Tag: mental health

Research in Social Work – January 2020 links (Open or Free Access papers)

When I started writing at the beginning of the year, I thought I’d compile a summary of links each month about news and research, but it became a bit too much to compile, and this is, fundamentally a hobby for me.

So, I’ve decided instead to highlight each month some open access papers that I’ve found useful, interesting or have bookmarked for later, that others might want to read because we all want accessible research information and the more we read, the more we understand what is worth reading. So here are a few for February – they aren’t always new, but they will be new to me!

This paper in Social Work Education (May 2019) looks at how critical reflection is taught in social work courses specifically in relation to working with older people.

This issue (2018) of the British Journal of Learning Disabilities is open access (most aren’t) so is worth browsing and includes (among other interesting ones) this article which is a study on what is it link to move house for people with learning disabilities.

This is a free access review of literature about trauma-informed care in inpatient mental health services (2013) from the International Journal of Mental Health Nursing which is a useful way to get a broader view of the topic at the moment.

On a slightly different tack, Critical Social Policy have an open access article from January 2019 on ‘Raising Critical Consciousness in the struggle against poverty’. Nice of them to make it free! Seriously though, we need to speak about poverty and the impact it has on our work at every level.

And Practice – Social Work in Action, has this article about decision-making of AMHPs which is a useful read from 2019.

Although this is not ‘my’ area of social work, this paper in Qualitative Social Work from December 2019 with birth mothers’ accounts of the impact of the removal of their children on their future lives has impact for all of us in the sector.

This 2017 paper on the role of trustworthiness in social work from Australian Social Work is definitely something I found helpful in my consideration of how we carry out ethical social work.

Paper review: The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospitals – A Mixed Methods Study

This post refers to ‘The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospital : A Mixed Methods Study‘ – Wickersham, A, Nairi, S, Jones R and Lloyd-Evans, B. Published in British Journal of Social Work in April 2019.

Introduction

This paper presents a mixed method study using data from mental health act assessments followed by interviews with AMHPs (approved mental health professionals), s12 doctors and some AMHP managers in a focus group.

A Mental Health Act Assessment is a formal process in England and Wales, which relates to the provisions of the 1983 (as amended 2007) Mental Health Act. It is the process by which a person can be compulsorily detained in a hospital which is registered to provide care and treatment. An application for detention is made by an AMHP (who is a social worker, nurse, occupational therapist or clinical psychologist who has received additional specialist training and is approved by the relevant local authority) and it requires the recommendation of two doctors, at least one of whom should be independent (the other can be the treating psychiatrist or can be a GP) and who has preferably received additional training under section 12 of the Mental Health Act.

This process is commonly known a ‘sectioning’ a person.

Methodology

The study is described as ‘mixed methods’ because it integrates elements of quantitative and qualitative research methodologies. The researchers took a range of data from AMHP reports following Mental Health Act Assessments and the information held on electronic databases within the trust to analyse some characteristics and outcomes of people who were assessed under the Mental Health Act within a specific time period. 150 records were analysed, including retrospective case record audits of which 146 were included. The researchers noted that there were fewer, and less complete records for assessments which had not resulted in detention which meant they covered a longer period in order to ensure some were included.

Only assessments which took place in the community were included and anyone who was recalled on a CTO was excluded.

Some of the characteristics identified or used to differentiate included what, if any, diagnosis the person assessed had, whether the reason for assessment was due to concerns about risk of harm to self and/or others and whether a ‘lack of capacity or insight’ was noted (I’ll come back to this).

Then the researchers undertook semi-structured interviews with 4 AMHPs, 4 section 12 doctors and ran a focus group with 3 AMHP service managers. These were subject to thematic and content analysis.

My first thought was that it was a small group of interviews and that it might reflect a lack of balance in the importance of each conversation but the number of AMHPs within one trust is small so as a representative sample of 53 AMHPs employed it was a fair percentage.

The paper refers to the outcome of the study being discussed with the AMHP leads and involving ‘a research colleague who has lived experience of using services and working as a peer support worker in the participating trust’ but that just begged a few more questions in my view.

Context

This study took place in one London trust. It is described as an ‘inner London trust covering two local authorities’ which, for anyone who knows London mental health, narrows it down to one trust. I had to try to stop myself being distracted by this because I was an AMHP in one of those boroughs, in that trust, so kept thinking of people I used to work with, but that’s not the best perspective from which to start reading a paper in a neutral manner. However, it does emphasise the truism that we don’t read papers in isolation of our own experiences and knowledge of situations. So while, in one sense, I am trying to move away from that and read the paper as if I had no idea where it was and who might be being interviewed, I am also able to acknowledge the role that self, and background knowledge always plays when we read papers and research.

