briefing on mental health

7/29/2019 briefing on Mental Health

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RESEARCH BRIEFING

26July 2008

Key messages Approximately one in six people in

England experiences some form ofmental health problem at any giventime, with some groups more vulnerablethan others.

The traditional skills of social work remain

important and social workers have adistinctive role in multi-agency settings.

Social work needs to develop practiceswhich help people with mental healthproblems identify and realise theirown needs.

Social work has a significant role to play incoordinating efforts to support individualsand groups who may often have negativeexperiences and perceptions of mental

health services.

Social workers need to maintain a broadsocial view of mental health problemsespecially in regard to concerns aboutdiscriminatory practices, civil rights andsocial justice.

Mental health and social work

By Mo Ray, Richard Pugh, with Diane Roberts and Bernard Beech

Policy makers need to focus on the rolethat social work plays in integratedmental health services and supportfurther professional development.

IntroductionProviding effective social support for people with

mental health problems is a key challenge in anenvironment where the views of people whouse services are seen as increasingly significant,where some social groups do not receive servicesfairly and equably, and where organisationalstructures are changing.

At a time of considerable change to professionalroles and organisational structures, whereconcerns have been expressed about thediminution of the distinctive part that social

workers have played in the broader provision ofhealth and social services for people with mentalhealth problems,4this briefing focuses on therole and contribution of social work incommunity mental health provision in statutorycommunity mental health teams, integrated ormultidisciplinary teams, assertive outreach and


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RESEARCH BRIEFING 26

crisis intervention teams within the UK. Itacknowledges the diversity of people who use

services throughout their lives, but does notreview research relating to acute in-patient care,residential or domiciliary care, or dementia inolder people. The issue of dual diagnosis is notincluded as this will be covered in a separate SCIEresearch briefing. The information contained inthis summary of recent research is drawn fromrelevant electronic databases, journals and texts.

What is the issue?Through the activities of user groups such asShaping Our Lives and the National Centre forIndependent Living, people who use services arefinding social inclusion through supportiverelationships, personal security and positiveaffirmations of hope, challenging the narrowdefinitions of their roles often made by mentalhealth professionals and organisations. Inparticular, people who use services aredeveloping knowledge and are effecting changes

in service provision through their personalexperiences of the social care sector.1,2,3

The independent living movement, whichoriginated in disability activism, and is nowactive in mental health, is becoming moreinfluential in shaping policy and practice.The emphasis upon personal choice and arights-based approach to service provision can beseen in the development of direct payments andpersonalised budgets for services. Social workers

with their longstanding, formal commitment tothe promotion of independence, dignity, choiceand self-control, are well placed to support thesedevelopments, but policy makers and theprofession as a whole need to recognise that thebroad agenda of people who use services goes farbeyond the promotion of a purely consumeristapproach to self-directed service.

Current mental health services do notadequately meet the needs of some people,

while others appear to be over representedin the more coercive areas of detention andcompulsion. It has been recognised for many

years that some sections of Britains black andminority ethnic communities have not receivedculturally appropriate services and have sufferedfrom ignorance and discrimination within themental health system. For some time, effortsto address these continuing inequities havebeen a key feature of the Department ofHealths plans,33 by developing training

materials to improve staff knowledge ofparticular ethnic groups, for example, and bycommissioning research into decision-making inservice provision.

Why is it important?Approximately one in six people in England has amental health problem at any given time, at anestimated cost of 77 billion a year, a cost which

includes health and social care.

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The possibilitythat mental health problems may derive fromsocial injustice and oppression6 is not widelyrecognised, nor is the fact that people withlong-term mental health problems are likely toexperience social exclusion and discrimination asa direct consequence of their difficulties. Theycan experience a vicious circle of social isolation,poverty, unemployment, insecure housing andscarce social and support networks.5 Underlyingsocial exclusion are the impacts of stigma and

discrimination about mental illness, whichcan reinforce inappropriate assumptions; poorcoordination between agencies; and a restrictivefocus on the clinical aspects of mentalhealth problems.5

There is significant under-recognition of mentalhealth problems amongst some groups, such


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as older people,7 rough sleepers,8 and peoplein the criminal justice system.9 Moreover, such

people as children and young people who havebeen abused or neglected;10 looked after oraccommodated children and young people;11

young offenders;12 people with drug and alcoholproblems;13 people who are homeless or at riskof homelessness;14 and people who seek asylumor who are refugees,15are all at greater risk ofmental health problems. A life course perspectiveis helpful in understanding why children and

young people with mental health problems,for instance, are more likely to continue to

experience them in adulthood.16 Similarly,older people may experience depression andpost-traumatic stress in later life as a result ofunresolved traumas earlier in their lives, relatingperhaps to war experiences, childhood sexualabuse, or loss and bereavement. In addition,people with mental health problems fromblack andminority ethnic groups,18 women,19,5asylum seekers and refugees are especiallyvulnerable to the consequences of oppressionand discrimination.

The National Service Framework for MentalHealth (1999)20 for the modernisation ofservices, continued to promote the integrationof health and social care services within mentalhealth trusts to provide joined up services,with a strong emphasis on interprofessionalcollaboration, and the active participationof carers and people who use services.Consequently, specialist mental health teamshave been developed to intervene quickly toprevent crisis and relapse, admissions to hospital,and to promote recovery. Assertive outreachteams, for example, provide support, treatmentand interventions for people with long-termmental health problems who have complexneeds and who may find it difficult to engagedirectly with services. Crisis assessment and

home treatment teams provide multidisciplinarysupport and intervention for people with acute

mental health needs who, without intensivehome support and intervention, would needto go to hospital. Social workers employed inmental health trusts are likely to have additionalresponsibilities which include care coordinationwithin the Care Programme Approach, caremanagement and representation of socialcircumstances in Mental Health Tribunals.21Social workers in their role as Approved SocialWorker (ASW) have traditionally had a key rolein providing an independent view in assessments

carried out under the 1983 Mental Health Act.The enactment of the provisions of 2007 MentalHealth Act, however, will replace this with a newrole, the Approved Mental Health Professional(AMHP). This role will be open to a wider rangeof professions, but will still require appropriatetraining and local authority approval.

The emphasis on professional collaborationand integration has sparked concerns thatthe distinctive contribution of social work inmental health services might be diminished.21,4The training of social workers in mental healthservices has been key in providing criticalperspectives drawn from a broad range of socialsciences.2 In particular, it has supported socialmodels of understanding which can challenge orcomplement clinically-oriented medical modelsof mental illness.4The widespread adoptionof anti-oppressive and anti-discriminatoryapproaches in social work education andtraining has developed professional awarenessand understanding of issues such as power,oppression and social exclusion, and socialworkers have become more aware of theirown potential for oppression towards users.Their practice is formally underpinned by acommitment to promote social justice andchallenge oppression, and social workers are


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potentially well placed to help other mentalhealth professionals work with the people who

use mental health services and collaborate onways to recovery.22

In this context, the National Institute for MentalHealth (NIMHE) as part of the New ways ofworking initiative reviewed the roles of a rangeof mental health practitioners including socialworkers, and identified the shared and distinctivecontributions of the different professions.23 Thedevelopment of values-based practiceacknowledges and recognises that people will

bring diverse and potentially conflicting values to mental health practice.24,25,26Values-based practice involves making visibleand working with this diversity and is at theheart of current mental health policy andpractice. Social workers have, and will continueto have a presence in a variety of generic andspecialist settings where they may work withpeople with mental health problems, even ifthese are not formally recognised throughstatutory assessment.27 Social workers may, forexample, work with children and young people inhighly specialised settings, such as childrens andadolescents mental health services (CAMHS) butmay also work with children with mental healthproblems in more general settings, such asleaving care or looked after children teams.Within community care teams, social workersmay work with older people experiencing acutestress associated with loss and change, ordepression, while emergency duty teams arelikely to encounter a range of people with mentalhealth problems who will often be experiencingacute distress.

What does the research

show?This section summarises key themes arisingfrom studies undertaken in the United Kingdomand also cites work undertaken elsewherewhere this has relevance. Unfortunately, thecoverage of research studies evaluating socialwork contributions to mental health practiceis patchy and many areas of practice remainunder-researched.28 Nonetheless, a SCIE reporton improving the evidence base concluded thatmodernisation provided a unique opportunity

to develop the coherent infrastructure needed.29Moreover, there is increasing recognition ofthe importance of using different types ofknowledge from a wider range of organisational,practitioner, user, policy and communityperspectives.2,30

The significance of professionalperspectives and values

People who use services value the

non-stigmatising help and access to servicesprovided by social workers31 and the core valuesof social work practice directly support theprinciples underpinning self-directed support andthe independent living movement.32 Similarly,analysis of the essential capabilities requiredto practice in mental health also emphasisesthe importance of a professional value basewhich promotes dignity, human worth andsocial justice, and includes a commitment tothe principles and social perspectives of therecovery model.33 Indeed, research exploringcommunity care practices34 found that social


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workers frequently identified empowermentas a fundamental principle in their practice,

both as a goal and as an underpinning value.There is also widespread agreement amongpeople who use services, practitioners andresearchers that service developments suchas mental health promotion, crisis resolution,and the implementation of support based onthe principles of recovery, must be explicitlyunderpinned by social perspectives.35,36 Theseperspectives can help promote access for peoplesusceptible to discriminatory institutionalpractices, including people from black and

minority ethnic communities.37

Holistic approaches combining practicaland emotional support

People who use services value social workerswho are able to provide practical help,counselling and advocacy on their behalf31,38and have responded positively to practice thatcombines practical assistance with emotionalsupport.39,21,40 Diary-based research examining

differences in approach to care managementin different settings, found that care managersin mental health settings were more likelyto provide direct help alongside their caremanagement role (that is, combining thepractice of assessment, care planning andreview, with a significant allocation of timefor counselling and emotional support), thancare managers in an older persons team, whotended towards spending more time involved incare brokerage (that is, procuring care packagesand practical support).41 A study that examinedattitudes and role perceptions in mental health

teams in a London borough concluded that of allprofessional groups, social workers were most

likely to identify the importance of support tochildren combining individual emotional andpractical support, as well as appreciation of theirsocial circumstances.42 The significant role ofsocial work in promoting the involvement ofpeople using services and developing systemicapproaches to practice with families andgroups has also been identified.38 Joint workinginitiatives between social services and CAMHS,which encompassed an extended therapeutic rolefor social work practitioners that included family

therapy, have identified positive outcomesincluding quicker response times, more effectiveprioritisation, improved multidisciplinary workand a more positive experience for childrenand families.43

Reducing isolation and developingsupportive networks

A number of studies have identified thechallenges that people with mental health

problems face in sustaining and preservingsocial contacts and social networks.44,45 Peoplewith mental health problems who live in moreisolated rural areas and small communities withlittle service provision are likely to find it moredifficult to develop and preserve supportivesocial contacts and networks.46,47 Research intothe development of social networks in ruralareas46 has shown the crucial role that someservices, such as drop-in and day centres, play inpromoting and sustaining relationships between

people who use services. The Highland UserGroup, for example, has provided opportunities


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for people who use services to work together toinfluence the development of those services and

challenge discrimination. Social work and socialcare staff have a key role to play in workingwith and supporting groups of people who useservices to secure better practice and resistmarginalisation and discrimination. For olderpeople, the most effective interventions aimedat alleviating isolation and loneliness appearto be those which have an educational focusor where clearly focused support interventionsare built into existing services, and where olderpeople have been consulted about their own

particular needs.48

As well as providing therapeutic emotionalsupport and promoting the development ofpractical skills, group work approaches to serviceprovision, especially those based on strengths,have also demonstrated the value of networkingand mutual support. For example, a social workchildcare team developed group work as aresponse to working with the needs of childrenwith a parent with mental health problems.49The evaluation of this approach found thatpositive effects included an improvement inchildrens self esteem and confidence, as well asimprovements in their academic achievement.Another study based in Northern Irelandassessed the benefits of therapeutic group workwith young children aged four and five withcontinuous traumatic stress syndrome.50 It alsoidentified a number of encouraging changes,including improved sleep and a reduction innightmares, and an increase in social confidenceand improved social interaction with peersand adults.

Promoting independence andself-directed support

A random sample of 262 people with severeand lasting mental health problems51 found thattwo thirds thought that their care programmeshelped them to be more independent, butreported that they were rarely asked if theywanted family members or informal carersinvolved in their care. Frameworks which helpedpeople participate in their own social careincluded common assessment protocols andthe identification of a named, single key worker

or care coordinator. Social work practitionersskilled in family work were identified as beingparticularly suited to this role. Research alsofound that people who use services respondedmore positively where there had been jointtraining of social workers and communitypsychiatric nurses towards a common goal ofperson-centred practice and a care managementmodel based on strengths.

Research has confirmed that direct payments

for people with mental health problems areunder-used.52 A national evaluation of directpayments identified a number of barriers to theiruse which included service reorganisation, workrole uncertainties and difficulties in managingworkloads.53 It also found that care coordinators(including social work practitioners), rather thanoffering direct payments as a matter of course,tended to decide themselves who was suitablefor these payments. The study reported thatcare coordinators overcame initial ambivalenceabout using direct payments as they foundthey were able to use a range of skills including


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advocacy, partnership working and facilitatingempowerment, to increase access to direct

payments.53 Nevertheless, there are gaps in thecurrent evidence and research on self-directedcare and direct payments. Little is known, forexample, about why some people elect not toseek direct payments, nor whether the use ofdirect payments has any significant impact onreducing episodes of mental ill health, or leads toany reduction in the need for services.54

Social workers have an important role, especiallywith marginalised groups, in supporting useradvocacy networks to promote the recognitionof their interests and perceptions of service.Studies have shown their contribution in workingwith people who use services from black andminority ethnic communities, with womenwho have experienced domestic violence, withrefugees, and with people in isolated ruralareas.55,56,40,57 These interventions focused onaccess to advocacy services, counselling andgroup work and highlighted the importance ofmutual support and assistance.

Vulnerable groups children andyoung people

The importance of challenging traditionalseparations between adult and child serviceshas been noted.58,59 One exploratory studyon infant mental health problems found thatmany mental health professionals, includingsocial workers, were reluctant to recognise thepossibility of such early difficulties and tendedinstead to see them as indicative of parentalbehaviour.60 The needs of children and young

people who play a vital role in caring for a parentor parents with mental health problems may

also be neglected42,61 and social workers have animportant role in mediating and liaising betweenprofessionals, and with families and children.42

It has been suggested that those children andyoung people who have been caring for aparent for some time, are themselves at risk ofdeveloping mental health problems and shouldreceive intervention from social workers.58Disruption to parenting capacity has been foundto have profound and persistent implications

for children and their parents.59 Because ahistory of childhood mental health problemsmay be a high risk factor for developing adultmental health problems,62 there is a need forbetter coordination between services as youngpeople make the transition to adulthood.Research indicates, however, that transferringfrom CAMHS to adult services is problematicfor young people, often resulting in multiplereferrals to a range of different agencies.16Service responses for black and minority ethnic

children and young people have also been foundto be inadequate, and deficiencies have beenreported in the availability of services for olderadolescents or young adults with mentalhealth difficulties.31,61

Vulnerable groups older people

Older people may enter later life with anenduring mental illness or may develop mentalhealth problems in old age. Unfortunately there

is little research into how potential risk factorsin later life, such as social inequalities, operate.


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There are many causes of mental distress inolder people, and biomedical perspectives on

ageing should not exclude the contribution ofpsycho-social and structural perspectives. Thereis, moreover, an absence of research which looksat the whole course of peoples lives in terms ofmental health and older age.63 Consequently,there is no comprehensive evidence base forproactive and preventive mental health andpromotion for older people.63 The NationalService Framework for Older People64 identifiedthe need for fully-resourced specialist mentalhealth services for older people to be in place

by 2011, but developing a workforce capable ofresponding to older people with complex needsand eradicating age-related discrimination areconsiderable challenges.65

There is evidence of unmet needs amongstolder people, especially those living in ruralareas where isolation and loneliness may besignificant factors.66 Depression in older people,for example, is a significant mental health issue67but it is often undetected and interventionsfor older people are poorly developed, rarelyincluding therapeutic interventions such ascounselling and cognitive behavioural therapies.7There is evidence that active treatment ofdepression in older people in residential care,based on a mix of social and health care goals,can lead to a significant improvement, especiallyfor those with pronounced depression.68Traditional social work skills, however, such asactive and empathetic listening and helpingolder people to manage change can also makea significant contribution to their wellbeing.69Achieving a balance between ensuring an olderperson retains a sense of autonomy and control,and helping them accept support is identified asa key social work skill.69 Depression and otherforms of mental distress are also risk factorsfor suicide amongst older people, and while a

relatively small number of older people attemptor succeed in suicide, it is thought that this

might be the tip of the iceberg for the existenceof under-detected psychological, physical, socialand health problems.70

Vulnerable groups people from blackand minority ethnic communities

Some black and minority ethnic groups havehigher rates of hospital admission, compulsorydetention, and interventions including seclusion,than the general population. The reasons for

these differences are not fully understood71but the greater risk of mental health problemsmay partly be due to social inequality, stressand marginalisation, while treatment andservices based on inappropriate assumptionsand prejudicial stereotypes can also play a part.These disparities have become a key focuswithin mental health planning and research.72 Ithas been suggested that national initiatives toimprove treatment across different social groupsare unlikely to be successful without a better

understanding of the decision-making processesthat apparently lead to these more intrusive andcoercive outcomes.61

There is evidence that people from black andminority ethnic communities may be reluctant toseek help from mental health services and maydelay an approach until a situation has reachedcrisis point.18 Black and minority ethnic peoplewho use services and their carers frequentlyexpress dissatisfaction with mainstream services

which they often perceive as misunderstandingor misrepresenting their situation.71 Servicescan be improved by raising the participation andprofile of black and minority user and advocacygroups in service planning and development.37For example, Hillingdon MIND have developed arange of services for Asians with mental health


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problems, such as befriending schemes, drop-incentres, and groups for women with anxiety

and depression, initiatives which demonstratethe value of working in partnership with thelocal community.

Vulnerable groups asylum seekersand refugees

Asylum seekers and refugees also appear to bemore vulnerable to mental distress than thegeneral population, often, it is thought, becauseof the experiences that led them to seek asylum,

but also because of their uncertain and marginalstatus within the UK. Asylum seekers are likelyto experience considerable uncertainty, severelycurtailed resources, difficulties in accessingservices and significant financial hardship.73Two-thirds of refugees have experienced anxietyor depression, compounded by experiences ofsocial isolation, poverty, racism and languagedifficulties.74 Research into the circumstances ofchildren who are asylum seekers has concludedthat a failure to understand their often complex

backgrounds and experiences can lead to poortake-up of services, inappropriate interventions,and loss of engagement with services.62 TheRefugee Council15 has recommended that socialworkers and other mental health workers receiveappropriate training to help them developculturally appropriate responses, and betterunderstand asylum seekers rights within mentalhealth and health services. Access to appropriatelanguage services can be a crucial factor inpromoting access to mental health services,75

though a survey of the general provision oflanguage services within local authoritiesand larger voluntary sector agencies showedconsiderable variability in the local availability ofinterpretation and translation.76

Detention, compulsion and concernsabout risk

An extensive study of people assessed by ASWsunder the 1983 Mental Health Act analysedsome 14,000 assessments over a nine-yearperiod and found that 73 per cent of theseresulted in detention in hospital.77 Overall, theseindividuals were less likely to be homeownersor in employment. In the early years of thestudy the proportion of women had exceededmen, but this had shifted so that younger menunder the age of 40 years were most likely to be

assessed and detained. These men were morelikely to be single and to have other problemswith alcohol and drug misuse. The reasons forthis shift are not known, but it may be that theincreased focus on public protection in recent

years has influenced perceptions. This possibilityis supported by the fact that the identificationof risk of harm to others had increased from48 per cent to 57 per cent of cases in the period2000 to 2004. The study also found an over-representation of people of African-Caribbean

origin being assessed in one local authority: 15per cent compared to less than three per cent inthe local population. The proportion of peoplealready known to mental health services at thepoint of assessment was 64 per cent, and nearlyhalf of those assessed were already receivingservices under the Care Programme Approach.In 48 per cent of cases, applications were fordetention for treatment for a period of up tosix months.

Concerns about the role of social workers indecisions about compulsory treatment outside ofhospital have arisen in a number of studies,78,79and reviews of the use of community treatmentorders in other countries question whether they


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produce better outcomes.80,81 The professionaldilemma being, how best to balance the need

for protection and care and uphold the civilrights of individuals when they appear to lackthe capacity to make informed decisions abouttreatment? A review of practice in Australia,Canada and the UK indicated that professionalguidance remained patchy and unsatisfactory.78User views from the small studies that havebeen conducted have found mixed feelings aboutcompulsory treatment in the community.82,79

There are concerns too about how social workersmake judgements about risk. In particular,concerns about the ways in which black menwith mental health problems may be perceivedas dangerous,83,84 and how gender assumptionsmay influence social workers assessments.While both male and female social workers aremore likely to judge male clients as risky, forexample, on the basis of potential harm to otherpeople, female social workers not only judgemore clients to be risky, but are also more likelyto identify female clients as high risk on thebasis of harm to themselves or impaired capacityto care for their children.84 Concerns about theeffectiveness of risk assessment procedures,poor record keeping and inaccurate transmissionof information about risks, and the potentialfor abuse of patients rights have also beennoted,85 as well as concerns about subjectivity inassessments of mental capacity.86,87

Best practice guidance in risk assessment88attempts to address these concerns byhighlighting the importance of positive riskmanagement as a required competence forall mental health practitioners. The guidancesuggests that positive risk assessmentis best undertaken by multi-agency andmultidisciplinary teams working collaborativelywithin an open and transparent culture,

grounded in reflective practice and using avalue base which recognises the importance

of the involvement of people using servicesand carers, as far as that is possible. Researchabout people who use mental health servicesand their involvement in risk assessment andmanagement89 found that user involvementwas variable and dependent upon the individualprofessionals decisions. While people who useservices often had some influence on the type ofsupport they received, the research found thattheir choice was typically limited to acceptingor rejecting services. This study recommended

developing formats for assessing and managingrisk that as a matter of course incorporated theviews and wishes of people using services, andstressed the importance of an holistic approachas a means of developing more appropriate riskmanagement strategies with individuals attheir centre.

User-led research and involvement

It is now increasingly accepted that an approachbased on a medical model, uncritically assumingthe superiority of ways of producing knowledgethrough randomised control groups andquantitative methods, is not always appropriate.Research methods should be appropriate to theproblems or research questions at hand andshould include the needs and concerns of peoplewho use services, their carers, and the widermental health community.2

User-led research understands that people whouse services and their carers are experts on theirown situations, and that research strategiesshould harness their active participation in theirown recovery.90 The Mental Health Foundationuser-led research, Strategies for Living,91identified the strategies and resources that werefound to be most helpful for living and coping


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with mental distress. In particular, it highlightedthe value placed on shared experience and

identity; having emotional support; feelingvalued and having a reason for living; takingcontrol and having choices; feeling safe andsecure; and being able to do things for fun andpleasure. Although the active involvement ofpeople who use mental health services in thedevelopment of those services is a formal aim ofmost service providers, this has been criticised asoften unproductive and tokenistic.3

Workforce issuesA large survey of mental health social workersfound high levels of stress arising from overwork,vacant posts, a lack of access to service resourcesand the pressures of constant change andreorganisation.92 It also noted, however, thatsocial workers positively rated direct contactwith people who use services, appreciatedthe support of colleagues and being valuedby their managers. Nonetheless, there are

some persistent workforce problems, includingprofessional isolation and a lack of supervisionand resources for some social workers.21 It hasbeen recognised that the numbers of mentalhealth social workers will need to be maintainedif integrated services are to remain genuinelymultidisciplinary in nature.93

Implications from theresearch

For organisationsSocial workers in the mental health sector needeffective leadership and governance in orderto be confident in their skills, knowledge andvalues,21 and contribute effectively to integratedmental health teams.39 There is evidence thatpeople who use services value some of the more

traditional contributions that social workers canmake in helping them, and integrated services

in multi-agency settings should recognisethis.23,93 Sustaining good mental health andsupporting those with problems is a complexand multifaceted task that involves social,political and economic issues as well as medicalfactors. Accordingly, the role of social workerswill overlap with other professions in helpingpeople to access stable and safe accommodation,education, training, and suitable employment,for example. In some areas the process of serviceintegration continues as Mental Health Trustsapply for Foundation status. Concerns have beennoted, however, that this process places a verylimited emphasis on partnership working, socialinclusion and the social care agenda,94 thoughthe participation of people who use servicesshould be fundamental to the modernisation ofthe mental health sector.

The challenge for social service organisations,at a time of great change in the sector, is tomaintain and preserve the existing skills basewhile providing opportunities for appropriatetraining and further develop the capacity of theworkforce. In order that informed judgementsmay be made about the merits of availableresearch, organisations need to develop theirown capacity for evaluating their services andextend their critical skills for the appraisalof research. Organisations with statutoryresponsibilities under the Mental Health Actwill have to ensure that the independence of

the AMHP role is not compromised and alsoestablish appropriate training and approvalprocesses so that wider social considerations ofcontext and culture are not neglected in suchassessments.95,23 The social work role itself couldalso be developed to include a wider range ofresponsibilities and be developed into a specialistcareer pathway,23 but this would require that


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social workers have access to reliableongoing professional development, supervision

and support.21

Social service organisations need to developmore effective ways of working with vulnerablegroups and ensure that broader perspectives onneed and user context are not overlooked.62,16For instance, they need to ensure that theycoordinate their efforts to support childrenand young people and their families, and tryto minimise the disruption to parenting thatcan occur when there are changes in a parents

mental health. The considerable misgivingsthat some sections of the community have inseeking help must be addressed in several ways.Social service organisations need to developbetter knowledge of and better links with localminorities, develop and recruit a more culturallyaware and representative workforce, and ensurethat people likely to use services from linguisticminorities can gain access to appropriate helpand support. It is imperative that people fromblack and minority ethnic groups have equalaccess to strategies and interventions thatwill preserve their independence and choice,and which are offered in a culturallyappropriate way.61,96

For the policy community

Policy makers should recognise that people whouse services value some forms of social workservice and that while existing legislation andregulation provide a potentially sound basis

for the delivery of integrated services, theywill need to be clear about the contributionof social work when contemplating furtherchanges. Considerable work remains to bedone to enable integrated services to achieve

significant change in challenging the inequality,oppression and stigma that people with mental

health difficulties face, and in providing equalaccess for all people regardless of their age,culture, or complexity of need. Mental healthsocial work is in a strong position to championthis work, but it will require strong leadershipand good links to local authority adult socialservices departments to implement policyinitiatives equitably across all adult care groups.For instance, direct payments are one crucialway of creating opportunities for choice,individual control and independence. Research

has indicated, however, that policy makers andpractitioners need to address the complexitiesassociated with fluctuating mental health andcapacity as these will have implications for theways in which direct payments are used and thedegree of flexibility required.96 As understandingof self-directed services and the move towardsthe personalisation of social services develops,policy makers will not only have to try to ensurethat the principles and values of the independentliving movement are sustained, but will also befaced with some difficult choices about whetherand how to sustain existing provisions forthose people who do not opt for directpersonal control.

For practitioners

Research so far undertaken indicates theimportance of maintaining a broad base ofprofessional skills in a range of methods ofintervention and support. Generally, the most

pressing challenges to social workers will beto respond effectively to the shift in serviceprovision towards self-directed and personalisedservices, and to develop the skills required forworking in integrated teams where there are


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overlapping responsibilities and expectations.23For example, social workers may need to have

improved access to therapeutic training, suchas cognitive behavioural therapy and psycho-social interventions.4 Developing the skills andknowledge to support individuals in accessingand commissioning personalised services mayrequire mental health social workers to adoptand adapt what has been learned in other adultsocial services. Recent developments in thepost-qualifying framework for social workeducation and training in mental health willprovide a valuable opportunity to develop

specialist knowledge and practice skills, whilesupporting the development of the proposednew career pathway.97,23

Social workers need to play their part in ensuringthat their contribution to the welfare of peoplewho use services is recognised, but the socialwork contribution to the mental health researchknowledge base remains minimal.98,98 Indeed, theNew ways of working initiative has identifiedit as an area for future development of the

workforce.23 The development of researchcapacity faces some hurdles, such as a lack ofacceptance of the need for a research-mindedworkforce, and the risk of social perspectivesbecoming subjugated in the interests ofintegration.28 Nevertheless, social workers arewell placed to work in partnership with peoplewho use mental health services to developservice evaluation, and undertake research whichcan challenge traditional power arrangementsand promote change.90,39,3 Finally, it has beennoted that the changing occupational locationof social workers in regard to health services willprovide them with opportunities to advocate

with and for people who use services when theydirectly witness inadequacies in in-patient care.75

For users and carers

People who use services and carers have a vitalrole in promoting and developing the knowledgeand research base. The gains that people who usemental health services have achieved in termsof, for example, highlighting the importanceof direct payments and individual budgets isevident. While considerable improvementshave been made in building user representation

into all areas of service development, effectiveparticipation is by no means guaranteed.3 Ifuser-led research and user-commissionedresearch is to develop it will need to besupported by appropriate training in researchskills and in the critical appraisal of research andfunding proposals. For instance, the participationof user groups and their representatives inlocal research governance review processes isone way in which such knowledge and skillsmay be developed. People using serviceswho are particularly at risk of exclusion fromparticipation, because their needs are deemedtoo complex, or due to oppressive practices,also need to be included. This will requirethe continuing development of researchmethods and practices that are sensitive tothis diversity. Furthermore, some existingresearch has highlighted the importance ofensuring that the aims and philosophy of theindependence movement are not diluted byprofessional interests, as well as ensuring thatthese developments are not used as a means ofmonitoring or managing people who use mentalhealth services. 61,96


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Useful links

Care Services Improvement Partnership (CSIP) supports positive changes in services and in thewellbeing of vulnerable people with health andsocial care needs.www.csip.org.uk

Department of Health (DoH)www.dh.gov.uk

Depression Alliance provides information andsupport services to those affected by depression

through publications, supporter services andnetwork of self-help groups. A user-focusedorganisation with offices in England and a sistercharity in Scotland.www.depressionalliance.org

Joseph Rowntree Foundation (JRF) charitysupporting research on social issues.www.jrf.org.uk

Mental Health Foundation leading charity

that provides information, carries out research,campaigns and works to improve services foranyone affected by mental health problems.www.mentalhealth.org.uk

MIND the leading mental health charityin England and Wales providing a varietyof services including publications and aconfidential information line for users,carers and practitioners.www.mind.org.uk

National Centre for Independent Living asupport, advice and consultancy organisationthat aims to enable disabled people to be equalcitizens with choice, control, rights and fulleconomic, social and cultural lives. The website

provides information on independent living,direct payments and individual budgets.

www.ncil.org.uk

National Institute for Mental Health isresponsible for supporting the implementationof positive change in mental health and mentalhealth services.www.nimhe.csip.org.uk

Refugee Council the largest organisation in theUK working with asylum seekers and refugees.www.refugeecouncil.org.uk

Sainsbury Centre for Mental Health worksto improve the quality of life for people withmental health problems, through research,policy work and analysis to improve practiceand influence policy in mental health as well aspublic services.www.scmh.org.uk

SANE a charity concerned with improving thelives of everyone affected by mental illness.

www.sane.org.uk

Shaping Our Lives is a broad network ofpeople who use services promoting userperspectives, involvement in service planningand development, and the sharing of informationbetween different user groups.www.shapingourlives.org.uk

Social Perspectives Network (SPN) based atthe Social Care Institute for Excellencein London,

SPN is a coalition of people who use services,survivors, carers, policy makers, academics,students, and practitioners looking at mentalhealth from a social perspective. SPN also seeksto promote the importance of social care andsocial work. Free membership and e-newsletterat www.spn.org.uk


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Related SCIE publications

Research briefing 03: Aiding communication withpeople with dementia (2004)

Research briefing 04: Transition of young peoplewith physical disabilities or chronic illnesses fromchildrens to adults services (2004)

Research briefing 11: The health and wellbeing ofyoung carers (2005)

Research briefing 12: Involving older peopleand their carers in after-hospital care

decisions (2005)

Research briefing 16: Deliberate self-harm (DSH)among children and adolescents: who is at risk

and how is it recognised (2005)

Research briefing 17: Therapies and approachesfor helping children and adolescents whodeliberately self-harm (DSH) (2005)

Research briefing 20: Choice, control andindividual budgets: emerging themes (2007)


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Acknowledgements

The Keele Editorial Board: Prof. Peter Jones (ProVice-Chancellor, Research and Enterprise, KeeleUniversity); Tom Owen (Research Manager,Policy, Help the Aged); Dr Sara Scott (DMSSConsultants) and Prof. Nick Gould (Professor ofSocial Work, Department of Social and Policy

Sciences, University of Bath). The Keele SteeringGroup: Prof. Richard Pugh (project coordinator

and Professor of Social Work); Prof. MiriamBernard (Director, Keele Research Institutefor Life Course Studies and Professor of SocialGerontology) and Prof. Steve Cropper (Director,Keele Research Institute for Public Policy andManagement and Professor of Management).


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About SCIE research briefingsThis is one of a series of SCIE research briefings that has been compiled by Keele University forSCIE. SCIE research briefings provide a concise summary of recent research into a particular topicand signpost routes to further information. They are designed to provide research evidence in anaccessible format to a varied audience, including health and social care practitioners, students,managers and policy-makers. They have been undertaken using the methodology developed byKeele in consultation with SCIE, which is available at www.scie.org.uk/publications/briefings/methodology.asp The information upon which the briefings are based is drawn from relevantelectronic bases, journals and texts, and where appropriate, from alternative sources, such asinspection reports and annual reviews as identified by the authors. The briefings do not provide adefinitive statement of all evidence on a particular issue.

SCIE research briefings are designed to be used online, with links to documents and otherorganisations websites. To access this research briefing in full, and to find other publications, visitwww.scie.org.uk/publications


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Social CareInstitute for ExcellenceGoldings House2 Hays LaneLondonSE1 2HB

tel: 020 7089 6840fax: 020 7089 6841textphone: 020 7089 6893www.scie.org.uk

Registered charity no. 1092778 Company registration no. 4289790

Preventing falls in care homes

Access to primary care services for peoplewith learning disabilities

Communicating with people with dementia

The transition of young people withphysical disabilities or chronic illnessesfrom childrens to adults services

Respite care for children with learning

disabilitiesParenting capacity and substance misuse

Assessing and diagnosing attention deficithyperactivity disorder (ADHD)

Treating attention deficit hyperactivitydisorder (ADHD)

Preventing teenage pregnancy inlooked-after children

Terminal care in care homes

The health and well-being of young carers

Involving older people and their carers inafter-hospital care decisions

Helping parents with a physical or sensoryimpairment in their role as parents

Helping parents with learning disabilities intheir role as parents

Helping older people to take prescribed

medication in their own homes

Deliberate self-harm (DSH) amongchildren and adolescents: who is at riskand how it is recognised

Therapies and approaches for helpingchildren and adolescents who deliberatelyself-harm (DSH)

Fathering a child with disabilities: issuesand guidance

The impact of environmental housing

conditions on the health and well-beingof children

Choice, control and individual budgets:emerging themes

Identification of deafblind dual sensoryimpairment in older people

Obstacles to using and providing ruralsocial care

Stress and resilience factors in parents

with mental health problems and theirchildren

Experiences of children and young peoplecaring for a parent with a mental healthproblem

Childrens and young peoplesexperiences of domestic violenceinvolving adults in a parenting role


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