Going Social: Championing a holistic model of mental distress within professional education
Article to be published in Social Work Education Vol 21(2), April 2002
Within the context of current debates as to how to raise the profile of social perspectives within mental health social work education, this Paper seeks to assemble various of the elements that might belong within a social (or psychosocial) model of mental health practice. A clarification of what may actually be meant by a social model would be helpful in starting to set the parameters of future social work curricula, both at qualification and post-qualification levels, in terms of an appropriate value base and theoretical orientation. This may be seen to be important if social workers are to be properly prepared for taking on some form of leadership around the promotion of social approaches within the practice of multi-disciplinary teams.
In recent years, despite a growing interest in alternative approaches within mental health, social work education has yet to clarify the parameters of what may be meant by a social (or psychosocial) model of mental distress. The domination of biomedical approaches to mental health has so far offered little space for the articulation of more holistic alternatives. Within interdisciplinary contexts, there has been a tendency to conflate a social perspective (and social work) with just the practical issues that may impact on a person’s life, such as benefits and housing – and this conflation may still be found in the recent framework that has been proposed for education and training in mental health across disciplines (Sainsbury Centre, 2000).
There is so far little evidence that a primary reliance on biomedical strategies for working with people with mental distress has been successful in terms of promoting longer term recovery, as, for example, rates of recovery from schizophrenia (defined in terms of remission of symptomatology) have not improved significantly over the last fifty years, during a time of rapid medical advance (Sargent, 1966; Harding et al, 1987; Harding and Zahnister, 1994). From long term longitudinal studies undertaken in areas with similar demographic characteristics in New England, there is some evidence that recovery rates may improve significantly where there is a more socially oriented service – for example, Vermont has achieved around a 15% better recovery rate than neighbouring Maine (Deegan, 1999; see also Brier and Strauss, 1984). This suggests a need to re-evaluate the knowledge base underpinning mental health practice across all professional groups (including psychiatry itself):
"For 150 years, psychiatry has fanned the flames of public hope and expectation, holding out promises of ‘cure’ and treatment for an ever-wider range of complex human and social problems. But these promises have failed to materialise… We believe that psychiatry should start a ‘decolonisation’, a phased withdrawal from the domains that it has laid claim to, including psychosis, depression and PTSD, by admitting the limited nature of its knowledge" (Bracken and Thomas, 2000 p.20; see also Michaelson and Wallcraft, 1997).
Research shows that it is social factors, such as substance misuse, unemployment, unstable family circumstances or poor education, rather than any categories of medical diagnosis, that correlate more closely with risks such as violence (Murray, 1989; Monahan, 1993; Taylor and Gunn, 1999). However, there has been a tendency to follow an individualised model of risk assessment, with the implicit assumption that people are intrinsically dangerous due to their ‘illness’, rather than engage in a more holistic dialogue which may "encompass the full spectrum of risk impinging on the lives of people in the mental health system" (Walton, 1999 p.384). There is little evidence that current practice in risk management has contributed to any overall improvement in levels of safety – indeed many service users report feeling oppressed and alienated by having assessment and monitoring done to them, thereby exacerbating levels of distress and risk (see Morgan, 2000).
A fundamental criticism of the main paradigms that currently dominate social work practice in mental health is that they may tend to reproduce ‘them’ and ‘us’ distinctions which locate expertise and initiative in the hands of the professionals, and marginalise users into roles of passivity, social exclusion and potential dangerousness. The impact of this may be particularly far-reaching on people who may be especially vulnerable due to the very nature of the experiences that they are going through. For example, recent research on user experiences of compulsion has shown how this can often (but not always) result in long term loss of self esteem, ability to trust others, and social connectedness (Barnes et al, 2000).
The basis of a holistic approach in mental health must be to move beyond a practice that is inherently stigmatizing, one that imposes or reinforces splits between ‘normal’ people and those suffering distress, or tends to define the totality of a person in terms of their ‘pathology’ (see Bainbridge, 1999). It also points to a practice which values and takes seriously the ‘dark side’ of people’s experience as part of "the meaning of our lives" (Plumb, 1999 p.471) - as potentially embodying some of the issues and dynamics that may have to be dealt with, if a person is to achieve self-acceptance and find their own unique route to recovery.
There are no generally accepted social models of mental distress that have had the same influence on current thinking and practice as the medical model. Over recent years, there has been somewhat of a reluctance for social work to clarify or promote a specifically social model of mental distress (Braye and Varley, 1992; Tew, 1999), although there are significant examples of practice that has been based on explicitly social perspectives (Ramon, 2001). Nor has social work theory made very effective links between social perspectives and the recent development of user-defined perspectives on recovery (Coleman, 1999). The existing CCETSW statement in relation to the mental health component of the DipSW knowledge base makes no mention of teaching a social model (CCETSW, 1994), and there is only a passing reference within the revised specification of ASW training (CCETSW, 2000a).
However, following on from CCETSW workshops reviewing the mental health curriculum for social work (CCETSW, 2000b), the TOPSS steering group for mental health has seen it as a central part of their remit "to encourage the use of social models of mental health intervention" (Foster, 2001), and important steps have been taken to locate this within a broader context of trends and dilemmas in health and social policy and in the organisation of practice (Duggan 2001a; 2001b; Ramon, 2001). Out of this work has emerged the Social Perspectives Network for Modern Mental Health, which seeks to build an alliance across all professional groups in clarifying and promoting the contribution that may be made by social understandings in promoting a recovery-focussed practice.
While the perspectives that social work may bring to bear on mental health may be useful in underpinning a more holistic approach, this must be proposed with some humility. It is not for ‘the social’ to compete with ‘the medical’ in order to establish some new domination of the way people in distress should see themselves and their situations. Space and recognition must be given to service users to understand both their distress and their journey to recovery in whatever combination of medical, social, personal, spiritual or other ways that works most effectively for them. Nevertheless, drawing on its somewhat eclectic roots, values and knowledge base, social work could be in a position to offer a relatively broad appreciation of a whole-person-in-their-contexts, and hence be in a position to offer some useful leadership in the development of a more holistic approach within multi-disciplinary teams.
In the following sections, I will seek to map out the values and knowledge base of a social model of mental distress that could contribute to a more holistic practice - and which could be used as a basis for constructing educational curricula and qualifying and post-qualifying levels within the new training structure for social work which is being developed in the United Kingdom. Such developments would need to be situated in the context of processes of professional education which are likely to become more interdisciplinary (Sainsbury Centre, 1997; CCETSW, 2000c; Darvill et al, 2001), and where service users may be playing an increasing role in devising and delivering curricula (Beresford, 1994; Crepaz-Keay et al, 1997; Reynolds and Read, 1999), especially given the National Service Framework recommendation that "service users … should be involved in planning, providing and evaluating education and training" (Department of Health, 1999 p.109).
Although the general orientation of social work values may be seen as helpful in relation to promoting a more user-centred social work practice, it may be important to ground this more effectively (Walton, 1999). A need to shift the value base of social work more explicitly towards notions of partnership with users, working towards outcomes that are primarily defined by the users themselves, has been signalled in relation to the development of the new social work degree curriculum (NISW, 2000), although this does not yet extend to any guidance in how to work towards partnership in relation to more potentially contentious areas such as risk taking. Such a shift in value base towards the enabling of user-defined outcomes would link well with the development of ‘recovery values’, which have been articulated by the survivor movement (Glover, 2001b). Such values are increasingly coming to underpin statements of service values across health and social services (Carling and Allott, 1999), and are likely to influence the ethos of the newly created National Institute of Mental Health in England (Department of Health, 2001).
What should lie at the heart of a holistic value base must be a commitment to engage honestly with all the fractured and contradictory elements that may constitute a person’s experience and social relationships. For working partnerships in mental health to become fully meaningful, they may need to combine a commitment to a recovery / empowerment agenda with an acceptance of, and an engagement with, conflictual, destructive and dangerous elements both within individuals, their social contexts and their professional support systems.
Such an approach would require a commitment to hear and take seriously what people may have to say about their mental distress: the content of their experiences, and the meanings, histories and aspirations that they attach to them. In order to do this, it can be important to be open to the unconventional ‘intermediary languages’ (Lefevre, 1996) by which people may be trying to express themselves, through metaphoric speech patterns, disembodied voices or self-harming behaviours. This quality of listening to people on their terms is something that users have consistently identified as lacking within much of existing service provision (Rogers, Pilgrim and Lacey, 1993; Mental Health Foundation, 1997), and explicitly challenges those traditions of mental health practice which have sought to classify, diagnose or interpret such experiences for people.
Such listening does not imply some one-sided process of ‘soaking up’ what people may have to say, but needs to take place within the context of an active dialogue. This may involve asking the questions that may never have been asked before, enabling people to make their own connections between elements of experience that had previously seemed confusing or contradictory. It may involve some self-disclosure by the worker. It may involve gently challenging some stories that carry messages of internalised oppression and disempowerment – ways in which people may have become used to diminishing themselves, taking on the negative attributions of others, or having opportunities closed off for them. It may involve validating strengths and potentials, and finding ways to deploy anger and outrage effectively in redressing unfairnesses. And it may involve a particular sensitivity to issues of abuse and violation.
This suggests an anti-oppressive practice that starts with the experience of service users, and maintains a concern with those factors which may be diminishing people’s sense of esteem or value, or constraining their personal, social or economic opportunities. It places questions of stigma, power, inequality and internalised oppression firmly on the working agenda – not as issues and definitions to be imposed on people, but as areas to be drawn out through processes of joint exploration. Alongside this, and drawing on its more structural heritage of anti-oppressive practice, there may also remain a need for social workers to engage in more proactive and preventative strategies of identifying and challenging wider practices of stigmatisation and exclusion (within families, communities, service provision or wider structures of society) that may contribute to people’s distress and impede their recovery. This may be seen to link with a commitment to mental health promotional activity that forms the basis of Standard 1 of the National Service Framework (Department of Health, 1999).
Working within a holistic model implies a very different language from that of the medical model – one that situates the user as someone who is active and responsible, and draws on the terms that have been proposed and negotiated by service users themselves. A shift from a discourse of ‘mental illness’ to one of ‘mental distress’ signals a move away from an emphasis on some objective disease entity (and the tendency to conflate the person with their hypothetical disease) to a more ‘full-on’ appreciation of the subjective pain, unhappiness or confusion that a person may be experiencing. Instead of inviting people into the essentially passive role of ‘patient’, waiting to be ‘done to’, other terms, such as survivor, consumer or service user, may offer identities that may enable people to reclaim some sense of responsibility for their situations, although in practice many people with lived experience have not been entirely comfortable with certain of these terms.
Of profound importance is a shift from a discourse of ‘symptoms’ in which the content of people’s experience or behaviour is not seen as important in terms of its intrinsic meaning, only in terms of any clues it provides as to where a person may fit within a system of diagnosis. A holistic approach demands a much deeper engagement with the many layers of feeling and meaning, concerning a person and their social experience, that may be bound up in their expression and acting out of their distress. It also entails a shift from discourses of ‘treatment’, which place the professional in the role of expert, in control of any healing or caring process, to ones of recovery and empowerment, which locate people themselves as in charge of navigating their own particular journeys. Such a shift away from the discourse of the medical model does not mean an abandonment of what medicine may have to offer in terms of managing people’s specific experiences, just a process of reclaiming the whole person from the partiality of a purely medical definition.
Social factors contributing to mental distress
Although non-medical research has been consistently under-funded and marginalised (Bainbridge, 1999), there are already many theoretical ‘building blocks’ upon which to construct a social model of mental distress. Alongside this, there is a growing evidence base arising out of the ‘situated knowledge’ of service users and survivors, grounded in narratives of lived experience, and developed through research conducted by, or in partnership with, service users and survivors (Beresford, 2000; Tew et al, 2000). A social model proposes that mental distress may typically be understood as a response to problematic life experiences. In one sense, it may represent a deployment of the best available set of coping or survival strategies that a person may be able to access. In another, it may represent direct or indirect expressions of painful issues or injustices that may feel unresolved. Thus, at one and the same time, it may constitute both an awesome story of survival in relation to an oppressive or ‘unliveable’ situation, and a desperate cry for help and understanding. Whether viewed as a coping strategy or as an expression of extreme disquiet, it may represent a way of being that is lived out at some considerable cost to the person, and may potentially pose difficulties or risks both to them and to those around.