The aim of the study was to focus on potential increases in the level of detentions and to look at any barriers to alternatives to admission or what might or might not influence decisions to detain someone under compulsion which is an extreme action regarding the deprivation of liberty of another person in the context of state infringement of the human rights of another person.

Key learning points

Some of the themes identified will be familiar to those who have worked in this field for any length of time. One related to the potential difficulties caused by not having three professionals assess at the same time. A doctor may make a recommendation and this can be followed up by an assessment with a doctor and an AMHP attended at the same time. One of the issues identified was that the first recommending doctor may be influenced to recommend detention, as the paper states

‘ one doctor suggested that, as the first to do an assessment, it can feel safe to recommend detention and pass responsibility to the second doctor’

p12

This was followed by the further discussion that the AMHP and second doctor may be influenced by the first recommendation.

Issues were raised as well about the individual different in attitudes, experience, knowledge and confidence with understanding risk thresholds which can be key to the outcome. Personality and unconscious bias may play a role in the outcomes of assessments.

One of the key themes to emerge, unsurprisingly, was that the impact that lack of alternative options to admission, made on the decisions to detain. If there were no places in crisis houses, capacity in crisis resolution teams, day services that met the needs of the person who required support, family and informal support in place, it could have a significant impact on the outcome and decisions made. Lack of access to substance misuse services may also have an impact on some decisions.

It may also be about the assessing team not knowing what the alternatives are for that person. One of the key pieces of learning the researchers emphasise is the potential difference in outcome when someone has a member of their community team present, or a family member or someone who knows the individual. This can help to identify both options and the lack of suitable options.

There were some issues raised around poor operational processes including the role of inpatient services. This included poor discharge planning which led to hasty readmission and poor continuity of care between community and inpatient teams. There were some additional factors which might be more relevant in the type of area it is, around access to support for people who are non-UK residents. This is an area which may include some people who are visiting the area.

Reflections and gaps

The paper identifies some of the difficulties in identifying data in the assessments considered for inclusion and reflects that out of the 150 assessments analysed, 22% had missing or incomplete AMHP reports.

The identification of ‘lack of capacity or insight’ as one of the categories in which the assessments were sorted, indicates to me a lax approach to the term and use of ‘capacity’. I never want to see the term ‘lack of capacity’ in any document that doesn’t refer to what the lack of capacity is for. I accept this is my pedantry, but is if it ‘lack of capacity to consent to an admission to hospital for assessment or treatment’ it wouldn’t take many more words to say so and these phrases add to the general misconception around capacity and/or insight, that it can be applied broadly, or maybe it’s me not understanding the implicit suggestion that this is specifically capacity to consent to admission.

The sample size is local to one trust so the findings can’t necessarily be used to evidence situations in other geographical areas. The interview sample sizes are small which can attribute far more importance to one or two, what might otherwise be, throw-away lines. That doesn’t mean that the importance of what is said isn’t valuable. It is, but it needs to be recognised in the context of the sample of assessments and the sample of interviews.

The involvement of management staff was key to understanding some of the context in which the study happened and the management team reviewed the data which was prepared for inclusion but that does offer a consideration about any self-imposed restraints that those interviewed might have felt in terms of criticism of the organisation, given that the sample size was so small. However, saying that, there was a fair bit of criticism for the organisation coming through but it may have been a factor.

The study only looked at community assessments because the focus was on avoiding hospital admissions. This meant that the voices of those who are detained in hospital and views of inpatient teams are lost. It is possible, especially with longer admissions, that some inpatient staff may have built up a different perspective about blockages and this aspect was intentionally lost. That is due to the limitations of the study rather than a lack of thought in the process.

This is research which is about the outcomes of Mental Health Act Assessments and the process of completing them. The study was focussed on professional views and records. There was a researcher who was there to review, who had lived experienced and the purpose of this research was to present a professional perspective but I wonder if there are more gaps around involving people who have experienced detention, in the processes of research and using social work research as empowerment. I know there are other studies which have and are doing this so it does feel like an unfair criticism but I felt it would be remiss to ignore it totally.

Use in practice

So what does the paper tell us that we can use in practice? The key headline and of course, this may be increasingly difficult in the face of cuts in services, is the importance of having someone who knows the person being assessed, present as part of the assessment, whether that is the care coordinator, or a family member or person who works with them through a third sector organisation.

It is also preferable to have the assessing team carry out the assessment at the same time. Often this is not lacking because there is an intention to make the process more challenging but due to availability of staff who are more frequently pressed by competing needs. It is useful to point to a study which evidences this as a factor.

