Mental Health and Social Work [1st ed.] 9789811369742, 9789811369759

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Social Work Series Editor: Richard Hugman

Rosaleen Ow Abner Weng Cheong Poon  Editors

Mental Health and Social Work

Social Work Series Editor Richard Hugman School of Social Sciences University of New South Wales Sydney, NSW, Australia

The MRW in Social Work enables social work practitioners, policy makers and academics across the world to access in-depth, authoritative literature and cuttingedge research into professional practice, ethics, practice-based research methods and policy in the field. Grounding practice and policy in systematic theories and principles, it covers all specialties in the field including children and families, older adults, mental health, people with disabilities, domestic and gendered violence, intercultural practice, sexuality, international social work and community development. Drawing on a strong scientific basis, it offers reviews and analyses of key social issues, policy frameworks and practice methods, including counseling, casework, family therapy, groupwork, community work, community development, social development and social policy practice. More information about this series at http://www.springer.com/series/15559

Rosaleen Ow • Abner Weng Cheong Poon Editors

Mental Health and Social Work With 21 Figures and 12 Tables

Editors Rosaleen Ow Department of Social Work National University of Singapore Singapore, Singapore

Abner Weng Cheong Poon School of Social Sciences University of New South Wales Sydney, NSW, Australia

ISBN 978-981-13-6974-2 ISBN 978-981-13-6975-9 (eBook) ISBN 978-981-13-6976-6 (print and electronic bundle) https://doi.org/10.1007/978-981-13-6975-9 © Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Series Preface

Professional social work now exists in over 90 countries. From its early origins in the later part of the 1800s CE it has sought to develop a strong scientific basis, grounding practice and policy in systematic theories and principles. Today, as social work grows in all parts of the world, its body of knowledge about social issues, practices to address these and relevant policy frameworks is expanding rapidly. Consequently, keeping up to date on such knowledge is increasingly challenging for practitioners, policy makers and academics in the field. This series makes research-based knowledge available for everyone who has an interest in maintaining their grasp of the discipline by bringing together leading social work scholars, practitioners and policy makers to examine contemporary evidence on various aspects of the field. In this way it provides an authoritative range of voices from which everyone in the profession may gain a deeper understanding grounded in evidence. As it has expanded, social work has developed many areas of specialty, each of which now has its own body of knowledge that constitutes a sub-field of the profession as a whole. The Major Research Works in Social Work series addresses the need for up-to-date, authoritative, extensive reviews and analyses of knowledge in a range of areas of social work. Edited by significant contributors in each aspect of specialty, these volumes offer in-depth discussion of the specific practices and issues of policy and the organization of relevant services. By taking this approach, it is possible to ensure appropriate coverage of the range of specialties and also at the same time to provide sufficient depth of analysis and discussion of key ideas. As a profession, social work can be understood in a number of ways. First, there are fields of practice. These include children and families, older adults, mental health, people with disabilities, domestic and gendered violence, inter-cultural practice, sexuality, and international social work. Second, methods of practice also define areas of knowledge in social work. These include counselling, casework and case management, family therapy, groupwork, community work and community development, social development, social policy practice. Third, there are overarching issues that contribute to social work knowledge and theory, including professional ethics, practice-based research methods, policy studies. These are examples indicative of the range, rather than forming a definitive list, and point to the way in which a series may enable both breadth and depth to be addressed. At the

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same time they point to the extensive coverage that is relevant to the broad social work field. Although much of the tradition of social work research and analysis came originally from those countries that experienced early industrialization (the ‘global North’), given the worldwide growth of social work the editorial approach for this series also aims to be global in its focus. Volume editors and contributors are drawn purposefully from around the world and they in turn are expected to take a worldwide view of ensuring that the current evidence and analysis is presented. In addition to established leaders in the field with identification of the emerging leaders of the future whose work is seen as cutting-edge. This series was developed by selecting major themes across fields of practice, methods of practice and over-arching issues. Future titles will be added to the initial five areas – community practice, mental health, family and gendered conflict and violence, children and families, and social work theory and ethics – , reflecting the breadth of the social work profession. At the same time, because Springer Major Research Works are ‘living’ publications, able to be updated, the continuing development of the profession will be reflected in analysis and discussion that grows with the field through publication of revised chapters as further evidence and analysis becomes available. As Editor-in-Chief, I acknowledge the commitment and insights of the editors to each specific volume. Their expertise and hard work enable this series to pursue its overall goal. In this volume Rosaleen Ow and Abner Weng Cheong Poon have brought together leading researchers, educators, and practitioners in community practice and social development to create an insightful and challenging view of this dimension of social work. I also thank our Publishing Editor at Springer Nature, Mokshika Gaur, for her vision, enthusiasm, and support, as well as other colleagues at Springer Nature who have assisted the process of creating these volumes. Professor of Social Work University of New South Wales, Australia Series Editor, Springer Nature Major Research Works Social Work Series April 2020

Richard Hugman, Ph.D.

Volume Preface

Much has been happening in the world of mental healthcare. Theorists, practitioners, researchers, the community at large, and not of least importance are the persons who had experienced mental health challenges themselves being involved in addressing issues related to the understanding of the multiple systemic factors that could contribute to mental well-being and illness. This book is an attempt to put together the thoughts and models of practice found in mental healthcare from the diverse perspectives of social work practice with individuals, families, and the community globally. It covers both established and new research findings from many countries. The book is divided into different parts that hopefully will help the reader to understand the context within which the chapter is located. Part One is an overview of the thoughts pertinent to understanding what had been known about mental well-being and illness, and the values and ethics that should underlie mental healthcare. Part Two elaborates on the concept of mental health and etiology from the perspective of different disciplines and the implications for social work practice. Part Three focuses on social work with individuals, families, and the community based on the general ecological-systemic approach and other social work theoretical frameworks. Part Four focuses on contextualized social work practice reviewing models of intervention, challenges, and possibilities in the course of mental healthcare with different groups of people. Part Five examines some structural factors that impinge on mental well-being and illness such as legal and financial contexts. Part Six is the concluding chapter attempting to review future work in the area of mental health and social work. As co-editors, we are extremely grateful for the contribution of all the chapter authors. Without their commitment and diligence, it would have been an impossible task to put all the knowledge and creative thoughts on mental healthcare into such a

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huge volume. We also appreciate Professor Richard Hugman, Series Editor, and the wonderful team at Springer for their support and advice. We also want to thank our families for their understanding, patience, and continual support. Much thanks! Singapore, Singapore Sydney, NSW, Australia April 2020

Rosaleen Ow Abner Weng Cheong Poon

Contents

Part I

Introduction

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1

Theories on Mental Health, Illness and Intervention . . . . . . . . . . . Rosaleen Ow and Abner Weng Cheong Poon

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2

Ethics, Values, and Recovery in Mental Health Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bani Aadam and Melissa Petrakis

Part II General Theories on Mental Health and Etiology of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3

Psychological Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virgil L. GregoryJr.

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4

Behavior Analysis and Social Work . . . . . . . . . . . . . . . . . . . . . . . . Bruce A. Thyer

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5

Social-Cultural Ecological Perspective . . . . . . . . . . . . . . . . . . . . . . Monit Cheung and Carol A. Leung

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6

Developmental Approach to Mental Health . . . . . . . . . . . . . . . . . . Antoinette Lombard and Nontembeko Bila

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7

Qigong Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jessie S. M. Chan and Siu-man Ng

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Medical Perspective on Mental Health . . . . . . . . . . . . . . . . . . . . . . Carol Harvey

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Part III Overview of Social Work Approaches in Working with Individuals, Families, and Communities . . . . . . . . . . . . . . . . . . . . . . 9

Individual Approach to Mental Health from a Psychodynamic and Cognitive Behavioral Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . Mun Heng Low and Stuart Stevenson

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Contents

An Overview of Social Work Approaches in Working with Families of People with Serious Mental Illness . . . . . . . . . . . . . . . . Abner Weng Cheong Poon and Winnie W. Kung

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Community and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert Bland and Gabrielle Drake

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Community, Mental Health, and Social Work . . . . . . . . . . . . . . . . Caroline Lim and Rosaleen Ow

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Māori Social Work and Māori Mental Health in Aotearoa New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hannah Mooney, Andrea (Ange) Watson, Paulé Ruwhiu, and Awhina Hollis-English

Part IV 14

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Contextualized Practice with Individuals and Families . . .

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Trauma-Informed Social Work Practice with Children and Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yogeswari Munisamy and Diane E. Elze

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Application of Mindfulness-Based Approaches in the Context of Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Si Ying Tan and Shian-Ling Keng

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Alcohol and Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wulf Livingston

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Social Work with Refugees and Migrants Maree Higgins

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Natural Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Timothy Sim and Joydeb Garai

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Mental Health and Social Work: The Islamic Perspectives . . . . . . Mohd Dahlan A. Malek

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Community Mental Health in South Korea . . . . . . . . . . . . . . . . . . You-Jin Chung and Ok-Kyung Yang

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Suicide Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lynette Joubert and Kristina Lainson

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Parenting Challenges for Persons with a Serious Mental Illness . . . Linda Campbell and Abner Weng Cheong Poon

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The Role of Religious Institutions in Mental Health Rehabilitation and Recovery in India . . . . . . . . . . . . . . . . . . . . . . . Srinivasan Chokkanathan, H. Sobhana, and Aravindhan Natarajan

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Contents

Part V

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Structural Factors in Social Work and Mental Health . . . . .

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Legal Provisions, Advocacy, and Empowerment . . . . . . . . . . . . . . Lisa Brophy

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Financial Challenges and Mental Health . . . . . . . . . . . . . . . . . . . . Irene Y. H. Ng and Trina R. Shanks

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Part VI

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Reflection of Future Social Work Practice in Mental Health . . . . . Abner Weng Cheong Poon and Rosaleen Ow

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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About the Series Editor

Prof. Richard Hugman was a social work practitioner in the UK for approximately 10 years, during which time he also completed his Ph.D. at Lancaster University. He has since held academic positions at Lancaster University (UK), Edith Cowan University and Curtin University (both Western Australia) and is now Professor of Social Work at University of New South Wales, Australia. He has published widely in the field, including nine monographs covering various aspects of professional social work, such as Power in Caring Professions (Macmillan, 1991), New Approaches in Ethics for the Caring Professions (Palgrave, 2005), Social Development in Social Work (Routledge, 2016) and most recently Virtue Ethics in Social Work: Towards Virtuous Practice (with Manohar Pawar, Bill Anscombe, Amelia Wheeler and Andrew Alexandra) (Routledge, 2020). Richard has been editor of British Journal of Social Work (1992–1995) and Australian Journal of Social Issues (1995–2000), as well as four edited books. Since 2004 he has been a consultant to UNICEF Vietnam and was ethics commissioner of the International Federation of Social Workers (2008– 2014). He continues to be engaged in various aspects of social development practice.

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About the Editors

Rosaleen Ow is currently Grant Manager of the Mrs Lee Choon Guan Endowed Research Fund in the Department of Social Work, National University of Singapore (NUS). She graduated with a bachelor’s degree in Social Work from NUS; a master’s degree (Econs.) from University College, Cardiff, Wales; and a Ph.D. in Social Work from the National University of Singapore. She was a social work practitioner working mainly with children and families in Singapore and Wales before becoming an academic at the National University of Singapore. Apart from teaching, she had been and is still an active volunteer for NGOs serving children with cancer and chronic illnesses and those with challenges in intellectual development. Working closely with NGOs and formal government bodies, her research and writing are focused on examining the social and cultural factors that are interlinked with the needs and challenges of different types of families and services available to support such families. She publishes in peer-reviewed journals and edited books mainly on issues related to direct social work practice and cross-cultural social work.

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About the Editors

Abner Weng Cheong Poon is Senior Lecturer of Social Work in the School of Social Sciences, University of New South Wales. He graduated with a Bachelor of Arts from the National University of Singapore, Master of Social Work (Mental Health) from the University of Melbourne, and Ph.D. from the University of Melbourne. He teaches social work practice in mental health and evidence-informed practice in social work. His research focuses on social work practice in mental health, impact of mental illness on families and caregivers, family intervention in mental health, children of parents with mental illness, health and wellbeing of migrants experiencing mental health problems, intimate partner violence in China, and community mental health teams. He has published peer-reviewed articles concerning caregivers of people with psychosis, families from culturally and linguistically diverse communities, intimate partner violence, community mental health teams, and parenting needs of people with mental illness. He collaborates actively with mental health services and non-governmental organizations to conduct practice-based research that provide important and useful implications for practice and policy.

Contributors

Mohd Dahlan A. Malek Faculty of Psychology and Education, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia Bani Aadam NSW Ministry of Health, University of NSW, Sydney, NSW, Australia Nontembeko Bila Department of Social Work and Criminology, University of Pretoria, Hatfield, South Africa Robert Bland Australian Catholic University, Brisbane, Australia Lisa Brophy School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia Mind Australia, Heidelberg, VIC, Australia Linda Campbell School of Psychology, University of Newcastle, Callaghan, NSW, Australia Jessie S. M. Chan School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, People’s Republic of China Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, People’s Republic of China Monit Cheung University of Houston, Houston, TX, USA Srinivasan Chokkanathan Department of Social Work, National University of Singapore, Singapore, Singapore You-Jin Chung Social Work Programme, S R Nathan School of Human Development, Singapore University of Social Sciences, Singapore, Singapore Gabrielle Drake Australian Catholic University, Sydney, Australia Diane E. Elze University at Buffalo School of Social Work, Buffalo, NY, USA

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Contributors

Joydeb Garai Department of Applied Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China Virgil L. Gregory Jr. School of Social Work – MSW Direct, Indiana University, Indianapolis, IN, USA Carol Harvey Department of Psychiatry, University of Melbourne and NorthWestern Mental Health, Melbourne, VIC, Australia Dr. Maree Higgins School of Social Sciences, UNSW Sydney, Sydney, NSW, Australia Awhina Hollis-English Awhina Hollis-English, Napier, New Zealand Lynette Joubert Department of Social Work, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia Shian-Ling Keng Division of Social Science, Yale-NUS College, Singapore, Singapore Winnie W. Kung Fordham University, New York, NY, USA Kristina Lainson Department of Social Work, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia Carol A. Leung University of California, Los Angeles, CA, USA Caroline Lim Department of Social Work, National University of Singapore, Singapore, Singapore Wulf Livingston Glyndwr University, Plas Coch Campus, Wrexham, Wales, UK Antoinette Lombard Department of Social Work and Criminology, University of Pretoria, Hatfield, South Africa Mun Heng Low AMKFSC Community Services Ltd., Singapore, Singapore Hannah Mooney Ngāti Raukawa ki te tonga, Te Āti Awa, Ngā Rauru, Te Ātihaunui a Pāpārangi, Massey University School of Social Work, Palmerston North, New Zealand Yogeswari Munisamy Child Protective Service, Rehabilitation and Protection Group, Ministry of Social and Family Development, Singapore, Singapore Aravindhan Natarajan Department of Criminal Justice, Social Work and Legal Specialties, School of Social Justice, University of Toledo, Toledo, OH, USA Irene Y. H. Ng Department of Social Work and Social Service Research Centre, National University of Singapore, Singapore, Singapore Siu-man Ng Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, People’s Republic of China

Contributors

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Rosaleen Ow Department of Social Work, National University of Singapore, Singapore, Singapore Melissa Petrakis Department of Social Work, Monash University, Melbourne, VIC, Australia Mental Health Service, St Vincent’s Hospital, Melbourne, VIC, Australia Abner Weng Cheong Poon School of Social Sciences, University of New South Wales, Sydney, NSW, Australia Paulé Ruwhiu Ngā Puhi, Ngāti Porou, Massey University School of Social Work, Albany, New Zealand Trina R. Shanks School of Social Work, University of Michigan, Ann Arbor, MI, USA Timothy Sim Department of Applied Social Sciences and World Health Organization Collaborating Center for Community Health Services, School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China H. Sobhana Department of Psychiatric Social Work, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, India Stuart Stevenson CASS School of Education and Communities, University of East London, London, UK Si Ying Tan Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore Bruce A. Thyer College of Social Work, Florida State University, Tallahassee, FL, USA Andrea (Ange) Watson Te Āti Awa, Ngāti Mutunga, Taranaki, Massey University School of Social Work, Palmerston North, New Zealand Ok-Kyung Yang Department of Social Welfare, College of Social Sciences, Ewha Womans University, Seoul, South Korea

Part I Introduction

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Theories on Mental Health, Illness and Intervention Rosaleen Ow and Abner Weng Cheong Poon

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spiritual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Structural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emerging Issues and Implications for Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The chapter attempts to provide an overview of thoughts and theories that influenced the understanding of etiology, manifestations, and management of mental health and mental illnesses from multiple perspectives. The perspectives of professional service providers and academia representing the social sciences, medicine and neuroscience, and those of service users and the implications for assessment and management of mental health and illness are discussed. The acknowledgment that the view of a human being must be holistic to be complete has put spiritual and cultural beliefs into the assessment and management of mental health. Hence, the biopsychosocial-spiritual framework may be the most R. Ow (*) Department of Social Work, National University of Singapore, Singapore, Singapore e-mail: [email protected] A. W. C. Poon School of Social Sciences, University of New South Wales, Sydney, NSW, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_1

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consensual framework upon which social workers in multidisciplinary teams base the assessment and formulation of service plans for persons experiencing mental health problems and working toward recovery. The progression from control by external systems such as religious institutions and the state historically to the present-day movement of gaining control of individuals’ own recovery from mental illness has been a long journey of discourse. Research has also resulted in changes in policy, service provision, and the societal interpretation of abnormal behaviors that are outside the social norm. Emerging issues that may affect future social work practice in mental health such as the genetics of mental health leading to the targeting of specific therapies to individual patients or the relationship between structural issues such as economic and social inequalities with mental health are discussed. Keywords

Mental health · Social science · Neuroscience · Social work · Theories · Biopsychosocial-spiritual

Introduction Social workers are one of the main providers of mental health services in both the public and private sectors. They are at the interface between the person with the mental health issue and the environment providing a critical link between the service user, the multidisciplinary treatment team, and the community. Since social work practice is shaped primarily by the context in which it is practiced, it is therefore imperative that social workers understand the social and medical aspects of mental well-being and illness as a foundation for their involvement in service provision with the individual, family, group, and community. Thus, social work in mental healthcare is multilayered. Mental healthcare includes patient care involving different professionals, institutional and community services, the use of medication, and interventions related to health and illness arising from theories of selfhood and relationships with the transcendental such as mindfulness therapies. According to Halliwell (2013: 1), illness means a “single diagnosable condition or a number of related factors (biological, psychological, physiological or social) that unsettle an individual’s balance.” Illness is therefore a descriptive term for a condition that is sometimes visible but always contains a subjective element that includes a humanistic, social constructionist approach to health and illness. It “rests between the public world of policy and medical treatment and the private world of cognition, emotion, and somatic response” (Halliwell 2013: 1). From a more humanistic perspective, Scull (2015: 11) described madness (or unreason) as “massive, and lasting disturbances of reason, intellect and emotions.” The World Health Organization (WHO) defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his

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community (World Health Organization 2014). The positive dimension of mental health stressed in the WHO’s definition of health is contained in its constitution as “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Mental health may be described in another way as a continuum (Sands 2001: 17) where “an individual is more or less functional with respect to different activities. A person may function at a relatively high level in some areas (manages own apartment, uses transportation), but at the dysfunctional level in others (interpersonal relationships, employment).” “Insanity,” “madness,” or “mental illness” and mental healthcare had been a subject of debate and study beginning from ancient religious texts such as the Holy Bible to Freud (1909/1959) to Foucault (2006/2009) to the study of neuroscience and mental health in modern times (Littrell 2015). “In important ways,. . . madness is indelibly part of civilization . . . a problem that insistently invades our consciousness and our daily lives” (Scull 2015: 10). The history of etiology was focused primarily on the person with the mental health issue and ranged from beliefs with spiritual roots to psychodynamic factors to a social disease model requiring segregation from the public to biological theories involving the state of the human brain, genetics, and neuroscience. In spite of the plethora of theories, the boundaries between people with mental illness and those without remain ambiguous, controversial, and contested. Social work, on the other hand, has aligned its professional approach with contextual biopsychosocial explanations supporting the inclusion of a broader perspective such as the impact of family, groups, and community on mental health and illness in addition to etiology related primarily to individual factors. This broader perspective will be elaborated in subsequent sections of the chapter related to frameworks for mental healthcare and social work practice (see Scull 2015). Any attempt to review the historical development of thoughts on mental illness is necessarily incomplete, culture-bound, and subject to limitations of reconstructing the thoughts of early theorists by current writers. However, almost all text writings on the understanding of mental health and illness in prehistoric societies attributed abnormal behaviors to evil spirits that inhabited the body of unfortunate individuals (Alexander and Selesnick 1966; Neugebauer 1979). The Holy Bible, for example, records the existence of mental illness from a spiritual perspective based on the Judeo-Christian tradition. One example of mental illness from the Bible could be found in the narrative of Jesus healing a man by supernaturally casting out a legion of demon spirits in possession of the man into a herd of pigs (Luke 8:27–39, New King James Version, The Holy Bible 1982). The spiritual etiology of mental illness and cures can also be found in other religious orientations. In Singapore, for example, when someone is exhibiting unusual behaviors for no apparent cause, one possible explanation in folk medicine is possession by evil spirits (Ow and Saparin 2014). However, Sabry and Vohra (2013) wrote that the commonly held belief of Muslims that mental illness is a disease brought about by demons or bad spirits was imputed to them by Europeans in medieval times who themselves viewed mental illness as demon-related. They quoted modern Muslim scholars (Gharaibeh 2008; Mafullul 2003) as having rejected such a concept but instead viewed mental illness as having a physiological base. In Islam, all diseases including

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mental illness can be considered as trials and tests for the individual and/or the family (Islamweb 2004) and having a healthy secure relationship with Allah would result in better psychological functioning quoting “. . . And whosoever puts his trust in Allah, then He will suffice him . . .” (Qur’an 65:3 quoted in Sabry and Vohra (2013: S205)). Beliefs in witchcraft and casting out of evil spirits from the afflicted person’s body were also common in the early days of Greek, Chinese, Indian, and Egyptian civilizations with exorcism performed on people whose behaviors did not conform to the norm and were perceived as harmful to the afflicted individual and to the community. Cheung (1986: 172) described Chinese folk medicine as including “supernatural as well as Taoist beliefs including divination, sorcery, spirits, and ghosts” as being responsible for illnesses with mental illness as “a common reason for consultation with shamans and fortune–tellers.” Religious and folk beliefs and such altered mental states were also described in Scull (2015: 31) as manifested in “dramatic symptoms as fits, foaming at the mouth, grinding of teeth and biting of tongues, loss of control of bladder and bowels, and descent into unconsciousness, all readily interpreted as signs of possession.” Elaborate prayers and rituals involving drugs and other substances as well as extreme practices such as flogging or starvation were practices used to drive out the evil spirit/s in possession of the afflicted individual.

Biological While supernatural causation continued to persist among the general population, naturalistic explanations began to develop among Greek physicians, such as Hippocrates (460–370 B.C.) and Galen (A.D. 129–199), during the period known as the Enlightenment. These early physicians believed that mental illnesses were rooted in bodily pathologies that were disorders in the brain and the body and that “deviant behaviour was caused by brain pathology” (Sue et al. 2003: 19). Organic physical causes consisted of four basic elements, blood, phlegm, yellow bile, and black bile, each having qualities that produced different temperaments including mania and melancholia. The biological explanation has been heavily influenced in the modern era by the neurosciences where the makeup of a human being and human behavior are a result of brain structure and function. Genetic material in a person’s cells decides their physical features, temperaments, and vulnerability to diseases. Human thoughts, emotions, and behaviors are associated with nerve cell activities, and any changes in activity or structure of the brain will result in changes in thoughts, emotions, and behaviors. As a consequence, using a biological perspective, maintenance of mental health and treatment of mental illness are best managed by the use of drugs that will reduce the impact of negative brain development or brain cell activities. In addition, biological explanations also include biochemical theories (such as dopamine theory) with the basic premise that mental illness is caused by chemical imbalances affecting the function of neurotransmitters in the transmission of messages by neurons (nerve

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cells). Littrell (2015) surmised that while the body affects behavior and subjective states and attitudes, the reverse can also be true. While physiological factors are associated with the presentation of behavior symptoms, the use of drugs may not be the only answer since the mind also affects the body. Therefore, other nonmedical, more naturalistic alternatives in altering physiology and consequently the mind should also be considered as interventions in mental health. Alternative measures such as appropriate diet, social support, meditation, yoga, exercise, and practicing mindfulness can be as, if not more, efficacious and have less side effects compared to drug therapy. Health psychology, for example, believes in the role of primary intervention because certain social, demographic, situational, and psychological behaviors can determine a person’s risk for illness or disease. Even the collective actions of society such as air pollution, consequences of climate change, and impoverished social and economic conditions can also lead to poor physical and mental health (Bishop 1994).

Psychological The spiritual and organic debates were challenged by a resurgence of scientific inquiry with a humanistic focus that included the psychological viewpoint which stressed an emotional basis for mental health and illness. Present-day psychological explanations of mental health and illness comprise a large number of orientations. Psychodynamic models view mental illness as a result of childhood traumas or anxieties that are largely in the unconscious but may manifest in symptoms that humans are not aware of. The earliest proponent of the psychodynamic model was Sigmund Freud (1938, 1949) who changed from practicing as a neurologist to a psychiatrist. Since the Freudian era, traditional psychoanalytic theories about mental health and illness have changed to a greater emphasis on the role of the ego to modern psychoanalysis that uses techniques of re-experiencing mental conflicts rather than understanding them (see Sue et al. 2003: 48) for a chart on post-Freudian and psychoanalytic therapists). Although psychodynamic models had exerted a large influence on the understanding of human behavior and mental disorders, criticisms arose from their focus on individual case studies and the difficulties of empirical generalizations related to the unconscious and dependence on the cognitive and verbal ability of the individual in the assessment and problem-solving process. As a result of the criticisms leveled at the psychodynamic school of thought, behavioral explanations on the development of human behavior including mental illness arose from applications on the work of Ivan Pavlov (1849–1936), a Russian physiologist, who discovered the associative learning process (classical conditioning) while studying salivation in dogs. The application of classical conditioning principles to the development of human behavior including abnormal behavior was largely credited to John B. Watson (Watson and Rayner 1920) and subsequently expanded by B.F. Skinner (1904–1990) in the process called operant conditioning. All behaviors including symptomatic behaviors in mental illness are therefore said to be the consequence of faulty learning and reinforcement, and many therapeutic

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strategies were developed from this orientation. Although empirically stronger and therefore in a sense more accountable than insight-oriented therapies, behaviorism was criticized as ignoring the inner determinants of behavior. Cognitive models, on the other hand, do recognize the importance of inner processes in human behavior but focus on conscious thoughts that mediate or influence an individual’s emotional or behavioral state rather than the unconscious. Behavior is a response and consequence of how an antecedent (experience of an event) is interpreted (through worldviews, values, and beliefs). Changing abnormal behavior therefore involves changing known irrational and maladaptive thoughts in the way an individual organizes, interprets, and labels experiences rather than changing emotions and thoughts arising from the unconscious. Cognitive therapies are structured exercises with specific learning goals to identify and alter interpretations that distort their experiences and the resultant behavior or attitude. However, cognitive theories and therapies have also been the subject of criticism from psychologists with other theoretical orientations. For example, cognition, perhaps similar to the unconscious in psychodynamic theories, is also not an observable phenomenon and cannot form the basis for empiricism. While behavioral and cognitive approaches continued to be influential in psychological thought, from a humanistic perspective the reduction of a human being to being merely a product of reinforcements or the sum of its cognitive parts is to ignore the holistic and active nature of being human (Goldstein 1986). Humanistic and existential approaches evolved as a reaction to the determinism resulting from past experiences. While there are many strains to the humanistic and existential school of thought, one common assumption is that an individual’s reality is a product of unique experiences and perceptions of the world and in phenomenology term, understanding comes from reconstructing the world from that individual’s point of view. People are active agents, capable of making free choices and given the opportunities will be able to fulfill their desire to live lives most suited to what they want for themselves. The earliest proponents of this positive view of the individual were humanistic psychologists such as Maslow (1954) and Rogers (1961). The very strength of the humanistic and existential approaches in focusing on the subjective understanding of the human condition and hence their lack of suitability for scientific or experimental investigation is also the area that produced the heaviest criticism in terms of theory construction and generalization. In addition, the principles of application also seem more suitable for generalization to individuals who are articulate and searching for positive mental health rather than for understanding and working with individuals with serious mental health problems that need resolution. Risk and protective factors are well-researched topics in theories of resilience because they are believed to be associated with the disorder, and understanding them will assist in the development of preventive strategies. Resiliency is part of the positive psychology movement because if “people are taught resilience, hope, and optimism, they will be less susceptible to depression and will lead happier more productive lives” (Seligman 2002 quoted by Greene 2007: 12). The resilience perspective embodies most of the current thinking on the recovery process in mental illness. The theory-guided dimensions of health and well-being include self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in

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life, and personal growth (Greene 2007: 13). These dimensions of well-being are congruent with the strength-based principles in social work practice that emphasize empowering the voice of the service user, tapping into inner resources, collaboration with the community in expanding opportunities for growth, and promoting membership that supports a sense of belonging.

Social In addition to explanatory theories located within the individual, other explanatory models include those that view individual behavior as a product of the systemic interaction between the individual and the family. In social work, systemic-perspective intervention is highly recognized as a core practice. A family systems perspective views “family members as inextricably intertwined in their lives and death, and all members of society as ultimately interconnected. Neither people, nor their problems, exist in a vacuum” (McGoldrick et al. 2008: 14). Family in most cases is the most powerful system to which an individual belongs, and the memories and culture of the family will remain with the individual wherever the person goes. This family interconnectedness is exemplified in the genograms used by many care professionals including social workers in understanding the individual and the family in the context of family structure and relationships, timeline, significant events, needs, and resources (McGoldrick et al. 2008). In addition, a genogram as a pictorial representation of a family can also be a tool for engagement of family members as they participate in constructing what is virtually a family tree for the purpose of problem-solving (Hepworth et al. 2017: 274–276). The family systems approach views personality development as mainly influenced by family attributes especially parental behavior. Abnormal individual behavior is a function of unhealthy family dynamics, and therefore the focus of help should not be on the individual alone but on the whole family. Families are subsequently blamed for causing someone to experience a mental illness or suffer a relapse, for example, the term “schizophrenic mothers” was commonly used in mental health services previously. The emphasis on family strengths in risk and resilience theory, for example, led to the inclusion of family members in the process of recovery for individuals with mental and/or substance abuse conditions by the Substance Abuse and Mental Health Services Administration (SAMHSA) (2017) in the United States. Family members are both impacted by, as well as potential support for, the individual with the mental health condition.

Spiritual Being religious and/or experiencing the presence of an inner spirit or self is increasingly recognized as a valid part of human experience. In the past, the spiritual approach to mental health based on folk beliefs had been focused on the negative effects of “spirits” as in evoking ill health. However, with the advent of phenomenology and the “strengths” perspective, there seems to have been a shift toward

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viewing spirituality as a factor that can contribute to positive health outcomes. Goldstein (1986) named this aspect of the self as the “person of faith,” primarily as religious beliefs associated with formal religious institutions. In the present era of vast possibilities and the trend towards embracing a holistic approach to understanding human behavior, belief in the presence of the transcendental, such as the spirits of ancestors or other animistic beliefs, exists within many indigenous groups. The acknowledgment of the transcendental, such as the spirits of ancestors or other animistic beliefs, resurfaced and exists within many indigenous groups in the twenty-first century. The presence of the transcendental, such as the spirits of ancestors or other animistic beliefs, has a bearing on cultural responses to experiences that are not shared by the majority of the community. A study conducted with Maori communities in New Zealand (Taitimu et al. 2018) found that participants had multiple explanatory models for commonly labeled “psychotic” or “schizophrenic” experiences with spiritual and cultural explanations being predominant. For example, hearing voices could be an everyday phenomenon of hearing an ancestor speaking words of advice and being connected with those who had gone before but are still very much a part of the present in the spirit. In another recent study on the grief experiences of mothers bereaved of a child, it was found that Chinese mothers across all religious orientations in the sample relied heavily on their religious teachings regarding life and death and the purpose of life on this earth to process their encounters with the “spirit” world during the periods of bereavement and adjustment to the loss (Mun and Ow 2017). It is not possible to discuss the beliefs related to mental health and illness among the myriads of belief systems among all peoples of the world but suffice to note at this point that the inclusion of spirituality and religiosity is an important aspect of social work practice with persons suffering from mental illness and also with their family and community. The incorporation of such experiences as valid in diagnosis and psychosocial assessment and intervention will render social work in the field of mental healthcare a more holistic profession respecting all aspects of the self that are significant to the individual in the journey of recovery.

Structural In recent years, the call to promote a more inclusive and fairer society globally (United Nations Development Programme (UNDP) 2016) has turned social work attention to the structural factors that impinged on the health and mental health of vulnerable persons including those with mental health problems. While progress in human development had been visible in the provision of basic health and other services, it had been an uneven process in that human deprivations still persist. In using an analytical and holistic approach to human development, the UNDP (2016: 2) concluded that human development includes having “things a person values being or doing”; having “a set of combinations of functionings that can be achieved”; and having “agency to do or achieve what is valued.” Human development focuses on the “richness of human lives rather than the richness of economies” and is both a

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process and an outcome. Arising from this fundamental approach to human development, social work’s involvement in mental healthcare will inevitably embrace the human rights and strengths-based approach in social development to alleviate issues related to mental illness and well-being. The social development which focuses on the strengths of people and the eradication of structural injustices that hindered the development of capabilities and freedom to act to achieve good health, access to knowledge, dignity, human security, and a decent standard of living are all within the wider social work agenda in mental healthcare. The social development approach works in tandem with individual and group approaches as part of the micro and macro practice that are aligned with the ecological and systemic frameworks that social work subscribes to in the assessment and problem-solving process. The social development approach is therefore aligned with the new recovery paradigm in mental healthcare where service users exercise their capabilities, rights, and participation in social, medical, economic, and legal issues related to their care and well-being (Webber and Joubert 2015). The process involves the partnership of all stakeholders from the individual to families and community to obtain the best outcome. Promoting the recovery agenda allows opportunities to manifest the vision that having a mental illness does not mean that an individual cannot live a fulfilled life. To live a meaningful and fulfilled life, one needs some measures of financial security. Although some people believe that one does not need to be rich to be happy, the relationship between socioeconomic status and mental illness had long been a subject of discourse and research (Tausig et al. 2004). Mental health problems can lead to disruptions in education and training and therefore reduce opportunities for entry and progress in employment, financial hardship, and a poorer quality of life for the individual and the family. Financial hardship and decreased opportunities in turn can impose mental stress on people and communities just as mental illness can impose financial hardship as a consequence. A quote from a recent review of poverty and mental health in the United Kingdom describes the systemic association as “Poverty increases the risks of mental health problems and can be both a causal factor and a consequence of mental ill health. Mental health is shaped by the wideranging characteristics (including inequalities) of the social, economic and physical environments in which people live. Successfully supporting the mental health and well-being of people living in poverty, and reducing the number of people with mental health problems experiencing poverty, require engagement with this complexity” (Elliot 2016). This social, economic, and environmental complexity increases when it is interfaced within a life course framework from birth to later life. The presence of social and financial pressures is common as part of the developmental needs of all individuals, but when they are interfaced with transitional crisis and/or poor physical health, the impact of the adversity and mental stress is increased. Recovery from mental ill health of people in chronic financial hardship may also be harder as they may be more susceptible to consequences of having a lower educational level, living in poorer and less supportive neighborhoods, food insecurity, lower social support networks, unemployment, stigmatization (including self-stigma), and discrimination. Understanding the correlates between financial stress and mental health is an important aspect of both micro and macro practice

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in social work. Therefore, “mental health must be addressed within poverty data and research, and, likewise, poverty addressed within mental health data and research” (Elliot 2016: 4). People with mental health may also need advice, support, and advocacy in managing the multiple services spread out in the community each with its own set of eligibility rules. Some people may require legal advice and support such as cases related to civil rights, stigmatization and discrimination, the law in forensic social work, protection from abuse and neglect, and debt management and repayment.

Conceptual Frameworks The question remains amid the myriads of explanatory theories and professions who possess the final authority on defining mental illness. What conceptual framework should we use to organize our social work practice in mental health? Psychiatrists use diagnostic tools such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association 2013) or the International Classification of Disease, Eleventh Revision (ICD-11) (World Health Organisation 2018) to determine the type of mental illness and drugs to manage psychiatric symptoms of humans presented with abnormal behavior. Neuroscientists and geneticists, on the other hand, believe that certain genes are the explanation for the existence of mental illness. In addition, the spiritual sage/philosopher might promote religious and cultural institutions for mental health problems (Hyman 2000). As a consequence of the existence of many plausible explanations for mental health and illness, social work as a profession which believed in problem-solving and the development of resilience from a holistic perspective has in recent years embraced two interrelated frameworks into practice. One is the biopsychosocialspiritual approach (BPSS) in understanding and working with individuals. The other is the ecological framework which is systemic in nature and engages a broader structural lens in viewing individual needs and resources. The BPSS approach started with the acceptance among professionals that the human experience is not solely a product of neurological and genetic processes. In healthcare settings, as shown above, there exist many different explanations of why behaviors are exhibited in particular ways especially in the field of mental health and illness. The biopsychological framework which is consistent with the strengths perspective has been and continues to be prominent in clinical practice in behavioral mental health (Sands and Gellis 2012). The biopsychosocial framework involves the need for social workers to possess and utilize adequate knowledge of biology such as genetics, neuro- and brain functioning, and psychopharmacology, although some argue that social work has largely neglected the “bio” component in practice and research (Maynard et al. 2017; Saleeby 1992). In addition, social workers should understand psychology and psychosocial factors that include interpersonal relationships with the family and significant others involved in the development of an individual’s behavior. In recent years, the spiritual aspects of the BPSS framework have developed rapidly with the acceptance that all behaviors have

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a contextual basis that may involve cultural, spiritual, and religious elements (Chan 2001; Gold 2010; Lee et al. 2009). The contribution of knowledge about the whole person and not only parts of the whole in assessment and management of the illness is within the domain and expertise of social workers in mental healthcare as part of a multidisciplinary team. In addition to the BPSS framework focusing on working with the individual, social workers in mental healthcare also work with external systems outside the individual such as the family, the immediate community, and the society at large. The systemic framework employed by social workers in practice was based on the ecological models of human development developed mainly by Bronfenbrenner in the 1970s (Bronfenbrenner 1979; Bronfenbrenner 1986). Ecological models differentiate the environment from the person. The ecological environment is conceived of a set of nested structures (Bronfenbrenner 1994) comprising of the microsystem (the immediate environment in which the individual functions), the mesosystem (the linkages and processes between or among two or more settings in the microsystem), the exosystem (the linkages and processes between two or among more than two settings of which one or more may not directly contain the individual but where events happening there may affect the individual such as the parent’s workplace), the macrosystem (the overarching culture of society or subculture of the community), and the chronosystem (change or consistency over time in the individual or the environment). The person-in-environment within the ecological framework has been and still is the most prominent approach in texts on social work practice such as Compton et al. (2005), Hepworth et al. (2017), and Sheafor and Horejsi (2008). The ecological perspective in mental healthcare is described as applicable to all clients but is particularly germane to the understanding and intervening with clients who are severely mentally disabled, many of whom are poor, socially isolated, and underserved by the human service system. In working with this vulnerable population, the clinical social worker can bridge the gap between the person with mental illness and the environment to create a better “fit” between the two systems (Green and McDermott 2010; Sands 2001). Different stages of life across the life span may give rise to different stressors as a consequence of the demands and resources required for achieving the developmental goals of each life stage. When the mental health needs of individuals are viewed in relation to the transitions and crises that occur throughout life within the context of the BPSS and the ecological frameworks, social work in mental health becomes even more complex in terms of assessment and intervention. For example, the mental health life course needs of an adolescent are different in nature from those of working adults or older retired persons in addition to biological differences and social environments, and hence approaches to working with them will also differ.

Emerging Issues and Implications for Social Work Mental health and illness are addressed in a variety of ways depending on which aspect of community mental health is the focus of attention. Community mental health principles include comprehensiveness of care, continuity of care, accessibility

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of care, provision of multifaceted care in the form of multidisciplinary teams of professionals, and accountability of care providers to the community and the service users. Community mental health services are conventionally provided at three levels: primary, secondary, and tertiary (Bentley and Taylor 2002). Primary prevention aimed at addressing the potential biological, environmental, and psychological causes of poor mental health through mental health education for high-risk groups, providing support with meeting basic needs such as housing and employment opportunities and reducing community or societal factors such as discrimination. Behavioral health is a broad term referring to one’s state of well-being and how behaviors and choices affect overall health and wellness. Behavior is generally perceived as changeable, and individuals can be empowered to make choices that can prevent, cure, or decrease symptoms of a large group of health disorders. Behavioral health is therefore also an important aspect of primary intervention in mental healthcare (Tackett 2018). Secondary prevention focuses on early identification of persons with mental illness and shortening the duration of the condition through specific treatment and intervention. Tertiary prevention is the attempt to reduce the rate of mental disability in the community through rehabilitation services and assisting individuals and families on the recovery journey. Measures taken to reduce ignorance, stigmatization, fear, and other exclusionary activities are part of tertiary intervention. People with serious mental illness were kept in asylums (or institutions) in the past. The living conditions of most psychiatric institutions were poor as seen in several inquiries reporting the overcrowding, inadequate treatment, and violations of human rights of individuals with mental illness in many countries such as Canada (Sussman 1998), the United Kingdom (Killaspy 2006), and Australia (Burdekin 1993). With the development of psychiatric medications (such as chlorpromazine and lithium) and the human rights movement, large psychiatric hospitals were closed in various places such as the United States around the 1950s (Hudson 2016). The sudden closure of psychiatric hospitals in the United States resulted in many people with mental illness becoming homeless, an increase in crime rates, and enormous burden on families caring for people with mental illness (Hudson 2016). Community mental health services have since been developed to support people living in the community. To coordinate the care of people with mental illness, case management has taken an important role in supporting people with mental illness and monitoring their mental health status (Fossey et al. 2012). Psychosocial rehabilitation programs such as supported housing, clubhouse, and social skills training have also been developed to improve the functioning skills of people with psychiatric disability. Social workers in mental healthcare are usually part of a multidisciplinary team (MDT) in the organizations providing formal services. Social workers are expected to perform many different roles in relation to working with individuals, families, and community and within the MDT. These numerous roles that social workers in mental health practice may be engaged in are described in detail in Bentley (2002). These roles include potentially being crisis counselors, diagnosticians, therapists, mediators, educators, skills trainers, case managers, medication facilitators, consumer and family consultants, collaborators on interagency and interdisciplinary teams,

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advocates and community organizers, program evaluators and researchers, and administrators and policy analysts. The generic role of a social worker in case management may pose additional opportunities and potential threats to the profession within the MDT (Lloyd et al. 2004; Renouf and Meadows 2012). As a result of these many different and potentially conflicting roles, mental health social workers need to have knowledge, values, and skills that together constitutes the “5 Cs” comprising being compassionate, committed, collaborative, creative, and competent (Bentley and Taylor 2002: 13–16). Social workers in mental health services often adopt a person-centered approach and family-oriented practice framework. In dominant individualized-focused mental health services, social workers may neglect the well-being and recovery of families in the treatment process (Hungerford and Richardson 2013; Poon et al. 2017). The recovery of individuals with mental illness and their families will need to be simultaneously addressed by social workers in mental health services (Poon et al. 2018). In addition, within a highly regulated practice context, social workers may overly emphasized risk management and paperwork, therefore neglecting therapeutic work with individuals (Sawyer 2008). In countries with more developed mental health laws, social workers may be required to align their practice with mental health legislations, which may cause an ethical dilemma in supporting individuals or families impacted by mental illness (Brophy and McDermott 2013). The social work role in mental health services in the future may be influenced by factors that relate to practice issues and macro-forces in the wider community. The direction of scientific inquiry on human behavior and change, economic, and political concerns in a world that is increasingly competitive in the development and utilization of scarce resources and the rise of social and cultural awareness all act to challenge the expertise of professional knowledge and skills in improving the quality of life for people with mental health problems. In mental healthcare, the movement from institution to community mental health services will put pressure on the process of integrating health and social care services. Antipsychotic medication may help to reduce symptoms and contribute to the stabilization of the psychiatric condition and restore functioning to premorbid state and regain roles that are valued in society. Rehabilitation is about the social service journey, and its success is influenced by the interface between the service user and the professionals in the working relationship. Anthony and Farkas (2012) in the preface to a guide to psychiatric rehabilitation practice concluded that there now exist a fundamental philosophy, principles, and values of psychiatric rehabilitation and substantial knowledge base with a variety of models of service that can make a critical contribution to promoting recovery. To be effective social workers involved in this area of mental healthcare require training not just in being competent in developing models of service but also gaining the knowledge base of psychiatric rehabilitation and the fundamental principles underlying its practice. Recovery, on the other hand, is often not a structured process and does not always move in a linear progression in gaining knowledge and skill. It is rather a personal journey unique to each individual that involves reassessing one’s attitudes, values, feelings, goals, and roles as a result of the mental health condition and how each of

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these together affects the individual’s ability to live a life that is functional and satisfying in spite of having to live with the mental health problem (Anthony 1993). The journey toward believing in one’s growth potential and taking responsibility for one’s life, disorder and problems is subject to internal as well as external processes. Accommodating one’s illness is an existential challenge in believing that one is worthy regardless of the illness and what the environment assesses one to be. The journey can be fraught with self-doubt and self-stigma as well as community stigma and lack of inclusion. Unexpected events and the ups and downs of everyday life during the recovery may make the journey like a roller coaster ride for both the individual and family. The ecological space of the recovering individual such as family, workplace, neighborhood, and community may also require similar changes in perceptions regarding the illness, the worth of the recovering person, and the importance of acceptance and social support. Social work in mental health therefore has to broaden its scope and practice beyond working with the individual and the family to include advocacy and social development in the mesosystem and the macrosystem of the recovering individual. Social integration of someone with mental illness is a community journey as much as recovery is a personal journey. In addition, the social worker in mental healthcare also has to contend with institutional responses in terms of programming and funding for services especially for those whose financial conditions make it difficult for them to access preventive and secondary care. Changing processes in organizations, managed care, and healthcare financing is a social policy journey that the social worker had traditionally been engaged in as a knight in white armor, but increasingly the battle is now joined by persons who have recovered or are recovering. People who had taken the responsibility for their own growth and quality of life are now more vocal and visible in advocating for policies that contribute to facilitating their journey to obtaining wellness and satisfaction in spite of the illness. The implication for social work is the need to adjust its role to one of partnership between the recovering individual and the practitioner rather than as an expert. The traditional paradigm established by psychiatry in delineating and labeling behaviors and syndromes as mental illness has been increasingly challenged especially with the publication of the DSM-5 in 2013 (American Psychiatric Association 2013). Controversy over the DSM-5 includes debates over many areas including the inclusion and categorization of disorders and relevance for different population groups across the life span such as the diagnosis and treatment of agespecific disorders and cultural relevancy in multicultural societies (Rose and Cheung 2012). Traditionally, mental health professionals have relied on the medical model using succeeding editions of the DSM from 1 to 5 to categorize disorders on the basis that mental disorders are diseases with the assumption that the individual with the disorder needs to be treated and fixed. For example, the use of medication that affects the biochemistry in the brain is expected to alter the physiology that gives rise to the problem. Social workers and counseling psychologists join other medical professionals as part of the multidisciplinary team in treating the behaviors of individual persons as diagnosed by the DSM. This paradigm in mental healthcare focuses primarily on correcting what has gone wrong with the individual (or the family)

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more than in promoting what can make it right such as understanding and alleviating broader social and environmental stressors impinging on the patients. Nevertheless, although modern research has debunked the separation of the mind and the body (Littrell 2008a), individuals do vary in their behaviors, and some of these variations can be attributable to genetic differences. Littrell (2015: 12) stated that “Scientists can identify which variations in the gene recipe for making a protein (called an allele) are associated with particular behavioral manifestations.” However, just as the body can affect behavior (as viewed within the field of neuroscience), subjective states can also affect behavior and disease processes (as viewed within the fields of social science and psychoneuroimmunology). Earlier research data showed, for example, that immunocompetence may be enhanced by psychosocial interventions (Kiecolt-Glaser et al. 1985). More recent research showed the link between stress and cardiovascular disease. Cardiovascular disease is presently viewed as an inflammatory disease. A summary of data on the subject showed that stressful events are associated with chronic inflammatory states and could explain the link between stress and cardiovascular disease (Littrell 2008b). For example, cardiovascular risk factors may include such stressors as unfairness in the workplace and lack of control over working conditions, racism, and, in societies with wider income gaps between the rich and the poor, increased stress may be a possible explanation for diminished health outcomes across all socioeconomic factors. The implication is that social work in mental healthcare must increasingly accept the challenge of working through both direct practice in the microsystem as well as on broader structural issues across the meso-, exo-, and macrosystems and not just practice within the medical model of diagnosis and treatment of the individual.

Conclusion Theories on the causes and the relevance of various treatment paradigms are spread over a wide range of disciplines and belief systems as expounded in the earlier sections of the chapter. Recent research in etiology and the use of psychosocial interventions in conjunction with medical treatment point to the continued importance of using a biological as well as a psychosocial and spiritual approach in the management of psychiatric symptoms and provision of psychiatric rehabilitation. However, recent research has also shown that the effect can be both ways. Biochemistry can affect behavior but emotional state of being can also alter biochemistry and behavior. Therefore, social workers should consider adopting a biopsychosocial-spiritual approach in mental health practice. Social work in mental health has also moved beyond the focus on treating the individual living with a mental illness as helpless and need to be “fixed.” The recovery movement has recognized that human beings can exercise agency when provided the opportunity and support to make sense of their illness and find the strengths within themselves and their eco-space to continue living lives that are satisfying and fulfilling for themselves. Social workers may take on many roles in mental healthcare with each role contributing to the alleviation of suffering for

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people with a mental illness. David Howe (1987) wrote about a taxonomy of social work theories and developed a framework for categorizing various social work activities in practice. Social workers have the “fixer” orientation when their work is functionalist in nature with the professional providing expertise and resources in working with individuals with a problem. Social workers who act as interpretivists in their practice are “seekers after meaning” focusing on the understanding of subjective interpretations of experience and problem-solving as individuals in their particular context. However, there are situations where the social worker’s focus of intervention is beyond the individual to the needs of the community of people with similar needs. Working with such communities or groups reflects the radical humanism in developing and supporting self-help and community development in social workers whose function is mainly as “raisers of consciousness.” Finally, in the last category, social workers roles may be that of a radical structuralist rallying people with similar problems to fight for social and political change. Although times changed and social work practice has developed in breadth and depth since the book (Howe 1987) was first published, it seems that social work in mental healthcare has continued to work on all these four paradigms. Social work in mental healthcare may need to do so even more visibly in the future. Human needs and conditions remain the same, and the interface between needs and solutions continues to be dynamic and requires addressing at all levels from the individual in the microsystem to the societal and global macrosystem.

Cross-References ▶ Developmental Approach to Mental Health ▶ Māori Social Work and Māori Mental Health in Aotearoa New Zealand ▶ Medical Perspective on Mental Health ▶ Mental Health and Social Work: The Islamic Perspectives ▶ Psychological Perspective ▶ Social-Cultural Ecological Perspective ▶ The Role of Religious Institutions in Mental Health Rehabilitation and Recovery in India

References Alexander FG, Selesnick ST (1966) The history of psychiatry. Harper & Row, New York American Psychiatric Association (2013) The diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, Washington, DC Anthony WA (1993) Recovery from mental illness: the guiding vision of the mental health service system in the 1990’s. Psychosoc Rehabil J 16(4):11–23 Anthony WA, Farkas MD (2012) The essential guide to psychiatric rehabilitation practice. Boston University Center for Psychiatric Rehabilitation, Boston

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Sands RG, Gellis ZD (2012) Clinical social work practice in behavioral mental health toward evidence-based practice, 3rd edn. Allyn and Bacon, Boston Sawyer A-M (2008) Risk and new exclusions in community mental health practice. Aust Soc Work 61(4):327–341. https://doi.org/10.1080/03124070802428183 Scull A (2015) Madness in civilization. Princeton University Press, Princeton Seligman MEP (2002) Positive psychology, positive prevention, and positive therapy. In: Synder CR, Lopez SJ (eds) Handbook of positive psychology. Oxford University Press, New York, pp 3–7 Sheafor BW, Horejsi CR (2008) Techniques and guidelines for social work practice, 8th edn. Pearson Education Inc, Boston Substance Abuse and Mental Health Services Administration (SAMHSA) (2017) Recovery and recovery support. Substance Abuse and Mental Health Services Administration (SAMHSA). https://www.samhsa.gov/recovery Sue D, Sue DW, Sue S (2003) Understanding abnormal behavior, 7th edn. Houghton Mifflin Company, Boston Sussman S (1998) The first asylums in Canada: a response to neglectful community care and current trends. Can J Psychiatry 43(3):260–264. https://doi.org/10.1177/070674379804300304 Tackett B (2018) Behavioral health issues. https://www.projectknow.com/research/behavioralhealth Taitimu M, Read J, McIntosh T (2018) Nga Whakawhitinga (standing at the crossroads): how Maori understand what western psychiatry calls ‘schizophrenia’. Transcult Psychiatry 55(2):153–177. https://doi.org/10.1177/1363461518757800 Tausig M, Michello J, Subedi S (2004) A sociology of mental illness, 2nd edn. Pearson Education Inc, Upper Saddle River The Holy Bible, New King James Version (1982) Thomas Nelson Inc., Nashville United Nations Development Programme (UNDP) (2016) Human development report, Human development for everyone. United Nations Development Programme (UNDP). https:// reliefweb.int/sites/reliefweb.int/files/resources/2016_human_development_report.pdf Watson JB, Rayner R (1920) Conditional emotional responses. J Exp Psychol 3:313–317 Webber M, Joubert L (2015) Social work and recovery. Br J Soc Work 45(suppl 1):i1–i8. https://doi. org/10.1093/bjsw/bcv125 World Health Organisation (2018) ICD-11 international classification of diseases for mortality and morbidity statistics (Eleventh revision). WHO, Geneva World Health Organization (2014) Mental health: a state of well-being. World Health Organization. http://www.who.int/features/factfiles/mental_health/en/

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recovery as a Value Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics, Recovery, and the Mental Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using Ethics to Guide Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normative Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rational Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contextual Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpersonal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Work Practice, Ethical Dilemmas, and Codes of Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Power and Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implicit Power Dynamics in Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical Dilemmas in Practice: A Case Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Description of Entering a Mental Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethical Dilemmas Brought Up in the Above Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coercion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discrimination and Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Listening to Lived Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enacting Compassion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Power, Culture, and Reflective Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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B. Aadam (*) NSW Ministry of Health, University of NSW, Sydney, NSW, Australia e-mail: [email protected] M. Petrakis Department of Social Work, Monash University, Melbourne, VIC, Australia Mental Health Service, St Vincent’s Hospital, Melbourne, VIC, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_2

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Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Abstract

Health care is bureaucratic and outcomes focused. It is influenced by market and political forces, as much as scientific ones, with friction between good practice and the neoliberal commodification of health services creating tensions. Decisions in health care are increasingly shaped by a myriad of “drivers and contingencies” against a backdrop of complex and conflicting values and ideas. Clinical governance, safety and quality, research and evaluation, cost-saving, and cost-efficiencies all intermingle to create a multifaceted working environment that needs to be agile to be responsive to people’s needs. It is against this backdrop, and in the growing complexity in all areas of health care, that recovery can be seen to enable the four core ethical principles (4Ps): respect (of autonomy), nonmaleficence (not doing harm), beneficence (doing good), and justice (treating people fairly). Our overall proposition is that the concepts and values that recovery drives, should be seen as central components to social work practice because it aligns with and complements codes of ethics, reinforces social work practice and standards, and enables better health and social outcomes. Keywords

Ethics · Values of recovery · Ethical practice · Code of ethics · Social work · Mental health · Recovery · Lived experience perspective

Introduction Ethics is a broad subject matter. It is fundamentally however, about what is right and wrong (Paalanen and Hopia 2017, p. 2). The purpose here then is to speak to ethics – which essentially orbits the notions of respect, nonmaleficence, beneficence, and justice (Beauchamp and Childress 2013; Hoop et al. 2008; Gillon 2003) – as it relates to mental health social work practice. Values is another expansive topic. Here we will define values as a set of collective and agreed-upon attitudes, beliefs, and ideas that inform and guide ethical behavior and decisions to pursue the normative ethical ideal of what we ought to do – or what is “good” practice. When we look at ethics and values in mental health practice, the idea of recovery is currently considered to be the most suitable ethical and value-laden concept today. Accordingly, this chapter will frame recovery as a set of values and outline how ethical practice can assist social workers. In doing so, we will look at what recovery means, what structures are involved in mental health practice, and how practice dilemmas can be addressed. Thoughts on what an “expert” or trained “professional” are; how we define duties and responsibilities; how we can delineate quality, safety,

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and risk; what is evidence-based practice; and what “diagnosis” and “illness” mean, will be explored as we look at ideas of coercion, informed consent, decision-making, self-determination, inclusion, and much more, through an ethical and value-based lens of recovery. Our paper will outline what should acceptable and not acceptable in the interaction between practitioner and consumer, service provider and service user, and service systems and culture. Implicit in these juxtapositions are the power dynamics at play, which have historically and culturally been curated (AASW 2010, p. 14). Although this will be far from an exhaustive survey, it should provide the reader with a taste of the ethical complexities (and opportunities) one may encounter and how recovery can supplement, even drive, better professional judgment, decision-making, and practice. This is an imperative, giving the necessary confidence to practitioners in their ability as social workers, to conduct their work to the high standard the profession holds itself in. This chapter draws upon both postgraduate scholarship in sociology and a lived experience of the use of mental health services. As such, this chapter examines the subject matter in a philosophical as well as person-centered and inclusive framing. Both authors hope this speaks to the reader as modeling recovery orientation and having mindfulness in terms of embodying the values and practices being discussed.

