a role that is secondary to medical intervention
(Bowles, 2005:54)
• Acceptance, counseling, family support and financial
accommodation
Welfare or
Policy Model
•
•
•
•
•
•
SocioPolitical
Model
•
•
•
•
Focus on rehabilitation
Grew out of post WW2 – rehabilitation for veterans
Clients not patients
Holistic
Multidisciplinary
Independent living, social groups, sexuality, self
esteem and assertiveness
• Welfare payments
• Disability advocacy – social justice
• Year of the Disabled
Human rights approach
Effects of the environment in creating disability
Social construction DisAbility
Structural change - advocacy
Legislation
•
•
•
•
•
•
State Disability
Plan - Vision
• By 2012, Victoria will be a stronger and more
inclusive community – a place where diversity is
embraced and celebrated, and where everyone has
the same opportunities to participate in the life of the
community, and the same responsibilities towards
society as all other citizens of Victoria.
Intellectual Disability Persons Act
Disability Discrimination Act 1992
Disability Services Act
Equal Opportunity Legislation
DHS State Plan
HACC & Disability Standards
Acceptance
Integration
• School support programs
• Community housing
• Employment programs
Cultural
Differences
• Attitudes vary across cultural groups
• Rural/metropolitan
• Family reactions:
– Punishment
– Gift from God
– Non medical beliefs
ABS Data
•
•
•
•
•
•
•
•
•
Intellectual
Psychiatric
Sensory/Speech
Acquired Brain Injury (ABI)
Physical
Profound
Severe
Moderate
Mild
AIHW
Definition
• Disability is conceptualised as a multi-dimensional
experience
• Effects on organs or hody parts
• Effects on activities
• Effects on participation
• Facilitate participation
• Physical and social environmental factors
Core
activities
• Self care – bathing, showering, dressing, eating, using the
toilet, and bladder or bowel movement
• Mobility – getting into or out of a bed or chair, moving
around at home and going to or getting around a place away
from home
• Communication – understanding and being understood by
others (strangers, family and friends)
Carers
• 1998 – 57% of the people with a disability needed
assistance with ADLs
• Carers – unpaid
• Issues – financial security, income support, workforce
participation, flexibility (Carers Australia, 2005)
• Carers provide unpaid care and support to family
members or friends who have a chronic or acute
condition, mental illness, disability, or who are frail
aged.
Social
Policy
Social
Work
Practice
•
•
•
•
Institutional to community based services
Discrimination
Advocacy
Power of legislative change
•
•
•
•
Human rights
Dignity
Social Justice
Individualised care packages rather than one size
fits all
Child with a
disability
•
•
•
•
•
•
•
Trauma and shock
Loss and grief
Marital stress
Integration
Tiredness
Life stage adjustments
Transitions – loss and grief
Case
•
•
•
•
•
•
•
•
•
3 days old baby girl
ICU
Requires cardiac surgery
SW asked to see family
Father 26/Mother 23 – both teachers
Live in rural area
1st child
What might the issues be?
What might you say if asked?
– Is she going to die?
– Have you got children of your own?
– Why did this happen to us?
loss and grief
•
•
•
•
•
•
•
•
Separation
Divorce
Moving House
Changing Schools
Unemployment
Chronic illness
Death of a dream
Death
On Death
and Dying
• Elizabeth Kubler-Ross identified five stages that a dying
patient experiences when informed of their terminal
prognosis.
– Denial (this isn't happening to me!)
– Anger (why is this happening to me?)
– Bargaining (I promise I'll be a better person if...)
– Depression (I don't care anymore)
– Acceptance (I'm ready for whatever comes)
• Not prescriptive
Worden (1987)
Complexity
• Face the reality of the loss
• Experience the pain of grief
• Adjust to an environment in which the deceased is
missing
• Emotionally relocate the deceased and move on with life
• Developmentally with every stage of the life course
there are losses and gains
• Mourning/Grieving of men and women
• Family grief – felt differently
• Disenfranchised grief –not recognised e.g. gay &lesbian
• Minimisation of the impact due to age elderly/children
• Role of hope – rebuilding and relearning
lifespan … loss
and grief
• What are the issues?
– Babies
– Children
– Teenagers
– Young Adults
– Middle Age
– Later Age
– Old Age
CASE STUDY
• Clive is 27 years old and has just been
diagnosed with leukaemia. What impact
might the diagnosis have on him?
• Social work role?
• What drugs have you or do you do?
History
Influences
on
changing
attitudes
• All societies use drugs
• Alcohol – central to life in Europe – safer than water – high
calories – helped people cope with work – festivals
• Alcohol also used therapeutically – build strength, digestion
and as an anaesthetic
• Ambivalent views – drunkenness
• 16th/17th Centuries increasing social concern about
drunkenness
•
•
•
•
•
•
•
Religious
Increased availability
Commercialisation
Transport/Stronger fortified wines – allowed storage
Public ale houses
Food changes
Conspicuous consumption
suffer
Understanding • Moral Model: moral weakness of the user – should th
legal, physical and psychological consequences (19 C)
drug use
• Pharmacological Model: drugs dangerous – focus on
abstinence – the power of the actual drug. Humans victims
of the drug – temperance /prohibition
• Disease Model: disease beyond the control of the
individual – develop alcoholism – treatment abstinence
• Spiritual Model: e.g. AA
• Educational Model: knowledge is power
• Public Health Model: person, drug and environment
• Harm minimisation
Types of
drug use
• Experimental – single or short term use – curiosity, new
experience, risk taking – harm reduction and education
• Social Recreational – controlled use of the substance in
prescribed circumstances – harm reduction and education
• Circumstantial use: exam, long distance driving, soldier in
combat, bereavement – harm reduction, education, medical,
counseling
• Intensive use – daily use, bordering on dependence –
medical, counseling, specialist care
• Compulsive Use – persistent, frequent high doses which
produces psychological and physiological dependence medical, counseling, specialist care, prison
•
•
•
•
•
Tobacco – most harmful recreational drug in terms of costs – 1976 advertising
banned on TV and radio
1988-1994 – sale of cigarettes to children illegal
Warnings, restrictions on promotion and sponsorship
Passive smoking – latest frontier
Paradox of tax revenue
VicHealth – public health model
Alcohol
•
•
•
•
•
•
High usage in Australia
One in five admissions to hospital alcohol related (Baum, 2002:40)
Personal choice – legal substance
Harm minimisation
Education
Industry self regulation
Illicit
drugs
•
1980-1990s – moderate approach – harm minimisation – health problem
rather than a criminal problem
Shift under the Howard Government – debate that illegal trade makes it difficult
for people to seek help - ties with crime and corruption
Ongoing debate
Policies &
programs tobacco
•
•
•
Harm
minimisation
•
•
•
•
•
Drug use will continue to be part of society
Eradication is impossible and maybe counterproductive
People make choices
Focus on the harm it causes rather than on the use itself
Choice
•
•
Supply reduction – legislation and law enforcement
Demand reduction – health promotion, education, alternatives to
drug use, treatment programs
Harm reduction – information about safe usage – e.g. needle
exchange, low-risk driving, safe injecting rooms, methadone,
warnings on labels
Harm minimisation – flexible approach, non judgmental, focuses
on client engagement, focus on individual and community
•
•
Previous
policy
• Tough on drugs
• Parents and families talking with their children –
“I believe that the best drug prevention program in the world is a
responsible parent sitting down with their children and talking with
them about drugs.” PM John Howard
• Ignores structural issues – assumes all children have
responsible parents and all parents share one view. Poverty,
stress etc.
• Importance of political agenda – evidence based research.
What does
this mean
for social
workers?
• Likely that many people you work with will use
alcohol and other drugs – across the life span
• Indigenous communities
• Links with violence
• Harm minimization
• What works?
• Public health but what happens in the meantime
• Range of interventions – self help, insight, groups,
medical, behavioural, dual diagnosis
What is
Evidence
Based
Practice?
Rubbin & Babbie
(2008)
What makes
an evidence
based
practitioner?
• Practitioners make practice decisions using the best
available research evidence
• Synthesis of scientific knowledge and practice
expertise
• Evaluation of outcomes of decisions
• E.g. new client you might:
– Identify diagnostic tools – assessment
– Treatment plan developed in light of the best research
evidence
– Same for policy development
• Critical thinking rather than authority based practice
• To do this need to find the evidence – ongoing
lifelong part of practice
• Evidence can be inconclusive, not there etc. the
important thing is that you seek it out
• Needs to be client centred research
Ethics and
BioEthics
•
What are ethics?
– A system of moral principles by which human proposals may be
judged good or bad, right or wrong
– The rules of conduct recognised in respect of a particular class of
human actions; for example medical ethics
– Moral principles of an individual
(Macquarie Dictionary, 1991)
Ethics and
Social
Work
• Values
– personal values
– social work profession’s values
– employer’s values
– underlying values of policies and programs
– underlying values of our political system
Code of Ethics
AASW
http://www.aasw.asn.au/adobe/about/AASW_Code_of_Ethics-2004.pdf
What are
your ethics?
Case Study
•
•
•
•
•
•
•
Euthanasia
Conflict with employing agency
Mental health
Child Protection
Family dynamics
Termination
Sexuality
A mother brings her 9 year old child to the child and
adolescent clinic because of behavioural problems. The
child’s parents are divorced but retain joint custody of
the child. The child needs help. The mother says the
father would object if he knew the child was coming to
the clinic. Should you tell the father about your contact
with the child?
Social work in health: foundation principles
• What does illness mean?
• The impact of illness
• Psychological consequences of illness
• Where does social work fit in?
Case study
Kim (42 years) and Mary (39 years) live
with their two children, Henry (15 years) and
Crystal (10 years) in a Housing Trust
apartment. Kim’s mother Mrs Lim (68 years)
lives there with them. Kim is devastated as
he has been diagnosed with cancer. Mary
has been referred to the hospital social
worker because she wants to understand
how to help her husband and children and
she would like to know what the options are.
Social Work
Practice in
Health Care
• Assessment is key response
• Who will be affected by the change of
circumstances?
• Systems and intersections:
• Who do you ask?
• What do you observe?
• What methods does social work
use?
• What is the social work role?
MENTAL HEALTH AND
SOCIAL WORK
What is mental
health?
What is mental
illness?
Mental health is the embodiment of social,
emotional and spiritual wellbeing. Mental health
provides individuals with the vitality necessary for
active living, to achieve goals and to interact with
one another in ways that are respectful and just.
(VicHealth 1999)
A psychiatric disorder is a psychological
“syndrome” (or pattern) that is associated with
distress (unpleasant symptoms) or dysfunction
(impairment in one or more important areas of
functioning) or with an increased risk of death, pain
or disability. (Bloch and Singh 2004)
Normalisation and
De-institutionalistion
• The de-insitutionalisation discourse follows the
historical response to mental illness when
sufferers were sent away from the town to live.
• Over time the unwanted people were then
placed in poor houses, asylums or gaols.
• Thus was an institutional system with a captive
population, the motivation for which sometimes
stemmed from kindness, sometimes from fear of
the different or the inexplicable.
• This institutional response remained the
dominant approach to problems posed by the
mentally ill, to those with permanent disabilities,
until the 1960’s.
• The institution and the community were seen as
two separate, and distinct entities: provision of
services to, thinking about the ‘disabled’, a group
seen as separate from the community.
Reform
• Reform of the institutional system brought a new way of
thinking about the mentally ill or persons with permanent
disability.
• Considered important to maintain individuals in the
community.
• Belief that institutionalisation may still serve a useful purpose:
for the severely socially disabled; for those who have no care
givers or supportive networks; for those who need specialist
services and professionals who understand the physiology
and treatment of disability and mental illness.
• Institutionalisation as a response to those who find deinstitutionalisation too complex, too problematic, who have no
independent living skills, who may become ‘transinstitutionalised’:
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.
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
Developing a critical and clinical paradigm for mental
health social work
Noel Renouf & Robert Bland
• Clinical work
–
–
–
–
–
A particular type of setting (the clinic)
Unlike others (NGOs, user run services)
A particular focus on the work (treatment)
Not necessarily rehabilitation, recovery
Increasingly associated with other
discourses – risk management, statutory
context and ‘evidence.
Clinical mental health social work
• Traditionally associated with –
– Structural understanding of the causes of mental health
problems and responses
– Critique of psychiatry
– Critique of institutional practices and power imbalances
– Emphasis on rights
• Increasingly associated with links and
alliances with service users and their
organisations and movements
The domain of mental health social work
• Social control of mental health
problems
• Social consequences of mental
health problems
• Social justice
How the dilemma plays out?
• Consider the social worker entering the
workplace – motivations, knowledge and
attitudes, developing skills
• In a clinical setting – diagnosis vs understanding,
narrowing of conceptions of therapy – CBT, EBP
• Treatment – Protection – Human Rights
• Place of service & community development
Difficulties in achieving a balance …
Critical
Concerned with
inequality and
powerlessness
Uncritical
Unconcerned with
inequality and
powerlessness
Difficulties in achieving a balance …
Clinical
Concerned with
treating symptoms
Non-clinical
Unconcerned with
treating symptoms
Key Issues
Concerned about
power
Unconcerned about
power
Concerned about
symptoms
Focus on both
e.g. housing - focus on
symptoms ?relationships,
advocacy etc
Unconcerned about
symptoms
e.g. housing – focus
on advocacy
Advocacy for housing
stock
???? Lost
Critical and Clinical Paradigm
•
•
•
•
Engagement with the lived experience
Healing power of relationships
Critical reflection
Openness to wider sources of knowledge
and evidence
• Close attention to the concerns of clients –
micro and macro
Social work in mental health
•
•
•
•
•
Strong management presence
Represented on almost every clinical team
Case management roles
Strength in disability support
Training and education
Workforce
• Growth in allied health – social work,
psychology and occupational therapy
• Over one third are in regional, rural and
remote areas
• More than 900 accredited mental health
social workers
• Practice Standards – AASW
• http://www.aasw.asn.au
Domain of social work
• Social context – the person in
environment
• Social consequences- impact on
individual, family and community
• Social justice – stigma, discrimination,
human rights, access, choice
Mental health social work
Individual
Family
Social
Networks
Community
Social
Structures
Consequence of Social Work Focus
• Beyond illness and treatment
–
–
–
–
–
Individual and family welfare
Identity and relationships
Housing
Work
Income security
Consumers and families – good mental
health social work practice
• Respect, dignity, empathy, kindness and compassion
• Common courtesies
• Honour strengths and abilities and set realistic goals and work
to achieve them
• Uniqueness of the individual
• Basic skills – assertiveness, reflective listening, advocacy,
conflict resolution
• Concerns of families and carers taken seriously – balancing act
• Open to feedback
• Appreciate their value and importance of their role in the mental
health system
Mental State
Examination
• Appearance - dress, grooming, posture, gait, voice, gender,
•
•
•
•
•
expression, odours, coordination, etc.
Perception - alertness, orientation to time and space, memory,
auditory and visual hallucinations, illusions, accuracy, etc.
Thinking Processes - content, main themes, general
knowledge, dreams, fantasies, wishes, obsessions, delusions,
coherence, disturbance in flow, abstract reasoning, defence
mechanisms, language, fluency, comprehension, insight and
judgement, objectivity, etc.
Affect - Emotional tone of interview, range, variation, intensity,
appropriateness to content, awareness and control of feelings,
congruence.
Behaviour and activity - i.e. themes, goal directed,
persistence, concentration, reaction to stimuli, ageappropriateness, etc.
Attitude to self and others - view of self, ideals and
aspirations, goals, body image, sexual identity, self esteem,
feelings of belonging or alienation, trust in self and others.
Risk
Assessment
(1)
• Involves determining whether a person is at
risk of harm to self or others.
• In completing a risk assessment, one needs to
establish with the patient/client :
– if they have ever considered harming
themselves or others.
– If yes, then what plans do they have and do
they have access to/or means to complete this
plan?
– One needs to establish how long this has been
their plan and if any attempts have been made
to date to carry it out and what were the
consequences.
– Furthermore, have they informed anyone else
about it or sought help.
– Also, establish whether they in fact wish to
seek help and how or from whom.
Risk
assessment
(2)
• If the person is clearly indicating a wish to harm
self or others, then establish a contract with
them i.e., a guarantee of safety.
• If the patient is unable to guarantee safety, then
steps need to be taken to ensure their safety
which may be to have them admitted to an
inpatient service. This may entail that they be
certified if they are unable to give consent and
are deemed to be mentally ill.
• At times it may be sufficient to contact next of
kin and ensure that the patient returns home in
the care of someone who can keep them safe.
Classification
of
psychological
disorder
• Certain behaviours/feeling are signals for mental
health problems.
• The common classification of mental illnesses (from
the DSMIV or the “Diagnostic and Statistical Manual
of Mental Disorders”) is:
1. Affective Disorders
2. Anxiety and Somatoform Disorders
3. Schizophrenic Disorders including Psychotic
Disorder
4. Personality Disorders
5. Organic Disorder (for example, Alzheimer’s Disease)
Assessment
• The DSM IV provides a framework for
treatment/rehabilitation and for prediciting likely
outcomes for the individual and their family.
• Assessment of any individual’s problem however must
be in their own environment, relate to their individual
personality and be mindful of sociocultural,
development, and historical factors.
• Problem signs are signals for assistance and
understanding rather than answers in themselves.
• The mental state examination is the assessment tool to
determine the severity and nature of an individual's
problems and whether the individual is a risk to
themselves or to others.
The
healthdisorder
continu
um
• Most emotional problems can be resolved with
or without professional assistance. Individuals
move along a “mood continuum”
• Everyone has the capacity to be depressed,
or anxious.
• These “neurotic traits” are extensions or
exaggerations of “normal” behaviour.
• When these traits, or behaviours, interfere
with individual functioning, they are
problematic and indicate what has been
termed in the past "a nervous disorder" or
"neurosis".
• This includes anxiety states (which include
phobia, obsessive compulsive disorder, panic
disorder), depression, post-traumatic stress
disorder and physical disorders that have a
psychological origin.
