The Individual, Health and Society: SWK 4220

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• The Individual, Health and Society SWK 4220
• Dr Ralph Hampson (Health)
• Dr Noel Renouf (Mental Health)
• Subject enquiries
• Off Campus Students
• Louise.oliaro_at_med.monash.edu.au

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Workshop timetable
9.30 Social Work in Health - Introduction
10.00 Health
12.30 Lunch
1.30 Mental Health
4.30 Summary and Close
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SWK 4220 The Individual, Health and Society -
Texts

• Grbich, Carol (Ed) (2004)
• Health in Australia sociological concepts and
  issues (3rd ed.),
• Prentice Hall.
• Pritchard, Colin (2005)
• Mental Health Social Work electronic resource
  London Routledge.
• Available via World Wide Web - access via Monash
  library (internet resource). 
• Unit guide refers to
• Meadows, Graham and Singh, Bruce (Eds) (2006)
• Mental health in Australia collaborative
  community practice (2nd ed.)
• Oxford University Press, Melbourne.
• Bloch, S and Singh, B (2006)
• Foundations of Clinical Psychiatry (2nd ed)
• Melbourne University Press, Melbourne

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• Recommended supplementary reading
• Alston, M and McKinnon, J (Eds) (2005)
• Social Work Fields of Practice - Second Edition.
  
• Oxford University Press, Melbourne
• - It provides a detailed analysis of social work
  practice.

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Context

• Shift over time from public health issues which
  were the concerns of the late 19th, early 20th
  Centuries.
• Health is a major focus of Government policy
• Evidence that ill health is closely linked to low
  income, unemployment, poor housing.
• Health system can be a safety net and/or it can
  operate as a preventive/health promotion project.
• Late 20th Century emphasis on equity, access,
  equality and participation
• Increasing focus on consumer involvement.

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Principal feature of the Australian health care
system

• A private, for profit component (GPs,
  pharmacists, dentists, private hospitals, private
  specialists and alternative practitioners)
• A public component (community health centres,
  maternal and child health, mental health,
  hospital, HACC)
• A non-government, not-for-profit (FPA, welfare
  services)
• A domestic component carers at home
• (Adapted from Owen and Lennie, 1992)

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Australian HealthCare System

• Medibank Whitlam Government 1970s
• Community Health Program 1973
• Medicare levy 1.25 levy 1984
• More recently -Increased focus on private health
  insurance after a drop off in the number of
  people taking out primary health insurance
• Introduction of the private health insurance
  rebate by the Howard Liberal Government.

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Key health policies and programs

• Commonwealth National Health Act (1953)
  universal health insurance scheme creation of
  the Pharmaceutical Benefits Scheme
• Medibank 1975/Medicare 1984
• Council of Australian Governments (1995)

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Key health policies and programs community
health

• Community health program 1973
• Local community involvement
• Deinstitutionalisation
• 1980 Community health became a state
  responsibility
• Is it marginal to the main game?

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National Health Strategy 1990s

• Needs of populations
• Inequality
• Efficiency
• Cost effectiveness
• Public engagement in debate
• Rights and responsibilities

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Health Policy

• Universal access to basic health care
• Services should be of a high quality
• Financing of health care should be equitable
• Services are delivered through a mix of public
  and private system
• Accountability and efficiency

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Levels of Service Delivery
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Primary health care

• Multidisciplinary in nature
• Based community needs
• Integration of health, welfare, private, public,
  not for profit a partnership approach
  tensions can emerge
• Social context
• Data traditionally not collected in a consistent
  manner

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Funding

• 200405, the majority of spending in health was
  funded by governments (68.2)
• Australian Government contributing 39.8 billion
  (45.6)
• State, Territory and local governments
  contributing 19.8 billion (22.6)
• Non-government sector funded the remaining 27.7
  billion (31.8)

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Challenges facing Health Services

• Private and public mix
• Prevention, early intervention and treatment
• Pressure Medicare /PBS -costs
• Bulk billing declining
• Tensions between State and Federal Governments
• Ageing of the population
• Infrastructure/Technology
• shorter admissions, high costs, emphasis on
  throughput
• Power of hospitals can they become self serving
  organizations
• Dental health services

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What changes to health care services have you
noticed in your area in the past five years?
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What factors have brought about these changes?

• Concern about increasing costs
• Clinical Governance, risk and safety issues
• Demographic changes
• Public/Private split
• Increasing consumer expectations
• Legal issues and medical insurance

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What is health?

• Health is shaped by
• Attitudes, beliefs and values
• Sex, age, religion and socio-cultural groupings
• History, knowledge and dominant understandings
  about health and illness
• Professional versus consumer experiences

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Definitions of Health

• World Health Organization (WHO) a complete
  state of physical, mental and social well-being,
  and not merely the absence of disease or
  infirmity.
• Bircher a dynamic state of well-being
  characterized by a physical and mental potential,
  which satisfies the demands of life commensurate
  with age, culture, and personal responsibility.
• Saracchi a condition of well being, free of
  disease or infirmity, and a basic and universal
  human right.
• Australian Aboriginal people Health does not
  just mean the physical well-being of the
  individual but refers to the social, emotional,
  spiritual and cultural well-being of the whole
  community. This is a whole of life view and
  includes the cyclical concept of life-death-life.

http//www.who.int/bulletin/bulletin_board/83/ustu
n11051/en/
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WHO definition of Health critical appraisal

• WHO definition of health is utopian, inflexible,
  and unrealistic, and that including the word
  complete in the definition makes it highly
  unlikely that anyone would be healthy for a
  reasonable period of time
• a state of complete physical mental and social
  well-being corresponds more to happiness than to
  health
• words health and happiness designate distinct
  life experiences, whose relationship is neither
  fixed nor constant
• Failure to distinguish happiness from health
  implies that any disturbance in happiness,
  however minimal, may come to be perceived as a
  health problem.