The other aspect is to keep pushing for better options around prevention. This isn’t something that everyone can change but we can keep advocating and shouting for improved services which lead to better outcomes . I don’t know how much difference this makes when it is a factor that is far bigger than the individual practitioner, team or even organisation but it always needs to be referred to and having the evidence to do so is helpful.

Conclusion

This was a very useful paper to me in a lot of ways. It helped to show the way that mixed methods can be used effectively and how they can form a cohesive approach to understanding a problem. The outcomes and concerns raised were ones I recognised and I suspect will be recognised by those of us working in this space. Did I learn new things? Possibly not, but I found I have evidence to back up some of the assumptions made and that is key to pushing changes and improvements. If organisations can be presented with evidence linking the lack of capacity in the service, to involve people who know the person being assessed in the assessments and show that this leads to more admissions and therefore more cost, it may be a trigger to change systems.

And even if it isn’t, it allows us to talk about about what we see with more authority.

Paper Review: An Australian perspective on Community Treatment Orders

A review of  ‘Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders, Australian Social Work, 66:1, 72-85, DOI: 10.1080/0312407X.2011.651727‘ Lisa Brophy and Fiona McDermott 2013

Introduction

By looking at this paper, I am reviewing some of the content to make it more accessible and combining a summary of what I find to be the key points, with my own understanding and interpretation. I am no expert and I am no academic. I am interested and with that proviso, I will continue.

I came across this paper as I was looking at the way that ethics and values reflect on social work decision-making and while my focus is more on decisions made about best interests and mental capacity, there is a clear line in comparison with studies completed in other areas, particularly the use of compulsion in social work and how we, as practitioners respond to it. I found the explanation of the methodology and the theoretical approach clear and helpful in my own thinking on two levels.

I’m interested in research design and comparing the robustness of the evidence gathered and different approaches taken, and secondly, when looking at how I integrate theory, both social work theory and broader social research theories into both my own practice and my research work, the most useful learning is reading papers where it has been done and other doctorate level theses available through EThOS (British Library free repositary of over 500,000 theses – and worth checking).

Background to the study

This is a paper written for Australian Social Work. It is looking at the use of community treatment orders specifically in the state of Victoria, Australia. It seems that CTOs have a longer history than their use in the UK and at the time of writing, the authors claim that there are around 5000 current CTOs. The paper looks at how compulsion links with social work values and practice particularly around theoretical perspectives. It is useful as it links the use of theory to practice in a setting where compulsion is used and reflects the tensions in the social worker’s role. It was definitely something that spoke to me, not just in terms of the research, which is useful for my own work in this area, but more interestingly, perhaps, for me when I go to work on Monday to consider with people I work with who do not choose to work with me and, indeed, are compelled to do so.

Methodology

Looking at the methodology, it is a mixed methods study. This means that there are both qualitative and quantitative aspects to the study. I tend to enjoy reading the methodology parts of papers. To me, it is what distinguishes research from opinion and most of the papers I read are pure qualitative studies, not by design, but because I am trying to learn more about qualitative research so approach this by reading more papers where these approaches have been taken.

This project started with a broad-ranging cluster analysis of 164 people who were on the community treatment orders used in Victoria, Australia. Cluster analysis is a specific quantitative methodological approach to using statistics to establish common ‘clusters’ of data, in this case, types of people who would be subject to community treatment orders. The specific methodology may be related to creating clustering algorithms and assigning different features so that the types or clusters emerge from the data. With some biographical and socioeconomic factors being allowed to emerge from the data, this allowed researchers to use the emerging key ‘clusters’ to identify a smaller group of people, reflecting some of the key ‘clusters’ identified, to be interviewed in more detail using semi-structured interviews. This was followed up with additional interviews of family or carers, case managers (presumably, although this is not explicit, who would be for the most part, social workers) and doctors involved.

There were then follow up interviews conducted after 6-12 months with people involved around the use of CTOs including those subject to them, professionals involved in working with them and family or carers. Additional interviews were undertaken with those involved in tribunal (or equivalent) hearings, senior managers and those involved in policy.

This is a brief summary so does not include all the complexities but it does reflect the thought process behind the choices of methodologies involved and reflects back how social work theories have led to each of these steps, including the involvement of people who are subject to these orders being at the heart of the process of researching about them.

Outcomes

The paper identified ‘significant clusters’ relating to being ‘connected’, ‘young males’, ‘chaotic’. The research team used these differing clusters to recruit for the interview stages of the research study.

The researchers, linking back to previous studies which had looked at the use of CTOs, identified five principles which could improve practice based on the interviews. While, they identified that these principles reflected some of the guidance currently in use in practice, the difference that the research was able to tap into was to highlight diversity within the groups of people subject to CTOs. I think these principles are valuable to reflect on and while this research is about a specific intervention in Victoria, Australia. It isn’t an enormous leap to see how they may reflect some potential to improve practice in areas where compulsion is used by and with social workers.