Recovery as a Value Set Above, we broadly defined values as a set of collective and agreed-upon attitudes, beliefs, and ideas. More specifically for the social worker in a mental health environment, it comprises of “unique preferences, concerns and expectations. . .which must be integrated into clinical decisions” (Sackett et al. 2000, p. 1). Today, recovery, as set of collective and agreed-upon attitudes, beliefs, and ideas that aims to address individuality via preferences, concerns, and expectations, is the most dominant paradigm shaping current mental health practice across the globe (Braslow 2013). Recovery emerged as a reaction of deinstitutionalisation and the anti-psychopharmaceutical transfiguration (Braslow 2013), as it challenged, and still continues to challenge, the perceptions of “experts” and their understanding of people with severe psychosocial challenges as “irrational” (Ramon 2009, p. 1616) and “passive recipients of treatment” (Hyde et al. 2014, p. 6). There is no consensus on what the concept of recovery exactly is (Davidson et al. 2016, p. 4), it has nevertheless become ubiquitous (Rose 2014, p. 17; Ramon 2009, p. 1615) across community, public and private settings, with recovery concepts (such as the CHIME: Connectedness Hope Identity Meaning Empowerment) and recovery-oriented practice and principles (such as Australia’s 2013 A national framework for recovery-oriented mental health services) being central features to mental health practice and policy, as well as service aims and objectives (Davidson et al. 2016, p. 4; Hyde et al. 2014, p. 5; Ramon 2009, p. 1615).

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For the individual who has experienced or is experiencing severe psychological distress, recovery means connecting and having relationships, attaining hope, understanding one’s abilities and limitations, engaging in an active and meaningful life, exploring one’s identity, having a positive sense of self, and learning or incorporating tools and techniques that make one resilient. Moreover, it is about personal autonomy, being able to make decisions about one’s own treatment and support; being given responsibilities, at least in part, of one’s own health care; and being empowered by the system and the people around them. For a practitioner, recovery is about listening, or better still, privileging lived experience voices and narratives (because it provides hope), including people in their health-care plans (because it empowers), allowing people the freedom and space to make decisions (to aid in self-determination and identity building), being responsive and allowing for some flexibility (to provide compassion and dignity), and allowing for mistakes via trial and error (to facilitate positive risk taking). It is sometimes referred to as “personal recovery” to distinguish it from the medical perspective of recovery – the idea that one is genetically and biologically lacking and whereby severe and persistent psychological distress is seen as one of pathology and dysfunction (Fulford 1989, p. 248). This medicalized approach subsequently impacts treatment, primarily through diagnosis and “disease” management (Fulford 1989, p. 85). Burns puts the distinction between the medical and personal models of recovery cogently by stating: The institutionalized medical language of mental disability is, at best, pejorative and situates mental conditions squarely within an individual disease framework. Terms such as ‘mental disease’ and ‘mental disorder’ construct psychological, emotional, and behavioral conditions as innate, biological, pathological states independent of socioeconomic, cultural, and political context. Likewise, the prevailing medical model of mental disability — which defines disability as an individual’s ‘restriction in the ability to perform tasks’ and handicap as ‘the social disadvantage that could be associated with either impairment and/or disability’ — serves to establish a direct causal relationship between individual impairment and disability. (2009, p. 11)

Recovery for the practitioner then is meant to go beyond pathological and deficitbased perspectives and looks at one as a complete and autonomous individual with self-determination. One of the critical components of recovery is to try and give power to the person seeking support, by placing them at the center of the decision-making process and shifting the focus on them rather than the service provider. By doing this, it starts to recognize the rationality and capacity of people even if it be temporarily impaired with experiences of extreme distress (Ramon 2009, p. 1620). As we can see then, recovery – as an agreed-upon set of beliefs, attitudes, and concepts – becomes a useful value-add for social work practice. A critical appraisal of recovery includes the “capture” of recovery by mainstream services (Pilgrim 2008; as cited by Davidson et al. 2016, p. 4). This has been seen to “dumb down opportunities” in critical thinking and practice (ibid). Detractors also argue that recovery is too narrow, mainly focusing on the inner subject experience of the individual while ignoring the relational and structural experiences that bring

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about distress, “inequality, and injustice” (Ramon 2009, p. 1620; Harper and Speed 2012, p. 23; as quoted by Davidson et al. 2016, p. 4). It is only when recovery is seen more broadly, namely, through the social model of disability (which argues that psychosocial disability is caused by the way society is organized, rather than by a person’s impairment or difference) or through the framework of human rights (which promotes equity, freedom and fairness) that recovery can claim to create something substantive in areas like participation, parity of opportunity, equality, and autonomy. Here, issues of inclusion, choice, control, and self-determination are “not considered to be solely issues of growth and development or [even] quality of life, but are viewed rather as fundamental to the rights and responsibilities of citizenship” (Davidson et al. 2009, p. 14). It is surprising then that the practice of the recovery has been, to an extent, uncritically accepted by practitioners working in the field (Davidson et al. 2016, p. 4), as well as by people who have themselves experienced acute psychological distress and have received recovery-type support. It could be because recovery is often said to be a personal and unique experience; facilitating a journey of growth, exploration, and awareness; and providing an opportunity for self-discovery and transformation. It could also be because recovery allows people who have historically been stripped of their power and ability to make decisions for themselves, to gain a modicum of control around treatment and support, enabling agency and allowing people to feel invested in their own recovery. This ownership creates a sense of responsibility and accountability, empowering people as they self-direct “in devising their own lives and values” (Gillon 2003, p. 16). In other words, people accept the concept of recovery because it is the best there is. It is a supportive and empowering experience, especially when comparing it to the medical model of recovery and other alternative treatment methodologies one usually comes (or has come) into contact with in mainstream treatment practices. Recovery is ultimately aspirational, with the idea of living life well, the way one wants, with or without the presence and experiences of mental health distress. Hence, recovery should be viewed by practitioners as an ethical obligation. So far, we have argued that recovery can be seen as a set of values and outlined what these values can translate to for both the individual and practitioner. The following section will look at how an ethical framework can assist in guiding practitioners in this challenging and dynamic system.

Ethics, Recovery, and the Mental Health System Ethics is a branch of philosophy that addresses notions of what is right and wrong, good and bad. When applied, ethics addresses practical everyday concerns and serves as a tool in establishing and clarifying boundaries (Paalanen and Hopia 2017, p. 2; Adams 2009, p. 84; Robertson 2009, p. 3). In this sense, ethics aims to find and implement the best possible answers to questions and dilemmas that arise as it guides decision-making and behavior. Ethics thus provides normative guidelines

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for behavioral and practice standards that are expected and even obligated (Adams 2009, pp. 83–84). For people labeled with a mental “illness,” many unacceptable scenarios that breach human rights have been normalized. For example, anger, frustration, and dissatisfaction with medical treatment are said to be part of one’s “resistance” and “non-compliance” with a “lack of insight” demanding compulsory treatment. There is a growing body of evidence that indicates this clinical and reductionist approach contributes to negative health, and social outcomes, even leading to death (McAnally 2017). Other ethical matters that one can point to as inherently controversial in the way they are understood include seclusion and restraint, hospitalization, assessment of capacity in decision-making, guardianship, and the rights of family (Paalanen and Hopia 2017, p. 10). With so much inherent systemic tension, social work practice can be precarious, particularly when the values and ethics of social work intersect with a health system that focuses on risk management, outcomes, and efficiencies (Fulford 1989, p. 131). Other discreet dilemmas include how mental health services focus on “monitoring symptoms and ascertaining the risks people may present to themselves and others. This well-intentioned but negative focus on deficits has contributed to stigma, discrimination and exclusion experienced by service users” (Davidson et al. 2016, p. 1). This culture of practice reinforces the image of people who experience severe psychiatric symptoms as “dangerous” and “irrational” and who need to be restrained and sedated to be treated. Here, structural violence is present alongside treatment.

Using Ethics to Guide Practice To avoid falling into a culture of apathy and maltreatment, social workers should use recovery to inform their practice. They should also use ethical decision-making methods that will assist them in fulfilling their responsibilities in maximizing health outcomes and minimizing abuse and mistreatment. Four methods in ethical reasoning to arrive at principled decisions will now be outlined.

Normative Approach Ethical reasoning asks how a professional should behave in a certain situation and how one can improve workplace protocols that support professional practice. In this normative approach, the practitioner uses rules or guidelines in their workplace to support the people they are serving. If the conventions they work under do not support the people they serve, then social workers should seek to change them (Paalanen and Hopia 2017, p. 3). Questions like “how will my decisions or actions affect people”; “how can my practice minimise harm”; and “what will create the least inconvenience and hardship” can assist practitioners in exploring solutions to some of the ethical dilemmas they encounter and to provide the moral justifications for the changes they want to see implemented.

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Rational Approach Decisions should always be logically consistent, compatible with the facts concerning the situation, and well-grounded in evidence (Paalanen and Hopia 2017, p. 3). This rational approach does not give space to one’s beliefs and assumptions. One’s instinctual feelings are not enough to disregard ethical boundaries or to validate exploitation. Moreover, prejudices and stigma shaped through diagnosis and illness need to be monitored, identified, and acknowledged, as questions of evidence-based treatment and how services and programs impact people exist as central features in this ethical line of reasoning.

Contextual Approach A service practice may not be ethically feasible to every person in every situation. It is always necessary that the social worker takes into account the milieu of the service user. This contextual approach thus needs social workers to discern the situation of the individual and service setting. Questions about family, culture, and religion; whether they are experiencing their symptoms intensely; what assets and strengths can they bring to the table; and what past treatment has contributed to their recovery can all be part of the conversation with the supporting team, as well as the service user, to explore treatment and support strategies.

Interpersonal Approach Finally, the interpersonal approach in formulating decisions dictates that ethical practice is found in the interaction or the interpersonal activities that occur between people. Therefore, ethically sound decisions transpire through the interaction with service users and the subsequent effects of that interaction. Here we find the relationship between the service user and service provider as fundamental to mental health service delivery (Paalanen and Hopia 2017, p. 3). Questions about how I should interact with people and what are the consequences of those interactions can be found at the forefront of this ethical technique.

Social Work Practice, Ethical Dilemmas, and Codes of Ethics When ethics is applied to a profession, it is usually in the form of codes of ethics (Robertson 2009, p. 3). Codes of ethics are values and practice standards that assist in addressing ethical dilemmas and conflicting practice principles (Adams 2009, p. 83; Robertson 2009, p. 42). They are there to assist in realizing respect for persons, beneficence, nonmaleficence, and justice – “the cornerstones of modern ethical codes for the health professions” (Hoop et al. 2008). Applying codes of ethics within the mental health service and support sectors can be challenging though. This is

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because these sectors are now human rights framed, demand a person-centered emphasis, call for collaborating with people and their supporters, and take an individualistic and nuanced approach to the needs and circumstances of people. Recovery values, principles, and approaches can assist here and are worthy explicit additions to social work codes of ethics. We state explicit because, implicitly, recovery is already alluded to in many practices and documents including the National Association of Social Workers (NASW) Code of Ethics (2017): The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession’s focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living. . .Social workers seek to enhance the capacity of people to address their own needs. Social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems.

The above quote lists empowerment, well-being, social context, and capacity building as goals for social workers to strive for when working with people which are all simultaneously corresponding core elements of recovery. Another example can be found in the Australian Association of Social Workers (AASW) Code of Ethics (2017) when it describes the profession’s purpose this way: The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance wellbeing. Utilising theories of human behaviour 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.

The above quote from the AASW Code of Ethics suggests that the interface between people and the environment is intrinsic to social work practice (Hyde et al. 2014, p. 10). This description refers to the interpersonal ethical value outlined above and echoes Slade’s (2009) characterization that “[r]ecovery happens in the space inbetween person and context” (p4, as quoted by Hyde et al. 2014, p. 10). It is clear from the above that although there is an “invisibility” of recovery in the conversation (Hyde et al. 2014, p. 10; Ramon 2009, p. 1620), notions of recovery are already deeply embedded in social work practice. This is demonstrated with the social work profession initiating a number of recovery type ideas, like: the involvement of service users in their own treatment; incorporating strength-based practice into treatment and care; and exploring narrative and anti-oppressive practice theories (Hyde et al. 2014, p. 10; Ramon 2009, p. 1615). Notwithstanding the close alignment of recovery and social work practice codes of ethics, ethical dilemmas will still arise because as Hyde et al. in Australia remind us: . . .an alignment between principles of social work. . .and recovery concept[s]. . .does not of itself guarantee that the concepts are one and the same or that true recovery-oriented practice will automatically be intrinsic to the practice of all mental health social workers. The move from principal to practice requires deeper critical reflection that needs to commence at the

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level of mental health social work training, acknowledging and respecting lived experience as an alternative participatory and patient-centred epistemology. This will equip the mental health social worker to resist and critique the ‘pull’ of the dominant [medical] discourse. . .. (2014, pp. 10–11)

Reamer agrees, however, further adds that codes of ethics embrace standards that reflect the concepts of professional paternalism and protection of third parties (2006, p. 26). For instance, Section 1.02 under Self-Determination of the NASW Code of Ethics states that social workers should “. . .respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals” but that “[s]ocial workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others” (2017). While social workers strongly believe in clients’ right to identify and pursue goals of their choosing, there is tension here since social workers characteristically also hold firm to the ethical practice necessary to protect clients from harming themselves and/or others. It is acknowledged by Reamer that: Paternalism is such a difficult problem for social workers because most practitioners are drawn to the profession by a sincere wish to help people who are experiencing difficult problems in their lives – for example, people with clinical depression, who are suicidal, who are living in unsanitary housing, who are involved in abusive relationships, or who are addicted to drugs or alcohol. That is, limits on professional paternalism may run counter to many practitioners’ instincts to protect vulnerable people from engaging in self-destructive behaviour. (2006, p. 27)

Fundamentally then, in this multifaceted environment, which is primarily driven by the medical model of recovery, codes of ethics “. . .cannot resolve all ethical issues or disputes, or capture the richness and complexity involved in striving to make responsible choices within a moral community” (NASW 2017, p. 4). Rather, code of ethics assembles a set of contemporary values, ethical principles, and ethical standards to which “professionals aspire and by which their actions can be judged” (ibid). When a system is largely illness centered (not person centered), driven by professionals (not led by service users), is deficit based (not strength based), and managed through diagnosis, risk, capacity, and disease labeling, then ethical dilemmas will undoubtedly emerge. This old medical model archetype where it views people with acute mental health challenges as an inherent liability to society by virtue of their “deficiency” is what leads to prejudicial, discriminating, and even dangerous beliefs and practices. Throughout history, we see the acceptance and normalization of horrific and dehumanizing practices.

Power and Social Work Practice Throughout the Middle Ages, people experiencing acute and chronic psychiatric experiences were considered demonically possessed and executed as “witches” (Robertson 2009, p. 30). In the time of “enlightenment,” people were placed into

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abject conditions, incarceration, and excluded from society (ibid). During this period, peoples’ confinement often involved physical restraint with such things as manacles or chains (ibid). The “mentally ill” systematically become the subject of “ridicule and demeaning curiosity” epitomized by the systematic practice of England’s Bethlehem hospital where a paying public could tour the hospital to laugh at, demean, and poke residents with sticks (ibid). The twentieth century did not get better for people who experienced acute psychological distress. The western world was deeply influenced by eugenics, which promoted the removal of “inferior genetic stock” from the population (ibid p31). As an example, long before the gas chambers of World War I were operational, European psychiatrists were assisting in the gassing of psychiatric patients (Robertson 2009, pp. 31–32): The murders were coordinated by a [German] official, Philip Bouhler, assisted by three professors of psychiatry – Nitsche, Heyde and Hannecke. Bouhler coordinated the process from Berlin at Tiergartenstrasse 4, hence the reference ‘T4’. Aktion T4 resulted in the murders of seventy to eighty thousand people with psychiatric disorders, mental retardation, brain diseases such as epilepsy and those with histories of asoziale (antisocial) behaviour. A questionnaire put to all psychiatrists in German hospitals helped to identify patients who were chronically mentally ill, or had criminal pasts.

To assist in ascertaining who should be exterminated, questionnaires were given to all psychiatrists working in hospitals to help identify people who were chronically mentally ill. This even included eliminating children suffering from “idiocy,” Down syndrome, and other mental and intellectual disorders. By 1936, many people in mental health facilities were being transferred to Dachau and other locations for extermination (Robertson 2009, p. 31). In Australia in the 1960s and 70s, the Chelmsford Hospital scandal involved the use of the discredited practice of continuous narcosis or “deep sleep therapy” (DST). This is when people were chemically induced into constant subduing sedation, fed through a nasogastric tube with an administration of ECT. There were 24 deaths that occurred with this “treatment,” and those who escaped death, but were perceived to be unresponsive to deep sleep therapy, were referred to a local teaching hospital for cingulotractotomy – or to put it more bluntly, holes in the head surgery (Robertson 2009, p. 37). Clear in the severity of medical negligence, Robertson states that Chelmsford Hospital was also culpable in the use of inexperienced nurses to care for people (ibid). And this was not an isolated incident or rogue behavior from one or a group of people, but a comprehensive failure of the system. The Human Rights and Equal Opportunity Commission summarized the findings of the Burdekin Report (an account of the national inquiry of human rights for people with severe and persistent mental health experiences in 1993) this way: “people affected by mental illness suffered from widespread systemic discrimination and were consistently denied the rights and services to which they are entitled” (HREOC 1993, p. 15). The above section briefly discusses the abuse of power by “experts” and systems toward vulnerable groups of people, as well as indicate why ethics and the values society places in formulating good practice in the treatment of people experiencing

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severe and persistent psychological distress have been absolutely essential for not only people experiencing “illness” but for practitioners who help support them (Ramon 2009, p. 1615). Having described some extreme forms of abuses, we will examine the subtler power dynamics that a social worker will face in their practice.

Implicit Power Dynamics in Social Work Practice By its very nature, social work practice is political because it examines social structures as a means of improving peoples’ lives. Further, it operates within a political and bureaucratic system, as it engages with a contradiction between social work’s emancipatory values and the controlling interventions common in mental health practice (Maylea 2016, 2017; Davidson et al. 2016; Ramon 2009). “The challenge. . .includes remaining consistent with. . .ethical principles while also capable of competently balancing the. . .control dimensions of practice” (Brophy and McDermott 2012, p. 3). As opposed to some form of coercion and compliance to diagnose and treat, collaboration – with the aim to motivate and inspire – has been emphasized wherein people are actively engaged in the planning and implementation of their health plans (Maylea 2017; Brophy and McDermott 2012, pp. 2–3). Personalizing and ensuring the voices of service users are being heard, and if possible privileged, particularly for people who have been scheduled, equalizes these power differentials (Brophy and McDermott 2012). Attributes like compassion, transparency, accountability to facilitate choice, and self-determination are suitable here as the practitioner attempts to be inclusive and collaborative – that is, ethical. Being and operating in this way has shown to reduce the need for coercive intervention, so that “casework practice with involuntary clients need not be characterised by hostility and resistance. Rather, such a relationship can be based on an understanding of the individual client and the social and structural forces influencing their behaviour” (Brophy and McDermott 2012, p. 2). As we can see, social workers locate themselves alongside rather than having power over people. Social workers are thus intent on being active and purposeful in improving the lives of people facing challenging psychosocial situations and experiences, with some commentators even recommending that social workers spend time speaking out against the “evils of institutional racism and other forms of discrimination,” as well as intervene when they see injustices involving the people they are supporting (Anderson 2004). This is because, it is argued, there is an “over reliance on pharmacological interventions, coercive approaches and inpatient treatment” which is inconsistent with the principles of doing no harm, human rights, and citizenship (United Nation’s Human Rights Council 2017, p. 13).

Human Rights Human rights are protections articulated in law that recognize the inherent dignity and “equal and unalienable rights of all members of the human family.” They enunciate why and how to keep people safe from exclusion, abuse, and neglect

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(WHO 2017). It is on the basis of this fundamental understanding that the notion of “patient” rights started to develop (ibid). The principal document for people with mental health and psychosocial disabilities is the Convention on the Rights of Persons with Disabilities (CRPD). Upholding and championing human rights is a core value of social work practice (Fronek 2012). However, Nipperess argues a need to move beyond rhetorical commitments to an in-depth exploration of the relationship and contested nature of human rights and social work in mental health social work practice (ibid). It is here that recovery can make an impact. Both recovery and human rights essentially advocate for agency through inclusion and self-determination, for people to be involved in their own treatment and care, giving people the opportunities to own their decisions and take responsibility of their own destiny. “Nothing about us, without us” is a phrase that succinctly summarizes the approach as a fundamental driver of good ethical practice when working with people to improve their mental health outcomes. The above outlined examples of the obvious abuses of power in the past, the implicit and subtle power relationships inherent to the system, and the responsibility to protect the dignity and rights of people. We will now look at a case scenario to ground our premise and link the concepts and ideas of this thesis to practice.

Ethical Dilemmas in Practice: A Case Scenario The following paragraph will be a description of a somewhat standard scenario. The subsequent paragraphs will then address key themes. In this, we hope to illustrate what a recovery-oriented set of values in addressing common ethical dilemmas can look like on the ground in practice. (The irony here is that we are using a generalized example with prototypical themes, aspects and experiences, while at the same time, railing against a system entrenched with uniformity and standardization, particularly with assessment and evaluation tools. If people reading this case scenario feel uncomfortable with the description of what one may go through when entering and staying at a mental health unit, we encourage them to think the inverse and empathize with how people experiencing acute psychological distress feel when being categorized and boxed into diagnosis and labels.)

A Description of Entering a Mental Health System When a person is coerced into entering a mental health facility because they have been assessed as a “risk,” they are not only interacting with the staff they see but with a system that has a long history of enforcing its will. Decisions and undue preferences by service providers in the “management” of the person are set in motion. Treatment and support are done in a vacuum, without completely understanding the person, their background, context, or experiences. They are assessed, evaluated,

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spoken at, and pried, as they feel overwhelmed, judged, and stigmatized. A person is kept out of discussions about their own treatment and is not completely informed to gain an understanding and depiction of what is occurring to them. There is no time to establish a genuine relationship as practitioners get on with maintaining the system they work in. In this system, the individuals find themselves in a strange place, in unfamiliar surroundings, being compelled to do things they do not want to do. When the individual is asked for their preferences, they are given limited options to choose from and only what a medical model of recovery can provide given the culture, environment, and constraints the facility operates in.

Ethical Dilemmas Brought Up in the Above Scenario Coercion Coercion diametrically opposes human rights and a recovery approach because it places an individual in a position of particular disadvantage and unique vulnerability through diminished (and deprived) autonomy, control, and decision-making (Maylea 2016, p. 465). Consequently, coercion in mental health practice is antithetical to social work values of respect for persons and social justice (AASW 2010). Despite this, however, social work practice is undertaken on the assumption that there is a need for coercion (Maylea 2016, p. 465). Some have argued that “social work as a profession should reject the notion of coercion, and work towards a mental health support system which respects capacity, agency and recovery” (Maylea 2016, p. 465). Coercion can be seen as a “result of a systemic failure to protect the rights of individuals” (UNHRC 2017, p. 15) with the social work profession requiring social workers to minimize compulsion to facilitate peoples’ enjoyment of rights, dignity, worth, and autonomy (AASW 2010). By reducing coercion and advocating for treatment in the least restrictive manner, one can – given the context – instill dignity, self-worth, and self-determination. Or to put it another way, if it can be accepted that the exercise of their given powers has the potential to facilitate a less restrictive, less traumatic, and less stigmatizing pathway, then social workers have a legal and ethical obligation to apply them (Maylea 2017, p. 473). (See Lisa Brophy’s, ▶ Chap. 24, “Legal Provisions, Advocacy, and Empowerment,” in this book for further reading.)

Risk Notwithstanding the positive developments in policy in most western countries, the focus of mental health services remains on the concept of risk. This is despite the inability to “accurately predict the future and so prevent all harm” (Davidson et al. 2016, pp. 1–2). The preoccupation with risk is perhaps because there is a misconception that violence to oneself or others is a “hallmark” of mental illness

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(Leblanc and Kinsella 2016, p. 64; Robertson 2009, p. 30) with services and systems feeling obliged to act to minimize this danger (Maylea 2016, p. 5). Maylea states that “the relationship between diagnosed mental illness and violence to others is poorly understood and regularly overblown.” He explains that the “inability of mental health professionals to accurately predict risk of harm entirely undermines risk management as a justification for involuntary treatment” (2016, p. 7). This argument is vindicated with a review of a number of studies determining that there is no solid evidence for this assumption. Maylea further argues the most effective way to manage risk is to apply recovery values and approaches to practice (2016, p. 7). While it is recognized that this may not entirely eliminate the need for coercion, it will however “affect the process, impact, frequency and duration of these types of intervention” (Davidson et al. 2016, p. 9).

Discrimination and Bias Social workers, whether implicit or explicit, have practice bias – the undue influence of their education, training, and organizational culture. Stull and colleagues state that there is evidence that implicit and explicit biases occur and “differentially” predict clinical decisions (2013, p. 6). In their own investigation, they discovered that when they modeled their review using potential factors “greater implicit, but not explicit, bias significantly predicted greater endorsement of restrictive or controlling clinical interventions” (Stull et al. 2013, p. 6). Moreover, a mental health facility has a very prescriptive method of dealing with people. As soon as one is admitted, they are systematically triaged and processed. Documents that are recorded are now what defines the person. A mental health system, absorbed with “service-determined outcomes under the strictures of clinical governance” and subsumed with preordained processes, cannot comprehensively and genuinely take on a recovery-oriented approach, which essentially caters to personal, individualized, and very diverse journeys of recovery (2010, p. 155). For as Trivedi reasons, how can the ethical dilemma of hope, transformation, and citizenship fit in with systems that preserve institutional structures (2010, pp. 153–154)? These ethical constraints prompt Stull and colleagues to argue for social workers to reflect and practice “on the ways in which attitudes [and processes] convey bias” against consumers and “how biases influence how they intervene with consumers” (2013, p. 2).

Listening to Lived Experience Although people depend on the expertise of social workers, the bigger expert is the person who is experiencing their own distress and treatment. This means that social workers should become listeners (as well as advocates) who work to a model that privileges the lived experienced voice and the will and preferences of the person over a model that privileges one’s “best interest” (as determined by the system).

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This is a correction in culture, because as psychiatric survivor and activist Erick Fabris writes: “we are not even credited with having experience” (as quoted by Leblanc and Kinsella 2016, p. 64), and this discrediting of people as legitimate knowers of their own experiences represents what Fricker (2007) refers to as testimonial injustice, which tacitly distorts judgments of peoples’ credibility as speakers (LeBlanc and Kinsella 2016, p. 63). Here again, we circle back to the notion that people who experience severe and persistent mental health issues are incapable of rational thought and insight into their own experiences and understanding (Leblanc and Kinsella 2016, p. 64; Robertson 2009, p. 30). Privileging peoples’ stories and experiences directly addresses the epistemic injustice perpetrated by the “disregard of the lived experiences of people and their supporters” (Bell 2014).

Enacting Compassion Compassion involves an authentic desire to help others. It is also about empathizing with the individual and what they are going through and acting in a way that assists in the alleviation of their distress. This could include listening empathically, validating peoples’ experience, cultivating a collaborative relationship, using positive language, and acknowledging the individual’s strengths, interests, and capacities. Social workers should not value professional routines over peoples’ needs. People often enter a mental health facility at a vulnerable time, overwhelmed and preoccupied with their own psychological and emotional experiences of distress – trying to make sense and meaning of it. The facility is an unfamiliar environment with unfamiliar people using an unfamiliar (medical) language. People who are admitted lose their control, lose their autonomy, are being observed, and feel skeptical. In this setting, compassion is absolutely critical and necessary in the interaction between social worker and service user.

Inclusion Participatory principles encourage social workers to include people in their own treatment and recovery plan. In order to do this, it will involve genuinely listening to people, having a gentile curiosity in order to understand them more holistically, self-checking undue preferences and biases, having a clear understanding of what is needed, and working together to achieve well-being goals. This is important because, historically, people placed in these systems are poorly informed and mostly excluded from the decision-making process (WHO 2010, p. 2 and NZ Guidelines Group pvii). Neither they nor their families have been listened to or been treated well (WHO 2010, p. 2). As a result, people in mental health systems continue to be socially excluded and discriminated against (ibid). Exclusion and discrimination do have deep and lasting effects on a person’s health, sense of identity, and worth. As a consequence, powerlessness though exclusion has emerged as a key risk factor in the etiology of disease (ibid).

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Conversely, the ability to exercise control and influence over one’s life and choices improves health outcomes and strengthens one’s identity and self-esteem. Accordingly, inclusion is an important therapeutic factor that promotes recovery and is considered a vital concept in relapse prevention. Through participation and engagement, a social worker fulfills their legal, moral, and professional obligations to the people they work with and to the code of ethics they subscribe to. Further, inclusion can lead to positive interactions and has the added value in breaking down stereotypes and misconceptions (WHO 2017, p. 54). A broader dimension of inclusion incorporates being able to own a home, opportunities to build financial resources, access to education and employment, and participation in political and public life, as well as, social and cultural life (WHO 2017, p. 22), these broader and holistic approach to recovery minimizes risk factors in the etiology of disease (WHO 2010, p. 2). This is why inclusion and participation in life are such critical aspects to recovery. Both the interpersonal and broader dimensions of inclusion sit well with social work values of social justice and citizenship.

Empowerment Empowerment is the “increasing capacity” (deBronkart 2017, p. 7) to “make choices, and to convert those choices into effective actions and outcomes” (World Bank 2016). It is a multifaceted social process through which individuals improve their understanding and control in life. It is intended to help individuals develop the necessary resources to cultivate identity, autonomy, and self-esteem, as they exert more influence in their social and political lives (WHO 2010, p. 1). This will allow people to change their social and physical environments, allowing themselves to facilitate their own improvements in their life circumstances (ibid p2). deBronkart argues that a necessary prerequisite to the mental health system achieving its desired outcomes is mental health services ensuring “past beliefs about patients don’t perpetuate limited capacities, or patient involvement will repeatedly fail” (2017, p. 5). Hence, the idea of empowerment here is essential, to break the cycle of biased, prejudiced, and stigmatized beliefs, as well as providing opportunities for people to reach their full potential. It is important to note that practitioners cannot empower people – they can just assist people in empowering themselves. This change of understanding will build confidence, self-esteem, and capacity – characteristics of empowerment – and should be looked at as an ethical goal. Further reading on empowerment, social justice, self-help, and other similar concepts can be found with Robert Bland and Gabrielle Drake’s work at ▶ Chap. 11, “Community and Mental Health.”

Competency Competencies are measurable standardized practice behaviors around performance. Being competent is critical to the social work profession. Robertson states

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competencies require three core components: specialized training and the acquisition of specialized skills; the provision of expert assistance to those who are vulnerable and in need; and the virtues of trustworthiness, efficacy, and knowledge (2009, p. 7). This proposition fits neatly with social work ethics and recovery-oriented philosophies. Competencies should be informed by evidence. People seeking assistance depend on social workers to be aware of and follow evidence-based practice and standards. Access to quality up-to-date information on how to interact, treat, and support people experiencing psychological distress will facilitate the implementation of effective health interventions. Competencies thus gives social workers the attributes and confidence to apply their skills and knowledge appropriately. The mental health environment is a very dynamic and rapidly changing ecosystem. The social work profession needs to be agile and responsive. History has proven that mental health social workers have a history of conceptual and practice innovation (Ramon 2009). Their competencies around ethical conduct and recovery-oriented practice will however need to shine through as they practice adjacent to a medical model that demands compliance in an “illness” framework.

Discretion There can be tension between the clinical practices of mental health systems and ethical practices underpinned by recovery values. This is because social workers will struggle to balance the needs of the people they are supporting with the system’s clinical culture, as they operate and respond to the conditions in which they work in, navigating the demands they experience and the beliefs they have about ethical practice. The system’s increase in standardization does not help, as it diametrically opposes recovery when recovery defined as a subjective, personal, and individual process. Although social workers have to conform if they are to become valued members of the organization they work for and the system they serve, the AASW Code of Ethics provides scope for social workers to use professional discretion to negotiate where this line is drawn. In other words, “Social workers engaged in statutory practice” and “any legally mandated authority” are to “ensure that the principles of natural justice are applied in all cases” (AASW 2010, p. 26). This means social workers have an opportunity to exercise professional discretion and judgment to ensure social justice and human rights are attained (AASW 2010) even when they clash with the system’s dominant values (Trevidi 2010, p. 160). The authors here contend that small pockets of opportunities can provide occasions for creative and innovative practice through an ethical value-based recovery approach.

Power, Culture, and Reflective Practice Laying at the foot of each personal interaction is the power differentials between service provider and service user. Historically speaking, it is one of paternalistic biomedical or “psychocentric” practice which has:

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B. Aadam and M. Petrakis . . .proliferated throughout society and can be seen in popular cultural expressions, organizational cultures, and academic discourse alike. The hegemony operates on different levels and through multiple mechanisms that blame the individual and thus erase the social context and social bases of many individualized problems in neoliberal society. Thus, in neoliberal culture, the forces of pathological individualism proliferate while social structural factors at play in mental, emotional, physical and social lives are expunged or downplayed. . .. (Croft et al. 2016, p. 1)

The “combination of a biomedical and [stigmatising] discourse forms a powerful partnership in creating a culture of control and coercion in mental health care” and acts as a significant barrier to practicing ethically oriented philosophies within inpatient settings (Hyde et al. 2014, p. 8). The archetypal justification for these abuses in practice may be due to the Kantian construct and makeup of the human, as a “rational being, able to construct maxims of rational moral action” (Robertson 2009, p. 14). Consequently, a mental health system’s assessment is not located “in [peoples’] suffering, their circumstances or their rights as citizens, but in their capacity to legislate moral action” (ibid). If they are seen as not having the capacity to make rational decisions, they are stripped of their humanity. It is this “rational capacity” that is assessed in relation to a healthy and functioning human being with the restoration of the mind being the goal of intervention by mental health systems (ibid). Social workers who are ethically orientated and values driven will be reflective of their own practice in critically analyzing, monitoring, and evaluating their work, to ensure they do not support and reinforce this paternalistic and authoritative culture. The ability to be reflective at one’s own practice in a continuous and methodical way is now considered essential to “good” practice. This involves scrutinising one’s own practice to identify the fundamental assumptions underpinning behaviours and decisions. Reflective practice also focuses on the underlying power dimensions in assumptive thinking, including “the many ways power operates, and a person’s own power and relationship to it” (Fook 2015, pp. 440–443). Social workers can be aided by a deconstruction of their thinking in order to expose how they participate in constructing and maintaining power in an oppressive mental health system. This will allow practitioners an opportunity to explore their place in the system and reflect on what they have normalized as part of their work (Fook 2015, p. 445).

Conclusion If ethics is about making the right decision and doing the right thing (Adams 2009, p. 84), then the means that guides ethical practice is the idea of recovery. In this light, recovery can be seen as inextricably linked in shaping ethical understanding (Robertson 2009, p. 3; Hoop et al. 2008, p. 354; Fulford 2008, p. 2). It is no wonder then that recovery has become the cornerstone of contemporary mental health practice, as it ultimately challenges the medical paradigm by fundamentally shifting the focus and power away from practitioners and service providers to the very

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individuals who seek out services and practitioners. Recovery should therefore be explicitly seen as a value-add in social work practice as it strongly aligns with social work values and is underpinned by the broader ethical framework of respect (for a person’s autonomy and self-determination), beneficence (doing good), nonmaleficence (not doing harm), and justice (treating people fairly, without bias and discrimination). Contested issues in an outcome-driven system will generate practice dilemmas (Davidson et al. 2016; Ramon 2009; Fulford 1989). However, recovery outlines what is acceptable and improper in contemporary mental health practice, and ethical strategies discussed in this chapter will help address practice dilemmas. Social work codes of ethics will assist, but should not be solely relied upon. This paper examined recovery as an ethical and value-based practice. A case scenario was presented to outline the subtlety of these abuses camouflaged under the normalization of practice. It is now up to the reader, as social workers, to delicately toil in a complex and rapidly changing environment that consistently produces ethical dilemmas (Davidson et al. 2016, p. 1; Fulford 2008, p. 3). These predicaments can appear in the appearance of professional standards against service user respect, organizational guidelines against personhood, and service systems against individual autonomy, treatment, and care. The quintessential ethical question to ask as a social worker in this environment is: How would I like to be treated?

Cross-References ▶ Legal Provisions, Advocacy, and Empowerment ▶ Medical Perspective on Mental Health ▶ Psychological Perspective ▶ Social-Cultural Ecological Perspective

References Adams P (2009) Ethics with character: virtues and the ethical social worker. eJ Sociol Soc Welfare 36(3) Article 5. http://scholarworks.wmich.edu/jssw/vol36/iss3/5. Accessed 12 Jan 2018 Anderson J (2004) Review – Mental health professionals, minorities and the poor, by Michael E. Illovsky. In Metapsychology Online Reviews 8(24). https://metapsychology.mentalhelp.net/ poc/view_doc.php?type=book&id=2196&cn=135. Accessed 20 Sep 2017 Australian Association of Social Workers (2010) Code of ethics. AASW, Canberra ACT. https:// www.aasw.asn.au/document/item/1201. Accessed 17 Nov 2017 Beauchamp TL, Childress JF (2013) Principles of biomedical ethics, 7th edn. Oxford University Press, New York Bell K (2014) Exploring epistemic injustice through feminist social work research. Affilia 29(2):165–177 Braslow JT (2013) The manufacture of recovery. Annu Rev Clin Psychol 9:781–809. https://doi. org/10.1146/annurev-clinpsy-050212-185642. Accessed 17 Nov 2017 Brophy L, McDermott F (2012) Using social work theory and values to investigate the implementation of community treatment orders. Aust Soc Work. https://doi.org/10.1080/ 0312407X.2011.651727 Burns JK (2009) Mental health and inequity: a human rights approach to inequality, discrimination, and mental disability. Health Hum Rights J 11(2). https://www.hhrjournal.org/2013/08/mental-

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health-and-inequity-a-human-rights-approach-to-inequality-discrimination-and-mental-disabil ity/. Accessed 3 Nov 2017 Croft L, Gray M, Rimke H (2016) Mental health and distress as a social justice issue: guest editors’ preface and acknowledgments. Stud Soc Justice 10(1):1–3. https://doi.org/10.26522/ssj. v10i1.1406 Davidson L, Rowe M, Tondora J et al (2009) A practical guide to recovery-oriented practice: tools for transforming mental health care. Oxford University Press, New York Davidson G, Brophy L, Campbell J (2016) Risk, recovery and capacity: competing or complementary approaches to mental health social work. Aust Soc Work. https://doi.org/10.1080/ 0312407X.2015.1126752 deBronkart D (2017) The paradigm of patient must evolve: why a false sense of limited capacity can subvert all attempts at patient involvement. Patient Experience J 4(2) Article 2. http://pxjournal. org/journal/vol4/iss2/2. Accessed 14 Aug 2017 Fook J (2015) Reflective practice and critical reflection. In: Lishman J (ed) Handbook for practice learning in social work and social care: knowledge and theory. Jessica Kingsley Publishers, London Fricker M (2007) Epistemic injustice: power and the ethics of knowing. Oxford online scholarship. https://doi.org/10.1093/acprof:oso/9780198237907.001.0001 Fronek P (Interviewer) (2012, Aug 2) On human rights and social work: In conversation with Sharlene Nipperess [Episode 17]. Podsocs. http://www.podsocs.com/podcast/on-human-rightsand-social-work/. Accessed 16 Nov 2017 Fulford KWM (1989) Moral theory and medical practice. Cambridge University Press, Cambridge, UK Fulford KWM (2008) Values-based practice: a new partner to evidence-based practice and first for psychiatry? [Editorial]. In: Singh AR, Singh SA (eds) Medicine, mental health, science, religion, and well-being. MSM, 6, Jan-Dec 2008, pp 10–21. https://doi.org/10.4103% 2F0973–1229.40565 Gillon R (2003) Ethics needs principles—four can encompass the rest—and respect for autonomy should be ‘first among equals’. J Med Ethics 29:307–312 Hoop JG, DiPasquale T, Hernandez JM et al (2008) Ethics and culture in mental health care. Ethics Behav 18(4):353–372. https://doi.org/10.1080/10508420701713048 HREOC (1993) Human rights and mental illness: report of the national inquiry into the human rights of people with mental illness. Canberra. https://www.aph.gov.au/Parliamentary_Business/ Committees/Senate/Former_Committees/mentalhealth/report/c03. Accessed 12 Jan 2018 Hyde B, Bowles W, Pawar M (2014) Challenges of recovery- oriented practice in inpatient mental health settings – the potential for social work leadership. Asia Pacific J Soc Work Dev 24(1–2):5–16. https://doi.org/10.1080/02185385.2014.885205 Leblanc S, Kinsella EA (2016) Toward epistemic justice: a critically reflexive examination of ‘sanism’ and implications for knowledge generation. Stud Soc Justice 10(1):59–78 Maylea C (2016) A rejection of involuntary treatment in mental health social work. Ethics Soc Welfare. https://doi.org/10.1080/17496535.2016.1246585 Maylea C (2017) Minimising coerciveness in coercion: a case study of social work powers under the Victorian Mental Health Act. Aust Soc Work 70(4):465–476. https://doi.org/10.1080/ 0312407X.2017.1326158 McAnally A (2017) ‘Their deaths were avoidable’: patients killed themselves while under observation at Scottish hospitals. Daily Record. 24 May 2017. https://www.dailyrecord.co.uk/news/ scottish-news/their-deaths-were-avoidable-patients-10485770. Accessed 15 Jan 2018 National Association of Social Workers (2017) NASW Code of ethics. https://socialwork.utexas. edu/dl/files/academic-programs/other/nasw-code-of-ethics.pdf. Accessed 17 Nov 2017 Paalanen T, Hopia H (2017) Introduction to professional ethics. JAMK University of Applied Sciences, Jyvaskyla Pilgrim D (2008) ‘Recovery’ and current mental health policy. Chronic Illn 4:295–304

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Ramon S (2009) Adult mental health in a changing international context: the relevance to social work. Br J Soc Work 39:1615–1622. https://doi.org/10.1093/bjsw/bcp066 Reamer FG (2006) Ethical standards in social work: a review of the NASW code of ethics 2nd edition. National Association of Social Workers. NASW Press, Washington, DC Robertson M (2009) An overview of psychiatric ethics. Health Education and Training Institute (HETI), Sydney Rose D (2014) The mainstreaming of recovery. J Ment Health 23(5):217–218 Sackett DL, Straus SE, Richardson SW et al (2000) Evidence-based medicine: how to practice and teach EBM, 2nd edn. Churchill Livingstone, Edinburgh/London Slade M (2009) Personal recovery and mental illness: a guide for mental health professionals. Cambridge university press, UK Stull LG, McGrew JH, Salyers MP et al (2013) Implicit and explicit stigma of mental illness: attitudes in an evidence-based practice. J Nerv Ment Dis 201(12):1072–1079. https://doi.org/ 10.1097/NMD.0000000000000056 Trevidi P (2010) A recovery approach in mental health services: transformation, tokenism or tyranny? In: Basset T, Stickley T (eds) Voices of experience: narratives of mental health survivors. Wiley, Chichester UNHRC (2017) Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. https://reliefweb.int/report/ world/report-special-rapporteur-right-everyone-enjoyment-highest-attainable-standard-0. Accessed 16 Oct 2018 World Bank (2016) Empowerment overview: what is empowerment? http://web.worldbank.org/ WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTEMPOWERMENT/0,,contentMDK:20272 299~pagePK:210058~piPK:210062~theSitePK:486411~isCURL:Y,00.html. Accessed 1 Oct 2017 World Health Organisation (2010) User empowerment in mental health – a statement by the WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0020/113834/ E93430.pdf. Accessed 23 Aug 2017 World Health Organisation (2017) Patients’ rights. Genomic resource centre. http://www.who.int/ genomics/public/patientrights/en/. Accessed 15 Nov 2017

Part II General Theories on Mental Health and Etiology of Mental Illness

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Psychological Perspective Psychodynamic, Humanistic, and Cognitive-Behavioral Theories Virgil L. Gregory Jr.

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concept of Psychological Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Positive Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychodynamic Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Humanistic Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive-Behavioral Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wave 3: Dialectical Behavior, Mindfulness-Based Cognitive, and Acceptance and Commitment Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The purpose of the present chapter is to explicate the specific etiological factors of mental illness, basic premises, concepts of psychological well-being, psychosocial interventions, and implications for social work practice with regard to psychodynamic, humanistic, and cognitive-behavioral theories. These specific psychological theories are included because of their historical and contemporary influence on explaining, researching, and treating psychopathology. As will be seen in the forthcoming text, each of the psychological theories has a unique perception of psychopathology and well-being that is of paramount practical benefit to the social work profession and the clients being served. The chapter concludes by specifying how clinical social workers can conscientiously

V. L. Gregory Jr. (*) School of Social Work – MSW Direct, Indiana University, Indianapolis, IN, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_5

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consume and ultimately produce or contribute to the development of social workoriented clinical theories. Keywords

Psychological theory · Social work · Mental illness · Well-being · Psychodynamic · Humanistic · Cognitive-behavioral

Introduction Thus far, the concepts of mental illness have been generally described and explained in ▶ Chap. 1, “Theories on Mental Health, Illness and Intervention” (Ow and Poon). The purpose of the present chapter is to explicate the specific etiological factors of mental illness, basic premises, concepts of psychological well-being, psychosocial interventions, and implications for social work practice with regard to psychodynamic, humanistic, and cognitive-behavioral theories. These specific psychological theories are included because of their historical and contemporary influence on explaining, researching, and treating psychopathology. An overt effort has been made to summarize the various theoretical perspectives using the writings of the actual pioneers of each theoretical perspective. The referencing of the original sources is also provided to allow readers to further independently review the various unique contributions of each respective psychological theory. It is recognized that while there are certainly strong intercontinental or national similarities in social work practice, there may also be differences with regard to the application of social work practice in mental illness. The various intercontinental or national differences could be explained by the specific psychosocial problems, political environments, social contexts, and other factors specific to a particular continent or nation. It is hoped that readers on an international level will understand and critically consider the psychological theories and concepts and appreciate the overt and contextual factors which distinguish them from one another, particularly as it pertains to the development and treatment of mental illness in their particular geographic or socio-environmental context.

Concept of Psychological Well-Being Positive Psychology A system that emphasizes reducing symptoms has led to the marginalization of affirmative or favorable indicators of mental health (Hayes 2012b). This sentiment has also been articulated by Shedler (2010) whom has stated that researchers, regardless of their theoretical and practice orientations, have not adequately assessed or measured the positive changes associated with psychotherapeutic intervention. In response to the focus on psychopathology and symptom reduction, positive

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psychology developed (Chou et al. 2013). Positive psychology focuses on strengths, assets, and other present factors in individuals which are contrary to and/or occur despite of psychological deficits or negatives (Seligman 1998). Both positive psychology and the recovery concept have many things in common, such as hope (Park and Chen 2016). According to Park and Chen within the context of positive psychology, hope is essential because it is required for one to believe that recovery is possible and hope provides the motivation for someone to begin the process of recovery.

Contemporary Implications for Positive Psychology Positive psychology is very consistent with the strengths-based perspective which thrives in social work. Assumptions of positive psychology include all individuals having the ability to experience self-improvement, live up to their own personal potential, and further their capacity for affection and labor (Chou et al. 2013). The strengths model, which has permeated social work literature, education, research, and practice, maintains that emphasis should be placed on an individual’s assets or strengths relative to their weakness or lack of ability, the environment which brings a number of opportunities, client self-determination, importance of relationship, and the potential for persons with mental illness to progress and improve (Rapp 1998).

Psychological Theories Psychodynamic Theory Sigmund Freud’s psychodynamic theory has had a profound effect on conceptualizing personality and treatment. Psychodynamic theory has received much literary attention in social work (Bliss and Rasmussen 2013; Deal 2007). Thyer (2017) has advocated for the removal of psychodynamic theory from the National Association of Social Worker’s (NASW) definition of clinical social work, claiming that its inclusion is not indicative of many practitioners in the social work profession, while Cummins (2017) has suggested that psychodynamic theory be included with behaviorally oriented theories. Psychodynamic theory includes a number of concepts pertaining to consciousness (Freud 1915/1989a, 1923/1989), personality (Freud 1923/1989), defense mechanism (Freud 1925/1989), and psychosexual stages (Freud 1933/1965) and continues to have a substantive presence in social work.

Basic Premise Psychodynamic theory is based on the ideal that processes that are considered to be unconscious or outside of the immediate awareness of the person are the cause of personality and psychiatric disorders (Freud 1923/1989). Unconscious, latent drives, cognitions, recollections, and desires have an influential effect on behavior (Freud 1915/1989a, 1923/1989). Freud (1915/1989a, 1923/1989) has identified types of consciousness: conscious, preconscious, and unconscious. At the conscious level, a

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person is cognizant of their thoughts and actions. At the preconscious level, thoughts and other such phenomena are under the surface; however these phenomena can be obtained fairly simply. The unconscious contains memories, thoughts, and other phenomena that were once conscious but are now reserved because awareness of them would be difficult and problematic. Psychodynamic theory suggests that the personality has three attributes: id, ego, and superego (1923/1989). The id is basic and unconscious and is in pursuit of pleasure and evades pain (pleasure principle, Freud 1911/1989). The ego is primarily conscious, logical, and rational and operates on the reality principle (foregoing desires until it is socially acceptable to obtain them, Freud 1911/1989). The superego is concerned with ethics (Freud 1925/1989). Psychodynamic theory also includes different defense mechanisms that address undesirable or difficult emotions (Freud 1925/1989). Several of the defense mechanisms in psychodynamic theory are regression (Freud 1925/1989), displacement (Freud 1913/1989), reaction formation (Freud 1907/1989), and repression (Freud 1915/1989a, 1915/1989b, 1925/1989), among others. Regression occurs when an individual slips back to juvenile behavior. Displacement involves the application of emotional energy on an individual or item who is not the true cause of the emotions. Reaction formation occurs when an individual expresses emotions or beliefs that are truly contrary to what the individual actually feels or believes. Projection is a defense mechanism where the individual takes what they truly feel and assigns those feelings to someone else. Repression is the act of taking undesirable internal content such as experiences and thoughts and placing them in the unconscious. Repression is the most frequently occurring defense mechanism. Psychosexual stages are another aspect of psychodynamic theory (Freud 1905/1989b, 1933/1965). Psychosexual stages include oral, anal, phallic, latency, and genital stages, each of which is characterized by a different source of pleasure and specific level of developmental progress ultimately in route to intimate adult relationships (Freud 1933/1965). The oral stage occurs during the first year, and pleasure is primarily obtained from the mouth. As the name implies in the anal stage, the anus is the primary source of pleasure and occurs during the potty training years. In the phallic stage, males and females recognize the phallus (and the vagina) as significant. From the ages of 6–12, the latency stage involves repressed sexual desires and emphasis on same-sex friendships. The last stage is the genital stage where sexual desires are stimulated, and the emphasis is now on intimate associations with persons of a different sex.

Etiology of Mental Illness In psychodynamic theory, mental illness can occur when an individual is stuck or fixated in one of the psychosexual stages (Freud 1925/1989, 1905/1989b, 1911/1989), regresses to a previous psychosexual stage (1933/1965), or experiences issues regarding repression (Freud 1925/1989). According to Freud (1905/1989b, p. 279), “every pathological disorder of sexual life is rightly regarded as an inhibition in development.” Anxiety from a Freudian psychodynamic perspective has been theorized to derive from a divergence between sexual energy and a repressed sexuality (Freud 1910/1989).

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Mental Well-Being Psychodynamic theory seeks to improve client outcomes via making repressed information conscious (Freud 1925/1989). In addition to insight, research has also shown that some of the most common goals of psychodynamic therapy have also included but are certainly not limited to the improvement of interpersonal relationships, improved functioning in various life domains (work, academic), self-esteem, and managing emotions (Philips 2009). Interventions Psychodynamic therapy uses interventions such as free association, interpretation, and analysis of transference among others to achieve its goal of making repressed information conscious (Freud 1925/1989). In free association, clients are discussing, without direction or self-restriction, any information which they are thinking of. Interpretation, which is related to free association, allows for meaning to be assigned to repressed information which makes itself available through dreams (Freud 1900/ 1989, 1911/1989) and free association. Transferences occur during analysis and are thoughts, impulses, wishes, or other mental experiences held by the client and deriving from the client’s past; yet these past mental experiences are from the client’s perspective represented by clinician (Freud 1905/1989a). In psychodynamic therapy, transference is brought to consciousness via the clinician/social worker persuading the client that the transference is a product of the repressed component of their childhood (Freud 1925/1989). This analysis of transference has been referred to by Freud as simultaneously the most complex and imperative aspect of analysis. Implications for Social Work Psychodynamic theory has a number of important implications for social work. Psychodynamic theory, including various aspects of the etiology of mental illness, as originally described by Freud, may not necessarily be consistent with various aspects of the social work profession. Since Freud’s articulation of psychodynamic theory, starting decades ago, there had been theoretical changes that were expressed, such as increased attention to object relations and psychopathological developmental deficiencies (Eagle 1987). With regard to clinical practice, greater focus on factors such as insight, empathy, and therapeutic rapport has gained importance (Eagle 1987). It has been argued that contemporary psychodynamic theory provides a more sophisticated conceptualization of human behavior and is indeed more consistent with social work values and ethics (Dean 2002). As noted by Bliss and Rasmussen (2013), modern psychodynamic social work practice includes collaboration, validation, and emphasis on therapeutic rapport, among other factors. Social work and contemporary psychodynamic theory recognize the importance of relationships; consequently social work practitioners can play a key role in the theoretical advancement of factors pertaining to therapeutic alliance (Deal 2007). Manualized interventions, such as those frequently employed in CBT, have a number of criticism which include lack of individualized treatment, decreased therapist creativity, and lack of external validity (Wilson 1996). Psychodynamic theory and its associated

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interventions may be particularly advantageous for marginalized, oppressed, and disenfranchised clients, who may not obtain as much benefit from manual-guided therapies (Bliss and Rasmussen 2013).

Humanistic Theory Humanistic theory encompasses an understanding of an individual’s unique experience, inherent integrity, and intrapersonal potential (Henry 2017). Two of the most profound and influential psychologists in humanistic theory are Abraham Maslow and Carl Rogers. The humanistic theories which are the foci of this chapter are those developed by both Maslow (1943) and Rogers (1951). Maslow published an often cited theory of human motivation pertaining to a hierarchy of human needs. Roger’s text on client-centered therapy is still commonly referenced in psycho-theoretical and psychotherapeutic literature. Maslow and Rogers’ theories were so influential that they are routinely referenced in introductory psychology textbooks today (Henry 2017).