http//www.who.int/bulletin/bulletin_board/83/ustu
n11051/en/
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Assumptions about health and illness

• People can choose to be sick or well?
• Encouraged to express dis-ease through the
  physical
• Changes over time childbirth, childrens
  hospitals, homosexuality, sexual abuse, mental
  illness

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Sociology of health

• Sociological lens
• social patterns age, sex, race, class, culture,
  geography, community profiles
• processes interest groups, beliefs and history
• social relationships power

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Risk factors

• Diet
• Environment
• Occupational health
• Stress
• Unemployment
• Poverty

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Role of social work

• Interrelationship between health and human
  functioning
• Individuals, families, groups and communities can
  have health concerns
• Social workers are both professionals and
  consumers of health services
• Person in environment

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Social Workers bring to Health

• Systemic thinking
• Political awareness and critical thinking
• Ethics
• Practice skills assessments and interventions
• Human development
• Social theory
• Macro and micro awareness
• Passion and idealism

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Typical Health seeking

• First port of call is the GP
• Beliefs, gender, family history, tolerance of
  pain e.g. men, pap smears
• Language/Culture
• Labeling of illness blame and sympathy

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What does this mean for social work?

• Health is political
• Social workers are part of the system and
  outside it at the same time
• Resources, access and information
• Social activist and/or keeper of the peace.

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History - Social Work

• 1905 Massachusetts General Hospital
• Australia growth in the health field Hospital
  Almoners
• Understanding our history - is this important?
• Psychosocial approach
• Family domestic and social situations
• Complying with medical treatment
• Hospital and the wider community
• Home visits a lost art perhaps?

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1960s

• Influence of psychoanalytic traditions
• Social investigation
• Diagnosis and treatment
• Caseworker, therapist splits in the profession
• Genericism versus Specialism

1970s

• Civil Rights movement
• Feminism
• Rights movements
• Anti-psychiatry encounter groups, humanism
• Radical social work structuralism
• Community health
• Community development

1990s

• Targeted benefits
• Economic rationalism
• Effectiveness
• Evidence based practice
• Accountability
• Competition

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Theoretical frameworks

• Bio-psycho-social
• Psycho-analytical
• Ego psychology
• Systems theory
• Behaviourism
• Feminist
• Strengths based
• Solution focused
• Others?

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Issues and Practice

• Shorter length of stay
• Family support
• Short term nature crisis
• Discharge planning bed blockers
• Person in environment

• Counselling
• Advocacy
• Community linkages
• Financial, accommodation, benefits
• Team work

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Crisis intervention
Constructive
Relative homeostasis
Destructive
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Group Work

• Bereavement Service Royal Childrens Hospital
• Stroke Support Group
• Incest survivors group
• Children of parents with a mental illness
• Parenting skills
• Siblings of children with cancer
• Transplant Support

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MultidisciplinaryInterdisciplinary

• Allied health profession
• Ownership of the patient
• Sharing of roles
• Emergence of case management
• Sharing of roles with others
• Negotiating boundaries and roles

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Allied Health
Psychology ?
Taken from Austin Health promotion The Well
Wisher Olivia Newton John Cancer Center Appeal
Spring 2007
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Rural remote challenges

• Being a member of the same community
• Dual and multiple roles
• Lack of anonymity
• Confidentiality and privacy
• Personal safety
• Supervision and debriefing

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Advanced Multi-Systemic Approach (AMS)

• Biological Dimension the mind-body connection
• Psychological/Emotional Dimension
• Family Dimension
• Religious/Spiritual/Experiential Dimension
• Social Environmental community, culture, class,
  social/relational, legal history, community
  resources
• Macro dimension e.g. policies, legislation,
  oppression, poverty, homophobia, sexism
• Ref Johnson, L J Grant, G (2005) Medical
  Social Work Pearson, New York

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Case examples

• Mark, a baby, is born with spina bifida. You have
  been asked to work with the parents re the
  diagnosis.
• What are some of the areas you may cover in your
  work with the family?
• Mrs Smith comes into hospital has a diagnosis of
  cancer which will require radiation and
  chemotherapy
• Referred to social work as she is depressed and
  does not want to have treatment, says she would
  rather die.
• What would you do?

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Meaning of health and illness

• People experience illness differently
• Lens for example
• Culture
• Class
• Gender
• Age
• Sexuality

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Immigration (Gbrich,2004)

• Immigration program post WW2
• Waves of immigrants
• Britain and Northern Europe
• Southern Europe
• 1973 White Australia Policy abandoned
• Asia
• Skilled migration/Family
• Refugees Humanitarian
• Assimilation
• Multiculturalism
• Cultural Pluralism

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Overseas Born Health Status (AIHW, 2006)

• Australia has one of the largest proportions of
  immigrant populations in the world
• 24 of the total population (4.75 million people)
  in 2004 estimated to have been born overseas
• More than half of theseone in eight
  Australianswere born in a non-English-speaking
  country
• Research has found that most migrants enjoy
  health that is at least as good, if not better,
  than that of the Australian-born population.
• Immigrant populations often have lower death and
  hospitalisation rates, as well as lower rates of
  disability and lifestyle-related risk factors
• (Ref AIHW Singh de Looper 2002)

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healthy migrant effect (AIHW, 2006)

• Believed to result from two main factors
• a self-selection process which includes persons
  who are willing and economically able to migrate
  and excludes those who are sick or disabled and
  a
• government selection process which involves
  certain eligibility criteria based on health,
  education, language and job skills (Hyman, 2001)
• but
• As length of residence in a destination country
  increases, the health status of immigrantsas
  gauged by health behaviours and by morbidity and
  death ratestends to converge towards that of the
  native-born population.

