Social work approaches to mental health work: international trends
Shulamit Ramon
The historical development of mental health social work
Social work was formally established in most European countries and North America at the end of the nineteenth century, before it took off gradually in other countries. It usually developed out of charitable work, which focused on financial support for poor families. The second main strand in social work was represented by the Settlement Movement, which concentrated on improving the communal life of poor people by living with them, using community work methods to support and empower.
The major impetus to developing mental health social work at the beginning of the twentieth century was related to the work of leading psychiatrists and psychologists with shell-shocked (PTSD) soldiers during the First World War.(1) This approach lead to the establishment of the psychodynamically oriented Tavistock Clinic in London, where the first British psychiatric social worker was appointed in 1920.(2) Stuart(3) argues that American mental health social work in the pre-1920 period concentrated more on care in the community in its social, rather than its administrative or psychological meaning, than after 1920, when it shifted further to the psychological dimension.
Social workers in both the children and the adults outpatient services provided comprehensive psychosocial history of the child/adult and their family, enabled parents, teachers, and partners of adult clients to understand the underlying psychological reasons for the index client’s mental ill health, and guided them as to how they could actively support that family members.(2) It was only in the 1950s that qualified psychiatric social workers began to work in hospitals.
Since the 1970s all English-speaking countries have also opted for deinstitutionalization as their core mental health policy, leading to the closure of many of their psychiatric hospitals, replacing them by community-based services and by small psychiatric wards in general hospitals.(4,5) With the notable exception of Italy,(6,7) most continental European countries have opted for bed reduction coupled with less extensive community services.
The trend towards deinstitutionalization is formally adhered to also in Latin America, but thus far is only practised in some small-scale projects.(8,9) This applies also to Asia. MHSWs (mental health social workers) there focus mainly on sorting out benefits, though some are based in rehabilitation focused facilities where they work on connecting users to educational and employment opportunities.(10)
This fundamental change has led to the relocation of MHSWs away from institutions into community services,(5) to a renewed interest in rehabilitation, and more recently also in the newly defined recovery.(11)
The paralleled development of private, for-profit mental health services especially—but not exclusively—in the United States, has led to a further shift in the location of MHSWs and their work focus. Most United States MHSWs are to be found today working as psychotherapists in private practice or in managed care residential units.(12) In the latter they work with users who have long-term mental illness to a per capita budget.
Although the not-for-profit sector has grown considerably with the focus on care in the community, MHSWs work there only in certain countries in which the public sector has either been reduced or never played the major part it does in the United Kingdom (e.g. the Netherlands, Hong Kong).
Underpinning values
Social work, including its mental health branch, is ethically governed by a set of values, which are expected to be universal and adhered to in everyday practice,(13) even though its implementation may prove at times to be problematic in terms of balancing care and control.
The values are derived from the liberal collectivist, humanistic, tradition of the twentieth century in which social work has developed.
The core values are social justice, respect for people who social workers meet at their most vulnerable state, readiness to help in a way which will enable the client to retain dignity, self-determination, and enhance their problem-solving abilities. Social workers are expected to take an active stance against any type of discrimination. Furthermore, social workers are committed to pursing a psychosocial approach in any type of their practice, and believe that most clients have the potential to grow and positively change.
Several elements stand out as central to MHSW:
1 The right to fail—this comes as part of the right to self-determination, in that social workers are aware that risk needs to be taken at times to enable people to grow and develop, or as a basic human right of making a mistake. When social workers take this right seriously, they are able to have a genuine discussion with clients as to the pros and cons of risk-taking, of learning from success as much as of learning from failure.(14,15)
2 The wish to take an active stance against discrimination applies to working well with clients who come from ethnic minorities, from sexual orientation minorities, and to combating stigma against mental illness in one’s practice.
3 The adherence to a psychosocial approach entails ensuring that both the psychological and the social aspects of users’ lives are attended to, an issue of importance in mental health where often biological aspects are attended to, but the psychosocial ones are not getting the same priority.(16)
Conceptual developments
Psychodynamic approaches
As outlined above, mental health social work originated within the psychodynamic fold, though social workers did not practice psychoanalysis as a work method.
Social workers have tended to select from the range of psychodynamic perspectives those theories, which were more focused on the ego, rather than on the id or the unconscious. The impact of ego psychology was/is in evidence in terms of understanding how people come to develop and maintain mental distress and mental
illness, the importance of family dynamics, and of attachment to significant others.(17, 18, 19, 20)
illness, the importance of family dynamics, and of attachment to significant others.(17, 18, 19, 20)
American social workers developed the crisis approach in its application to all areas of social work.(21) Based on Erickson’s notion of the normal crisis every person goes through when moving from one stage of life to another, major life events may lead initially to adverse reactions. However, with professional support people can reorganize their reactions more constructively, reduce the duration of these reactions, be more ready for change at the point of crisis, and learn how to improve their coping strategies and emotional responses. The problem-solving approach also originated from the United States, developed by Perlman.(22) Although the psychodynamic understanding of relationships is in evidence in her work, she focused on the process of social work with individuals and families (casework) and the client–worker relationships, beginning with the presenting problem.
The identification of child abuse, especially child sexual abuse, and its implications for the mental health of children and adults in the 1970s and the 1980s led to refocusing on the psychodynamic approach among social workers in this area(23) at a time in which all other approaches have paid less attention to the impact of such abuse on mental health.
Learning theory applications in social work
Behavioural social work
Behavioural social work developed in the United States in the 1950s, and is a leading approach in relation to people with milder forms of mental illness and problems of living.(24) Its application within social work does not differ in any significant way from its application within psychiatry or psychology. In this sense it is not a social work approach. A number of influential texts appeared in the United Kingdom which demonstrated the research evidence pertaining to the effectiveness of the approach in a number of social work areas.(25)
Task-centred social work
This orientation takes further the crisis perspective and the lessons from learning theories and behaviour modification.
Reid and Epstein(26, 27), as well as Marsh and Doel,(28) proposed that people work better on their problems if focused on specific targets and if the problem-solving effort leads to success, however small. Research evidence demonstrated the usefulness of this approach to different aspects of social work, such as direct work with children and their parents, as well as with people suffering from mild mental distress symptoms.
The social dimension in mental health social work
Social workers and theorists interested in the social dimension began usually from the assumption that inequality in opportunities and in civic participation due to poverty may increase the rate of mental illness among poor people. This assumption follows Merton’s classical matrix of the reactions to the gap between social goals and means, in which mental illness is a reaction of people who accept socially desirable goals, but withdraw from obtaining them after being frustrated in doing so, whilst at the same time not adopting antisocial means (as in criminal behaviour) or developing an alternative model of society (social rebels).
This strand of thinking was reinforced in the 1960s and 1970s by the application of Marxist thinking and the combined impact of the deviancy and anti-psychiatry orientations.(29) Discrimination on the basis of age, ethnicity, gender, or sexual orientation was added in the 1980s to the likely social factors which foster inequality.
Social workers accepted the logic presented by sociologists such as Goffman and Scheff (30, 31, 32) that the stigma attached to mental illness is largely irreversible, as it is accepted both by others and by the individual concerned who in turn internalizes his or her poor social status.
Interestingly, although accepting the enormity of the labelling process, social workers did not count themselves among the labellers.
The appeal of the anti-psychiatry approach for social workers related to acknowledging the price of labelling for the individual concerned, and the considerable shortcomings of a system focused on the psychiatric hospital and medication in which psychological and social factors were largely ignored.
Today the social perspective implies a greater focus on social inclusion, supporting users and carers-led initiatives, ensuring financial support side-by-side with the critique of the medicalized approach to mental health and illness, of modernity and postmodernity.(16)
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