A role for social workers in mental health was established early in Canada's history of service delivery in this field. Primary mental health care was institutionally based for the first half of the century, with a period of de-institutionalization beginning in the late sixties preceding the current emphasis on community-based care. Throughout these changes, the role of social work has developed from one of providing social histories and supervising community placements to that of interdisciplinary team member/independent practitioner. The field of mental health provides a unique opportunity for social workers to practice collaboratively with allied professionals and at the same time maintain the integrity of their knowledge and skill base.
This document will define health and mental health; describe the current roles of social workers within the spectrum of mental health services; identify the necessary education and knowledge base; and consider future directions.
The following definitions are widely acknowledged and increasingly form the basis for developing and configuring the delivery of health and mental health services in Canada.
1.1 The Definition of Health
The World Health Organization defines health as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. It is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and, on the other hand to change or cope with the environment." (Health Promotion Glossary, p. 1) Achieving Health For All, a discussion document released by Health and Welfare Canada in 1986, reflects a growing awareness that health must be viewed in terms of our personal and social resources for action. It speaks of health as "a resource which gives people the ability to manage and even to change their surroundings...a basic and dynamic force in our daily lives, influenced by our circumstances, our beliefs, our culture and our social, economic and physical environments." (Achieving Health For All, p. 3)
This active concept of health a accords greater prominence than ever to the mental and social determinants of health. It also requires us to think of health as something experienced not only individually, but also collectively. Most significantly, this new understanding of health dwells less on people's traits as individuals and more on the nature of their interaction with the wider environment. "Environment" in this context is interpreted in its broadest sense, and includes not only our physical surroundings, both natural and artificial, but also the social, cultural, regulatory and economic conditions and influences that impinge on our everyday lives.
1.2 The Inseparability of Mental Health from Health b
Mental Health for Canadians: Striking a Balance, a 1988 discussion paper from Health and Welfare Canada, proposes a set of ideas designed to expand our understanding of mental health. This document points out that until recently much of what we know about mental health actually came from the study and treatment of mental disorders. Past attempts to define mental health have usually focused on the psychological and behavioural characteristics of individual people, rather than on conditions in society as a whole. In much the same way, most of the services, programs, laws and professions that have to do with "mental health" are really oriented towards dealing with mental disorder. In these circumstances, it is easy to understand how mental health has come to be viewed simply as freedom from psychiatric symptoms, or the absence of mental disorder.
In the past few decades there have been significant developments in our understanding of mental health. They have arisen from a growing community mental health movement and a body of social science research that places increasing importance on the ability of external forces and events to influence individual mental health. Social and economic situations, family and other relationships, the physical and organizational environment - all are plainly recognized as contributing factors. As a result, current concepts of mental health reflect a number of themes:
- psychological and social harmony and integration;
- quality of life and general well-being;
- self-actualization and growth;
- effective personal adaptation; and
- the mutual influences of the individual, the group and the environment
The essential role of physiological processes (and, in particular, brain function) in all mental life has become more and more evident. We now know that human biology and human experience interact continually in shaping mental life.
Mental life embraces both inner experience and interpersonal group experience. Our interactions with others take place within a framework of societal values; therefore, any definition of mental health must necessarily reflect the kind of people we think we should be, the goals we consider desirable, and the type of society we aspire to live in. Social workers do not isolate ideas about mental health from such wider social values as the desire for equality among people, the free pursuit of legitimate individual and collective goals, and equitable distribution and exercise of power.
1.3 The Definition of Mental Health
It is from this perspective that the following dynamic and interactive definition of mental health has been developed:
Mental health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality.
In this definition, mental health moves into the realm of the relationship between the individual, the group and the environment. Mental health is no longer conceived of as an individual trait, such as physical fitness; rather it is regarded as a resource consisting of the energy, strengths and abilities of the individual interacting effectively with those of the group and with opportunities and influences in the environment.
This conceptualization leads to certain conclusions about the factors that can enhance or weaken mental health. Whatever makes it difficult for the individual, the group and the environment to interact effectively and justly (for example, poverty, prejudice, discrimination, disadvantage, marginality or poor coordination of or access to resources) is a threat or barrier to mental health.
A key feature of this new definition is that it does not define mental health in terms of the presence or absence of mental disorder, nor does it imply that mental health and mental disorder are simply opposite poles on a single continuum.
1.4 The Social Work Code of Ethics and Practice Domain
The social values which underpin this interactive definition of mental health are strongly congruent with the "humanitarian and egalitarian ideals" which form the value base of social work (Social Work Code of Ethics, p. 7). Further, the emphasis on "interaction" between person, group and environment fits closely with social work's "person-in-environment" practice domain: "The primary focus of social work practice is on the relationship networks between individuals, their natural support resources, the formal structures in their communities, and the societal norms and expectations that shape these relationships. This relationship-centred focus is a distinguishing feature of the profession." (CASW National Scope of Practice Statement, p. 2) Work in the mental health field requires an ability to work collaboratively and is strengthened by a systems perspective. As these knowledge and skill areas are emphasized in social work education, social workers are well positioned to play a significant role as our society strives to achieve mental health goals in the twenty-first century.
SOCIAL WORK ROLE DESCRIPTIONS
Although formal mental health services are generally delivered through the public service in Canada, voluntary or private sector agencies as well as private practitioners also play major roles in most provinces. Social workers are involved at the micro, mezzo and macro levels in all sectors. "The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilizing theories of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work." (Definition of Social Work, adopted by the General Assembly of the International Federation of Social Workers, Montreal, Quebec, Canada, July 2000.)