Basic Premise Maslow’s (1943) theory of human motivation maintains that humans have five levels of related and interdependent hierarchical needs/motivations: physiology, safety, love, esteem, and self-actualization. Once needs at a lower level are satisfied to some degree, higher-level needs take place and become more prevailing. Physiological needs are the most basic and include the need or motivation for food, intercourse, hydration, and safety. Maslow substantiated the physiological need level by referencing various bodily homeostatic mechanisms for maintaining optimal biological functioning and stating that the various appetites can signify or represent a specific physiological insufficiency. The second level of need/motivation is safety. Maslow describes the need for safety as being represented by a structured, routine, hazard-free, and conventional environment with relationships that provide protection and security. Maslow further states that paradigms, religion, and science are premised on safety. Love is the third level of need/motivation in Maslow’s hierarchy, and it includes factors such as acceptance from others, substantive and meaningful relationships with others, and being both a provider and recipient of compassionate interaction. Maslow divides the fourth level of need/motivation, esteem, into two subsections. Esteem consists of the need for intrapersonal autonomy, accomplishment, and power as well as an interpersonal need for reverence or admiration from others. The highest level of need/motivation in Maslow’s hierarchy is self-actualization which includes an individual finding their unique purpose in life and realizing their true potential. According to Maslow, self-actualization cannot be obtained until the aforementioned lower-level needs are reasonably met. The client-centered theory developed by Rogers (1951) includes a number of propositions pertaining to individual experiences, construction of the self or one’s identity, a subjective nature of reality, value systems (internal and external influences), goals, self-actualization, environment, emotions, and ultimately the

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reconciliation of the one’s experience and self-identity. The propositions collectively explain ways in which an individual develops a sense of self and factors which contribute to or detract from that development of self/personality.

Etiology of Mental Illness Maslow (1943) has explicitly theorized regarding the psychopathological etiology and its relationship to various needs not being met. According to Maslow any potential or actual threat to the aforementioned fundamental human needs is linked to the overwhelming majority of mental illnesses. As it pertains to the need for safety, anxiety is considered to possibly derive from the world being viewed as threatening, dangerous, and results in individual behavior that assumes a catastrophic outcome is inevitable and seeking a savior to prevent some catastrophe. Maslow has described obsessive compulsive disorder as an attempt to find safety. Unmet love needs have been theorized by Maslow to account for psychopathology pertaining to antisocial personality (referred to as “psychopathic personality” by Maslow, p. 386) and contributed to an inability to provide and be receptive to love (Levy 1937). Unmet esteem needs can result in feelings of inadequacy and vulnerability and can be associated with neurotic psychopathology. According to clientcentered theory, mental illness or “psychological maladjustment” as referred to by Rogers (1951, p. 499) occurs due to stress or “tension” from an individual rejecting the recognition of substantive observational or emotional experiences which are contrary to the individual’s perception of self. Once an individual is cognizant of the difference between their perception of themselves and their various experiences, anxiety and ambiguity can develop. Mental Well-Being Well-being from a Maslow (1943) hierarchy of needs perspective is achieved when physiological, safety, love, esteem, and self-actualization needs are primarily fulfilled. Moreover Maslow has quite succinctly stated that in contrast to an individual who has unfulfilled long-term ongoing needs, a well-adjusted individual has needs which serve as motivation to achieve their full potential. Maslow has acknowledged that having all of the needs essentially satisfied is not typical. Maslow also stated in his theory of human motivation that for most individuals, the different levels of need are to some degree simultaneously satisfied and unsatisfied. According to Maslow as needs grow from physiological (lowest) to self-actualization (highest), the degree of satisfaction at each level decreases. It is important to note that according to Maslow, there are certain prerequisites necessary for the fulfillment of the aforementioned five levels of needs. These prerequisites appear to be social or environmental in nature and include free speech, self-determination, self-expression, justice, and impartiality. Mental well-being or “psychological adjustment” as described by Rogers (1951, p. 513), from a client-centered perspective, is indicative of a reconciliation of or consistency between the perception of self and individual’s various experiences. The mental well-being in client-centered theory has also been associated with feelings regarding decreased internal strain and further intrapersonal growth toward one’s true self. It is important to note however that Rogers (1957) has stated that

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psychiatric diagnosis is not important for client outcomes, unless the diagnosis of the client is necessary for the therapist to utilize factors (six in total, however three therapist’s factors are discussed in the next section on “Interventions”), which are ultimately believed to actually be responsible for therapeutic change.

Interventions Rogers (1951) has placed much emphasis on the attitude of the clinician and far less emphasis on techniques. In fact Rogers (1957) has identified a number of therapist characteristics that are believed to entirely facilitate psychotherapeutic change. These characteristics or factors include the therapist having and showing toward the patient (1) a honest, genuine, transparent, and self-aware presentation of himself; (2) unconditional positive regard which involves the therapist accepting the experience of the client without the acceptance being contingent on some prerequisite factor(s); and (3) empathy for client emotions and meanings. Rogers has maintained that the aforementioned three therapist’s characteristics and other factors produce psychotherapeutic change in all clients, regardless of diagnosis (see previous statements discounting the importance of psychiatric diagnosis). Moreover with regard to psychotherapeutic technique, Rogers argues that techniques or interventions, such as the ones listed in psychodynamic interventions, for example, are only useful to the extent to which they facilitate the aforementioned congruence, unconditional positive regard, and empathy. Similar to other therapies, humanistic therapy has defining characteristics, is offered in different modalities, has empirical support, and is used to address various mental health or psychosocial issues (Elliot 2001). Therapies that stem from humanistic theory focus on autonomy, interpersonal rapport, development, and other values as the active ingredients of change (Elliot 2001). From humanistic theory a number of different humanistic therapies have developed including Gestalt therapy, existential therapies, and experiential therapies (Cain 2001). As demonstrated in what is perhaps the most extensive meta-analysis on humanistic therapies, humanistic therapies have been shown to have some favorable outcomes with regard to mental illnesses or psychosocial problems such as depression, anxiety, adjustment issues, and relationship problems (Elliot 2001). This meta-analysis of humanistic therapies included individual, group, and couple modalities. Implications for Social Work As it pertains to humanistic theory, implications for social work include issues regarding the actual clinical necessity of psychiatric diagnosis and questions of what are the actual active ingredients in clinical interventions. Roger’s (1957) argument is by no means new, not even in 1957. Rosenzweig (1936) has already explained the belief that common factors, rather than specific so-called active ingredients, are responsible for similar outcomes among different psychotherapeutic interventions. As clinicians, social workers are responsible for being conscientious consumers of relevant research. The ongoing research regarding the dodo bird verdict and it’s implication for humanistic theory remains an ever-present factor for psychotherapeutically oriented social work practitioners and researchers.

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Humanistic psychological theory, as espoused by both Maslow and Rogers, has obvious and rather overt overlap with social work values and ethics (National Association of Social Workers – NASW 2017). Maslow and Roger’s humanistic theories are consistent with social work values and ethical principles pertaining to dignity and worth of the person, human relationships, helping people, and trustworthiness.

Cognitive-Behavioral Theories Cognitive-behavioral therapy (CBT) has thus far seen three different sets or waves of psychotherapeutic systems (Hayes 2016). The first wave consisted of behavioral therapies and associated theoretical underpinnings. The second wave includes both cognitive and behavioral interventions with theories that emphasize the relationships between thinking and emotion/behavior. The third wave of cognitive-behavioral therapy includes but is not limited to dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT). Unlike the first two waves of CBT, the third wave lacks a clear unifying aspect; however the third-wave therapies have “acceptance, mindfulness, cognitive defusion, dialectics, values, spirituality, and relationship” in common (Hayes 2016, p. 869). The discussion of cognitive-behavioral theoretical perspectives follows these three waves of cognitive-behavioral psychotherapeutic treatments.

Wave 1: Behavioral Theory Behavioral theory addresses both respondent and operant conditionings. There are a number of behavioral therapeutic approaches which are rooted in behavioral theory. Functional analysis, also called behavioral analysis, stems from operant conditioning. Functional analysis is now a key component of assessment in behavioral methods. Moreover applied behavioral analysis has contributed to social work practice, research, and education in various ways (Briggs et al. 2016). ▶ Chapter 4, “Behavior Analysis and Social Work” of this volume addresses behavior analysis (Thyer), and readers are referred there for further information pertaining to behavioral theory, intervention, and relevance to social work. Wave 2: Cognitive Theory Basic Premise Cognitive theory is based on the idea that flawed interpretations or appraisals (cognitions) of situations lead to unhealthy and problematic emotional and behavioral responses (Beck 1976). Cognition is viewed as having a hierarchical structure with specific implications for cognitive restructuring interventions that will be used (Beck 2011). The essential aspect of cognition is core beliefs (Beck 2011). Beliefs are perceptions that individuals have “about the self, world, and/or the future” (Wenzel et al. 2012, p. 30). Beck and Haigh (2014) have further expounded on the cognitive model and provided further clarification regarding phenomenological

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aspects of psychiatric disorder and a spectrum of functionality of beliefs. Belief systems occur on a spectrum from functional to dysfunctional and can be situational or constant. The likelihood of a psychiatric disorder occurring increases as beliefs become more skewed and exceed the innate functional threshold. The cognitive model has provided an overall framework which can be applied to a range of psychiatric disorders (Beck and Haigh 2014). Third-wave CBTs contain some component or variation of the second-wave CBT theory and/or interventions; therefore the second wave is given more detailed attention.

Etiology of Mental Illness The aforementioned basic cognitive model and its application to the explanation of various psychiatric disorders have been used to identify and target thoughts and beliefs systems specific to various mood, anxiety, psychotic, and personality disorders. For example, cognitive theory has been used to describe distinct dysfunctional belief systems that are presumed to underlie a number of different psychiatric disorders such as substance related (Wenzel et al. 2012), major depression, anxiety, bipolar, and psychosis (Beck 1976), among others. Mental Well-Being Mental well-being from a cognitive theoretical perspective is not a Pollyanna, hyperpositive worldview that exists contrary to reality. Persons with a psychiatric disorder can appropriately or inappropriately identify situations or events to be negative. In accordance with cognitive theory, associated cognitive-behavioral interventions are used to aid clients in recognizing, systematically evaluating, and changing dysfunctional beliefs and consequent thoughts (Beck 2011). Likewise if negative thoughts and/or beliefs are substantiated by objective evaluation, behavioral interventions are used to problem-solve and address problematic situations (Beck 2011). Interventions The interventions of cognitive therapy directly stem from cognitive theory and the case conceptualization of the individual patient. Cognitive therapy interventions are also based on a sound therapeutic rapport; incorporate collaborative empiricism, are structured, include homework; and adhere to other important principles of cognitive therapy (Beck 2011). Psychoeducation is used in cognitive therapy to help educate clients on the cognitive model. Albert Ellis’s (1994) ABCDE model is used to educate clients on the relationship between situations (A), irrational thoughts/beliefs (B), consequent emotions (C), challenging irrational beliefs (D), and the development of new/alternative rational beliefs (E). Dysfunctional thoughts and beliefs can be modified with cognitive restructuring or via various behavioral methods (Beck et al. 1979). Cognitive restructuring interventions include Socratic questioning pertaining to the evidence base for or usefulness of dysfunctional cognitions which contribute to emotional and behavioral disturbance (Beck et al. 1979). Beck and associates (1979) have used various Socratic questions such as the evidence for, costs and benefits of, and alternative explanations for dysfunctional thoughts and/or beliefs to ameliorate maladaptive

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emotion and behavior. These and other cognitive interventions used by Beck and associates continue to be applied in cognitive therapy manuals for a range of psychiatric disorders (Beck 2011; Beck et al. 2015; Clark and Beck 2010; Wenzel et al. 2012, among numerous others). Behavioral interventions commonly used in cognitive therapy include but are certainly not limited to problem-solving, behavioral experiments, activity scheduling, assertiveness, and role-playing among others (Beck 2011).

Implications for Social Work Licensed clinical social workers are the number one providers of mental health treatment in America (Heisler 2018), and CBT interventions are among the most frequently used by licensed clinical social workers (Pignotti and Thyer 2009). To provide successful CBT, it is necessary to understand the theory from which it derives (Beck et al. 1979). Given their training in the person in environment perspective (PIE), social workers who use cognitive theory to conceptualize cases and ultimately treat individuals are at a particular advantage to understand and address both micro- and macro- or social-environmental factors which could play a role in the client’s presenting problem. Perhaps one of the biggest implications of the second-wave cognitive-behavioral theory of mental illness and well-being is the consequent evidence-based CBT interventions which stem from the theory. There is a profound amount of research supporting the evidence base of CBT for the treatment of psychiatric disorders including anxiety, depressive, bipolar, psychotic, substance-related, personality, eating, as well as other disorders (Beck 2011). Moreover social workers have also discussed the specific use of second-wave cognitivebehavioral theory and therapy as it pertains to their application to social work practice with regard to severe mental illness such as bipolar disorder (Gregory 2010a) and schizophrenia (Gregory 2010b). Another attractive feature of cognitive-behavioral theory and the associated treatment is its consistency with social work value and ethics. With regard to social work values and ethics, CBT underscores the importance of interpersonal relationships, the innate and intrinsic value of all individuals, a collaborative relationship between the social worker and client, and recognition of the role of the social environment (González-Prendes and Brisebois 2012).

Wave 3: Dialectical Behavior, Mindfulness-Based Cognitive, and Acceptance and Commitment Theories There are a number of third-wave therapies and various theories associated with each. The present theoretical discussion of third-wave therapies is by no means inclusive of all the third-wave behavioral treatments. Instead several of the thirdwave theories which have received considerable clinical and empirical attention are discussed here. The theoretical underpinnings of DBT, MBCT, and ACT are discussed in the present chapter. Of the third-wave behavioral therapies, DBT, MBCT, and ACT are also discussed here because they have several features in

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common such as emphasis on mindful interventions and a dual focus on “acceptance and change” (Segal et al. 2004, p. 55). Other notable third-wave behavioral therapies include integrative behavioral couples therapy and functional analytic psychotherapy (Hayes 2016).

Basic Premise The theoretical premises of DBT, MBCT, and ACT collectively encompass various aspects of the aforementioned third-wave behavioral therapies. First DBT derives from biosocial theory which maintains that some individuals are biologically more vulnerable to emotions and impulsivity, and these factors in conjunction with dismissive or rejecting environments contribute to marked difficulty with effectively managing emotions (Linehan 1993, 2015). Second, MBCT is based on the theory pertaining to doing and being mind modes (Dimidjian et al. 2010). The theoretical premises associated with ACT are arguably the most complex psychological theories presented in this chapter. Relational frame theory (RFT) is associated with ACT and accounts for the relationship between language and thought (Hayes 2012b). Acceptance and commitment therapy is based on the theory that mental illness is associated with the interaction between language and thinking in conjunction with situational factors that collectively help create and sustain a psychological inflexibility (Luoma et al. 2007). In other words, ACT maintains that a number of factors act in concert to create psychological rigidity referred to as psychological inflexibility, and the purpose of ACT is to create psychological flexibility (Hayes 2012a). Other theoretical aspects of ACT are described below; however readers can obtain further information regarding RFT and the theoretical underpinnings of ACT via a number of resources (Hayes 2004, 2012a, b; Hayes et al. 2001). Etiology of Mental Illness Although all are considered third-wave behavioral therapies, DBT, MBCT, and ACT all offer unique explanations for the development of various disorders. Dialectical behavior therapy was initially created to treat women diagnosed with borderline personality disorder who had been suicidal (Linehan 1993). The aforementioned biosocial theory maintains that borderline personality disorder results from problems with regulating emotions (biological), invalidating environments, as well as a deficit in emotion regulation skills (Linehan 1993). Biosocial theory has since been applied to explain a number of disorders including comorbid borderline and substance use disorders, eating disorders, comorbid personality, and depression disorders (Dimeff and Koerner 2007). In MBCT problems such as depression occur when clients are stuck in doing mind mode (to decrease the difference between the actual state of being and the desired state of being), when it is not truly possible to obtain the preferred resolution (Dimidjian et al. 2010). Acceptance and commitment theory states that cognitive fusion, experiential avoidance, inflexible attention, lack of chosen values, inaction/impulsivity/avoidant persistence, and attachment to conceptualized self collectively create psychological inflexibility (Hayes 2012a). Previous research has shown that experiential avoidance, a component of psychological inflexibility, was often associated with a number of psychiatric disorders (Ruiz

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2010). Other research has shown psychological inflexibility to be associated with trichotillomania (Houghton et al. 2014), chronic pain (Kwok et al. 2016), depressive symptoms (Kato 2016), and pathological worry (Ruiz 2014).

Mental Well-Being Concepts of mental well-being in DBT, MBCT, and ACT theories are unique and congruent with their specific conceptualizations of mental illness or psychological pain. Mental well-being in DBT is in part characterized by the attainment of skills to develop a meaningful life (Linehan 2004). Given the biosocial theory upon which DBT was developed, specific skills are taught to manage emotions and self-validate (Linehan 1993). More will be said about DBT skills in the interventions section below. Mindfulness-based cognitive theory conceptualizes mental well-being as the accurate differentiation between modes of mind regarding doing and being, such that client/individual resources are used to their full potential (Dimidjian et al. 2010). Mindfulness-based cognitive therapy has several aims and themes pertaining to mental well-being (Segal et al. 2013). These aims and themes include providing clients with autonomy and disengagement from negative thought patterns as well as developing mental well-being via preventing relapses of depression; increasing awareness of cognitions, emotions, and physiology; and developing alternative methods for addressing disturbing cognitions and emotions. Mindfulness-based cognitive therapy skills which are employed to achieve this goal are discussed below. Psychological flexibility is the goal of ACT, and in ACT theory mental well-being is represented by six processes pertaining to psychological flexibility: defusion, acceptance, flexible attention to the present moment, values, committed action, and perspective-taking sense of self (Hayes 2012a). In ACT mental wellbeing includes psychological flexibility which is described as current awareness and acceptance with a simultaneous congruency between actions and values (Hayes 2012b). Interventions In accordance with their theories, DBT, MBCT, and ACT include various cognitive and behavioral interventions as well as other distinguishing factors which are indicative of the third-wave behavioral therapies (Hayes 2016). Marsha Linehan’s (2015) DBT uses sets of skills to achieve mental well-being: general, mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance interventions. The DBT skills are presented in a sequential fashion and overtly embody the previously mentioned core third-wave traits described by Hayes (2016). Dialectical behavioral therapy skills are similar to second-wave interventions in that, for example, both CBT and DBT conduct functional analyses of behavior and use cognitive restructuring. However DBT has less emphasis on challenging content of thoughts and more emphasis on restructuring the style of thinking and the considerable use of validation (Linehan 1993). These differences in cognitive restructuring are especially important given the aforementioned biosocial theory which states that dismissive or rejecting environments contribute to problems with managing emotions in persons with borderline personality disorder (Linehan 1993).

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Mindfulness-based cognitive therapy, relative to second-wave behavioral therapy, has several unique characteristics as well (Segal et al. 2013). Mindfulnessbased cognitive therapy maintains that facilitators should actively participate in mindfulness exercises, and this experience, in addition to increasing the practitioner’s legitimacy, also increases the mutual understanding that exist between the practitioner and client regarding the skills. That is, MBCT has a solipsism perspective with regard to practitioners using the interventions with clients. In accordance with the theory and aims, MBCT includes interventions such as meditation, breathing exercise, pleasurable and meaningful activities, acceptance, and cognitive interventions (greater focus on relationship to thoughts rather than content of thoughts) (Deckersbach et al. 2014; Segal et al. 2013). Currently there are manuals which apply MBCT to depression (Segal et al. 2013) and bipolar disorder (Deckersbach et al. 2014) and use MBCT with second-wave CBT (Ciarrochi and Bailey 2008). Readers are directed to ▶ Chap. 15, “Application of MindfulnessBased Approaches in the Context of Social Work” of this volume for more information regarding stress, mental well-being, and mindfulness-based therapy (Ling and Siying). Acceptance and commitment therapy uses processes which are consistent with the aforementioned six components of psychological flexibility (Hayes 2012a). In ACT the so-called interventions are actually referred to as “processes” (Hayes 2012b, p. 274). These six components of psychological flexibility are further subdivided into a mindfulness and acceptance subcomponent and a commitment and behavior change subcomponent. Hayes’ (2012b) manual provides a thorough explanation of the processes used in ACT. Some mindfulness and acceptance ACT processes intended to increase psychological flexibility are defusion (the use of metaphors, techniques to separate language from associated symbolism, recognizing thoughts without being critical of them), acceptance (exposure, willingness), and perspective-taking sense of self (whole, complete, perfect method). Some commitment and behavior change ACT processes intended to increase psychological flexibility are flexible attention to the present moment (meditation, focusing, progressive muscle relaxation), values (assessment of values, using values in conjunction with mindfulness and acceptance processes), and committed action (identification of goals and behavior to achieve goals, resolving obstacles to committed action). The previously mentioned ACT interventions are not at all exhaustive, as a totally inclusive identification of all ACT interventions is beyond the scope of this chapter. In addition to the previously mentioned texts by Hayes (2012a, b), readers can also find additional information pertaining to ACT interventions in other resources as well (Luoma et al. 2007). Although there are noted differences between second- and third-wave CBT, all of the aforementioned thirdwave CBTs use homework.

Implications for Social Work Third-wave CBTs such as DBT, MBCT, and ACT have a number of important current and future implications for the social work profession. Relative to the second-wave cognitive-behavioral theory, the third-wave theories address a number

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of different variables (spirituality, language, invalidating environments, and modes of mind) which offer social workers different ways of conceptualizing and ultimately treating the diverse clients they serve. There is now greater emphasis on the role of spirituality in social work practice. Some of the aforementioned third-wave CBTs may be able to integrate client’s spiritual beliefs in the therapeutic process and therefore further build therapeutic rapport and improve outcomes and support from family and others who share the client’s spiritual beliefs. Similar to the second-wave CBT, the third wave also provides social work involved in clinical research with the opportunity to develop and disseminate findings regarding the effectiveness and/or efficacy of DBT, MBCT, and ACT. Third-wave therapies such as MBCT (Hick and Chan 2010), DBT (Cooper and Parsons 2010), and ACT (Boone et al. 2015) have been discussed in the social work literature with specific implications for social work practice. Randomized controlled trials which use social work practitioners and social work’s PIE perspective may be of particular importance to clients served by clinical social workers. Dialectical behavior therapy’s biosocial theory (Linehan 1993, 2015) is particularly consistent with the PIE perspective, given its acknowledgment of the role of invalidating environments and associated interventions to address the deficit. Given that the social work profession has historically been action-oriented with regard to using micro and macro interventions to bring about needed individual and social change, respectively, the modes of mind theory behind MBCT are stimulating for the social work because it emphasizes acceptance and being with regard to dilemmas that do not currently have an available solution. The unique characteristics of the third-wave cognitive-behavioral theories (as described by Hayes 2016) are beneficial not only because of the new ways of conceptualizing client problems and providing new ways of helping people in treatment but also because of the new or stronger connections which are made in support of social work values and ethics (NASW 2017). With the third wave’s emphasis on spirituality, relationships, values, and acceptance, each of these thirdwave characteristics can be viewed as another way of validating the inherent dignity of worth of clients social workers serve.

Conclusion As can be seen across the aforementioned psychodynamic, humanistic, and cognitive-behavioral theories, each has substantially different ways of conceptualizing psychopathology and different clinical techniques for achieving psychological wellbeing. Clinical social workers should complete formal training, continue education, and obtain appropriate clinical supervision to stay abreast of various developments and evolutions in each of the psychological theories. In addition to being consumers and practitioners of psychological theories, clinical social workers must be appropriately critical and discriminating of theories to ensure any theories they adopt are consistent with social work values and ethics. Moreover, in addition to using psychological theories, social workers should be consistent consumers and

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producers of clinical social work research regarding the psychotherapeutic interventions which derive from these theories. The development of new theoretical knowledge can be conducted by social workers in academic settings testing clinical theories; clinical social work practitioners using meta-analytic statistical techniques to test theories pertaining to treatment effect, moderation, and mediation; or clinical social workers theorizing about their recurring clinical observations observed in everyday practice. It is the author’s desire that clinical social workers will not only be discriminating consumers of psychological theories but producers of clinical theories which uniquely serve the profession and advance individual, group, family, and community outcomes.

Cross-References ▶ Application of Mindfulness-Based Approaches in the Context of Social Work ▶ Behavior Analysis and Social Work ▶ Community and Mental Health ▶ Theories on Mental Health, Illness and Intervention

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Behaviorism as a Philosophy of Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Respondent Learning Theory Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operant Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Observational Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Methods in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment and Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specific Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter provides an overview of the social work applications of the practice approach known as behavior analysis to the field of mental health. Behavior analysis has been an empirically supported approach to mental health practice for over 50 years, and its general principles have been accepted within social work since the 1930s. The chapter distinguishes between the philosophical foundations of this approach, known as behaviorism, from the practice applications derived from learning theory, and its hallmark approach to evaluation of clinical practice known as single-system research designs. Behavior analysis makes use of the theoretical principles of respondent, operant, and observational learning and through these concepts has derived a very wide array of empirically supported B. A. Thyer (*) College of Social Work, Florida State University, Tallahassee, FL, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_22

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methods of mental health assessment and treatment. The focus on behavior analysis is on a client’s behavior, but behavior includes not only overt, publicly observable actions but also one’s emotions and thoughts, since these too are functions of the human body. Behavior analysis has always been concerned with promoting functional behavior of clients, but also the enhancement of positive feelings and thoughts, with parallel efforts to reduce dysfunctional behavior, maladaptive thinking, and dysphoric affect. The widespread belief that behavior analysis is solely focused on overt behavior is a harmful myth. Some clinical social workers are complete, or radical, behavior analysts, accepting the philosophy of science called behaviorism, the conceptual framework of social learning theory, and the research approach of single-subject designs. Others borrow selectively from among these principles to improve their practice in a more eclectic manner. Keywords

Social work · Behavior analysis · Evidence-based practice · Clinical practice · Empirical · Social learning theory

Introduction Approaches to social work practice in the field of mental health derived from learning theory, and given the labels of behavior analysis or behavior therapy, have been present in our professional literature for a very long time. One quote illustrating this perspective can be found in Robinson (1930, pp. 83–84): “Two dominant schools of thought may be recognized as differentiating case work approach and treatment at the present time: behaviorist psychology and psychiatric interpretation. The former emphasizes habit training, conditioning and reconditioning in treatment. . .illustrations of a partial use of this psychology in treatment are abundant in any case work area.” Other early social work writers commenting on the value of behavioral methods for social work include Berman (1927) and Bruno (1936). A general definition of behavioral social work was provided by Thyer and Hudson (1987, p. 1): “. . .the informed use by professional social workers of assessments and interventions based on empirically derived learning theories. These theories include, but are not limited to, respondent learning, operant learning, and observational learning. Behavioral social workers may or may not subscribe to the philosophy of science known as behaviorism.” Let’s be clear from the outset of what is meant by the word “behavior” when we talk about behavior analysis and therapy. In turning to The Social Work Dictionary (Barker 2014, p. 38), we read that behavior is defined as “Any action or response by an individual, including observable activity, measurable physiological changes, cognitive images, fantasies, and emotions.” In other words, the term behavior subsumes everything a person does, internal or external, volitional or not. A fist pump is as much behavior of the person as is the pumping of their heart. Squeezing the hand

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in a friendly handshake is behavior, as is the peristaltic squeezing of our intestines. Reading aloud is as much behavior as is whispering or reading to oneself without making a sound. The toothache pain one experiences is as real as one’s teeth chewing food, and love for one’s family is as real as a physical kiss. All are seen as behavior and can be the focus of behavioral intervention. Indeed, from the earliest years of the development of behavioral therapies, many have been focused on non-observable behaviors, dysfunctional feelings such as depression and anxiety, reducing nightmares or hallucinations, changing irrational thoughts, correcting delusions, and ameliorating obsessional thinking. This point is stressed because behavioral approaches are often (incorrectly) claimed to only focus on overt, public behavior and that this is a serious limitation of this approach. Such incorrect claims are simply ignorant or malicious. The complete or radical perspective of behavior analysis includes four discrete elements: a philosophy of science (properly called behaviorism), an empirical theoretical foundation, a repertoire of research-supported methods of assessment and intervention, and an approach to assessment and evaluating clinical practice outcomes known as single-system research designs. Each of these elements will be reviewed.

Behaviorism as a Philosophy of Science We shall start with behaviorism’s philosophy of science. Critical social work reminds the profession that often the assumptions of social work practice go unacknowledged or at least unchallenged. Behaviorists cannot be reasonably accused of these sins, as there is an extensive literature outlining, elaborating, and sometimes critiquing its philosophical assumptions. The journal Behavior and Philosophy has been published since 1972 and is explicitly devoted to the philosophical foundations of the study of behavior (see https://behavior.org/journals/), articulating and defending the behavioral position. A number of books are also available that do the same thing (e.g., Hayes and Ghezzi 1997; Lattal and Chase 2003; O’Donnell 1985; Rachlin 1991; Thyer 1999). The core assumptions of behaviorism appear in Table 1 and generally reflect the perspective of mainstream contemporary scientific inquiry. It is of course recognized that these assumptions may not be themselves “provable” in a scientific sense. Like the axioms devised by Euclid, from which he constructed an extremely useful system of plane geometry, behaviorally oriented clinicians and scientists find the array of axiomatic positions listed in Table 1 very useful in their approach to social work practice and scholarly research.

Respondent Learning Theory Foundations Behavioral social work is strongly grounded in several interconnected theories of human behavioral development and change. The broad outlines of each of the distinct approaches will be familiar to most social workers. Most fundamentally,

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Table 1 Some of the components of the philosophy of science called behaviorisma Acceptance of Realism – The point of view that the world has an independent or objective existence apart from the perception of the observer Determinism – The assumption that all phenomena have physical causes that are potentially amenable to scientific investigation Positivism – The belief that valid knowledge about the objective world can be arrived at through scientific research Empiricism – A preference to rely on evidence gathered systematically through observation or experiment, and capable of being replicated (i.e., verified) by others, using satisfactory standards of evidence Rationalism – The belief that reason and logic are useful tools for scientific inquiry and that, ultimately, truthful explanations of human behavioral will be rational Operationalism – The assertion that it is important to develop measures of phenomena (e.g., client problems, interventive procedures) that can be reliably replicated by others Parsimony – A preference of the simpler available adequate explanations for behavioral phenomena Pragmatism – The view that the meaning or truth of anything resides in its consequences in action Scientific skepticism – The point of view that all claims should be considered of doubtful validity, until substantiated by credible scientific data a

From Royse et al. (2016, p. 30)

the principles comprising respondent learning theory attempt to partially explain the development, maintenance, and elimination of relatively simple reflexive types of behavior and of human feelings. Also known as Pavlovian conditioning, after its foremost investigator the Russian physiologist Ivan Pavlov, respondent learning is a person-in-environment approach that examines the simple forms of reflective reflexive, not reflective behavior all humans demonstrate from birth (and sometimes in utero) and can acquire afterward. We blink in response to a puff of air on our eye. Humans do not learn this behavior; it exists from birth. We flinch when we hear an unexpected loud noise. This too is unlearned, and similar responses have been observed with the human fetus. These natural phenomena have been given some labels, with the event that triggers a naturally occurring reflexive reaction called an unconditioned stimulus (UCS) and the unlearned reflex called a unconditioned response (UCR). Pavlov (and many others prior to and after him) observed that events which immediately precede a UCS can themselves come to evoke a URC. When this happens the formerly neutral prior event is called a conditioned stimulus, or CS, and the response evoked by the CS is now called a conditioned response, or CR. If I stand behind you and murmur the word “bang,” you will likely not react very much. But if I murmur the word bang and a moment later I crash a pair of cymbals behind you, you will flinch and winch to the loud sound. If I do this a number of times, shortly, when I murmur the word “bang,” you will flinch and winch, even if I do not clash the cymbals behind you. When I was young, I had my first bowl of Chinese hot and sour soup. Initially, when the bowl was set before me, nothing in

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particular happened, but during later meals over the years, when the hot and sour arrives, I begin to salivate, just like Pavlov’s famous dogs. In these examples of soup and cymbals, can you label the UCS, UCR, CS, and CR? The phenomena of respondent learning have been demonstrated not only among human beings all around the world but across all animal species examined. It seems to be a universal property of living animals, down as far as single-celled organisms. While human beings may possess certain unique characteristics that distinguish us from other animals (and that itself is a debatable topic), we are undeniably members of the animal kingdom and are subject to its fundamental principles of learning. To bring this topic closer to the field of social work and mental health, there is strong evidence that respondent learning principles are implicated in the etiology, as least partially, of a wide variety of behavioral disorders. Specific and social phobias, agoraphobia, post-traumatic stress disorder, acute stress reactions, and racism (see Arhin and Thyer 2004) are some examples. Many specific phobias, for example, begin when someone has a frightening experience with a previously neutral stimulus (a dog, a scary movie depicting something horrible). Coelho and Purkis (2009) provide a review of the evidence relating the onset of phobias to conditioning experiences. Sometimes the CS is experienced directly (being bitten by a dog), or sometimes vicariously (seeing a horror movie involving a mad dog), via information (reading about the diseases dogs can spread to humans) or seeing someone else (e.g., a parent) act extremely frightened around a dog. One may be able to eliminate a dysfunctional CR through the process called respondent extinction. The clinical social worker presents the CS at a low level which does not evoke a strong CR. This is repeated, and gradually the intensity of the CS is increased, slowly, at a level tolerable to the client. I recently used this approach to help someone with a severe fear of balloons. She lived several hundred miles away, so we used the audiovisual program called Skype to conduct a respondent extinction-based treatment called exposure therapy to help her. At a prearranged time, she called me via Skype and both of us could see and hear each other clearly. She could not tolerate watching and hearing me blow up a balloon to its full size and then pop it (her worst fear), so I had her minimize her screen so my image was very small and turn off the volume. She could tolerate watching me partially blowing up balloons then, which I did and proceeded to pop them. Soon she stopped flinching to the soundless image of small balloons being popped, and I asked her to maximize the image so she had greater exposure to the sight of popping balloons. Then, I asked her to increase the volume slightly, so she could, barely, hear the popping sounds. At her own pace, she increased the volume. After an hour or so, she was flinching much less and intermittently yelling in fear and laughing while watching me pop balloons with the volume and image at their maximum. At that point she could try and blow balloons up herself, initially only part way, and then pop them and then blow them up bigger and bigger. After 2 h she was blowing them up all the way and popping them with a pin, albeit with flinching and muted screams. After this session, when she could pop balloons on her own, I had her continue daily balloon inflating and popping exercises. After several months her severe fear of balloons had all but disappeared (see Elmhurst and Thyer 2019, for details).

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The details of respondent learning principles are quite involved, and it is not at all such a simple process of learning new behavior as is commonly viewed. One social work resource which reviews this approach to learning can be found in Thyer (2012).

Operant Learning More complex or volitional behavior in people can often be explained through a different form of learning theory, called operant conditioning. This too is a personin-environment perspective which focused on how the consequences which have followed a given behavior in the past influence its future occurrence. Behavior which has been followed by a rewarding consequence usually becomes strengthened or more probable in the future, a process called reinforcement. In operant learning there are two types of reinforcement, positive reinforcement, wherein something is presented or experienced by a the person, after they display a given behavior, and negative reinforcement, wherein something is removed after a particular behavior, and the behavior is also subsequently strengthened or becomes more probable. If you put coins in a vending machine and candy is delivered, you are more likely to put coins in that machine when you are hungry. If hard work on term paper is followed by a good grade, you are more likely to work hard on similar assignments in the future. The word positive in positive reinforcement refers to something being presented, and the word negative to something being removed, after a behavior. If turning the volume down on the television reduces obnoxious noise, this is a form of relief, and you are more likely to use the volume control in the future when obnoxious noise is being played. Because the consequence consists something being removed and the behavior is strengthened, this process is called negative reinforcement. Negative reinforcement is a good thing and examples abound – putting on sunglasses in the bright sun, opening an umbrella in the cold rain, escaping the boring house when chores are completed, and scratching an itch, all examples of behavior maintained by negative reinforcement. Punishment involves consequences that are either presented (positive punishment) or removed (negative punishment), which reduces the likelihood of performing a given behavior in the future, at least under similar circumstances. If you are jabbed with a fork by your mother when you rudely reach across the dining table, and you reach rudely across the table less often in the future (at least when your mom is there), your mom is using positive punishment, positive in that she presented you with something and punishment because behavior became less likely. We do not like experiencing positive punishment (usually). If your mom deducts some money from your usual allowance when you reach across the table, and you decrease your rudeness, your mom is using negative punishment, negative because something was removed and punishment because the behavior became less likely. Examples of both types of punishment are also all around us. If we get a fine for speeding and speed less in the future, the ticket and fine served as effective negative punishment (because your money was taken away). Fines as a form of social control in general are designed, intentionally or not, as negative punishment. See if you can identify what form of operant learning is present in each of the following four examples:

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• You tend to leave your dirty clothes lying around the house. Your partner begins a program of picking them up and throwing them away. After a while you leave your clothes lying around the house less frequently (even though you have not run out of clothes). • You are late returning a library book and are charged a fine. You become less tardy in the future in terms of returning library books. • You put some money in a slot machine and WIN! Hundreds of dollars come spilling out into your bucket. You play slot machines even more frequently in the future. • You have a headache. You take aspirin, and within an hour, your headache has disappeared. In the future you are more likely to take aspirin when you have a headache. How did you do? Get them all right? Good job! When reinforcement that has been maintaining a given behavior is halted, the behavior tends to temporarily strengthen and then to decrease and eventually cease. In the past, a child has found that when she yells for her mom, mom tends to approach her and give her attention. If one yell does not do the trick, then two, three, or more yells have usually induced mom to attend to the child, perhaps give her something tangible she desires. Such reinforcement processes, often extending out during months of learning history, can produce a child who has severe tantrums regularly. If mom is instructed by the social worker, as a part of a behavior management plan, to only attend to the child when she makes a request in a normal voice, and to steadfastly ignore loudly yelling demands for mom’s presence, the first few times this approach is followed, the “tantrums” will likely increase, before diminishing. This eventual decrease in problem behavior is called extinction, and the temporary increase is called an extinction burst. Another operant learning process is called shaping and involves the differential reinforcement of approximations to a desired terminal behavior that may ultimately be quite complex. When I am teaching my students to write papers in APA style, initially their prose and citations are hopelessly incorrect. I provide some corrections to their draft and praise them for what they got correct, and they turn in a more accurate assignment. This is repeated, and after a few drafts, with corrective feedback and praise along the way as they improve, soon most are completing APA-compliant papers. When teaching my kids to set the table, I showed them a complete service setting and asked them to duplicate it. They got some things right and other things wrong (e.g., the fork should be on the left). I praised them for what they got right and the next time asked them to try again. They usually got a few more steps correct. Again, praise, repeat, praise, and soon they were setting the table correctly (and I could comfortably pass along this one onerous chore to them for years!). Professors use shaping with their doctoral students. The ultimate task for most Ph.D. students is to produce an independent research project called the dissertation, a long and complex affair. However, during the 4 or more years of doctoral study, the students engage in tasks that successively approximate steps toward a real dissertation. They learn APA style, a statistical software package, and how to search the literature and perform a systematic review, collect empirical data

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and assess for reliability and validity, come up with one or more research questions and hypotheses, assist on my projects or those of senior doctoral students, and eventually begin their own research exercise, shaping. There are two additional ways to categorize operant learning and that is viewing some types as contingency-shaped, wherein there is actual contact with reinforcing, punishing, and shaping consequences, and of personal experience with the removal of reinforcement and the decrease in behavior (Do you recognize operant extinction?). However, with humans, there is a second, perhaps broader, category of operant learning called rule-governed behavior (RGB). In RGB, behavior is changed by a verbal or written description of contingencies of reinforcement and punishment, rather than by direct contact. Some of us wear sunscreen because we have gotten burned, and later, when we wore sunscreen, we did not get sunburned and had a much nicer day at the beach. Others of us heard the advice, “Wear sunscreen at the beach so you do not get burned.” We wore sunscreen and have avoided most sunburns. Following directions, verbally or manually, and reading and adhering to what signs say are efficient ways of conveying the presence of the contingencies present in a given situation, without having to directly experience them. “Do not touch the stove element. It is hot and you will get burned” is an example most of us have followed. Using the manual containing instructions on setting up your computer is another. Take learning to drive a car. We could give someone a key, let them get in the car, and fumble around for days figuring out what to do. Learning would take very long, be terribly inefficient, and involve many mistakes. But having an instructor tell us what to do, each step of the way, is a much more rapid way of learning to drive than the trial and error method of self-shaping. Following a recipe for baking a cake is more likely to produce an edible cake than giving someone the ingredients and letting them figure it out on their own. RGB only works so long as it usually leads to reinforcement. If the directions are incorrect or omit a crucial step, people may abandon attempting to acquire the new behavior. Usually RGB involves the verbal/ written specification of the behavior and the outcome. Think of assembly instructions for a piece of furniture, or install a new software on your computer. But sometimes RGB is a more generalizable method of learning. Learning to comply when mother says “Come here” is usually a good idea, and most children learn to obey such rules reasonably consistently, but only because compliance has been followed by reinforcement in the past. If in the past when mother said “Come here” and compliance was followed by punishment, then adherence to the rule will be followed weakly, if at all. To be most effective, rules describing contingencies should yield fairly immediate consequences. Having a deadline is also a way to strengthen the efficacy of rules. Telling my children “If you make an A on this week’s test I will take you to the movies” is more likely to strengthen studying behavior this week than telling them “If you make an A for the semester I will take you to the movies then.” Hayes (1989) is a good source to learn more about the distinctions between contingency-shaped and rule-governed behavior. Both are seen as forms of operant learning. Like respondent learning, operant learning has been demonstrated in all animal species tested – other primates, mammals like dogs, cats, pigs, elephants, reptiles,

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fish, amphibian, insects, etc. Again this suggests this is a universal and powerful mechanism of learning which is crucially important in human development across the life-span and in the emergence of both functional and dysfunctional behavior. Wong (2012) is an excellent overview of operant theory, written from a social work perspective.

Observational Learning A third form of learning which is foundational to behavioral social work is learning via imitation, also known as modeling. In short “. . .a good deal of learning occurs through vicarious rather than a personal experience. We observe the behavior of others, observe the consequences, and later we may imitate their behavior” (Mazur 1998, p. 289). Learning by imitation is not limited to humans but has been observed through the animal kingdom (other primates, dogs, cats, rodents, bird, octopi, and even fish!), including learning fairly complex repertoires. One-month-old infants have demonstrated the capacity to imitate adults, suggesting a strong evolutionary component to this form of learning. It is likely that the ability to learn from others (especially their mistakes and successes) enabled our distant ancestors to survive and reproduce more successfully than those who lacked such a capacity. Of course the same can be said for respondent and operant learning. Overlapping with the principles of rule-governed behavior, one can readily see the value of being able to learn not from what others tell us to do but what they demonstrate doing. Being shown a new skill is often a more effective method of skill acquisition than being told what to do. Modeling is facilitated by observing people similar to oneself, by observing models being rewarded for their success, and models who initially display less than perfect skill but who gradually improve and then get rewarded, are more effective exemplars than demonstrating perfect performance the very first time. Many behavior therapies combine all three elements of learning theory principles. When I do real-life exposure therapy, I am using principles of respondent extinction. I almost always model what I am ask fearful clients to do before asking them to do something difficult (e.g., touch a snake), and I am liberal in my use of reinforcement contingent upon their undertaking more fearful behavior, with praise and the judicious use of humor being foremost tools in this regard. Very few behavioral methods are purely one form or another.

Practice Methods in Mental Health Social workers making use of behavioral methods fall along a continuum with respect to adherence to the complete behavioral model. At one end are practitioners who respect the empirical research foundations enjoyed by many behavioral interventions, and they apply them with their clients, who they may have diagnosed using the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association 2013). They may not subscribe to the

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philosophy of science called behaviorism, and they may make no use of singlesystem research designs to evaluate their practice. They simply pragmatically adopt methods that work. Many practitioners fall into this camp. Others, such as the author of this chapter, fully embrace the perspective known as behavior analysis, make little to no use of the DSM, use learning theory to guide their assessment and interventive techniques, and attempt to use single-system designs to evaluate the outcomes of their practice. The DSM is viewed by behavior analysts as a scientifically flawed document which is both empirically and conceptually of little value in terms of being able to effectively help clients. As reviewed in a number of critical articles (e.g., Thyer 2006, 2014, 2015), the very definition of mental disorder found in the DSM-5 is tautological. This definition states “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functions” (APA 2013, p. 20). Claiming that a mental disorder is a disturbance in the processes underlying mental functioning is simply repeating words, like saying you can recognize sleeping pills because they put you to sleep. Imagine cardiology claiming that we can recognize heart disease because heart functioning is disturbed. Maybe the cause is not heart disease but diet, endocrine problems, medication side effective, or overuse of caffeine. Yet virtually any condition that is distressful can be labeled a mental disorder, according to the DSM-5. Behavior analysts suggest that when conditions adversely effecting thoughts, emotions, or behavior can be etiologically attributed to factors such as genetics, physical diseases such as Alzheimer’s, the effects of drugs or other ingested substances, or one’s environmental history, it is scientifically inappropriate to label the resultant changes in behavior as a mental illness. The disciplinary overreach contained within the DSM-5 can be correctly viewed as a self-serving effort on the part of psychiatry to reclaim and even expand upon their professional purview. If all disturbances in cognitive, emotional, and behavioral functioning are said to be mental illnesses, irrespective of the etiology of that disturbance, and we are further told that the “DSM is a medical classification of disorders. . .” (APA 2013, p. 10), then the supremacy of psychiatrists as being the diagnosticians and treatment providers of choice (by virtue of their medical background) is unblinkingly asserted. This means that nonmedical professionals such as clinical social workers, psychologists, behavior analysts, etc. are seen as suboptimally trained practitioners. Situational contexts, upbringing, parents, peers, impoverishment, and lack of opportunities are largely ignored in the DSM, even though these factors are frequently the etiological precursors to disturbances in behavior (and recall that in behavior analysis, the term behavior also includes emotions and thoughts). One response by clinical social workers is to hold our nose and use the DSM criteria and terminology in our practice, in effect turning a blind eye to the deficits of the DSM. This is perhaps the most common practice. Another approach is to not use the DSM at all. Some very distinguished practitioners have advocated this approach, people such as Thomas Szasz and Carl Rogers. The whole approach

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known as client-centered therapy largely eschews the DSM categorical system, as do practitioners who use family systems therapy, who tend to view individual disturbance as a reflection of familial dysfunction. The approaches to clinical social work developed by de Shazer and Berg, solution-focused brief therapy, Michael White’s narrative therapy, and Saleebey’s strengths-based perspective all avoid psychiatric categorization, focusing instead on client’s strengths and possible solutions, not problems. Behavior analysts too make no use of the DSM (except perhaps for insurance billing purposes). They are aware of the conceptual and reliability problems contained within the pages of the DSM-5 and instead focus on measuring behaviors and addressing them without stigmatizing labels. For example, a client who may meet the DSM-5’s criteria for PTSD may not be approached with an omnibus therapeutic approach (e.g., a medication, psychoanalysis, etc.) which is intended to treat the “disease” of PTSD. Instead, the behavioral analyst would work with the clients to assess the discrete behavioral issues that are disturbing them. These may include features such as nightmares, intrusive thoughts during the day, avoidance of situations resembling their trauma, an exaggerated startle response, hypervigilance, etc., all of which are amenable to empirical assessment. Each such difficulty could be individually addressed using different therapies derived from learning theory, and by reducing the severity of each aspect of the problem, which collectively gave rise to the presumptive diagnosis called PTSD. At some point the client is significantly improved, ideally demonstrated by a reduction in the presenting problems which lead the client to seek treatment. If the nightmares are now gone, avoidance is eliminated, intrusive thoughts absent, etc., the client is “cured,” all without resorting to using the label of PTSD. These various behavioral aspects troubling the client are not seen as symptoms of some underlying illness or disease; there is no disease present, not any other medical condition behind the problems. The nature of PTSD is environmental, not mental. The etiology resides in the client’s past environmental experience, the traumatic event. Now, of course the trauma may interact with some pre-existing aspect of the client. Someone with prior vulnerabilities may develop PTSD-like problems, whereas someone with a background that had presented less averse experiences may emerge relatively unscathed from the same “trauma.” The young soldier with a history of being severely battered as a child, or parental substance abuse and spousal fighting, may well be more likely to develop PTSD to a horrible combat-related situation, but the heightened vulnerability to develop PTSD is itself related to the soldier’s prior environmental experiences, not to their character, intrapsychic functioning, or attachment patterns. These three patterns, if they exist at all, are behaviors caused by one’s past environment; they do not cause or contribute to PTSD directly.

Assessment and Measurement In keeping with good social work practice, after the conventional introductory session(s) spent establishing a relationship and a verbal or written treatment contract

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with the client, the behavioral practitioner devotes some time to selecting a method to empirically measure client functioning, with a focus on their presenting problem(s). As defined by The Social Work Dictionary, behavioral assessment is “. . .the attempt to establish the antecedent stimuli and consequences that shaped and/ or maintain a given discrete behavior or more complex repertoire. The psychosocial origins of behavior are sought in terms of environment events, not mental ones. Behavior is defined in quantifiable dimensions such as how much, how often, and how long” (Barker 2014, p. 38). Unlike psychodynamic therapy, behavior is not seen as symbolic of underlying intrapsychic issues. Little Hans’ fear of horses would be taken at face value, and not interpreted as a fear that his father would castrate him (Freud 1909). Assessment may involve the direct measurement of overt behavior; obtaining client self-reports of private events, either overt behaviors which are not amenable to direct observation by others (e.g., bedroom or bathroom-related behaviors) or of internal experiences such as feelings, thoughts, obsessions, hallucinations, etc.; or of some relevant physiological measurement (e.g., biofeedback-related assessments, blood sugar, blood pressure, drug testing, etc.). When clinically feasible such measures are repeatedly assessed so as to establish a baseline or data-based sense of client functioning. In a very real way, taking a baseline is congruent with the social work dictum of “Beginning where the client is at.” It is also fulfilling Mary Richmond’s advice from over 100 years ago when she told us “. . .special efforts should be made to ascertain whether abnormal manifestations are increasing or decreasing in number and intensity, as this often has a practical bearing on the management of the case” (Richmond 1917). In some clinical situations, such as a crisis, the delays involved in obtaining a baseline may not be advisable, and this step is omitted. Ideally the baseline shows that the client’s problem is stable, or perhaps growing worse. Thus when intervention begins and continuing measurements are taken, the social worker is in a better position to determine if the client is improving, stable, or perhaps getting worse, on the selected outcome measures (there are be more than one). In behavioral social work, results are usually displayed in the form of a line graph, in addition to the traditional narrative case report. One can augment clinical judgment based on talking with the client by referencing the graphed data and thus be able to more compellingly say if the client is improving or not. There is a substantial literature on the use of this methodology, usually called single-system research designs, in the evaluation of social work practice (e.g., Thyer and Myers 2007). In some situations, wherein the intervention is removed and reinstated, the level of causal inference can be substantially enhanced, to the point one can say not just that the client got better, but they improved because of your social work services. Here the adoption of single-system designs segues into what the behavior analysts call the experimental analysis of behavior, and in the contemporary practice of behavior analysis, this is almost expected of each case. But this level of methodological rigor has not penetrated the field of social work to any great extent. Still, the use of regular, systematic, reliable, and valid empirical measurement of client functions, ideally before, during, and after social work intervention, is a hallmark method which has long distinguished this behavioral mode of practice of others.

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Specific Disorders Anxiety Anxiety is usually defined as the client self-report of fear and active avoidance or escape from, feared situations, behaviors which are disproportionate to the actual danger of the situation. There are many ways in which such clinically anxious behavior has been categorized, and the use of this common nomenclature may be used for convenience sake, so long as one keep in mind there are not actual diseases in a medical sense, and the boundaries between the supposed discrete conditions offer considerable blurriness. One behavioral therapy which has been around for many years, and enjoys a considerable amount of supportive clinical research, is called real-life exposure therapy and is based on respondent and operant learning theory. In this approach the social worker attempts to determine the nature of the anxiety-evoking stimulus (AES) for the client and to arrange to recreate it in carefully titrated amounts or dosages of exposure. For example, someone with a fear of heights may be introduced to an open stairwell, wherein during treatment they may be induced to gradually ascend at their own pace. The client with a severe fear of dogs enters a room containing a small puppy and only encounters larger dogs in later sessions as fears to the small dogs have been removed. The client is introduced to the AES with their full and informed consent, knowing they can have the situation terminated at any time. The social worker models coming into contact with the AES and asks the client to reflect on what they are feeling and thinking as they watch. With time the client usually calms down, and the therapist asks them to come closer, to briefly touch, and then to hold the AES. Homologous steps are arranged for different types of AES – heights, enclosed spaces, public speaking, insects, etc. With prolonged contact, the client almost inevitably calms down, permitting upping the intensity of the exposure exercise. With time, the clinician usually sees a reduction in avoidance, with subjective fear and physiological arousal remaining elevated. With more time, variables such as heart rate and perspiration subside, leaving the self-report of anxiety to be the last variable comprising “anxiety” to extinguish. Sessions usually last at least 1 h and should end on a “high note,” when the client is reporting feeling calm. Subsequent sessions pick up where the previous one left off or perhaps a bit behind the end of the previous session. Significant improvements are usually seen within the first few hours, and most clients obtain significant improvements so that all functional limitations are eliminated, as is excessive physiological arousal and the experience of subject anxiety. A search of YouTube using phrases such as “exposure therapy for phobias” will bring up many clips depicting this approach (e.g., https:// www.youtube.com/watch?v=zKTpecooiec). Clearing houses and websites describing research-supported treatments for anxiety disorders indicate the high value of this approach (e.g., https://www.div12.org/ diagnoses/) and in some cases provide clinical materials to assist with the application of the method, such as therapist treatment manuals, client manuals, assessment forms, and training opportunities. The applications of real-life exposure therapy

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are strongly supported for a wide array of conditions described in the DSM, such as specific and social phobias, post-traumatic stress disorder, panic disorder, agoraphobia, obsessions, and compulsions. Adaptions of this approach are used to effectively help reduce the craving of substance abusers and people with anorexia, bulimia, morbid grief, and pathological jealousy.

Schizophrenia The varied conditions that have been labeled schizophrenia have been known for millennia. While it is possible that the condition will ultimately be shown to have a primarily biological etiology, at present insufficient evidence exists to support such a claim. In particular the hypothesis that this condition is related to underlying disturbances in neurotransmitter function has been known to be false for decades, even though this idea remains widely prevalent, reinforced by the pharmaceutical industry which profits from promoting this point of view (Whitaker 2002). While it is ideal that social workers have a clear and valid etiological formulation crafted before undertaking the treatment of clients, it is not always possible and for many conditions such as schizophrenia and other chronic mental illnesses is unlikely to be obtained. Nevertheless we must proceed with offering clinical services, and fortunately the absence of a clear etiological understanding of a condition does not prevent us from being able to effectively care for someone. Just as lime juice was known to prevent scurvy before the discovery of vitamins, and proper hygienic practices beneficial in surgery and wound care before the discovery of bacteria, there are many effective interventions that can be used to help people with chronic mental illnesses, absent a scientifically compelling etiological theory, or causal mechanism for the treatment’s effectiveness. One such approach to provide effective care for persons with schizophrenia is called assertive community treatment (ACT), a multidisciplinary form of therapy which has been around for over three decades. Free treatment resources to learn about the research-based foundations of ACT can be found on the Evidence-Based Practices Resource Center (https://store.samhsa.gov/product/Assertive-CommunityTreatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345) with information on how to build such a program, how to train frontline staff, treatment manuals, and how to evaluate your local ACT program. ACT has many behavioral methods built within it, relating to enhancing job skills; remaining employed; taking medication reliably, anger control, social skills training; and performing the functional daily living activities needed for independent, community-based living. A 15-min video describing ACT can be found here – https://www.youtube.com/watch?v= o6NtKACjwps&feature=youtu.be. Social workers have a central role on the ACT team. In inpatient settings reinforcement-based programs called token economies have long been used to promote adoptive behavior and reduce psychotic-like actions of clients (Paul and Lentz 1977; Hackenberg 2018). In these systems patients are regularly awarded tokens or points throughout the day for displays of socially

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adaptive behavior and other actions associated with normality. The earned points are exchanged daily (usually) for consumables and extra privileges such as outings, movies, etc. above and beyond those normally used in the hospital. The general approach called social skills training makes extensive use of reinforcement and shaping techniques to help persons with psychosis (see Turner et al. 2018, for a recent meta-analysis of this research) and has the potential to not simply promote functional skills but also to reduce the so-called negative symptoms of schizophrenia (Grantholm and Harvey 2018). In this method, discrete aspects of positive social interaction are broken down into small behaviors, actions like gaining and maintaining appropriate eye contact, initiating appropriate greetings, engaging in conversation, saying farewell, enquiring about the well-being of others, etc. Each is taught, sometimes alone, using praise and shaping, the use of mirrors and video feedback, and repeatedly practiced under conditions that increasingly resemble real-life settings. Social skills training is a remarkable effective psychosocial intervention which social workers are quite naturally able to provide. There is also considerable literature on the use of behavioral methods to reduce or eliminate hallucinations, without the concomitant use of antipsychotic medications (Haddock et al. 1998). Very simply put, hallucinatory or delusional behavior is put on extinction, and normal conversation is selectively attended to and reinforced. Distraction methods (listening to music via earphones) can be useful and are teaching the client to simply ignore the experiences. Data can be taken surrounding the circumstances and times of day when hallucinations and delusions are more frequent and also time when they are less likely to occur. The social worker then works with the client to seek to expand the environmental situations where hallucinations and delusions are less likely (productively engaged in interesting activities) and minimize the times when they are more likely (e.g., alone with nothing to do). This latter approach is similar to the exception-seeking questioning undertaken in solution-focused brief treatment (SFBT), except behaviorally oriented therapists had been doing it years before SFBT was invented, and they augment simply asking questions about exceptional times by taking empirical data to see if their client’s reports are accurate. And then data continues to be taken to see if the intervention is having any effects. The use of methods such as these has even been shown to impact the display of so-called multiple personalities (e.g., see Kohlenberg 1973).

Depression The experience of depression can take many forms and occur under different circumstances. There is postpartum depression; post-myocardial infarction depression; depression following the death of a loved one, the loss of a job, or loving relationship; and depression which is otherwise apparently uncaused (an assumption the behaviorist rejects, since all phenomena are seen as having potentially identifiable causes). In traditional psychodynamic theory, depression is seen as angerturned-inward. Behaviorally oriented clinicians take a more parsimonious approach and investigate environmental aspects of the client’s life which may contribute to

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dysphoric mood. The model of Peter Lewinsohn is a particularly well-developed theory of depression in this regard. “In the mid 1970s, Peter Lewinsohn argued that depression is caused by a combination of stressors in a person’s environment and a lack of personal skills. More specifically, the environmental stressors cause a person to receive a low rate of positive reinforcement. . .. According to Lewinsohn, depressed people are precisely those people who do not know how to cope with the fact that they are no longer receiving positive reinforcements like they were before. For example, a child who has newly moved to a new home and has consequently lost touch with prior friends might not have the social skills necessary to easily make new friends and could become depressed. Similarly, a man who has been fired from his job and encounters difficulty finding a new job might become depressed. In addition, depressed people typically have a heightened state of self-awareness about their lack of coping skills that often leads them to self-criticize and withdraw from other people (e.g., depressed people may avoid social functions and get even less positive reinforcement than before). To make matters worse, some depressed people become positively reinforced for acting depressed when family members and social networks take pity on them and provide them with special support because they are ‘sick.’ For example, some spouses may take pity on their depressed partners and start to do their chores for them, while the depressed person lays in bed. If the depressed person was not thrilled to be doing those chores in the first place, remaining depressed so as to avoid having to do those chores might start to seem rewarding.” (c.f. https://www.mentalhelp.net/articles/psychology-of-depression-behavioral-theories)

Lewinsohn has developed an array of measures which can be used in the assessment and response to treatment of depressed clients, such as the Unpleasant Events Scale, the measurement of the experience of pleasant events, the measurement of coping skills, and the like. Treatment involves attempting to minimize the client’s further exposure to unpleasant, depressogenic experiences and to schedule and promote the client’s exposure to pleasant events that they find rewarding. Lewinsohn developed a manualized “Coping with Depression” (CWD) course. “Treatment” can be undertaken more or less independently by the client (e.g., self-help) as well as in a group format or via individual therapy, and the program is now available in hard copy book form and also via computer, CD-ROM, and DVD. Clients are taught an array of skills to cope with depression – social skills, how to seek out and proactively schedule their engagement in rewarding activities, identifying negative thoughts, and promoting ways of thinking that elevate one’s mood. Baseline data is usually gathered for each client and the results used to plan an individualized program of treatment. The CWD program has been used with an array of diverse client populations and in many countries and has been tested in over 25 randomized controlled trials. It has also been shown to be an effective method to prevent depression (Cuijpers et al. 2009).

Summary Social work practice guided by the principles of modern social learning theory, the philosophy of science known as behaviorism, the assessment and interventive methods of behavior analysis and therapy, and the evaluation of outcomes using

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single-system research designs is a comprehensive approach to mental health practice. Illustrations were given of the effective use of this model for clients with anxiety, persons with schizophrenia, and clinically depressed persons. This approach is widely used to help people with an array of so-called mental disorders, as well as to help clients with substance abuse problems, intellectual disabilities, and associated problems such as self-abusive behavior and aggression. The professional infrastructure of behavior analysis and therapy is solidly established. The Association for Behavior Analysis International (ABAI) has over 7500 members worldwide and an affiliated chapter membership of more than 28,000. The ABAI presidency is now held by a social worker, Dr. Mark Mattaini, and the organization supports numerous journals and annual national and international conferences. The practice of behavior analysis is now licensed as an independent discipline in over 25 states, and insurance reimbursement for behavior analytic services is widespread. The primary independent practice qualification is the masters-level Board Certified Behavior Analyst (BCBA) credential, awarded by the Behavior Analyst Certification Board (https://www.bacb.com/), after passing the accredited courses, passing a rigorous national-level examination, acceptance of the BACB Code of Ethics, and obtaining suitable continuing education biannually. There is a doctoral qualification to the BCBA, a bachelor’s level qualification, and a lower-level Registered Behavior Technician qualification. There are over 29,000 BCBAs and over 300 academic programs providing approved courses and degrees leading to certification. The related discipline of behavior therapy has its own professional association, the Association for Behavioral and Cognitive Therapies (http://www.abct.org/ About/?m=mAbout&fa=dAbout) and is dominated by psychologists although social workers are welcome to join. The past president of ABCT is social worker Dr. Gail Steketee, one of our field’s most widely cited scholars, notably for her outcomes research in the behavioral treatment of persons with obsessive compulsive disorder, PTSD, and hoarding. Previously, social worker Dr. Richard B. Stuart served as the President of this organization (1974–1975). He was a pioneer in the fields of behavioral marital and family therapy, the treatment of obesity, and violent behavior. ABCT publishes a number of high-quality journals and sponsors annual conferences and continuing education programs. ABCT is clearly more of a cognitive-behavior therapy organization, while ABAI largely eschews any notions of the role of cognitive factors as etiological agents of mental disorders. For the behavior analysts, cognitions, while real, are simply more behavior to be explained. Where do the negative thoughts of the depressed come from? Most likely from their upbringing and current environment experiences. Thus thoughts and beliefs, like overt actions, stem primarily from the environment, and the focus of treatment is on what is felt, not the feeling. Behavior analysis omits the middleman. A traumatic experience causes behavioral avoidance, negative feelings, and upsetting thoughts. All three aspects of behavior are the sequelae to the experience. The cognitive-behavior therapist is more likely to contend that the trauma occurs; it causes thoughts and feelings, which lead to changes in overt behavior. Thus the focus would be on changing the client’s ways of thinking.

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Most social workers will perhaps not be prepared to make the jump to identifying more as a behavior analyst or as a behavior therapist by becoming involved with these membership organizations. But all social workers should be thoroughly familiar with social learning theory and of the principles and practices of behavior methods. To the extent we believe that it is important to follow the latest research demonstrating that some treatments are effective and some are less, so (and some are harmful) behavior analysis and therapy should be an array of methods we are prepared to provide our clients with so-called mental disorders. Indeed, it has been said that our clients have a right to effective treatment (Myers and Thyer 1997). If we really believe this, becoming familiar and competent with these methods is an ethical imperative (Thyer 1995).

Cross-References ▶ Community, Mental Health, and Social Work ▶ Social-Cultural Ecological Perspective ▶ Theories on Mental Health, Illness and Intervention

References American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. Author, Washington, DC Arhin A, Thyer BA (2004) The causes of racial prejudice: a behavior analytic perspective. In: Chin JL (ed) The psychology of prejudice and discrimination: volume I, Racism in America. Praeger, Westport, pp 1–19 Barker R (ed) (2014) The social work dictionary, 6th edn. National Association of Social Workers, Washington, DC Berman L (1927) The religion called behaviorism. Boni and Liveright, New York Bruno F (1936) The theory of social work. DC Health, New York Coelho CM, Purkis H (2009) The origins of specific phobias: influential theories and current perspectives. Rev Gen Psychol 13:335–348 Cuijpers P, Munoz RF, Clarke GN, Lewinsohn PM (2009) Psychoeducational treatment and prevention of depression: the “Coping with Depression” course thirty years later. Clin Psychol Rev 29:449–458 Elmhurst K, Thyer BA (2019) Self-conducted and Skype-mediated exposure therapy of a woman with a severe balloon phobia: a single-case study. Manuscript submitted for publication Freud S (1909) The analysis of a phobia in a five year old boy. In: Strachey L (ed) Standard edition of the complete psychological works of Sigmund Freud. Volume 10. Hogarth Press, London Grantholm E, Harvey PD (2018) Social skills training for negative symptoms of schizophrenia. Schizophr Bull 44:472–474 Hackenberg TD (2018) Token reinforcement: translational research and application. J Appl Behav Anal 51:393–435 Haddock G, Tarrier N, Spaulding W, Yusupoff L, Kinney C, McCarthy E (1998) Individual cognitive–behavior therapy in the treatment of hallucinations and delusions: a review. Clin Psychol Rev 1:821–838 Hayes SC (ed) (1989) Rule-governed behavior: cognition, contingencies, and instructional control. Plenum Press, New York, pp 191–220

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Hayes LJ, Ghezzi PM (1997) Investigations in behavioral epistemology. Context Press, Reno Kohlenberg RJ (1973) Behavioristic approach to multiple personality: a case study. Behav Ther 4:137–140 Lattal KA, Chase PN (eds) (2003) Behavior theory and philosophy. Plenum, New York Mazur JE (1998) Learning and behavior, 4th edn. Prentice-Hall, Upper Saddle River Myers LL, Thyer BA (1997) Should social work clients have the right to effective treatment? Soc Work 42:288–298 O’Donnell JM (1985) The origins of behaviorism. New York University Press, New York Paul GL, Lentz RJ (1977) Psychosocial treatment of chronic mental patients: milieu versus social-learning programs. Harvard University Press, Cambridge, MA Rachlin H (1991) Introduction to modern behaviorism, 3rd edn. W.H. Freeman, New York Richmond M (1917) Social diagnosis. Russell Sage Foundation, Philadelphia Robinson V (1930) A changing psychology for social casework. University of North Carolina Press, Durham Royse D, Thyer BA, Padgett DK (2016) Program evaluation: an introduction to an evidence-based approach, 6th edn. Cengage, Boston Thyer BA (1995) Promoting an empiricist agenda within the human services: an ethical and humanistic imperative. J Behav Ther Exp Psychiatry 26:93–98 Thyer BA (ed) (1999) The philosophical legacy of behaviorism. Kluwer, Dordrecht Thyer BA (2006) It is time to rename the DSM. Ethical Hum Psychol Psychiatry 8:61–67 Thyer BA (2012) Respondent learning theory. In: Thyer BA, Dulmus CN, Sowers KM (eds) Human behavior in the social environment: theories for social work practice. Wiley, New York, pp 47–81 Thyer BA (2014) A review of Essentials of psychiatric diagnosis: responding to the challenge of DSM-5 by Allen Francis. Res Soc Work Pract 24:165–169 Thyer BA (2015) The DSM-5 definition of mental disorder: critique and alternatives. In: Probst B (ed) Critical thinking in clinical assessment and diagnosis. Springer International, Cham, pp 45–68 Thyer BA, Hudson W (1987) Progress in behavioral social work: an introduction. J Soc Serv Res 10(2/3/4):1–6 Thyer BA, Myers LM (2007) A social worker’s guide to evaluating practice outcomes. Council on Social Work Education, Alexandria Turner DT, McGlanaghy E, Cuijpers P, van der Gaag M, Karyotaki E, MacBeth A (2018) A metaanalysis of social skills training and related interventions for psychosis. Schizophr Bull 44:475–491 Whitaker R (2002) Mad in America: bad science, bad medicine, and the enduring mistreatment of the mentally ill. Basic Books, New York Wong SE (2012) Operant learning theory. In: Thyer BA, Dulmus CN, Sowers KM (eds) Human behavior in the social environment: theories for social work practice. Wiley, New York, pp 83–123

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Social-Cultural Ecological Perspective Monit Cheung and Carol A. Leung

Contents Introduction: Ecological Approach as a Social Work Modality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Social-Cultural Ecological (SCE) Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Theoretical Link to Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Social-Cultural Ecological (SCE) Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case #1: Don’t Underestimate How Hard We Are Trying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case #2: Everyone Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Tools: Culturagram and Ecomap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ASK Cultural Competency Instrument for Practice Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why Use SCE Perspective in Mental Health Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion: Functions of the SCE Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter describes the complexity of ecological theory for building the socialcultural ecological (SCE) framework for social work practice. It addresses the cycle of problem formulation, solution, and evaluation of practice, which is a basis for understanding how clients’ micro-level problems may directly or indirectly be associated with the macro-level issues in their environment. Particularly, this chapter will illustrate how to measure clients’ social-cultural awareness – a concept linking mental health assessment to service planning. Two case studies will be presented to illustrate how to apply the SCE framework into practice using M. Cheung (*) University of Houston, Houston, TX, USA e-mail: [email protected] C. A. Leung University of California, Los Angeles, CA, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_25

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tools such as ecomaps and culturagrams. Clinical questions will be formulated and illustrated in these case studies. Lastly, six elements from the SCE perspective will be summarized to apply clinical skills for the promotion of effective prevention and intervention strategies, culturally relevant assessment of clientin-environment factors, and competency-based evaluation of an effective plan to improve mental health and social care services. Additionally, the ASK (Attitude Skill Knowledge) cultural competency instrument is introduced as a tool for self-assessment. The purpose of this multidimensional assessment is to empower individuals, specifically about replacing their negative thoughts with positive engagement using a holistic view to assess, implement, and evaluate interventions. Keywords

Ecological perspective · Culture · Clinical practice · Social work practice · Ecomap · Culturagram · ASK cultural competency instrument

Introduction: Ecological Approach as a Social Work Modality Social workers have adopted the ecological approach in practice for screening and assessing problems from a broader angle to plan effective interventions. Since the seventeenth century when social work claimed its goal in poverty relief, the ecological approach became a practice guiding post that helped social workers focus on the roles of the environment on human development. The long-term vision of social work has been to remove environmental barriers and sociocultural biases that can raise serious personal and justice concerns to the community. Individual or family problems that were considered private matters became public concerns, as they had a negative impact on the community. For example, a child with hair lice may seem to be only an individual or family problem, but actually this problem can develop into a school concern because hair lice can be passed to others due to close proximity between this child and other children. In another example within a populated low-income neighborhood, the diseases passed on by rats through contaminated food not only affect one family but also the entire community because of the highly contiguous diseases. The concept “person-in-environment” (PIE) has become a cornerstone to support the implementation of casework, group work, and community work that informed practitioners about the multiplicity and complicity of social work practice. The PIE principles incorporate an assessment route involving individual, family, social, ethnic/cultural political systems, as well as environmental conditions to facilitate social work practice, including a focus on planning, assessment, and service delivery. In the early ecological-focused works, Germain (1973), Barker (1973), and Grinnell (1973) offered a theoretical base for social workers to identify contributing factors of individual changes based on environmental shifts. Later works of Bronfenbrenner (1989) also postulated the same premises

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Fig. 1 Multiple levels of a social work client system

that individuals react to the conditions for changes that lead to societal beliefs and attitudes toward interpersonal relationships. The ecological approach studies individuals interacting with the environment with results testifying the cycle of social changes accompanied by individual changes. These changes include individual biopsychological factors (microsystem); multidimensional interactional elements within the environment (mesosystem); the conditions in social, political, cultural, and economic contexts that influence the general beliefs and attitudes shared by the members in society (macrosystem); and people’s reactions to the different parts of social and cultural changes in relation to the change in time (chronosystem) (Fig. 1).

The Social-Cultural Ecological (SCE) Perspective The ecological approach in social work addresses the cycle of problem formulation, solution, and evaluation of practice. Based on the theory of social work by Compton and Galaway’s earlier work (1975), social workers perform various tasks through a series of personal and social processes that mobilize resources along with client-worker interactions and an environmental analysis. The “social work processes” are designed to help clients become self-sufficient, and thus the social work goal is to “help clients to help themselves” (Osmo 2001). The cycle of the social work processes can be demonstrated with at least seven stages: (1) define the problem; (2) identify resources and constraints in the environment; (3) set up goals and objectives; (4) assess individual strengths, problems, and sociocultural barriers; (5) implement service plans; (6) measure success and evaluate outcomes; and (7) end

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the service. The processes are evaluated with input from the entire social work system including clients, workers, collaterals, and others who have interactions with the clients. The end stage is typically called “case closure” or “termination” with a follow-up evaluation. Each stage involves processing of human interactions, service engagement, problem assessment, and intervention, to untie the complicated relationship problems (between individuals and their environment) that have affected the well-being of the client. The social-cultural ecological (SCE) perspective emphasizes an understanding of the client’s social and cultural environment that aims to promote living standard and family harmony. It analyzes the interrelationships between and among social, cultural, economic, and political systems that generate changes for an expansion of service scope to promote quality of life. In a mental health setting, services are designed to help individuals deal with behavioral changes and then use the collective power from the individual’s larger support network as a base to affect systemic changes. With the SCE perspective, social workers generate strategies to achieve different goals: (1) client engagement at a micro level of individual intervention and (2) community engagement at a macro level of social changes. Reciprocally, small steps toward appropriate changes in the environment will lead to changes in the individual (McLeroy et al. 1988). Psychologist Albert Bandura (1977) developed the reciprocal determinism (RD) theory to assess how a person’s behavior is influenced by both the personal factors and the social environment in a bi-directional manner. SCE expands from the RD theory to include multidimensional connections among social and cultural factors within one’s environment for the promotion of mental health. Manitiu and Pedrini (2016) describe the characteristics of this multidimensionality as “smartness” and “sustainability” in personal successes within the totality of social, cultural, and environmental adjustments. Currently, “green social work” and “global social work” are the most recent practice innovations that aim to provide a safe environment with cultural heritage and geographic relevance to promote social justice and self-care regardless of boundary and geographic differences (Dominelli 2014; Lyons et al. 2006; Noble 2016). The emphasis of these innovative ideas is for social workers to be the change agent and for the clients to be the change carrier for promoting environmental support to meet personal and community needs. For instance, environmental pollution is a “green social work” concern with which social workers work with people who live in a community with high rates of cancer diagnoses to identify impact of chemical contamination on personal well-being. Through collective actions, people in the polluted community receive additional healthcare support and mobilize advocacy efforts to ask for governmental sanction. The personal concern has no boundary as environmental malice must be controlled to promote the mental health of the entire community. Combining the social and cultural factors in the environment, the SCE perspective not only helps to impact a client system through counseling and family-based services but also promotes social changes through individual participation in policy analyses and advocacy work (Cheung et al. 2017). With both direct and indirect

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practice strategies for intervention, a culturally relevant approach with an ecological perspective is uniquely generated for each client system. This perspective empowers social workers to be a specialist in effectively assessing problems and identifying needs from various systemic levels including individual, family, small group, larger community, and society as a whole. With the social and cultural aspects being assessed within the entire client system, social workers have obtained a society-recognized professional identity to play various roles in disseminating resources and promoting changes within the individual and the larger system. This ecological approach has been expanded to offer the SCE lens for refining and expanding the scope of mental health practice to specifically include an integrative cultural perspective based on social and environmental changes.

The Theoretical Link to Mental Health When assessing the mental health of an individual, social workers must first identify the contributing factors that are internal and external to the person. These factors include an individual’s biological makeup, developmental growth process, personal definition of happiness, quality of life, social inclusiveness, sense of belonging, environmental support, and other social and cultural influences. Mental health is more than an individual’s life fulfillment but also a community integration of such fulfillment, from resolving problems to creating hopes, in the social, cultural, and ecological context – such as combating poverty, gender inequalities, cultural biases against immigrants, and ethnic discrimination and removing structural barriers to access services (Ritchie 1994). As facilitators to remove barriers, such as obtaining a driver license, accessing proofs of academic credentials, or creating a safe zone for disclosing traumatic experiences, social workers can engage clients and enhance their full participation in the intervention process. The primary needs of some clients may not be similar to the basic needs of other clients due to variation of their past experiences. From a psychological point of view, the key variables for defining one’s mental health are typically abstract in nature and relate mainly to the emotional wellbeing as perceived by the individual. In contrast, from a social work point of view, both internal and external factors are important to determining one’s mental health. With a holistic analysis, the client becomes more aware of how these contributing factors affect and protect the individual’s development and resilience, thus moving toward recovery and healing from the presenting problem. As the biopsychological assessment is performed, external influences must also be analyzed to find positive ways to improve the social-cultural ecological interactions among individuals so as to improve each individual’s mental well-being within the same system. In turn, the individuals apply effective communication and adjustment strategies to promote their mental capabilities for resolving challenges and mutually helping each other. Mental health is thus enhanced along with the successes in obtaining an adequate level of self-esteem and achievement. Both internal and external factors are important in measuring happiness and promoting the quality of life.

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The Social-Cultural Ecological (SCE) Measures While mental health is measured based on individual functioning, this measure must have a close relationship to the social, cultural, and ecological systems (Leung and Cheung 2013). Based on the social systems theory, a social system has many interrelated parts. Each part interacts with others to find ways to connect, resolve conflict, produce solutions, and fulfill the purpose to connect each part with its respective role and function. From an ecological perspective, all parts within a system must be integrated to justify the continuity of each part in a balanced and meaningful way in conjunction to other parts. An individual is a part of this integral system. The SCE perspective is derived from this social systems theory to help social workers conduct comprehensive assessments. The overall goal is to assist clients in improving their situations within the environment. It starts with the presenting problem, using nonjudgmental questions such as “What problem have you experienced that is connected to your environment?” Clients are encouraged to define their environment in the assessment process and are empowered to engage in an intervention that is not only based on the presenting problem but also planned with environmental support or adjustment. Culturagrams and ecomaps are tools used for assessment, which aim to identify sources of emotional stability and create helpful changes for the individual and family systems (Cheung and Leung 2008). The SCE perspective highlights the essentiality of these interpersonal relationships, patterns of behaviors that have been connected to the environment, and awareness of diversity in various social-cultural ecological environments. Social-cultural awareness is a client-focused term illustrating ways to stimulate the client to think about how the ecological surrounding has impacted the well-being of an individual in the family system (Cheung and Leung 2008; Cribb and Haase 2016). Together, these three terms – social, cultural, and ecological – are used to represent the essence of the SCE practice model. This SCE model places importance on the dynamic interactions between the client and the surroundings, such as family, other individuals, community (school, work, neighborhood), society (healthcare system, policy), and other socioeconomic and cultural components (gender, race, ethnicity, sexual orientation, socioeconomic status, language, geographic and immigration factors) for the analysis of a client’s needs, problems, and solutions. The reason it is called “dynamic” is that the social worker will help the clients to measure the changes after each step of the intervention or advocacy work has been implemented. The purpose of applying the SCE perspective in social work practice is to improve the well-being between people and their environment (Gitterman and Germain 2008). Using the SCE perspective, social workers provide services to (1) eliminate, alleviate, or reduce life stressors on an individual level and (2) influence social and physical environmental characteristics or advocate for changes that are responsive to the needs of diverse client systems. Environmental factors including social inequalities and ethnic disparities can inform clients about the different ways to develop strategies for influencing individual and family decisions or impacting the long-term implementation of government policy (Kaskie et al. 2016). Social workers

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apply a systematic way to address the gaps or disparities within the clients’ ecological systems so that social, economic, ethnic, and political justice can be promoted. Analysis of environmental impact is a key tool in political social work which is a specialization in social work for advancing social justice for all.

Case Examples This chapter presents two cases to demonstrate how social workers use the SCE perspective to analyze the presenting problem and the environment of the client system and to identify the service gaps. The first case provides clinical questions involving the client’s social-cultural awareness, strengths of the client system, how to identify solutions to the presenting problem, and intervention strategies. The second case illustrates the use of a culturagram and an ecomap to visually assess the interpersonal and intersystem dynamics. The strengths of individuals and social-cultural resources are highlighted to promote the well-being and quality of life in the client system.

Case #1: Don’t Underestimate How Hard We Are Trying Catherine and Joshua, a Caucasian couple, both 36 years old, have been struggling to start a family for the last 5 years in a rural county. When they turned 30, Catherine and her husband had hopes for becoming parents, only to quickly discover that the journey would be difficult. After a year of attempting with one early miscarriage, Catherine was diagnosed with polycystic ovary syndrome. This is a common endocrine disorder that affects nearly 15% of women in the reproductive age. The couple had been undergoing in vitro fertilization (IVF) over a period of 6 months. Catherine describes her experience as “gut-wrenching and filled with heartache.” She obsesses daily about how and when they can conceive. She explains that she is feeling an excruciating amount of pressure to conceive because the majority of her friends have either one child and/or are currently pregnant with their second child. Upon her most recent therapy session, Catherine discloses that the couple took out additional loans to pay for uncovered medical bills. Many couples with infertility have a higher risk of anxiety, depression, and stress that contribute to marital distress and divorce (Cousineau and Domar 2007; Donarelli et al. 2016). For example, Catherine has been obsessing over wanting a child, which may be compromising her feelings of happiness and creating marital problems. The social worker examines whether Catherine is having feelings of depression and anxiety and assesses her support system. Since the issue of infertility may also affect her husband’s emotions, Catherine can invite her husband to work through this issue together. Next, the social worker validates that this situation is common and that Catherine is not alone. Referring her to a group with a focus on infertility helps Catherine feel supported. Therapeutic questions (five levels) from the SCE perspective are asked:

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1. Individual: Health and emotion issues • How are you taking care of yourself? • Think of something you like to do but do not do any more. What are your feelings surrounding this issue? 2. Family: Family support • How do you and your husband support each other during this journey? • Tell me about the various options for starting a family. • Who in your extended family would you go to when you encounter a difficult decision? 3. Community: Values and support • How do you define a supportive community (friends, church, school, work)? • How has the community supported you in this process? • What would your closest friends say if they wanted you to feel happy? • If you do not feel supported, what obstacles are you facing? • Assess how your community has influenced your plan (of starting a family). How does this community influence your thoughts about having a child? 4. Culture: Beliefs and support • In your culture, what factors are the most important to you (and your husband)? • What cultural perspective has been helpful to help you deal with difficulties? • Name a philosopher in your culture. What would this philosopher say or do to advise you about your current situation? 5. Society: Social pressure and reasoning • You mentioned the pressure of society about having a baby at a certain age. What is your belief around that? • How does your insurance policy influence your decision? • What advice do you want to hear from society?

Case #2: Everyone Matters A teacher contacts a school social worker regarding Carl, a 12-year-old boy, for his behaviors in the classroom: sad and scared for seemingly no reason and not able to complete assigned homework. Carl does not respond to any comforting comments once he gets upset. His parents have spent little time with him and do not know much about his classroom problems. During the first session, Carl discloses that he is undocumented (a foreign-born person not having the appropriate legal documents or visa to stay in the United States) and “terrified that I will have to leave my home.” The school social worker conducts a family session and finds out that the parents are working long hours and not even earning a minimum wage. The parents are struggling to pay rent, electricity, and other necessities. The social worker assesses family stressors and addresses the difficulties faced by Carl particularly when he cannot complete his homework. The home electricity has been shut off for a week. Carl is unable to do his homework at night but is embarrassed to explain this situation to his teachers. The social worker connects Carl to an after-school program

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and a national school lunch program (low-cost or free school meals for low-income families). The parents show gratitude for the assistance. 1. Individual: School performance • What do you think about your (Carl’s) current school work? • Who is your (Carl’s) primary caretaker? • When Carl cannot complete his homework, who would be able to help? • Who would be the best person to help you (Carl) with homework? • What feelings are bothering you (Carl) regarding your home situation? 2. Families: Parents’ employment and current household environment • In addition to your (parents’) current employment, what kind of financial assistance has your family received (or tried to get)? • What can we do to help you build/have a better home? • If your family receives electricity assistance, how would that improve your (Carl’s) homework completion? • How comfortable are you to be the main help-seeker who tries to get support? 3. Community: • What resources within your immediate environment have you tried to get? • What do you know about our school lunch program (or other social services)? • Has your immigration status affected the support you tried to get? • Connecting resources is critical for you (Carl) to excel in school. What kind of resources do you (and your family) need in order to help you (Carl) study and complete homework each day? 4. Culture: • What brought you to the United States (from your country of origin)? • Describe the relationship between you (your family) and your extended family. • Which part of your culture has helped (or hindered) you to seek help when needed? 5. Society: • You know that students must receive K-12 education. That’s great. Tell me more about what you know about college education. • What worries do you have about your (Carl’s) education? • How has the American immigration policy, Deferred Action for Childhood Arrivals (DACA), impacted your thoughts about seeking support from the school? • How would your best friends react to you if you told them you were receiving support from the US government?

Practice Tools: Culturagram and Ecomap Both culturagrams and ecomaps are visualization tools that help the social worker prepare information, document needs, and assist clients to see the connection between a presenting problem and the SCE components. By doing so, the clients

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Reasons for Relocation

Length of Residency in the Community

Values about Family

Values about Education and Work

Health Beliefs

FAMILY Name (Age) Name (Age) Name (Age)

Legal Status

Language Spoken at Home and in Community

Affiliation with Cultural and Religious Communities Life Stressors and Crisis Events

Holidays and Special Events

Fig. 2 Culturagram

can move, remove, and/or add new components into a graphic format to clearly see what has been impacting their or their family’s well-being. Using Case #2 (Carl) as an example, the clinician uses a standardized culturagram (Fig. 2) to prepare main headers collected from intake. Typically, the assessment components can be typed or written on the culturagram to show that social workers ask similar questions to most families to identify (1) reasons for relocation, (2) values about family, (3) values about education and work, (4) health beliefs, (5) time in the current community, (6) legal status, (7) language spoken at home and in the community, (8) holiday and special events, and (9) impact of the crisis event. It aims to encourage the clients to modify these headers and/or provide additional information, such as connecting the presenting problem with other environmental and external issues, causes of the problem, influences, environmental impact on decisions, congruence between decision-making process and cultural values, and possible solutions. After completing the initial assessment, a culturagram is used for further assessment (Fig. 3). According to Carl’s case, a summary statement in each of the areas is provided to indicate the different levels of social, cultural, and environmental assessments of the family. Once the social worker includes specific information on the culturagram, culturally relevant resources such as how to define youth transitioning (Mandarino 2014) can be discussed and identified to improve the presenting problem. This family may report feelings of shame because of their son’s poor grades. However, the social worker can reframe the presenting problem by informing the family that there might be secondary problems that have not been addressed. Understanding the root of the problem may help the family identify necessary services for the family and individual. Because there are multiple problems such as school performance, low income, and other interpersonal relationship problems, policies such as free lunch for the child and after-school tutoring services are other resources that can improve the child’s behavior outcomes. Ultimately, if the

Maria: Didn’t know that her son was struggling in school. Jorge: Struggling to keep a stable job and blames himself for Carl’s poor academic performance.

Maria & Jorge: No health care benefits. Use of home remedies to get rid of aches and pains.

Fig. 3 Culturagram with client’s input

Holidays and Special Events Family: The majority of the family lives in Mexico besides Maria’s sister and her husband. They celebrate major holidays together but their relationship i s conflictual at times.

Affiliation with Cultural and Religious Communities Maria & Jorge: Christianity The family attends church service every Sunday.

Language Spoken at Home and in Community Spanish-speaking parents who speak limited English. Carl speaks English well.

Legal Status Undocumented immigrants who brought Carl from Mexico at the age of 2.

Life Stressors and Crisis Events

FAMILY Jorge (42) Maria (38) Carl (12)

Jorge, Maria & Carl: All for ten years

Length of Residency in the Community

Health Beliefs

Values about Education and Work Both parents have an elementary school education. The parents hope that their child can be a firstgeneration college-educated graduate.

Values about Family Women are the primary caretakers at home. However, with their family stressors, Maria started working at a store three months ago.

Reasons for Relocation Jorge: Came to US to build a different career. Maria: Moved with husband.

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Fig. 4 Ecomap

surrounding environment is stabilized, Carl can rebuild his self-esteem, reduce his sad mood, and improve his interpersonal relationship with friends, families, and his teacher. Lastly, shame and guilt must be addressed so that the entire family can come together to resolve difficulties. Without making any assumptions, the social worker may also prepare an ecomap as a success measure for the family to move, revise, add, and subtract information from the graph. Figure 4 is the beginning graph that is prepared as a standardized form to normalize the situation; for example, the social worker may say, “We use this standardized graph to measure family successes against adversities in the environment. Please check if you would like to modify the graph after we have a chance to work together to adjust the situation as this is only the beginning effort to measure changes in your individual, family and community functioning.” The universalization technique is used when a uniform format is presented before placing the child’s name on the graph. This ecomap graph can be prepared on computer as PowerPoint slides that all circles, lines, and texts can be adjusted or modified according to the input from the clients. Figure 5 illustrates how clients may add lines and circles to represent relationships that have not been included in the standardized graph. In Carl’s case, his parents identify additional circles to represent “lack of health insurance” for the family and “friends” for Carl. At the first two sessions, the clients are encouraged to work on this ecomap to show family dynamics, particularly related to the extended family or friends and coworkers. As a result of encouragement, stressful lines are added between insurance and finance, between finance and health, and between Carl’s immediate household and the extended family. Direct impact lines are also added between immigration status and work and between immigration status and

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Fig. 5 Ecomap with clients’ input: Carl’s case

Carl’s friends. With visualization of the social, cultural, and environmental connections, Carl describes how he has found ways to protect himself from being bullied in school. Counseling services are offered, and training programs are planned in the school to prevent and stop school bullying. Again, this case illustrates the importance of environmental interventions to stop violence, solve mental health problems, and work with the immediate environment of the identified client. Many factors are identified, such as home, school, friends, and other individuals, who can provide support or other types of resources for the client and his family.

ASK Cultural Competency Instrument for Practice Evaluation Evaluation of the social worker’s cultural competency is an important task throughout the entire social work processes. Leung and Cheung (2013) have tested 97 items of cultural competency with input from 171 child protection workers and supervisors in Texas. These evaluative items were categorized into seven social work practice stages (or phases): contact, problem identification, assessment, service planning, intervention, evaluation, and termination. The aim of this 97item ASK instrument is to encourage workers and supervisors to focus on knowledge (K), skills (S), and attitude (A). Although knowledge is a prerequisite before skill application, attitude is a must when working with clients of diverse backgrounds. In order to empower clients to work toward their goal to be successful or to be able to resolve their issues, social workers must use positivity and focus on strengths from the beginning and conduct their own self-assessment on a regular

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basis. The acronym ASK is named reversely from KSA for the purpose of heightening frontline workers’ awareness toward a comprehensive evaluation of their practice with a strong commitment and a cyclical approach. Figure 6 is the entire instrument with 97 items for self-assessment, and Fig. 7 contains 24 items (also bolded in the 97-item instrument) tested with factor analysis results with supervisors’ input. In order to encourage social workers’ efficient assessment of their cultural competency, supervisors can use the short version (24 items) as a tool for training and staffing purposes.

Why Use SCE Perspective in Mental Health Services? Social workers have applied many theories such as client-centered theory, strengthsbased theory, and psychodynamic and cognitive-behavioral interventions to social work practice to ground their clinical skills. However, social workers need a framework to guide their professional practice skills in social work when applied to various populations. More specifically, in certain subpopulations, targeted interventions are used to improve the well-being and social functioning of each client. The combination of applying a practice-focused perspective along with a theoretical framework of clinical practice is an essential guide and tool. To accomplish the tasks of how to apply the culturally sensitive and strengths-based practice perspective in social work, six elements in the SCE perspective are summarized, with “SOCIAL” as the acronym: S: Sustainability: The ultimate goal of sustainability is to preserve the needs of the social worker and be able to maintain the needs of the clients without compromising the values, beliefs, and ethical standards of a social worker. Effective practice skills always start with the clinicians themselves by approaching ways to improve their self by using self-care, peer supervision, or therapy to enhance the culture, ideology, and values perspective on their clients. Social workers are at risk for burnout and secondary traumatic stress. If symptoms of compassion fatigue are detected in the early stages, negative consequences of the therapeutic work between the client and clinician may be prevented. In this area of practice orientation, social workers develop their skills by observations, analysis of social influences, and identification of the relationship between self and social control. O: Organization of Knowledge, Values, and Skills: The use of a systematic way to document knowledge for certain subgroups is extremely important. For example, treating the symptoms of psychosis is very different from the symptoms of anxiety. In order to stay informed and organized, a strong skill set in practice is documentation. Social workers must show an ethical and professional standard to their client by staying up to date with treatment planning. One tool is the use of documentation to identify salient characteristics and life events of the clients to improve their environment or social functioning. In this area of practice, social and cultural expectations of the individual, family, community, and society must be examined. C: Competence-Based Comparisons: Social workers should compare practice with evidence and consult with their supervisors to determine whether their clinical practice techniques may or may not work for a particular individual. Additionally,

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The “ASK-97 Cultural Competency Assessment” Instrument Revised version in 2018 by Monit Cheung and Patrick Leung The following self-assessment tool is used in different stages when working with clients who are culturally different from me: Contact Phase As I conduct the first interview, 01 K 02 K 03 K 04 K 05 K 06 S 07 S 08 S 09 S 10 S 11 S 12 S 13 A 14 A 15 A 16 A 17 A 18 A

I show my understanding toward my clients’ reaction. I understand that culture may influence perception. I consider my clients' expectations toward how an interview is arranged. I greet clients with respect. I share agency policy about accepting food from my clients. I know how to select an appropriate translator. I use greeting skills to build rapport. I explain who I am and why I am here. I apply skills that are appropriate for clients in a cross-cultural environment. I ask clients about their previous experiences with social service professionals. I express my desire to understand my clients' experiences. I validate my understanding of my clients’ culture. I anticipate that my clients may want to know more about this interview. I accept the fact that my clients may refuse to talk to me. I believe that my clients do not like to be interrupted when speaking. I must be careful not to show disrespect. I respect differences as long as they do not cause harm. I do not confront my clients in front of their children.

Problem Identification Phase As I help my clients identify their problem, 19 K 20 K 21 K 22 K 23 S 24 S 25 S 26 S 27 S 28 S 29 S 30 A 31 A 32 A 33 A 34 A

I prepare myself to share culturally relevant ideas with my clients. I have knowledge about clients’ problem definitions. I explore how a person’s upbringing may influence behavior. I contemplate how clients’ expectations may connect to their behavior. I acknowledge my clients’ contributions to helping me understand their culture. I explain how my increased understanding of my clients’ culture can help us work better together. I discuss the cultural appropriateness of the presenting problem with my clients. I validate the meaning of my clients’ use of words or expressions. I ask further questions with attention to my clients’ use of words or expressions. I restate relevant statements made by my clients. I ask my clients to reflect what they heard me saying about their situation. I listen. I understand that cultural differences may influence attitude. I value input from clients to clarify their perceptions of the problem. I understand that my definition of problem may be perceived differently from my clients’ cultural perspective. I feel it is important to be mindful of my own biases.

Fig. 6 (continued)

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Assessment Phase As I conduct assessment, 35 K 36 K 37 K 38 K 39 S 40 S 41 S 42 S 43 S 44 S 45 A 46 A 47 A 48 A

I know how to ask culturally relevant questions about my clients’ personal background. I update myself on evidence-based practices that are culturally relevant to my clients. I know how to assess my clients’ belief system. I understand the importance of motivating my clients to describe their support system. I explain the reasons of asking questions about my clients’ family. I involve my clients in collecting culturally specific information. I assess family strengths within the context of my clients’ cultural norms. I help my clients understand culturally specific behaviors within the limit of the law. I assess my clients’ access to informal support. I assess my clients’ access to formal support. I understand how my clients see my role differently based on previous experience. I value mutual understanding between my clients and myself. I believe my clients’ choice of communication means can be culturally based. I value my clients’ cultural expectations.

Service Planning Phase As I set goals and objectives for service planning, 49 K 50 K 51 K 52 K 53 S 54 S 55 S 56 S 57 S 58 A 59 A 60 A 61 A 62 A

I develop case planning relevant to clients’ culture. I know how to set goals and objectives in congruence with my clients’ values. I know how to target culturally specific services when needed. I learn from my clients about culturally relevant resources within their environment. I include culturally specific resources in service plans when appropriate. I develop a culturally specific contract with a focus on client strengths. I use culturally specific input from my clients in developing the service contract. I help the client identify culturally specific barriers. I use culturally appropriate language. I value culturally specific ideas contributed by my clients in service planning. I enjoy learning from my clients about their culture. I respect my clients’ contributions to their service planning. I value my clients’ definition of culturally specific outcomes. I acknowledge the importance of securing support services valued by my clients.

Intervention Phase As I work with my clients, 63 K 64 K 65 K 66 K 67 S 68 S 69 S 70 S 71 S 72 A 73 A 74 A 75 A

I ask questions and share information related to cultural differences. I am aware of culturally sensitive approaches in designing interventions. I have knowledge about my clients’ cultural expectations. I know how to conduct assessments with reference to my clients’ culture. I acknowledge the importance of culturally specific practices. I explore other possible meanings of clients’ behaviors. I address inappropriate behaviors without judging. I use culturally relevant methods to build client strengths. I help my clients set up a goal to identify sources of cultural pride. I continue learning about my clients’ culture. I am ready to adjust interventions to meet the cultural needs of my clients. I use my previous experiences in working with clients from a specific culture as a guide. I am open to hearing about other people’s ideas.

Fig. 6 (continued)

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Evaluation Phase As I evaluate our work, 76 K 77 K 78 K 79 S 80 S 81 S 82 S 83 S 84 A 85 A 86 A

I identify culturally relevant information for outcome evaluations. I monitor progress with attention to my clients’ cultural context. I use information about clients’ cultural characteristics when designing interventions. I use culturally relevant methods of evaluating clients' success. I use culturally relevant information for outcome evaluation. I display my satisfaction about goal achievement. I address how the situation can be improved. I am open to hearing about clients’ self-evaluation. I value clients’ participation in the evaluation process. I seek out culturally relevant information for measuring outcomes. I maintain a positive attitude toward my clients.

Termination Phase As I end my work with my clients, 87 K 88 K 89 K 90 S 91 S 92 S 93 S 94 S 95 A 96 A 97 A

I acknowledge my clients’ reactions when dealing with termination. I communicate with my clients about issues of termination. I know that my clients’ reactions to termination may be based on cultural values. I discuss issues of termination with my clients within a cultural context. I encourage my clients to express feelings about termination. I respect cultural rituals and beliefs that address termination. I use appropriate cultural resources. I summarize my clients’ accomplishments with their cultural strengths. I value the discussion about my clients’ reactions to termination. I am open to discussing the cultural meaning of case termination. I understand that my clients have an option on how to express feelings toward case closure.

Fig. 6 “ASK” for cultural competency

staying informed with social work research is critical as well. While social workers may not have access to peer-reviewed journal articles discussing newly designed interventions, attending relevant conferences can improve social worker’s competence. In this area of practice, the social, cultural, and environmental theories must be integrated into a thorough understanding of interpersonal relationships, with which a multidimensional exchange process can be carried out to highlight the importance of the environmental impact on individual functioning. I: Internationally Informed: Staying updated about international affairs can promote a deeper connection between you and the client. While most clinicians are treating specific subgroups, knowing a broad range of ideology, current events, and perspective can enlighten the client. Using global information to understand the diversity of our clients who may come from different geographical regions or countries can be used as a practice tool. A client’s psychological, social, racial, economic, political, immigration, and physical forces can be further analyzed for the client to understand the impact of social and cultural influences.

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Use the following scale between 1 and 5 to assess your readiness in terms of Attitude, Knowledge and Skill when working with a specific family or client: 1=Totally Unprepared 2=Somewhat Unprepared 3=Prepared but Need Practice 4=Ready to Practice 5=Competent Attitude Assessment 1. I continue learning about my clients’ culture. 2. I am open to hearing about my clients’ self-evaluation. 3. I am open to hearing about other people’s ideas. 4. I value input from clients to clarify their perceptions of the problem. 5. I maintain a positive attitude toward my clients. 6. I am open to discussing the cultural meaning of case termination. 7. I listen. 8. I value my clients’ cultural expectations.

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5

Skill Assessment 9. I use culturally relevant methods to build client strengths. 10. I explore other possible meanings of clients’ behaviors. 11. I use culturally appropriate language. 12. I respect cultural rituals and beliefs that address termination. 13. I address inappropriate behaviors without judging. 14. I ask questions and share information about cultural differences. 15. I acknowledge the importance of culturally specific practices. 16. I use appropriate cultural resources. 17. I greet clients with respect.

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2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5

Knowledge Assessment 18. I understand how to include clients’ cultural characteristics in designing an effective intervention. 19. I communicate with clients about issues of termination. 20. I know how to conduct assessments with reference to clients’ culture. 21. I have knowledge about clients’ problem definitions. 22. I develop case planning relevant to clients’ culture. 23. I use culturally relevant information for outcome evaluation. 24. I have knowledge about my clients’ cultural expectations.

1 2 3 4 5 1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5

TOTAL SCORE: __________ AVERAGE SCORE = Total Score / 24 =

__________

Fig. 7 ASK instrument (version 2013) for use in cultural competency assessment working with people of diverse cultures: attitude (A), skill (S), and knowledge (K)

A: Attitude Positivity: The adaptation of the SCE perspective through research, clinical practice, and societal changes must be noted. Beliefs and values may shift due to cultural shifts in seeing things from a positive angle. In this area of practice, social workers must stay informed about updated evidence-based clinical practice

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strategies, to be applied when there is a paradigm shift from problem-focused thinking to social cognitive “doing.” L: Leadership: The practice perspective of social workers involves taking on many responsibilities, including leadership roles. A leader will identify the needed changes, create the visions for the change, and guide others to create healthy changes. The executions of the change must be from the voices of the population being served or how policy affects the social environment. In this area of practice, an ideal candidate for leadership must embrace the values of the social work profession and join the social network to reinforce knowledge dissemination and skills refinement.

Conclusion: Functions of the SCE Perspective The SCE perspective provides a comprehensive theoretical base for social workers to apply relational skills during the delivery of effective prevention and intervention strategies, in the assessment of client-in-environment factors, and in the evaluation of an effective plan to improve mental health and social care services. The concepts in SCE are linked to the social systems theory for multidimensional treatment strategies. The main goal of SCE is to improve the social functioning of clients who are struggling with mental health issues. Thus, the main variables for future research from the SCE perspective include sustainability, dependability, equity development, and engagement of clients to change the maladaptive pattern of behaviors. The functions of SCE serve across practice arenas from micro to macro practices. There is an evaluation component in SCE that client-oriented measures must be used for validating client’s own definition of the problem and for recording client successes. Two clinical cases are included in this chapter for illustrating how to prevent hospitalization of clients due to individual mental health symptoms. From the SCE perspective, social workers act as an advocate for the clients who may be marginalized in getting adequate resources to support changes. In conclusion, SEC aims to promote social, ethnic, and economic justice. The ripple effect of prevention is expanded through the first few stages of social workers’ involvement: (1) contacting clients to engage them in assessing the environment factors of their problems, (2) assessing resources and constraints that may help clients make significant attitudinal changes toward the presenting problem, and (3) participating in the entire intervention process to plan, implement, and evaluate successes in resolving difficulties. The strengths of the SCE perspective include the use of nonjudgmental assessment with client engagement tools. Its challenges are related to the functioning of the individuals involved in the entire process, in that people with severe and persistent mental health illnesses may not be able to be engaged independently in the process. Nevertheless, this approach empowers families to be involved. A SCE question is: “Would your expectations toward treatment be identified in conjunction to their environment?” or “Who in this environment would continuously provide support, and how?” Clients’ idea to

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change would be supported and reinforced throughout the entire social work process. Our final words are first, individual satisfaction is a function of how well the individual connects to the strengths of the environment and how the person can untie negativity from the presenting problem; second, self-care helps integrate internal and external well-being of us all. Helping clients to care for self and others at every level of their engagement with their social and cultural environment is the best way for them to understand themselves, their needs, and their solutions. The roles of social workers are to encourage, empower, and enforce, so that clients can appreciate their effort, fulfill their expectations, and adapt to or change their environment.

Cross-References ▶ Community and Mental Health ▶ Developmental Approach to Mental Health ▶ Medical Perspective on Mental Health ▶ Natural Disaster ▶ Suicide Prevention

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Kaskie BP, Leung C, Kaplan MS (2016) Deploying an ecological model t stem the rising tide of firearm suicide in older age. J Aging Soc Policy 28:233–245. https://doi.org/10.1080/ 08959420.2016.1167512 Leung P, Cheung M (2013) Factor analyzing the “ASK” cultural competency self-assessment scale for child protective services. Child Youth Serv Rev 35:1993–2002. https://doi.org/10.1016/j. childyouth.2013.09.014 Lyons KH, Manion K, Carlsen M (2006) International perspectives on social work: global conditions and local practice. Palgrave Macmillan, New York Mandarino K (2014) Transitional-age youths: barriers to accessing adult mental health services and the changing definition of adolescence. J Hum Behav Soc Environ 24:462–474. https://doi.org/ 10.1080/10911359.2013.835760 Manitiu DN, Pedrini G (2016) Urban smartness and sustainability in Europe. An ex ante assessment of environmental, social and cultural domains. Eur Plan Stud 24:1766–1787. https://doi.org/ 10.1080/09654313.2016.1193127 McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15:351–377 Noble C (2016) Green social work – the next frontier for action. Soc Altern 35:14–19 Osmo R (2001) A conceptual tool: making social workers’ assumptions explicit. Soc Work Educ 20:209–217. https://doi.org/10.1080/02615470120044301 Ritchie MH (1994) Cultural and gender biases in definitions of mental and emotional health and illness. Couns Educ Superv 33:344–349

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Developmental Approach to Mental Health Antoinette Lombard and Nontembeko Bila

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health, Vulnerability, and Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health and Human Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developmental Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Human Rights-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . People Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Integrating Social and Economic Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Linking Micro and Macro Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Partnerships for Human Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The developmental approach to mental health aligns social workers’ commitment to the services they provide with the need to promote a fairer and more inclusive society. The 2030 Agenda for Sustainable Development’s vision is to leave no one behind – this is central to social work and lies at the core of mental health approaches. In the 2030 Agenda, mental health is associated with well-being, which is essential for human development. A developmental approach focuses on structural injustices that impede human progress and mental health. It is a holistic, human rights-based approach in which participation, social and economic development, micro and macro practice, and partnerships are equally important and are integrated to promote and protect mental health. The approach is in line with the new recovery-oriented human rights-based and strength-based approaches to A. Lombard (*) · N. Bila Department of Social Work and Criminology, University of Pretoria, Hatfield, South Africa e-mail: [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_3

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mental health which position mental illness and mental health along a continuum of health and where service users’ participation is central. In keeping with a mental health recovery approach, a developmental approach uses social investment strategies and interventions on a continuum of micro and macro practice levels where service users’ rights, their participation, and social and economic development and inclusion are inherent to the process and outcomes. The chapter concludes that the developmental approach to mental health offers social workers a platform to promote and protect mental health on an individual, household, community, policy, and research level. Furthermore, in partnership with stakeholders, including service users, this approach to mental health contributes to sustainable development and promotes justice for all. Keywords

Developmental approach · Mental health · Leaving no one behind · Recovery · Human rights · Partnerships · Sustainable development · 2030 Agenda for Sustainable Development

Introduction The Global Agenda for Social Work and Social Development’s (2012) commitment to contribute to a more just, inclusive, and peaceful society is aligned with the United Nations (UN) 2030 Agenda for Sustainable Development to transform the world to a more “just, equitable, tolerant, open and socially inclusive world in which the needs of the most vulnerable are met” (UN 2015, p. 4). The developmental approach, which underpins both these agendas, creates a platform for social work to promote and protect mental health within a sustainable development framework. The 2030 Agenda for Sustainable Development [hereafter 2030 Agenda] is a charter for the people and the planet in the twenty-first century. It recognizes that people are central in preserving the planet for current and future generations (UN 2015). The commitment of the 2030 Agenda to the notion that “[n]o one must be left behind” (UN 2015, p. 7) was strengthened by devoting the United Nations Development Programme (UNDP) 2016 Human Development Report to the theme of human development for everyone (UNDP 2016). Leaving no one behind is a universal aspiration that unites the globe in the commitment, in the words of Helen Clark, administrator of the UNDP, to the premise that “[h]uman development has to be sustained and sustainable and has to enrich every human life so that we have a world where all people can enjoy peace and prosperity” (UNDP 2016, p. iv). Leaving nobody behind is also central to social work and lies at the core of the call for mental health for all. In the 2030 Agenda, mental health is associated with well-being (UN 2015), as captured in its vision: “A world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” (UN 2015, p. 2). Mental health is thus an essential

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and inseparable component of health. This implies that mental illness is also a mental health issue (Prince et al. 2007) – suggesting that it is possible for a person to have a mental illness and to experience mental health at the same time (Caplan 2010). This assertion is embedded in the updated 2014 World Health Organization’s (WHO) definition of mental health, which indicates that mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” The definition reflects a shift in the dominant paradigm in the mental health field from the conventional social work approach in the late twentieth and twentyfirst century, which was an expert-clinical approach, to one of recovery, collaboration, and human rights, focusing on strengths rather than weaknesses (Caplan 2010) as the key principles underlying a developmental approach to social work and mental health. From a well-being perspective, mental health cannot be seen in isolation, separate from other spheres relevant for human development. This means that Goal 3 of the 2030 Agenda, namely, to “[e]nsure healthy lives and promote well-being for all at all ages,” is an integral part of all 17 sustainable development goals, as they “are integrated and indivisible and balance the three dimensions of sustainable development: the economic, social and environmental” (UN 2015, p. 2). This is an important premise in understanding a structural approach to mental health. Those who use mental health services often face stigmatization and exclusion. These challenges are exacerbated by structural injustices, including inequality, poverty, unemployment, and factors such as gender, race, ethnicity, sexuality, and disability (Fawcett 2012). Caplan (2010, p. 74) alludes to the disabling effects of mental illness and how they can affect individuals in a multitude of ways, “depending on the severity, duration, treatment, and the support structure” available to those individuals. Furthermore, Caplan (2010, p. 74) asserts that the disabling effects cannot be seen in isolation – various socioeconomic factors influence mental health, such as “unemployment, poverty, relationship issues, lack of housing, stigma and discrimination, and difficulty functioning in everyday life.” Caplan (2010, p. 74) points out that these are “just a few of the many common impairments that affect individuals and families.” Mental illness imposes a significant economic burden, not just on the individuals with a mental disorder but also on households, communities, employers, the healthcare system, and government budgets (Foresight 2008; McCrone et al. 2008). It perpetuates the cycle of poverty by interfering with individuals’ capacity to function in paid or non-income roles, leading to decreased social and economic productivity. This explains why people with mental health problems are often the poorest of the poor, because it may be impossible for them and/or their caregivers to work (Jenkins et al. 2011). The Human Development Report (UNDP 2016) states that whatever the reach of societal challenges may be, whether they are lingering (deprivations), deepening (inequalities), or emerging (violent extremism), most are mutually reinforcing and have an impact on people’s well-being in both the present and future generations. A developmental approach to mental health includes biopsychosocial approaches

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to mental health that explore social causative factors, which predominantly emphasize social determinants and a social framework in addressing them (Fawcett 2012). To ensure human development for everyone, it is not enough to identify the nature and the reasons for the deprivation of those left out (UNDP 2016). The Human Development Report (UNDP 2016) asserts that some aspects of the human development analytical framework and assessment perspectives must be shown upfront to address the issues that prevent universal human development. Such aspects include “human rights and human security, voice and autonomy, collective capabilities and the interdependence of choices [which] are key for the human development of those currently left out” (UNDP 2016, p. iii). Other factors, such as gender, must also be considered to “assess and ensure that human development benefits reach everyone” (UNDP 2016, p. iii). Human development is thus influenced by inequalities and structural injustices in society which should be addressed to ensure mental health and well-being for all. Fawcett (2012) suggests that in order to address inequalities, there needs to be a balanced focus on social, cultural, and economic conditions that support family and community life. A developmental approach to social work involves a holistic approach that integrates human, social, and economic development by taking the broader environmental context into consideration. Because it is embedded in a social justice- and human rights-based framework, a developmental approach to social work connects the micro/individual/personal level with the macro/political/ structural level (Patel 2015). In this context, a developmental approach is about sustainable development with a global and national developmental agenda. According to the UN, “[s]ustainable development recognizes that eradicating poverty in all its forms and dimensions, combating inequality within and among countries, preserving the planet, creating sustained, inclusive and sustainable economic growth and fostering social inclusion are linked to each other and are interdependent” (UN 2015, p. 5). In social work’s commitment to leave nobody behind, a developmental approach to mental health therefore has to promote human development within the framework of sustainable development. The chapter begins with a discussion of mental health in the context of vulnerability and protection. Next, mental health is discussed in relation to human development. A developmental approach to social work in promoting human development is then outlined in relation to its respective themes, namely, a human rights-based approach, people’s participation, the integration of social and economic development, the linking of micro and macro practice, and, finally, partnerships for development (Patel 2015). The conclusion summarizes the main points.

