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The Individual, Health and Society: SWK 4220

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Title: The Individual, Health and Society: SWK 4220


1
  • 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

2
Workshop timetable
9.30 Social Work in Health - Introduction
10.00 Health
12.30 Lunch
1.30 Mental Health
4.30 Summary and Close
3
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

4
  • 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.

5
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.

6
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)

7
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.

8
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)

9
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?

10
National Health Strategy 1990s
  • Needs of populations
  • Inequality
  • Efficiency
  • Cost effectiveness
  • Public engagement in debate
  • Rights and responsibilities

11
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

12
Levels of Service Delivery
13
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

14
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)

15
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16
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

17
What changes to health care services have you
noticed in your area in the past five years?
18
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

19
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

20
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/
21
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/
22
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

23
Sociology of health
  • Sociological lens
  • social patterns age, sex, race, class, culture,
    geography, community profiles
  • processes interest groups, beliefs and history
  • social relationships power

24
Risk factors
  • Diet
  • Environment
  • Occupational health
  • Stress
  • Unemployment
  • Poverty

25
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

26
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

27
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

28
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.

29
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?

30
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

31
Theoretical frameworks
  • Bio-psycho-social
  • Psycho-analytical
  • Ego psychology
  • Systems theory
  • Behaviourism
  • Feminist
  • Strengths based
  • Solution focused
  • Others?

32
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

33
Crisis intervention
Constructive
Relative homeostasis
Destructive
34
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

35
MultidisciplinaryInterdisciplinary
  • Allied health profession
  • Ownership of the patient
  • Sharing of roles
  • Emergence of case management
  • Sharing of roles with others
  • Negotiating boundaries and roles

36
Allied Health
Psychology ?
Taken from Austin Health promotion The Well
Wisher Olivia Newton John Cancer Center Appeal
Spring 2007
37
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

38
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

39
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?

40
Meaning of health and illness
  • People experience illness differently
  • Lens for example
  • Culture
  • Class
  • Gender
  • Age
  • Sexuality

41
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

42
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)

43
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.

44
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)
45
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

46
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

47
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?

48
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

49
  • Indigenous health
  • DVD Bringing Them Home

50
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

51
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)
52
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

53
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
54
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

55
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

56
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

57
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

58
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

59
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.

60
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

61
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64
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65
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66
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70
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.

72
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.

73
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.

74
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75
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

77
Intergenerational tensions
78
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79
Social work roles
  • Acute hospitals
  • Rehab
  • Residential Care
  • Grandparents as parents
  • Community health services
  • Community support
  • Community development

80
  • Disability
  • DisAbility

81
Images
82
http//www.pwd.org.au/
83
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)

85
Chronic illness
www.chronicillness.org.au
86
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87
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.

88
Stereotypes
  • Dependent
  • Passive
  • Non-compliance blame
  • Expensive
  • Walker, C (1999) Health Issues, V59, pp 10-13

89
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
91
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
93
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
94
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
96
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

97
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)

98
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
100
Child with a disability
  • Trauma and shock
  • Loss and grief
  • Marital stress
  • Integration
  • Tiredness
  • Life stage adjustments
  • Transitions loss and grief

101
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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