The following are identified on p78 of the paper:

  • Use and develop direct practice skills
  • Take a human rights perspective
  • Focus on goals and desired outcomes
  • Aim for quality of service delivery
  • Enhance and enable the role of key stakeholders

Theoretical perspective

The paper establishes it’s focus on the framework of critical theory, which allows a discussion about the role of power in social work and particularly in areas of social work where compulsion is used. This is also carried through to understanding the role of power within research. The authors have acknowledged this and reference their awareness of the principles of emancipatory research by ensuring that those who are subject to CTOs have been central to the research design. One of the principles the authors reflect, is that of empowerment and by giving people a voice through research carried out about them, it is enabling change to be made.

Additional reflections and gaps

I think of this research both in connection to my own studies and my own work. The first thing that jumped to my mind is that the need to have an international perspective when it is relevant but to be aware of the differences as well. This study is very much about one system of compulsion within mental health with adults. I don’t know the age range or diagnosis types of those who were interviewed and didn’t need to for the scope of the study. One thing that struck me, which may, very well reflect differently to a social worker based in London, is the analysis of race. This is not as a criticism of this study but one which might have different focus in different settings. Critical theory looks at the differing, sometimes competing and often co-existing ‘labels’ determined by studies and organisations to typify people who receive different types of input and I am particularly interested in where internal biases from professionals might impact outcomes.

Learning for practice

The key learning that I have taken from this study is an understanding of how we work within paternalistic frameworks of compulsion as social workers and I found some of the discussion around theoretical approaches and particularly the use of critical theory, to be most useful in both identifying this tension and acknowledging some of the hypocrisy between values which say they promote empowerment but work within frameworks which can be the most oppressive. The authors acknowledge this tension in trying to pull out ‘best practice’ guidance using the input of those subject to these interventions, while also acknowledging the purpose of the study was not to challenge the existence of CTOs and frameworks of compulsion, but that doesn’t mean we can’t and shouldn’t, indeed, we should, continue to constantly challenge the way we work with compulsion in mental health care and look at other options.

Regarding the specific good practice identified, as listed above, some are about organisational needs, such as ensuring that social workers have specific training and space to reflect on the use of compulsion in practice, rather than just being expected to ‘pick it up on the job’. As social workers in the UK, if we are trained as AMHPs, there will be a focus on this as part of the training, but that doesn’t mean there isn’t room for more learning as this training is not necessary to work with people who are compelled to work with social workers. And it is not enough in itself to give people training at key points and then leave them too it. This is the way one can become overly familiar with compulsion as a tool and desensitised to it. We need to guard against this which can be done through supervision and reflection.

An interesting aspect of the human rights perspective, was identified as well – which recommended ensuring people who are under compulsion are aware of their rights and why the limitations to liberty have been imposed. The study refers to procedural fairness and thoughtful decision-making being a key factor. This phrase is something we can always work harder on.

Involving other stakeholders, and in my role, I am thinking particularly of family members, friends, carers, is something that I can always do better. It is true that sometimes the conversations are not easy and there are issues of confidentiality around information sharing but support can be offered and must be in order to work best for people. There are other stakeholders in the form of commissioners, regulators etc but for my own work ‘on the ground’ the involvement of those people around the person I am working with is the key learning.

Finally, the importance of being able to deliver a quality service when people are compelled to have treatment is something that I might not be able to change individually, but it is key factor and it certainly reflected my concerns as an AMHP when I was practising as one (I am no longer warranted). If we compel someone to a hospital admission but the hospital care is poor, we can be complicit in harm rather than help. It is difficult to justify compelling someone to treatment when the treatment is of a poor quality. This is something we must always challenge and complacency can be easy.

Conclusion

I am no academic, but sometimes finding papers which can speak to me in practice can provide a real motivation to the value of research and the importance of being aware of what research is and has happened around the world that can lead to better outcomes tomorrow. What’s more, we can tell our managers that we can link our need for additional training (for example) to evidence.

I’m not pretending my analytical skills are on a par with any academic, they aren’t. But by trying to portray what I can take from this paper, I am hoping that it will encourage others to read more where the papers are accessible, at least, and learn about the profession and how it has and will continue to grow.

I’m absolutely sure as I’ve read through this paper, there are key points I’ve missed, misunderstandings and poor analysis. I am not setting myself up as a font of knowledge but rather, in my ramblings, hoping to take an opportunity for others to try to learn with me but the original research is always the best place to start, rather than any commentary I might be able to ramble through.

%d bloggers like this: