Mental health work in the community theory and practice in social work and community psychiatric nur
Mental Health Work In The Community Theory And Practice In Social Work And Community Psychiatric Nursing 1st edition By Michael Sheppard 9781850009795 1850009791 pdf download
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First published 1991
British Library Cataloging in Publication Data Sheppard, Michael Mental health work in the community. 1. Mentally disordered persons. Community care I. Title 616.8903
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Appendix 2 Research Questionnaires175 Bibliography 185
Preface
This book presents a comparative analysis of the work of mental health social workers and community psychiatric nurses. Both professions lay claim, to a considerable degree, to the same ‘territory’, and, in view of developments in community care, the examination of the relative merits of the claims of these professions to this territory, is of considerable importance. The findings, which are ultimately favourable to social workers, are bound to be controversial, since occupations do not generally willingly leave territory to which they have previously laid claim. This, however, cannot be helped, and I have attempted to be scrupulously fair by working with meanings common to both professions.
Had I realized the size of the task I had set myself at the outset, I might have hesitated to embark on this project. It involved not only the comparison of two professions, but also both the detailed examination of the theoretical foundations of both professions and the empirically researched examination of practice. However, the findings potentially have far reaching implications for policy and practice in the mental health field, and they address issues which are likely to remain significant for the foreseeable future. Additionally, however, this book presents a further contribution to a debate in which I have previously been involved: the relationship between theory and practice (and particularly the place of the social sciences) in social work.
I have been helped by a number of people in preparation of this book. My colleagues George Giarchi and Pamela Abbott have discussed various aspects with me. Terry Mangles has been free with his time in giving me both statistical and computing advice. Ted White of Manchester University’s Department of Nursing helpfully discussed various aspects of community psychiatric nursing. Chapman-Hall were kind enough to send me an advanced copy of Charles Brooker’s Community Psychiatric Nursing: A Research Perspective. I am most grateful of all to Sheryl Lester and her social work team, and Chris Bulley and his CPN team for their involvement in this project.
They inevitably gave an enormous amount of time to this project, and it goes without saying that without them it simply would not have happened. Finally, I wish to thank my typists, and in particular, Sally Petherick and Sue Ellicott who typed the bulk of the book. I alone, of course, am responsible for any errors which may appear.
Chapter 1 Introduction
The context for the practice of social work and community psychiatric nursing (CPN) as well as the development of community mental health centres (CMHC) is provided by the increasing emphasis since 1945 on community care of the mentally ill. To a large degree this arose from the development of psychotropic drugs in the 1950s, which revolutionized the control of major mental illness, such as schizophrenia, creating an atmosphere of therapeutic optimism. This was allied to a growing disenchantment with hospitals as an appropriate setting for managing mental illness, and the potential debilitating effect of institutional care (Goffman, 1961). The term ‘institutional neurosis’ described a process by which hospital regimes created individuals with characteristics such as submissiveness, apathy and a shuffling gait (Barton, 1959). Closely associated with this was the preferred notion of ‘normalization’: ‘The conviction that if people with handicaps are treated like everyone else, their handicaps will cease to be of importance to them and to society’ (Jones, 1988, p. 90). In political terms the focus for decarceration of patients was most evident in Powell’s well known speech as Minister of Health planning to halve the number of hospital beds in fifteen years (Powell, 1961), which was followed by the ‘Hospital Plan’, which envisaged the run down and eventual closure of existing hospitals and their replacement by short stay psychiatric units and community care facilities provided by local authorities (Ministry of Health, 1962). Figures for bed occupancy reflect the subsequent reduced emphasis on institutional care: average daily bed occupancy reduced from 118,800 in 1966 to 83,800 in 1976 and 61,500 in 1986 (Department of Health, 1988).
While reduced hospital care focused primarily on major mental illness, research has identified high levels of morbidity, primarily in minor mental illness, in general population surveys. The point prevalence of psychiatric disorder is somewhere between 90 and 200 per 1000 at risk, primarily constituting various combinations of depression and anxiety (Goldberg and Huxley, 1980). These disorders arise in a social context and rates, notably of depression, are about twice as high for women as men, and higher in urban
than traditional rural contexts. (Brown and Harris, 1978; Brown et al., 1977). While Goldberg and Huxley (1980) assert community depression is generally less severe than that encountered in hospital, research by Brown and his colleagues (1985) indicates that, except for a small proportion of severely depressed, depression in the community is as severe as that in hospital. The implications of research were not simply the discovery of high levels of morbidity, but that much of it goes untreated.
The growing emphasis on care in the community was accompanied by the establishment of Social Services Departments in 1971, followed by National Health Service reorganization in 1974 with the associated organizational separation of social work from health professionals. Workers formerly concentrating on mental health, child care, elderly and handicapped work respectively, were brought together in one unified social work profession. The effect was to create two empires, one social work based in local authorities and the other, dominated by medicine, based in health authorities, Together with the other developments in community care, this generated a number of issues evident in subsequent policy documents. The first was interprofessional collaboration, recognized increasingly as a problem with organizational separation. The 1975 White Paper (DHSS, 1975a) advocated the attachment of social workers to primary care teams as well as their involvement in specialist multiprofessional psychiatric teams, the advantages of which were closer collaboration and the pooling of a variety of perspectives and skills. A later document (DHSS, 1978) charted the problematic nature of collaboration deriving from differences in organization, knowledge and status, and suggested joint work, bringing together different skills in the service of particular clients, as superior to individual work.
A further issue relates to medical and non-medical approaches, which the White Paper (DHSS, 1975a) considered partly competing and partly complementary. Hence, the belief in the importance of biochemical factors and the efficacy of drug treatment was contrasted with approaches stressing underlying social, psychological and environmental causes of mental illness, particularly neurotic problems. The alternative to competing positions was an eclectic approach incorporating biological, psychological and social elements. The competing positions tend to emphasize to different degrees ‘medical’ and ‘non-medical’ approaches. A third, associated, issue relates to prevention. Primary prevention was considered in broad terms of reducing individuals’ exposure to social circumstances likely to place their mental health at risk. Concern was expressed about early recognition, assessment and support for those caring for the mentally ill, involving not just professionals but employers, managers and planners (DHSS, 1975a). A fourth issue related to the target group. The Social Services Committee (Short, 1985) contrasted the concern with decarcerated patients with the non-hospitalized mentally ill in the community. They commented on the ‘almost obsessive concentration’ in public policy on the former group, and
suggested the balance should be redressed by a greater involvement with the latter. To a considerable degree this entailed a change in the balance of emphasis: from major mental illness, predominantly associated with hospitalization, to minor mental illness, predominating in the community. Throughout, there has been a concern that political and financial commitment to community care has been more rhetorical than practical, and concerns have been expressed that community care should not be viewed as a cheap option (Short, 1985; Audit Commission, 1986). These concerns have not been dispelled with the publication of the White Paper (Department of Health, 1989) giving primary responsibility, as suggested in previous reports, to local authorities (Jones, 1988).
Community Mental Health Centres (CMHCs)
CMHCs represent an important response to the development of care in the community. Echlin (1988, p. 2) comments that
Judging from the evidence of the rapid expansion of CMHCs in Britain in recent years, planners are increasingly turning to CMHCs as their favoured method for moving mental health provision out of hospital.
The first centre was opened in 1977, since when there has been an exponential growth: by 1987, 122 centres existed or had planned funding, and 155 were at the unfunded planning stage (Craig et al., 1990). Most authorities possessed, or planned, CMHCs (Sayce, 1987). The inspiration came largely from American (and Italian) experience, where CMHCs arose within the Civil Rights movement of the 1960s, but subsequently suffered both political and service delivery problems (Jones, 1988). However, unlike their American counterparts, British CMHCs have no mandated services: their development stemmed rather from enthusiasm and commitment. There is, however, no simple definition of a CMHC. Sayce (1989) comments that the CMHC has become something of a buzzword, reflecting the belief that, even if an authority did not have one, they nonetheless should. But a cursory glance at British developments shows a bewildering variety: mental health advice centres, mental health resource centres, day centres, community mental health teams as well as those avoiding explicit reference to mental health in their title (hoping to reduce stigma) (Sayce, 1988).