Mental Health, Vulnerability, and Protection The factors that contribute to mental health and well-being interact with one another. These factors are individual attributes and behaviors, social and economic circumstances, and environmental factors (WHO 2012). Individual attributes relate to a person’s natural and learned ability to deal with thoughts and feelings and

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to manage him/herself in daily life (emotional intelligence), as well as the capacity to deal with the social world by participating in social activities, taking responsibility for and respecting the views of others (social intelligence) (WHO 2012). Social and economic circumstances refer to the fact that an individual’s capacity to develop and flourish is deeply influenced by his/her immediate social surroundings – including his/her opportunities to engage positively with family members, friends, and colleagues and earn a living for himself/herself. Restricted or lost opportunities to gain education and income are especially pertinent socioeconomic factors (WHO 2012). Environmental factors refer to the wider sociocultural and geopolitical environment in which people live, which can also affect an individual’s household or community’s mental health status, including levels of access to basic commodities and services (water, essential health services, and the rule of law). They also include exposure to predominant cultural beliefs, attitudes, or practices, as well as social and economic policies formulated at a national level. Discrimination, social or gender inequalities, and conflict are examples of adverse structural determinants of mental well-being (WHO 2012). These factors can threaten or protect mental health – as Beckett (2006, cited in Fawcett 2012) argues, all people are vulnerable in some respects, and most people are potentially or actually vulnerable in relation to a very wide range of risks and various old and new forms of social exclusion. The WHO (2010) affirms that vulnerability can lead to poor mental health. If mental health is to be promoted for all from a developmental approach, the vulnerability of people with mental health problems cannot be omitted from the discussion. Mental health problems lead to reduced development and increased vulnerability, which are reflected in poverty, inequality, social and economic exclusion, stigma, violence and abuse, and restricted exercise of civil and political rights. In turn, this situation may worsen already poor mental health, as it leads to hopelessness, sadness, social withdrawal, and problems with sleeping, eating, and concentrating (Drew et al. 2011). Poor mental health can be both a cause and a consequence of the experience of social, civil, political, economic, and environmental inequalities (Friedli 2009). Mental health conditions are more common in areas of deprivation, and, in addition to poor physical health and adverse life events, poor mental health is consistently associated with unemployment, less education, and low income or a low material standard of living (Friedli 2009). An ongoing cycle can develop involving vulnerable groups, mental health conditions, and adverse development outcomes which perpetuate existing vulnerability. Cavill et al. (2017) caution that vulnerability itself is a risk factor for developing mental health problems and leads to stigma and marginalization, which further generates poor self-esteem, low self-confidence, reduced motivation, and less hope for the future. As the result of stigmatization and discrimination, the rights of people with mental health problems may be violated. Many are denied economic, social, and cultural rights with restrictions on their right to work and education, and they may be denied reproductive rights and rights to the highest attainable health (WHO 2013a). Despite their vulnerability, people with mental health problems – including schizophrenia, bipolar disorder, depression, alcohol and drug use disorders, child

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and adolescent mental health problems, and intellectual impairments – have been largely overlooked as a target of development work (WHO 2013a). This is despite the high prevalence of mental health conditions, their economic impact on families and communities, and the associated stigmatization, discrimination, and exclusion (Ngui et al. 2010). Mental illness frequently leads individuals and families into poverty (WHO 2011). In some instances, people with mental health problems are homeless or unjustly imprisoned, which worsens their vulnerability (WHO 2013a). A developmental approach to social work focuses on people who are vulnerable, not from a deficit point of view, but from a human rights- and strength-based perspective, to tackle inequalities and create opportunities for human development and growth. The developmental approach aligns the Agenda for Social Work and Social Development (2012) with the 2030 Agenda for Sustainable Development by committing social workers to leave nobody behind in the global action plan for the next 15 years (UN 2015). Jenkins et al. (2011) indicate the three main approaches that have been used to improve mental health in low- and middle-economy countries. The first is the public mental health approach, which focuses on a combination of prevention and treatment of severe mental illness (SMI) such as schizophrenia and bipolar mood, as well as the integration of mental healthcare into existing health services. The second is the human rights-based approach, which emphasizes the deinstitutionalization of people with a chronic mental disorder/illness. The third is a developmental approach, which targets poverty reduction to expand access to health, and assumes that mental health will improve with increased national wealth. These three approaches, prevention and treatment, human rights, and poverty reduction, are combined in a developmental approach to social work and mental health within a sustainable developmental framework. In the context of this chapter, the call to leave nobody behind is about protecting and promoting mental health in relation to human development, which is discussed next.

Mental Health and Human Development Human development is about people and human freedom: the freedom to realize the full potential of every human life – now and in the future (UNDP 2016). The two fundamental types of freedom for human development are freedom of well-being, represented by functionings and capabilities, and freedom of agency, represented by voice and autonomy (UNDP 2016). Functionings include the different things a person may “value being and doing – such as being happy, adequately nourished and in good health, as well as having self-respect and taking part in the life of the community.” Capabilities are the various sets of combination of functionings (beings and doings) that a person can achieve (UNDP 2016, p. 1). Agency is about having a voice and autonomy and to do or achieve what is valued (UNDP 2016). Mental health is embedded in a set of functionings such as opportunities to learn and be educated in order to enhance capabilities, for example, to work and experience freedom from discrimination, being homeless, poverty, unemployment, and

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exclusion. Being treated with dignity is fundamental to developing agency. It is important for a person’s mental health to have a sense of self-worth and selfawareness, self-confidence, and self-esteem, have maturity to judge and make decisions, be able to form affectionate relationships, generate and sustain supportive networks, be able to tackle life’s tasks and deal with complex demands, and, “most important of all, hav[e] the capacity to grow as a person” (Fawcett 2012, p. 516). Freedom, justice, and peace in the world are embedded in recognition of the inherent dignity and the equality and rights of people (UN 1948). Sen (1999) argues that there is a link between different types of freedom and distinct types of rights and opportunities. Mental health is a freedom and a human right which is embedded in social justice, which is a core value of social work. Isbister (2001) affirms that freedom can only reach its fullest potential in the presence of equality. Therefore, making development matter for all people in the world, now and in the future, is a universal approach which lies at the core of the human development paradigm, acknowledging the life claims of everyone (UNDP 2015). From a structural point of view, the developmental approach is, first and foremost, about human development. In order to leave no one behind in its aspiration to promote mental health and well-being, the developmental approach is embedded in human rights and the call to achieve social justice within a sustainable development framework.

Developmental Social Work A developmental approach to social work embraces a human rights-based approach, people’s participation, the integration of economic and social development, bridging micro and macro practice, and partnerships (Patel 2015). These elements, which are discussed below, are intertwined in promoting human development. They are underpinned by the five Ps of the 2030 Agenda, namely, people, the planet, prosperity, partnerships, and peace (UN 2015), all of which anchor the development approach in a sustainable development framework.

Human Rights-Based Approach The human rights-based approach to development recognizes protection and promotion of human rights as an explicit development objective and encourages participation, long-term planning, and a multidimensional understanding of poverty (Drew et al. 2010). Drew et al. (2011) point out that people with mental health problems are often denied civil and political rights, such as the right to marry and find a family, personal liberty, and the right to vote and to participate effectively. The WHO (2013a) states that people with mental health problems are often denied the right to exercise their legal capacity on issues affecting them, including treatment and care. Furthermore, people with mental health problems often live in vulnerable situations and may be excluded from society, which constitutes a significant

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impediment to the achievement of national and international developmental goals (WHO 2013a). Human rights are indivisible and interconnected (Ife 2012). Hence, civil and political rights; social, economic, and cultural rights; and environmental rights are all equally important to promote mental health. From a structural and social justice perspective, the lives of people with mental disorders can be improved through policies, plans, and programs that lead to better services in general and for this vulnerable group in particular (WHO 2005). Declarations and treaties play an important role in progressive mental health policies that seek to increase opportunities for people with mental disorders to live fulfilling lives in the community. International human rights documents broadly fall into two categories: ones that legally bind states that have ratified such conventions and ones that are referred to as international human rights standards, which are considered guidelines enshrined in international declarations, resolutions, or recommendations, issued mainly by international bodies (Freeman and Pathare 2005). Examples of the first kind of document are international human rights conventions, such as the International Covenant on Civil and Political Rights (ICCPR) (UN 1966a) and the International Covenant on Economic, Social and Cultural Rights (ICESR 1966b). The second category includes UN General Assembly Resolutions such as the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (UN MI Principles 1991). The second category of documents are not legally binding, but they can and should influence legislation in countries, since they represent international consensus (WHO 2010). The WHO (2008) indicates that the adoption of the UN Convention on the Rights of Persons with Disabilities (CRPD) in 2006 was a major step forward in improving the lives of people with mental health problems. Moreover, the WHO (2013a) asserts that this marks a paradigm shift away from viewing people with disabilities as objects of charity toward viewing them as bearers of human rights with the capacity for self-determination. Notably, the CRPD provides a comprehensive legal framework for ending the discrimination experienced on a daily basis by many people with mental health conditions. It protects and promotes their rights and promotes their inclusion in international cooperation, including international development programs (WHO 2013a). The African (Banjul) Charter on Human and Peoples’ Rights (1981) is a legally binding document supervised by the African Commission on Human and Peoples’ Rights. The instrument contains a range of important articles on civil, political, economic, social, and cultural rights. Clauses pertinent to people with mental disorders include Articles 4, 5, and 16, which cover the right to life and the integrity of the person, the right to respect of dignity inherent in a human being, and the prohibition of all forms of exploitation and degradation (WHO 2010). The European Convention for the Protection of Human Rights and Fundamental Freedoms (1950), backed by the European Court of Human Rights, provides binding protection for the human rights of people with mental disorders residing in all the states that have ratified the Convention (Drew et al. 2011).

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There are several human rights standards applicable to mental health. Firstly, the UN principles for the protection of persons with mental illness and improvement of mental healthcare (UN MI principles 1991) serve as a framework for the development of mental health legislation in many countries. Secondly, the Standard Rules on the equalization of opportunities for people with disabilities reiterate the goals of equalizing opportunities established by the World Programme of Action (WHO 2005). The Declaration of Caracas (1990), adopted as a resolution by legislators, mental health professionals, human rights leaders, and disability activists convened by the Pan American Health Organization (PAHO/WHO), has major implications for the structure of mental health services. It states that exclusive reliance on inpatient treatment in a psychiatric hospital isolates patients from their natural environment, thereby generating greater disability. The Declaration establishes a critical link between mental health services and human rights because it concludes that outmoded mental health services put patients’ human rights at risk. It aims to promote community-based and integrated mental health services by suggesting that existing psychiatric care should be restructured (Drew et al. 2011). The Madrid Declaration on Ethical Standards for Psychiatric Practice adopted by the General Assembly of the World Psychiatric Association (WPA) in 1996 is an example of an international association of mental health professionals’ attempt to protect the human rights of persons with mental disorders by issuing its own sets of guidelines for standards of professional behavior and practice (WHO 2010). Among other standards, the Madrid Declaration insists that treatment should be provided in partnership with persons with mental disorders and that involuntary treatment can only be enforced in exceptional circumstances (WHO 2010). Based on various declarations and treaties, many progressive mental health policies have sought to increase opportunities for people with mental disorders to live fulfilling lives in the community. Freeman and Pathare (2005, p. 4) indicate that legislation can foster such opportunities if it prevents inappropriate institutionalization and provides for appropriate facilities, services, programs, personnel, protections, and opportunities to allow people with mental disorders to thrive in the community. This suggests that legislation plays a role in ensuring that a person suffering from a mental disorder can participate in the community. The prerequisites for such participation include access to treatment and care, a supportive environment, housing, rehabilitative services (e.g., occupational and life skills training), employment, nondiscrimination and equality, and civil and political rights (such as the right to vote, drive, and access courts) (Freeman and Pathare 2005). Legislation can be a means to secure more resources for mental health and improve rights and mental health standards and conditions in a country (Funk et al. 2005). However, in order for a law to make a positive difference to the lives of people with mental disorders, it must have realistic and attainable goals (Funk et al. 2005). The WHO (2013b, p. 30) presents an overview of the opportunities that legislation can facilitate for mental health outcomes:

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Mental health legislation, or mental health provisions integrated into other laws for example, anti-discrimination, general health, disability, employment, social welfare, education, housing, and other areas may cover a broad array of issues including access to mental health care and other services, quality of mental health care, admission to mental health facilities, consent to treatment, freedom from cruel, inhumane and degrading treatment, freedom from discrimination, the enjoyment of a full range of civil, cultural, economic, political and social rights, and provisions for legal mechanisms to promote and protect human rights, for example, review bodies to oversee admission and treatment to mental health facilities, monitoring bodies to inspect human rights conditions in facilities and complaint mechanisms.

The human rights-based approach to development recognizes the protection and promotion of human rights as an explicit development objective and encourages participation, long-term planning, and a multidimensional understanding of poverty (Drew et al. 2010). This understanding is important in tackling the inequalities that contribute to mental illness and in advocacy for socioeconomic rights and the inclusion of people affected by mental illness. Green (2012) argues that people’s right to socioeconomic development is related to concepts of citizenship, participation, and power, which underscores the importance of the participation of service users in mental health planning and activities.

People Participation Developmental social work emphasizes the inclusion of people’s voices in their own development (Lombard 2014). A developmental approach thus recognizes that people with mental health problems are key actors in their own development, rather than merely passive recipients of commodities and services (WHO 2010). Caplan (2010) points out that the power of participation in the mental health field is now well established in the recovery vision for mental health, which is an initiative articulated by service users. Service users define recovery in terms of what is important to them (Fawcett 2012). In this context, Double (2002, quoted in Fawcett 2012, p. 525) avers that recovery “is not about becoming symptom free, but about reclaiming an individually determined and socially valued lifestyle, retaining control over decision-making processes, and utilising advance directives if necessary.” A recovery-oriented approach assumes that individuals have the capacity to take responsibility for their lives (Bila 2017). Empowerment is therefore central in recovery-oriented mental healthcare. Slade (2009) explains that empowerment emerges from agency beliefs and involves behavior that has a positive impact on people’s lives. Contrary to older approaches that regard the person as the problem, there has been a fundamental shift in the recovery perspective to mental health toward seeing the person as part of the solution. Having agency and a voice is about enlarging people’s freedoms so that they can pursue the choices that they value in building their capabilities (UNDP 2016). Human development therefore implies that people must influence the processes

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that shape their lives, including mental health recovery through active participation (UNDP 2016). It is not only important that people with a mental illness have choices in their treatment but also that they have a choice about participating in society. Therefore, people with mental health problems should be supported to participate in development opportunities in their communities (Janardhana and Naidu 2012). Self-determination can be achieved on both individual and collective levels. Hence, service users, as a distinct group, should be included as equals in policy and service decisions (Caplan 2010). From a developmental approach perspective, service users are key partners in their recovery. Their inclusion also applies to decisions on development and poverty reduction activities such as education, employment and livelihood programs, and the human rights agenda (WHO 2013b), all of which are essential components for social and economic inclusion.

Integrating Social and Economic Development Given the strong role of social determinants in mental health, rehabilitative interventions must also address poverty reduction (Jenkins et al. 2011). Mental health conditions are associated with high rates of unemployment (WHO 2010), and therefore livelihood interventions are increasingly linked to mental health interventions (Baingana 2011). Chisholm (2013) indicates that grants and support for small business operations have demonstrated benefits, not only for people with mental health conditions but also for their families and communities, which can strengthen their capacity and enable them to participate fully in public affairs. The recovery vision that emphasizes that each individual has unique talents to have a meaningful and productive role in society, either as an individual or as a collective, harmonizes with a social investment approach to mental health (Caplan 2010). The social investment approach is a strategy toward prosperity and sustainable livelihoods. The premise of a social investment approach is “that economic development must promote social welfare and that social welfare interventions, in turn, must promote economic development, that interventions are not consumptionbased but are productive and driven by consumers [service users], and that human rights are at the forefront of all efforts” (Caplan 2010, p. 78). Consumers refer to people with mental illness who are service users of mental health services. Social investment strategies build on people’s capabilities to be productive citizens and lead normal and fulfilling lives (Midgley and Conley 2010). Social enterprise is an innovative social investment strategy in mental healthcare and other disabilities to foster social and economic development and inclusion (Caplan 2010). Social investment, as in the case of recovery, nurtures the skills and knowledge of people and encourages participation in education, community involvement, and employment to develop and use these talents (Caplan 2010). Integration of social and economic development strategies is important for human development and in particular for service users who have a say in their recovery. Social investment strategies contribute to building social capital, which is important for service users to develop cohesive relationships through mental health peer support groups (Caplan

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2010). Furthermore, social investment strategies strengthen mental health service users’ right to socioeconomic development and the development of their capabilities to live independent lives. It provides “opportunities for the social inclusion for some of the most marginalised people in society, working with them to overcome the experiences of isolation and stigma that are often the most debilitating effects of mental illness” (Caplan 2010, p. 71). Both micro and macro interventions are required to create opportunities for social and economic inclusion.

Linking Micro and Macro Practice As indicated above, mental health, like other aspects of health, can be affected by a range of socioeconomic factors that must be addressed through a comprehensive strategy of promotion, prevention, treatment, and recovery (WHO 2013b). The developmental approach’s focus on both micro and macro interventions is aligned with the recovery focus in mental health, which Caplan (2010, p. 71) refers to as “a new paradigm in the conceptualization, discourse, and treatment of mental health.” This shift was sparked by the “advocacy of mental health consumers and [is] grounded in the concepts of hope, relationship, meaningful activity, empowerment, self-determination, and education” (Caplan 2010, p. 71). In this framework, recovery does not necessarily mean the absence of illness; rather, it describes the ability to cope with the symptoms of a mental illness and have quality of life in whatever way is significant for the individual (Caplan 2010). Recovery can also be viewed as learning how to cope effectively, not only by addressing the symptoms of mental illness but also by overcoming its negative consequences (to which social stigma contributes considerably), such as homelessness, unemployment, or problems with relationships (Caplan 2010). Similar to the argument that people can and do recover from mental illness to lead fulfilling and meaningful lives (Caplan 2010), a developmental approach does not discard the remedial or treatment approach but accommodates its implementation through human rights- and strength-based approaches. In promoting mental health, the emphasis should therefore be on services, policies, legislation, plans, strategies, and programs that protect, promote, and respect the rights of people with mental health problems (WHO 2013b). Through a micro-macro practice lens, recovery is seen as lying on a continuum, ranging from the individual/personal intervention level, including treatment and development of agency, to the macro/political level where advocacy practice is important in challenging and breaking down inequalities that impede socioeconomic development and inclusion. Linking micro and macro practice interventions is therefore an important feature of developmental social work in shifting from a remedial or clinical perspective to a structural perspective that exposes injustices and abuses of human rights and, most importantly, addresses the socioeconomic factors that impede mental health and human development. On a macro level, it requires engagement on a political level to influence policy through advocacy practice. Funk (2010) indicates that targeted policies, strategies, and interventions for reaching people with mental health conditions should be developed and mental

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health interventions should be mainstreamed into broader poverty reduction programs. Mainstreaming involves the elements of participation, accountability, nondiscrimination, empowerment, and an explicit linkage to human rights standards (Department of Social Development 2013; Baingana 2011). To make implementation a reality, adequate funds must be dedicated to mental health interventions and mainstreaming efforts. Furthermore, service providers should be encouraged to address the needs of people with mental health problems as part of their development work (Drew et al. 2011). In this regard, Fawcett (2012, p. 515) refers to the challenge to make what she calls “underfunded systems” actually work, which is an important issue for social work advocacy on a macro level. Linking micro and macro practice interventions emphasizes the holistic nature of a developmental approach. The approach sees recovery as lying on a continuum where human rights, participation, and social and economic development play an inherent role in influencing the “core concepts of recovery.” These concepts are self-direction, hope, empowerment, the involvement of supportive personal relationships, having a meaningful role in society, and a process of nonlinearity – meaning to be flexible in achieving recovery (Caplan 2010, p. 79). Shifting the continuum of recovery to a full circle requires active partnerships among various stakeholders.

Partnerships for Human Development The premise of recovery-oriented mental health approaches is that everyone should be involved in mental health services and that everyone should be given opportunities to work together and integrate various skills and experiences to promote and protect mental health (Bila 2017). Therefore, mental health partnerships cut across all sectors on global and national levels, including governments, nongovernmental organizations (NGOs), community-based organizations (CBOs), the private sector, ordinary citizens, and service users. The importance of partnerships is reiterated on a global level in the 2030 Agenda for Sustainable Development, where one sustainable development goal (SDG) has been dedicated to this end. SDG 17 reads: “Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development” (UN 2015, p. 26). The partnership goal applies to the remaining 16 SDGs. This includes SDG 3, which relates to health and mental health and well-being. Fawcett (2012, p. 526) explains the global link of mental health, commenting: “Across the globe, improving mental well-being, preventing mental ill-health, and responding to mental distress in all its manifestations are key concerns.” WHO (2010) emphasizes that support for opportunities for exchange between countries on effective policy and legislative intervention strategies to promote mental health, prevent mental illness, and promote recovery from illness based on the international and regional human rights framework is vital. Partnerships thus play an essential role in sustainable human development and hence in mental health and well-being. States that are signatories of the 2030 Agenda declaration have committed themselves to a collaborative partnership that will forge transformation of the

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world through achieving the sustainable development goals. In the commitment to leave no one behind, they promised the following: “As we embark on this great collective journey, we pledge that no one will be left behind” (UN 2015, p. 3). From a global perspective, all governments should work along with the WHO, which is responsible for “promoting measures which focus on mental health promotion and mental ill-health prevention on reducing inequalities within and between nations” (Fawcett 2012, p. 526). However, the WHO (2013b) asserts that of all development stakeholders, governments play the most important role in creating enabling environments, reducing stigma and discrimination, promoting human rights, and improving the quality and quantity of services (education, health, social services, and poverty alleviation). From a human rights-based perspective, governments have a duty to promote and protect mental health and well-being for all and should be held accountable by civil society in the fulfillment of this duty. Commitment to the 5-year action plan to achieve the 17 SDGs and its 167 targets includes the government’s duty to implement commitments such as the Accra Agenda for Action, the CRPD, and other human rights conventions (McInerneyLankford and Hans-Otto 2010). The new focus on recovery, which has progressed from the lived experiences of people who use such services (Care Services Improvement Partnership [CSIP] 2007), emphasizes the key role that they have to play in mental health partnerships. In this regard, Fawcett (2012) points out that service users’ perspectives are gaining ground and that many public services in countries such as Australia and especially the UK now employ service user advocates. However, this has not escaped implementation challenges. Hence, Fawcett (2012) emphasizes the importance of staff training, good use of resources, and effective communication and support systems to enable agencies and organizations to foster links with service user movements. Partnerships should also be developed with the broader community from which service users come. Bracken and Thomas (2004, p. 13) argue that problems such as poverty and unemployment are social and not individual problems. Because they are “at the heart of mental health crises,” they also require social responses (Bracken and Thomas 2004, p. 13). Services provided by civil society can include healthcare, social services, education programs, and livelihood projects (Fawcett 2012, p. 515). In addition, the WHO (2010) states that civil society can play an important role in supporting people with mental health conditions to access the resources they need and to integrate fully into the community through direct service provision and advocacy. Partnerships in the community should support the creation and promotion of associations and organizations for people with mental health problems, as well as for their caregivers (WHO 2013b). Dialogue between health workers; government authorities in the areas of health, human rights, disability, education, and employment; and the judiciary is important in supporting and strengthening service users, caregivers, and associations and organizations who work with people with mental health problems to integrate recovery services (WHO 2013b). In addition, the WHO (2010) states that strong links should be developed between mental health services, housing, and other social services, because mental health conditions often coexist

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with a number of other problems, such as homelessness. Furthermore, the WHO (2013b) indicates that civil society can advocate and lobby the government and funders to recognize and support people with mental health conditions. In order to improve development outcomes, government can provide support to build and strengthen mental healthcare users’ groups and offer opportunities for these groups to express their views and participate in decision-making processes (WHO 2013b). Medical-legal Partnerships (MLPs) have recently emerged in the global mental health environment as a new private initiative to enhance mental health service users’ rights to recovery. An established network of MLPs operates in various contexts in the USA, including general practice medicine and specialized services, such as psychiatry and social work (Cohen et al. 2010). MLPs are joint ventures between lawyers and medical professionals that integrate legal assistance with a medical setting. The purpose is for partners to seek to identify and resolve legal issues that have an impact on patients’ health and well-being (Cohen et al. 2010). MLPs provide legal assistance in areas such as income support, rights to divorce, education, guardianship and power of attorney, and issues pertaining to tenancy (Zuckerman et al. 2008). Ryan et al. (2012) highlight three key activities in which MLPs engage: providing legal help in a healthcare location, transforming the practices of legal and health institutions, and influencing policy change. Cohen et al. (2010) assert that evidence shows that the availability of legal support and services to those who are disadvantaged significantly influences their health. Through an MLP, legal practitioners can support the reduction of psychological stress of a person with mental health concerns by being present and available to resolve issues such as tenancy, fines, and custodial orders, which are issues that can exacerbate the deterioration of the person’s mental health (Ryan et al. 2012). MLPs strengthen the human rights-based basis of the developmental approach to mental health. This facilitates the engagement of partnerships on a legal basis. It creates space for partnerships between professionals such as lawyers, medical professionals, psychologists, and social workers (Colvin et al. 2011). Furthermore, collaborations between physicians, nurses, social workers, and attorneys enhance service delivery, helping it to meet the needs of families who require a one-stop service. Colvin et al. (2011) have highlighted the integral role that social workers play in an MLP and argue that MLP team members recognize the need for teaching and adopting social work’s empowering approach, which is important in achieving social justice for all. Rand (2006) affirms that the empowerment approach can enhance social justice and systemic changes adopted by lawyers and other MLP team members. MLP strategies are developmental, but their impact in a broader sustainable development context in fostering social and economic inclusion of mental health service users is determined by their availability and accessibility to all mental health service users but in particular by those that are mostly affected by structural injustices. The emphasis on structural injustices shows that research can and should play an important role in a developmental approach. This implies that research institutions are important partners in mental health recovery. Drew et al. (2010) call on academic and research institutions to improve development outcomes by generating and

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synthesizing policy-relevant research findings, as well as building capacity to conduct and interpret research at local levels. These authors argue that research which is properly formulated and conducted can inform the planning and implementation of development programs and the allocation of scarce human and financial resources. Academic and research institutions should play a key role both in building and managing knowledge and in building the capacity of policymakers, planners, and service providers from different sectors (Drew et al. 2010). The importance of partnerships in relation to the other themes of a developmental approach, as well as the overall responsibility of governments to promote citizens’ mental health and well-being on all levels, can be demonstrated as the key direction for public mental health promotion and protection for individuals, households, communities, and vulnerable groups, who are all important stakeholders in recovery partnerships. The WHO (2012) advocates for public mental health responses across these levels by means of a number of key strategies and interventions which provide a platform for developing strong partnerships among all stakeholders involved in mental health promotion, protection, and recovery. These strategies and interventions are summarized below in three broad categories.

Developing and Protecting Individual Attributes • Mothers and infants: Enabling early attachment, providing appropriate parenting training and natal care (including postdepression care, developing safe, stable, and nurturing relationships between children and their parents and caregivers) • Children and adolescents: Ensuring sufficient nutrition and stimulation • Older adults: Implementing healthy aging policies and community activities • All age groups: Encouraging regular physical activity and a healthy diet; discouraging or restricting the use of tobacco, alcohol, and other psychoactive substances Supporting Households and Communities • Families: Ensuring secure living conditions for children and adolescents, targeting prevention at those with behavioral disorders and those with a parent with mental illness, and preventing intimate partner violence • Workers/employees: Supporting increased employment opportunities and promoting safe and supportive working conditions (including stress management) • Low-income households: Ensuring basic living conditions (shelter, water, and sanitation) and providing social and financial protection • Communities: Making neighborhoods safe, enhancing civic assets/social networks, and restricting the availability of alcohol, drugs, and tobacco Supporting and Protecting Vulnerable Groups in Society • Developing and implementing social inclusion policies • Implementing anti-discrimination laws and policies • Making education available and accessible to all • Promoting women’s rights and freedoms and gender-equity policies • Providing early intervention to refugees after exposure to trauma (including those caught up in conflict)

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• Conducting awareness-raising campaigns • Fostering responsible reporting in the media The proposed strategies and interventions illustrate that mental health rests on individuals’ capacity to manage their thoughts, feelings, and behaviors, as well as their interactions with others (WHO 2005). It is essential that these core attributes of self-control, resilience, and confidence be allowed to develop and become ingrained in the formative stages of life, so that individuals are equipped to deal with the complex choices and potential adversity they may face as they grow older (WHO 2004). Promoting a healthy start in life is therefore vital (WHO 2004). On an individual level, mental health and well-being are strongly mediated by the immediate social context in which people live, work, and carry out their day-to-day activities (Tol et al. 2011). At a family and community level, the focus is therefore on fostering living and working conditions that enable psychosocial development and promote positive interactions within families and social groups (WHO 2010). The proposed strategies and interventions relate to the recovery continuum of micro and macro practice, which underpin the other themes of a developmental approach, namely, human rights, participation, the integration of social and economic development, and partnerships.

Conclusion Social workers who adopt a developmental approach to mental health commit to challenging and addressing structural injustices and inequalities to promote a more just and inclusive society for all. In social work’s commitment to leave nobody behind, a developmental approach creates a platform to promote and protect mental health within a sustainable development framework. Mental health and well-being are essential for human development. A developmental approach to mental health is in line with a recovery-oriented, human rights-based approach to mental health, presented on a continuum of micro and macro practice interventions that emphasize treatment, protection, prevention, and promotion. The underpinning themes of a developmental approach, namely, human rights, participation, the integration of social and economic development, the linking of micro and macro practice, and the development of partnerships, are interrelated. Hence, those who adopt such an approach embrace a holistic approach to mental health promotion, protection, and recovery. Within the framework of sustainable development, a developmental approach values people, the planet, prosperity, partnerships, and peace in its pursuit to leave no one behind (UN 2015) and achieve social justice for all. Partnerships are essential for human development and mental health and wellbeing. Improving development outcomes for vulnerable groups should be a priority for partners in mental health promotion and protection. Social investment strategies are important to address the structural determinants that contribute to and exacerbate mental distress and illness. Such strategies are essential to strengthen mental health service users’ agency, capabilities, and livelihoods, enabling them to live independently.

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All development stakeholders have a responsibility to ensure that the rights of people with mental health conditions (as a vulnerable group) are protected. This means making sure that they are provided with opportunities to improve their living conditions and lead fulfilling lives within their communities. Government in particular must play a key role in creating an enabling environment to promote and protect mental health, and government should be held accountable by all stakeholders to deliver on this duty. Finally, Fawcett (2012, p. 515) calls on social workers to pose critical questions and look creatively at options for what she calls a more “responsive mental health practice.” The developmental approach to mental health is such a response: it offers a platform for social workers to promote and protect mental health on an individual, household, community, policy, and research level and, in doing so, to contribute to sustainable development and promote justice for all.

Cross-References ▶ Community and Mental Health ▶ Community, Mental Health, and Social Work ▶ Legal Provisions, Advocacy, and Empowerment

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Qigong Practice Healing and Self-Management for Mental Health and Mental Illness Jessie S. M. Chan and Siu-man Ng

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Integration of Self-Management, Healing, CAM, and BMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-Management and Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Integration of CAM and Self-Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BMS and Innate Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Importance for Social Work to Integrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Concepts in TCM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BMS Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Mental health is a major public health concern. Nearly two-thirds of people with mental disorder never seek help from a health professional due to stigma. Furthermore, conventional therapies are not always effective. The use of complementary and alternative medicine (CAM) is common in persons with mental disorders. On the other hand, healthcare systems also face the challenges of a lack of capacity due to limited resources. Self-management using CAM will be a J. S. M. Chan (*) School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, People’s Republic of China Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, People’s Republic of China e-mail: [email protected] S.-m. Ng Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, People’s Republic of China e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_23

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crucial approach and instill individual responsibility and offer tools to patients and train them to utilize relevant skills, which may be one means of bridging the gap between patients’ needs and the capacity of health and social service. Social workers have an important role to play in health education and promotion of the self-management of mental health and mental disorders. Inspired by traditional Chinese medicine (TCM) and Eastern philosophies, an Eastern body-mind-spirit (BMS) model was developed to ignite innate healing power, which aims at fostering a harmonious dynamic equilibrium within clients and between clients and their social and natural environment. It is a multidimensional and holistic approach that can be used to guide social work intervention. Qigong, an ancient simplified BMS practice, can be adopted as a healthy lifestyle and behavior in the daily self-management of mental health and mental illness. In the future, there is also a need to train more health professionals to ensure the patients can truly master the self-management skills (e.g., BMS and Qigong practice), and new health behaviors are sustainable over time. Keywords

BMS · Qigong · TCM · Healing · Self-management · CAM · Mental health · Mental illness

Introduction Mental health is a major public health concern. World Health Organization (WHO) report showed that one in four people in the world will be affected by mental or neurological disorders at some point in their lives (WHO 2001). The high prevalence of mental disorders results in high, long-term personal, healthcare, and societal costs. Mental disorders are among the strongest contributors to the global burden of disease (de Jonge et al. 2017). Nearly two-thirds of people with a known mental disorder never seek help from a health professional due to stigma. Furthermore, conventional therapies are not always effective. Merely half of depressed individuals seek medical treatment, and just over 30% of them receive an efficacious treatment (Cuijpers et al. 2011; Gourgouvelis et al. 2018). The use of complementary and alternative medicine (CAM) is common in persons with severe mental disorders, particularly high in persons receiving conventional care (8.6–17.8%) and persons receiving specialist mental healthcare (14.0–22.5%) (de Jonge et al. 2017). A nationally representative survey in the USA found that complementary and alternative therapies are used more than conventional therapies by people with mental disorders such as self-defined anxiety attacks and severe depression (Kessler et al. 2001). Use of complementary and alternative medical therapies is more than twice as common among youth with mental health concerns as those without (Kemper et al. 2013). In addition to mental

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disorders, CAM also may be applied for promotion of mental health (Kemper and Shannon 2007). CAM refers to the practices and products that people use as adjuncts to or alternatives to Western medical approaches, including a variety of self-care interventions, such as taking natural products, doing meditation, mindfulness practice, Qigong, Tai Chi, or Yoga. Traditional Chinese medicine (TCM) is one of CAM, which is the most common adopted by the Chinese community and has become increasingly popular in other countries. Inspired by TCM and Eastern philosophies, Chan (2001) developed an Eastern body-mind-spirit (BMS) model, which aims at fostering a harmonious dynamic equilibrium within clients and between clients and their social and natural environment. This model has four basic assumptions. First, everything is connected: human existence is a manifestation of physical, psychological, and spiritual being. The different domains are interconnected and come together to form a whole. Human existence is also connected with the bigger world, in both the social and natural environments. Second, life is the eternal dance of Yin and Yang. Life is ever changing, and the interflow of energy maintains a harmonious dynamic equilibrium. The disruption of such harmony is the cause of life problems. Third, healing comes from within: therapy aims to ignite the client’s innate healing power that will bring them back to a state of balance. Intervention looks for strength rather than pathology. Fourth, restoring harmony not only cures illness and resolves problems; it also opens up opportunities for growth and transformation. The BMS model is composed of three themes: body (body scan, breathing and meditation, mindful body exercise, Qigong practice, massage, therapeutic touch), mind (emotional expression, social support, appreciation, self-affirmation, letting go), and spirit (meaning of life, harmony with nature, personal transcendence, forgiveness, compassion). Details of the BMS model will be described in the following section. This approach has been applied to various target groups such as cancer patients, infertile couples, divorced women, and adolescents. Systematic outcome studies were conducted for the approach, and evidence of its efficacy and its potential for generalization are growing (Chan et al. 2000, 2001a, 2017a; Ho and Chan 2002). Qigong practice, which is an integral part of the BMS model and also a simplified BMS practice, has also been independently adopted and proved to be effective for mental health in different chronic diseases (Chan et al. 2014, 2017b, c). This chapter will introduce an Eastern BMS approach inspired by ancient TCM and Eastern philosophy and propose a simplified BMS practice (Qigong) as a self-management skill in mental health and mental illness. Firstly, the concepts of CAM, BMS, selfmanagement, healing, and social work intervention will be introduced, and then the concepts of Yin-Yang and Five Elements in TCM will be elucidated. Secondly, BMS interventions with SMART principle, one-second technique, and Qigong will be described in detail. Thirdly, our empirical research and application on BMS and Qigong in Hong Kong will be shared. Lastly, future direction for social work practice/research in BMS will be stated in the conclusion.

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Integration of Self-Management, Healing, CAM, and BMS Self-Management and Healing Persons with mental disorders experience many physical and emotional consequences which worsen their quality of life and affect their ability to function in familial, social, and vocational realms, and they also experience discrimination in many aspects of their life (Herrman 2001). However, many people with mental illness, particularly anxiety and depression, are not early recognized and receive the appropriate treatments. Many people with potentially remediable disorders are not properly treated (Herrman 2001). On the other hand, healthcare systems also face the challenges of a lack of capacity due to limited resources. Available evidence supports the need for improved integration of mental health services in primary healthcare and strengthening of community services (Jacob and Coetzee 2018). Increased attention has been concentrated on approaches managing chronic symptoms to maintain patient independence and quality of life over longer periods of time (Grady and Gough 2014). Based on the concept that patients are active participants in their own treatment, self-management is defined as the day-to-day management of chronic conditions by individuals over the course of an illness. “Self-management refers to the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition. Efficacious selfmanagement encompasses ability to monitor one’s condition and to test the cognitive, behavioural and emotional responses necessary to maintain a satisfactory quality of life” (Barlow et al. 2002). Three sets of tasks associated with selfmanagement include medical management of the condition, behavioral management, and emotional management (Grady and Gough 2014). Self-management will be a crucial approach in managing these chronic conditions, preventing illness and promoting wellness (Grady and Gough 2014). Selfmanagement programs instill individual responsibility and offer tools to patients and train them to utilize relevant skills, which may be one means of bridging the gap between patients’ needs and the capacity of health and social service (Barlow et al. 2002; Grady and Gough 2014). Self-management interventions can positively affect both the outcomes and cost of chronic illness (Lorig and Holman 2003). A growing body of evidence has shown that self-management approaches can provide benefits to participants in terms of knowledge, performance of self-management behaviors, self-efficacy, and health status compared with standard care without intervention and appear to be as effective as other cognitive-behavioral interventions (Barlow et al. 2002). Given the time-consuming nature of many interventions and the involvement of the cost of health professionals’ time and delivering interventions, self-management approaches are relatively cost-effective. There is a need to tailor self-management approaches to different age groups in different cultural settings and even extend them to include carers and family members using the Internet (Barlow et al. 2002) to reduce the burden of healthcare services. Selfmanagement is a holistic and multicomponent approach including providing

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information, drug management, symptom management, dealing with psychosocial consequences, lifestyle (including diet and exercise), social support, communication, and other strategies (Barlow et al. 2002).

Integration of CAM and Self-Management The maintenance of health and the management of illness may be viewed as being the responsibility of the individual; thus the concept of self-management is integral to both the maintenance of wellness and the management of illness (Grady and Gough 2014). Responsibility for day-to-day disease management gradually shifts to the individuals from healthcare professionals (Barlow et al. 2002). Self-management education needs to become a central mission of health education and be integrated with all other services such as medical care and health promotion. The self-management may be regarded as the efforts to maintain wellness and control symptoms and illness progression for primary, secondary, and tertiary prevention (Grady and Gough 2014). Traditionally, self-management has been linked to secondary and tertiary prevention to strengthening the healthcare system by improving the quality of care and controlling cost (Grady and Gough 2014). The enhancement of self-efficacy was found to be associated with changes in health behavior and future health status (Lorig and Holman 2003). Furthermore, self-management may serve as a model for all levels of prevention and wellness to engaging people to actively stay healthy and avoid illness through making choices and changing their own health behavior (Grady and Gough 2014). In a review paper, among the 145 studies extracted, the majority of self-management focuses on asthma (n = 66), followed by diabetes (n = 18) and arthritis (n = 17). There were only five papers that implemented self-management in mental illness, which included depression (n = 1), psychiatric disorder (n = 1), and schizophrenia (n = 3) (Barlow et al. 2002). Collectively, self-management interventions aim to increase participants’ knowledge, self-efficacy, and use of self-management behaviors. These interventions have been shown to have a beneficial effect on the well-being of participants. The findings have shown an improvement in mood, particularly depression (Barlow et al. 2002). In conclusion, self-management in mental health and mental illness is beneficial. Mindfulness-based interventions as CAM merged as a self-management strategy. Daily mindful meditation practice has been shown to be safe, portable, and costeffective and can be recommended as an adjunct to standard care as self-management strategy for mental illness such as major depressive disorder and post-traumatic stress disorder (PTSD). After an 8-week course, participants are encouraged to adopt meditation practice as a lifestyle change and self-care strategy (Khusid and Vythilingam 2016). When patients are committed to adopting mindfulness meditation as a health behavior change, it can become a powerful self-care tool that encourages individuals to actively engage in enhancing their mental health (Khusid and Vythilingam 2016). Mindfulness-based cognitive therapy (MBCT) learned through the Internet or telephone and home mindfulness meditation practice also showed some

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Spirit

Body

Body scan, breathing and meditation, mindful body exercise, massage, therapeutic touch.

Meaning of life, harmony with nature, personal transcendence, forgiveness, compassion.

Mind Emotional expression, social support, appreciation, self-affirmation, letting go.

Fig. 1 Body-mind-spirit transformation

preliminary promising results in reducing depressive symptoms (Khusid and Vythilingam 2016). More information on mindfulness can be found in ▶ Chap. 15, “Application of Mindfulness-Based Approaches in the Context of Social Work.”

BMS and Innate Healing Different from most existing problem-based psychotherapy interventions, the BMS model incorporates a strength-focused and growth-oriented perspective, goes beyond coping and symptom reduction, and aims for transcendence to a higher level of connectedness within the self, with others, and with the universe. The essence of the body-mind-spirit model is graphically represented in Fig. 1.

Body Processes and Emotional Healing Body scan: the healing process can start with getting in touch with the body and connecting it with the emotions. Body scanning is a useful technique. In a relaxed and mindful state, clients are instructed to use mental imagery to scan through their whole body to check if any part is experiencing pain or discomfort. They are then encouraged to talk about the physical pain and discomfort and explore the relationship with their emotions. The process enhances the clients’ awareness of their physical discomfort and emotions and the connection between them. Unlike Western medicine, Chinese medicine does not classify emotions as good (e.g., happiness) or bad (e.g., sadness): it sees all emotions as natural and necessary.

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Adopting a systemic perspective, which is similar to the modern systems theory, Chinese medicine regards health as a state of harmonious dynamic equilibrium among the different emotions, maintained by the facilitative and repressive forces between the emotions. A fully healthy person should be able to experience their emotions fully, including those emotions such as sadness, anger, and fear, which may be labeled as negative emotions in some Western literature. Proper expression of emotions in a balanced way is very important for the health. Through the meridians, the emotions and different systems of the body are connected into an integrated whole, but both an excess and a lack of certain emotions will upset the balance and hence affect health. For example, excessive anger and fear damages the bodily functions and general health. Through the liver meridian, excessive anger brings about disturbances to various parts of the body, most notably the head and chest, resulting in headache, dizziness, elevated blood pressure, and feeling of congestion or pain in the chest area. Through the kidney meridian, excessive anger brings about genitourinary dysfunctions. This systemic perspective on emotions is a reflection of the deep influence of the Yin-Yang Theory and the Five Elements Theory on Chinese medicine.

The Power of the Mind and Spirit The corresponding Chinese word for mind is Xin, which literally means “the heart.” We believe that the power of the heart is more important and ultimately greater than the power of the brain. When the heart is dead, a person cannot be truly living. Effective intervention must include the rekindling of the heart as a goal. As such, the concept of mind (Xin) is a complex construct that encompasses will power, vision, hope, emotion, human sensitivity, passion, cognition, or the whole of humanity in one word. Techniques for mobilizing the power of the mind include mindfulness practices, meditation, letting go, forgiveness, compassion, and loving kindness. The process of transformation in our BMS model involves five “As” – three of them (acknowledge vulnerability, accept adversity and the unpredictability of life, and activate self-healing capacity) are related to the mind and two (affirmation and appreciation) are related to the spirit. The mind concerns adaptive coping strategies, whereas the spirit concerns wisdom in life. Acknowledge vulnerability: influenced by Buddhist and Christian teaching, we help clients normalize suffering as part of life. By acknowledging our own vulnerability, we can face pain and loss with tranquility. Trauma and loss can result in ultimate growth. Accept adversity and the unpredictability of life: acceptance is different from resignation. Resignation represents the assumption of the role of victim, but acceptance is the peaceful understanding of the reality of a situation. “Acceptance is not a passive surrendering, but rather an act of taking responsibility; it is not blaming oneself for having the disease, but working energetically to restore one’s system to balance” (Abramson 2003, p. 20). Acceptance means fully embracing whatever is in the present. The yin-yang metaphor inspires us to understand that gains and losses are embedded in each other. People who embrace loss are more ready to appreciate gain.

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Activate one’s self-healing capacity: by letting go of intense emotional attachment, we can free our energy for self-healing. Buddhism teaches people not to cling to things or persons. Frustrations can be caused by unmet expectations. Letting go and genuine forgiveness are the ultimate solutions to our emotional problems. In our experience of working with Chinese cancer patients, bereaved widows, and divorced women, we have found that clients’ self-healing power is largely ignited from their determination to let go of the victim role and to maximize their own healing capacity. We invite our clients to read aloud affirmation statements like “I am determined to let go of the past and to live a new, independent life”; and “I choose to love myself and be the master of my own life.” If an individual can move through and beyond illness patterns and discover the inner self, they can regain a state of well-being. Among persons suffering from depression, clinging is common and is often a core cause of the mental disorder. Clinging can be attached to internal or external objects and can be related to the past, present, or future. Examples are not able to let go of what has been lost and preoccupation with certain desires or hatreds. Transcending clinging is the critical step for activating one’s self-healing capacity and moving towards full recovery.

Affirming Spirituality and a New Appreciation of Life The remaining two As are affirmation and appreciation: affirming the meaning of life and a renewed appreciation of life through suffering help recreate the oncedisrupted harmony of body, mind, and spirit. Traumatic events may shatter a person’s world view and self-identity (Fife 1994; Janoff-Bulman and Berg 1998). The cognitive reappraisal of a traumatic event, the search for meaning, and the integration of the experience into one’s life helps people to adapt to the loss brought about by the event (Fife 1994; Janoff-Bulman and Berg 1998; Lazarus and Folkman 1984; Taylor 1983). The reconstruction of meaning after loss involves the process of “sensemaking,” “benefit finding,” and “identity reconstruction” (Davies et al. 1998; Neimeyer 2000, 2002). We engage clients in a process of re-storying their lives to develop a more coherent narrative of their life experiences. We help them to discover the positive in suffering. The BMS model uses the concepts of impermanence and the unpredictability of life from Buddhism and Daoism to help patients to reconstruct their experience of illness or loss and make sense of their misery. Our recent study of cancer survivors confirms our belief that life affirmation (e.g., “I can face life challenges with a peaceful mind”) and appreciation of life (e.g., “I enjoy life every day”) are two important factors constituting spirituality (Chan et al. 2004). While Western forms of therapy largely work to help patients better master, control, and overcome their problems, Buddhist teaching encourages the individual to detach and let go so that they can flow with the here-and-now and the “momentby-moment experience,” instead of being controlled by, or preoccupied with, desire. Paradoxically, one gains control by letting go of control. By practicing emotional detachment and letting go, people find it easier to forgive. Forgiveness is the ultimate solution to emotional disharmony.

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Importance for Social Work to Integrate Mainstream psychotherapy focuses on the psychosocial domain, emotions, behavior, cognition, and interpersonal relationships. As influenced by the evidence-based movement of conventional medicine, evidence-based practice is now a widely recognized goal in mainstream psychotherapy. However, many interventions are narrowly focused on a particular aspect of the client. Despite obtaining evidence of the efficacy of a measure in a controlled experimental situation, knowledge of its general application in a real clinical situation is often scant. A common fault in social work intervention is that of reductionism and a compartmentalized view of the total well-being of individuals and groups. Fragmentation of services tends to narrow the focus of the helping professionals within a certain mandated scope of interventions. Such an approach fails to address the multidimensional and interconnected nature of the problems or to bring about meaningful benefits to the clients’ lives. However, there is growing evidence that the body, mind, and spirit are interconnected. This evidence includes research findings in diverse areas such as biofeedback, psychoneuroimmunology (Ader et al. 1991), holistic body work such as Tai Chi (Cheng and Macfarlane 2001) and Yoga (Manocha et al. 2002; Panjwani et al. 2000), mindfulness training (Baer 2003; Kabat-Zinn 2003), and spirituality in clinical care (Culliford 2002). There is a strong indication that health professionals should incorporate bodily and spiritual dimensions in their interventions so that they may respond to their clients in an integrated way.

Social Work Intervention to Embrace Holistic Well-Being Inspired by the conceptual framework of these ancient theories, a social worker in the role of therapist may stimulate clients to explore their own body-emotion connections. The role of mental health social workers is to enhance the person’s social functioning, promote recovery and resilience, and aim to reduce stigma through therapeutic interventions and the mobilization of services and supports (Australia Association of Social Worker 2015). The scope of social work intervention is extremely wide, ranging from the remedial to the developmental, and even transcendental. We can conceptualize it as a four-level model as shown in Table 1. 1. Personal safety: in cases where personal safety is under imminent threat, the primary objective of intervention is to ensure safety. A social worker’s most prominent role is as an official agent who performs duties in line with their position and, if necessary, exercises the relevant statutory power. Common examples of such case scenarios are child abuse, domestic violence, dealing with people with mental disorders in an unstable mental condition, and negligence in caring for people with mental incapacitation. Crisis intervention skills are often necessary in these situations. 2. Basic needs and physical illnesses: when basic needs are unmet and physical illnesses untreated, the primary objective of intervention is to ensure that the necessary resources are mobilized to address those needs. These resources can include medical services, rehabilitation services, and other tangible support. A

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Table 1 Scope of social work intervention Scope of intervention 1. Personal safety

2. Basic needs and physical illnesses

3.Psychosocial distresses and pathology

4. Holistic wellbeing

Key intervention strategy Exercising positional duties and statutory power in relation to: Child abuse Domestic violence People with mental disorders in an unstable mental condition Negligence in caring for people with mental incapacitation Victims of crime/violence Crisis intervention Mobilization of resources Medical service Rehabilitation service Support for the underprivileged or disabled Problem-solving and a task-centered approach Psychosocial therapies Individual therapies Marital and family therapies Group therapies Responding to clients as an integrated whole Achieving body-mind-spirit harmony The SMART principle Strength focused Meaning reconstruction Affirmation of self Resilience training Transformation

Social workers’ primary roles Official agent in implementation of welfare legislation

Case and care manager

Counselor and therapist

Coach and counselor

social worker’s most prominent role in such cases is that of case and care manager. Competence in case management is required in such situations. 3. Psychosocial distresses and pathology: in cases where individuals or families are experiencing distress, the primary objective of intervention is one of problemsolving and, if appropriate, treatment of the underlying psychosocial pathology. A social worker’s most prominent role in such cases is that of counselor and therapist. Competence in problem-solving training, task-centered approaches, and various counseling and psychotherapy approaches is required. 4. Holistic well-being: many social workers may see this term as being non-specific. “Holistic” refers to the integration of the whole in terms of the physical (body), the cognitive and emotional (mind), and peace of mind and life meaning (spirit). “Well-being” refers to a positive state and growth, rather than pathological problems. The focus of intervention at this level is on strength rather than on problems and on the whole person rather than a narrow interpretation of cognition

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or behavior. The primary objective is to promote growth and transformation through achieving mind-body-spirit harmony. A social worker’s most prominent role here is as a coach and counselor. Most social work textbooks cover levels 1–3 very well, but few of them provide information about specific intervention at level 4. Traditionally social workers are shy of working in the bodily and spiritual domains. Similarly, enquiring into the spiritual domain does not require a social worker to have had intensive training in a monastery deep in the mountain for tens of years. As spirituality is a natural part of every person, reflection on and sharing of spiritual issues should not be too alien to social workers or their clients. Reflections on growth through pain and the search for a meaning of life are core spirituality interventions. In particular, we will introduce the body-mind-spirit approach in the social work intervention (Chan et al. 2001b). Many social workers work under immense pressure and spend most of their time struggling with the problems of their clients at levels 1 and 2. Some more fortunate individuals can also afford to play a role at level 3. Level 4 is often regarded as something too impractical, idealistic, and remote. Such a concept is incorrect. Strength- and transformation-oriented intervention can speed up the recovery process and shorten the entanglement in problem-focused interventions. As is shown in the following sections, it is not as difficult as it seems to be and can be incorporated into the intervention process early on. Intervention is about inducing change in the client. Change can involve the reduction or extinction of the negative or the increase or synthesis of the positive. Research and clinical experience suggest that the former is far more difficult to achieve than the latter. A good example is that many people found establishing a new good habit much easier than getting rid of an old bad habit. It is easy to understand. The negative factors, including emotional, behavioral, or cognitive reactions, have usually been in existence for years and have become a habit of the client and a part of their whole system. Taking away the negatives will trigger homeostatic forces to restore the old pattern. By contrast, inducing positives is often rewarding, selfreinforcing, and reinforced by the system. In return, in making positive changes, clients will gain more capacity to cope or live with the negatives. Therefore, adding level 4 intervention at an early stage can help to free social workers from the entanglement of intervention at levels 1–3. Through fostering growth and transformation, BMS intervention may achieve the social work ideal of “helping people to help themselves.”

Basic Concepts in TCM The Yin-Yang Theory and the Five Elements Theory were first described in the ancient book Yi Jing (also known as I Ching, The Book of Changes, written around 7 BC) and had great influence in the conceptualization of the original theories of Chinese medicine. Both theories propose a universal model to understand the pattern of change of all things in the world, from the microscopic to celestial phenomena.

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Firstly, they propose that all things in the world can be classified by broad categorical systems – the Yin-Yang System or the Five Elements System. Secondly, they propose that there is a universal pattern of interactions and changes among these broad categories. Thirdly, by applying the knowledge of the universal model, one can understand the pattern of interactions and changes between anything, for example, the relationships between the different bodily organs.

The Yin-Yang Theory Yin and yang are opposites and are a mutually facilitating but are also a mutually repressing pair. Yin signifies substance, stillness, storage, darkness, and softness. Yang signifies energy, movement, transporting, brightness, and hardness. Examples of such yin-yang pairs are earth and sky, night and day, moon and sun, winter and summer, and woman and man. The Yin-Yang Theory proposes a universal model depicting the pattern of interactions and changes within a yin-yang pair. Some core relationships are as follows. 1. Yin and yang are mutually facilitating as well as mutually repressing. These two opposite forces together maintain a dynamic equilibrium. 2. Yin and yang are mutually dependent. They cannot flourish on their own. 3. Yin and yang are relative but not absolute concepts. For example, among a group of yin subjects, there can be subjects that are relatively yang, as well as subjects that are extremely yin. 4. At either extreme of yin or yang, there can be sudden qualitative change, i.e., extreme yin changes to yang or extreme yang changes to yin. Yin and yang working in a harmonious dynamic equilibrium is considered to be fundamental to good health. This classic yin-yang logo (Fig. 2) shows the mutually embedded nature, dynamic interflow, and dual metamorphosis of yin and yang.

Fig. 2 Yi-Yang logo

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Fig. 3 An integrated whole – body-mind-spirit interconnectedness

Wood

Water

Fire

Metal Note:

Earth Facilitating force Repressing force

The Five Elements Theory The Five Elements Theory proposes the classification of everything into five broad categories: wood, fire, earth, metal, and water (Fig. 3). Each category is representative of a cluster of characteristics. For example, wood stands for growth, blossom, stretching, and decongestion. Two normal forces – the facilitating force and the repressing force – work on each other among the elements. Wood facilitates fire, fire facilitates earth, earth facilitates metal, metal facilitates water, and water facilitates wood. Meanwhile, wood represses earth, fire represses metal, earth represses water, metal represses wood, and water represses fire. Each pair of forces working together maintains the dynamic equilibrium among the five elements and prevents any element from becoming “hypo” or “hyper.” Such a state of equilibrium is considered to be essential for good health.

