Fields of Social Work Practice 2 Social Work in Mental Health

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Fields of Social Work Practice 2 Social Work in Mental Health University of Melbourne Bachelor of Social Work
19th May, 2006
Recovery is a term increasingly used in the mental health field. Discuss its origins and the nature of this concept, and its implications for social work practice.

Social workers have a long history of involvement in the provision of services for people with a diagnosed mental health issue. Working predominantly within the framework of a medical model, many criticisms have been made on the effectiveness and limited scope of treatment options and the conflicts with a

number of central social work values. This paper will explore the idea of recovery as an alternative framework that conceptualises the experience and outlook of people experiencing mental health issues from a perspective which is more closely aligned to the values of social work practice. A brief review of the origins of recovery in mental health will be given followed by a discussion exploring the concept and definitions of recovery. Finally the implications of recovery for social work practice will be considered.

Origins of recovery
In the past an accepted prognosis for an individual diagnosed as having a mental health issue was that they would remain a burden on society, needing to be cared for, rather than encouraged to become independent, contributing members of society (Ralph and Muskie, 2000; McGrath and Jarrett, 2004; Turner-Crowson and Wallcraft, 2002). In the last few decades, however, there are signs of greater appreciation for the potential of those considered to have a severe mental health issues. This has happened partly as a result of a growing consumer empowerment movement in the United Kingdom, America, Australia and some other countries. People labeled as having severe mental health issues have formed influential local and national organisations, are advocating for more empowering services, and are helping to shape both services and research (Turner-Crowson and Wallcraft, 2002).

It has been argued that the recovery vision was given sight in the aftermath of the era of deinstitutionalization (Anthony, 1993). Anthony (1993, pg.521) suggest that the failures in the implementation of the policy of deinstitutionalization confronted us with the fact that a person with severe mental illness wants and needs more than just symptom relief. In the early 1980s, the term recovery rarely appeared in mental health related articles or papers. In the late 1980s and early 1990s, the word recovery was introduced by individuals with an experience of mental health issues, identifying

themselves as consumer/survivors. These individuals gave voice to the recovery vision by publishing accounts of their own experience in professional journals (Deegan, 1988; Lovejoy, 1984; Leete, 1989).

Such articles showed how some patients originally considered by mental health professionals to have a poor prognosis were overcoming many of their difficulties and discovering ways to live satisfying and contributing lives, despite their diagnosis. At the same time, it was also becoming apparent in the self-help and consumer movements that many people earlier considered to have severe and disabling mental illnesses were becoming leaders and examples for others (Turner-Crowson and Wallcraft, 2002)

Motivated by such writings and experiences, the rehabilitation research and training centre at Boston University started collaborating with various consumer/survivors to develop the concept of recovery. By the early 1990s, the centres director, William Anthony (1993), began urging that the idea of facilitating recovery be adopted as the guiding vision for mental health services and research, on an equal standing with preventing mental illness, and providing effective treatment and care (Turner-Crowson and Wallcraft, 2002, pg. 245).

This guiding vision has been adopted, and consumer/survivors, professionals, and researchers have begun to explore the process of recovery and define the recovery paradigm (Carpenter, 2002). As a result both services and research have been reoriented towards recovery as opposed to severe or long-term mental illness (Anthony, 1993). During the 1990s, the implications of a recovery vision have been extensively debated by the various stakeholder groups. In fact, the recovery vision has become so influential in America that the Surgeon General (1999) in a report on mental health has urged all mental health systems to adopt a recovery orientation (Turner-Crowson and Wallcraft, 2002). Recently, the recovery vision has attracted considerable interest in Australia, and

it is now government policy to include consumer participation in all levels of mental health service provision (McGrath and Jarrett, 2004, pg. 62). Today the paradigm continues to evolve, but a number of central beliefs, values, and concepts are common to most of the recovery literature.

What is Recovery
The recovery paradigm is built upon the belief that individuals with a psychiatric disability can and do recover. This belief is a challenge to the prognosis that individuals can expect less from a life affected by an experience of mental health issues. Carpenter (2002, pg. 4) states that the recovery paradigm springs from dissatisfaction with the medical model's declaration of symptom relief as the primary and ultimate goal of mental health services. The vision describes a life beyond psychiatric diagnosis that is both vital and valuable, whether or not symptom relief is ever achieved. In any discussion on the concept of recovery it is important to consider that many individuals with an experience of mental health issues do not believe that the word recovery fully describes the journey through mental illness or the results of the journey. Many individuals whose lives have been interrupted by an experience of mental health issues state that they have gone beyond where they were when the illness struck (Ralph and Muskie, 2001, pg. 9). Many have started or continued their education, begun new careers or reached new heights in their existing careers. Caras (cited in Ralph and Muskie, 2001, pg. 9) supports this view stating
I am not recovered. There is no repeating, regaining, restoring, recapturing, recuperating, retrieving. There was not a convalescence. I am not complete. What I am is changing and growing and integrating and learning to be myself. What there is, is motion, less pain, and a higher portion of time well-lived.

Acknowledging this any use of the term recovery within this paper will look beyond the implication that something was once broken and then was fixed to a broader more holistic definition suggesting a dynamic and ever-evolving process

of personal growth and transformation. Walsh (cited in Onken et al, 2002) suggests that the term recovery is a multifaceted concept with an overarching belief that persons with a mental illness and varying severity of disability can and do restore and/or generate to full human capacity. Onken et al (2002, pg 69) proposes that recovery is a product of dynamic interaction among characteristics of the individual (the self/the whole person, hope/sense of meaning/purpose), characteristics of the environment (basic material resources, social relationships, meaningful activities, peer support, formal services), and the characteristics of the exchange.

While recovery is a deeply personal journey, there are many commonalities in peoples experiences. As stated above recovery is facilitated or impeded through the dynamic interplay of many forces that are linked. In a review of recovery literature, Ralph and Muskie (2001, pg 11) identified the following four dimensions of recovery found in personal accounts: internal factors: factors that are within the consumer, such as awareness of the toll the illness has taken, recognition of the need to change, insight as to how this change can begin, and the determination it takes to recover; self-managed care: an extension of the internal factors in which consumers describe how they manage their own mental health and how they cope with the difficulties and barriers they face; external factors: include interconnectedness with others, the supports provided by family, friends, and professionals, and having people who believe that they can cope with, and recover from, their mental illness; and empowerment: a combination of internal and external factorswhere internal strengths are combined with interconnectedness to provide selfhelp and caring about what happens to ourselves and to others. As with psychosocial rehabilitation, basic material resourcesan adequate income, safe and stable housing, healthcare, transportation, a means of communication contribute in the journey towards recovery. Onken et al (2002,

pg 72) states that when basic material needs are met in a stable and reliable fashion, a sense of safety is created. the establishment of safety is the starting point for healing.

Along with basic material needs is the need for the opportunities and supports necessary to engage in the responsibilities and benefits of community membership. Recovery involves a social dimension, experiencing social relationships and being connected through families, friends, and peers, etc in mutually supportive and beneficial ways. Supportive and accepting personal and social relationships contribute to the recovery journey (Onken et al, 2002).

A diagnosis of mental illness and the experience of psychiatric disability can have devastating effects on self-esteem, identity, and personhood. Central to the recovery process is an opportunity to reconstruct, or in some instances construct for the first time, a strong and mature sense of self (Everett et al, 2003).

In a study conducted by Onken et al (2002, pg 69) participants talked about the internal sense of self, inner strivings and their whole being (physical, emotional, mental, and spiritual) as affected by and affecting the recovery process. Participants also described how developing a sense of meaning, purpose and spirituality as well as having goals, options, peers, friends, optimism, and positive personal experiences support recovery (Onken et al, 2002).

Self in relation to spirit, whether defined from a religious, cultural, or secular perspective can help to support recovery. Although interventions in this area may be contentious, more basic interventions such as art and music therapy work towards the development of an individuals spirit. Everett et al (2003, pg 30) support the promotion of spiritual development stating that celebration of the spiritual side of life can occur on many levels and is best supported as part of life and not as a service.

Peer support is also an essential component of recovery, that helps promote the development of self. Individuals benefit from sharing their experiences and coping strategies with others who have had similar experiences. Within peer support groups, all participants have value and all experience is considered valuable. This creates a foundation for building self-esteem and for counteracting the marginalisation associated with a diagnosis of mental illness (Everett et al, 2003)

To promote recovery, literature on recovery should be made available, since this can inform and inspire individuals, families and support workers. The recovery approach offers fresh ways of viewing ones situation, and clearly the choice of how to view ones predicament is fundamental to the development of self. People interested in the recovery approach should be encouraged to explore the idea of recovery through self or group study. This could include transforming part of the service system into an educational experience for service users. In doing this service users become students, and as students they learn how to recover (Hennessy, 2004). The basic premise is role transformation. Hennessy (2004, pg 16) states that .in this system, the consumers become students, and this helps people jump into recovery because being a student is a valued social role.

Self determination and choice are both important elements of empowerment. Empowerment could be loosely defined as people gaining power and control over their lives through access to meaningful choices and the resources to implement those choices (Everett et al, 2003). Individuals are empowered when they are able to make choices regarding where they live, housing, finances, employment, personal living/daily routine, disclosure, who they associate with, self management and treatment (Onken et al, 2002; Everett et al, 2003). For this to occur however Onken et al (2002, pg 9) argues that meaningful options must exist and people must have training and support in making choices, and the freedom to take risks and fail.

A desired outcome for individuals in the development of self and empowerment is the development of a strong sense of self. Through the process of recovery, Everett et al (2003) suggests tat these stronger selves will begin to rely less on professional help and demonstrate improved judgment expressed by a capacity to manage the symptoms of their illness, keep themselves safe, and make healthier life choices. For recovery to occur, people need to make choices and to experience the consequences of these choices.

Social work implications

Social workers undergo a variety of social science training, encompassing a wide range of theoretical perspectives and methods of intervention, underpinned by participative approaches, anti-oppressive practice and the principles of social inclusion. This knowledge informs the contribution that social workers make to mental health services that could be considered consistent with the concept of recovery (Gilbert, 2003).

The consistency between the concept of recovery and social work values may be illustrated through an examination of Social Works guiding principles, the AASW Code of Ethics (1999). Core principles of recovery supported by social work values include self-determination, worth of the individual, the strengths perspective and empowerment.

It could also be argued that mental health social workers have a number of inherent strengths within their practice that contribute to the vision of recovery (Gilbert, 2003), some of these strengths include: An emphasis on the preferences and choices of service users and carers grounded within anti-oppressive practice Working in partnership with service users and carers towards meaningful change Strong advocates for the social model of disability, the social inclusion agenda and the strengths approach social workers work with people

within the context of their families and wider communities to promote inclusion Initiatives which actively promote service user and carer involvement in consultation and service planning and service evaluation Positive record on anti-discriminatory services, promoting the needs of ethnic minority communities and disabled people The AASW (1999, pg. 5) identifies the following as activities that constitute social work practice: engaging in interpersonal practice, group work, advocacy, community work and social action to address both personal difficulties and public issues undertaking research, social policy development, administration,

management, consultancy, education, training, supervision and evaluation to further human well-being and social development.

The literature regarding the recovery paradigm suggests basic values, assumptions, and guidelines for a number of these activities associated with social work practice. Social workers can support the recovery process by providing an environment that is rich with what Anthony (1993) termed recovery triggers. The most important of these triggers is the information that many people with psychiatric disabilities do recover. Social workers should disseminate this information to all clients who have psychiatric disabilities. A second related trigger is the provision of accurate and thorough information regarding services and treatment options. Only through such information can the consumer begin to exercise self-determination and choice. It follows that the practitioner also must offer a variety of services so that the consumer has the opportunity to exercise choice. Acknowledging this, no matter how varied the services offered recovery is unlikely to happen through the mental health system alone. Social workers can also support consumers to engage with the wider community, provide support to access and participate in other community settings, such as educational

institutions, pre-vocational agencies, community groups wanting volunteers, employment agencies, recreation and sporting groups, etc (Pinches, 2000).

Another critical aspect of support is the need for positive helping relationships based on partnership or a therapeutic alliance. Onken et al (2002, pg 59) suggests that people do not want to interact with neutral detached helpers, nor do they want to meet a new professional or paraprofessional each time they seek help. they want to have people care for them and listen to them and empower them. Respect in this relationship is essential, as is the actualisation of the individual through self-determination and choice (Onken et al, 2002). The recovery paradigm has implications for all aspects and levels of mental health systems (Anthony, 1993). Social workers can advocate for recoverysupporting policy change throughout their local system. Consumer/survivor involvement at all levels of the services system is also essential. Some states have worked toward this by opening consumer positions within the mental health service system.

As already mentioned social work training encompasses a wide range of theoretical perspectives and methods of intervention. To build on this mental health work should be an integral part of all social work education, reflecting social works commitment to a holistic approach to the individual, families and communities. Curriculums should reflect the idea that recovery can and does occur and that individuals experiencing issues with their mental health are the agents of their own recovery. Carpenter (2002, pg. 9) suggests that students should be encouraged to think critically about their own assumptions about the nature of psychiatric disability, as well as the attitudes reflected by the services system, policymakers, and the public. Finally, social work educators should incorporate consumer-survivor perspectives into their courses through the use of assigned readings written by consumers and guest lectures by consumers (Carpenter, 2002).

Conclusion
The concept of recovery challenges the medical model and the negative prognosis often given to individual experiencing issues with their mental health. The recovery vision supports the idea that people can and do recover and that people are able to live a life that is both vital and valuable, whether or not symptom relief is ever achieved. Social work is well situated within the mental health service system to both support this vision and to develop within it. Social workers through their training and guided by the AASW code of ethics are wellsuited to the tasks of answering the mandates of the recovery paradigm: supporting self determination, individual worth and empowerment, advocating for meaningful system change at all levels; and working toward community change that will help to facilitate the recovery of people with psychiatric disabilities.

References Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation Journal.

Australian Association of Social Workers (1999). AASW Code of Ethics. Canberra: Australian Association of Social Workers. Carpenter, J. (2002). Mental Health Recovery Paradigm. Health & Social Work, 27(2) Everett, B., Adams, B., Johnson, J., Kurzawa, G., Quigley, M., Wright, M. and Pape, B. (2003) Recovery rediscovered: Implications for mental health policy. Canadian Mental Health Association, Canada. Gilbert, P. (2003) The Value of Everything. Russell House Publishing UK. Hennessy, R. (2004) Focus on the States: Implementing Recovery-based Care from East to West in NASMHPD/NTAC ed., Implementing Recovery-based Care: Tangible Guidance for SMHAs. e-Report on Recovery. McGrath, P. & Jarrett, V. (2004) A slab over my head: Recovery Insights from a Consumers Perspective. International Journal of Psychosocial Rehabilitation, 9(1), 61-78 Onken, S. J., Dumont, J. M., Ridgway, P., Dornan, D. H. and Ruth O. Ralph, R. O. (2002) Mental Health Recovery: What Helps and What Hinders? Prepared for: National Technical Assistance Center for State Mental Health Planning (NTAC), National Association for State Mental Health Program Directors (NASMHPD) Pinches, A. (2000) Revisiting the 15 psychosocial rehabilitation principles: some consumer - focused pathways to the future. VICSERV conference, 2000. http://www.alphalink.com.au/~alpin/principles.htm Ralph, R. and Muskie, E. (2000). A Synthesis of a Sample of Recovery Literature. Prepared for: National Technical Assistance Center for State Mental Health Planning (NTAC), National Association for State Mental Health Program Directors (NASMHPD) Turner-Crowson, J., and Wallcraft J. (2002). The Recovery Vision for Mental Health Services and Research: A British Perspective. Psychiatric Rhabilitation Journal, 25(3).