Echlin (1988) identifies two models. The first is a base or building in the community for a multidisciplinary team serving a prescribed catchment area. Others see a central base as a barrier to service provision and work instead peripatetically in different settings such as community centres, church halls and health centres. Dick (1985) also identifies two models as approaches to managing psychiatric morbidity. The first is a service acting as a ‘funnel’,
passing most work to local resources (e.g. primary health care, social services) and only maintains that which cannot otherwise be managed. The second is a specialist service providing particular styles of treatment: however if the particular skills available do not match client needs, the client cannot be helped. It is service driven rather than client need led. Sayce (1987) identifies three approaches: first, as an entry point for most of the locality’s mental health referrals to a devolved psychiatric service; second, a sessional model offering counselling and/or group work; third, a community development model, with an emphasis on initiating formal and informal networks of care. Although models may differ, there are common characteristics for which CMHCs strive. Accessibility is the first (Peck and Joyce, 1985). This contains a number of elements: potential clients should have direct access to the service rather than requiring intermediate referral by professionals (‘walk-in service’); the service response should be as speedy as possible; the premises should be geographically easily available, either being local or on major transport routes; and stigma should be reduced (encouraging referral) by using nonstigmatizing (ordinary) buildings and service titles. Second, CMHCs tend to emphasize psychosocial rather than medical (biophysical) methods of intervention. This involves an emphasis on social and familial dimensions, and a greater available range of therapies and intervention provided in a coordinated way which would be unavailable (without attachments) in GP services. Third, multidisciplinary teamwork is emphasized. For some, this involves greater equality, rather than medical leadership, between involved professions. It certainly emphasizes greater cooperation and collaboration between mental health workers. Most centres are based around CPNs and social workers, and some advocate the development of generic mental health professionals, because of apparently overlapping skills and consequent ‘role blurring’ (Peck and Joyce, 1985; Jones, 1988) which, it is argued, makes demarcation by professional group obsolete. Fourth, comprehensiveness is often emphasized. In part this relates to multidisciplinary teams offering various skills, and it may be more accurate to describe CMHCs as part of a comprehensive service (Sayce, 1989). Finally community links are often considered important. This can involve links with other agencies, such as ‘outposting’ to general practice (Grey et al., 1988). It can also involve taking seriously consumers’ views of the service, through, for example, consumer studies, or even consumer participation in the planning and development of CMHCs.
Social Work and Community Psychiatric Nursing
Although social work has a history going back to the nineteenth century, it dates back in its modern form to 1971. Prior to this, with the establishment of Social Services Departments, social work was fragmented into separate groups, and Mental Welfare Officers (MWOs) were local authority based,
while Psychiatric Social Workers (PSWs) were hospital based. MWOs were incorporated into the new departments in 1971, followed in 1974 by PSWs, with NHS reorganization. Removal from medical oversight and incorporating PSWs into the professional mainstream might be considered beneficial. However, other ‘immediate consequences were well nigh catastrophic’ (Hargreaves, 1979, p. 77). Although Seebohm did not condemn specialization, the word ‘generic’ (referring to skills or knowledge common to different aspects of work) was misused, and redefined as ‘generalist’ with the ‘unrealistic expectation that all social workers should be professionally competent in dealing with every kind of human problem and need’ (Sainsbury, 1977, p. 77). This had various effects on mental health work. To a considerable extent this meant the loss of previously available specialist mental health skills. Hargreaves (1979, p. 77) calculated there was a reduction of a third in social work person-hours devoted specifically to mental health between 1967 and 1976. He set this against an increase of 35 per cent in the number of psychiatric nurses during the same period. Together with the loss of specialist skills, the interprofessional relationship between doctors and social workers generally worsened. Psychiatrists and PSWs/MWOs had formerly had close professional relationships based on a high degree of specialization and common concerns, which were disrupted by reorganization. This loss was frequently accompanied by drifting apart and disillusionment. Third, mental health was given a relatively low priority by the new departments, which were increasingly dominated—particularly with child abuse deaths—by child care. The recent White Paper (Department of Health, 1989) comments on the still small fraction of SSD budgets devoted to mental health.
Although this era was dominated by a generalist orientation, many exMWOs maintained an interest in mental health work and were able to continue with this as an aspect of their caseload (Howe, 1986). More recently widespread reorganization by individual SSDs has led to increases in specialist interests, with a realization that expertise in all aspects of social work is unrealistic. Reorganization has occurred either at a department wide level, with changes associated with central policy, or on a ‘bottom up’ basis where changes, occurring at area team level, are decided by the area teams themselves. This has taken three forms: structural changes in teams involving specialist subgroups, a growth in the number of individual specialist mental health posts, and bias in individual workers’ caseloads, whereby 75 per cent of cases involve a particular client group (Challis and Fairlie, 1986, 1987). From a position of virtual abandonment of mental health posts following the 1971 reorganization, there has been a drift back to more specialist work in more recent years, and the growth of specialism has been marked in mental health. This process is likely to be emphasized with the effects of changes presaged in the 1989 White Paper.
Community psychiatric nursing is a relatively recent development. According to Hunter (1974) the first recorded service began at Warlingham Park Hospital, Croydon, and services began at Moorhaven, Devon in 1985.
The impetus for a community service arose, according to Hunter, from informal contacts with patients’ relatives and the influx of ex-service personnel with extensive life experiences outside the mental hospital. They were subject to haphazard development, and by 1966, forty-two hospitals used nursing staff in community work. The remarkable growth of CPN services followed local government reorganization and the emphasis on generalist social work. This appears not to be coincidental. The Community Psychiatric Nursing Association (CPNA) representatives giving evidence to the Social Services Committee (Short, 1985) commented that, with the loss of specialist expertise and the resulting gaps in social work provision, CPNs moved into a vacuum created by ‘the genericism (sic) of social work’. This may not have been the only factor: it is noticeable that the growth in the number of CPNs occurred contemporaneous with the decline in the number of hospital beds, reflecting an increased emphasis on community care.
It is difficult to identify the exact growth in CPN numbers, although while they were hardly mentioned in the 1975 White Paper Better Services for the Mentally Ill (DHSS, 1975a) they were considered important in the 1985 Short Report, reflecting their much higher profile. By 1980 there were 1667 CPNs employed nationally, a figure which rose to 2758 (a 66 per cent increase) by 1985 (CPNA, 1985b). However, while the 1985 ratio of CPN:population was 1:23,800, the CPNA aim was for 1:10,000, indicating further developments, ‘warmly welcomed’ by the Short Report (1985). However, the overall figure concealed considerable variations in CPN provision between different regions. Parnell (1978) noted considerable variation also in the organization of services, reflected in the 1985 National Survey. Thus while the majority of CPNs worked in general psychiatry teams, 29 per cent worked in a specialist capacity, the majority with the elderly. Furthermore, their organizational base varied: the largest group (though declining relative to others) were based in psychiatric hospitals (37 per cent) while others, each comprising between 16 and 19 per cent of CPNs, were based in DGH psychiatric units, health centres and ‘other’ bases (CPNA, 1985b).
Role
Social work, as the better established occupation has a role, the core of which is well established, although it has developed over time. Although recognized as largely determined by the profession, their role has nonetheless been outlined in official documents. The Ottan Report (DHSS, 1975b) identified various elements to health social workers’ role: the assessment of social factors contributing to diagnosis; providing advice on social factors and approaches contributing to treatment; assessing social factors affecting discharge from hospital; and provision of, if necessary, long term after care support. Additionally in the primary health setting the role advocated included therapeutic work with individuals, families or groups; mobilizing
practical resources and liaison with outside agencies; educating the team on social factors in health care; and specialist consultant to social services staff. The White Paper (DHSS, 1975a) discussed the social work role specifically in relation to mental health, identifying three main areas. First, they should have a working knowledge of symptoms, treatment, cause and prognosis of an individual’s illness. Second, therapeutic work with individuals and families involves developing and maintaining a consistent relationship with the individual, knowing the ways the family may be affected, being aware of their particular family relationships and offering psychological and practical support to them. Third, they identify the use and mobilization of support services and outside agencies, such as primary health care, social security, housing, social services, and the ability to judge not just what is viable but also apply professional skill in considering what is best for each client.
Subsequent developments have expanded upon this traditional social work role. The Barclay Report (National Institute for Social Work [NISW], 1982), a semi-official document, advocated the development of community social work. Beyond concerns with individuals and families, this advocated the use and development of social networks, involving a partnership between social services, informal carers and voluntary agencies. Its focus is upon actual or potential links which exist or could be fostered between those with similar concerns. Two broad categories are identified: the first involves a focus on locality in which particular interests are related to geographical area, while the second is distinguished by a shared concern or problem, e.g. the needs of particular client groups. The report identified the need for social workers to increase their capacity to negotiate and bargain, to act as individual and group advocates, and recognize and use communities of interest between different people. This of course involved roles general to social work rather than specific to mental health. More recently the 1989 White Paper has outlined a further role, that of case manager, likely to be taken on primarily, but not entirely, by social workers. Where complex needs exist (e.g. chronic mental health problems) case managers may ensure that individuals’ needs are regularly reviewed, act as assessor of care needs, plan and secure delivery of care, monitor the care provided and review client needs. Case management will be linked to budgetary responsibility and occur in the context of a range of resources. Finally, social work contains the specialist role of Approved Social Worker, primarily involving assessment for compulsory admission, unique to the profession, which has been discussed in detail elsewhere (Sheppard, 1990).
To a considerable degree, the role ascribed to themselves by CPNs overlaps with that of social workers. There are, however, no descriptions of the CPN’s role in official documents (which social workers have), and there is some lack of professional clarity. The Short Report (1985) stated that ‘it is in need of self discipline and definition’ commenting that not just health managers, but many CPNs are uncertain about their role (vol 1, para 193). Early statements of the CPN role were relatively limited, reflecting a ‘medical handmaid’ service: the
provision of basic nursing care (medically supervised),supervision of prescribed medication, consultant to non-psychiatric nurses, keeping close contact with PSWs and other agencies, and providing reassurance and encouragement to individuals and their families, although significantly problems involving family dynamics were to be immediately referred to the PSW (Greene, 1968; Moore, 1964). Such modest representations of the practical nurse did not long survive social work reorganization. Hunter (1974) identified additional to continuing care, the provision of psychotherapeutic treatment, crisis intervention, groupwork and behaviour therapy with increasing emphasis on group and interpersonal dynamics.