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Refugee Health

• Refugees, asylum seekers and detainees share
  similar life experiences
• Experience higher rates of unemployment and
  welfare dependency than other migrants
• Health and trauma imprisonment, sexual assault,
  torture
• Witnessing of death in refugee camps disease
  etc
• Loss and Grief
• Understanding health within a global framework
• Holistic approach to health
• Social capital and well being
• Preventing disease, promoting health and
  prolonging life
• Shift away from othering of the migrant
• Paradigm shift?

New perspectives on migrant and refugee health
(Gbrich, 2004119)
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Gender Health (Gbrich, 2004, Ch6)

• Life Expectancy women have outpaced men but gap
  is narrowing
• 1920-22 Male 59.1Female 63.3
• 1950-62 Male 67.9Female 74.1
• 2000 Male 76.6Female 82.1
• Why do men die younger?
• Violent behaviour
• Aggression
• Excessive alcohol use
• Dangerous driving
• Smoking
• Quality of relationships

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Gender Health (Gbrich, 2004, Ch 6)

• Social Model of Health
• Holistic approach
• Health Service Utilisation
• Women access health services more than men
• Womens health issues associated with
  reproduction
• Medicalisation of womens health
• Mens health legal problems, being a lad
  growth in the issue of mens health

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Explaining gender differences

• Fixed roles and expectations
• mediated by age and responsibilities dual
  responsibilities of women and increased burden
• Sex role socialisation
• masculinity and femininity stoicism of men,
  women more likely to report medical no evidence
• Clinician bias
• Critical and feminist theory
• messiness of womens health
• Blinkers what are some you can think of?

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Social Class

• Class analysis social conflict used to
  explain social health inequalities
• Social stratification focuses on social
  consensus used to describe social health
  inequalities using socioeconomic status
• Consistent pattern death rates go up as
  socio-economic status goes down
• Physical, psychological and social dimensions of
  illness all show that illness rates go up as
  socioeconomic status goes down (Smoking? The
  Age, 190209)
• Conflict Theory the physical work environment
  and the way work is organised lead to higher
  levels of illness for working class
• Consensus its not what they do at work its
  what they do outside of work that causes the
  problems consumption/risk taking

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• Indigenous health
• DVD Bringing Them Home

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Trauma

• Trauma refers to situations where a person is
  confronted with situations that exceed and
  overwhelm their coping capacity. These situations
  threaten the physical and psychological integrity
  of the person and cause an intense reaction of
  horror. Typically there is a significant impact
  on at least immediate functioning, if not long
  term, involving distress and disturbance and, for
  some, disorder.
• Harms,L (2005) Understanding Human Development A
  Multidisciplinary Approach, OUP, 146

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Characteristics

• Sudden and unexpected events, leaving the
  individual unable to prepare psychologically for
  the event
• Events which are out of ones control
• Unfamiliar events so the individual cannot draw
  on past experience in order to cope
• Can create long lasting problems
• Tedischi Calhoun (1995)
• Natural and technological e.g. nuclear,
  bushfires
• Wars and related atrocities
• Individual traumas
• Individual acts of violence, abuse
• Car accidents, ABI, disability
• Sudden deaths/Infectious diseases cancer,
  AIDS/HIV

Types of Trauma(Aldwin, 1993)
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Trauma Models of Understanding

• Trauma can be political silenced
• Lunacy weak gene pool linked to eugenics
• Shell shock troops WW1/WW2 now PTSD
• Talking models of helping
• Treatment holocaust survivors soldiers
• PTSD DSM IV 1980
• Transient response 2 days to 4 weeks
• PTSD can be
• Acute (less than three months)
• Chronic (symptoms last for more than 3 months)
• Delayed onset (more than 6 months after the
  event) e.g. Vietnam Veterans stolen generation
• A Problematic term?
• Neurological responses to trauma

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309.81   DSM-IV Criteria for Posttraumatic
Stress Disorder

• The person has been exposed to a traumatic event
  in which both of the following have been
  present 
• (1) the person experienced, witnessed, or was
  confronted with an event or events that involved
  actual or threatened death or serious injury, or
  a threat to the physical integrity of self or
  others
• (2) the person's response involved intense fear,
  helplessness, or horror.
• Note In children, this may be expressed instead
  by disorganized or agitated behavior.
• 2.3 of the male population
• 4.2 of the female population
• Meadows Singh, 2001124

Prevalence
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Risk Protective Factors (Harms, 2005115)

• Developmental stage of the individual
• Gender (violence)
• Socioeconomic position
• Culture
• Traumatic event
• Type of trauma
• Blame and personal responsibility
• Personality of the individual
• the subjective construction of the event thus
  becomes of critical importance.
• The role of hope
• Recovery environment

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Core tasks Critical Incident Stress Management
(Harms,2004169)

• Defusing
• Formal debriefing (2-3 hours)
• Establishing facts
• Behaviours
• Thoughts and feelings about the event
• Educational and preventive focus
• Education short and long terms responses
  coping strategies
• Counseling typically a longer term response
• Referral

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Crisis Intervention

• Assessment here and now focus avoid dealing
  with long term issues safety and security
• Planning concentrate on the immediate This
  turns the crisis from an unstructured,
  frightening and bewildering situation into
  something manageable(p40).
• Intervention calmness, listening, in touch with
  self use of resources and systems advocacy
  awareness of culture, hope and confidence
• Termination clarify what will happen next
  write it down
• Truswell, S et al (1988) In the Eye of the
  Storm Crisis Intervention in Hospital Aust
  Social Work, March, V41,No138-43

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Refugee survivors of torture and trauma

• Confronted by trauma and the depth of human
  cruelty
• Social justice and valuing the rights of all
  people
• Confronting the issues of torture and trauma
• Migration and resettlement issues loss and
  grief
• Lifestyle, personality and family issues

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Child Maltreatment

• Physical, sexual and emotional abuse, neglect
• Long term effects
• Re-victimization in later life
• Mental health problems
• Self harm suicidal behaviours
• Sexual difficulties - intimacy

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Child Maltreatment

• Change from family/private issue to
  criminalisation
• Harming children is not OK
• State has a role to play
• Social work role prevention, interventions with
  children, family, child welfare etc.
• The wider safety net neglect housing, income
  support, education, physical health etc.

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AIDS/HIV

• Diagnosis
• First diagnosed in 1982
• Death to long term chronic illness
• Impact on the gay and lesbian community
• Changes over time from central health issue
  Grim Reaper to ?
• Positive Counselling Service Bouverie Clinic
• Recognise the family however presented
• Listen
• Show and feel compassion, respect, interest and
  understanding
• Do not take an authoritarian stance
• Hold the belief that clients can manage their
  lives
• Raise issues that are difficult for our clients
  to raise
• Comfort use touch when appropriate
• Share information and transparent
• Avoid pathologising families

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Growing old

• Most older Australians are neither frail nor in
  need of long term care.
• Around 20 per cent of people aged 70 years and
  over use Government-funded care services about 8
  per cent live in nursing homes and hostels and
  around 12 per cent receive community care
  services.
• There are many more women than men in the oldest
  age groups and more women than men live alone at
  older ages
• women comprise almost 70 per cent of people aged
  85 years or more
• around 38 per cent of women and 30 per cent of
  men aged 80 years and over live alone.

71
Growing old

• Likelihood of needing residential care increases
  as people get older and is higher for women than
  men at 80 a woman has a 59 probability of
  entering a nursing home during her remaining
  lifetime compared to 39 for a man.
• Most who need care receive some support from
  informal carers, that is, family, friends and
  neighbours. In 1998, the ABS estimated that there
  were 201,000 primary carers of people aged 65
  years and over.
• The incidence of dementia increases with age
• about 5 of people over the age of 65 and 20
  over the age of 80 have some form of dementia
• the number of people with dementia is expected to
  increase from 148,000 in 1999 to 258,000 people
  in 2021 and 450,000 in 2041.

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Growing old

• Depression is often under-diagnosed in older
  people.
• Significant proportion of older Australians are
  from culturally and linguistically diverse
  backgrounds.
• Aboriginal and Torres Strait Islander people have
  poorer health status than non-indigenous
  Australians across all age groups.

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Costs

• In 19992000 the Commonwealth Government will
  spend over 5 billion on residential aged care,
  home and community care , respite and support for
  carers.
• Public and private spending on health has been
  around 8.2 to 8.4 of Gross Domestic Product from
  19911998.
• Expenditure on health needs of people aged 65
  years and over accounts for 24 of medical
  services, 31 of pharmaceutical services and 35
  acute hospital services.

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Understanding Ageing

• Physical changes
• Psychosocial changes
• Disengagement theory (Cummings and Henry, 1961)
• Activity theory
• Continuity theory
• Multidimensional approach person, time and
  environment
• Life Course perspective
• Stereotyping
• closed minded, demented, deaf, slow, unfit and
  ugly
• Advertising
• There are many ways to be old not homogenous

What is ageism?
76
Ageing Reforms

• Market based reform agenda
• Means testing of aged pensions
• Reforms to the Superannuation system
• Means testing or targeting of a range of health
  and welfare services
• Increased competition in the sector
• Increasing reliance on user pays
• As user pays increases the grateful elderly
  will disappear
• Focus on community based services

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Intergenerational tensions
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Social work roles

• Acute hospitals
• Rehab
• Residential Care
• Grandparents as parents
• Community health services
• Community support
• Community development

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• Disability

• DisAbility

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Images
82
http//www.pwd.org.au/
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Some facts

• 1998 3.6 million people reported a disability
• Largest proportion of people over 65
• Ageing of the population likely to be an
  increase
• Main disabilities sensory, intellectual and
  psychiatric
• (AIHW, 2000, 2003)
• What does disability mean to you?
• What does chronic illness mean to you?
• What experience do you have?
• How do you think our community reacts to
  disability?

Meaning
84
Defining disability

• May 2001 the WHO adopted a multi-dimensional
  definition
• International Classification of Functioning,
  Disability and Health (ICF)
• WHO definition highlights
• Importance of environment, social and political
  in defining disability
• Problems within peoples bodies impairments
• Dynamic interaction between health conditions,
  environment and social factors (WHO, 2001
  Bowles, 2005)

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Chronic illness
www.chronicillness.org.au
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Defining chronic illness

• Chronic illness is usually defined as a medical
  condition lasting at least six months.
• Usually has an impact on the quality of life
• Examples asthma, arthritis, depression, heart
  disease, neurological, MS (Baum, 2002)
• Chronic Illness Alliance consumer body 2005
• an illness that is permanent or lasts a long
  time. It may get slowly worse over time. It may
  lead to death, or it may finally go away. It may
  cause permanent changes to the body. It will
  certainly affect the persons quality of life.

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Stereotypes

• Dependent
• Passive
• Non-compliance blame
• Expensive
• Walker, C (1999) Health Issues, V59, pp 10-13

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Predictability

• When I was diagnosed with breast cancer, I got
  my affairs in order and left money in my will to
  care for the cat. Well the cats dead Ive
  stopped cleaning out of my cupboards and I wish I
  hadnt given away my Zeppelin collection.
• Walker, C (199910-13)

90
Diagnostic tools - categorical

• Diagnostic and Statistical Manual of Mental
  Disorders
• International statistical classification of
  diseases and related health problems (ICD)
• Burden of disease
• Quality of life
• Individual medical model
• Welfare or policy model
• Socio-political model
• (Bowles, 2005)

Understanding
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Individual medical model

• Viewed as victims
• Expert help to recover
• Not recover exempted from normal social roles
  employment, marriage, sex, raising families
• Treated like children
• Biomedical problem
• Charity/welfare approach
• Social work under the medical model has generally
  been restricted to a role that is secondary to
  medical intervention (Bowles, 200554)
• Acceptance, counseling, family support and
  financial accommodation

92
Welfare or Policy Model

• Focus on rehabilitation
• Grew out of post WW2 rehabilitation for
  veterans
• Clients not patients
• Holistic
• Multidisciplinary
• Independent living, social groups, sexuality,
  self esteem and assertiveness
• Welfare payments
• Disability advocacy social justice
• Year of the Disabled
• Human rights approach
• Effects of the environment in creating disability
• Social construction DisAbility
• Structural change - advocacy

Socio-Political Model
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Legislation

• Intellectual Disability Persons Act
• Disability Discrimination Act 1992
• Disability Services Act
• Equal Opportunity Legislation
• DHS State Plan
• HACC Disability Standards
• By 2012, Victoria will be a stronger and more
  inclusive community a place where diversity is
  embraced and celebrated, and where everyone has
  the same opportunities to participate in the life
  of the community, and the same responsibilities
  towards society as all other citizens of
  Victoria.

State Disability Plan - Vision
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AcceptanceIntegration

• School support programs
• Community housing
• Employment programs
• Attitudes vary across cultural groups
• Rural/metropolitan
• Family reactions
• Punishment
• Gift from God
• Non medical beliefs

Cultural Differences
95

• Intellectual
• Psychiatric
• Sensory/Speech
• Acquired Brain Injury (ABI)
• Physical
• Profound
• Severe
• Moderate
• Mild

ABS Data
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AIHW Definition

• Disability is conceptualised as a
  multi-dimensional experience
• Effects on organs or hody parts
• Effects on activities
• Effects on participation
• Facilitate participation
• Physical and social environmental factors

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Core activities

• Self care bathing, showering, dressing, eating,
  using the toilet, and bladder or bowel movement
• Mobility getting into or out of a bed or chair,
  moving around at home and going to or getting
  around a place away from home
• Communication understanding and being
  understood by others (strangers, family and
  friends)

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Carers

• 1998 57 of the people with a disability needed
  assistance with ADLs
• Carers unpaid
• Issues financial security, income support,
  workforce participation, flexibility (Carers
  Australia, 2005)
• Carers provide unpaid care and support to family
  members or friends who have a chronic or acute
  condition, mental illness, disability, or who are
  frail aged.

99
Social Policy

• Institutional to community based services
• Discrimination
• Advocacy
• Power of legislative change
• Human rights
• Dignity
• Social Justice
• Individualised care packages rather than one size
  fits all

Social Work Practice
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Child with a disability

• Trauma and shock
• Loss and grief
• Marital stress
• Integration
• Tiredness
• Life stage adjustments
• Transitions loss and grief

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Case

• 3 days old baby girl
• ICU
• Requires cardiac surgery
• SW asked to see family
• Father 26/Mother 23 both teachers
• Live in rural area
• 1st child
• What might the issues be?
• What might you say if asked?
• Is she going to die?
• Have you got children of your own?
• Why did this happen to us?

102
loss and grief

• Separation
• Divorce
• Moving House
• Changing Schools
• Unemployment
• Chronic illness
• Death of a dream
• Death

103

• Elizabeth Kubler-Ross identified five stages that
  a dying patient experiences when informed of
  their terminal prognosis.
• Denial (this isn't happening to me!)
• Anger (why is this happening to me?)
• Bargaining (I promise I'll be a better person
  if...)
• Depression (I don't care anymore)
• Acceptance (I'm ready for whatever comes)
• Not prescriptive

On Death and Dying
104
Worden (1987)

• Face the reality of the loss
• Experience the pain of grief
• Adjust to an environment in which the deceased is
  missing
• Emotionally relocate the deceased and move on
  with life
• Developmentally with every stage of the life
  course there are losses and gains
• Mourning/Grieving of men and women
• Family grief felt differently
• Disenfranchised grief not recognised e.g. gay
  lesbian
• Minimisation of the impact due to age
  elderly/children
• Role of hope rebuilding and relearning

Complexity
105
lifespan loss and grief

• What are the issues?
• Babies
• Children
• Teenagers
• Young Adults
• Middle Age
• Later Age
• Old Age

106
CASE STUDY

• Clive is 27 years old and has just been diagnosed
  with leukaemia. What impact might the diagnosis
  have on him?
• Social work role?

107

• What drugs have you or do you do?

108
History

• All societies use drugs
• Alcohol central to life in Europe safer than
  water high calories helped people cope with
  work festivals
• Alcohol also used therapeutically build
  strength, digestion and as an anaesthetic
• Ambivalent views drunkenness
• 16th/17th Centuries increasing social concern
  about drunkenness
• Religious
• Increased availability
• Commercialisation
• Transport/Stronger fortified wines allowed
  storage
• Public ale houses
• Food changes
• Conspicuous consumption

Influences on changing attitudes
109
Understanding drug use

• Moral Model moral weakness of the user should
  suffer legal, physical and psychological
  consequences (19th C)
• Pharmacological Model drugs dangerous focus on
  abstinence the power of the actual drug. Humans
  victims of the drug temperance /prohibition
• Disease Model disease beyond the control of the
  individual develop alcoholism treatment
  abstinence
• Spiritual Model e.g. AA
• Educational Model knowledge is power
• Public Health Model person, drug and environment
• Harm minimisation

110
Types of drug use

• Experimental single or short term use
  curiosity, new experience, risk taking harm
  reduction and education
• Social Recreational controlled use of the
  substance in prescribed circumstances harm
  reduction and education
• Circumstantial use exam, long distance driving,
  soldier in combat, bereavement harm reduction,
  education, medical, counseling
• Intensive use daily use, bordering on
  dependence medical, counseling, specialist care
• Compulsive Use persistent, frequent high doses
  which produces psychological and physiological
  dependence - medical, counseling, specialist
  care, prison

111
Policies programs - tobacco

• Tobacco most harmful recreational drug in terms
  of costs 1976 advertising banned on TV and
  radio
• 1988-1994 sale of cigarettes to children
  illegal
• Warnings, restrictions on promotion and
  sponsorship
• Passive smoking latest frontier
• Paradox of tax revenue
• VicHealth public health model
• High usage in Australia
• One in five admissions to hospital alcohol
  related (Baum, 200240)
• Personal choice legal substance
• Harm minimisation
• Education
• Industry self regulation
• 1980-1990s moderate approach harm
  minimisation health problem rather than a
  criminal problem
• Shift under the Howard Government debate that
  illegal trade makes it difficult for people to
  seek help - ties with crime and corruption
• Ongoing debate

Alcohol
Illicit drugs
112
Harm minimisation

• Drug use will continue to be part of society
• Eradication is impossible and maybe
  counterproductive
• People make choices
• Focus on the harm it causes rather than on the
  use itself
• Choice
• Supply reduction legislation and law
  enforcement
• Demand reduction health promotion, education,
  alternatives to drug use, treatment programs
• Harm reduction information about safe usage
  e.g. needle exchange, low-risk driving, safe
  injecting rooms, methadone, warnings on labels
• Harm minimisation flexible approach, non
  judgmental, focuses on client engagement, focus
  on individual and community

113
Previous policy

• Tough on drugs
• Parents and families talking with their children
  
• I believe that the best drug prevention program
  in the world is a responsible parent sitting down
  with their children and talking with them about
  drugs. PM John Howard
• Ignores structural issues assumes all children
  have responsible parents and all parents share
  one view. Poverty, stress etc.
• Importance of political agenda evidence based
  research.

114
What does this mean for social workers?

• Likely that many people you work with will use
  alcohol and other drugs across the life span
• Indigenous communities
• Links with violence
• Harm minimization
• What works?
• Public health but what happens in the meantime
• Range of interventions self help, insight,
  groups, medical, behavioural, dual diagnosis

115
What is Evidence Based Practice?Rubbin Babbie
(2008)

• Practitioners make practice decisions using the
  best available research evidence
• Synthesis of scientific knowledge and practice
  expertise
• Evaluation of outcomes of decisions
• E.g. new client you might
• Identify diagnostic tools assessment
• Treatment plan developed in light of the best
  research evidence
• Same for policy development
• Critical thinking rather than authority based
  practice
• To do this need to find the evidence ongoing
  lifelong part of practice
• Evidence can be inconclusive, not there etc. the
  important thing is that you seek it out
• Needs to be client centred research

What makes an evidence based practitioner?
116
Ethics and BioEthics

• What are ethics?
• A system of moral principles by which human
  proposals may be judged good or bad, right or
  wrong
• The rules of conduct recognised in respect of a
  particular class of human actions for example
  medical ethics
• Moral principles of an individual
• (Macquarie Dictionary, 1991)
• Values
• personal values
• social work professions values
• employers values
• underlying values of policies and programs
• underlying values of our political system

Ethics and Social Work
117
Code of Ethics AASW
http//www.aasw.asn.au/adobe/about/AASW_Code_of_Et
hics-2004.pdf

• http//www.aasw.asn.au/adobe/about/AASW_Code_of_Et
  hics-2004.pdf

118
What are your ethics?

• Euthanasia
• Conflict with employing agency
• Mental health
• Child Protection
• Family dynamics
• Termination
• Sexuality
• A mother brings her 9 year old child to the
  child and adolescent clinic because of
  behavioural problems. The childs parents are
  divorced but retain joint custody of the child.
  The child needs help. The mother says the father
  would object if he knew the child was coming to
  the clinic. Should you tell the father about your
  contact with the child?

Case Study
119
Social work in health foundation principles

• What does illness mean?
• The impact of illness
• Psychological consequences of illness
• Where does social work fit in?

120
Case study

• Kim (42 years) and Mary (39 years) live with
  their two children, Henry (15 years) and Crystal
  (10 years) in a Housing Trust apartment. Kims
  mother Mrs Lim (68 years) lives there with them.
  Kim is devastated as he has been diagnosed with
  cancer. Mary has been referred to the hospital
  social worker because she wants to understand how
  to help her husband and children and she would
  like to know what the options are.

121
Social Work Practice in Health Care

• Assessment is key response
• Who will be affected by the change of
  circumstances?
• Systems and intersections
• Who do you ask?
• What do you observe?
• What methods does social work use?
• What is the social work role?

122
Mental health and social work
123
What is mental health?

• Mental health is the embodiment of social,
  emotional and spiritual wellbeing. Mental health
  provides individuals with the vitality necessary
  for active living, to achieve goals and to
  interact with one another in ways that are
  respectful and just. (VicHealth 1999)
• A psychiatric disorder is a psychological
  syndrome (or pattern) that is associated with
  distress (unpleasant symptoms) or dysfunction
  (impairment in one or more important areas of
  functioning) or with an increased risk of death,
  pain or disability. (Bloch and Singh 2004)

What is mental illness?
124
Normalisation and De-institutionalistion

• The de-insitutionalisation discourse follows the
  historical response to mental illness when
  sufferers were sent away from the town to live.
• Over time the unwanted people were then placed in
  poor houses, asylums or gaols.
• Thus was an institutional system with a captive
  population, the motivation for which sometimes
  stemmed from kindness, sometimes from fear of the
  different or the inexplicable.
• This institutional response remained the dominant
  approach to problems posed by the mentally ill,
  to those with permanent disabilities, until the
  1960s.
• The institution and the community were seen as
  two separate, and distinct entities provision of
  services to, thinking about the disabled, a
  group seen as separate from the community.

125
Reform

• Reform of the institutional system brought a new
  way of thinking about the mentally ill or persons
  with permanent disability.
• Considered important to maintain individuals in
  the community.
• Belief that institutionalisation may still serve
  a useful purpose for the severely socially
  disabled for those who have no care givers or
  supportive networks for those who need
  specialist services and professionals who
  understand the physiology and treatment of
  disability and mental illness.
• Institutionalisation as a response to those who
  find de-institutionalisation too complex, too
  problematic, who have no independent living
  skills, who may become trans-institutionalised

126
Mental Health Continuum

• HealthygtUnhappy/Anxiousgt Miserable/Withdrawngt
  Mental health problem or illness
• Ideas about mental health and mental illness, and
  causes, range from view that an emotional, or
  psychiatric, illness, is like any other illness
  and so is treated as a physical illness, to being
  seta apart.
• Mental health and mental illness are on a
  continuum, according to events internal and
  external in their lives.

127
Social Work Role

• Are usually employed as part of a
  multi-disciplinary team - required to contribute
  a social work perspective to this team.
• Some of the contributions of social workers are
  complex case management skills, information on
  child protection, a holistic and systemic view of
  the problem, discharge planning skills,
  advocacy and networking skills etc.
• Social workers need to be able to do the
  following
• provide a social work perspective to the
  multi-disciplinary team
• undertake a Mental State Examination
• carry out a Risk Assessment
• present treatment options

128
Developing a critical and clinical paradigm for
mental health social workNoel Renouf Robert
Bland

• Clinical work
• A particular type of setting (the clinic)
• Unlike others (NGOs, user run services)
• A particular focus on the work (treatment)
• Not necessarily rehabilitation, recovery
• Increasingly associated with other discourses
  risk management, statutory context and evidence.

129
Clinical mental health social work

• Traditionally associated with
• Structural understanding of the causes of mental
  health problems and responses
• Critique of psychiatry
• Critique of institutional practices and power
  imbalances
• Emphasis on rights
• Increasingly associated with links and alliances
  with service users and their organisations and
  movements

130
The domain of mental health social work

• Social control of mental health problems
• Social consequences of mental health problems
• Social justice

131
How the dilemma plays out?

• Consider the social worker entering the workplace
  motivations, knowledge and attitudes,
  developing skills
• In a clinical setting diagnosis vs
  understanding, narrowing of conceptions of
  therapy CBT, EBP
• Treatment Protection Human Rights
• Place of service community development

132
Difficulties in achieving a balance
133
Difficulties in achieving a balance
134
Key Issues
Concerned about power Unconcerned about power
Concerned about symptoms Focus on both e.g. housing - focus on symptoms - ?relationships, advocacy etc
Unconcerned about symptoms e.g. housing focus on advocacy Advocacy for housing stock ???? Lost
135
Critical and Clinical Paradigm

• Engagement with the lived experience
• Healing power of relationships
• Critical reflection
• Openness to wider sources of knowledge and
  evidence
• Close attention to the concerns of clients
  micro and macro

136
Social work in mental health

• Strong management presence
• Represented on almost every clinical team
• Case management roles
• Strength in disability support
• Training and education

137
Workforce

• Growth in allied health social work, psychology
  and occupational therapy
• Over one third are in regional, rural and remote
  areas
• More than 900 accredited mental health social
  workers
• Practice Standards AASW
• http//www.aasw.asn.au

138
Domain of social work

• Social context the person in environment
• Social consequences- impact on individual, family
  and community
• Social justice stigma, discrimination, human
  rights, access, choice

139
Mental health social work
140
Consequence of Social Work Focus

• Beyond illness and treatment
• Individual and family welfare
• Identity and relationships
• Housing
• Work
• Income security

141
Consumers and families good mental health
social work practice

• Respect, dignity, empathy, kindness and
  compassion
• Common courtesies
• Honour strengths and abilities and set realistic
  goals and work to achieve them
• Uniqueness of the individual
• Basic skills assertiveness, reflective
  listening, advocacy, conflict resolution
• Concerns of families and carers taken seriously
  balancing act
• Open to feedback
• Appreciate their value and importance of their
  role in the mental health system

142
Mental State Examination

• Appearance - dress, grooming, posture, gait,
  voice, gender, expression, odours, coordination,
  etc.
• Perception - alertness, orientation to time and
  space, memory, auditory and visual
  hallucinations, illusions, accuracy, etc.
• Thinking Processes - content, main themes,
  general knowledge, dreams, fantasies, wishes,
  obsessions, delusions, coherence, disturbance in
  flow, abstract reasoning, defence mechanisms,
  language, fluency, comprehension, insight and
  judgement, objectivity, etc.
• Affect - Emotional tone of interview, range,
  variation, intensity, appropriateness to content,
  awareness and control of feelings, congruence.
• Behaviour and activity - i.e. themes, goal
  directed, persistence, concentration, reaction to
  stimuli, age- appropriateness, etc.
• Attitude to self and others - view of self,
  ideals and aspirations, goals, body image, sexual
  identity, self esteem, feelings of belonging or
  alienation, trust in self and others.

143
Risk Assessment(1)

• Involves determining whether a person is at risk
  of harm to self or others.
• In completing a risk assessment, one needs to
  establish with the patient/client
• if they have ever considered harming themselves
  or others.
• If yes, then what plans do they have and do they
  have access to/or means to complete this plan?
• One needs to establish how long this has been
  their plan and if any attempts have been made to
  date to carry it out and what were the
  consequences.
• Furthermore, have they informed anyone else about
  it or sought help.
• Also, establish whether they in fact wish to seek
  help and how or from whom.

144
Risk assessment (2)

• If the person is clearly indicating a wish to
  harm self or others, then establish a contract
  with them i.e., a guarantee of safety.
• If the patient is unable to guarantee safety,
  then steps need to be taken to ensure their
  safety which may be to have them admitted to an
  inpatient service. This may entail that they be
  certified if they are unable to give consent and
  are deemed to be mentally ill.
• At times it may be sufficient to contact next of
  kin and ensure that the patient returns home in
  the care of someone who can keep them safe.

145
Classification of psychological disorder

• Certain behaviours/feeling are signals for mental
  health problems.
• The common classification of mental illnesses
  (from the DSMIV or the Diagnostic and
  Statistical Manual of Mental Disorders) is
• 1. Affective Disorders
• 2. Anxiety and Somatoform Disorders
• 3. Schizophrenic Disorders including Psychotic
• Disorder
• 4. Personality Disorders
• 5. Organic Disorder (for example, Alzheimers
  Disease)

146
Assessment

• The DSM IV provides a framework for
  treatment/rehabilitation and for prediciting
  likely outcomes for the individual and their
  family.
• Assessment of any individuals problem however
  must be in their own environment, relate to their
  individual personality and be mindful of
  sociocultural, development, and historical
  factors.
• Problem signs are signals for assistance and
  understanding rather than answers in themselves.
• The mental state examination is the assessment
  tool to determine the severity and nature of an
  individual's problems and whether the individual
  is a risk to themselves or to others.

147
The health-disorder continuum

• Most emotional problems can be resolved with or
  without professional assistance. Individuals move
  along a mood continuum
• Everyone has the capacity to be depressed, or
  anxious.
• These neurotic traits are extensions or
  exaggerations of normal behaviour.
• When these traits, or behaviours, interfere with
  individual functioning, they are problematic and
  indicate what has been termed in the past "a
  nervous disorder" or "neurosis".
• This includes anxiety states (which include
  phobia, obsessive compulsive disorder, panic
  disorder), depression, post-traumatic stress
  disorder and physical disorders that have a
  psychological origin.

148
(No Transcript)
149
Framework of adult psychological disorder

• Anxiety and depression
• Dr Noel Renouf

150
Recap of assessment the building blocks

• Disturbance of mental functions
• cognition
• thinking
• perception
• mood
• behaviour
• These building blocks are what psychiatrists and
  others generally assess, and from these they try
  to make a diagnosis

151
Cognition

• All core thinking functions
• conscious state
• memory and its subdivisions
• concentration and attention
• maths like calculation
• executive functions
• Key disorders delirium dementia

152
Logical thinking

• Using your cognitive abilities to think things
  through clearly and relatively efficiently!!
• Stream getting from A to B
• Form logical or not
• Content major thinking themes e.g. paranoid,
  suicidal etc
• Key Disorder schizophrenia

153
Perception

• Disorders of the five senses
• typically hearing and vision, but any.
• Hallucinations mainly
• Key disorders psychotic disorders

154
Mood

• Feeling state, emotions etc
• Mood is how you feel generally, and affect how
  you feel now.
• Mood is said to be the climate, and affect the
  weather
• Key Disorders depression, bipolar disorder,
  anxiety disorders

155
Behaviour

• The things we do Eat, sleep, move about, dress,
  social interaction, play games etc etc
• Risk behaviour including suicidal and homicidal
  ideas
• Eating behaviours
• Key disorders personality disorders, eating
  disorders, drugs and alcohol.

156
Neuroses

• Anxiety States
• Obsessive Compulsive Disorder
• (Reactive) Depression
• PTSD
• Social phobia
• Eating disorders
• Panic disorder

157
Indicators of neurosis

• First, decreased efficiency in social functioning
  and disturbances in interpersonal relationships
• Second, behaviour patterns are self-defeating
  or maladaptive life patterns. Intensity and
  duration of behaviour are key factors in
  assessing behaviour as problematic and in need of
  attention and possibly professional assistance.
• Third, assessment must take into account the
  individuals own personality, life situation and
  general social situation.
• Fourth, with anxiety and depression (excluding
  psychotic depression) and the other states
  mentioned above, the individual has insight into
  their situation The individual with a psychotic
  disorder may not have this insight, and their
  detachment from reality may render them unable to
  see themselves and their behaviour relative to
  others.
• Fifth, non-sufferers can identify, more likely to
  be sympathetic they may have experienced elements
  of these behaviours themselves, or can see that -
  given certain circumstances - it could happen to
  them.

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