BMS Interventions The Smart Principle The mind-body-spirit model (Chan et al. 2001c) is a multidimensional and holistic approach that can be used to guide social work intervention. Its uniqueness can be summarized by the SMART principle. The SMART principle is consistent with the theoretical shift from psychosocial pathology to positive psychology and empowerment interventions. The five SMART components are as follows. Strength focused: intervention should focus on identifying, assuring, and enhancing the strength of the clients. By actively identifying strength, a social worker can truly respect the healing capacity of their clients. Meaning reconstruction: the therapist may help their clients to emerge from the victim role and to obtain meaning from and transcend the suffering. The ability to find meaning in suffering can be a motivating force for perseverance and the generation of healing strength. Affirmative and appreciative: the therapist helps the client to affirm and appreciate themselves as well as the external world of both their social and natural

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environments. The process of downward comparison by the clients can also help them to mobilize energy to help other people. Resilience: this is not only about coping ability but also about the ability to acknowledge vulnerability, accept adversity and unpredictability, recognize impermanence, and let go. Transformation: this is a state of body-mind-spirit harmony that enables a person to live fully and completely. With transformation, individuals can develop a personal capacity of self-sufficiency in life and are able to formulate selfless goals to help other people and to collectively benefit society.

One-Second Techniques The bodily processes that are highlighted in this model are not necessarily very complicated. Inspired by traditional Chinese holistic health practices, Chan (2001) developed one-second techniques that are simple to learn for counselors and easy to follow for clients. Dialogue Box 1 provides some examples of these interesting techniques. By working with the body, the client can develop a sense of control because they are doing something to help themselves physically and emotionally. The mood changes as the clients focus on the physical movements and massage. Tai Chi and Qigong practice can also be used as a psychological distraction for clients who are troubled by an obsessive indulgence in pain. Box 1 One-Second Techniques

Techniques of the Hands Health is in our hands. According to Chinese medicine, all the 12 meridians pass through the hands, feet, and ears. Massage of the hands, feet, and ears can activate our self-healing capacity. 1. Palm rubbing: with palms facing one another, fingers to fingers, palm to palm, rub the palms and fingers hard until they are warm. With palms slightly cupping and palms facing each other about 6–8 in apart, close your eyes and feel the tingling Qi (invisible energy that circulates around our body through the meridians) sensation between the palms. 2. Healing hands: rub the hand until they are warm and then place the hands over the body parts that feel pain or discomfort. Pass the heat and healing energies of the hands onto the part of the body that needs nurture and love. Our hands have healing abilities which we do not utilize effectively. Put the hands on the abdomen when going to bed, imagining calming and soothing energies going into the body and go to sleep with such comforting energies. 3. Clapping Qigong: for people who are prepared to work much harder on their hands, the clapping Qigong is the simple single technique that one can try. With fingers and palms facing each other, hold the fingers upward with palms in front of the chest like hands folded in prayer. Open the palms to shoulder width and make loud forceful claps. The hands should feel the (continued)

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Box 1 (continued)

pain and may look blue for the first 2 weeks of practice. Do this for 5 min, three times a day for effective results. For people with acute grief or extreme anger, do it for half an hour twice every day. 4. Open and close fingers: both hands on both sides of the body form a straight line with the shoulders. With some force, stretch all the fingers out and fold them back into a fist and then stretch out again. Imagine that there is dirt on the tips of your nails, and while stretching your fingers, try to discard the dirt. Do this 50 times twice a day. 5. Roll the wrists with hands like a lotus flower: there are acupuncture points along the wrist which can be calming and stabilize heartbeat. Roll the wrists in big circles so as to stimulate the acupuncture points. Do the rolling of the wrists 50 times twice a day. These are examples of one-second techniques taken from Chan (2001). An Eastern Body-Mind-Spirit Approach – A Training Manual with OneSecond Techniques. Hong Kong: Department of Social Work & Social Administration, The University of Hong Kong. There are techniques of the ears, eyes, mouth, and feet in Chan’s book.

Acupressure and light massage: acupuncture and tuina (therapeutic massage) were originally conceived based on the meridian theory of Chinese medicine. They aim to manipulate the flow of Qi in the meridian system so as to restore the state of healthy balance. There is evidence that acupuncture and tuina are effective for a number of conditions such as insomnia, depression, migraine, pains, and perimenstrual problems. For safety reasons, acupuncture and tuina need to be administered by qualified personnel. For social work intervention, acupressure and light massage are more appropriate alternatives. Chan (2001) simplified these practices into one-second techniques. Mastery of these techniques can help clients regain a sense of control over both the body and the mind. Prescribing acupressure and light massage to couples or families can help to enhance marital and family relationships, as massaging one another is a way of communicating and expressing concern and love. Sometimes it can work quicker and better than words.

A Simplified BMS Practice: Qigong Tai Chi, Qigong, and Yoga are good examples of this type of body-mind-spirit exercise. Through mindful movement and breathing, the clients get in touch with their true total being and develop an appreciation of themselves and their environment. Simplified Tai Chi, Qigong, and Yoga are practical options for use in counseling work. If these exercises are practiced in a group, they can provide additional benefits of social support. Breathing can be used as a powerful tool to bring stability to the body and mind. Mindful breathing helps us get in touch with our deep

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emotions, whether they are feelings of pain, fear, anger, joy, or contentment. In deep breathing meditation, one moves to a state of total concentration and consciousness. People in a state of supreme consciousness are able to connect with their internal self – body, mind, and spirit – and the outer world – the social and natural environment. During breathing meditation practice, a therapist may verbally guide clients to achieve harmony within themselves and with the external world. Values such as appreciation, self-affirmation, forgiveness, and compassion can be cultivated in clients during this practice. Breathing exercises do not necessarily have to be practiced while the body is still but can be practiced along with movement and mental imagery. As one of body-mind-spirit practices, Qigong is an ideal and efficient way of cultivating Qi to maintain and heal the body, mind, and spirit and achieve optimal health, well-being, and spiritual cultivation (Manek and Lin 2012). Qigong combines two parts: “Qi” is the fundamental “vital energy” or “dynamic force” in the entire universe and all living organism; and “Gong” means the skill of cultivating, regulating, and harnessing (strengthening and directing) “Qi’ (the vital energy) for general self-preservation and health, healing, longevity, and particularly spiritual development (Lee and Lei 1999; Manek and Lin 2012). Qigong can keep the equilibrium between yin and yang in the body and is helpful both physical and mental health. Qigong is very simple and easy to learn. Anyone can practice it anytime and anywhere. It does not require any facility and special location and only requires low demands either physically or cognitively. It is suitable for all ages including the elderly and people with chronic illness.

BMS and Qigong: Research and Application in Hong Kong Since 2009, in addition to BMS therapy, our team also has adopted Qigong as an alternative therapy and self-management skills in the persons with chronic illness such as chronic fatigue and sleep disturbances with anxiety and depressive symptoms. Our findings are very promising, which showed Qigong not only reduces physical and mental fatigue symptoms and alleviates anxiety and depressive symptoms but also improves quality of sleep, mental health-related quality of life, and even spirituality (Chan et al. 2011b, 2013a, 2014; Ho et al. 2012; Li et al. 2015; Ng et al. 2013). Qigong has been shown to shape body, mind, and spiritual health (Chan et al. 2013b). An effective practice regimen was identified as at least 3 times per week and at least 30 min per session (Chan et al. 2012b). Adopting relevant objective biomarkers, we further explored the underlying mechanism and demonstrated that Qigong may improve the telomerase activity (antiaging effects) (Ho et al. 2012) and reduce the adiponectin level in chronic fatigue person with depressive symptoms (antidepressive effects) (Chan et al. 2017c) and salivary cortisol level (Ho et al. 2013). Besides that, BMS therapy and Qigong were also found to reduce interleukin-1 beta and interleukin-6 (which are proinflammatory cytokines) among persons with mid and moderate depressive symptoms and sleep disturbances (Chan et al. 2017c, b). An increasing number of studies have demonstrated the effectiveness of Qigong exercise in mood regulation and improvement of psychological well-being (Yeung et

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al. 2018). The effect of Qigong has been found to be comparable with that of cognitive-behavioral therapy in significantly reducing depressive symptoms among outpatients with clinical depression (Chan et al. 2012a) and adults with depressive symptoms (Chan et al. 2011a). Given the dyadic associations between psychological distress and sleep disturbance among patients with cancer and their family caregiver, especially spouses (Chan et al. 2016), BMS and Qigong exercise as self-management approaches were adopted in psycho-oncological area and even extended to include the patient-caregiver dyads to manage their negative symptoms and improve their quality of life (Lau et al. 2018; Chan et al. 2013c). Based on the above evidence for Qigong exercise, Qigong practice as a healthy lifestyle was introduced to person with chronic fatigue in a nongovernmental organization (NGO) in Hong Kong. In this knowledge exchange activity in The University of Hong Kong, “train the trainer” course was conducted to train more Qigong trainers to lead daily Qigong practice in the workplace to promote holistic well-being. A web-based self-health management system (https://learning.hku.hk/ qigong/) was developed to help the participants and the public to do the selfassessment for self-monitoring purpose. In the future, Qigong will be offered to individuals with mental illness who are interested in self-management to decrease negative symptoms and improve mental health. Online health approaches in helping individuals to learn Qigong practice as self-management skills are needed. Social workers have an important role to play in health education and the promotion of the self-management of mental health and mental disorders. This can be achieved through advocacy, mass education, and community intervention. To adopt evidence-based practice and self-management skills using a holistic approach in social work intervention, social workers need to master practice research skills and continuously keep up to date with the latest developments in evidence-based interventions, regardless of whether they are originated from within social work or from other disciplines. As roles of the caring professions merge, social workers can maintain role differentiation by asserting basic social work values and principles. In a multidisciplinary team, social workers can be the champion for a holistic view in understanding a person and an empowerment approach in working with our service users.

Conclusions The chapter introduced the concept of holistic intervention and proposed an Eastern BMS approach in mental health and mental illness. The BMS approach facilitates growth and aims to foster a harmonious equilibrium within a client and between the client and his/her social and natural environment. This strengthoriented holistic approach can speed up recovery and help shorten the entanglement in problem-focused intervention. Based on our research evidence and empirical application, Qigong is a simple, efficient BMS practice, which can be adopted as a healthy lifestyle and behavior in the self-management of mental health and mental illness.

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In the future, in addition to physiological and psychosocial outcomes, longer-term follow-ups and the assessment of cost-effectiveness are needed in the evaluation of self-management interventions. Use of technologies, such as the web-based systems or apps on cell phone, should be incorporated into the self-management of mental health and chronic mental illness. There is also a need to train more health professionals to ensure that patients can truly master the self-management skills (e.g., BMS and Qigong practice), and that the new health behaviors are sustainable over time.

Cross-References ▶ Application of Mindfulness-Based Approaches in the Context of Social Work

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Chan JSM, Yuen LP, Chan HY, Ho RTH, Sham JST, Chan CLW (2012b) Effects of Qigong exercise and its dose-response relationship in reducing fatigue for patients with chronic fatigue syndrome: a randomized waitlist-controlled trial. Ann Behav Med 43(S1):s282. Oral presentation at the 23rd annual meeting & scientific sessions of society of behavioral medicine and was recognized as a meritorious student abstract, April 11–14, 2012, New Orleans Chan JSM, Ho RTH, Wang CW, Yuen LP, Sham JST, Chan CLW (2013a) Effects of qigong exercise on fatigue, anxiety, and depressive symptoms of patients with chronic fatigue syndrome-like illness: a randomized controlled trial. Evid Based Complement Alternat Med 2013:Article ID 485341), 8 pages. https://doi.org/10.1155/2013/485341 Chan JSM, Ng SM, Ho RTH, Ziea ETC, Ng BFL, Chan CLW (2013b) Does qigong shape body, mind and spiritual health for patients with chronic fatigue syndrome (CFS) in a RCT? Ann Behav Med 45(S2):s278, D-085 Chan THY, Yuen LP, Lee T, Chan JSM, Sham JST, Chan CLW (2013c) The effects of qigong on quality of life and cognitive functioning in people with cancer. In: Presented as an abstract at annual meeting of Society of Behavioral Health (D-176K) Chan JSM, Ho RTH, Chung KF, Wang CW, Yao TJ, Ng SM, Chan CLW (2014) Qigong exercise alleviates fatigue, anxiety, and depressive symptoms, improves sleep quality, and shortens sleep latency in persons with chronic fatigue syndrome-like illness. Evid Based Complement Alternat Med 2014:Article ID 106048), 10 pages. https://doi.org/10.1155/2014/106048 Chan JSM, Yu NX, Chow AYM, Chan CLW, Chung KF, Ho RTH, . . . Chan CHY (2016) Dyadic associations between psychological distress and sleep disturbance among Chinese patients with cancer and their spouses. Psychooncology 26(6):856–861. https://doi.org/10.1002/pon.4240 Chan CHY, Ji XW, Chan JSM, Lau BHP, So KF, Li A, . . . Chan CLW (2017a) Effects of the integrative mind-body intervention on depression, sleep disturbances and plasma IL-6. Psychother Psychosom 86(1):54–56 Chan JSM, Li A, Chan CLW, So KF, Chen JP, Ji X, . . . Ng SM (2017b) Qigong exercise improved quality of sleep and reduced interleukin-1 beta and interleukin-6 among persons with depressive symptoms and sleep disturbances: a randomized controlled trial. https://doi.org/10.1093/sleepj/ zsx050.1086 Chan JSM, Li A, Ng SM, Ho RTH, Xu A, Yao TJ, . . . Chan CLW (2017c) Adiponectin potentially contributes to the Antidepressive effects of Baduanjin qigong exercise in women with chronic fatigue syndrome-like illness. Cell Transplant 26(3):493–501. https://doi.org/10.3727/ 096368916X096694238 Cheng WK, Macfarlane DJ (2001) Effects of a modified Tai Chi programme on the physical and psychological wellbeing of elderly Chinese. In: Paper presented at the the 2nd international symposium on Chinese elderly, Shanghai Cuijpers P, Clignet F, van Meijel B, van Straten A, Li J, Andersson G (2011) Psychological treatment of depression in inpatients: a systematic review and meta-analysis. Clin Psychol Rev 31(3):353–360. https://doi.org/10.1016/j.cpr.2011.1001.1002 Culliford L (2002) Spirituality and clinical care. Br Med J 325:1434–1435 Davies CG, Nolen-Hoeksema S, Larson J (1998) Making sense of loss and benefiting from the experience: two construals of meaning. J Pers Soc Psychol 75(2):561–574 de Jonge P, Wardenaar KJ, Hoenders HR et al (2017) Complementary and alternative medicine contacts by persons with mental disorders in 25 countries: results from the world mental health surveys. Epidemiol Psychiatr Sci 27:1–16. https://doi.org/10.1017/S2045796017000774 Fife BL (1994) The conceptualization of meaning in illness. Soc Sci Med 38(2):309–316 Gourgouvelis J, Yielder P, Clarke ST, Behbahani H, Murphy BA (2018) Exercise leads to better clinical outcomes in those receiving medication plus cognitive behavioral therapy for major depressive disorder. Front Psych 9(37). https://doi.org/10.3389/fpsyt.2018.00037. eCollection 02018 Grady PA, Gough LL (2014) Self-management: a comprehensive approach to management of chronic conditions. Am J Public Health 104(8):e25–e31. https://doi.org/10.2105/ AJPH.2014.302041 Herrman H (2001) The need for mental health promotion. Aust N Z J Psychiatry 35(6):709–715

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Ho RTH, Chan CLW (2002) The effect of eastern psychosocial intervention support group in breast cancer patients in Hong Kong: a pilot study on salivary cortisol, GHQ12 and HADS. In: Paper presented at the 6th psycho-oncology conference, Hong Kong Ho RTH, Chan JSM, Wang CW, Lau BW, So KF, Yuen LP, . . . Chan CLW (2012) A randomized controlled trial of qigong exercise on fatigue symptoms, functioning, and telomerase activity in persons with chronic fatigue or chronic fatigue syndrome. Ann Behav Med, 44(2):160–170. https://doi.org/10.1007/s12160-12012-19381-12166 Ho RTH, Chan JSM, Ng SM, Lau BWM, So KF, Cheung IKM, . . . Chan CLW (2013) The regulation of HPA activity and anti-aging effect of Qigong exercise for patients with chronic fatigue syndrome: telomerase activity and salivary cortisol. In: Poster presentation at the 34th Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine, March 20–23, 2013, San Francisco Jacob N, Coetzee D (2018) Mental illness in the Western Cape Province, South Africa: a review of the burden of disease and healthcare interventions. S Afr Med J 108(3):176–180. https://doi.org/ 10.7196/SAMJ.2018.v7108i7193.12904 Janoff-Bulman R, Berg M (1998) Disillusionment and the creation of values. In: Harvey H (ed) Perspectives on loss. Brunner/Mazel, New York Kabat-Zinn J (2003) Mindfulness-based intervention in context: past, present, and future. Clin Psychol Sci Pract 10(2):144–156 Kemper KJ, Shannon S (2007) Complementary and alternative medicine therapies to promote healthy moods. Pediatr Clin N Am 54(6):901–926 Kemper KJ, Gardiner P, Birdee GS (2013) Use of complementary and alternative medical therapies among youth with mental health concerns. Acad Pediatr 13(6):540–545. https://doi.org/ 10.1016/j.acap.2013.1005.1001 Kessler RC, Soukup J, Davis RB, Foster DF, Wilkey SA, Van Rompay MI, Eisenberg DM (2001) The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry 158(2):289–294 Khusid M, Vythilingam M (2016) The emerging role of mindfulness meditation as effective selfmanagement strategy, Part 1: clinical implications for depression, post-traumatic stress disorder, and anxiety. Mil Med 181(9):961–968. https://doi.org/10.7205/MILMED-D-7214-00677 Lau BH, Chow AYM, Wong DFK, Chan JSM, Chan CHY, Ho RTH, . . . Chan CLW (2018) Study protocol of a randomized controlled trial comparing integrative body–mind–spirit intervention and cognitive behavioral therapy in fostering quality of life of patients with lung cancer and their family caregivers. J Evid Inf Soc Work 15(3):258–276. https://doi.org/10.1080/ 23761407.23762018.21435325 Lazarus RS, Folkman S (1984) Stress, appraisal, and coping. Springer, New York Lee CT, Lei T (1999) Qigong. In: Jonas WBL, J. S. (eds) Essentials of complementary and alternative medicine. Lippincott Williams & Wilkins, Philadelphia, pp 392–409 Li J, Chan JSM, Chow AYM, Yuen LP, Chan CLW (2015) From body to mind and Spirit: qigong exercise for bereaved persons with chronic fatigue syndrome-like illness. Evid Based Complement Alternat Med 2015:Article ID 631410 Lorig KR, Holman H (2003) Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 26(1):1–7 Manek NJ, Lin C (2012) Qigong. In: Yuan CS, Bieber EJ, Bauer BA (eds) Traditional Chinese medicine. Informa Healthcare, London Manocha R, Marks GB, Kenchington P, Peters D, Salome CM (2002) Sahaja yoga in the management of moderate to severe asthma: a randomized controlled trial. Thorax 57(2):110–115 Neimeyer RA (2000) Searching for the meaning of meaning: grief therapy and the process of reconstruction. Death Stud 24(Issue 6):541–559 Neimeyer RA (2002) Mourning and meaning. Am Behav Sci 46:235–251 Ng SM, Chan JSM, Ho RTH (2013) The effects of qigong exercise on quality of life for persons with chronic fatigue syndrome: a randomized controlled trial. Ann Behav Med 45(S2):s299, D174

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Panjwani U, Selvamurthy W, Singh SH, Gupta HL, Mukhopadhyay S, Thakur L (2000) Effects of Sahaja Yoga meditation on auditory evoked potentials (AEP) and visual contrast sensitivity (VCS) in epileptics. Appl Psychophysiol Biofeedback 25(1):1–12 Taylor S (1983) Adjustment to threatening events: a cognitive theory of adaptation. Am Psychol 38:1161–1173 WHO (2001). Fact sheet: the world health report. Retrieved from https://www.who.int/whr/2001/ media_centre/en/whr01_fact_sheet1_en.pdf Yeung A, Chan JSM, Cheung JC, Zou L (2018) Qigong and Tai-Chi for mood regulation. Focus 16:40–47. https://doi.org/10.1176/appi.focus.20170042

Further Reading Abramson RJ (2003) The unity of mind, body, and spirit: a five-element view of cancer. Adv Mind Body Med 192:20–21 Chan CLW (2001) An eastern body-mind-Spirit approach – a training manual with one-second techniques. Department of Social Work & Social Administration, The University of Hong Kong, Hong Kong Chan CLW, Ho PSY, Chow E (2001) A body-mind-spirit model in health: an eastern approach. Soc Work Health Care 34(3/4):261–282 Chan JSM, Ho RTH, Chung KF, Wang CW, Yao TJ, Ng SM, Chan CLW (2014) Qigong exercise alleviates fatigue, anxiety, and depressive symptoms, improves sleep quality, and shortens sleep latency in persons with chronic fatigue syndrome-like illness. Evid Based Complement Alternat Med 2014:Article ID 106048), 10 pages. https://doi.org/10.1155/2014/106048 Chan JSM, Li A, Ng SM, Ho RTH, Xu A, Yao TJ, . . . Chan CLW (2017) Adiponectin potentially contributes to the antidepressive effects of baduanjin qigong exercise in Women With Chronic Fatigue Syndrome-Like Illness. Cell Transplant 26(3):493–501. https://doi.org/10.3727/ 096368916X096694238 Engel GL (1977) The need for a new medical model: a challenge for biomedicine. Science 196 (4286):129–136 Ho RTH, Chan JSM, Wang CW, Lau BW, So KF, Yuen LP, . . . Chan CLW (2012) A randomized controlled trial of qigong exercise on fatigue symptoms, functioning, and telomerase activity in persons with chronic fatigue or chronic fatigue syndrome. Ann Behav Med 44(2):160–170. https://doi.org/10.1007/s12160-12012-19381-12166 Lee MY, Chan CHY, Chan CLW, Ng SM, Leung PPY (2018) Integrative body-mind-spirit social work for health and mental health: an empirically-based approach to assessment and treatment, 2nd edn. Oxford University Press, New York Ng SM, Leng LL, Ho RTH, Zhang Z, Wang Q (2018) A brief body-mind-spirit group therapy for Chinese medicine stagnation syndrome: a randomized controlled trial. Evid Based Complement Alternat Med:1. https://doi.org/10.1155/2018/8153637

HKU Website on Qigong and Chronic Fatigue https://learning.hku.hk/qigong/

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Medical Perspective on Mental Health Carol Harvey

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment and Diagnosis of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Providing a Diagnosis to Consumers and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis as a Guide to Treatment and Service Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis as an Aid to Clinical Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Narrow Medical or Brain-Disease Model of Mental Illness: History and Critiques . . . . . . The Biopsychosocial Model of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Biopsychosocial Model in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Psychiatric Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Psychiatric Formulation in Mental Health Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Place of Culture within Diagnosis, Formulation, and the Biopsychosocial Model . . . . . . . Beyond the Brain-Disease Model: Other Aetiological Theories of Mental Illness . . . . . . . . . . . . Socio-developmental Influences on the Genesis and Course of Mental Disorder: Accumulating Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Understandings of Causation of Psychiatric Disorders: Gene-Environment Interactions and Epigenetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter provides a medical perspective on mental health, including current diagnostic systems which inform and underpin treatment and service delivery. Conceptualizations of mental disorders and their advantages and disadvantages for the assessment and treatment of persons living with mental illness are C. Harvey (*) Department of Psychiatry, University of Melbourne and NorthWestern Mental Health, Melbourne, VIC, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_4

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outlined. Despite its limitations, diagnosis remains central to communicating a shared understanding of disordered experiences and behaviors between consumers, families, and professionals. Talking about a diagnosis in mental health is a skilled task, requiring sensitivity, an individualized approach within a trusting relationship, and sufficient time to address and revisit concerns and misunderstandings. All mental health professionals, including social workers, can helpfully contribute. Current etiological theories in mental health are described, including the medical or brain-disease model of mental illness which has been dominant in recent decades. Although not unique to psychiatry, the biopsychosocial (-cultural) model and psychiatric formulation both help to address some of the challenges of current diagnostic conceptualizations and to counterbalance the medical model. Further, these approaches are consistent with social work theory and practice and contribute strongly to a more person-centered, recovery-oriented approach to mental health practice which recognizes social aspects of human experience. Gene-environment interactions and epigenetics are also consistent with this since they integrate accumulating research evidence about social and environmental contributions to the development and course of mental disorders into etiological theory. They also reaffirm the value of psychosocial interventions and person-in-environment approaches to recovery. The implications of these medical perspectives for social work practice in mental health are elaborated. Keywords

Diagnosis · Biopsychosocial model · Formulation · Medical model · Braindisease model of mental illness · Social factors · Gene-environment interactions · Epigenetics

Introduction This chapter will first focus on the psychiatric contribution to diagnostic systems in mental health. The underpinning conceptualizations of mental disorders and their associated advantages and disadvantages and the challenges and solutions these present for the assessment and treatment of persons living with mental illness will be outlined. The importance of the biopsychosocial (-cultural) model, and of formulation, will be elaborated as a way of addressing some of the challenges represented within current diagnostic conceptualizations. An overview of current etiological theories in mental health will also be provided, including consideration of the medical or brain-disease model of mental illness. Other theories which link with broader conceptualizations of causation and emphasize findings derived from social psychiatric research and recent work in gene-environment interactions and epigenetics will be briefly described. The implications of these medical perspectives on mental health for social work practice will be elaborated. The term “consumer” is used throughout this chapter to refer to people living with mental illness of various types. This is consistent with the widespread use of this

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term in Australian mental health services. However, it is acknowledged that other terms such as “patient,” “client,” or “service user” are in more common usage elsewhere. The term “patient” will also be used if also used in the source material.

Assessment and Diagnosis of Mental Disorders A key contribution of medical practitioners to multidisciplinary mental health practice is their expertise in assessment and diagnosis of mental disorders. Consequently, there is a strong emphasis on knowledge and skills relevant to this area of practice in psychiatric training (Chaplin et al. 2007).

Diagnosis There are many reasons for accurate diagnosis in mental health, although most agree that the major reason is to guide treatment planning (Chaplin et al. 2007; Outram et al. 2014). There are two major diagnostic classification systems in widespread use in mental health internationally: the Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychiatric Association (APA) and the International Classification of Diseases (ICD) which is published by the World Health Organization (WHO).

Brief Overview of the Two Major Diagnostic Systems The classification of mental disorders was included in the 8th edition of the ICD in the 1970s (Singh et al. 2012). The ICD is in its 10th edition (World Health Organisation 1992), an edition first endorsed in 1990 and regularly updated but soon to be replaced by version 11. According to the WHO ICD website, the ICD is “used in clinical care and research to define diseases and study disease patterns, as well as manage health care, monitor outcomes and allocate resources.” The ICD provides a common language for the identification of health trends and statistics globally (http://www.who.int/classifications/icd/factsheet/en/). The DSM has existed in various versions since 1952; DSM-5 was released in 2013 (American Psychiatric Association 2013). The APA DSM website describes the DSM as “an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research” (https://www.psychiatry.org/ psychiatrists/practice/dsm). Both these major diagnostic classification systems have drawn on expert scientific advice. The development of earlier versions of the mental disorder classification within ICD was linked to large multicountry epidemiological studies such as the International Pilot Study of Schizophrenia (Leff et al. 1992). In the case of each DSM revision, expertise is drawn from numerous research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. For DSM-5, relevant research was evaluated by a task force and work groups to

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propose draft criteria which were finally approved after expert advice on the strength of evidence for proposed changes and their clinical utility and public health impact.

Categorical and Dimensional Approaches to Diagnosis A weakness of current diagnoses in mental health is the lack of corresponding evidence about the physiological processes or mechanisms, whereby such conditions develop and progress. So, there is a lack of laboratory tests or other investigations to inform most diagnoses (Nemeroff et al. 2013; Nesse and Stein 2012; Timimi 2014). Therefore, diagnostic classification systems in mental health are symptom-based and rely heavily on the recognition of syndromes – a collection of symptoms (and signs) that occur together as an identifiable condition in a group of people. Psychiatric syndromes are complex phenomena which can potentially be conceptualized and assessed in two contrasting ways: either as categories or as dimensions. Categorical approaches to diagnosis tend to diagnose a case of a disorder at a threshold number of symptoms. For instance, major depressive disorder is diagnosed in DSM-5 when a person reports that five (or more) of nine possible symptoms have been present during the same 2-week period (American Psychiatric Association 2013). The most obvious advantage of this approach is that it assists clinicians to decide who is sufficiently ill to require treatment, by applying this categorical “cut point.” However, observations from both clinical practice and research reveal that there is no separation at this “cut point” between “non-cases” and “cases” of disorder, as expected within a categorical model of diagnosis; in other words, a number of people score just below the threshold for disorder (“subthreshold cases”). Therefore, “zones of rarity” between mental disorders which indicate clear separations between each syndrome are rarely observed, and it is difficult to draw clear boundaries between many disorders and normality (Nesse and Stein 2012; O’Donovan and Owen 2016). These observations fit better with a dimensional approach to diagnosis (described more fully below). Categorical diagnoses are arguably most valuable for homogeneous disorders, for example, diagnoses where symptom profiles and severity are similar, where etiological factors are shared, and where categorical diagnosis guides treatment with some accuracy (Macneil et al. 2012). However, few psychiatric disorders match this description (Nesse and Stein 2012; O’Donovan and Owen 2016). As these and other authors have argued, two individuals with major depression may have quite different symptom profiles and severity. Conversely, symptoms such as auditory hallucinations can be shared across several diagnoses, for example, schizophrenia and mania with psychotic features. Further, phenomena as diverse as mood and personality disorders, psychoses, and anxiety disorders can be associated with varied etiological factors, ranging from genetic to environmental. These may include trauma, personality styles, and interpersonal stressors, with each factor playing a greater or lesser role for each person (Macneil et al. 2012). Thus, a categorical approach is not only a less than perfect fit for the observed phenomena but also has the added disadvantage that it may lead clinicians to overlook the complexity and heterogeneity inherent in an individual’s symptomatology or within the etiological factors for their disorder.

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Another important limitation of the categorical approach to diagnosis is that many individuals are found to have more than one disorder, that is, to experience comorbidity. Thus, it appears necessary in clinical practice to make more than one diagnosis to encompass the experiences and difficulties of a significant minority of people. Epidemiological surveys provide support for these clinical observations. For example, analyses of the 2007 Australian National Survey of Mental Health and Well-Being (Teesson et al. 2009) show that 25% of all cases of the common mental disorders were comorbid with at least one other disorder. Given the difficulties raised by a categorical approach to diagnosis, there is increasing interest in applying a dimensional approach to conceptualizing and assessing psychiatric syndromes. A dimensional approach classifies mental disorders by quantifying a person’s symptoms or other characteristics of interest and representing them with numerical values on one or more scales or continuums, rather than assigning them to a mental disorder category (Nesse and Stein 2012). Thus, traits such as mood or interpersonal functioning exist on a continuum ranging from normal variation to pathology (Tyrer et al. 2011). As mentioned, this better describes the existence of subthreshold cases of various disorders. Subthreshold cases are important to encompass within any diagnostic approach since they involve impaired functioning and may result in appropriate clinical referral and need for services (e.g., Rutter 2011). However, there are also potential problems with a dimensional approach, including the generation of multiple combinations of high and low scores on each of a number of dimensional characteristics, which makes the system unwieldy and impractical (Tyrer et al. 2011). Both major diagnostic systems use categorical and dimensional approaches, although relying more heavily on categorical. These two approaches should be seen as complementary. Thus, dimensional assessments allow for more fine-grained descriptions which may often inform the more user-friendly categorical approach to treatment decisions.

Overall Critique of Current Diagnostic Systems in Mental Health Many critiques emphasize the conceptual and empirical limitations of diagnostic systems in mental health, although these have particularly focused on the latest version of the DSM (e.g., Frances 2012; Pemberton and Wainwright 2014; Timimi et al. 2014). These have come from within psychiatry as well as other disciplines, including social work (e.g., see the special issue of Research on Social Work Practice, including Lacasse 2014a). It is important that social workers are informed about current diagnostic systems and their advantages and disadvantages (see Table 1). A recurring criticism of the main systems of psychiatric diagnosis is that disorders are reified, that is, something subjective is turned into something “concrete,” despite the noted limitations of classificatory systems. Also, links between life experiences and symptoms of emotional distress can be lost or obscured (Humphreys and Thiara 2003; Lacasse 2014b; Pemberton and Wainwright 2014; Timimi 2014; Wong 2014). Further, clinicians may be distracted from other relevant symptoms and contributory factors, including their complexities and interactions, which are not described

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Table 1 Implications for social work practice It is essential for social workers to be well informed about current diagnostic systems and their conceptual underpinnings and the implications of these for the individual consumer, their family, and the service system, as well as for policy, funding, and research Social workers should understand the main advantages and disadvantages of diagnostic systems and diagnoses, so as to adopt an appropriately critical stance to their application within practice Understanding the wide range of responses of consumers and families to receipt of a diagnosis and how and why these occur is essential for social work practice Social workers can play a helpful supporting role in the provision of a diagnosis to a consumer and their family, grounded in their acquisition of effective communication skills and the application of these in team-based approaches The biopsychosocial model and psychiatric formulation represent useful knowledge and skills sets for all mental health professionals, including social workers Social workers should ensure that the “bio-” continues to be part of their application of the biopsychosocial model and of person-in-environment approaches within their practice Social workers can play an important role by advocating for, and applying their understanding of, the wider context of mental disorder within the practice of diagnosis and treatment; this includes contributing person-in-environment perspectives Advances in the understanding of biomedical contributions to the aetiology of mental disorders, especially gene-environment interactions and epigenetics, should prompt social workers to rethink their knowledge base Social workers should aim to be informed, but not expert, readers of biomedical developments The integration of biological and social perspectives, underpinned by robust research, is essential, and social workers have an important contribution to make to this Advocacy for ethical and person-centered translation of emerging scientific knowledge and the protection of vulnerable populations continues to be a very important role for social workers

within the operationalized diagnostic criteria for each disorder (Macneil et al. 2012; Wong 2014). For instance, Humphreys and Thiara (2003) argue that an exclusively medical model approach to diagnosis for women with mental health symptoms due to domestic violence may result in pathologizing the individual rather than acknowledging and addressing the abuse context. This decontextualized view of behavior, in which problems in living are medicalized, may have dehumanizing and unhelpful consequences in terms of treatment and service responses (Frances 2012; Humphreys and Thiara 2003; Lacasse 2014b). One way of attempting to better represent the complex nature of psychiatric disorders was the multiaxial diagnostic assessment system introduced in DSM-3. Thus, each individual could be evaluated in terms of several different domains of experience which went beyond acute symptoms to try to encompass the diverse factors that account for a patient’s mental health. This multiaxial system included Axis IV – sometimes referred to as the social work axis – which could highlight psychosocial and environmental problems. Unfortunately, the multiaxial system was removed from DSM-5 (Lacasse 2014b). The validity of psychiatric diagnoses, that is, whether they represent actual entities, is undermined by the existence of widespread comorbidity, as previously described. Many authors have pointed out that the reliability of many psychiatric diagnoses is poor and this is especially the case in clinical settings (Lacasse 2014b; Timimi 2014). Thus, two clinicians seeing the same patient

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independently will not reach the same diagnosis on most occasions. Inter-rater agreements were reported to be uniformly poor for some common diagnoses such as major depressive disorder and generalized anxiety disorder in DSM-5 field trials, a finding linked with the marked heterogeneity of people who meet criteria for these disorders and comorbidity between these and other disorders (Lacasse 2014b; Regier et al. 2013; Timimi 2014). The sheer number of diagnoses in DSM has been criticized: DSM-1 listed 106 diagnoses and DSM-5 describes 157. In part, this represents efforts to increase the coverage of the system by identifying new disorders or specific subtypes of existing disorders with purported treatment or other clinical implications. The aim is to explain more of the observed phenomena and, through refinement of diagnoses, to lead to more appropriate and effective treatments. However, one adverse consequence is the creation of circumstances in which comorbid disorders are increasingly common. Most would agree that the number of diagnoses is far too many for any clinician to remember the criteria for each, which arguably undermines the usefulness of the system (Nemeroff et al. 2013). Moreover, some critics have linked the number of diagnoses in DSM with the financial (as opposed to scientific) utility of DSM-5 (Frances 2012; Lacasse 2014b). Concern has also been raised that this represents a medicalization of human problems and/or problems of daily living (Frances 2012; Lacasse 2014b). A frequently cited example is the removal of bereavement as an exclusion criterion for the diagnosis of major depression. This challenges the view that grief after the loss of a loved one, which frequently comprises depressive symptoms, belongs to the category of healthy psychic reactions and coping strategies (Frances 2012; Nemeroff et al. 2013). Notwithstanding these challenges and difficulties in assigning reliable and valid diagnoses in mental health, formulating diagnoses continues to be a very important activity for pragmatic reasons. Diagnosis assists with collecting data at a service or population level – a purpose for which the ICD classification is explicitly designed (http://www.who.int/classifications/icd/factsheet/en/). This can be useful for service planning, benchmarking between services, and research, especially epidemiological research on variations in prevalence and outcome of mental disorders and their associated biological, psychological, and social factors. Further, receipt of a diagnosis by an individual may facilitate access to treatment, services, and resources for the individual as well as their family, as well as enabling funding for specific treatments and medication subsidies (Frances 2012; Nemeroff et al. 2013). Making and providing a diagnosis to consumers and their families is therefore a significant contribution of medical practitioners in mental health. However, providing a meaningful diagnosis in a timely and sensitive manner is by no means a uniformly shared and applied knowledge and expertise.

Providing a Diagnosis to Consumers and Families In their review article, Milton and Mullan (2014) describe how rates of provision of diagnoses to consumers have increased in the last decade and how they vary by

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diagnosis and probably by culture and migrant status. Thus, diagnostic discussion for schizophrenia diagnoses and for general mental health diagnoses varies between 77% and 88%, except for consumers who had immigrated (22%). Communicating a schizophrenia diagnosis appears less common than, say, providing a depression diagnosis, and a substitute or euphemistic diagnosis such as psychosis or major mental illness may be provided for the former (Outram et al. 2014). This is associated with consumers having a poorer understanding of their condition (Milton and Mullan 2014). While most clinicians in an Australian study supported the need to give a diagnosis of schizophrenia, they gave multiple reasons for not doing so in practice (Outram et al. 2014); psychiatrists interviewed in a separate study even thought it might be anti-therapeutic to discuss diagnosis when prescribing antipsychotics (Chaplin et al. 2007). These perplexing and contradictory findings raise important questions about what should be a fundamental practice in mental health care. In part, clinicians’ varied responses and practices concerning provision of a diagnosis may relate to their awareness of the diverse reactions of consumers and their families to receiving a diagnosis. It cannot be assumed that receipt of a diagnosis is either “good or bad news” (Gallagher et al. 2010), since reactions are complex and vary between individuals provided the same diagnosis and between individuals according to diagnosis; for example, there are more negative responses to a diagnosis of Alzheimer’s disease compared with vascular dementia (Aminzadeh et al. 2007). Recognized negative reactions include anger, anxiety, fear, despair, shock, denial, and shame, the latter especially due to cultural beliefs. Some of these reactions relate to concerns about feelings and experiences of stigma, with more widespread concerns among those receiving diagnoses of psychotic, as opposed to nonpsychotic, disorders (Dinos et al. 2004; Mestdagh and Hansen 2014; Milton and Mullan 2014). The negative impact of a mental illness diagnosis on an individual’s social identity and relationships with others is regularly reported and may undermine their willingness to share diagnostic information with others and/or lead to selective hiding of their diagnosis or even avoidance of contact with others (Mestdagh and Hansen 2014; Milton and Mullan 2014). Nevertheless, the importance of accuracy in diagnosis is emphasized. For example, parents of children with autism have reported that confusion may be experienced in the context of misdiagnosis, which is common in the early stages of assessment (Altiere and Von Kluge 2009). However, even when technically correct information is given, such as more than one diagnosis when this is consistent with comorbidity in current diagnostic systems, consumers have reported confusion (Gallagher et al. 2010). A diagnosis may be rejected because it pathologized issues or did not help individuals make sense of their situation (Humphreys and Thiara 2003; Milton and Mullan 2014). This may link with previously described deficiencies of existing diagnostic systems. Finally, and despite the importance of diagnoses in enabling treatment access, treatment dropouts have been reported because of hearing a diagnosis (Milton and Mullan 2014). On the other hand, there is potential relief for the consumer in having a diagnosis to help explain what they have been experiencing. This is because the initial onset

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of illness may involve confusing and/or frightening changes such as distressing symptoms, isolation from friends and family, difficulties in everyday functioning, or a long-standing sense of difference from others. This sense of relief may apply equally to family members. Relief in response to a diagnosis is most apparent in people diagnosed with depression or anxiety (Milton and Mullan 2014; Dinos et al. 2004). Nevertheless, most research with people with schizophrenia (and their families) suggests a preference to have a named diagnostic entity rather than uncertainty (Magliano et al. 2008). Similarly, some adolescents interviewed by Buston (2002) spoke about a lack of diagnosis being frustrating and leading to uncertainty, even though clinicians reported greater reluctance to give younger people a diagnosis because of stigma-related concerns (Outram et al. 2014). Other positive responses include viewing the diagnosis as validating or helpful to treatment and presenting an opportunity to develop positive coping skills (Aminzadeh et al. 2007; Milton and Mullan 2014). Overall, the review of Milton and Mullan (2014) concluded that most consumers want diagnostic information and see it as their right choice. Therefore, current practice suggests a gap between the information preferences of consumers and their level of satisfaction with diagnosis discussion (Fossey et al. 2012; Milton and Mullan 2014). There is increasing recognition that providing a diagnosis requires an individualized approach to giving information in the context of a trusting relationship and with active involvement of the consumer and their family and key supports wherever possible (Gallagher et al. 2010; Mestdagh and Hansen 2014). This should include discussion about the meaning and implications of the diagnosis, so as to avoid misunderstanding and help the consumer and their family to develop a realistic appraisal of their situation. It is apparent that this requires time (Gallagher et al. 2010) and is often an ongoing process of care rather than a one-off event, as exemplified in the disclosure of a dementia diagnosis (Aminzadeh et al. 2007). It requires mastery of the “subtle interplay of hope and pessimism” in communication of diagnosis (Outram et al. 2014, page 551). While focused on reported practices of consultant psychiatrists when prescribing antipsychotics, Chaplin et al. (2007) provide useful strategies for strengthening the therapeutic alliance in the context of potentially difficult discussions with consumers. Intervention studies aimed at facilitating diagnostic communication are still few but showed significant improvements in consumer satisfaction and mood and in clinician communication skills, without negative outcomes for consumers or clinicians (Holm-Denoma et al. 2008; Milton and Mullan 2014). Further, satisfaction with diagnosis is higher if it is received faceto-face and if there is supplementary support from other professionals (Milton and Mullan 2014), suggesting a specific and important role for social workers (see Table 1). There are growing recommendations for development of detailed protocols for communicating diagnosis, including coordinated team-based approaches, and to feed these into training (Chaplin et al. 2007; Milton and Mullan 2014). However, more research is needed to achieve this aim, including with more professional groups and with greater inclusion of participants with psychosis and taking cross-cultural issues into consideration (Aminzadeh et al. 2007; Holm-Denoma et al. 2008; Milton and Mullan 2014).

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Diagnosis as a Guide to Treatment and Service Access As already emphasized, diagnosis can be useful to guide treatment and is commonly perceived as the main purpose of diagnosis. Current psychiatric medications are mostly symptomatic treatments, as is consistent with the largely symptom-based nature of psychiatric diagnoses. As argued by Nemeroff et al. (2013), helpful associations between treatment efficacy and existing diagnostic boundaries do exist: for example, lithium is very effective for many people with a diagnosis of bipolar disorder but is not an effective antipsychotic. However, it should also be noted that other treatments are helpful for more than one diagnosis, for example, antipsychotics may be effective treatments for schizophrenia and mania (Nemeroff et al. 2013). Provision of a diagnosis may facilitate access to diagnosis-specific services that are available for people with autism or dementia. Individuals without a definitive diagnosis may therefore be excluded from needed services and resources, such as access to supports, benefits, or medication subsidies (Milton and Mullan 2014; Milton and Mullan 2017). Some mental health services are organized according to diagnosis-specific care pathways (e.g., borderline personality disorder) to improve quality of care and efficiency through the systematic application of treatment recommendations in clinical practice guidelines (e.g., National Institute for Health and Care Excellence 2009). Whether diagnostic (and therefore eligibility) criteria are met therefore becomes an important issue. For example, it has been argued that changes within DSM-5 to the diagnosis of autism will affect access to services such that those with “higher-functioning autism” may lose out (see Nemeroff et al. 2013). Particularly important is the role of diagnosis in facilitating access to early intervention. Most would agree that early intervention is a worthwhile goal; nevertheless, the practicalities are not straightforward (van Os and Guloksuz 2017; Yung and Nelson 2013). By way of example, it has been argued that the existence of a prodromal phase in most cases of schizophrenia (i.e., changes or deterioration in diverse subjective symptoms and behavioral signs that precede the onset of psychotic symptoms) creates a target for early intervention. The rationale is that early intervention would prevent, ameliorate, or delay onset of psychosis (Yung and Nelson 2013). Criteria for “ultrahigh risk” (UHR) or “clinical high risk” (CHR) for “transition” to a psychotic disorder have been developed, with accompanying treatments and services. Treatments remain controversial, however, due to concerns that a substantial proportion of people not truly at risk (false positives) may be treated, including with antipsychotic medications which carry attendant risks of side effects (Frances 2011; Yung and Nelson 2013). The latest evidence does not support use of antipsychotics in the UHR group (Stafford et al. 2013; Yung and Nelson 2013); even so, the concept of an ultrahigh-risk diagnosis continues to be debated and has not been formally included in DSM-5 (Frances 2011; Frances 2012; Nemeroff et al. 2013; van Os and Guloksuz 2017). Van Os and Murray (2013) question whether the ultrahigh-risk state is a reliable and valid binary concept. They also question whether treatment of this condition can prevent the transition to frank psychosis, which may be an invalid or overly simplistic concept (van Os and Murray

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2013). Instead, they and others argue for a public health perspective rather than the relatively inefficient medical high-risk approach (van Os and Guloksuz 2017). Thus, while the importance of timely access to appropriate services and resources is largely undisputed, whether diagnosis is accurate and meaningful in so far as providing a helpful therapeutic target is clearly a crucial prerequisite.

Diagnosis as an Aid to Clinical Communication Diagnosis may facilitate communication between clinicians and provide a useful shorthand for conveying information and orientating all concerned to relevant considerations, such as treatment options and prognosis (e.g., American Psychiatric Association 2013). On the other hand, Lacasse (2014a) has argued that unreliable diagnostic labels are probably unhelpful in clinical communication. Further, shorthand descriptions such as diagnosis carry the risk of overlooking the rich and nuanced details of each person’s situation and may lead to professionals treating all persons with a specific diagnosis as being the same, with identical issues and needs. Despite these caveats, diagnoses continue to be “invaluable working concepts for clinicians” (Kendell and Jablensky 2003). Also, person-in-environment perspectives contributed by social workers can assist with mitigating this risk (see Table 1). Further, there are several important conceptual developments which, when applied in practice, mitigate the potentially adverse consequences of applying diagnoses in mental health practice and represent an important medical contribution. These are elaborated below – see sections “The Biopsychosocial Model of Mental Illness” and “The Psychiatric Formulation.”

The Narrow Medical or Brain-Disease Model of Mental Illness: History and Critiques The brain-disease model of mental illness has been dominant in recent decades and underpins current research and approaches to diagnosis. Neurobiological models of mental illness are too varied to be satisfactorily summarized here. However, a brief overview of the most common and enduring conceptualization, the dopamine hypothesis of schizophrenia, will be provided. Kendler and Schaffner (2011) have written a useful account of the history of the dopamine hypothesis of schizophrenia, pointing out that this has been one of the most prominent etiological theories in psychiatry for over 50 years. Dopamine is one of a number of neurotransmitters, that is, chemical mediators between nerve cells in the brain. In its earliest form, the dopamine theory proposed that schizophrenia may be related to a relative excess of dopamine-dependent neuronal activity in the brain (Meltzer and Stahl 1976). A selective synthesis of meta-analyses and reviews of studies attempting to validate the dopamine hypothesis, ranging from measuring brain levels of dopamine and its metabolites to genetic association studies, is summarized by Kendler and Schaffner

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(2011). They conclude that efforts to empirically validate the hypothesis have largely failed, leading to it being reformulated. The current and most accepted reformulation of the dopamine hypothesis is that schizophrenia is characterized by reduced dopamine in the frontal areas of the brain and excessive dopamine in neurons in the mesolimbic pathway, sometimes referred to as the reward pathway (Davis et al. 1991). The former dysregulation is postulated to lead to negative symptoms of schizophrenia, such as cognitive impairments, and the latter to positive symptoms, such as hallucinations. Further, experts increasingly agree that dopamine does not explain the cause of schizophrenia per se, rather it acts as the final common pathway of diverse predisposing factors, environmental or genetic or both (Howes et al. 2017; Kendler and Schaffner 2011; Lau et al. 2013). This is consistent with the pharmacological dopamine hypothesis of antipsychotic action for which there is more substantial support. Kendler and Schaffner (2011, p. 59) point out that evidence for “other leading ‘neurochemical’ etiological theories in psychiatry, such as the serotonin hypothesis of depression,” may be similarly lacking. There have undoubtedly been many advances in understanding the neurobiology of psychiatric disorders, for instance, through brain imaging studies. However, the narrow conception and/or application of a medical, and especially brain disease, model of mental illness has received many criticisms (e.g., Healy 2016; Malla et al. 2015; Timimi 2014; Wakefield 2013; Wong 2014). It has been argued that a braindisease model of mental illness would reduce stigma and accusations that people with mental illness are weak-willed or have a character defect but it appears that the contrary is true (Timimi 2014; Wakefield 2013). It seems that the public do not have an explanatory model of mental illness as “just like medical illness,” and, contrary to previous assumptions, those who adhere to such a model are less optimistic and accepting of people with mental illness (Malla et al. 2015). Malla et al. (2015) have also argued that a neurobiological model of mental illness is unhelpful in other respects. Unlike somatic illnesses such as diabetes, mental disorders “affect the very core of one’s being through a range of experiences and phenomena of varying severity that alter the individual’s thinking, perception and consciousness about the self, others and the world” (Malla et al. 2015, p. 148). Thus, therapy goes beyond restoring dysfunctional physiological mechanisms and encompasses helping the person feel better and to interact more adaptively with their physical and social environments (Malla et al. 2015). A brain-disease model is arguably not helpful for acceptance of psychological and social treatments (Malla et al. 2015; Wong 2014) and, moreover, may lead to overuse of medication (Wakefield 2013). Indeed, it has been argued that overreliance on a medical model is associated with poor treatment outcomes in the current service system (Pemberton and Wainwright 2014; Timimi 2014; Wong 2014). The example of evolving models for understanding alcohol addiction or dependence provides a useful illustration of the dilemmas posed by over-adherence to a brain-disease model of mental illness. In the nineteenth century, a moral model of addiction was evident which held people responsible for their behavior and tended to be applied in a harshly moralistic or punitive manner (see Elam 2015; Morse 2004). It was argued that application of a chronic brain disease or medical model to

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alcohol (and other) addictions would alleviate stigma, reduce “victim-blaming,” and encourage many to seek help (Ferentzy and Turner 2012) since the condition was then seen as wholly outside their control. However, one of the adverse consequences of this model is to remove any idea of the drinker as an active participant in their recovery (Peele 2016). Recent research contradicts this in so far as it reveals that change in addictive behavior is usually self-initiated (Peele 2016). Further, motivational interviewing approaches have been shown to enhance consumers’ intention to change and are now regarded as evidence-based practices in the substance abuse field (Lundahl et al. 2010). A relevant conclusion in this field, but also more broadly applicable in mental health, is that while the medical, and more particularly the brain disease, model should not be abandoned, its narrow application is unhelpful (Healy 2016).

The Biopsychosocial Model of Mental Illness Despite the recent dominance of the brain-disease model of mental illness, other models of mental disorder have also existed for some time and may be considered to complement (rather than replace) the brain-disease model. They have helped to reposition the person experiencing the mental disorder as a more active participant in their own recovery, particularly by emphasizing the centrality of the person’s experiences in understanding psychiatric disorders (Healy 2016; Pemberton and Wainwright 2014). A good example is the biopsychosocial model which has been influential within psychiatry for some time. Detailed histories and descriptions of the biopsychosocial model are provided in most psychiatry and mental health textbooks (e.g., Bland et al. 2012, pp. 399–400). The term owes a great deal to the American psychiatrist George Engel. He suggested that the biological, psychological, and social dimensions of illness must be attended to simultaneously rather than taking a narrow medical approach to mental illness (Borrell-Carrió et al. 2004; Engel 1977). Further, Engel’s model implied that biological, psychological, and social elements and factors interact dynamically, in health and in illness, and emphasized a systems view of health and illness, with each system forming part of higher-order systems (Engel 1977; Garland and Howard 2009; Healy 2016). Thus, systems extended from cells, tissues, and organs through an individual person and beyond to a family, a community, culture and subcultures, and society (Bland et al. 2012; Borrell-Carrió et al. 2004; Farre and Rapley 2017). Reciprocal interactions between biological, psychological, and social factors and the multiple levels of the various systems are conceptualized, consistent with models of circular rather than linear causality. This conceptualization has underpinned other models, such as the World Health Organization’s (2001) International Classification of Functioning, Disability and Health (http://www.who.int/classifications/icf/en/ accessed 19 April 2018). There are many potential implications of applying the biopsychosocial model in practice. It is widely accepted that the biopsychosocial model can guide clinicians in their everyday work and has the potential to lead to more humanistic and patientcentered care (Borrell-Carrió et al. 2004; Farre and Rapley 2017). The model has

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helped to include consideration of emotional well-being, functioning in daily life and performance of social roles within patient assessment and care, which are particularly important in chronic disease (Fava and Sonino 2008; World Health Organisation 2001). The model is more consistent with the recovery movement and consumer demands for more psychologically based mental health care, as well as with a public health orientation to mental health (Pemberton and Wainwright 2014). Consistent with social work practice (Healy 2016), the biopsychosocial model underlines the importance of understanding the person in their context (Timimi 2014) which is central to the person-in-environment approach (Wong 2014). Implicit in these approaches is the involvement of the patient’s relatives and/or significant others in assessment and treatment planning because of their often-extensive knowledge of the patient as well as their significance for the person’s recovery (Harvey and O’Hanlon 2013). The biopsychosocial model (and related approaches which emphasize the relevance of psychological and social factors, as well as biological factors, to the causation and outcome of mental illness) is consistent with accumulating evidence for sociodevelopmental influences on the genesis and course of mental disorder. Evidence is comprehensively outlined in other texts (e.g., see “Principles of Social Psychiatry,” Morgan and Bhugra 2010) and will be briefly summarized later – see section “Beyond the Brain-Disease Model: Other Aetiological Theories of Mental Illness.”

The Biopsychosocial Model in Practice Concerns about the biopsychosocial model have been raised. These include that it is imperfectly applied in day-to-day practice and the end result is often to preference one aspect of the model over another. So, biological considerations may still dominate in some settings, or psychoanalytic concepts may be preeminent elsewhere (Ghaemi 2009). Within social work (see Table 1), some have argued that the “bio-” has been ignored (e.g., Maynard et al. 2017). Some critics identify deficiencies in the model itself and argue these explain its imperfect implementation. These include that the model is too vaguely defined and therefore not testable; does not include a method to identify relevant biopsychosocial data; gives no indication of what level of analysis (biological, psychological, or social) to prioritize and when; and cannot be efficiently put into practice because it is too time-consuming (Farre and Rapley 2017; Ghaemi 2009). Ghaemi (2009) has argued that the model is of limited value since it is so vague as to lead to dogmatic pursuit of eclectic and nonevidence-based approaches. Modifications or enhancements of the model have been proposed which include emphasizing cultural considerations (which were always a component of Engel’s model) or proposing patient-centered interviewing methods which could be used to elicit relevant biopsychosocial data (Engel 1977; Farre and Rapley 2017; Smith et al. 2013). Despite the identified drawbacks, however, the biopsychosocial model continues to influence much psychiatric practice and is routinely used as a guiding framework for formulation, another significant component of psychiatric assessment and treatment planning.