Recent conceptions of CPNs’ role demonstrates further its similarity with mental health social work. The CPNA recognized CPNs required ‘techniques and strategies’ previously associated with other professions, and even used the social work term ‘good casework’ to identify desired practice (CPNA, 1985a, p. 7). They are concerned ‘with people’s emotions’ (p. 11), the way they behave, the expression of feelings through individual and groupwork, and helping families explore their problems. In their evidence to the Social Services Committee (Short, 1985) the CPNA drew on two authors; Sladden (1979), who considered CPNs distinguished by their (ubiquitous) ability to operate within the medical, social and psychological frame of reference and Carr et al. (1980). The latter provide a description of the CPN role remarkably similar to the traditional social work role, which is divided into six. First, they act as assessor of nursing requirements of patients and families or carers. Second, they offer individual and family psychotherapy. Third, they are managers of their own work, setting priorities and communicating with community agencies. Fourth, they are educators of nurses and other professionals on mental illness. Fifth, they are consultant to nurses and other professionals about nursing care required in specific cases. Finally, they act as clinician—a role not shared with social workers—either basic, monitoring self care and diet, or technical, providing injections and monitoring medication. Thus there is great apparent role overlap: although CPNs may be clinicians, and social workers can be Approved Social Workers.
Role overlap is evident in assessing and working therapeutically with patient and family, working with community agencies and acting in specialist educational and consultant roles. It is most graphically illustrated by those arguing for the common title of community mental health worker. This is advocated by MIND (1983) and has been enthusiastically taken up by some CPNs. Simmons and Brooker (1986), somewhat arrogantly, consider CPNs have been ‘sitting on the sidelines waiting for everybody else to catch them up’, and consider the title particularly appropriate for CMHCs. However, the British Association of Social Workers (BASW) consider that social work skills are not sufficiently duplicated by CPNs to merit the role blurring inherent from a common title. BASW evidence considered variations in training and knowledge too wide to allow this (Short, 1985, vol III para 1073). The Social Services Committee agreed: ‘the general merging and blurring of skills into
some kind of “community mental health worker”… would be unfortunate’ (Short, 1985).
Research
Very little published research exists on CMHCs. Most relates to Lewisham Mental Health Advice Centre, constituting a mixture of pamphlets and articles (Bouras and Brough, 1982; Bouras and Tufnall, 1983; Boardman et al., 1987; Boardman and Bouras, 1988). Much of these publications cover the same ground, with updated data. They have two main teams, the Multiprofessional Team (MPT), providing an assessment and intervention service, and the Crisis Intervention Team (CIT) available at short notice. The overwhelming majority of both teams’ referrals were from health sources, with GPs providing the lion’s share but self referrals comprising only 15 per cent of MPT and 3 per cent of CIT referrals. Two thirds of both teams’ referrals were for women, but the MPT saw more neurotic and the CIT more psychotic people. The age of MPT clients was more frequently under 40, and more CIT clients were on drugs. Only about two fifths of both groups had a partner, and while nearly half MPT clients received counselling a quarters of CIT clients were hospitalized and a third received mainly domiciliary support or drug therapy. The results showed major differences according to the purpose of the service, with the CIT specializing in particularly disturbed clients. It showed also that it could tap a large pool of untreated, particularly non-psychotic, morbidity. However, low levels of self referrals question its accessibility. Another small retrospective study examined fifty-three self referrals to Eastgate CMHC (Hutton, 1985). The main presenting problems were marital, relationship and anxiety; two fifths dropped out or were referred elsewhere, and others received mainly counselling, group or family therapy. One Coventry study examined client views of a predominantly social work service (Davis et al., 1985). Two thirds felt their goals were mainly or completely achieved and all clients considered counselling very or quite helpful, although only a third felt they were helped with social and economic conditions. Three quarters of clients considered their problems to be somewhat or much better and they cited the relaxed personalized service as particularly welcome.
Mental health social work has been subject to limited research since 1971, and it may broadly be divided into that focusing on Area teams and that focusing on health settings.
Area Teams
A number of studies have examined psychiatric morbidity in social work clients. Huxley and Fitzpatrick (1984) conducted a pilot study using a
screening instrument, the general health questionnaire (GHQ), followed by a later more extensive study using the standardized present state examination (PSE), of area team and GP attached social workers. They found 25 per cent of newly referred and consecutively allocated clients were cases, which with threshold cases increased to 53 per cent (Huxley et al., 1987). Corney (1984b) combining the GHQ and standardized clinical interview schedule, studied an intake team and found two thirds to be cases. Cohen and Fisher’s (1987) study of a representative sample found, with the widely used 4/5 cut off point, 52 per cent to be cases, and with 10/11, reducing misdiagnosis, 35 per cent. Isaac et al. (1986) found 38 per cent of fathers and 56 per cent of mothers who were primary caregivers of children received into care were GHQ cases. Although figures vary, mental health is a major aspect of social work. However, the extent of mental illness has been consistently underestimated. Very few are departmentally designated mental health cases (Corney, 1984b, Huxley et al., 1987), and although social workers identify a mental health problem correctly in half to two thirds of cases (Corney, 1984b: Cohen and Fisher, 1987; Huxley et al., 1987), they show no more than chance ability to diagnose precisely. Overall Huxley et al. (1989) conclude that it is important for social workers to understand the nature of psychiatric disability, broadly to recognize and account for it in their work.
Most research of social work intervention suffers from the problem of limited departmental case definition, concentrating only on those defined as mental health cases. Referral shows a fairly consistent pattern: health personnel are major referrers, followed by relatives and friends (Goldburg and Wharburton, 1979; Black et al., 1983). The health origin of referrals may influence client definition as mental health cases. Howe (1986) found emotional and self care, social isolation, familial and financial difficulties to be the most frequently associated problems. Studies show some consistency in work undertaken: investigating and assessing, provision of emotional support and facilitating problem solving are most frequently cited (Howe, 1986; Black et al., 1983). Goldberg and Wharburton (1979) distinguished between short term work—lasting up to one year—and long term work, already on caseloads, and open for at least two years. Of short term cases, 16 per cent were closed after one day and 43 per cent after a month. They were mainly referred at crisis point because a chronic psychiatric illness had upset the family equilibrium. The main work undertaken was assessment and information and advice. With long term work, except in crises, workers largely held a watching brief, and additionally extensively provided assessment, information and advice and emotional sustaining. Outside agencies were frequently contacted, although these were primarily with health agencies and professionals.
One study of social work intervention, not relying on departmental definitions, has been undertaken (Fisher et al., 1984). Clients in three area teams were defined as mentally disordered where impaired mental state or social functioning (a heuristic device) was identified, regardless of agency
definition. They combined the examination of referrals with those on longer term caseloads. In relation to the former group, the fairly high proportion of unallocated cases, although often referred to other agencies or appropriately briefly dealt with left, in some cases, a ‘cause for concern’ because of priorities which prevented their allocation. Of those allocated, 37 per cent were closed within three months and a further 30 per cent within twelve months of referral. Women outnumbered men 2:1 and clients were generally deprived: two fifths were unemployed and those employed were mainly in unskilled or semi-skilled occupations. Of those allocated, only 40 per cent were departmentally defined as mental health cases, the rest being elderly or child and family care. Longer term work was examined through interviews with a sample of clients and workers. They found intervention, averaging over four years on open cases, was characterized by unlimited emotionally supportive friendship and practical help rather than being purposive. Clients who felt supported were generally clear about why social workers were visiting, and contact varied according to need. Clients feeling unsupported generally considered social workers had failed to acknowledge fundamental elements of their problems and overlooked areas of personal distress. Social work accounts of work with these clients were divided into monitoring the elderly, supporting socially isolated people and supervising families and children. With the first two groups workers felt they were carrying out a holding operation with little hope of improvement, they considered interviews difficult, and with the socially isolated felt clients lacked motivation for improvement. With families and children workers felt great commitment was necessary, though relationships were profound, and overall they reported greater improvement than with other groups. Overall, however, workers felt much of the work was demoralizing, time consuming and demanding. They also examined relationships with doctors, confirming evidence extensively provided elsewhere, about poor relationships. Workers’ approaches to mental health were largely pragmatic, and they showed some suspicion of a ‘medical approach’, related to a concern about the deleterious effects of labelling. The only circumstances which the majority were prepared to define as mental illness per se were those they could not understand, and individuals’ behaviour appeared deluded, bizarre and inexplicable.
Health Settings/Specialist Work
Most research on health settings has concentrated on GP attachments. The clientele is, however, different from area teams. Corney’s study (1980) showed attachments to have a higher proportion of women, more people aged 16 to 44, and clients living with their families. Referrals were predominantly from health professionals, with a greater proportion of relationships, emotional and mental health problems. Overall attachment scheme clientele were more representative of the general population. Corney
(1984b) also examined the mental health of attachment clients using the GHQ and CIS. On both instruments about two thirds of clients were cases, and as in area settings social workers underestimated the extent of mental illness. Cooper et al. (1975), and Shepherd et al. (1979) undertook a controlled study of attached social work with chronic neurotic clients. They found that, in both clinical and social adjustment scores, social work clients improved significantly more than the control group receiving routine help at one year follow up. Fewer social work clients required psychotropic medication, or were referred for specialist psychiatric help, indicating it was a partial alternative to specialist services. However, the examination of social work activities showed no specific types to be particularly effective.
Corney (1984a) studied the effectiveness of attached social workers with depressed women, comparing social work with conventional GP treatment. It comprised two groups: acute—women with symptoms of three months or less—and acute on chronic—(a on c) women with symptoms of more than three months. Overall there were no significant differences between the experimental and control groups in both clinical and social outcome. However, significantly more a on c clients improved in clinical outcome if referred to a social worker, though the reverse was the case for acute clients. There was some evidence that a on c clients improved in social outcome more when referred to a social worker than control group, and they also made fewer demands on their doctor. Clients with poor social contacts and major difficulties with their sexual partners benefited in their clinical though not social scores from social work referral. This was particularly marked in a on c clients. The evidence, then, suggested social work benefits some but hinders other clients. They are most helpful with clients with chronic problems and poor social supports. These clients tended to be more highly motivated, and fared better when given both counselling and practical help. McAuley et al. (1983) reported on the social work task in an acute inpatient unit. This differed from both attachment and area team work. Fewer clients were female or employed than Corney’s (1980) attachment clients, although about the same were of working age. Over half had family relations problems, more than Goldberg et al.’s (1977) area team group, while like that group over half received some practical help, and information, advice and mobilizing resources were most frequent activities. However, noticeably more in-patient clients received emotional sustaining. Gibbons et al. (1978) compared task centred social work (E group) with self poisoning patients with a routine service (C group). Depressive mood fell in both groups, with no significant difference between them, although improvement in social problems was significantly greater in the E group. Repetition of self poisoning showed no significant difference between E and C groups, although client satisfaction at four months was significantly greater in the E group. A further study (Gibbons et al., 1979) examined clients’ views in more detail. E clients felt significantly more helped, particularly with their social life, and feeling less upset and disturbed. They were significantly more likely to see their problems
as ‘better’ or ‘much better’ at follow up (four months). At four months E clients showed significantly more improvement than C clients in social problems, particularly personal and social relations, although differences were not significant at eighteen months. Hudson (1974, 1978) carried out two small studies of behavioural work. With agoraphobic clients (Hudson, 1974) she found clients from well adjusted families had a better prognosis than sick (poorly adjusted) families. Her analysis of work with schizophrenic people involved only five clients, with limited success and only suggestive results (Hudson, 1978).
CPNs have been, if anything, even less subject to case based research than mental health social work. Some studies have attempted to identify the nature of psychiatric disorders on CPN caseloads, although using psychiatrist diagnosis rather than standardized instruments. Sladden’s (1979) study of five Edinburgh CPNs found the overwhelming majority (61 per cent) were diagnosed schizophrenic, while depressive and manic depressive clients jointly accounted for 13 per cent. Wooff and her colleagues (Wooff, 1987; Wooff et al., 1986) used case register data to examine the diagnostic make up of CPN clients in Salford. On average between 1976 and 1985 they worked with slightly fewer schizophrenic (28 per cent) than depressed (32 per cent) clients. However, while rates per thousand of both groups grew, the proportion which were schizophrenic fell while depressives concomitantly grew. The changes were related to a change from hospital to primary care base, indicating the importance of agency base.
Some studies have described or evaluated CPNs’ work. Sladden’s (1979) Edinburgh nurses worked primarily with women, unmarried and unemployed people. Their main problems were lack of social contacts, personality problems, family problems and difficulties with everyday activities. Some features of the clientele were apparently associated with specific nursing tasks, particularly phenothiazine injections for schizophrenic people. Clinical and psychosocial functions were by far the most frequently mentioned practice aims and methods; clinically oriented aims were associated with clinical attendance and psychosocial aims with community visits. However, while clinical functions were described in appropriate technical language, there was a lack of theoretical basis for interpersonal aspects of work, resulting in a difficulty defining needs and problems in ways which could be used for rational selection of methods. There was a tendency to refer environmental problems to social workers. Overall this indicated a frame of reference emphasizing a clinical perspective, concomitantly reducing attentiveness to social problems with which they had difficulty knowing how to deal. Hunter (1978) undertook a retrospective comparison of clients receiving a hospital based CPN service over five years with those not receiving such care. This service was associated with a greater number of hospital admissions where the reverse was hoped for, although fewer CPN than comparative group clients failed to take medication. Both groups had similar proportions in employment, and for a similar length of time, but social contacts were rather
lower amongst the CPN group. Interviews with caregivers showed three quarters considered them helpful, with abilities to be friendly, understanding and liaise with doctors. However, only a fifth of the CPN and no comparative caregivers would turn first to CPNs for help, with an even lower figure for patients.
Paykel and Griffiths (1983) conducted a controlled trial comparing CPN work with chronic neurotic clients with outpatients receiving routine psychiatric after care, primarily using clinical and social adjustment measures. Mean symptom levels of both groups decreased over time, and although there was some intra group variability, differences between groups were slight and not significant. Social adjustments also showed some improvement but there were no significant differences between the two groups. Family burden ratings were obtained for a limited number of clients, but again there were no significant differences. They concluded that for all these ratings CPNs were as effective (or ineffective!) as routine psychiatric follow up. These results may be interesting compared with Corney’s (1984a) a on c group. Some benefits were identified. Psychiatric outpatient visits were greatly reduced in the CPN group, and greater number of discharges were achieved without deleterious consequences. Most contacts were with the client alone and the most common activities identified were information and instruction, support/reassurance, ventilation and enhancement of self awareness. Patients’ views showed a tendency for greater satisfaction with nurses who were considered more caring, easier to talk to, interested and more able to relax their clients. However, only half their clients saw them as the main treatment agent, whereas this was generally considered to be the psychiatrist in the outpatient group.
Marks and his colleagues (1977, 1985) have studied nurses as behaviour therapists. The first (1977) study was primarily hospital based, but showed improvement in phobic and obsessive compulsive disorders. The second (1985) control study examined neurotic clients in primary care settings in diagnostic areas most likely to respond to behavioural treatment (mainly phobics). Overall CPN clients improved significantly more than controls receiving GP care in most target behaviour areas and social adjustment. These are, of course, specialist nurses rather than CPNs, and strictly represent a vindication of psychological behavioural approaches rather than training general to CPNs. Skidmore and Friend (1984) who studied 1000 CPN visits to clients commented that ‘community psychiatric nurses’ work methods have developed more by trial and error than by logical progression’ and cited their research showing little difference between those holding CPN post qualifying training and these without it. Indeed they found only 1 per cent of visits were for counselling.
Work has been published though only in article form (Wooff, 1988a and b) comparing CPNs and social workers in Salford. More detailed analysis is available from Wooff’s PhD (1987). It was broadly divided into two. First, client diagnosis was examined through case register data, and is discussed
above. CPNs tended to hold clients longer than social workers in continuous care. The second part was based on a study of face to face work with clients, involving ten CPNs and five social workers. She found CPNs and social workers gave similar amounts of support and advice, but social workers asked significantly more questions than CPNs and used general conversation less. Social workers were considerably more concerned with social adjustment than medical issues, while the reverse was the case for CPNs. Work largely reflected this: the main social work activities were counselling and practical assistance, while the main CPN activity was drug administration. Following client contact social workers were more likely to contact outside agencies. CPNs contacted each other or primary care professionals. This appeared related to work base. Overall Wooff attributed differences largely to theoretical base: with little theory of their own CPNs relied on a medical emphasis, while social workers possessed a psychosocial theory base. However, her cursory glance at theory provides little foundation for these comments.
The Study
The examination of professional and policy developments together with existing studies, demonstrates a great need for further research. In particular the development of community care, with CMHCs as a significant means for care delivery, the awareness of widespread minor mental illness in the general population, the potential significance of non-medical approaches to working with these problems and the competing role claims of CPNs and social workers present issues in urgent need of further examination. This book aims to do precisely that: it is a study and comparison of the theory and practice of social work and CPNs at a mental health centre. ‘Theory’ here refers to the knowledge and skills foundations for practice. It represents a number of advances on previous work.
1There is currently no published research on the work of social workers and CPNs at CMHCs and in view of developments this research is of some importance.
2The two occupations were based in the same agency and hence exposed to the same overall clientele. Agency function, as Wooff (1987) noted is significant. Her research examined social workers and CPNs in different settings, creating a further variable affecting comparison.
3CMHCs have, as Sayce (1989) noted, tended to work with previously (specialist) untreated morbidity, usually managed in general practice and involving neurotic problems. Research offered the opportunity of examining specialist non-medical intervention with those previously without access to specialist help.
Mental Health Work in the Community
4Decisions about who should do what were made in relation to the same overall pool of clients. It became possible thereby to examine the division of labour between CPNs and social workers.
Wooff’s study, although providing welcome information, suffers two further disadvantages. Although she relates CPN-social work differences to the psychosocial theory base of social work compared with the lack of any substantive CPN theory and a consequent reliance on medical perspectives, she fails to examine in detail these theory bases. These, as we shall see, present very complex issues. Second, she consciously takes ‘the perspective of community medicine’. This endows her research with meanings which may at times coincide with the professions studied, but which are, taken as a whole, external to them. Such external approaches, furthermore, evaluate the subjects in terms of the external agents—hence implicitly subordinating both CPNs and social workers to community medicine. Our research is characterized by three approaches.
1A comparative analysis of theory, which provides the basis for practice.
2A comparative analysis of the practice of CPNs and social workers, examining both division of labour and different approaches to intervention.
3An examination of clients’ views of intervention focusing particularly on agreement and disagreement with workers on perceptions of intervention, and their perception of workers’ skills.
The examination of both theory and practice may help us judge the relative merits of the territorial claims of CPNs and social workers, and where their strengths and weaknesses lie. The former provides some indication of the knowledge and skills foundations while the latter examines the actual practice.
This study was based on the work of the Walk In Service (WIS), which took referrals from any community agency, professional or individual, at a CMHC in an urban setting in Southern England. This comprised one element of the community psychiatric facilities of the district. The city had a population of about 250,000 which was overwhelmingly white. The district was served by an old mental hospital which, like elsewhere, has in recent years combined a reduction in bed occupancy with increased resources in the community. Another community based unit contained social work, nurse behaviour therapist and outpatient services, in addition to which there was a drug-alcohol unit. The adult nursing service comprised behaviour therapy and rehabilitation teams (the latter associated with transferring long stay patients into community settings), an elderly care team and general psychiatry team. The general psychiatry team comprised eleven CPNs responsible to a senior CPN, and received referrals of those aged between 18 and 65 from various sources,
particularly acute admissions wards, and increasingly from the WIS. The mental health social work team was part of the health district team of social services. It comprised one social work supervisor (senior) and nine social workers. The team carried both in patient and community based services. Areas of work included acute psychiatry, rehabilitation and elderly care. The general psychiatry CPN team and mental health social work team staffed the WIS. All the social workers were qualified and had a minimum of three years post qualifying experience in a mental health setting and all but one were approved under the Mental Health Act. All the CPNs involved held the RMN (Registered Mental Nurse) qualification and had extensive post qualification experience, the minimum being five years and the maximum twenty-eight years. With the exception of one CPN, they had worked in a community setting for at least three years, with most above five years. Most CPNs had taken post qualifying training, primarily developments in psychiatry, and a short course in behavioural work. None, however, had taken the post qualifying CPN training (English National Board, ENB 810, 811, 812). However, this was a stable team with extensive community experience. It is not clear that CPN training has an impact on practice (Reed, 1988), and the overwhelming majority of CPNs (four fifths) do not, in the most recent national survey (CPNA, 1985b) have this post qualifying training.
The CMHC was situated in a quiet road near the city centre with easy access from all parts of the city through public transport. The Centre provided out patient facilities, a day centre, psychological services and the WIS. The WIS was set up in 1978 and was one of the most well established community based services available directly to the public in Britain. It had a number of elements.
1The provision of a specialist assessment and crisis intervention service.
2A specialist advisory service to local agencies and professionals.
3An easily accessible counselling service to clients and families.
4Acting as specialist gatekeepers, assessing clients, and where appropriate referring them on to other agencies or professionals.
The service was established and primarily resourced by the mental health social work and general psychiatry CPN teams. Organization and planning were made by the senior CPN and social worker: it was not, therefore, headed by a psychiatrist and was very much a CPN-social work service. Additional medical input was provided by a psychiatric registrar. Referrals to the WIS represented, as noted earlier, one (important) source of social work and CPN work, although not all of them were involved. There was, furthermore, strong emphasis on what was perceived by workers as two related themes: joint work and role blurring. This was, it was felt, facilitated by shared office accommodation which helped interprofessional learning and the development
of shared perspectives. The WIS pamphlet claimed (WIS, 1989) that the arrangement ‘greatly reduces demarcation disputes and a considerable amount of learning and problem sharing takes place’.
The WIS operated a duty service each weekday from 9.00 am to 5.00 pm. At other times cover was provided by an out of hours social work team. Referrals were accepted from any source, and included a ‘walk in’ service for clients and their relatives. The duty team generally comprised a social worker, one or two CPNs, and the psychiatric registrar. The team endeavoured to undertake joint multiprofessional assessment, but the pressure of referral often made this impossible, and they might only be seen by one professional. Clients might be seen at home, or at the centre, or occasionally elsewhere. There were three likely outcomes. The client might be seen once or perhaps twice and no further intervention occurred. Alternatively, an assessment could be followed by referral on to other agencies or professionals (e.g. in-patient, behaviour therapy, district social services). Third, clients could be taken on by a CPN or social worker for short term or long term caseload intervention. This would occur at the allocation meeting attended by CPNs and social workers on Monday mornings.
The WIS possessed a number of characteristics sought by CMHCs. In terms of models identified (Sayce, 1987; Dick, 1985) it contained elements of two models: that where the CMHC acts as a ‘funnel’ through which clients are passed on to local resources, and that which offers specialist services such as counselling and group work. It emphasized also further elements: accessibility was stressed by the walk in service, its geographical availability, and its quick response to referrals. It involved multidisciplinary teamwork, without medical leadership encouraging greater interprofessional equality, and emphasized though not exclusively, a psychosocial approach. Finally, its gatekeeping element gave access to a comprehensive range of resources, and it had community links in terms of its relationship with health and social service agencies, although clients were not involved in managing service development.
Details about the conduct and timing of the study are given in Appendix 1. Chapter 2 examines the way in which social workers and CPNs define the phenomena with which they deal and the nature and scope of theory underlying practice. Chapters 3, 4 and 5 are based on a survey of the work of the WIS. Analysis is based on the framework provided in Chapter 2. Chapter 6 examines the interpersonal relationship practice foundations, Chapter 7 compares clients and workers’ perceptions of intervention, and Chapters 8 and 9 discuss clients’ perceptions of workers’ skills. Chapter 10 concludes the study. We may first, then, turn to the theoretical base.
Chapter 2
Theoretical Foundations
Nursing literature in particular has called for a more scientific professional base (Kim, 1983; Reihl and Roy, 1980) while social work has conducted a drive for an adequate research base (Davies, 1974). Such an enterprise is necessarily both conceptual and empirical—hence research developments must be founded on a clear conceptual framework (Harre, 1970; Keat and Urry, 1982). This chapter will outline a framework through which theory developments by both CPNs and social workers may be examined. The development of this framework is useful in itself for individual professions by identifying core elements of these professions. However, comparative analysis of two professions can highlight still more effectively these core elements. Finally, it can provide, by identifying key elements, the base for a more empirical, research based analysis of each profession’s work.
There are two key elements to such conceptual developments. First we must work from meanings and expectations arising from within the professions themselves. What distinguishes professional actions is not just their concerns or behaviour, but the meanings attached to these by members of the profession (Kim, 1983; Rees, 1978). Hence we are concerned with what they think they are doing, who are their ‘constituents’, how they should work and so on. Second this must provide a basis for operational measurements which are applicable to practice, i.e. transfer the more theoretical considerations to practice work. This is no easy matter, and it becomes more difficult with two separate professions: we must provide a framework which is meaningful to both professions in order to compare them.
Our framework will be divided as follows:
1Knowledge orientation
2Practice orientation
3Defining the client or patient
4Context of intervention
5Contexts specific to mental health
6Direction of work with clients
7Duration of intervention.
The analysis will conceptualize CPNs and mental health social workers as branches of their professions, i.e. emphasizing one to be a nurse and the other a social worker. Butterworth (1984) has suggested that CPNs and general nurses do not share common perspectives or roles. However, as will become apparent, CPNs have developed no distinctive theory of their own, and hence, unless they become something other than nurses, are reliant on the theory base commonly shared amongst nurses.
Knowledge Orientation
Social work has, for some considerable time, emphasized its social science knowledge base (Leonard 1975, Bartlett 1970). This social science emphasis produces predefined categories—stigma, class, socialization, attachment etc.—which provide a means for interpreting situations through a range of alternative explanations. Hence child battering may occur through stress, failure of attachment, poverty, cycle of abuse and so on (Sheppard, 1982). They provide reasons or causes for what is occurring, thus making clients’ actions meaningful.
These explanations occur within broad paradigms, of which Leonard (1975) identifies two: physical science and human science, each of which have further subdivisions according to emphasis within these paradigms. These paradigms to a considerable degree involve commitment to different knowledge assumptions, hence even within social science controversy exists about how to interpret and resolve particular problems. However, this largely exclusive use of social science knowledge may exclude consideration of alternative knowledge domains. Those derived from physiology or biology, for example—if not literally unthinkable because of the ‘seepage’ from alternative disciplines in everyday life (e.g. through the media or visiting the doctor)—will nonetheless in practice be minimized in importance. The interpretive frameworks in the form of ‘legitimate professional knowledge’ will both emphasize social science knowledge and de-legitimate alternatives. Hence explanations of depression emphasizing social deprivation and feminist perspectives will have more influence on social work than biological explanations, particularly when compared with the medical profession (Corob, 1987).
However, there is no unified professional view of the place of social science knowledge—an illustration of professional segmentation (Bucher and Strauss, 1966). Some—although a small minority—have sought to marginalize social science. Davies (1986) suggests that social science has done little to improve practice, while Howe (1980) argues that it is riven by such great paradigmatic and theoretical disputes as to make it difficult to develop a knowledge base or apply it with any effectiveness. Others, however, accept the necessity of social science, seeking to identify means for choosing and applying appropriate approaches. Stevenson (1971) suggests
‘frames of reference’ by which a range of available theoretical contributions may be examined in specific practice contexts. Others are concerned that eclecticism provides no route to an adequate knowledge base. Sheldon (1978) argues for the need to develop a common perspective on evidence— criteria which are scientific (emphasizing refutability) and by which some knowledge may be adopted and other knowledge discarded. Sheppard (1984) suggests choice of knowledge for any particular problem should be based on explanatory adequacy—measured in terms of values, theoretical framework, methodology and consistency of findings—and its applicability in practice. Despite Davies’ criticisms, and although debate exists about how it should be applied, social science remains the dominant knowledge base for social work. Indeed, Hardiker (1981) maintains it is indispensable, drawing on research to demonstrate that it makes the difference between adequate practice and possible disasters.
The presentation of the CPN knowledge base is different in a number of respects. Reflecting professional role, knowledge focuses specifically on mental health. Although there is some variation (Davis, 1986, Kalkman and Davis, 1974) this is generally organized in terms of models or psychiatric ideologies. Hence Burgess, A. (1985) states:
the specific tasks and activities used in psychiatric nursing are best described within…conceptual models of psychiatric mental health care
a view with which others concur (Carr et al., 1980; Stuart and Sundeen, 1983; Mitchell, 1974; Puttnam, 1981). Two reasons for their significance are presented: constructing a model of mental illness allows us to see its nature, causation and effects (Mitchell, 1974), and they allow nurses to function rationally and evaluate their effectiveness (Stuart and Sundeen, 1983). Because they go beyond social science this represents a broader trawling of knowledge but with a narrower focus (mental health) than evident in social work. The use of models is allied to the general advocacy of eclecticism. It is seen as a means of overcoming the ‘limitations’ and ‘simplifications’ of theory, and the belief that there is no ‘right way’ to approach problems (Lancaster, 1980). Neither eclecticism nor the choice of model is generally seen as problematic—choice may be based on the nurse’s personal preference, provided it is explicit (Burgess, 1985). Although some social workers also advocate eclecticism (Pincus and Minahan, 1975; Whittaker, 1974), they appear more aware of inherent inconsistencies, the threat to developing a consistent knowledge base and the need for rigorous criteria to choose between models. ‘The nursing literature’ writes Sladden ‘does not waste time over the conceptual problems of the eclectic approach’ (1979).
The delineation of models reflects an awareness of their interest to psychiatry as a whole (Siegler and Osmond, 1966; Strauss et al., 1964; Tyrer and Steinberg, 1987). Model construction, however, varies between different
authors. The core division, identifying medical, social and psychological models, is presented by Mitchell (1974). The medical model (Burgess calls this ‘biologic’), he says, presents psychiatric disorder like any other involving a pathological lesion and disturbed function which is resolved physiologically (e.g. by drugs). Others add a characteristic process of examination, diagnosis, treatment and prognosis (Carr et al., 1980; Stuart and Sundeen, 1983). Mitchell suggests the social model focuses on individuals’ failure to function in groups, while others emphasize the causal significance of social environment and conditions. The third model is psychological, which is presented as behavioural disturbance or distress due to powerful psychological forces, resolved only by therapy confronting the intra-psychic conflicts. However, additional divisions exist between psychoanalytic and behavioural or cognitive behavioural models (Burgess, 1985; Stuart and Sundeen, 1983), and ‘Third Force’ psychology emphasizing peoples’ potential for personal growth. Stuart and Sundeen (1983) present two further models, existential and interpersonal, emphasizing the importance of relations between people. A ‘community orientation’, loosely defined as an ideology focusing on those needing help but unwilling or unable to seek it, is identified by Carr et al. (1980) (cf. Baker and Schulberg, 1967). Finally Davey (1984) identifies an anti-psychiatry perspective (better called perspectives) broadly denying the validity of an illness label for those suffering psychiatric problems. Overall, although models may be helpful, the CPN is confronted by a great, perhaps bewildering, variety of alternatives and no consensus about divisions between them.1
Practice Orientation: Judgment and Experience
The limited nature of social science knowledge concomitantly increases the importance of judgment and experience, well recognized in social work. Emphasizing the importance of judgment, Howe (1980) states it
cannot be resolved into information and documented in the way information can…for some skills judgment may form the greater part of their knowledge.
while Sheppard (1984) suggests:
it is often easier to identify the uniqueness of and differences between one person and another…many studies are too general to provide a clear direction to practitioners working with specific problems and clients.
Indeed, those who emphasize social work as ‘art’ rather than ‘technique’ stress this most strongly. What is important in the process of social work, and what
is effective in achieving its ends, they argue, is not some technical expertise, but the quality of the person of the helper (Jordan, 1979; Keith-Lucas, 1972). To a considerable degree this emphasizes the understanding of others by social workers: using abilities which most of us possess, but the social worker—to be any good—should develop to an advanced level.
The worker knows about the client’s meaning because of the worker’s own ‘human nature’ tells him what it is to experience…mental or emotional states and can sensitively extrapolate from them. (England, 1986).
Additionally, their work leads to contact with problems to a far greater degree than normal social life, and involves focusing on these problems. Hence practice experience allows them to refine their understanding and responses to these problems, thus providing a legitimate ‘knowledge base’ in itself.
The issue of judgment is significant for nursing as a whole and CPNs in particular, though not all are agreed. Neuman (1980) and Johnson (1980) both emphasize the technical expertise derived from their models. Orem (1980) however, stressing personal qualities, recognizes the importance of particular techniques, but emphasizes the individual patient and correct nursing judgments. Most significant for good judgment is the nurse’s experience, but other factors such as innate ability, life experience, personality and style of thinking are also important. Rogers (1970) also sees a relationship between the technical aspects of knowledge and the more creative, individualized, and experience based use of judgment in applying that knowledge:
It must be thoroughly understood [she says] that tools and procedures are adjuncts to practice and are safe and meaningful only to the extent that knowledgeable nursing judgments underwrite their selection…[and] use.
These views, general to nursing, are apparent in psychiatric nursing. Hence Ward (1985) believes that:
The nature of nursing…decreed that innate artistic qualities of human caring…should be incorporated into the general pattern.
Likewise, Barker (1985) states:
Judgments…are found in almost all forms of patient care. Even when we use highly objective means of recording and measuring the patient’s state…we end up using our own subjective judgments.
It is, then, as with social work, the limitations of knowledge when applied to practice which leaves experience and judgment a vital place in practice. Lack
of experience and good judgment can be inimical to adequate practice. Kim (1983) writes
Wrong decisions are made because the nurse has a limited experience of specific life and nursing situations with which he or she can develop evaluative framework.
In theoretical terms, judgments and experience are significant because they limit the effect on behaviour of knowledge approaches discrete to each profession. Of course, experience is not somehow divorced from theory— implicitly or explicitly used to give situations meaning. However, the more important experience is, the more scope exists for creative understanding and responses to problems on the part of individual practitioners. Indeed, where frequent contact occurs, this may well encourage ‘seepage’ of concepts and theories from one discipline to another.
Defining the Client or Patient
Both social workers and CPNs define clients with meanings particular to their profession: either in terms of problems or needs. Social workers’ concern is with psychosocial problems or needs (Haines, 1981; Roberts and Nee, 1970). Reid (1978) refers to ‘problem oriented theory’ and states that the major concern of clinical social work is to alleviate problems of individuals and families.
Hoghughi (1980) also emphasizes problems, referring to the ‘symbiotic relationship’ of social work with social problems. ‘Social work’ he says, echoing Perlman (1957) ‘is about solving problems.’ Reid (1978) distinguished between acknowledged problems—problems clients consider themselves to have—and attributed problems—problems attributed by others, in this case social workers, to clients. Furthermore, fundamental disagreements exist about problem definition. What does or does not constitute a social problem depends upon the social processes by which it becomes a matter of concern as well as theoretical assumptions underlying them (Rubington and Weinberg, 1977). Social work definitions of problems possess implicit standards influenced greatly by their position in Social Service Departments (Howe, 1979).
Need definitions also possess an ideological dimension. Hardiker, (1981; cf. Davies, 1982) argues that
The social worker’s brief in welfare states is to identify and meet personal need and find acceptable ways of representing deviants to the rest of society.
Their freedom to define need, however, she considers is limited by structural boundaries provided by their agency. Smith and Harris (1972), like other authors, argue that social workers adopt ideologies of need, based on perceptions of unit of need, cause of need and assessor of need. Rees (1978) indicates these ideologies are related closely to perceptions of moral character, while Hardiker (1977) suggests they are key to understanding central issues of punishment/freewill and treatment/determinism, and that interpretations of need are made through frameworks originating from psychological or sociological knowledge.
Nursing differs from social work in its emphasis on health. Their biopsychosocial orientation is more ambitious than that of social work, which emphasizes only the psychosocial (Kim, 1983; Chrisman and Fowler, 1980, Pearson and Vaughn, 1984; Roper et al., 1980; Kyes and Hofling, 1980). Kim (1983) argues that problem or need definition is critical for nursing diagnosis, providing a means for conceptualizing the client in terms of the concerns of nursing. Both Henderson (1964) and Roper et al. (1981) perceive need as nurses’ central concern: they are interested in the ‘observable behavioural manifestations of basic human needs’ (Roper et al., 1980). This is just as true for CPNs: Simmons and Brooker (1986) state that ‘true mental health requires basic needs are met.’ Likewise Carr et al. (1980) suggest that ‘patients need to be approached as individuals who have needs.’ However, when need is explored more deeply, there is little reference to its ideological component. Maslow’s hierarchy of need—which is, like other need definitions, ideological—is particularly influential (Maslow, 1970). This hierarchy of need has five levels from basic physiological needs through more ‘advanced’ needs up to self actualization. These are ordered in priority: it is only when the lower needs are satisfied that motivation is established to seek fulfilment of higher level needs. Nursing is also conceived in terms of problems. Rambo (1984) indeed recognizes the relevance of both need and problem definition, but suggests the superiority of the latter by linking it with scientificity. ‘The nursing process’ she writes ‘as a method of problem solving represents a scientific avenue of nursing care.’ Barker (1985) likewise prefers problem identification to (medical) diagnosis in psychiatric nursing.
The common denominator [he suggests] is the search for and ultimate detection of, problems…. Aspects of a person’s performance and presentation which might be ignored or overlooked in (medical) diagnosis will be caught under this broader frame of reference.
Problem definition in nursing, however, must reflect nursing’s concern with the biopsychosocial aspects of the human condition. Stevens (1979), for example, lists five conditions: experiential states, physiological deviations, problematic behaviour, altered relationships and reactions of others. However, problem identification is largely theory related—hence different
approaches will emphasize different aspects (Roy and Roberts, 1981; Orem, 1980). Nonetheless, problem identification is seen as crucial to the development of a nursing classification system—it becomes a tool for intervention (Roy, 1975): ‘an essential next step in the development of the science of nursing.’ What is required is not a problem classification which is atheoretical—which is not possible—but one which is framed in terms of meanings appropriate to CPNs (and social workers) and which may be applied across different models (Kim, 1983). Kim suggests problem identification requires three elements: a problem label, a definition of causal elements, and a description of the characteristics of the phenomenon, interestingly close to that advocated by Huntington (1981) for social work.
Context for Intervention
The context of social work practice, like problem definition, reflects its psychosocial orientation and the related intervention modes. Social work possesses theoretical diversity and some conflicting assumptions. Practice is rarely characterized by explicit use of theory, but when examined closely, theoretical constructs provide an implicit though critical context for practice. Curnock and Hardiker (1979) have shown that good practice requires theory, without which mistakes would be made. It necessarily involves flexible and imaginative use of such theory. However, because of this theoretical diversity it is difficult to characterize social work in terms of a particular approach: it is best reflected in the pragmatic use of different contexts for intervention rather than specific methods which may be adopted. Analysis based on a specific method would not reflect the known, and diverse, use of theory in practice.
Recent theoretical developments suggest four stages. The basic division is between interpersonal intervention, largely but not exclusively concerned with clients, and environmental intervention, involving individuals and systems within the social structure in the process of providing services to the client (Haines, 1981). This configuration, classically presented by Hollis (1972) was ‘person in situation’: the person, his situation and the interaction between them. She referred to ‘internal’ and ‘external’ pressure to signify forces within the individual and the environment. Drawing on psychoanalytic and sociological concepts, intervention involved addressing both internal psychological conflicts and ‘life pressures’ such as economic deprivation, poor housing and educational disadvantage. Bartlett’s (1970) concern with social work’s overemphasis on the client’s immediate circumstances led to her conception of ‘interventive repertoire’, involving the use of a variety of approaches as appropriate. Hence the practitioners may involve themselves with the client, encourage groups, develop social supports and act for change within the community. Work could be both proactive and reactive. Unitary models attempted to provide a conceptual schema for this repertoire, moving beyond a ‘dichotomous view’ of people and environment, to a focus on
linkages between people and resource systems (Pincus and Minahan, 1975). This systems approach meant the issue was not:
who has the problem, but how the elements of the situation…are interacting to frustrate people coping with their tasks.
The ecological perspective has much in common with unitary models. However, it goes one stage further by identifying ‘levels’ of context. Whittaker and Garbarino (1983) developed a four-fold distinction based on concepts of social networks and support. To a considerable degree this provides a theoretical base for community social work developments (NISW, 1982). Microsystems represent the immediate social networks of individuals—their family, school, immediate workplace and so on. Mesosystems are the relationships between these microsystems (e.g. relations between home, school and work related groups). Exosystems are situations that affect a person’s development, but in which the person does not play a direct role. These include political agencies and centres of economic influence. Macrosystems are ideological and cultural expectations in a society: they reflect shared beliefs creating behavioural patterns (e.g. how cultures define and respond to dependency, how political ideologies allocate resources between public and private agencies and different groups). Whittaker (1974) calls work using this ecological approach social treatment. He defines five major roles (Whittaker, 1986):
1Treatment agent
2Teacher—counsellor
3Broker of services or resources
4Advocate
5Network/systems consultant
Each of these represent role clusters—ways of working or responsibilities the professional may assume according to the circumstances of the case and may operate in different and overlapping contexts.
Wooff (1987) suggests community psychiatric nursing is characterized by the lack of a theoretical base:
Neither psychiatric nurses nor CPNs have developed a common set of principles or an organized set of professional values…integral …for decision making skills.
However, models exist in the wider realm of nursing as a whole. In this respect it resembles social work—possessing models which are, on the whole, general to the profession but not specific to psychiatry. Kim (1983) classifies nursing in terms of its domain. Using Kim, we can distinguish two areas in the domain of nursing—the phenomena with which it is concerned —that focusing on the
patient and that focusing on the environment. Beyond Kim’s typology, however, we can distinguish the context of nursing—the phenomena on which it will act—from its domain. This likewise can be divided between client and environment.
Although a variety of different approaches are available—activities of living, interpersonal, total person, behavioural systems and so on—two broad factors are consistent to these models. First nursing concerns itself with biopsychosocial factors affecting health. Hence Kim (1983) writes:
the nursing perspective is to conceptualize a person as a biopsychosocial being with an emphasis on health.
a position adopted by other theorists (Roy, 1976; Neuman, 1982; Rogers, 1970). This is both all embracing in terms of the human condition and more ambitious than the more limited psychosocial concerns of social work. Second, while the domains of interest to nursing frequently encompass biopsychosocial aspects of both patient and environment, the context of intervention invariably focuses primarily on the patient. This can at times appear as a puzzling disjunction, between domains relevant to health, such as social factors which suggest the need for environmental intervention, and the specific intervention focus on the patient. This may be related to perceptions of the appropriate role of the nurse, which would lead to the development of role appropriate models for practice. This individualism is consistent with some models emphasizing nurse-patient interaction. King’s (1981) theory of goal attainment emphasizes interactional elements—particularly ‘nurse-client interactions that lead to achievement of goals.’ She is quite explicit: although the domains of concern for nursing are personal, interpersonal and social systems, and health problems may be caused by environmental stress, the main focus for action is the nurse-patient dyad. Others claim domains which are equally comprehensive, without being explicit as King is, about the narrower focus for intervention. Rogers’ (1970) concept of Unitary Man accepts only the inter-connectedness, in reality, of environmental and human elements, although conceding the possibility of distinguishing conceptually between the two. Johnson’s model (Johnson, 1980; Grubb, 1980) recognizes physical, psychological and social elements, and expresses interest in the domains of both client and environment. Grubb (1980) lists a number of relevant environmental variables, yet: ‘The predominant focus of nursing is on the person who is ill or threatened with illness.’ Roy also recognizes both personal and environmental variables, with physiological, self concept, role function and interdependence elements (Roy and Roberts, 1981). She, however, emphasizes the need for individual adaptation to the environment whether involving biophysical or social elements. This, of course, begs the question: just how adequate for health is the environment to which the patient must adapt?
This disjunction between domain and context is well illustrated by
Rambo’s (1984) explication of Roy’s model. She clearly recognizes many American black peoples’ health is affected by structural disadvantage, involving segregation, discrimination and poverty. She also recognizes these can affect the patient’s health and performance, causing maladaptive behaviour, with which the nurse is legitimately concerned. Yet the nurse should only work with the patient to:
attempt to bring their [my italics] maladaptive behaviour within the normal or adaptive range.
There is no concern here to work on those environmental factors directly which cause large numbers of black people ill health.
Some writers do recognize approaches beyond the individual, although they are more tentative and lack the alternatives available to social work. Kim (1983) differentiates between the client-nurse system, involving nurse-patient interaction, and the nurse system, largely excluding the patient, but does little more. Pepleau, whose interest is primarily in a therapeutic interpersonal process does advocate involvement in health care planning and social policy issues (Pepleau, 1962, 1980). However, between individual work and social policy issues, she has little on work with patients in an environmental context. Neuman (1982) goes further in this direction. She recognizes nurses’ claim to be concerned with phenomena relating to both client and environment. She identifies stressors originating in intrapersonal, interpersonal and extrapersonal areas. Additionally, however, she suggests preventive care and health education programmes, and that nurses should help ‘individuals, families and groups’ attain a maximum level of wellness (Neuman, 1980). Chapman (1985) suggests this model is useful applied not just to individuals but also communities.
This dominant individualist focus—contrasting with detailed theoretical developments beyond individual clients in social work—is significant because, as Kim (1983) suggests, the focus provides a ‘space’ within which knowledge and skills may develop. A dominant individualism militates against the inclusion of skills oriented to the environment in the nurse’s repertoire.