This version of a social model owes much to the libertarian anti-psychiatry movement, in that it argues that what may conventionally be labelled as ‘illness’ may be better understood simply as unresolved conflicts or ‘problems of living’ (Szasz, 1961). However, by locating the problem just in societal reactions to unconventional coping mechanisms, and in psychiatry’s complicity in the social control of ‘difference’, anti-psychiatry has tended to overlook the profound sense of subjective distress, confusion and inability to cope that may come with many experiences of emotional or mental breakdown. A social model of understanding should take this seriously and be open to hear mental distress as a desperate plea that things as they are may be almost unbearable. This suggests a professional agenda which is both about supporting people in bringing about change in their situation, and challenging any inability of family, professionals or communities to accept and accommodate to coping strategies which may be an important part of people’s survival.
A consistent thread that may be seen to run through the subsequent discussion is that of oppression, exclusion and powerlessness. Whereas an illness model suggests ‘bad luck’ in terms of genes, viruses or biochemical disorders – something that could befall anyone indiscriminately, and where no-one external to the person has any responsibility – a social model locates experience within an understanding of social relations in which power plays a determining role, both in terms of ‘macro’ scale structural inequalities in relation to gender, ‘race’, class, age, sexual orientation, and so on, and in terms of the ‘micro’ scale dynamics of conflict, exclusion or abuse that may take place within families or other intimate social contexts. As Jennie Williams argues:
"Behaviours defined as symptoms and disorders are best understood as creative responses to difficult personal and social histories, rooted in a person’s experience of oppression(s)" (1999 p.31).
Rather than taking the extreme position that ‘mental illness’ does not exist, a social model need not rule out the possibility that some people may have greater innate vulnerabilities to particular experiences due to medical, nutritional, genetic or other factors. However, over and above any biological predisposing factors, evidence suggests that a variety of social factors may play a major role in contributing to longer term vulnerability to breakdown or distress. There is a considerable body of research which has correlated membership of social groups that may be subject to systematic oppression or disadvantage with various indices of mental distress (Gomm, 1996; Pilgrim and Rogers, 1999; Bruce et al, 1991; Fernando, 1995; Prior, 1999). Typically (although not in every instance) significant positive correlations were recorded - in some cases, such as the admission to hospital of African-Caribbean people (Carpenter and Brockington, 1980), the correlations could be very strong indeed:
"In terms of the three main dimensions of power in the Western capitalist nations – class, race and gender – there is considerable evidence to indicate that those at the powerless ends – the working class, black people and women – tend to be more prone to psychological problems. The precise extent to which this distribution is a product of these power relations is difficult to determine. That the relationship exists, however, seems clear" (Goodwin, 1997 p.76).
Alongside such generalised structural factors, there is increasing evidence that many people suffering mental distress are able to link its onset with some previous history of major social trauma. Research with problematic voice hearing experiences indicates that the majority of people with diagnoses of schizophrenia and dissociative disorder could link the onset to some previous and specifiable trauma (Romme et al, 1994). Physically and psychologically invasive acts such as sexual or emotional abuse – particularly when there was little support available to the victim at the time - would seem to be particularly frequent precursors of experiences of mental distress (Ensink, 1992; Mullen et al, 1993; Staples and Dare, 1996; Williams and Watson, 1996). Other events, such as abandonment, bereavement or witnessing domestic violence may also be experienced as traumatic in this sense (see, for example, Brown, 1996; Perry et al, 1990).
What may be seen as common to all these forms of trauma is that they render the person as a powerless victim of circumstances or forces beyond their control, unable to negotiate their boundaries and relationships with others. It is this that may be seen to construct the social (as distinct to any physical) aspect of a traumatic experience, and may come to have a profound impact on a person’s sense of self and attachments with others.
At a theoretical level, it may be possible to chart how people’s social experiences following on from a trauma may (or may not) lead individuals towards manifestations of mental distress that are conventionally given a range of medical diagnostic labels from anorexia to psychosis (Perry et al, 1990; Zerbe, 1993; Brown et al, 1995; Plumb, forthcoming). Where this approach differs so markedly from the medical model is that what would have been seen just as clusters of ‘symptoms’ come alive as meaningful responses to sequences of often horrendous life circumstances. This sets the foundations for new forms of alliance and dialogue between social worker and user, one that starts with a validation of the user’s immense expertise in living with and surviving situations that may be well beyond the direct experience of the worker.
For some people, vulnerability would not just seem to stem from some identifiable trauma (although there may be evidence of trauma as well), but from difficulties in relationships with powerful others during critical periods such as early childhood. Research on attachment has shown how children may adapt when faced with situations of no-one being there for them in any real sense, or just as potentially problematic, when key figures may be inconsistent and unpredictable (Ainsworth et al, 1978). Some, giving up on external care-givers, may look to develop their inner resources to find the basis of hope or, at least, survival - creating complex and idiosyncratic worlds of fantasy, distraction, rationalisation and inner guidance in order to find their best way of surviving. Others, may seek to develop techniques and strategies (often at some considerable cost to themselves) whereby to try to ‘manipulate’ powerful and unpredictable others in to being there for them more consistently. Identifying such patterns and strategies may be a key to understanding and working with certain ways of living that have conventionally been characterised as different forms of personality disorder or mental illness (see, for example, de Zulueta, 1998).
These perspectives may be seen to link with a nearly forgotten tradition of work looking at how communication styles and patterns of relationships within families might relate to the development of psychosis. The seminal work of pioneers such as Bateson, Lidz and Laing, albeit based on largely anecdotal evidence, suggested that having to respond to logically conflicting or emotionally intrusive communications from powerful others could lead to the developing of ‘thought disorder’ as a survival strategy. Interestingly, the more systematic work conducted subsequently which has linked the effect of such ‘trapping’ communication patterns with higher probabilities of schizophrenic relapse (Leff et al, 1983) has baulked at any exploration of how these might also precipitate initial breakdown – although this would seem to be the logical extension of such research (Johnstone, 1999; Tew, 1999). However, any development and updating of this work would need to place problematic communication and relationship patterns within a more sophisticated analysis of power relations. There is a need to move beyond, say, the potential blaming of the ‘schizophrenogenic’ mother for her apparent over-involvement as if it were her conscious choice, with a recognition that she, in turn may have been trapped by wider constructions and oppressive expectations upon women within contemporary forms of social and family organisation.
As with other forms of crisis situation with which social work may be involved, mental health crises may often be seen to have histories – processes of build-up of conflicts and tensions leading up to some recent ‘trigger’ event or precipitating circumstance (see Tew, forthcoming). The vulnerability factors discussed above may typically be understood in terms of unresolved issues of unfairness, oppression, abuse and loss, coupled with well-rehearsed (if sometimes rigid or dysfunctional) strategies for keeping these issues under some sort of control. What may then lead to a crisis or breakdown may be some combination of events and changes in external circumstances, and problems arising with a person’s current repertoire of coping strategies.
Often the most potent ‘trigger’ events are those whose dynamics connect in some way with previously unresolved issues. Stressful life events or circumstances, such as relationship breakdown, poverty and unemployment, may be seen to have a wide-scale impact on levels of mental distress (Warner, 1994; Fryer, 1995; Brown et al, 1995), and these may link with earlier experiences of discrimination or loss. Research on stress suggests that any form of life transition, whether imposed on the person (as, for example, redundancy), or chosen shifts in lifestyle and affiliation (such as leaving home), may be destabilising for someone already vulnerable. Life transitions typically involve the renegotiation of personal relationships and social identities. Where these are already fraught with unresolved conflicts and internalisations of oppression, such processes may become problematic. There may also be resonances with previous experiences – perhaps earlier memories of having elements of familiarity or security taken away arbitrarily by powerful others, or being forced into situations of having to make choices where there would be no support if things went wrong, or whatever choice was made might incur the displeasure of powerful others.
Contradictory pressures associated with social roles, such as caring or work responsibilities, may constitute a form of stress (as can losing, or being excluded from, such roles). What may be crucial can be the often conflicting patterns of expectations that may attach to these roles when they are located within oppressive patterns of power relations. For example, many women may have little ability to control or negotiate taking on caring responsibilities – and may also find that the importance and difficulty of this work is devalued within prevailing social and family structures (Finch and Groves, 1983).
Theorising the social impact of mental distress
Arising out of the previous discussion, mental distress may be conceptualised as both a response to, and an implicit revolt against, experiences of injustice, enforced loss or abuse. Viewed from the outside, it may appear as either a failure, or a refusal, to perform the image of a rational, consistent and responsible subject that may be expected in order to fit within a modern social order (Foucault, 1967; Tew, forthcoming). Appearances of breakdown may be seen as signalling a disturbing reality that must be ‘hushed up’ and denied respect within both professional and everyday discourses (Barnes, 1999).
In articulating its version of a social model, the disability movement has argued that it is not physical impairments that are hardest to live with in themselves - it is society’s responses, in terms of stigma and discrimination, that can be most damaging (Oliver, 1996). The attitudes and practices of both the community in general, and of professional services, may be prejudicial in that they can promote social exclusion through the establishment of segregated services and by failing to open access to mainstream facilities – thereby marginalising people’s access to crucial forms of social capital (see Duggan, 2001b).
These issues apply similarly to people who are experiencing mental distress. However, in many ways, the stakes would seem to be even higher in mental health. Both at an individual and at a societal level, there may be vested interests in avoiding the uncomfortable truths and testimonies of those whose social experiences may be re-enacted through their mental distress. Particularly where this may touch on their own (similar) experiences, ‘ordinary’ people may choose to project their anxiety and disquiet on to a segregated category – the ‘mentally ill’ – who may then have to deal, not just with their own issues, but with being ‘dumped’ with the issues that others are not prepared to face in their own experience. It is this that may start to explain why, although not posing a greater physical threat than any other group of citizens (Taylor and Gunn, 1999), people with mental distress may continually come up against exaggerated reactions of fear, exclusion or repulsion throughout their daily lives (Barnes, 1999; Foster and Zagier Roberts, 1998).
In turn, such social responses of stigmatisation and ‘scapegoating’ may feed into the very experiences of oppression or exclusion that may have been contributing to people’s original experience of mental distress, thereby instigating a potentially vicious circle of increasing victimisation, powerlessness and distress. Over time, people may lose their social and family networks and become either socially isolated or ghettoised within mental health services. There may be shifts in identity, with a loss or distortion of any positively valued sense of self.
A social model and recovery practice
There has been a sustained critique of current service models from sections of the user movement. Firstly, as medicine is not, in fact, able to deliver any ‘cure’ for mental distress – only long-term management of symptoms - medical diagnosis may actually serve to deliver a ‘life sentence’ of dependence on services (Coleman, 1999). Medical treatment tends not to be located within a paradigm of hope and recovery, although longitudinal research indicates that a substantial proportion of people do recover from psychosis - interestingly with much higher recovery rates recorded in some Third World settings where biomedical practice is less dominant (World Health Organisation, 1979).
Secondly, users have also questioned the usefulness of medical definitions of recovery which are couched purely in terms of remission of symptoms. Users have argued for more holistic definitions of recovery in terms of the ability to ‘get on with life’ in a way that seems appropriate and meaningful to them. This may involve accepting and living with parts of themselves or their experience that had previously appeared frightening or shameful – such as finding ways of valuing and negotiating with voices rather than seeking to eradicate them (Coleman and Smith, 1997). It may involve challenging structures or relationships which have been oppressive, discriminatory or abusive, and in establishing new social networks of support and mutuality. It may simply involve reclaiming aspects of ordinary life, such as decent housing and employment opportunities.
Research indicates that a crucial pre-requisite for recovery is not some form of ‘expert’ professional intervention, but for the person to find a way of understanding their experience that makes sense to them, and which returns to them some sense of personal value, together with the responsibility (and potential capability) for working it through (Deegan, 1999). Writing from the perspective of her lived experience, Helen Glover argues that "people who experience the distress of mental illness have the right to understand their distress and develop the understanding that one can grow from the experience" (2001a p.7). Here, for some, the medical model can be problematic in that it can hand over this responsibility to the physician, leaving people waiting passively for a cure to come. However, for others, the medical model can be useful, both in providing an explanatory framework that gives a semblance of order to previously chaotic experience, and in giving them a key role in managing their distress, perhaps through being empowered to play an active part in monitoring their medication.