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The Psychiatric Formulation The information gleaned from the clinical activities of history-taking and mental state and physical examination, which underpin the generation of a diagnosis as a fundamental part of psychiatric practice, may be summarized and then synthesized to construct a formulation. Diagnosis and formulation are essential components of psychiatric practice, and formulation enhances the value of diagnosis and may serve to mitigate some of its shortcomings. As previously argued, a diagnosis in isolation tells us little about a person’s experience of mental disorder, fails to take account of current and historical environmental events, and typically overlooks external causal or contributory factors (Macneil et al. 2012; Wong 2014). Therefore, it is relevant to identify and understand these broader aspects of experience to guide a more individualized and personalized approach to treatment planning and select potential targets for therapeutic change (de Beer 2017; Macneil et al. 2012; Wong 2014). One way to achieve this is to generate a formulation. A formulation goes beyond a summary and attempts a synthesis of available clinical information by concentrating on those aspects of the history that appear most significant and including some understanding of the interactions between events (de Beer 2017; Kirby and Grover 2017; Meadows et al. 2012). It aims to identify and explain etiological factors (de Beer 2017). Further, formulation synthesizes the patient’s experience with relevant clinical theory and research and thereby forms the bridge between assessment and treatment (Macneil et al. 2012). Thus, the selection of information and the inferences drawn from it depend on the theoretical framework used and the evidence which informs the formulation (Macneil et al. 2012; Meadows et al. 2012). Examples of theoretical frameworks include Bowlby’s attachment theory and Erikson’s life cycle stages (Kirby and Grover 2017). A formulation should be devised to assist with further assessment as well as with treatment planning; it may be particularly helpful for people who have not had an adequate response to traditional interventions and/or those with complex presentations and comorbidities (Macneil et al. 2012; Meadows et al. 2012). Formulation can be especially useful in identifying treatment challenges, such as difficulties in establishing a therapeutic alliance or ongoing problems of poor adherence to recommended treatments, and how to overcome these. Formulations are a living document which should be revisited to enable new information to be incorporated as it emerges (Macneil et al. 2012).

The Psychiatric Formulation in Mental Health Practice There are varied approaches to formulation. All attempt to address the question: Why has this patient presented in this manner at this time and why the condition (s) has/have continued (de Beer 2017). Although formulations can be biomedical in orientation, a common approach is to use the biopsychosocial model to frame the information gathering and synthesis. The “five Ps” constitute one popular approach to organizing the content of a formulation and are summarized by Macneil et al.

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(2012). Descriptions of variants of this approach are readily accessible elsewhere (e.g., Kirby and Grover 2017; Meadows et al. 2012). Thus, a two-dimensional grid may be generated to assist in synthesizing material using the five Ps along one axis and the biopsychosocial model along the other. In brief, the five Ps (often also referred to as the four P model if the initial summary is not included as one of the Ps) start with a summary of the presenting problem containing demographic details, relevant history and symptoms or behaviors, and how the person’s life is affected. Next, predisposing factors such as biological contributors (such as genetic vulnerability which may be indicated by a family history of mental illness, acquired brain injury), psychological elements (such as the person’s habitual coping style), and social factors (such as early childhood adversity, experience of migration as a child) are synthesized. Precipitating factors are then organized using the same biopsychosocial approach, and likely significant events preceding the onset of disorder are identified, such as stressors or losses. After this, perpetuating factors are summarized and encompass factors which may be hypothesized to maintain current problems or difficulties such as ongoing substance use, social isolation, chronic physical ill-health, prolonged unemployment, and poor engagement with services. The fifth P considers protective factors or the person’s strengths which could include social supports, their motivation to change, their role and identity as a parent or employee, aspects of resilience, or helpful coping strategies. Whatever the structure or approach used to generate a psychiatric formulation, all involve clinical reasoning skills which are underpinned by critical thinking and synthesis (de Beer 2017; Macneil et al. 2012; Meadows et al. 2012). As pointed out by de Beer (2017), step-by-step guidelines are lacking because psychiatric formulation is highly case specific; therefore, he has proposed that Bloom’s taxonomy (an educational classification system) might be used to help teach formulation skills. Recognizing a similar lack of guidelines for psychosocial case formulation, Restifo (2010) proposed an initial set of psychosocial factors drawn from a range of theoretical perspectives which are accompanied by treatment implications. These include mismatch between coping skills and level of adversity; problematic beliefs, expectations, or wishes; disturbance of interpersonal attachments; “undigested” psychological material; and a systemic issue in which the disturbance is located with a group (see Restifo 2010 for further examples and details). Although still not commonplace, there are increasing calls for collaborative formulations which are co-constructed with consumers (Pemberton and Wainwright 2014). Similar care should be applied to developing collaborative formulations as to sharing diagnoses, due to the varied nature of consumers’ reactions.

The Place of Culture within Diagnosis, Formulation, and the Biopsychosocial Model In acknowledgment of one of the shortcomings of diagnostic systems and standard approaches to formulation, there has been growing acceptance of the need for eliciting and organizing cultural information relevant to diagnostic assessment and

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treatment planning (see ▶ Chap. 5, “Social-Cultural Ecological Perspective” for detailed consideration of social/cultural perspectives). This recognizes that culture affects the clinical encounter for every consumer, not only minority groups, since culture impacts psychiatric care through diverse influences on identity such as gender, age, and sexual orientation (Lewis-Fernandez et al. 2014). The biopsychosocial model is also sometimes elaborated to the biopsychosocial-cultural model to prompt consideration of cultural factors. Mezzich et al. (2001) point out that cultural factors play a significant role at each stage of the data gathering process in psychiatric assessment. They highlight that activities, ranging from, for example, engaging appropriately with relatives and significant others, the manner of exploring intimate personal matters, the interpretation of patient reports concerning the significance and severity of emotional complaints, the evaluation of difficulties with social functioning, through to assessing the extent and value of social supports, are all impacted by culture. The Outline for Cultural Formulation (OCF) was introduced with DSM-4 to provide a framework for clinicians to organize cultural information relevant to diagnosis and treatment. The OCF organized clinical information in four domains: (1) cultural identity of the individual consumer; (2) cultural explanations of illness; (3) cultural interpretations of psychosocial stressors, supports, and levels of functioning; and (4) cultural aspects of the consumer-clinician relationship. DSM-5 introduced a Cultural Formulation Interview that operationalizes the data gathering process for the OCF and consists of a core 16-item questionnaire, reportedly taking about 20–25 min to complete (Lewis-Fernandez et al. 2014; Lewis-Fernandez et al. 2017).

Beyond the Brain-Disease Model: Other Aetiological Theories of Mental Illness Socio-developmental Influences on the Genesis and Course of Mental Disorder: Accumulating Evidence In keeping with biopsychosocial approaches to causation and outcome of mental disorder, it is increasingly acknowledged that the disease risk associated with adverse environmental stimuli exceeds the effects of common genetic risk variants in exposed individuals by far (Meyer-Lindenberg and Tost 2012; Van Os et al. 2008). A plausible biopsychosocial model for the aetiology of depression is reasonably well accepted (Craig 2010). This builds on seminal work by the medical sociologist Professor George Brown and his colleagues who studied life events and difficulties which preceded the onset of depression in women (Brown and Harris 1978). As summarized by Craig (2010), up to 90% of depressive episodes are preceded by a severe life event within the previous months involving loss, humiliation (defined as likelihood that the event would provoke a sense of being put down or loss of self-esteem), and entrapment (defined as the extent to which the event underscored the fact of being trapped in a punishing situation). Subsequent studies

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have also identified psychosocial vulnerabilities such as negative self-evaluations and negative interactions in the home, which in the presence of a severe life event, were associated with depression onset (Craig 2010). In relative contrast, evidence is still emerging to suggest that “adverse social contexts and experiences over the life course” are relevant to the onset of psychosis (Morgan and Hutchinson 2010). Studies examining whether social factors play a role in the onset of psychosis are limited by methodological challenges and the complexity of the enquiry. Nevertheless, strong and consistent evidence exists for elevated rates of schizophrenia and other psychoses in migrant and minority ethnic populations (Cantor-Graae 2007; Van Os et al. 2008). The overall relative risk for developing schizophrenia associated with migration is more than double (MeyerLindenberg and Tost 2012; van der Ven and Selten 2018). Cantor-Graae (2007) points out that this risk is greater than most other risk factors associated with schizophrenia, except for family history of psychosis; she concludes that these findings are hard to explain solely in terms of biological factors. Instead, they point to a role for social factors, although underlying mechanisms remain unclear (Cantor-Graae 2007; Morgan and Hutchinson 2010). A review of recent studies has proposed that migration or ethnic minority status are proxies for exposure to an inferior social status or discrimination, which remains the most credible explanation (van der Ven and Selten 2018). There is also reasonably consistent evidence for the association of urban environments with an approximately two- to threefold increased risk of schizophrenia (e.g., Cantor-Graae 2007; Meyer-Lindenberg and Tost 2012; Morgan and Hutchinson 2010; Van Os et al. 2008), although whether this is explained by social or other risk factors is yet to be established. At present, urbanicity represents an indicator of risk factors which are more prevalent in many densely populated environments (Cantor-Graae 2007; Morgan and Hutchinson 2010). Meyer-Lindenberg and Tost (2012) suggest that the more an individual stands out from their social milieu in terms of minority status, social fragmentation, and socioeconomic status, the higher their risk of developing schizophrenia. There is also emerging evidence to implicate childhood adversity, especially sexual, physical, and emotional abuse, in the onset of psychosis, although more longitudinal and population-based studies are needed (Bendall et al. 2008; Cantor-Graae 2007; Morgan and Hutchinson 2010). Further, early childhood adversity is an increasingly accepted risk factor for other severe mental illnesses (e.g., borderline personality disorder and depression) (Meyer-Lindenberg and Tost 2012). Psychosocial influences on the course and outcome of disorders such as schizophrenia are well researched and recognized. For example, research has demonstrated a link between the emotional climate in families and the likelihood of relapse of a family member who has been diagnosed with schizophrenia (Farhall et al. 2012; Harvey and O’Hanlon 2013). Higher rates of relapse were observed in families where there was a high level of critical, hostile, or over-involved responses by family members toward the person living with schizophrenia (high expressed emotion), than in families where there was a low level of expressed emotion (Brown et al. 1972; Vaughn and Leff 1976). Such responses are best viewed as an understandable and common reaction to the experience of living with someone with a severe and

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relapsing condition (Harvey 2018). Arising from this research, family psychoeducational interventions were developed to reduce relapse by reducing high expressed emotion and helping family members to cope more effectively with the illness through education, stress reduction techniques, and skills training (Farhall et al. 2012; Harvey and O’Hanlon 2013).

Current Understandings of Causation of Psychiatric Disorders: GeneEnvironment Interactions and Epigenetics There is general agreement that there has been a failure to identify biomarkers for psychiatric diagnoses despite considerable research efforts, including studies of neuroimaging, cognitive neuroscience, and blood markers for cortisol suppression (e.g., Lacasse 2014b; Nemeroff et al. 2013; O’Donovan and Owen 2016; Timimi 2014). However, recent advances in genetic research have led to studies seeking to identify specific genetic markers for psychiatric disorders. The current state of knowledge concerning the genetics of psychiatric disorders is a vast and actively debated topic which can only be briefly summarized here. The most significant advances have been made for schizophrenia with 50 genes identified compared with only 3 genes for anxiety disorder, according to a recent review of meta-analysis studies (Gatt et al. 2015). The emerging consensus is that most psychiatric disorders, including schizophrenia, bipolar disorder, and major depressive disorder, are complex genetically and highly polygenic (O’Donovan and Owen 2016). That is, they show evidence of the combined effects of many common genetic variants of small effect, as well as rare and de novo variants of large effect (Cattaneo et al. 2016; Gratten et al. 2014; O’Donovan and Owen 2016). Gatt et al. (2015) describe some examples of genetic variants specific to a disorder, but, overall, risk alleles tend not to be specific to any disorder (O’Donovan and Owen 2016). Thus, many of the individual genetic associations are shared across multiple disorders which points to extensive biological pleiotropy, that is, the altered function of a gene influences multiple traits (Gatt et al. 2015; O’Donovan and Owen 2016). An example of the cross-disorder effects of genetic variation comes from studies of copy number variants (CNVs) in which sections of the genome are repeated. These show that CNVs that influence risk for schizophrenia also often do so for autism spectrum disorders, intellectual disability, developmental delay, and attention deficit hyperactivity disorder (O’Donovan and Owen 2016). This is a rapidly evolving field in which current methodological limitations are likely to be incrementally addressed (Gatt et al. 2015). It is now largely accepted that the best way to understand and integrate available evidence is to regard psychiatric disorders as being characterized by a complex interplay between genetic and environmental factors (Cattaneo et al. 2016; Van Os et al. 2008). Put another way, nature interacts with nurture to produce psychosis (and other psychiatric disorders) and not in a linear fashion but “where the effect of one is conditional on the other” (Van Os et al. 2008, p. 1066). Intriguingly, this echoes the systems thinking and reciprocal interactions described by Engel (1977)

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in the biopsychosocial model (Garland and Howard 2009). These developments should prompt social workers to rethink their knowledge base. In their influential paper, van Os et al. (2008) described that “biological synergism (co-participation of causes to some outcome) between environmental exposure and background genetic vulnerability is thought to be common in multifactorial disorders such as psychosis.” Added to this, the rapidly growing science of epigenetics has become increasingly relevant. Epigenetics is the study of changes in organisms caused by modification of gene expression (active versus inactive genes) rather than alteration of the genetic code itself. That is, it concerns biological mechanisms that produce variability in phenotype (observed characteristics of an individual) without a change in genotype (their genetic sequence) (http://epialliance.org.au/whatis-epi/; Cattaneo et al. 2016; Garland and Howard 2009). In their recent overview of current knowledge, El-Sayed et al. (2013) summarize the main epigenetic mechanisms, which include DNA methylation, and report that epigenetic modification has been demonstrated in the aetiology of autism, schizophrenia, bipolar disorder, depression, anxiety disorders, and suicide. This extends our understanding of how both the environment and individual lifestyle can directly interact with an individual’s genetic code to influence epigenetic change (http://epialliance.org. au/what-is-epi/), providing additional points of intervention on the pathway to development of psychiatric disorders.

Conclusion The psychiatric contribution to mental health includes an emphasis on the importance of robust approaches to assessment and diagnosis which inform and underpin treatment and service delivery. Despite the limitations of the major diagnostic systems, diagnosis retains its central place in communicating a shared understanding of disordered experiences and behaviors between consumers, families, and professionals. Talking about a diagnosis in mental health is a skilled professional task, requiring sensitivity, an individualized approach within a trusting relationship, and the time to address and revisit concerns and misunderstandings. Helpful contributions can be made by all mental health professionals, including social workers. The biopsychosocial (-cultural) model and psychiatric formulation, although not unique to psychiatry, are both noteworthy contributions to mental health practice from a medical perspective. Both help to complement and counterbalance the medical or brain-disease model of mental disorder which has been dominant in recent decades, and, consistent with social work theory and practice, they contribute strongly to a more person-centered, recovery-oriented approach to mental health practice which recognizes social aspects of human experience. Rapidly evolving understandings of aetiology in mental health, especially concerning gene-environment interactions and epigenetics, are consistent with these approaches. They help to integrate accumulating research evidence about social and environmental contributions to the development and course of mental

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disorders into etiological theory and reaffirm the value of psychosocial interventions and person-in-environment approaches to recovery. Some of the key implications for social work practice are summarized in Table 1.

Cross-References ▶ Alcohol and Drug Use ▶ Community and Mental Health ▶ Ethics, Values, and Recovery in Mental Health Social Work Practice ▶ Mental Health and Social Work: The Islamic Perspectives ▶ Individual Approach to Mental Health from a Psychodynamic and Cognitive Behavioral Perspective ▶ Social-Cultural Ecological Perspective ▶ Theories on Mental Health, Illness and Intervention ▶ Trauma-Informed Social Work Practice with Children and Youth

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Peele S (2016) People control their addictions. No matter how much the chronic brain disease model of addiction indicates otherwise, we know that people can quit addictions – with special reference to harm reduction and mindfulness. Addict Behav Rep 4:97–101 Pemberton R, Wainwright T (2014) The end of mental illness thinking? Int J Clin Health Psychol 14(3):216–220 Regier D, Narrow W, Clarke D, Kraemer H, Kuramoto S, Kuhl E, Kupfer D (2013) DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry 170(1):59–70 Restifo S (2010) An empirical categorization of psychosocial factors for clinical case formulation and treatment planning. Australas Psychiatry 18(3):210–213 Rutter M (2011) Research review: child psychiatric diagnosis and classification: concepts, findings, challenges and potential. J Child Psychol Psychiatry 52:647–660 Singh B, Ng C, Meadows G (2012) The global perspective. In: Meadows G, Grigg M, Farhall J, McDermott F, Fossey E, Singh B (eds) Mental health in Australia: collaborative community practic, 3rd edn. Oxford University Press, Sydney, pp 31–37 Smith R, Fortin A, Dwamena F, Frankel R (2013) An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Educ Couns 91(3):265–270 Stafford M, Jackson H, Mayo-Wilson E et al (2013) Early interventions to prevent psychosis: Systematic review and meta-analysis. BMJ 346:f185 Teesson M, Slade T, Mills K (2009) Comorbidity in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 43:606–614 Timimi S (2014) No more psychiatric labels: why formal psychiatric diagnostic systems should be abolished. Int J Clin Health Psychol 14(3):208–215 Timimi S, Thomas P, Davies J, Kinderman P (2014) Antipsychiatry and the antidepressants debate Lancet. Psychiatry 1(3):174 Tyrer P, Crawford M, Mulder R (2011) Reclassifying personality disorders. Lancet 377(9780):1814–1815 van der Ven E, Selten J (2018) Migrant and ethnic minority status as risk indicators for schizophrenia: new findings. Curr Opin Psychiatry 31(3):231–236 van Os J, Guloksuz S (2017) A critique of the “ultra-high risk” and “transition” paradigm. World Psychiatry 16(2):200–206 van Os J, Murray RM (2013) Can we identify and treat “schizophrenia light” to prevent true psychotic illness? Br Med J 346:f304 Van Os J, Rutten B, Poulton R (2008) Gene-environment interactions in schizophrenia: review of epidemiological findings and future directions. Schizophr Bull 34(6):1066–1082 Vaughn C, Leff J (1976) The influence of family and social factors on the course of psychiatric illness. A comparison of schizophrenic and depressed neurotic patients. Br J Psychiatry 129:125–137 Wakefield J (2013) DSM-5 and clinical social work: mental disorder and psychological justice as goals of clinical intervention. Clin Soc Work J 41(2):131–138 Wong S (2014) A critique of the diagnostic construct schizophrenia. Res Soc Work Pract 24(1):132–141 World Health Organisation (1992) The ICD-10 classification of mental and behavioural disorders. World Health Organisation, Geneva World Health Organisation (2001) International Classification of Functioning, disability and health (ICF). World Health Organisation, Geneva Yung A, Nelson B (2013) The ultra-high risk concept-a review. Can J Psychiatr 58(1):5–12

Part III Overview of Social Work Approaches in Working with Individuals, Families, and Communities

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Individual Approach to Mental Health from a Psychodynamic and Cognitive Behavioral Perspective Mun Heng Low and Stuart Stevenson

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Psychodynamic Approach in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Application of Psychodynamic Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychodynamic Notions of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychoanalytic Theory and Human Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychodynamic Theory and Reflective Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychodynamic Social Work Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychodynamic Formulation of a Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Behavior Approaches in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How People Change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Behavioral Therapy as Theory of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Behavioral Therapy’s View of Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Goal of Cognitive Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Motivating the Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment in Cognitive Behavioral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Following Is a Case Example of an Assessment Using Cognitive Behavioral Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment Plan in Cognitive Behavioral Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Therapy, Mindfulness-Based Cognitive Behavioral Theory, and Acceptance and Commitment Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Issues for Consideration in Cognitive Behavioral Theory . . . . . . . . . . . . . . . . . . . . . . . . Cognitive Behavioral Theory and Reflective Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . .

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M. H. Low (*) AMKFSC Community Services Ltd., Singapore, Singapore e-mail: [email protected] S. Stevenson CASS School of Education and Communities, University of East London, London, UK e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_6

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On Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . On Learning from the Experts for Social Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . On Learning from the Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Working with mentally ill individuals not only requires social workers to understand psychopathology and the etiology of mental illness, but it also requires them to have specific skills to counsel and manage service users suffering from various and often complex mental health conditions. This requires social workers to develop a range of skills to manage these clients. Central to this task is the social worker’s ability to build a solid therapeutic relationship. This would be regardless of any specific therapeutic approaches that underpin their work. This would enable social workers to be able to provide a tailored approach for the clients. This chapter adopts a reflective approach reviewing how social workers utilize a psychodynamic and cognitive behavioral approach in working with people with mental health conditions that includes case study vignettes. Keywords

Relationship building · Mental health · Therapeutic alliance · Social work · Psychodynamic · Cognitive behavioral

Introduction All social work intervention begins with relationship building. The management of relationship with complex service users is a central aspect of the work. Mental health problems, though they might have some biological origins, are precipitated by stresses in relationships and situations. Harry Stack Sullivan reminded us that human problems are rooted in human relations, whether these relationships are healthy or unhealthy (Sullivan 1968). Sullivan’s significant contribution is that while he recognized the importance of the biological aspects of mental health issues, he also acknowledged that powerful social and cultural forces play a determining role in creating ineffective patterns of interpersonal relating, which are often mistaken for disease. Additionally, Sullivan believed these forces were crucial even when biological disorders were evident (Evans 1996). Anti psychotics may alleviate the psychotic symptoms but will not resolve the intrapersonal and interpersonal challenges. Some symptoms may persist even with the best medication. Therefore, social work intervention begins at establishing a good therapeutic relationship that comes from the core of social work values (NASW 2017). The interest in the therapeutic alliance has increased exponentially in recent years, as well-conducted

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research pointing to the central importance of the relationship in the outcome of therapeutic work are reported (Norcross 2002). Regardless of the therapeutic approaches, the ability to engage the clients is the core of effective intervention. Through such intervention, named “therapeutic alliance” by Freud in his own words, “we make our clients our collaborators” (Breuer and Freud 1893–1895). Nevertheless, the concept of therapeutic alliance, whose origin could be traced to Freud and Sterba, was later elaborated by many psychoanalysts and, while remaining a controversial idea, gradually acquired a position of respectability. Therapeutic alliance often is defined as the contractual arrangement through which the logistics of treatment are specified (e.g., scheduling, fee setting and payments, confidentiality). Similarly, behavioral and cognitive behavioral therapy may sometimes appear to be unconcerned with the relationship and have paid increasing attention to the therapeutic relationship as a crucial factor in their work (Goldfried and Davison 1994). With this therapeutic alliance, we could work collaboratively with our clients to promote psychological health. Standing on the shoulders of established therapeutic traditions developed across various disciplines, social work pioneers such as Florence Hollis had built upon the learning and the continual developments in these traditions to help clients with mental health challenges to better manage their psychological health. As pointed out by Shedler (2010), “psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life into a greater sense of freedom and possibilities” (Shedler 2010, p. 107). Different approaches address the same problem at very different angles, which nevertheless are equally effective. Though cognitive behavioral therapy has often been cited as the evidence-based approach to manage psychological issues, a metaanalysis conducted by Scott Miller found that the result was insignificant, and that points to the fact that all methods are as effective or ineffective (Duncan et al. 2010). Different schools of thought would approach the presentation of the problem differently. Milton Erickson would help clients to deal with the state; cognitive behavioral therapy will address the faulty cognition, and psychodynamic approaches focus on assisting clients to make sense of their early childhood experiences, and others (Erickson and Rossi 2014). While some techniques carry some research evidence to show their efficacy, not one therapeutic approach holds an exclusive license to good therapy. In my opinion, they can be equally effective as there is variability in their outcomes, depending on various factors. For example, a good Rogerian therapist who could provide empathetic listening may be enough to “melt” the depression as the client feels supported while others require the therapist to challenge their default cognitions. Other approaches like emotion-focused therapy have developed empathetic intervention like empathetic attunement and empathetic conjecture, to strengthen the therapeutic relationship (Greenberg 2004). This therapeutic alliance will enable the client to feel safe and to accept the worker and the help. The fundamental sense of acceptance is implied or acknowledged in the work of Carl Rogers (1951), Les Greenberg (2002), and Diana Fosha (2000), among many others (Huges 2007). However, not all emotions are a result of faulty cognitions; emotions may arise due to various interpersonal reasons, and these need to be addressed in therapy so clients can make sense of these emotions from their own story. Thus, there is no one way toward the resolution of these predicaments.

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When a solid relationship is built between the social worker and the client, the social worker needs to provide a comprehensive case assessment based upon the biopsychosocial-spiritual framework to ascertain the issues and needs that plague the client. Once this is done, the social worker could determine the kind of intervention required. In most mental health cases, the social workers cannot avoid providing case management service that looks into the various practical and social needs of their clients. This cannot be taken lightly, as when the client is unable to get their basic needs met, it is hard to progress to another. The social worker, while attending to all the practical needs, tends to decide on how to help the client deal with the psychological predicaments using various counseling/psychotherapy approaches. While doing this, it will not just strengthen the therapeutic relationships but also provide aid in the therapy process as the client would perceive the worker as someone who is showing interest in helping them. From the casework process, the client will also develop some sense of readiness to deal with deeper issues. This chapter will focus on two classical approaches in mental health, namely, the psychodynamic and the cognitive behavioral approach.

A Psychodynamic Approach in Mental Health This section discusses the potential usefulness and the link between psychodynamic theory and its relationship-based practice – to demonstrate how psychodynamic principles can act as “interpersonal tools” to enable social workers to navigate complex relationships with the more vulnerable and challenging clients more effectively. This section addresses two main issues in mental health social work with individuals. First is the notion of an individual within a social context, positing that individuals live in a relational way and cannot be engaged in isolation. Any social work intervention, therefore, needs to engage the multifaceted aspects of the individuals in the context, to be more effective. The second part of this section addresses how psychodynamic understanding can assist the social worker in engaging with the internal and external worlds of the client to enable effective intervention while being cognizant of the material reality of their experiences concerning structural oppression, trauma, and abuse. An effective psychodynamically oriented social worker needs to traverse a complex terrain of internal and external reality between the client and the context. Psychodynamic theory enhances the reflective aspects of social work intervention that has come to the fore in the area of social work proactive education, research, and training that will be discussed in more detail. Psychodynamic theory and its sophisticated reflective capacities also provide social workers with powerful interpersonal tools to manage complex relationships with the most vulnerable clients – within the chaotic and turbulent organizations and environments in which they often inhabit.

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Application of Psychodynamic Approaches Psychodynamic theory is premised on the notion of the unconscious and conflict: the defense mechanisms employed by the individuals to manage their psychic reality. An individual will resort to defensive maneuvers unconsciously in times of stress as it becomes a challenge to self-image, for example, wanting to be a good and effective parent or member of the community or professionals such as social workers who can resort defensively if they are not perceived in a certain way by self and others (Trevithick 2011). An understanding of unconscious phenomena by social workers when working with their clients can be a particularly useful strategy to manage complex phenomena such as destructive enactments. Indeed, a psychodynamic understanding, even when psychotherapy is not involved, can enable social workers to operate beyond the surface phenomena and with a greater understanding regarding unconscious processes in their interaction with clients. The interaction, therefore, between the client and the psychodynamically informed social worker has the potential to be more sensitive to what may become enacted between the two of them. There is a need to understand what motivates human behaviors and an acknowledgment of both external and internal processes. Psychodynamic concepts and formulations deepen the understanding of what it means to be human and to recognize distress and our responses to them in terms of how people attempt to manage painful anxiety by defensive maneuvering. Examples of the more common defense mechanisms include dissociation, denial, splitting, projection, and projective identification. Additionally, the notions of transference and countertransference are also pivotal in the understanding of psychodynamic practices. Clients who are most defended are often the most traumatized; they need their defenses more than an average person. Defenses and resistances need to be understood and respected and worked skillfully and sensitively (Evans 1996). Emotional responses are not neutral phenomena. Each human encounter with a professional or person in a social situation is imbued with complex emotional aspects of prior relationships. The skills required of a psychodynamically oriented social worker are to know how to think through difficult feelings and the impact these feelings have on relationships and responses. This includes insight and management of their own defenses in the face of challenging interventions. A relationship-based practice has increasingly become an essential aspect of social work education and practice (Ruch 2005). Social work has been criticized for being too formulaic and a tick box – acting defensively and in a risk-averse way (Cooper et al. 2003; Armstrong and Rustin 2014; Cooper and Lousada 2004). Consequently, reflective practice and the use of self have come to the fore and are central to social work education. This is a requirement and practice for all social work students throughout their training in the UK – to explicitly demonstrate social work competencies and standards of proficiency for social work accreditation.

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Psychodynamic Notions of Mental Health The need to relate is innate; it begins at our very earliest days (Stern 2000). Many notions of mental health, however, are culturally specific and can change over time (Marsella and Yamada 2000). According to Freud, an indicator of good mental health is the ability to love and work (Freud 1925). This still has relevance today concerning service users whose social workers often come into contact with them while struggling with personal relationships and the maintenance of a stable lifestyle – which includes employment and the capacity to care for their own children. Melanie Klein’s (1959) notion of mental health includes the ability to maintain the “depressive position” for a significant amount of time. The depressive position requires the internal capacity to view the world in a balanced way, without needing to split relationships excessively with those we love and hate, instead recognizing that most people are far more nuanced. The ability to relate without becoming too enmeshed by projective processes with others is to see people and experiences more realistically and not excessively based on our unconscious expectations of them – an essential developmental achievement that requires the ability to have a realistic view of others that is not overly dominated by unconscious fantasy and the need to project inordinately. This is based on the premise that people have unconscious tendencies to: (i) Project the unconscious fantasy to others, thereby disavowing aspects of themselves that they need to face in order to gain a better quality of life via greater psychic health. This is through addressing rather than denying destructive aspects of themselves. The process is known as projective identification. Projective identification is important in the clinical process for the social worker; as Ogden (1982) said, “it offers a way of integrating his understanding of the social worker’s internal experience with that which he is perceiving in the client. Such an integrated perspective is particularly necessary to work with clients with schizophrenia because it safeguards the social worker’s psychological equilibrium in the face of what sometimes feels like a barrage of chaotic psychological debris emanating from the patient.” The awareness of the projective identification process in the social worker is vital to manage their own transferences and at the same time identify such observation to the client. (ii) Repeat traumatic experiences that they have been unable to manage but unconsciously revisit these experiences – this is known as repetition compulsion. Freud in his book Beyond the Pleasure Principle highlighted four ways that repetitive compulsion manifests. In the first way, the client keeps going back to traumatic incidents in their dreams rather than revisiting the good pleasure past. The second way comes from Freud’s observation that children in distress kept throwing their favorite toys from the crib, became upset with the loss, and then reeled the toy back in, only to repeat this action. Freud theorized this as the child trying to master the sense of loss. The third way is when the client brings up repressed materials of the past in therapy as if there was a compulsion to repeat the events of his or her childhood and in the transference evidently disregarding the pleasure principle in every way. The

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fourth is the so-called destiny neurosis, manifested in “the life-histories of men and women. . .[as] an essential character-trait which always remains the same and which is compelled to find expression in a repetition of the same experience” (Freud 1920). The understanding of repetitive compulsion helps the social worker to have a further understanding of the client’s behavior. For example, the victim of interpersonal relationship keeps going back to the abusive relationship.

Psychoanalytic Theory and Human Development A personality develops throughout the life span and is built primarily on early childhood experiences that are enacted and repeated in the present – in an unconscious way (Fonagy and Target 2003). Classical psychoanalytic thinking theory stemming from Freud (1925) and Klein (1959) was far more inclined to locate pathology in the individual. They saw the mind as residing within the person and a person’s mind, simultaneously relating to others’. Psychopathology in this paradigm is, therefore, generated from within the individual based on early experiences of poor parenting, innate constitution, trauma, and abuse. The idea of what constitutes an individual from a psychodynamic perspective has increasingly shifted from the individual’s mind as internal to the individual to the mind being viewed as relational and intersubjective (Stolorow 1997). It is clear that the context is an essential aspect of how clients should be engaged and of particular importance to social work due to the contextualized nature of social work and social work education. The prioritization of structural oppression and how it contributes to the development of service users’ difficulties, along with the most appropriate response to such prioritization, are the cornerstone of much social work training. Therefore, when working with individuals, even from the psychodynamic perspective, it is essential to work within their context and within their relational field, which would include the community, families, and professions. Even when working within a psychodynamic paradigm, the external world of the client needs to be held very firmly in mind in order to engage them effectively and consider their needs strategically. Clients who are often involved in statutory services tend to be the most vulnerable – requiring the involvement of multiple agencies (Evans 1996). It is, therefore, important for social workers to understand how clients’ context responds to them and vice versa, as this can be highly indicative of their state of mind that will provide invaluable information for how best to engage them. Therefore, intervention in isolation risks a potentially skewed view of their difficulties.

Psychodynamic Theory and Reflective Social Work Practice An ability to think before acting in a reflective manner is an essential requirement for social work engagement (Stevenson 2018). It is often argued that the projective

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process is deployed much more aggressively and frequently with more vulnerable individuals. The process organizes its world and those around it far more powerfully. This means that those on the receiving end of such projections are impacted more forcibly; hence, necessary skills are required to manage powerful projections and projective identification. Fundamental to psychodynamic approach in social work is the ability for the social worker to think about difficult, uncomfortable, and painful feelings and view them as communication that can be responded to in the right way and at the right time. This is no easy feat, particularly in the face of clients who may be in a crisis and who may be demonstrating violent or distressing and destructive behaviors. The reflective practice required from practitioners in these contexts is to disentangle their own feelings based on prior history with other service users, thereby creating a space for empathy and not allowing an excess of identification and enactment (Hinshelwood 2004; Evans 1996). This reflective experience requires an understanding of transference (Freud 1912; Klein 1952; Ruch 2005) in which social work practitioners may have redirected their unconscious emotions based on prior experiences with other clients, usually relating to experiences with authority figures, which may be their parents or other professionals, to other groups of clients, and the understanding of countertransference of the social workers (Heimann 1950; Corbett 2016) – feelings invoked by these groups of clients that require sensitive management and insight.

Psychodynamic Social Work Strategy The role of contemporary social work has been increasingly complex. It requires social workers to skillfully traverse many highly challenging social phenomena, societal structures, and cultural assumptions as well as powerful unconscious forces. Effective social work practitioners require an understanding of both external and internal phenomena to enable the ability to manage the balance between thinking, doing, and being as a basis of the “use of self” as a resource that they offer. The social work task demands a clear theoretical framework as a basis for social workers to plan and deliver each step (of social work activities) methodically and systematically. A well-thought-out theoretical formulation that is cognizant of clients’ predicament, the role of social workers in the context of their agency and its policies, procedures and the ethos of the community at any given time is, therefore, an essential aspect of an effective social work strategy and a basis for establishing relationships with clients. The most challenging clients require an understanding of the meaning of their behaviors especially when it involves the criminal justice system, like criminal offenses. The enactment requires understanding as a form of communication (Gordon and Kirtchuk 2008; Doctor 2003). An important way in which to access this meaning is via understanding transference and countertransference – social work practitioner-client relationship; often under the disturbed behaviors are psychotic anxieties relating to fragmentation. The task of a mental health professional is to

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enable such individuals to resist withdrawal or to regress from psychic reality – instead of facing reality and the demands of everyday life. An essential aspect of what could be an attempt at recovery is the development of insight and psychological thinking about the factors that underpin the disturbing behaviors and state of mind (Evans 1996). Attempting to make emotional contact with a traumatized and troubled state of mind is challenging for both the practitioner and the client. A response to clients’ concrete demands obfuscates an opportunity of understanding their more latent anxieties and the risk they pose to themselves and others. Overall, their behaviors can be best managed if practitioners are able to allow themselves to be emotionally impacted by the relationship they have with clients while maintaining enough distance to enable reflection during the process (Gutheil and Gabbard 1998) – this allows a more balanced view of the clients. Social workers need a model to enable them to understand communication and human suffering to manage themselves emotionally during the process, without resorting to defensive maneuvering such as withdrawing emotionally.

Psychodynamic Formulation of a Case Study The authors will bring this theory together when the social worker considers an assessment of a 35-year-old female, Ms. B, who has had a history of sexual abuse and severe neglect, chronic depression, anxiety, occasions of psychosis, and a diagnosis of borderline personality disorder. This woman had her own children removed due to severe neglect. With social work support, she began to make progress, and the children were returned to her care. However, matters deteriorated again, and the children were again removed from her care due to further neglect. Social services felt that they had given her many chances, but she was still unable to provide care for the children who were placed again in foster care. When the social worker met with Ms. B, he was struck at the poor and empty quality of her life and the complexities of essential needs. She was apparently in no position to resume the care of her children due to her own experience with trauma and abuse. Her inadequate welfare provision for children had somehow inflicted trauma and abuse on them. Considering a victim/perpetrator dynamic (Corbett 2016; Gutheil and Gabbar 1998), the social worker was simultaneously concerned with her manifestly passive, depressed, victim persona and the latent, perhaps very angry and vengeful woman due to incidents unconsciously leading her trauma and abuse to being re-enacted in her children (Motz 2016; Welldon 2011). This woman’s personality structure is highly complex and requires sophisticated understanding and management. In addition to her manifest depression and anxiety, it is essential to understand some of the unconscious and perhaps more destructive aspects if she is to be effectively helped and the risk she exposes her children to be assessed accurately. Exclusively seeing her as a victimized and lonely woman, who she indeed is, does not give a sufficiently dimensional impression of the specialist input she requires. She seems to demonstrate an example of one of the dysfunctional

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defenses called “an identification with the aggressor” (Ferenczi 1949; Freud 1936). It is a dysfunctional defense against the knowledge of the pain of previous trauma that comes at a great cost by exacerbating personal difficulties. It is often deployed by people who have been victimized and traumatized in their own lives in an attempt to master unprocessed trauma where “childhood trauma has been turned into adult triumph” (Stoller 1986). It is a significant driver for the intergenerational transmission of trauma and abuse. During the assessment process, the social worker had to manage his feelings of wanting to withdraw from her and to express his frustration at her very obvious errors leading to the harm suffered by the children, as well as her seeming oblivion to further risk of sexual abuse. However, an understanding of unconscious processes, especially projective identification, the repetition compulsion, and an identification with the aggressor, enabled the social worker to understand the complex psychological dynamics that Ms. B was caught up in, of which she had very little insight. This helped him to manage his relationship with Ms. B more sensitively and with more empathy during the assessment process, in line with child protection principles, which places the children’s welfare at the center of any recommendation and decision-making. Providing the children with the care that she never received herself but so gravely craved was perhaps a great undertaking for Ms. B. Her situation elicited a powerful and envious response, potentially fueled by resentment of the children as they were receiving the support and care that she previously did not. This prevents her from providing the children with a consistent standard of care. Factors mentioned above would need to be addressed in any psychotherapeutic work with Ms. B. Work includes any unconscious identification she has made on her own family, specifically her parents, who betrayed her and by whom she was sexually abused or despairingly longed to be provided protection from. These feelings of betrayal were re-enacted in her relationships with the social services personnel and her children. An understanding of both Ms. B’s more vulnerable and destructive aspects, albeit unconscious, would hopefully lay down the foundation for her to engage with the input that she so desperately required.

Cognitive Behavior Approaches in Mental Health This section introduces cognitive behavioral therapy (CBT) – a way of managing mental health clients. While mental health conditions may have a biological origin, for example, schizophrenia, bipolar disorders, the way we respond to the conditions and deal with it might give more power to the conditions. The success rate of this approach in dealing with a wide variety of challenging mental health conditions ranging from depression, anxiety to chronic pain, and sleep disorder have been empirically validated in numerous studies (Butler et al. 2006; Beck and Clark 1997). Cognitive behavioral paradigm is not a single school of thought; it embraces several approaches within the paradigm. Cognitive behavioral therapy is now established as a major psychotherapeutic approach and has a strong empirical basis for a range of difficulties, particularly anxiety disorders and depression (Beck et al. 1979).

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How People Change? Different schools of psychotherapy have different ideas about how people change. Indeed, the ideas have changed over time with more understanding of the human minds from different disciplines; the knowledge of mental health and wellness is also evolving (Goldstein and Siegel 2017). As such, different schools have fine-tuned their understanding of how people change. This is an ongoing process – human beings are complex, and many variables might affect these intrapersonal and interpersonal aspects.

Cognitive Behavioral Therapy as Theory of Change Beck is a pioneer in the school of cognitive behavioral therapy; Ellis has contributed a slightly different model of cognitive behavioral therapy called rational emotional behavioral therapy. Padesky and Mooney (1996) put the key ideas proposed by Beck and Ellis into a five-part generic model that the authors find very helpful in their clinical practice. Regardless of the schools, the basic premise is that human suffering is the result of faulty cognitions. These defective thinking biases implicate in the maintenance of specific problematic emotions and behaviors. The cognitive techniques could be utilized to make these cognitions more explicit and, in the process, assist clients to develop alternative useful and realistic cognitions. When default cognitions are corrected, emotions can be changed and behaviors can be managed or brought under control through cognitive and behavioral interventions that are tailored to treat these problems. The techniques include elements of both cognitive techniques and behavioral techniques such as: self-monitoring, identifying and challenging faulty cognitions and assumptions that maintain the issues and experiences, decatastrophizing, scheduling activities and behavioral experiments. Specifically, Padesky and Mooney’s (1990) five-part generic cognitive model is found to be helpful. The model outlines five domains: thoughts, physical reactions, moods, behaviors, and the environment. This model is grounded on the assumption that each element is an important aspect of life experience and that they are all interconnected. This model assumes that each area affects the others and that changes in one could lead to changes in all. We could use this model to understand mental health problems and to see how cognitive behavioral interventions could be used to deal with specific problems in different areas.

Cognitive Behavioral Therapy’s View of Mental Illness Cognitive behavioral therapy views mental illness as a result of how people view the situation that consequently affects the way they interpret the situation. The result of these views and interpretations are often manifested in a particular behavior or manner as a response to the situation.

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Aaron Beck’s theory of depression was based on the modern version of Hippocrates’ theory (Sullivan; Neale and Kendler 2000). The theory postulates that we are all susceptible to any mental health conditions; it could be biological and/or a triggering situation like stress. A good example of this would be that if an individual perceived his current state as hopeless and the individual tells himself that it is because the individual is useless, then the individual will starts to react and not try to work on the problem. Eventually, the condition will deteriorate and the prediction will cause itself to become true, also known as the self-fulfilling prophecy. Even in a situation in which one might be having auditory hallucinations, cognitive behavioral therapy would suggest that intervention would depend on how we think of these voices and how we react to them. Cognitive behavioral therapy is also used to treat psychoses and it has been proven that clients are able to develop new strategies to manage their symptoms better.

The Goal of Cognitive Behavioral Therapy The goal of clinical social workers using cognitive behavioral therapy is to help clients change effectively. Fundamentally, the primary goal of intervention in cognitive behavioral therapy is to enhance the clients’ subjective well-being and their increased feeling of well-being regardless of the reduction of their symptoms (Pinto et al. 2008). The overarching goal of the social worker using this approach could be accomplished using the following tasks. The social worker could: 1. Educate the clients about their mental health condition. The social workers need to help them understand the etiology and prognosis of the conditions. Through psychoeducation, social workers provide clients with information including sharing on the treatment plan. It is also vital for them to explain the nature of the conditions to empower the clients in the process. 2. Show the clients how they may monitor their thoughts to keep them in check. The clients could try out some exercises that can help them reconstruct more balanced thinking. This reality testing is another important task in providing help to the clients. 3. Instruct them with the principles and practice of problem-solving; this in itself is empowering as it may effectively address the actual problems that the clients might otherwise overlook. 4. Give constructive and corrective feedback on the clients’ behavior during the session. It is also important to share with them some techniques of selfmonitoring between sessions. They will benefit from this if they are given the rationale for the benefits of self-restraint, patience, and reflective delay. This is to control clients’ tendency to be reckless and impulsive when in a hypomanic state. 5. Arm the clients with strategies that help them to maximize planning, focusing, and repetition. This would help the client to overcome their disorganization and distractibility.

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As social workers, we do not prescribe any medication to our client; our primary goal is to help clients manage their distress using psychological and behavioral intervention. The treatment is often done in conjunction with motivational interviewing. We have to work along with clients based on their stages of change. The reason why stages of change are of such importance is because for the interventions to be meaningful – for the clients and for the clinical work to progress – the social worker needs to start from the stage where the client is at. At times, the clinical work may seem prematurely terminated, but it can still be a meaningful experience for the clients. The fact that clients are given an opportunity to respond to a relationship and draw out strengths and resources from their own capacities (Coker 1996) is itself empowering. There may be times that the social worker just needs to “plant a seed” for the clients and allow them to work on it after some contemplation.

Motivating the Client According to Prochaska et al. (1995), clients are often at different stages of change; for effective intervention, we need to direct different interventions to clients at a different stage of change. Prochaska et al. (1995) conceptualized the stages of change into five: pre-contemplation, contemplation, preparation, action, and finally maintenance/relapse. Pre-contemplation is when the client does not see that he or she has a problem. Contemplation, on the other hand, is when the client starts to doubt his or her perception of things, but the need to change is still ambivalent. When the client’s perception is shaken and leans toward change, he or she will start taking steps toward it. They may start reading about the situation, for example, but mostly nothing much will change. Change is when they are taking concrete actions – when they are working on the problem in the action phase. After active actions are taken then the client will move into a state of recovery. This is when they move into the stage of maintenance/relapse depending on his or her ability to maintain the change. If the client fails to sustain the change, then he or she may relapse back to the pre-existing state. At the different stages of change, the social worker needs to use different strategies to engage the client and provides intervention that may facilitate the client to move onto the next stage. For almost all clients, they are oblivious of the problems and have no insights to their situations. For example, even when a client is experiencing auditory hallucinations, he or she may still think that it is a “normal” experience. Some would think that they may have acquired some special power. Usually, they do not seek help even if they notice something is abnormal; they may still be bargaining with themselves that maybe the problem will resolve by itself. Building on the strength of the therapeutic alliance, social workers can then start collecting data that helps in case conceptualization. Figure 1 adapted from both the biopsychosocial-spiritual framework, and the 4 Ps along with cognitive behavioral formulation illustrates how to make sense of things. Social workers need to identify presenting problems (reason for treatment), precipitating (factors that trigger the

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Biological

Psychological

Social

Family history of mental illness

Poor coping

History of physical /emotional abuse

Spiritual

Poverty

Core beliefs

I am a failure I am unlovable

I am no one in society

God only loves if I am successful.

I am only happy/ accepted if I have money Triggering factors

I am unemployed!

Compensatory behaviors Precipitating factors/

Never stop chasing for money Maintenance cycle Situation

triggering event

Thoughts

Physical

Mood

Behavior Wife’s critics

Current predicaments

Perpetuating factors

Financial difficulties Rigid thinking

Low education/ society changes Lack of support in family

Mediating factors

Protective factors

Fig. 1 CBT case formulation

Open for help seeking Religious beliefs

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problem), predisposing (factors that fuel the problem), and the protective factors within the framework.

Understanding the Context Gambrill (1997) highlighted the importance of understanding behaviors in the context of clients’ environment to improve our assessment (Gambrill 1997; Cormier and Cormier 1991). The following will discuss more on assessment in cognitive behavioral therapy.

Assessment in Cognitive Behavioral Therapy It is crucial for social work practitioners to identify psychopathology by putting on cognitive behavioral therapy lenses. Using cognitive behavioral therapy to manage a hoarding disorder, social work practitioners need to conceptualize the symptoms and related challenges through processing information, understanding emotional attachment, and overvaluation of objects. Such cognitive deficits can allow and foster the development and sustainment of many irrational beliefs (Williams and Viscusi 2016). Clients with hoarding behaviors may present themselves with a set of fixed mentality that objects are precious and too valuable to be discarded. They would have assigned meanings to these objects, which might undermine the ability to dispose the items, for example, growing up during wartime in which things were hard to find. In the process of case conceptualization, practitioners have to be mindful of cultural expectations or differences as specified by the Diagnostic and Statistical Manual (DSM) (Rathod et al. 2015). It will also be useful to assess clients by looking at their beliefs systems – the cognitive triad (Beck et al. 1979). The cognitive triad comprised of three parts, clients’ belief about (1) themselves, (2) others, the world, and life in general, and (3) the future. Social workers can ascertain these belief systems via the following methods: • Direct questioning – no digression. This is exceptionally important when practitioners try to get insights on the faulty cognitions. • Homework assignments – a short write-up about how they view themselves, their lives, and the future. • In the Singapore context, practitioners who work with clients with low levels of literacy may want to propose a mobile voice recorder to audiotape their thoughts. Audios can be played during sessions with the help of visual aids, like diagrams. • Personal (and psychiatric) history of the clients – to generate hypotheses about what kind of life experiences had shaped clients to believe in what they believe. • Ultimately, the presentation of scenarios – for clients to elicit faulty cognitions through the sharing of life experiences in sessions.

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Case Example

Presenting Issues Mr. Eric, a 54-year-old gentleman, was brought to see the social worker because he was experiencing low mood and lethargy and had had no mood to engage in any activities. He was married with two school-going children. His wife was working as a salesperson to help the family finances. He had become very withdrawn, and that had caused his wife’s agitation. His symptoms included believing that he was useless because he could not provide sustenance for the family and failed to take on responsibilities of maintaining a stable income to support the wife and two children. He had gotten anxious when he was thinking of going back to work and had lost confidence in almost everything. He was fired due to some on the job mistakes he had made and was worried about his tarnished reputation. Current Situational Issues (Including Family Issues, Culture, and Community Issues) He had lived with his wife and children in a three-room flat, in an old estate in Singapore. He grew up in a traditional Chinese family of six and the parents. He managed to complete secondary education and had been working as a technician since he left school. He had worked hard for years and was promoted to a supervisory level. However, in his last employment, he had made some mistakes in his workplace which had put his colleagues at risk. Fortunately, the equipment was disabled in time to save some of the colleagues from getting injuries. The Board of Inquiry had held him accountable for breaching the safety regulations. Since the incident, he had been laid off from work where he had spent 30 years of his life doing. Cognitive Behavioral Therapy Case Formulation Mr. Eric is feeling useless as he is currently not working. He is distraught; blaming himself for not being able to provide for his family. He feels inadequate; he has no capabilities to do things and to make full use of himself. His condition has triggered wife to confront him about these negative symptoms. His two children are too scared to talk to him because he often seems unapproachable and unresponsive. Wife’s lack of insight into his condition has worsened the situation. His sense of self is significantly affected.

The Following Is a Case Example of an Assessment Using Cognitive Behavioral Approach Sharing of case conceptualization is recommended to reach a common understanding of what the goals of the treatment are (Beck 2011). The sharing can also help clients alleviate their sufferings. Most clients would feel better when they know what to expect from the therapy sessions, and when they recognize the support that the therapists are providing. When both expectations are laid on the table, and the support system is strengthened, the clients are more likely to proceed with the treatment plan.

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Besides identifying and addressing faulty cognitions, social work practitioners are expected to understand clients’ life predicament – to ascertain and eliminate causes (e.g., biomedical/organic causes, developmental delays/deficits, and other issues pertinent to immediate family and social environment) (Gambrill 1997). For instance, Mr. Eric’s unemployment may be due to unexpected economic situations, or medical conditions that have caused him not to find a job. It is crucial for us to have a holistic appreciation of the case before we can work collaboratively with clients on the treatment plan.

Treatment Plan in Cognitive Behavioral Theory By using the principles of cognitive behavioral theory, the social worker will be able to help a person to challenge his black and white thinking, that is, he is either a successful person or a complete failure. This enables him to shift his mind and begin looking at things from a different lens. The goal of challenging his erroneous beliefs is aimed at guiding him to shift his values and to face criticism head-on. There were moments when Mr. Eric could not bring himself to do so; the social worker then encouraged him to utilize some of the mindfulness-based approaches that teach individuals to resist the temptation to react; Steve Hayne’s has termed this process as psychological flexibility. After some time, he started partaking in activities and got himself a part-time job. This “break” from work is encouraged to help him cope with present situations and learn to adapt to the new demands of the workforce. As part of the recovery process, the social worker had worked with him in educating him on the low mood and shedding some insight on his state of affairs. Besides guiding him and assisting him in strengthening positive coping strategies, the social worker had proposed to him a simple problem-solving approach should he need it in times of distress, with the following steps: • • • • • •

Identify the problem. Prioritize the problem to be solved. Decide on the goals and set targets for self. Work on the steps that are necessary to achieve the targets. Review and recognize achievement. Reward self.

Cognitive Therapy, Mindfulness-Based Cognitive Behavioral Theory, and Acceptance and Commitment Therapy Current cognitive behavioral theory approaches integrate the traditional practices of mindfulness. Instead of focusing on erroneous beliefs, the clients are encouraged to take a step back and refrain from engaging in compulsive/impulsive behaviors but instead look at the situation objectively and calmly before deciding on any course of action (Segal et al. 2012). Steve Hayes in his acceptance and commitment therapy has integrated mindfulness into his intervention. He introduced intervention like

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helping clients develop psychological flexibility, where the clients are encouraged to heighten their awareness and presence of mind to the thoughts, feelings that are intruding, and choose not to respond to them, but to focus on their goal (Hayes et al. 2011).

Cultural Issues for Consideration in Cognitive Behavioral Theory The practice of any clinical work has to take cultural issues into consideration. The belief system of the clients and the practitioners are equally fundamental – belief systems can influence the outcome of an intervention. One important consideration would be the “concept of work” in the Asian culture. It can be explained that Mr. Eric’s wife (a case study presented above) had reacted strongly to the situation due to her perceived cultural expectations. Mr. Eric was unable to fulfill the set of expectations about work that resulted in the reinforcement of faulty cognition that he was useless and a failure.

Cognitive Behavioral Theory and Reflective Social Work Practice The reflective practice arose from Schon’s mistrust of technical rationality – it fails to recognize that understandings of concepts are developed from the integration of theory and practice rather than a simple application of “scientific” knowledge to the practice field (Kinsella 2010). Reflective social work practice replaces the rigidity of technical rationality; a more fluid approach in which a greater emphasis is placed on integrating both theory and practice. The process involves tailoring theoretical and research-based knowledge (what Schon refers to as the “high ground”) to fit the circumstances encountered in specific practice situations (“the swampy lowlands”) (Thompson and Pascal 2012). This translates the ability of social workers to link their own clinical experiences with knowledge derived from research to predict the efficacy of the intervention. Classical cognitive behavioral therapy would encourage social workers to challenge the faulty thought processes of clients, while the presentday approaches like mindfulness practice would advise clients to pause and look at the options presented before them before eliciting any response – to train clients not to react impulsively. As a reflective social work practitioner, we need to question and reexamine what we know (theory) and how we do (practice) what we are doing. Essentially, we need to critically look into instances such as whether a change in faulty cognition will necessarily improve the clients’ well-being. Well-being could be improved subsequent to clients’ realization of their own emotions and meaning-making.

On Learning Social workers, like many other professionals, need to constantly engage in various levels of learning. Learning could be at various levels. Social workers could engage in self-reflections, in learning from the experts, and from the clients.

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On Learning from the Experts for Social Workers Irrespective of the school of thought, social workers when faced with clients who present with mental health challenges are advised to adopt Erickson’s (1993) deliberate practice framework highlighted by Miller et al. (2017) – it contains four key elements, namely: 1. A focused and systematic effort to improve performance pursued over an extended period; 2. Involvement of and guidance from a coach/teacher/mentor; 3. Immediate ongoing feedback; 4. Successive repetition and refinement via solo performance outside of performance (Miller et al. 2017).

On Learning from the Clients Patrick Casement (1985), a psychodynamic trained social worker, in his book On Learning from the Patients, has reminded us of the value of learning from our clients. The role of supervision in social work allows social workers to guide their practice. An internal supervisor will work on cases with the assigned supervisee on topics such as personal biases – preconceived notions or conceptual misunderstandings. Social workers might have underestimated the power of their biases or unresolved issues in the past or present that could easily trigger the “sleeping” (unconscious) mind. Values play an important role in cognitive behavioral therapy. Social workers’ values may not be the main focus of analysis; they still have to be cognizant of their personal values that could affect the working relationship with clients. Schon (1983) emphasized the significance of reflecting both in and on action. Reflection in action is to reflect on behavior as it happens, whereas reflection on action reflects the behavior after an event – to review, analyze, and evaluate the situation. Another term coined was “knowing in action” to describe tacit knowledge. Unlike cognitive behavioral therapy, psychodynamic-oriented social workers place an emphasis on the process of projective identification, which provides “fertile grounds for the client blame and avoidance of the therapist responsibility” (Grotstein 1981; Whipple 1986). This issue entails competing debates in which different schools of therapy present different concepts and opinions. In this context, it will suffice to suggest that every social worker needs to raise self-awareness and to seek supervisory consultations if the issues are beyond the area of expertise. Further, Casement (1985) urged social workers to learn from their mistakes to improve and enrich their clinical experiences through constant reflection, which will help us gain insight into the psyches of people.