At the micro and mezzo levels social workers are primarily concerned with "the social well-being of individual clients and their families equally valued with the importance of their physical, mental and spiritual well-being." (CASW National Scope of Practice Statement, p. 1) At the macro level "social workers generally demonstrate a greater capacity to look beyond the illness and treatment issues, to consider the broader human, social and political issues in mental health.
This breadth of analysis and focus are specific strengths of social work in mental health." (The Development of Competency Standards for Mental Health Social Workers, p. 23) Social workers recognize the complexity of the social context. Social work goes beyond the medical model's focus on individual diagnosis to identify and address social inequities and structural issues. A distinguishing characteristic of social work practice is the dual focus of the profession. Social workers have, simultaneously, ethical responsibilities to address both private troubles and public issues.
Many of the roles that social workers perform are common to all mental health disciplines. Specific to the domain of social work are roles of building partnerships among professionals, caregivers and families; collaborating with the community, usually with the goal of creating supportive environments for clients; advocating for adequate service, treatment models and resources; challenging and changing social policy to address issues of poverty, employment, housing and social justice; and supporting the development of preventive programs. Prevention occurs on many levels and includes a focus on early intervention, individual and public education, advocacy and improving access to services, resources and information.
Mental health settings usually include services in three broad levels of health care application: prevention, treatment and rehabilitation. It is recognized that individual social workers may practice exclusively within one setting or cross the boundaries of all three in response to diverse client, family and community needs.
2.1 Prevention c: aims to reduce the incidence of disease or dysfunction in a population through modifying stressful environments and strengthening the ability of the individual to cope. Prevention involves the promotion and maintenance of good health through education, attention to adequate standards for basic needs and specific protection against known risks. In mental health settings, preventive activities include public and client education regarding emotional self-care and healthy relationships, building community knowledge and skills (community development), social action, and advocacy for social justice.
2.2 Treatment: aims to reduce the prevalence (number of existing cases) of a disorder or dysfunction and includes early diagnosis, intervention and treatment. In mental health settings, treatment activities are focused on individuals experiencing acute psychiatric symptoms, emotional trauma, relationship problems, stress, distress or crisis and include assessment, risk management, individual, couple, family and group counselling, intervention or therapy and advocacy. Social work uses relationship as the basis of all interventions.
2.3 Rehabilitation: aims at reducing the after effects of disorder or dysfunction, and involves the provision of services for re-training and rehabilitation to ensure maximum use of remaining capacities by the individual. In mental health settings, rehabilitation activities focus on clients who are disabled by mental illness and may include individual, couple, family, and group interventions to build knowledge and skills, provision of specialized residential, vocational and leisure resources, and advocacy to ensure the development of needed services and to change community attitudes.
Specific to their employment setting, social workers in mental health deliver the following professional services:
- Direct Services to individuals, couples, families and groups in the form of counselling, crisis intervention, therapy, advocacy, coordination of resources, etc.
- Case Management - coordinating inter-disciplinary services to a specified client, group or population.
- Community Development - working with communities to facilitate the identification of mental health issues and development of mental health resources from a community needs perspective.
- Supervision and Consultation- clinical supervision/consultation, maintaining quality and management audits and reviews of other social workers involved in mental health services.
- Program Management/Administration - overseeing a mental health program and/or service delivery system; organizational development
- Teaching - University and college level; workshops, conferences and professional in-services
- Program, Policy and Resource Development - analysis, planning, establishing standards
- Research and Evaluation
- Social Action
- BSW is the minimum standard; MSW is often required.
- Social work knowledge base which facilitates practice in this field includes theories of intervention, practice-based research, concepts and theories of human development through the lifespan, mental health, family functioning, group behaviour and the broader socio-political processes that shape society.
- Specialized knowledge of mental disorders and their impact on individual family and community including the psychiatric classification system, major syndromes, theories and knowledge of aetiology, and current concepts of intervention, treatment, risk assessment and rehabilitation; organizational aspects of mental health services; community structure, social and political processes, development and resources; and knowledge and understanding of the paradigms for practice of the other mental health disciplines.
- Continuing education/professional development is essential.
- Registration in the appropriate Provincial/Territorial Social Work Association is often required
The foregoing provides an outline of the current roles available to social workers in the field of mental health. Social work has a long and distinguished history of service to persons with mental disorders and their families. Because of the high degree of congruence between the conceptual framework through which mental health services are now provided and the value base and practice domain of social work it is expected that the profession will play a strong leadership role in this field in the decades ahead.
Since its inception, social work has focused on the social contributions to emotional well being and mental health. As health care moves towards a "population health" approach that emphasizes the importance of social and psychological determinants of health, social workers will continue to make a significant contribution to the health care/mental health team.
a For a detailed discussion of the determinants of health see Statement on Preventive Practices and Health Promotion, CASW, March 1998, pages 2 - 4.
b This section and section 1.3 are taken from Mental Health For Canadians: Striking a Balance, pages 6 & 7.
c The following definitions are taken from Foundations for the Future: A Report of the Working Group on Child and Youth Mental Health Services, March 1990, page 8.
- Health Promotion Glossary, World Health Organization, 1998.
- Achieving Health For All, Health and Welfare Canada, Ottawa, 1986
- Mental Health for Canadians: Striking a Balance, Health and Welfare Canada, Ottawa, l988.
- Social Work Code of Ethics, Canadian Association of Social Workers, Ottawa, 1994.
- National Scope of Practice Statement, Canadian Association of Social Workers, Ottawa, 2000.
- Definition of Social Work, International Federation of Social Workers, approved Montreal, 2000.
- The Development of Competency Standards for Mental Health Social Workers - Final Report, Australian Association of Social Workers, Kingston, Australia, 1999.
Foundations for the Future: A Report of the Working Group on Child and Youth Mental Health Services, Health and Welfare Canada, Ottawa, 1990.