For those who do not find the medical model a helpful or sufficient tool in finding their route to recovery, elements of a social model may provide insights or perspectives that are helpful to the user in making sense of what is going on for them, and what may be their way forward. In practice, if a person is to be enabled to own their experience and chart their unique journey of recovery, then they will need to make their own connections. Therefore workers would need to use a social model more as a basis of asking questions, than as a way of delivering insights or answers. Their most important role may be one of taking seriously and being the ‘enlightened witness’ for the histories of trauma and powerlessness that may emerge, once connections start to be made. A key difference between the recovery paradigm from that of rehabilitation is that recovery cannot be ‘done to’ people; it cannot be led by ‘experts’ who claim to know both the destination and the route by which this is to be reached.
As well as individual work supporting people towards their recovery, there may be other important roles for social work involvement. In a very real sense, family, friends and social networks may also need to recover from their own elements of distress – a breakdown can involve relationships as well as individuals, leaving a legacy of confusion, blame, guilt, anger and sadness. Whereas the medical model tends to focus only on the assumed internal pathology within individuals, leading to a potential marginalisation of family and friends, a social model which locates distress in its social context should seek to include all significant others as part of the ‘action system’ working towards recovery. This would suggest an important role in supporting the renegotiation or rebuilding of social and family networks (or in establishing new ones), and in seeking to challenge any tendencies towards oppression or exclusion that may be present within them.
The social model in the social work curriculum
In the previous sections, I have sketched out some of the parameters of a social model of mental distress, one that is essentially more complex than the social model of disability, in that it is not only the oppressive consequences of distress that may be seen to be socially constructed, but also, major aspects of the distress itself. Its essential premise is that all expressions of mental distress may be meaningful in terms of the person and their social environment – it is just a question of finding the meaning!
The model also clarifies the links between mental distress and subjection to experiences of oppression and inequality, which has clear implications in defining what may be most relevant in terms of both values and knowledge base. It suggests a bringing together of a number of themes which are already familiar to social work – enabling the voice of the service user, anti-oppressive practice and a focus on systems, networks and relationships – and developing these at greater depth within the specific context of mental health and recovery practice. It also demands a reclaiming of expertise in interpersonal work - the art of staying with and responding to the content of people’s distress - that has tended to be lost to social work practice in recent years. However, conventional models of counselling may not always be appropriate here, as they may not encourage a sufficiently social orientation, tending towards an individualisation of distress and a neglect of wider contexts of power, oppression and abuse – and the realities of everyday living.
Within the context of the new three or four year Degree level qualification training that will start in the United Kingdom from 2003, there may be a need to specify, firstly, a baseline level of understanding of a social model for all social workers and, secondly, a more advanced development of these ideas for those social workers specialising in mental health, at a level roughly corresponding to that of the current first stage of post-qualification training (PQ1). In facilitating this learning, connections (and differences) need to be explored between social theories and values in mental health and those in other areas of social work practice. Just as importantly, joint learning experiences need to be developed between social work and other professional training routes committed to a holistic and recovery-oriented mental health practice – perhaps nursing and occupational therapy in the first instance. Perhaps most crucially of all, if new curricula are going to be effective in equipping social workers to work as allies in promoting safety and recovery, they must be devised, delivered, assessed and evaluated in full partnership with service users and survivors.
At qualification level, this would aim to offer social workers in training the opportunity to become confident in advocating social perspectives in interdisciplinary settings, while being able to learn from the distinctive strengths of other professional viewpoints, and to work across professional identities towards generating more holistic models of practice. Beyond this, in terms of subsequent post-qualification training, there is a need to look beyond the specific requirements of the Approved Social Worker role (one that is anyway unlikely to remain the exclusive preserve of social work, given the proposed reform of the Mental Health Act). Instead, training at this level would need to address wider issues of implementing social perspectives in relation to risk, need and aspiration. Social work will need to justify its existence, not on the basis of its use of statutory powers, but on its expertise in joining with colleagues from other disciplines, service users and others in delivering a social model in practice.
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