Contexts Specific to Mental Health
Social work approaches to mental health problems largely entail the application of their broader professional skills to the more specific area of mental health. As with other areas of work such as child care, they limit their concern—wide enough in itself—to the psychosocial, perceived to complement the more biophysical medical orientation of psychiatrists. This approach is supported by social psychiatry research which has emphasized the interconnection between those very personal and
environmental factors on which social work skills concentrate (Cochrane, 1983; Miles, 1987). Much of the social work knowledge development specific to psychiatry involves identification and recognition of mental disorders, core—in more detail—to psychiatric nurse training, examining this in terms of the social process, context and prognosis of mental illness (Hudson, 1982; Munro and McCulloch, 1969; Butler and Pritchard, 1983). In recent years, Approved Social Work training has emphasized the legal context as well as symptom recognition plus specific skills in case material analysis (Central Council for Education and Training in Social Work [CCETSW], 1986).
The theoretical limits of nursing as a whole clearly disadvantage CPNs interested in placing patients within a broader environmental context. Developments in this respect specific to CPNs are extremely recent. Moore commented when introducing one significant book in 1980 (Carr et al., 1980) that it was: ‘but a starting point in the debate on community psychiatric nursing.’ Another writer (Ward, 1985) stated that:
there are very few texts available to United Kingdom nurses which relate…to the very special needs…of psychiatry.
Indeed, the community rather than institutional hospital perspective has led to an emphasis on individualized care of the patient (Carr et al., 1980; Ward, 1985). Some attempts to incorporate a psychosocial dimension have not transcended this individualism. Hence Barry (1984) developing Roy’s adaptation model focuses on the patient, emphasizing psychological rather than social variables. Likewise Barker (1985) emphasizes a ‘person centred approach’ designed to identify what is significant for ‘this particular patient’ who is ‘a unique person.’
In the face of theoretical limitations, CPNs have, to a considerable degree, taken refuge in skills information, pragmatically chosen on the basis of professional need (Marram, 1973; Looms and Horsley, 1974). This is largely ‘borrowed’ knowledge, generated within other disciplines, but apparently useful to CPNs. Barker (1985) states, for example, that
The methods I discuss in this book are influenced strongly by psychological research and practice.
In this respect, approaches like social skills, and particularly behaviourism have taken on some significance (Roach and Farley, 1986; Marks et al., 1977; Barker, 1982; Pope, 1986; Hargie and McCarton, 1986). Given the psychological orientation, the focus tends primarily to be on the individual, although there is a greater interest in their immediate interactional context, as with behavioural approaches. Likewise, Pope (1986) discusses family skills training in relation to high expressed emotion families of schizophrenic patients.
A potentially wider context is provided by an ecological approach (Lancaster, 1980) emphasizing the:
dynamic interaction between the patient’s internal environment and the multiple external environments.
These are linked by a systems approach, but there is little theoretical development, such as different types and levels of environmental intervention. Rather, there are hints of relevant factors such as familial or social systems linkages, which are not fully developed. The exploration of the context of social environment has been rather too brief for detailed skills development (Carr et al., 1980). Simmons and Brooker (1986) have been boldest in this respect, examining in some detail social factors in the family and wider society. Their analysis is stimulating, suggesting wider possible contexts for intervention, but ultimately limited in detail about the ways to work in these wider social contexts. Overall, then, while nursing does possess a theoretical base, CPNs may be viewed as struggling to free themselves from its limits. They have taken a few tentative steps without developing a consistent theoretical base beyond individualism.
Direction of Work with Clients
The client/environment distinction relevant to both social work and nursing may be related to direct and indirect work. This is a distinction extensively used in social work as a means of delineating the locus of intervention (Specht and Vickery, 1978; Whittaker, 1974; Haines, 1981; Whittaker and Garbarino, 1983). In our framework it is significant because it indicates the worker’s approach to particular problems, hence linking problem type with locus of intervention. Whittaker (1974) adopts the most frequently used definitions. Direct work is ‘what the worker does directly in their face to face encounter.’ Indirect helping ‘refers to all activities that the worker undertakes on behalf of the client to further mutually agreed upon goals’ i.e. work with others designed to influence the client’s behaviour and/or circumstances. Middleman and Goldberg (1974) extend this to a second category—the problem group. Hence working with people with common problems—e.g. schizophrenic people or those in poverty—constitutes direct work. Working with others concerned with that problem—agencies, voluntary organizations, even politicians—constitutes indirect work. Specht and Vickery (1978) identify two further uses of the term. In relation to group work, attempts to influence an individual directly are contrasted with work on the structural relations of the group or others in the group, which is indirect. Finally, it may relate to the participation of the worker in problem solving. Direct work entails actual involvement with the client in problem solving. Indirect work involves discussing the relevant problem with the client, without the worker being
present when the problem is actually worked upon. For our purposes, the most frequently used distinction—that of Whittaker—is most helpful. It can be as easily applied to CPNs as social workers, and is relevant to problems. Specht and Vickery (1978) argue this is most appropriate—whether an approach is direct or indirect, the focus is on the particular problem with which client and worker are concerned.
Duration of Intervention
The final element is the duration of intervention. This issue has been particularly prominent in social work, although because some of the approaches used transcend that particular occupation—e.g. crisis intervention, psychoanalytically and behaviorally oriented methods—the debate has considerable relevance for CPNs. Perlman (1969) commented on a previously well established tendency by social workers to value longer term work without, compared with brief work, demonstrating its greater effectiveness. Extended work is associated with three general influences. Psychoanalysis has influenced significantly the knowledge base of social work. With its emphasis on in-depth analysis of underlying psychological problems, and development of ‘insight’ (a term used by social workers differently from psychoanalysts) it has a tendency towards lengthy intervention (Yelloly, 1980; Hollis, 1972). Others regard the ‘relationship’ as crucial. By valuing relationships for their own sake, and where the goal is presented as self realization or self-fulfilment, importance is implicitly attached to extended intervention (Keith-Lucas, 1972; Jordan, 1979). Although an end in itself, the relationship is also seen as the most effective means of promoting change (Truax and Carkhuff, 1967). A third associated element is a generalized ‘supportive’ orientation of some social workers. In mental health work, the professional role becomes a form of ‘unlimited supportive friendship’ coupled with practical help. Additionally there is little negotiation of the purpose of the work if this places the ‘friendship’ in jeopardy (Fisher et al., 1984).
Extended intervention may be long term by design, but tends instead to be ‘open ended’ rather than time limited. It may be of low or high intensity. However, advocates of brief intervention (Reid and Epstein, 1972): ‘take the position that planned short term treatment should be the dominant form of contact.’ Brief intervention is associated with task centred, crisis intervention and some behavioural work (Reid, 1978; Rappaport, 1970; Sheldon, 1982). Crisis intervention emphasizes the therapeutic potential of work over a relatively short crisis period (Rappaport, 1970). During this period the client is in a state of disequilibrium, when normal problem solving techniques are ineffective. However, there are natural processes of growth and development which, during this time, the worker may help mobilize in the client. Key characteristics of this approach are that it is both goal oriented and time
limited, in this respect similar to task centred work. This also emphasizes exactitude in formulating problems, methods to deal with them, and evaluation of outcome. Task centred work is more widely applicable, not limited to states of crisis. Rather than emphasizing in-depth work (or ‘underlying conditions’) task centred work directs change efforts at manifest problems of interpersonal conflict—role performance and the like—working on the ‘here and now’. Although there is an element of expediency in advocating brief intervention (given limited resources) supporters argue it is no less effective than extended work (Reid, 1978). Some intervention is unintentionally brief because clients discontinue contact, but debates on duration reflect basic differences in philosophies of practice.
Concluding Comments
Social workers and CPNs have carried out a discourse about their respective occupations largely independent of each other. Comparison is instructive, providing a yardstick by which professional ideas and development may be measured against each other. The adequacy of the social work knowledge base, for example, is more realistically assessed when compared with the problems confronted by other occupations in developing and applying their own knowledge than when measured against some arbitary and perhaps ideal criteria (Howe, 1980). Although neither social work nor CPNs are rigidly demarked by approaches discrete to each profession they are characterized by significant differences of emphasis. Each is characterized by different elements (and degrees) of integration. Thus the biopsychosocial CPN orientation adopts models from wider realms of knowledge, but this is far from systematic lacking criteria for integration. Problems of eclecticism arise which are not confronted. Social work, with a less ambitious psychosocial orientation, has considered issues of integration within their narrower social science framework (Sheldon, 1978; Sheppard, 1984; Stevenson, 1971; Whittaker and Garbarino, 1983). Both professions, furthermore, recognize a significant degree of indetermination, hence the importance of judgment. When combined with paradigmatic and knowledge realm diversity, this indeterminacy encourages segmentation within these professions, with individuals or groups committed to different approaches. There is, furthermore, some overlap between these professions. Hence the uncertainty of the social science foundations of social work is reflected in the variety of available mental health models; significance is ascribed by both professions to judgment; both claim an interest in the psychosocial (though CPNs are also interested in the ‘bio’); and both borrow knowledge from other disciplines, although unlike CPNs social workers have also generated their own knowledge (e.g. task centred, problem solving).
However, significant differences exist. Some issues of relevance to both professions, such as the duration of intervention, have been considered in