Framework of adult psychological
disorder
Anxiety and depression
Dr Noel Renouf
Recap of assessment:
the building blocks
• Disturbance of mental functions:
–
–
–
–
–
cognition
thinking
perception
mood
behaviour
• These building blocks are what psychiatrists
and others generally assess, and from these
they try to make a diagnosis
Cognition
• All core thinking functions
–
–
–
–
–
conscious state
memory and it’s subdivisions
concentration and attention
maths like calculation
executive functions
• Key disorders = delirium & dementia
Logical thinking
• Using your cognitive abilities to think things through
clearly and relatively efficiently!!
• Stream = getting from A to B
• Form = logical or not
• Content = major thinking themes e.g. paranoid, suicidal
etc
• Key Disorder = schizophrenia
Perception
• Disorders of the five senses
– typically hearing and vision, but any.
– Hallucinations mainly
• Key disorders = psychotic disorders
Mood
• Feeling state, emotions etc
• Mood is how you feel generally, and affect how you
feel now.
• Mood is said to be the climate, and affect the
weather
• Key Disorders = depression, bipolar disorder,
anxiety disorders
Behaviour
• The things we do: Eat, sleep, move about, dress,
social interaction, play games etc etc
• Risk behaviour including suicidal and homicidal
ideas
• Eating behaviours
• Key disorders = personality disorders, eating
disorders, drugs and alcohol.
Neuroses
•
•
•
•
•
•
•
Anxiety States
Obsessive Compulsive Disorder
(Reactive) Depression
PTSD
Social phobia
Eating disorders
Panic disorder
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 may not have this insight, and their
detachment from reality may render 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.
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.
Some types of 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
Post-traumatic Stress Disorder
• PTSD develops after exposure to an extremely
traumatic event
• Reaction involves intense fear, horror or helplessness
• Traumatic events include: war, torture, rape, child
sexual or physical assault, physical assault, being
kidnapped, terrorism, a natural disaster (e.g. a bushfire,
flood or cyclone), a major car accident, being diagnosed
with a potentially fatal illness e.g. cancer
• Discovering body of suicide or murder victim
Symptoms
• Intrusive symptoms- distressing thoughts or
images, nightmares about the event, feeling or
acting as if the traumatic event were recurring,
intense psychological distress when exposed
to something that triggers memories
• Physical symptoms- sweating, muscle tension
and rapid heartbeat when exposed to trigger
memories
First aid for anxiety disorders
•
•
•
•
Assess risk of suicide or harm
Listen non-judgementally
Give reassurance and information
Encourage person to get appropriate
professional help
• Encourage self-help strategies
- Kitchener, B. & Jorm, A. 2002, Mental health first aid manual, Orygen Research
Centre, Melbourne
Depression
• A disorder of mood lasting at least two weeks,
associated with functional impairment.
• Common- 15% lifetime risk
• Often undetected in primary care (50% missed
at any consultation)
Major depressive disorder (according to DSM)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood
Decreased interests and pleasures
Weight loss or loss appetite
Insomnia or hypersomnia
Psychomotor agitation/retardation
Fatigue
Worthlessness or guilt
Loss concentration or thinking
Recurrent thoughts of death or suicidality
‘Major depression’
Depression is a disorder of mood, so
mysteriously painful and elusive in the way it
becomes known to the self – the mediating
intellect – as to verge close to being beyond
description. It thus remains nearly
incomprehensible to those who have not
experienced it in its extreme mode.
- William Styron, Darkness Visible
Depression: from the building blocks
• Cognition: slowed and negative (hopelessness
and helplessness), with poor concentration, but
logical and no confusion
• No perceptual disturbance
• Mood - depressed, irritable
• Affect - lack reactivity
• Behaviour – loss of motivation, little social
interaction, poor eating & sleeping, tearful.
One model for understanding depression in
women
- Clarke, H. (2006). Depression: Women's Sadness or High-Prevalence Disorder?
Australian Social Work, 59(4), 365-377
Dysthymic Disorder
(according to DSM)
• Criteria similar to major depression, but
– Minimum of only 2 symptoms is required
– Symptoms + depressed mood are present for at
least 2 years.
Recognition
Person is usually slow in moving & thinking, but may be agitated. Speech may
be slow & monotonous.
Lack of interest & attention to personal hygiene & grooming.
Usually looks sad & depressed, often anxious, irritable, easily moved to tears.
Themes of hopelessness & helplessness, negative view of self, the world, and
the future.
- Kitchener, B. & Jorm, A. 2002, Mental health first aid manual, Orygen Research Centre, Melbourne
Two screening questions:
•
•
During the last month, have you often been bothered by feeling down,
depressed or hopeless?
During the last month, have you often been bothered by havign little
interest or pleasure in doing things?
Why is recognition hard?
• Differentiating from:
–
–
–
–
•
•
•
•
Sickness
Personality
Loss of motivation
Help seeking
No time
No language
People may be embarrassed or feel it’s weak etc
People don’t see it as something for which they can get
help
• Workers don’t ask (rush, too hard etc)
Is it ok to ask so directly?
‘Then I ask them how they’re going in
themselves and I suppose it’s not coming
straight out and saying “Are you depressed?”
or “Have you got anxiety?”, but it’s “What do
you feel?”, “How are you going at the
moment?”, “Do you feel good in yourself, are
you happy?” It’s a bit like asking someone
about their sex life. You can’t just sort of jump
straight in there. ‘
(GP; interview)
- Clarke, D. M., Cook, K., Smith, G. C. & Piterman, L. 2008, 'What do general practitioners think
depression is? A taxonomy of distress and depression for general practice', Medical Journal of
Australia, vol. 188, no. 12, pp. S110-S113
Getting treatment for depression…
• Separating other disorders that mimic
depression (demoralization, grief, illness,
dementia, delirium)
• Figuring out why (“biopsychosocial”)
• Convincing the person
• Negotiating an acceptable treatment
Bipolar Disorder
• A much more rare form of affective disorder in
which depression is mixed with episodes of
mania
• One percent of population
• Tends to be episodic
• Also called manic depression
Psychiatric
• Biological Treatments
– Drugs
– ECT
• Psychological
– Psychotherapies:CBT, dynamic, IPT, hypnosis and the
list goes on!
• Social
– Social connection, vocation, housing, finance,
relationships etc etc
Treatment for depression depends on severity
• Mild: watchful waiting, education, relaxation,
exercise, diet, social interaction, work
• Moderate: medications +/or psychotherapy
• Severe: Medications +/- psychotherapy (??ECT)
Anti-depressants
• Many to choose from, similarities outweigh
differences
• Take 2 - 4 weeks to work
• Take once a day
• Good for anxiety and depression
• Stay on for 1+ years
ECT
• Induces a fit
• Often works better than medications for depression
• Unpopular in most places
• Main problems are stigma related
• Side effects: ?memory effects
Psychosocial intervention
•
•
•
•
•
•
•
•
Structured problem solving
CBT
Interpersonal therapy
Relaxation
Social skills development
Psychodynamic psychotherapy
Family therapy
Group work
Social interventions
• On a large scale:
– Building social capital
– Education: “mental health literacy”
– Opposing discrimination
• On a smaller scale:
– Reinforce protective factors
– Reduce risk factors
How do we decide?
• In severe depression, medications, otherwise
we don’t decide, the client does, usually!
• Depends on who you see:
– GPs use medications
– Psychologists & SWs use psychotherapies
– Psychiatrists use both
• Also: age, illness, duration, (Cause?)
- National Institute for Health and Clinical Excellence 2007, Depression: Management of depression in primary and secondary care: Quick reference guide,
National Institute for Health and Clinical Excellence, London
Responding: Assess risk
Always ask directly about suicidal ideas & intent, and advise
people and their families to be vigilant for changes in
mood, negativity & hopelessness, & suicidal intent,
particularly during high risk periods. Give advice about
where to go for help.
Assess whether people with suicidal ideas have adequate
social support and are aware of where to go for help.
Consider urgent referral to a specialist mental health
service.
Make contact with people who do not follow up.
“The ascendency of depression as a social
trend”
•
•
•
•
•
•
Amount of depression in the community
Number of patients in treatment for depression
Prescription of anti-depressant medication
Estimates of the social cost of depression
Scientific publications on depression
Media attention to depression
- Horwitz, A. V. & Wakefield, J. C. 2007, The loss of sadness: How psychiatry
transformed normal sorrow into depressive disorder, Oxford University Press,
Oxford
Burden of disease
• DALY: Disability-adjusted life year
• Mental disorders account for 22% of DALYs lost in
Australia
• Cancer & cardiovascular disease  the most mortality
(mostly in older people) whereas mental disorders  the
most non-fatal disability, mostly beginning in younger
people.
• 40% of the non-fatal burden of disease in men & nearly
50% in women is caused by mental disorders.
• Yet, in Australia, less than 10% of the health budget spent
on mental disorders
SWs in primary health care
e.g. Commonwealth Government ‘Better Access’ Scheme
Focused psychological strategies:
• Psycho-education (including motivational interviewing)
• Cognitive-Behavioural Therapy (including behavioural interventions and
cognitive interventions)
• Relaxation strategies (including progressive muscle relaxation and
controlled breathing)
• Skills training (including problem-solving skills and training, anger
management, social skills training, communications training, stress
management, and parent management)
• Interpersonal Therapy (especially for depression)
• There is flexibility to include narrative therapy for Aboriginal and Torres
Strait Islander people (Australian Government Department of Health and
Ageing 2006).
Evidence-based
Yet…
People with anxiety and depression will often
have complex needs.
Evidence from the caseloads of SWs in private
practice in Australia suggests the following:
Poor &/or unstable housing
Low income / unemployment
Domestic violence
Discrimination
Relationship difficulties
Grief & loss
Understanding
suicide
• Reasons people suicide are broad.
• Suicide evokes often quite powerful feelings in
others, and is accompanied by overwhelmingly
powerful feelings, of desolation, helplessness, selfpunishment or other-punishment. Those left behind
may experience fear, distress, anger, blame and the
agony of not knowing why this has happened.
• Suicide may come from profound emotional pain or
depression, or great anger, with feelings of anger
internalised. The anger may be directed at others,
who are left behind to deal with other people’s
reactions, grief and blame.
• A person feeling hopeless may see suicide as an
escape from the disorder they feel. Not all those who
attempt suicide wish it to be successful, but to signal
their despair.
• Motives for suicide are complex but generally we
see an absence of hope for the future, helplessness,
and urgency, a belief there is no way out from real or
perceived problems.
Why do
people
commit
suicide?
• The inquiry into Aboriginal Deaths in Custody found the
same sense of isolation and social exclusion.
• Suicide often masked as an accident, statistics are
inexact, but young men are committing suicide in alarming
proportions.
• A positive correlation between substance abuse and
suicide; mental illness and suicide (the risk of suicide is
high in severe depression, in schizophrenia).
• People without a sense of “connectedness”, isolated from
others, more likely to commit suicide than those who have
family responsibility, supportive relationships, community
life.
• Often those intending to commit suicide give a warning of
some kind and it is important for social workers to assess
this risk of suicide.
Suicide
attempts
• Suicide attempts generally considered:
– a message for help, or
– designed to provoke a reaction from a significant other(s)
• Careful psychosocial assessment of the individual involves:
–
–
–
–
–
–
circumstances of attept
motivation of individual to deal with their problems
what happened and how (that is, the attempt)
why the decision to attempt suicide? (the last straw)
did the individual expect to die?
what reaction has there been to the attempt and, from whom?
• What does still being alive mean to the person - what plans
do they have for the future?
• The degree of risk and the likelihood of being rescued
important in assessment of seriousness of a suicide
attempt. This is important for understanding what the
individual hoped would happen, and what prospects for
change there might be.
Suicide
Factors
Recognised trigger factors:
• Family breakdown
• Poor self-image
• Pressure to achieve
• Physical and sexual abuse
• Money problems
• Unemployment
Legacy of
suicideimpact on
others
• Individuality of response
• People’s reactions to the death, to those left behind vary
widely and are not predictable
• Professionals also vary in how they deal with those left
behind, ranging from sympathy, to being judgemental, to
not mentioning the death
• Lack of support
• Few formal or familiar structures in place to assist those left
• Those not directly affected may find it difficult to identify
with the nature of the loss and associated feelings
experienced by survivors
• No accepted social norms for suicide survivors
• Uncertainty of survivors and those around them about
feelings, how to relate to others, how to explain death
• Mourning period: how long is ‘normal’, what is ‘normal’?
Legacy of
suicideimpact on
others
• Suicide- a very different grief
• Grief associated with other losses tend to have accepted
processes attached to them
• Language- how to disclose the nature of the individual’s
death to others
• Outsiders find it hard to identify with the nature of the loss
• Irrevocability of the impact of suicide
• ‘Short-term solution brings permanent change’, distress that
is individual’s choice
• ‘No going back’ aspect – difficult to explain when not known
precisely why, no time for discussion orgoodbyes
• Loneliness and isolation of survivors
Legacy of • Child survivors
suicide• How to respond to children left behind: how much to
impact on
disclose?
others
• Trauma vs honesty
• Children need open and honest discussion
• Truthful accounts
• Be mindful children may feel responsible
• Be alert to behaviour changes- anger, shame, hurt, low selfesteem
• Stigma
• How others view those left behind
• Viewed as responsible for another’s actions
• Anger at victim, at unleashed hurt, at shame, sense of failure
• Stress in other relationships
• Vulnerability and need for support
The framework of adult psychological
disorder:
Schizophrenia
Dr Noel Renouf
‘Low prevalence disorders’
• Psychosis
•
•
•
•
Schizophrenia
Bipolar affective disorders
Schizoaffective disorders
Delusional disorders
Main symptoms of psychotic disorders
•
•
•
•
Delusions
Hallucinations
Passivity experiences
Disorganised thought, speech, & non-verbal
communications
• Loss of motivation & planning ability
- adapted from Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Morgan, V.,
et al. (1999). People Living with Psychotic Illness: an Australian Study 1997-1998.
Canberra: Mental Health Branch, Commonwealth Department of Health and Aged
Care.
What is schizophrenia?
•
Aetiology is complex and uncertain and still contested
•
A recent view expressing the dominant medical consensus:
•
“We believe that there is sufficient evidence to call schizophrenia a
disease related to brain abnormalities that are the final ‘common pathway’
caused by an assortment of specific genetic and/or environmental factors.
“While many etiological factors appear relevant to what we consider
schizophrenia and it is almost certain that our construct of schizophrenia
encompasses not one but several diseases, precise delineation of the
constellation of distinct ‘individual diseases’ that are part of this entity is not
possible at present…”
•
- Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008). Schizophrenia, “Just the Facts”: What we know in 2008.
Part 1: Overview. Schizophrenia Research, 100, 4-19.
What happens?
• Onset may be rapid with acute symptoms developing over several
weeks or it may be slow developing over months or even years.
• Schizophrenia interferes with the mental functioning of a person.
• During the onset the person often withdraws from others, gets
depressed, anxious, develops phobias (extreme fears) or
obsessions (fixations).
• First onset is usually in adolescence or early adulthood. It can
develop in older people but is not nearly as common. It occurs in
all races, cultures, social classes and both sexes.
- Inner North Brisbane Mental Health Service Royal Brisbane and Women’s Hospital and
health Service District (2001-2003). Schizophrenia: Just the facts.
“First episode” psychosis
Warning symptoms:
• irritability
• constant tiredness
• losing concentration
• suspiciousness
• depression
• rudeness
• anxiety
• withdrawal from friends
• feeling “uneasy”
Investigate further:
• social functioning
• mood
• cognition
• thought content
Experience of schizophrenia
•
•
•
•
Pervasive loss of interpersonal connections
Demoralising experiences of stigma
Hypersensitivity
Difficulties with attention, processing information, organising
thoughts
• Loss of sense of identity and personal control
• Struggle between seeking out relationships & withdrawal
- From Davidson, Stayner & Haglund (1998)
+ Restorative power of relationships & occupation
- Fossey, E. (2000). The lived experience of schizophrenia. In Meadows, G., Singh, B., and Grigg, M.
(eds.) Mental Health in Australia. Melbourne. Oxford University Press. pp. 536-537
Responding to
delusions & hallucinations
• Do not argue
• Connect with the emotion & the experience
• Limit stimuli
• Respect the content and accommodate it where
possible
-
Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7
August 2008
Responding to paranoia (a delusion)
• Do not argue
• Validate the feeling of fear
• Avoid confrontation
• Stay calm
• Consider safety of self, the person, and others
-
Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7
August 2008
Responding to disordered thinking and
behaviour
• Communicate clearly and simply
• If necessary, repeat things, talk slowly and give
plenty of time for the person to respond
• Give step-by-step instructions
Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7 August
Responding to flat mood or reduced range of
emotional expression
• Be aware that these are symptoms of the illness
• Don’t get frustrated or hurt by the lack of emotion the person
displays
- Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7
August 2008
Responding to reduced ability to initiate or persist in
goal-directed activities
• Understand and acknowledge that these are symptoms
– not deliberate acts or laziness
• Don’t get frustrated
• Provide persistent gentle encouragement and support
- Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7
August 2008
Responding to
‘poverty of speech’
• Be aware that these are symptoms of the illness
• Don’t get frustrated or hurt by the lack of emotion the person
displays
• Don’t take it personally
• Keep verbal communication simple
• Keep communicating
• Be aware that this does not mean the person is not thinking or
feeling anything
- Adapted from Mental Illness Fellowship of Australia (2005). Understanding schizophrenia
Accessed from http://www.mifellowship.org/downloads/fact-sheet/USchizophrenia.pdf, 7
August 2008
Social context and consequences of
schizophrenia
• Social & occupational functioning
• Social isolation
• Alcohol & drug problems
• Physical health problems
• Safety
• Secondary effects of treatment
Class
“Schizophrenia is the mental illness most
strongly linked to class, with working class
people being about five times more likely to
be diagnosed with schizophrenia than other
groups.”
- Mulvany, F., O'Callaghan, E., Takei, N., Byrne, M., Fearon, P., & Larkin, C. (2001).
Effect of social class at birth on risk and presentation of schizophrenia: casecontrol study. British Medical Journal, 323(7326), 1398-1401.
People living with psychotic illness in Australia
(1)
•
•
•
•
•
•
4-7 per 1000 adults in urban areas are in touch with mental health
services in a month because of psychotic symptoms
60% have schizophrenic type disorders
15 year average length of illness for those interviewed
43% have chronic illness with no complete recovery between
episodes
47% seriously impaired in everyday functioning
30% impaired in self-care
- Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Morgan, V., et al.
(1999). People Living with Psychotic Illness: an Australian Study 1997-1998.
Canberra: Mental Health Branch, Commonwealth Department of Health and Aged
Care.
People living with psychotic illness in
Australia (2)
•
•
•
•
•
•
•
84% single, separated, divorced or widowed
33% have children
31% living alone
45% in institutions, supported housing or homeless
45% need more friends
72% without regular occupation
85% reliant on welfare benefits
•
“Thus, the majority of people with psychotic disorders interviewed in
this study had lost essential life roles that normally provide an
individual with a sense of self-esteem and meaning.”
- Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Morgan, V., et al. (1999). People Living with Psychotic
Illness: an Australian Study 1997-1998. Canberra: Mental Health Branch, Commonwealth Department of Health and
Aged Care.
People living with psychotic illness in
Australia (3)
•
•
•
•
•
•
•
Very high rates of smoking, alcohol and other drug abuse
25% with dual diagnosis of psychosis and substance abuse
Use of health services, both mental health and primary care, very
high
86% on prescribed medication for mental health problems
83% report psychotic symptoms responded to medication
75% report side effects of medication to extent that impairs them in
daily functioning
Less than 20% had participated in any rehabilitation services in the
past year
- Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Morgan, V., et al. (1999). People Living with
Psychotic Illness: an Australian Study 1997-1998. Canberra: Mental Health Branch, Commonwealth
Department of Health and Aged Care.
Jablensky et al. (1999) “People living with a psychotic
illness” (4)
•
•
•
•
•
18% have been victims of violence; 17% had attempted suicide or
deliberate self harm in the past year
47% expressed an unmet need for a service, predominantly a mental
health one
60% satisfied with current level of independence
44% felt satisfied with life as a whole in prior year
Small but significant sub-group with little or no impairment in ADL or
major roles
- Jablensky, A., McGrath, J., Herrman, H., Castle, D., Gureje, O., Morgan, V., et al. (1999). People
Living with Psychotic Illness: an Australian Study 1997-1998. Canberra: Mental Health Branch,
Commonwealth Department of Health and Aged Care.
Mental illness & preventable physical illness in
Australia
• 2.5 times the death rate of general population
• 16% of unexpected deaths from heart disease; 8% from
suicide.
• Cancer rate about the same but 30% higher death rate
following diagnosis
• Hospitalisation rates were lower than expected based on
need.
• 44% of Hepatitis C cases and 19% of HIV cases occurred
in users of mental health services
• mentally ill at higher risk for all types of injuries, particularly
drug-related poisoning and those inflicted by others
- Coglan, R., Lawrence, D., Holman, D. A., & Jablensky, A. (2001). Duty to care: Preventable physical
illness in people with mental illness. Perth: Department of Public Health and Department of
Psychiatry and Behavioural Science, University of Western Australia.
Diagnosis of schizophrenia
• Imprecision & heterogeneity
• A persistent pattern of symptoms
• ‘Types’ of schizophrenia (DSM IV)
–
–
–
–
–
Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
Treatment for people with schizophrenia
•
Crisis intervention – ensuring safety
•
Medical (physical) treatment, principally ‘anti-psychotic’
medication
•
Psychosocial intervention, e.g.
– Cognitive-behavioural treatment
– Behavioural family intervention
– Relapse prevention (based on identification of early warning signs
or ‘relapse signature’)
– Medication adherence
•
Rehabilitation & recovery
Responding: Social interventions
•
Based in social work models
•
Interventions (i.e. joint work) in relevant life domains e.g.
– e.g. ecosystems, strengths, solution-focused…
–
–
–
–
–
–
–
–
Housing
Financial / legal
Health
Leisure
Occupation
Daily living
Social connections
Spiritual & cultural
•
Giving priority to
•
This work applies in ‘clinical’, ‘rehabilitation’, and individual practice
settings
– The practical
– What has meaning for each specific client
Social work practice
• Across all domains except medical
treatment
–
–
–
–
–
Crisis intervention
Psychosocial + social interventions
Rehabilitation & recovery
Community development
Prevention & promotion
Family carers’ experiences
• Trying to make sense
• Dealing with some of the most difficult
family situations
• Family members’ constructions of
schizophrenia
• Families a lynch-pin of community care
An example: Effective family work
• Common elements:
– Psychoeducation, problem solving, family support, crisis
management
• Common set of assumptions:
– Schizophrenia is an illness
– Family environment not implicated in aetiology
– Support is provided & families are enlisted as therapeutic
agents
– FI part of a treatment package used in conjunction with routine
drug treatment & case management
Spirituality and Mental Health
Ethics & Mental Health Social Work
Dr Noel Renouf
Spirituality and mental health
Definitions of spirituality include references to
deep human longings for:
• Wholeness
• Connection
• Transformation
Dimensions of spirituality
Meaning-making
• What is the purpose of my life?
• Why did I become ill?
• Why do people suffer?
• Is there are any justice in life?
Spirituality offers transcendence
• Connection with the divine transcends the mudane and
ordinary
• Includes beliefs about what is sacred
Spirituality enlivens
• The energy that inspires, enlivens and motivates
• Impact of mental illness on a person’s
sense of self
• Making sense of a uniquely traumatic
experience
• Place of hope
• Where professional relationships are
marked by respect and compassion,
these too can be transformative.
Should workers initiate discussion about
spirituality?
Evidence that consumers believe that spirituality (and sexuality) are
neglected in professional relationships
Simply be mindful of the ways that consumers and families seek to
make sense of their experience:
• How does this person find meaning in their life?
• What makes life worth living?
Incorporation of spirituality into contemporary therapy
• e.g. mindfulness meditation
The worker’s spirituality
• Consumers really value hopefulness & compassion – as
much as technical skills
• Workers might struggle with sense of personal inadequacy in
the face of overwhelming distress
• Is there less permission for workers to explore spirituality
than for clients?
– Brokenness
– Giftedness
– Sense of calling
Social Work Values & Mental Health
Practice
Work in mental health will challenge:









personal values;
employing agency values;
the values of policies and programmes available to clients;
the values embedded in the political context;
the value of client self-determination. Who is the client?
what is meant by choice?
what happens when values conflict?
how to manage confidentiality?
how much to intervene?
When such challenges arise in mental health, social workers ask:
1.
What are the ethical issues?
2.
Where does the social worker’s primary responsibility lie?
3.
What is my role as the social worker?
Some big ethical issues
1.
Consent & capacity
2.
Confidentiality
3.
Protection
e.g. child welfare
e.g. suicide & self harm
4.
Philosophy & quality of services
Ethics
Ethics are generally understood as:
• 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
In mental health, ethics are often closely related to legal, but
ethical considerations are different – they go beyond
consideration of the legal
Social Work Ethics
The AASW Code of Ethics sets out five basic
values:
1.
2.
3.
4.
5.
Human dignity & worth
Social justice
Service to humanity
Integrity
Competence
“The practice of psychiatry must confront a number of serious
ethical dilemmas: the modification of personality, the right to
commit suicide, and the social construction of psychiatric
diagnoses. But the most serious question of all in psychiatric
practice is treatment compulsion. Psychiatrists are
empowered by society to deprive patients of their liberty, and
impost treatment by force against their wishes – even, under
certain circumstances, when those patients have the capacity
to make their own decisions.”
- Owen, G. S., & Kanaan, R. A. A. (2008). The legal and ethical framework for psychiatry. Medicine, 36(8), p.
391.
Capacity
“A fundamental threshold issue is whether an involuntary
treatment scheme should be maintained and, if so, whether it
should be stand-alone legislation or form part of generic
capacity legislation. This reflects complex debates about how
best to balance respect for personal autonomy and
intervention when a person poses a risk to themselves or
others. Despite these debates, most international and local
jurisdictions have maintained involuntary treatment schemes
in separate mental health legislation.”
- Mental Health and Drugs Division Victorian Government Department of Human Services. (2008). Review of
the Mental Health Act 1986 Consultation Paper - December 2008. Melbourne: Department of Human
Services, p 12.
Capacity
• A person may have the capacity to make some decisions and
not others.
• If the person has the capacity to consent, the law of informed
consent applies;
• If not, the law of ‘best interests’ applies.
Victorian Mental Health Act does not define capacity.
Common-law definition:
- Essentially, whether a person understands the nature of the
illness and the proposed treatment, any alternatives and the
option of no treatment
Sally
You are a community mental health social worker. You visit Sally, a 16 year old girl in hospital with what
appears to be a psychotic episode. In the course of the consultations with Sally, her parents and
doctors, it is discovered that Sally is pregnant. An ultrasound examination is arranged confirming that
Sally is 15 weeks pregnant.
Sally's mother confirms that Sally has been staying much of the time with Peter, an 18 year old young
man with whom she went to school. He lives in a local caravan park. Sally's mother is worried about this,
especially as marks and bruises on Sally suggest Peter has been violent to Sally.
You attend a case conference at the hospital to review Sally’s treatment and care. The medical staff
believe it is Sally’s (and the infant’s) best interest to terminate the pregnancy. This would need to
happen soon and you are asked to speak to Sally to convince her that termination is the best option.
You talk to Sally who appears very sad and confused. She does not seem capable of giving you an
answer either way.
Sally: Consider
• Is Sally capable of providing informed consent?
• How would you define informed consent?
• What should be considered?
• How would you deal with the health
professionals if your views are in conflict with
theirs?
Informed consent in involuntary
situations
• Be proactive about describing the nature of the
interactions. Tell the truth about why you are there.
• Describe potential risks, including the fact that not
all risks can be predicted
• Describe time lines & potential consequences
• Describe limits to confidentiality
• Describe divided obligations & responsibilities
From Regehr, C. & Antle, B. (1997). Coercive influences: Informed consent in
court-mandated social work practice. Social Work, 42, pp. 300- 301.
Confidentiality
A key issue in contemporary mental health laws is
how to protect the patient’s right to privacy as far as
possible while providing necessary information to
those involved in their treatment and care.
Deinstitutionalisation policies 
• Families and carers have an increased
responsibility to help manage and support the
treatment and care of patients in the community;
• Other services & agencies increasingly providing
aspects of treatment & care.
Confidentiality smokescreens?
“Policy and training guidance on confidentiality is scattered,
ambiguous, confusing for professionals and inconsistent.
There is uncertainty in practice about the information that
professionals may share, and many professionals do not take
into account carers’ rights, not least to basis information to
help them care for service users. ‘Confidentiality
smokescreens’ may sometimes lead to information being
withheld from carers. Professionals sometimes find it easier
and safer to say nothing.”
- Gray, B., Robinson, C., Seddon, D., & Roberts, A. (2008). 'Confidentiality smokescreens' and carers for
people with mental health problems: the perspectives of professionals. Health & Social Care in the
Community, 16(4), p. 378.
Protection of the person
•
The pursuit of this goal immediately engages one of the classic dilemmas of
biomedical ethics, the proper relationship between respect for patient autonomy
and the demands of beneficence:
•
If we allow mental health professionals to treat a person in the interests of her
own health despite her competent refusal we are allowing the values of
beneficence to trump those of respect for personal autonomy;
•
Whereas if we insist on respecting the competent refusal of care and treatment,
whatever the outcome of that refusal, we are elevating personal autonomy
above beneficence, from which it springs.
E.g. suicide & self-harm:
– People with mental illness ‘not their real selves’; vs.
– ‘Rational’, ‘well-considered’ decisions of people to end their own life.
Protection of others
• Contentious question of the relationship between
mental illness and harm to others
• It is usually argued that, where there is a significant
risk of harm to others due to mental illness, it is
justifiable to override the person’s autonomy in the
interests of the protection of others
E.g. protection of children