Conclusion Psychodynamic and cognitive behavioral approaches in working with people with mental health issues highlighted in this chapter are the two important approaches that have significant influence on the development of social work. Pioneers in social

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work have drawn heavily on these two approaches to devise ways of working with clients with various problems. However, similar to the historical development of psychotherapy that has evolved over the years, practitioners in the field are urged to build up their understanding and the application of knowledge when engaging their clientele. Issues can present themselves as far more complex; the need to constantly review existing treatment models and learn to develop new ones to improve clients’ quality of life is central. As new approaches emerge, practitioners need to keep abreast of all the developments. Furthermore, practitioners are required to master clinical skills, irrespective of differences in schools of thoughts, to be able to establish good relationships with their clients. As pointed out by Scott Miller (Duncan et al. 2010), the pivot of the relationship is the practitioner-client alliance.

Cross-References ▶ Medical Perspective on Mental Health ▶ Psychological Perspective ▶ Trauma-Informed Social Work Practice with Children and Youth

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An Overview of Social Work Approaches in Working with Families of People with Serious Mental Illness

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Abner Weng Cheong Poon and Winnie W. Kung

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of Mental Illness on Families and Carers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Objective Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subjective Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Positive Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Interventions for Serious Mental Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Do Families Need? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Elements and Forms of Family Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Intervention as an Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Why Family Intervention Works? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barriers in Provision of Family Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Emphasis on Individual-Focused Treatment Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Structural Barriers to Family Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lack of Cultural-Sensitive Family Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Families commonly assume the role of providing care to their relatives with serious mental illness in the community. Caring for someone with a serious mental illness can often result in negative consequences such as disruption in family activities, poor psychological and physical health, and diminished quality A. W. C. Poon (*) School of Social Sciences, University of New South Wales, Sydney, NSW, Australia e-mail: [email protected] W. W. Kung Fordham University, New York, NY, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_8

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of life. Social work, with its unique emphasis on systems theory, can provide a useful understanding of the relational dynamics between the people with mental illness and their families and help ameliorate such negative interactional cycles. With the strengths perspective, social workers can also recognize and support families’ resilience and positive attitudes in caregiving. Family interventions have shown robust effects in reducing patient symptomatology and relapse rate and in enhancing their functioning. They have also improved quality of life of both patients and their families, bettered communication, and reduced negative expressed emotions within families. Key elements of family psychoeducation include education about the illness, skills training in problem-solving and communication, and social support. Partnership with carers in the treatment process is also crucial. Despite evidence supporting the effectiveness of family interventions, notable barriers that limit the implementation of this evidence-based practice include the emphasis on individual-focused models, limited financial resources, and the lack of skilled family-oriented workers. By aligning with the current focus on recovery in the mental health field, social workers should utilize the systems perspective in their practice to support the recovery of people with mental illness by assisting them and their families to lead more productive lives in the community. Keywords

Families · Carers · Caregiving · Family intervention · Burden · Mental health and serious mental illness

Introduction Families have played a significant role in the lives of people with mental illness (Lefley 2009). Following the closing of psychiatric hospitals in the 1960s and 1970s in the USA, UK, and other countries, patients were discharged into the communities. Care of people with mental illness was then shifted from institutions to communities. For many, families took up the major role in caregiving. This deinstitutionalization movement was fuelled by increasing advocacy for human rights and the recognition of poor conditions and discriminatory treatment of people with mental illness in psychiatric facilities reported globally (Burdekin and Gallagher 1998). However, support was not provided to the families as they faced their challenging role in caregiving. In social work, the systems perspective has contributed to the understanding of the impact of individuals’ mental illness on the families caring for them on one hand and how families can influence the trajectories of individuals’ mental illness on the other (Bland et al. 2015a). In addition, environmental factors such as healthcare resources and legal provisions (more discussion appears in ▶ Chap. 24, “Legal Provisions, Advocacy, and Empowerment” of this book), as well as cultural perception of mental illness, also influence the experience of families. The quality and

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accessibility of mental health services play a critical role in shaping the impact of mental illness on families. Moreover, families have been seen as allies in treatment for persons with mental illness (Lefley 2009; Thorning and Dixon 2016) as they are an integral part of patients’ support systems in the community. Given that a high percentage of people with mental illness have contacts with their families (Morgan et al. 2012; Thorning and Dixon 2016), the social work profession with its unique systems view has an important role in working with both people with mental illness and their families to reduce the stress for both parties and, from a strengths perspective, to bring forth what they each can offer to one another in the caregiving process (Bland et al. 2015b; Chen and Greenberg 2004). Society’s perspective toward families in mental health has shifted considerably over time. For example, in the past, when knowledge of mental illness was inadequate, mothers of people with schizophrenia were blamed and labeled as schizophrenogenic mothers (Neill 1990). Some studies that looked at how families’ communication patterns, such as double-bind, “caused” family members to “split” cognitively to adapt to the pathological environment (see chapter by Bateson et al. (1956)) also resulted in the notion of schizophrenogenic families (Morris 2012). With increasing knowledge about biological factors involved in the development of mental illness (Healy 2016), and the advocacy movement of families of patients with mental illness, for example, the National Alliance on Mental Illness (NAMI) in the USA (Lefley 2009), blaming of families as causes of serious mental illnesses is now much less common in the field. More comprehensive discussion of the various perspectives on the etiology of mental illness can be found under Part II of this book. The notion of expressed emotion yielded many significant findings in studies relating families’ communication patterns with patients’ mental health outcomes. High expressed emotion, as characterized by family members’ hostility, criticism, and emotional over-involvement toward the person with mental illness, was found to reduce patients’ functioning and shorten the period between relapses (Kavanagh 1992; Wearden et al. 2000). Although some interpreted the research findings as blaming families for worsening the conditions of the patient, the findings sparked family interventions that aimed to help families adapt to their caregiving role and reduce their highly charged and emotionally intense interactions with their relatives (Wearden et al. 2000). As a result, these studies helped to improve the quality of life for both the patients and their families. Increasing recognition of the rights and privacy of people with mental illness in psychiatric services has resulted in families and carers not being provided with adequate information about their relatives and sometimes being shunned or sidelined in the treatment process (Rowe 2012; Thorning and Dixon 2016). In recent years, family advocates, researchers, and practitioners have argued for involving families in the treatment planning of people with mental illness. Families are increasingly being recognized as collaborators and allies in the treatment process. In this chapter, we shall address the impact of mental illness on families and carers, the benefits of family interventions for individuals with serious mental illness (hereon as patients), and the barriers that need to be addressed in order to provide such interventions more effectively. Although we acknowledge that family therapy is used by mental health

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workers in their practice, especially with patients and families affected by milder mental health issues, we will not be discussing family therapy in this chapter. This is because we are focusing our discussion on patients with serious mental illnesses which include schizophrenia and schizophrenia spectrum disorders, bipolar disorders, and other psychotic disorders. We shall use family/carer interchangeably to describe people who provide some caring responsibilities to their relatives/friends with mental illness while acknowledging that people with mental illness may not consider themselves as needing a carer and that their families/friends may not consider themselves as carers to their loved ones (Lawn and Mcmahon 2014).

Impact of Mental Illness on Families and Carers Serious mental illnesses compromise individuals’ cognitive and affective functioning. When these patients are in an actively psychotic state, they can lose contact with reality through delusions and hallucinations, and at other times they can also become very inert and withdrawn. Such symptomatology can be debilitating to their day-today functioning and can be very disturbing to people around them, especially their family members. Because of their compromised level of functioning, they need a lot of assistance, and families often get involved in providing assistance and protection. These mental illnesses also have relapsing courses requiring long-term care, thus putting chronic strain on the carers (Thorning and Dixon 2016). The impact on families who are caring for someone with mental illness has been well documented in numerous studies. Early studies exploring the experience of family members found largely negative effects from caring for someone with mental illness, as carers bore the brunt of the burden of care for their ill relatives with few pertinent services in the community shortly after deinstitutionalization (Grad and Sainsbury 1968). The challenge in caregiving to people with serious mental illness seems to persist to date (Caqueo-Urízar et al. 2017; Poon et al. 2018b; Thorning and Dixon 2016). Diverse negative effects on carers include disrupted relationships, psychological distress, and financial difficulties (Kung 2016a; Lin et al. 2018). Researchers have developed the notion of caregiving burden to capture these negative effects experienced by families. Objective burden refers to challenges imposed on carers’ activities, relationships, health, housing, and finance; subjective burden refers to individuals’ perception of the emotional challenges and difficulties in caregiving (Schene et al. 2006). Studies have indicated that the degree of caregiving burden was mediated by factors such as levels of appraisal of the illness, social support, coping strategies, and relationship between family and patient (Joyce et al. 2000; Zegwaard et al. 2011).

Objective Burden The most commonly reported burden experienced by families is the disruption of their daily activities when caring for someone with mental illness (Kung 2016b). They may need to put their own activities on hold or curtail them in order to care for

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their loved ones. Many studies reported that carers often felt socially isolated (Hayes et al. 2015). Some families reported not attending social gatherings out of worries about leaving the person with mental illness alone at home or fear of embarrassment or shame due to patients’ sometimes disruptive or socially inappropriate behaviors (Kung 2016b). Some carers only shared their challenges with some close friends, as they perceived that most people would not understand or were worried that others would judge them. Some carers reported finding that their relatives and friends avoided visiting or socializing with them (Kung 2016b). Relationships between different family members may be affected as the primary carers may sacrifice their relationships with other relatives while focusing on their responsibilities caring for the person with mental illness (Caqueo-Urízar et al. 2017). Siblings of people with mental illness may feel that their parents give more attention to their siblings (Bowman et al. 2015). Likewise, spouses of the primary carers may feel neglected; poor relational and sexual satisfactions have also been reported (Lawn and Mcmahon 2014). People with mental illness who themselves are parents may experience additional challenges in managing their parenting responsibilities and mental health. Many studies in the last decade examined the needs of young children and their parents with mental illness (Campbell et al. 2012). Children affected by parental mental illness are more likely to have behavioral problems and feel isolated and have higher risk of developing mental illness (Reupert and Maybery 2016). Parents with mental illness may need coaching and emotional support in parenting and community or home-based interventions (Reupert and Maybery 2016). Challenges of parents with serious mental illness are discussed more comprehensively in ▶ Chap. 22, “Parenting Challenges for Persons with a Serious Mental Illness” of this book. Carers’ experience of poor mental health is well established (Jansen et al. 2015). They tend to develop anxiety disorder, depression, or both. Studies have also documented that carers may experience poor sleeping pattern, psychological distress, and worries (Jansen et al. 2015). Carers seeking psychological or psychiatric treatment for their own mental health problems has also been reported (Kung 2016b). Poor physical health status of carers that deteriorated significantly over time has been reported recently (Poon et al. 2017; Thunyadee et al. 2015). Some carers experience some somatoform expression of stress such as pain and fatigue due to long-term caregiving responsibilities, and they tend to neglect their own physical health (Thunyadee et al. 2015). Due to overwhelming caregiving responsibilities, financial burden, or personal neglect, carers often do not maintain a healthy lifestyle. A recent study reported that carers of young people with early psychosis have a high risk of diabetes, being overweight, and having other long-term physical health problems (Poon et al. 2018a).

Subjective Burden Families also worry about long-term care of their loved ones with mental illness. People with serious mental illness tend to have difficulty finding employment and

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lack independent living skills; thus parents are often very involved in supporting them financially and in day-to-day care. This burden of care becomes increasingly poignant as the parents age and begin to have their own health problems. They often worry about who will take care of their mentally ill children when they can no longer care for them (Kung 2016b). Siblings who take over the caregiving responsibilities when parents are gone may also experience caregiving burden and psychological distress (Bowman et al. 2015). Carers also reported experiencing grief over their loved ones’ mental illness and the related lost opportunities in life (Miller et al. 2008). This sense of grief is clearly documented in studies of parents of children with mental illness. Carers’ levels of grief were noted to be related to the deterioration of the functioning levels of their relatives over time (Poon et al. 2017). The prolonged grief in carers of people with long-term mental illness is often not recognized and neglected by mental health professionals (Poon et al. 2017). Overall, carers perceived their quality of life to be poor (Hayes et al. 2015). Studies conducted in various countries showed that carers experienced poorer quality of life than the general population, and such poor quality persisted over time (Hayes et al. 2015; Poon et al. 2017). Carers’ perception of their quality of life was found to be closely related to their own physical and mental health and to their perceived caregiving burden (Hayes et al. 2015). Carers’ quality of life was also found to be related to patient-related factors such as psychiatric symptoms and functioning (Boyer et al. 2016). Given the immense burden of care that families experience, social workers should consider assessing the needs and well-being of family members as a routine practice. In addition, social workers should consider ways to ease carers’ stress by educating families about mental illness and its effects, medications, and resources. Providing family intervention is an important option, which will be discussed more comprehensively later.

Positive Impact While there are negative impacts from caregiving, some families are able to appreciate the experience as positive transformations when they manage to cope with the challenges. Some carers were able to experience a deepening sense of self-awareness and inner strength and greater capacity to empathize with those who were more vulnerable in society (Zauszniewski et al. 2010). Some relatives reported seeing themselves become stronger, more tolerant, less judgmental, and more sensitive toward others (Lukens and Thorning 2011). Others found the positive effects of caregiving by achieving a sense of purpose in life and altruism (Chen and Greenberg 2004). Most carers did not choose this role for themselves but rather acted out of a sense of responsibility they get involved in the care for their ill relatives (Lawn and Mcmahon 2014). Many, however, accepted the role positively and demonstrated devotion to their loved ones (Kung 2016a; Thorning and Dixon 2016). Moreover, caregiving could sometimes be reciprocal as carers also received emotional and practical help from the family members for whom they cared (Chen and Greenberg 2004; Coldwell et al. 2011). Caregiving relationships were reported to be rewarding

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for both carers and recipients of care (Coldwell et al. 2011). Limited studies have investigated the positive effects of caregiving; as a result, understanding of the transformation process and benefits of caring for people with mental illness is inadequate. Coming from a strengths perspective, it is important for social workers to embrace families’ experience of personal growth and the role of patients in contributing to these gains as they facilitate the journeys of recovery for both patients and their carers simultaneously.

Family Interventions for Serious Mental Illnesses Given the chronic nature and the relapsing course of serious mental illnesses like schizophrenia, bipolar, and other psychotic disorders, and their debilitating impact on patients’ cognitive and psychosocial functioning, family involvement in caregiving is often necessary. Family interventions have been developed to help families with the immense challenges in assuming the caregiving role and the possible mutually reinforcing negative interactions between carers and patients that ultimately worsen the illness trajectory. In the following section, we shall examine (1) what these families may need in order to ease the burden of care and facilitate patient recovery; (2) the key elements and forms of family interventions; (3) research findings that indicate family intervention as an evidence-based practice; and finally (4) why family intervention works.

What Do Families Need? The positive symptoms of schizophrenia, bipolar, and other psychotic disorders which manifest as the presence of delusions, hallucination, and disruptive behaviors and the negative symptoms that manifest as the absence of certain behaviors in the form of inertia and paucity of affects may cause relatives to feel anxious, angry, guilty, sad, and frustrated. These feelings of relatives may intensify their expression of criticism and overprotection of the patient (Anderson et al. 1986; Kavanagh 1992). Because of the core psychological deficits these patients experience, they are particularly vulnerable to internal and external stimuli (Anderson et al. 1986). Thus, families’ intensely expressed emotions and behaviors are likely to exacerbate patients’ stress and lead to greater vulnerability to relapse. Such mutually reinforcing cycles of negative interactions need to be stopped (Kung et al. 2012). Very often the ways that patients tend to react and what may help them could be counterintuitive to many carers and clinicians (McFarlane 2016). Thus, carers need knowledge about the nature and course of the illness so that they can form realistic expectations of patients’ functioning and the illness trajectory and keep pace with their gradually increasing capacity without exerting undue demands (McFarlane 2016). Families also need to be coached on effective communication with their ill relatives to reduce the escalation of these expressed emotions that causes excessive stimuli and stress to patients. They also need coping strategies to handle the immense burden of care and resolve problems and conflicts arising in the caregiving process.

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Such support to families could lead to calmer family interactions which not only benefit the carers but also delay patient relapse (Hooley 2007). Given the immense stress experienced by these families and their social isolation, it is also important to provide emotional and practical support as they go through the emotional upheavals resulting from the relapsing cycles of the illness. Crisis intervention and home-based services would also be helpful during critical periods. Respite care may sometimes be necessary for carers as well so that they have some space to recuperate from the burden of care. Moreover, support not only from professionals but from other carers who have had similar experiences is very important as they are able to empathize and share their experiences with each other. Since the continual use of psychotropic drugs is of paramount importance in helping patients maintain their mental functioning, families need to be educated to help them support patients’ medication compliance and consult with the psychiatrist regularly. To facilitate patients’ attainment of their longer-term recovery goals, families need help to understand and support patients in completing their educational goals and securing employments at the level they can achieve. This not only fulfills the goals of their loved ones with mental illness but also provides a source of hope and reduces dependence, thereby easing the caregiving burden (Thorning and Dixon 2016). Due to the debilitating effect of these serious mental illnesses, patients often are not able to maintain independent living and rely on services and government benefits to satisfy their tangible and psychosocial needs. Due to the myriad of service provisions and the complex bureaucracies in the mental health and government systems, families often need information about community resources and assistance in navigating them to gain access to needed services and benefits. The aims of family interventions are two-pronged: to improve conditions for persons with mental illness and those of their families. For persons with mental illness, improvement of their clinical outcome and functioning levels is the main goal. Key targeted areas of clinical outcomes include reduction of psychiatric symptoms, relapses, and hospital stays. Functional outcomes involve social and occupational functioning such as employment, independent living skills, and quality of social relationships. Family interventions also aim to reduce carers’ stress so as to enable them to support their ill relatives, so that they can improve their own quality of life and attain some of their own life goals in the recovery process.

Key Elements and Forms of Family Interventions In response to the needs of caregiving families and to professionals’ increasing recognition of families as allies and indispensable partners in the treatment process, numerous family interventions have been developed and researched. They are basically grounded in psychoeducation which integrates educational elements and therapeutic theories (Thorning and Dixon 2016) such as family systems and problem-solving. According to the World Schizophrenia Fellowship (1998), family intervention is a structured method for incorporating patients’ family members, other relatives, and friends into acute and ongoing treatment and rehabilitation.

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Family psychoeducation includes cognitive learning such as information about the etiology and course of the illness, medication, treatment management, community resources, and service coordination to facilitate community integration. It also involves imparting knowledge and skills to improve family communication and addressing both patients’ and carers’ expectations, emotional reactions, and distress. Family members are helped to maintain clear boundaries through appropriate lowkey direct communications and to share both their positive and negative thoughts and feelings toward each other. Clinicians can coach carers to express themselves calmly, clearly, and briefly and to avoid critical and hostile comments as well as nagging and emotionally charged exchanges. Carers are guided on implementing structured problem-solving strategies and coached on individualized coping and rehabilitative strategies. Finally, facilitating the expansion of social support networks, integration with the community, and crisis planning with professional involvement are also essential. In family intervention, the family is not the object of therapy but rather an indispensable partner to the mental health professionals. Through the intervention, family members become more sophisticated key implementers of interventions, with their own different expertise and potential skills, thereby complementing clinicians to counter the neurologic deficits inherent in the disorder (McFarlane 2016). However, carers’ self-care should be emphasized to avoid burnout. Similar elements are noted for family intervention for bipolar disorder, namely, psychoeducation, communication enhancement training, problem-solving skills training, and self-care for carers (Reinares et al. 2014). Regardless of the type of disorder, many family interventions include elements of a peer group format to provide the much-needed emotional support, practical advice, and information sharing on community resources among people who can identify with their challenging caregiving ordeals and whom they can trust without the fear of stigma. In the process of helping others, carers also feel empowered. Unlike some psychotherapy groups, members of these carers’ support group are encouraged to socialize outside of the group sessions and become each other’s social network after the formal conclusion of the group to combat the social isolation in the caregiving process (Lefley 2009). Over the past four and a half decades, various models of family intervention with varying lengths and formats have been developed and tested. Family psychoeducation was found to be more potent than other family interventions in attaining positive outcomes for patients and families. There are at least two main types of family psychoeducation conducted by mental health professionals such as social workers, psychiatrists, and nurses. One involves single-family sessions with both the carers and the patients, following workshops in which information about the mental illness is shared mainly with carers (Anderson et al. 1986; Falloon et al. 1984). Another involves a psychoeducational multifamily group in which a few families with both patients and carers attend the sessions together (Kopelowicz et al. 2012; McFarlane 2004). Commonly used models today are a mix of family psychoeducation (Anderson et al. 1986), behavioral family therapy (Falloon et al. 1984), and multifamily group therapy (McFarlane 2004). Other models include

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individualized family consultation (Poon et al. 2019), modified forms of more traditional family therapies (Marsh 2001), and open dialogue which is a modern adaptation of systemic family therapy (Seikkula et al. 2006). Some professionally led short-term models of family education or therapeutic education have also been developed and implemented (Amenson 1998). In addition to programs led by professionals, family-led information and support classes or groups have mushroomed in the past two decades, such as those offered by Carers Australia and the National Alliance on Mental Illness (NAMI) in the USA and the Journey of Hope (Dixon et al. 2011), which are all delivered in the community. One advantage of having these programs in the community is that even when patients are not involved in the mental health system, families can still obtain such practical and emotional support (Thorning and Dixon 2016). With the increasing use of technology, the latest development seems to be online programs of family psychoeducation which shows positive results for both patient and carer (Rotondi et al. 2010). Through the Internet this approach could expand its reach to persons with serious mental illnesses and their families who live at a distance from other families, treatment facilities, or family support and advocacy groups, so that they can still obtain needed support in the community and reduce social isolation (Thorning and Dixon 2016).

Family Intervention as an Evidence-Based Practice Various models of family intervention have been implemented and studied, and results indicate that they are one of the most persistently effective interventions for the treatment of schizophrenia, bipolar, and other psychotic disorders. In a comprehensive review funded by the US National Institutes of Health on Schizophrenia Patient Outcome Research Team (PORT), family intervention was highlighted as being of critical importance to positive patient outcome compared to other psychosocial treatments, pharmacotherapies, and electroconvulsive therapy (Dixon et al. 2010). The most recent reviews by McFarlane (McFarlane 2016) and Thorning and Dixon (Thorning and Dixon 2016) reiterated its high acclaim for patients with schizophrenia, and that by Reinares et al. (2014) reported the same for patients with bipolar disorder. With over 100 outcome studies on family psychoeducation in the past over four decades, meta-analyses of the studies indicated a reduction in relapse rate by 50–60% in individuals receiving family psychoeducation compared to those receiving treatments as usual (McFarlane 2016). Other positive patient outcomes included reduction in psychiatric symptoms, especially positive symptoms (Magliano et al. 2006), reduction in rehospitalization and patients’ perceived stress (Dyck et al. 2000), increased medication adherence (Mueser et al. 2001), and improved social functioning and enhanced vocational outcome (Zhang et al. 1994). For carers, there was notable lowering of burden and distress levels (Sellwood et al. 2007) and an increase in illness knowledge and a sense of efficacy and well-being. Improvement in family relationships and functioning (Jewell et al. 2009; Lefley 2010), together with increased perception of professional and social

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support (Magliano et al. 2006), was also noted. These positive outcomes were found to persist at 1–2 years of follow-up after intervention (McFarlane 2016). While the aforementioned positive outcomes were mainly reported in studies on patients with schizophrenia, similar findings were also noted in patients with bipolar disorder (Reinares et al. 2014). It should be recognized, however, that the level of effectiveness of family intervention is related to the duration of treatment implemented (dosage effect) and the state or stage of the patient’s illness. In the PORT report in the USA, family psychoeducation was highlighted as the recommended treatment to be offered for at least 6–9 months to patients with a recent relapse or exacerbation in order to attain significant reduction in relapse and rehospitalization rates (Dixon et al. 2010). While studies on stable patients without recent episodes also showed reduction in relapse and hospitalization rates, the results were weaker compared to those with recent exacerbation (Thorning and Dixon 2016). Interventions of less than 6 months showed varied results, with longer interventions for those without recent episodes bearing better results in general (Thorning and Dixon 2016). In situations where at least 6 months of family intervention was not feasible or acceptable, a minimum of four sessions was shown to have positive patient and family outcome for both stable patients and patients with a recent relapse (Thorning and Dixon 2016; Vaughn et al. 1992). However, another meta-analysis of 16 studies found that family interventions of fewer than 10 sessions had no important effects on relatives’ burden (Cuijpers 1999). For bipolar disorder, positive outcomes for both patients and families were reported when the intervention was started post episode or when the patient was in remission. However, studies showed inconsistent findings when family psychoeducation was introduced when the patient was in the acute phase of their illness. Family intervention seems to improve mood for at least a subgroup of patients such as those whose families have high impairment levels (Miller et al. 2008; Reinares et al. 2014). In general, family intervention is particularly beneficial in the early years of the course of a serious mental illness when improvements can have a dramatic and longterm effect when family members are still involved, open to participation, and willing to change in attitude and interaction with the patient. It seems that family intervention provided to people with first episode and prodromal psychosis yields the most promising results with substantial return of functioning and prevention of psychotic episodes altogether (McFarlane 2016).

Why Family Intervention Works? One of the important functions of family intervention is that it seeks to engage family members in collaborative decisionmaking among patient, family, and clinician. Thus clinicians’ empathic engagement of patients and family members is of prime importance (McFarlane 2016) so that they can work as a team in the treatment and rehabilitation process. Studies indicated that when clinicians reached out to families

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by conducting in-home sessions, it promoted positive outcome (Falloon et al. 1985; Reinares et al. 2014), likely by conveying clinicians’ earnestness in helping as well as reducing practical and psychological barriers of the families to receive treatment. Furthermore, although psychoeducation is an important element in family intervention, studies have shown that programs that present information without also imparting skills to carers in communication and problem-solving regarding illness management and rehabilitation fail to reduce relapse rates (Falloon et al. 1985; Greenberg et al. 1995). Thus clinicians need to not only instruct but also provide opportunities for carers to practice the skills learned to increase their sense of selfefficacy in coping with the illness situation (Cuijpers 1999). Another important element that makes family intervention so potent is that it helps to increase social support to families and expand their social network such as through the multifamily psychoeducation groups or carer support groups, whether facilitated by professionals or carers themselves. This building of community support in the longer run is important to combat the sense of isolation through the sharing of concerns, burdens, and ultimate coping strategies, especially in view of the stigma around serious mental illnesses and the immense challenges in the caregiving process. Although the original goal of family intervention was to decrease high expressed emotion as a means to prevent relapse, studies found that while many of the effects of family intervention were mediated by reductions in expressed emotion, such effects were enhanced by elements that focused on clinicians’ general empathic support to families and patients; problem-solving, coping, and communication skills training; and the enhancement of social networks and support (McFarlane 2016). Some argue that services should not consider providing a particular type of family intervention only but rather consider a range of family interventions and offer appropriate multiple interventions to families (Harvey et al. 2012). As interventions address different areas, no single intervention will be able to address all the needs of people with mental illness and their families. Family inclusive approaches then serve as a first level of family intervention to engage carers, which can be used further to introduce other appropriate family interventions to meet their needs accordingly (Poon et al. 2019). Family interventions should not be provided as a once off program but ongoingly in order to support families long term, especially those having a patient with a serious and chronic mental illness such as schizophrenia.

Barriers in Provision of Family Interventions Despite substantial evidence showing the effectiveness of family interventions, especially family psychoeducational programs, family interventions are often not routinely provided in mental health services (Harvey and O’Hanlon 2013). Many researchers have highlighted that there are multiple barriers hindering such provision. We are categorizing commonly known barriers in three broad areas: emphasis on individual-focused models, structural factors, and the lack of cultural-sensitive models.

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The Emphasis on Individual-Focused Treatment Models Due to the recognition of the importance of case management in mental health, public mental health services have largely reorganized services into case management approaches and emphasized on individualized care of people with mental illness in the community (Dieterich et al. 2017). Within individual-focused models, case managers have a key role in coordinating services to support people with mental illness in obtaining necessary resources to cope with the impact of the illness. While there are benefits to individualized care in supporting people with mental illness, there has been a neglect in providing holistic care to families coping with caregiving responsibilities. Numerous studies have reported that families felt dissatisfied with their low level of inclusion in the planning and discussion of the treatment of their relatives with mental illness (Poon et al. 2018b). Sometimes in the name of the protection of patient confidentiality, families who had more contacts with patients were not solicited for information that may have given a fuller picture of their functioning. In addition, with the emphasis in recovery of individuals, services may focus solely on the betterment of individuals. The burden of caregiving for someone with a long course of psychiatric illness and the failure of services to address families’ needs have resulted in some carers experiencing poor health and well-being and becoming dissatisfied with mental health services as discussed earlier. As family inclusive practice and family intervention have shown promising results, it is important to obtain management’s support by elucidating them on the effectiveness of these treatments in order to promote a family-sensitive practice culture and to increase the uptake of family intervention.

Structural Barriers to Family Intervention The second barrier to family intervention is related to structural factors. Along with the implementation of individual-focused models, organizations receiving funding tend to focus on their responsibilities in providing individualized psychiatric treatment and care to people with mental illness. Thus, minimal funding is available for additional family interventions within routine care (Harvey and O’Hanlon 2013), and the incentive within organizations to provide additional work with families may be minimized. In addition to finance, other resources are required to implement family intervention. One of them is skilled mental health workers to provide the service. As training in family intervention is often not provided in discipline-specific tertiary education, mental health workers need to learn how to work with families on the job. Furthermore, there is a lack of skilled supervisors in mental health services who can provide supervision to staff with keen interest in family intervention and promote a culture that supports family work. This points to the importance of family systems in general and of family intervention in particular in social work professional training as well as postgraduate professional development training. It is only with adequate training and supervision that staff could have confidence and motivation to work with families.

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Another structural barrier is related to the availability of space in which to provide family interventions. Most community mental health services operate within the context of a clinic. Most psychiatric clinics have limited adequate consultation rooms for workers to provide family interventions. Although workers can provide family interventions at homes of families, this limits the type of family treatments to interventions with single-family units. Thus creativity in space use and intentional design in mental health settings are important to accommodate the conduct of family sessions, psychoeducational workshops, and support groups.

Lack of Cultural-Sensitive Family Intervention The last barrier is the lack of cultural-sensitive models in family interventions (Barrio and Yamada 2010; Rooney et al. 2006). Most family interventions are developed in White culturally dominant contexts. While not minimizing the benefits of existing family interventions for diverse cultures, these practices may not be readily applicable in local contexts. For example, the topic of emancipation in Anderson’s family psychoeducational model (Anderson et al. 1986) and open family communication in Falloon’s Behavioral Family Therapy (Falloon et al. 1984) may not be useful for families with more traditional cultures in which it is a norm for unmarried family members to stay home with their parents and more subtle communication styles are preferred. Many have argued that family interventions could be useful for ethnic minorities but need to be modified to ensure that they are culturally relevant (Giacco et al. 2014; Lucksted et al. 2012). To address this need, some culturally sensitive family intervention programs have been developed. Based on family psychoeducational programs (Anderson et al. 1986) and multifamily groups (McFarlane 2004), a family psychoeducational program was developed for Chinese American families with a patient having schizophrenia (Kung et al. 2012). The program recognized the need for the psychoeducation element of imparting knowledge about the mental illness and providing support among carers. It also accommodated the Chinese culture’s sensitivity to shame when patients’ problematic behaviors are revealed directly in front of “outsiders” and thus adopted a single-family model to coach carers in communication and problem-solving with their ill member. The study showed promising results in supporting Chinese immigrant families. Positive outcome was also seen in a multifamily group trial (McFarlane 2004) for Vietnamese families in Melbourne, Australia (Bradley et al. 2006). In this modified multifamily intervention, patients were invited to participate in multifamily educational sessions, ethnospecific explanatory models were recognized before introducing the biopsychosocial model of illness, and both traditional and western treatments were acknowledged (Bradley et al. 2006). Another culturally modified multifamily group therapy based on the McFarlane’s model (2004) found improvement in medication compliance among Mexican Americans with schizophrenia by considering their belief and attitudes toward medications (Kopelowicz et al. 2012). In addition, Mooney and colleagues have provided a discussion of a Māori model of practice which includes cultural, spiritual, and contemporary indigenous practices in working with Māori

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families in New Zealand in ▶ Chap. 13, “Māori Social Work and Māori Mental Health in Aotearoa New Zealand” of this book. Given the clear need for culturally sensitive programs, more family interventions need to be developed and studied among different cultural groups in different countries.

Conclusion As social workers constitute a large number of the work force in the mental health field, they have an important role in providing services to patients with serious mental illness and their families. Understanding the intricate relationship between the wellbeing of patients and that of their carers, social workers should advocate for family involvement in the treatment process and attend to carers’ needs resulting from their caregiving burden. With the growing emphasis on recovery in the mental health field which aims at facilitating people with serious mental illness to regain autonomy in the community (Davidson et al. 2008), the role of families/carers in assisting these patients is of paramount importance. Social workers are well equipped to work with both families and their relatives with mental illness given their systems orientation in both theory and practice. As members of the multidisciplinary mental health team which has a large number of medical and nursing professionals, rather than conforming to the norm of individualized approach in mental health treatment, social workers should advocate for families in mental health practice. They should play a major role in contributing to the provision of family interventions such as family psychoeducation programs in partnership with carers and other professionals. By seeking the perspectives and contributions of carers, social workers can help to develop or adapt innovative family interventions that are well suited to the local contexts. By aligning with mental health policies concerning recovery, social workers can advocate for working with families as being essential in contributing to the recovery of people with mental illness (Poon et al. 2018c).

Cross-References ▶ Legal Provisions, Advocacy, and Empowerment ▶ Māori Social Work and Māori Mental Health in Aotearoa New Zealand ▶ Parenting Challenges for Persons with a Serious Mental Illness ▶ Reflection of Future Social Work Practice in Mental Health ▶ Theories on Mental Health, Illness and Intervention

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Domain of Social Work Practice in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lived Experience as an Organizing Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Nature of Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding Recovery Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Element 1: Connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Element 2: Hope and Optimism About the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Element 3: Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Element 4: Meaning in Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Element 5: Agency and Empowerment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stigma, Shame, and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Example: Our Consumer Place – Empowerment Through Collective Action . . . . . . . . . . . . . . . . . Empowerment Through Challenging Orthodoxy and Promoting an Alternative Voice . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Contemporary mental health policy and practice has been based on two basic principles – the need for an evidence-based approach to practice and a recognition of the importance of understanding the lived experience of mental illness. Beyond the symptoms of the various disorders is the range of personal and social consequences of illness. These include disruptions to a sense of self, R. Bland (*) Australian Catholic University, Brisbane, Australia e-mail: [email protected] G. Drake Australian Catholic University, Sydney, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_7

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relationships, economic security, work, and housing. The social context and social consequences of mental disorder are central to social work practice in the mental health area. This chapter has explored a number of theoretical perspectives including the concept of lived experience, recovery theory, stigma, shame, and empowerment. A practice focusing on these social dimensions of mental illness demands an engagement both with the broader evidence base shared by all disciplines, and a specific concern for individuals and their families, and the experience of mental illness and its consequences in their lives. Keywords

Recovery · Community · Empowerment · Social work · Mental health

Introduction While the experience of mental distress is acutely personal, we acknowledge that people experience that distress within a network of intimate and other social relationships. Social work has traditionally sought to apply a broad focus to understanding mental health problems. We see an individual within a family, within a community. We understand the importance of life stage; of schooling and work; of physical health; of gender, ethnicity, and culture; of sexuality, disability, and spirituality; and of housing and income security. A broad social work perspective on mental illness seeks to understand how each of these dimensions of social life shapes the experience of mental distress. In this chapter we will explore a number of important theoretical aspects of social work practice, specifically the concept of “lived experience” of mental illness, the concept of community, and the potential for recovery theory to provide a coherent theoretical basis for organizing social work practice. We will consider the nature of social inclusion, stigma, and shame. Empowerment is often identified as a goal for social work practice, and we will consider this concept and examples of empowerment in group and community settings. In this chapter, we have chosen to use the term consumer to describe individuals who have a lived experience of mental illness and treatment. This is the term preferred by individuals with a lived experience in the Australian context. In other countries the term service user is commonly used.

The Domain of Social Work Practice in Mental Health In their review of the various ways of understanding the domain of social work in mental health, Bland et al. (2015) identify different approaches to practice in different national contexts. For example, many social workers in North America work as private practice therapists on a fee for service basis. In Britain and Australia, this is less common, and social workers are generally employed in public

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mental health settings as part of multidisciplinary teams or in community-based recovery-oriented services. Mental health legislation and differences in policy and funding of services in various countries shape the way that social work is practiced. In New Zealand, for example, mental health services have been strongly influenced by multicultural principles so that Maori culture is acknowledged and broader community approaches are incorporated to complement more individual treatments. In Australia over the last 20 years, there has been a significant effort within the social work profession, to articulate the role of social work in mental health and to lift the practice competence of mental health social workers (Bland et al. 2015). The Australian Association of Social Workers (AASW) has specified core knowledge and skills that all schools of social work have to teach in social work programs as a condition of accreditation (AASW 2017). The AASW has established a specific category of membership that recognizes advanced competence in mental health that qualifies accredited members for private practice work in the national health insurance scheme. A key aspect of the AASW reforms has been an articulation of the domain of social work in mental health, and the 2008 definition of the domain has been central to professional identity, education, and training. The domain statement is produced below: The domain of social work in mental health is that of the social context and social consequences of mental illness. The purpose of practice is to promote recovery, restore individual, family, and community wellbeing, to enhance development of each individual’s power and control over their lives, and to advance principles of social justice. Social work practice occurs at the interface between the individual and the environment: social work activity begins with the individual, and extends to the contexts of family, social networks, community, and the broader society. Social context At the level of ‘social context’, social work is concerned with the way each individual’s social environment shapes their experience of mental illness and mental health problems. Its concerns include issues of individual personality, vulnerability and resilience, family functioning, strengths and stressors, support networks, culture, community, class, disability, ethnicity and gender. In addition to the intrapsychic aspects of ego functioning, self-esteem, spirituality, and interpersonal aspects of family functioning and personal relationships, its concerns include broader social issues of economic wellbeing, employment and housing. Social consequences At the level of ‘social consequences’, social work is concerned with the impact of mental illness and mental health problems on the individual, the family and personal relationships, and the broader community, including the impact on sense of self, on life chances, on family wellbeing, and on economic security, employment, and housing. Social work is concerned with the interface between mental illness and broader health and welfare issues such as child protection and domestic violence. Social justice At the level of ‘social justice’, social work is concerned with issues of stigma and discrimination, of political freedoms and civil rights, of promoting access to necessary treatment and support services, and of promoting consumer and carer rights to participation and choice in mental health services. It is concerned with making all human services more accessible and responsive to the specific needs and wishes of people with mental illness, and their family and other carers. (AASW 2008, pp. 8–9)

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The statement reflects the familiar social work concept of understanding the “person in environment” and provides a basis for understanding a community approach to practice in the mental health area that is distinctly social work in focus – with an emphasis on social justice and social consequences of mental illness in areas such as housing, employment, economic security, and family welfare.

Lived Experience as an Organizing Principle In the mental health field, the dominant research narrative is that of the scientific delineation of diagnostic categories and the search for evidence to inform practice. These positivist approaches underpin broad areas of policy and practice, including psychiatric assessment, epidemiology, the development of targeted medications, the assessment and management of risk, and the articulation and evaluation of psychosocial interventions. All mental health disciplines share this knowledge base, and social workers in mental health settings will absorb and contribute to the evidence base for practice (Victorian Government Department of Health 2013). We would, for example, endorse the principle of careful assessment and rigor in psychiatric diagnosis, together with the search for effective interventions for mental health disorders. This positive embrace of evidencebased practice as an underpinning principle for social work practice is strongly and cogently argued by academics such as Thyer, both in this book and elsewhere (Thyer and Myers 2011). Alongside this principle, and central to the definition of the domain of social work described in the previous section, is a recognition of the broader social context in which both disorder and treatment are experienced. This is an important dimension of mental health consumer advocacy over the last 20 years, an insistence that people are not defined by their diagnostic label and that the labels themselves do not effectively describe the experience of mental illness (Bland and Tullgren 2015). This principle encourages us to focus not on a set of symptoms but on the realities of life with a mental illness. When we do this, we discover that people describe problems of isolation and loneliness, poverty, disrupted family relationships, housing, and income security – social problems that are at the heart of social work practice. Lived experience becomes a starting point for understanding the impact of mental illness, not just for individuals but for their families as well (Bland and Renouf 2017). The practice principle for social work here is the need to start not with a diagnostic label but with a concern for the lived experience of the client and their family and friends. The experience of loneliness, powerlessness, poverty, stigma, and discrimination provides a focus for social work activity and indeed for research and knowledge building consistent with Thyer and Myers’ (2011) demand for a strong evidence base for practice. In the next section, we set out the principles of recovery theory that build on a focus on lived experience and provide a theoretical basis for social work practice.

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The Nature of Community A community approach to mental health practice is based on a recognition of the community as a potential site of intervention, both in health promotion and prevention and in moderating the impact of mental illness on individuals and families. It is consistent with the broad definition of the domain of social work in mental health described earlier in this chapter. We can touch only briefly on the very diverse literature on prevention and health promotion, but we will offer some useful definitions that help to frame the discussion of examples of empowerment that we will develop later in the chapter. Mental health promotion is any action taken to maximize mental health and well-being among populations and individuals (Commonwealth of Australia 2000). It aims to protect, support, and sustain the emotional and social well-being of the population by promoting the factors that enhance mental health. It is a relevant concept across the spectrum of interventions – before, during, and after the onset of mental health problems and mental disorders. Prevention is defined as “interventions that occur before the initial onset of a disorder to prevent the development of disorder” (Mrazek and Haggerty 1994, p. 23). In her overview of the scope of mental health promotion, Barry (2007) argues that promotion relies on three key determinants of mental health – social inclusion, freedom from discrimination and violence, and economic participation. This assertion connects broader promotion and prevention activities with the social justice themes of social work practice. Other relevant concepts familiar to social work practice include risk, resilience, protective factors, resources, and vulnerability. The Commonwealth of Australia monograph Promotion, Prevention and Early Intervention (Commonwealth of Australia 2000) identifies the creation of supportive social, cultural, and physical environments as a key strategy for encouraging positive mental health in communities.

Understanding Recovery Theory The concept of recovery has emerged as a consistent unifying principle in contemporary mental health policies and services in many different cultural and political contexts. Despite unanimous endorsement of the principle and the enthusiasm of service providers and policy-makers to describe their services as recovery based, considerable difficulties remain in its definition and application. The principle is essentially radical, challenging a preoccupation with illness and symptoms, diagnosis, and standardized treatments, in favor of a concern for the individually based lived experience of illness (Bland and Tullgren 2015). Recovery as a philosophy emerged partly from the rehabilitation movement based in Boston (Anthony 1993) but mainly from the published first-person accounts of the consumer empowerment movement (Deegan 1988).

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Anthony (1999) defines recovery as: A deeply personal, unique process of changing one’s attitudes, values, feelings and goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life. (p. 3)

O’Hagan’s definition from New Zealand’s Blueprint (Mental Health Commission 1998) is simple: Recovery is living well in the presence or absence of one’s mental illness.

Onken (2014) and Slade (2009) emphasize the dual nature of the recovery experience. It can be understood both as the management and moderation of distressing symptoms, what Slade calls clinical recovery, and the personal journey of restoring a positive sense of self and meaningful sense of belonging. Onken insists that this journey of recovery is about building a life in the community (Onken 2014). Jacobson and Greenley (2001) emphasize the community dimensions of recovery including a sense of connection with others and external conditions such as human rights, a positive culture of healing, and recovery-oriented services (Jacobson and Greenley 2001). Slade maintains that recovery also involves a radical change in the way that mental health services engage with consumers: Overall, proponents of a recovery approach seek to reverse some priorities. People with mental illness don’t need treatment—they need a life. Treatment may contribute to the process of striving for a life worth living, but it is a means, not an end...The overarching principle of recovery is that the impoverished expectations, clinical preoccupations, and stigmatizing beliefs sometimes held by mental health workers should not preclude everyday ways of addressing common human problems. (Slade 2009, p. 704)

In recent years, there has been extensive work in conceptualizing and theorizing the nature of recovery, and there is an emerging consensus among the different writers about the dimensions of recovery (Onken 2014; Davidson et al. 2005; Topor et al. 2011; Leamy et al. 2011). In the following section, we use a recovery framework developed by Wyder and Bland (2014) and emphasize those dimensions of recovery most relevant to our analysis of the place of community in social work practice.

Element 1: Connectedness Being connected is a cornerstone of recovery from a mental illness. Indeed, recovery from a mental illness is not done in isolation, and relationships and support from others play a crucial role in this journey. Consumers as part of their journey will need to have supportive others and role models, whether they

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are family members, friends, professionals, community members, or peers, who will provide them encouragement through the difficult times and help celebrate the good. There is now also mounting evidence of the importance of peer support in the consumer’s recovery journey (Craze 2013). Being connected also means being connected to their community. In this, consumers need to have the opportunity to expand and start occupying functional social roles such as partner, worker, student, taxpayer, or friend and to be able to make worthwhile contributions to a community of their choice. In summary, social support serves as a protective factor both for consumers and families, and good support will facilitate coping and family functioning.

Element 2: Hope and Optimism About the Future Hope and optimism have consistently been identified as being at the center of the recovery journey of consumers. People with the lived experience of mental illness need to have a sense of hope that recovery is possible (Davidson et al. 2005; Leamy et al. 2011). While this is true for consumers, hope plays a central part in the recovery journeys of families and indeed the mental health workers themselves (Bland and Darlington 2009; Tweedell et al. 2004). There is emerging evidence of a connection between the family’s hopefulness and its capacity to sustain the hopefulness of the consumer. Both consumers and family members identify the hopefulness of mental health workers as central to their capacity to sustain the recovery journey (Bland and Darlington 2009). Hope is a complex concept, a part of the worker’s being rather than necessarily anything that they do. Valuing hope in mental health practice is an acknowledgment of the humanity of working with others.

Element 3: Identity As part of their journey, consumers redefine themselves and start viewing their mental illness as only one aspect of a multidimensional identity rather than the mental illness being their primary identity. Many consumers, over time, have been able to rebuild and redefine a more positive sense of self. This task of rebuilding identity is invariably done through relationships with others. People recovering from a mental illness need to recover not only from the effects of the illness itself but also from social consequences and societal stigma associated with this (Davidson et al. 2005; Leamy et al. 2011). Many with lived experience of mental illness felt that they had struggled to overcome the stigma associated with mental illness and the impact this had on their sense of self. As we will show later in this chapter, peer-based programs offer both consumers and families opportunities to challenge stigmatizing and limiting illness identities. A second strategy for identity change is the careful use of language, preferring strengths-based words and concepts over the pathology-saturated labels and language of psychiatry (Sartorius 2002).

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Element 4: Meaning in Life Throughout their illness consumers start to make meaning of the experiences of mental illness and incorporate these into their lives. As part of this, many with lived experience learn to accept the limitation imposed by their illness and discover talents, gifts, and possibilities that allow them to pursue and achieve new life goals despite the presence of the disability. This can involve pursuing and achieving new life goals and/or increasing their quality of life. Those with lived experience will start to resume ordinary community roles such as partner, worker, student, taxpayer, and friend. This represents a turning to a community of their choice (Davidson et al. 2005; Leamy et al. 2011). This journey of re-engagement with friends, family, and community is often shared with the family, who have often been isolated by caring responsibilities and the shame and stigma that they feel in response to the mental illness. Families moved from “fixing” and “doing for” to “being with” and “journeying alongside” (Tew et al. 2012).

Element 5: Agency and Empowerment As part of their recovery journey, consumers learn to assume primary responsibility for their transformation to a person in recovery. The important concept here is a sense of agency. This process involves gaining control over one’s life and treatment. Consumers often talk about having the opportunities to make choices and being given the dignity of risk, where they are allowed to make decisions that allow them to succeed and fail (Davidson et al. 2005; Leamy et al. 2011). Assuming control over their lives is complex and involves the ability to resume control of a life that has been controlled not only by an illness but also by a treatment system and possibly family. As part of this process, consumers learn to manage their own levels of distress, stress, or depression. While complete symptom remission is not necessary, being able to manage symptoms in some way is essential for recovery (Davidson et al. 2005). Recovery always involves periods of good and difficult times, setbacks and accomplishments, and times when symptoms may be more or less controlled. A shift happens when consumers move away from simply receiving services to actively participating in and using treatments of their choice to bring symptoms under some degree of control and having their own coping strategies rather than being merely a recipient of other people’s interventions (Davidson et al. 2005; Deegan 1988). A sense of empowerment and control over one’s life also emerges when people in recovery begin to demand the same rights and take on the same responsibilities as other citizens (Davidson et al. 2005; Leamy et al. 2011). These citizen rights include the right to decide where to live, whom to love, and how to spend one’s time. Responsibilities include paying taxes and voting. Becoming empowered is also linked to the concept of social inclusion, which has both a component of active citizenship and a sense of connection.

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Empowerment happens through accessing resources such as housing and employment and confronting stigma and discrimination (Tew et al. 2012). Empowerment is a popular concept in social work, emphasizing as it does the importance of the social justice focus for mental health practice. Linhorst’s analysis of the meaning of empowerment in mental health is useful in identifying the practical dimensions of the concept (Linhorst 2006). He outlines a number of basic principles of empowerment which are relevant to our analysis of community and recovery and the broader concepts of social context, social consequences, and social justice that comprise the domain of social work. These principles include: • Empowerment involves holding power, control, and influence over one’s life and treatment. • Resources are critical to empowerment. Obtaining resources gives increased control over one’s life. • Empowerment can refer to both a process and an outcome. Participation is central to the process of empowerment. • Empowerment involves an interconnection between the individual and their environment. • Empowerment is situational – what is happening in a specific context at a specific point in time. • One cannot empower another – people empower themselves (Linhorst 2006, p. 10). Onken builds on these and the familiar recovery concepts in arguing for the importance of building community capacity as a distinct and important dimension of recovery (Onken 2014). Recovery depends on system change, not just personal change. He identifies the need for basic material supports in housing, employment, and health care. He emphasizes the importance of citizenship, stewardship of the environment, and the development of social capital. We look at these aspects of community development in the next section of this chapter.

Stigma, Shame, and Discrimination Goffman’s (1963) early definition of stigma as “spoiled identity” is still a useful starting point for our understanding of the nature of stigma. Stigma is typically defined as a visible mark of disgrace or infamy, while shame is seen as the painful feeling arising from the consciousness of something dishonorable, improper, and ridiculous that is done by oneself or another (Johnson 2015). Within the psychiatric literature, there is an awareness of the nature and impact of stigma in mental health (Horsfall and Cleary 2010), yet the nature of shame is less frequently acknowledged. Both stigma and shame are relevant to the analysis of the community dimensions of social work practice, because they are both fundamentally socially constructed and operate in a social and community context.

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Bakshi et al. (1999) suggest that stigma in mental illness denotes an unjust and involuntary labeling process that misconstrues the character and personalities of individuals affected by mental disorder. The effect of stigma is to “other” and dehumanize. The identity of the individual is “spoiled,” lost in the power of the label. Corrigan and Watson (37) distinguish between public stigma and selfstigma. Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination (Corrigan and Watson 2002, p.16). In their analysis of the concept of stigma, Epstein et al. (2012) provide a consumer perspective on the lived experience of stigma. They argue that the label conveys expectations that people with mental illness are peculiar, dangerous, and incompetent but that the concept of stigma does not place sufficient responsibility with those who discriminate on the basis of such thinking. The expectations and actions of others compound the very real difficulties already imposed by the illness. The impact of stigma and discrimination can be profound. Consumers have written extensively about the power of stigma (Epstein 1995) and the powerful and destructive impact of stigma for consumers. Epstein has argued that the stigma of some disorders is greater than for others and that there is, in fact, a hierarchy of stigmas in which depression and anxiety are widely accepted in the community, but personality disorder remains highly stigmatized. Other consumers have written about the experience of shame. Remi, for example, wrote: I think that the price of shame surrounding having or even knowing someone with mental health problems is too high a price to pay. Shame is why symptoms escalate, shame is why people don’t go to therapy, it’s the reason why people don’t tell their family and friends, shame costs lives, it leads to suicide and strange behaviours that others don’t or won’t understand, shame is what causes isolation and keeps a person harbouring a secret that should not be their sole burden to bear when professional help is available. It has taken me so long to realise that the shame isn’t worth it. (Remi’s Blog 2017)

Research by Wyder et al. (2015) found high levels of shame among the families of inpatients detained under mental health laws. Confronting that sense of shame was identified as part of the family’s recovery journey and involved developing a new identity, sense of self, and sense of control over their situation. This study identified the treatment service as a source of stigma for the families and argued for a more “family-centered” approach to inpatient care. An analysis of the connection between social inclusion and mental illness (Leff and Warner 2006) develops the ideas of stigma and discrimination as fundamental to social exclusion. Reviewing the international research literature on community approaches to challenging stigma and discrimination, Sartorius (37) argues that we need to work on a number of different social sectors, for example, health ministries, social welfare services, labor ministries, nongovernment organizations, and the media. Each of these sites provides multiple opportunities to challenge the negative impact of stigma.

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Leff and Warner (2006) remind us that stigma can be imposed by a hostile or ignorant community but can be most effective in the form of “self-stigma,” the process of individuals and families absorbing negative stereotypes of mental illness and acting on these stereotypes. This results in low self-esteem, sense of shame, and low expectations – both of self and of service response. Other research, for example, the Anglicare Tasmania study of poverty and mental illness (Cameron and Flanagan 2004), has emphasized the power of the double stigma. People with mental illness often experience poverty, and their clothing, dental health, and physical appearance are visible signs of their status as poor and mentally ill. The two stigmas are mutually reinforcing. One area of research has argued that the power of stigma is a barrier to helpseeking – that people suffering from mental distress avoid treatment services because of the stigma. Bathje and Pryor (2011) found that public stigma and selfstigma both worked to discourage people from seeking mental health care. A similar finding by Chronister et al. (2013) and research by Rüsch et al. (2009) recommended working at the community level to challenge stigma and facilitating social supports for people, in order to overcome the barrier of stigma to effective help-seeking. The research is significant because it locates the potential site for intervention not with the individual consumer but with the broader community. Stigma is maintained through popular media. Advocacy groups in Australia such as ARAFMI, SANE, and Beyond Blue have worked hard to confront stigma and community ignorance about mental illness through community education and “media watch” activities. These programs appear to rely on the assumption that bad attitudes are based on ignorance and that change will happen when people better understand the nature of mental illness. It is significant however that Australian research (Mental Health Council of Australia 2005, 2011) has found that a major site of stigma and oppression was the mental health system itself. Consumers reported that mental health workers often treated them with a lack of respect and were patronizing, dismissive, blaming, and judgmental. Research in the UK by Sartorius (37) reached similar conclusions. He argued that mental health professionals perpetuate stigma through the application of diagnostic labels and low expectations. These findings challenge the basis for an educational strategy to reduce stigma. Consumers in these studies reported that health professionals were capable of the most disrespectful and dehumanizing response to people with mental illness. In recognition of this, the Australian National Mental Health Strategy includes a major priority of engaging consumers and family carers in the education and training of the mental health workforce. The National Practice Standards (Victorian Government Department of Health 2013) set out in detail the attitudes and values of workers that reflect a respectful relationship with consumers that must be the start of non-stigmatizing mental health practice. The focus of anti-stigma campaigns remains difficult. Programs like Beyond Blue have been successful in promoting the simple idea that depression is common and that treatment is available and effective. Others, such as the Wesley Report

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Living with Mental Illness (Wesley Mission 2007), take a broader approach seeking to build awareness of mental illness and challenge misinformation in the community based on a concept of “mental health literacy.” This task of community education and attitude change continues to pose a long-term challenge. Many campaigns seem to have the problem of explaining two competing truths: firstly that people with mental health problems are not “others” but “us” and secondly that mental illness is serious and profoundly life changing (Bland et al. 2015). All this is made more difficult by the wide range of disorders grouped uncomfortably under the common tag of “mental illness.” In summarizing the UK approach to confronting stigma, the Sainsbury policy paper The Future of Mental Health: A Vision for 2015 concludes that it is debatable how far stigma can be challenged: “To achieve genuine change, increased investment in mental health promotion will be vital, but so will attitudinal change within services, among employers and in society as a whole” (Sainsbury Centre for Mental Health 2006, p. 15). While stigma and discrimination are related concepts, it may be helpful to recognize that strategies to confront these issues may be different. Public education and marketing campaigns may be needed to present mental illness in a more positive light, but discrimination might be confronted more directly and with the weight of the law rather than the vagaries of public opinion. Perhaps the most valuable challenge to stigma has come from advocacy groups within the consumer movement. Agencies such as Our Consumer Place provide a strong consumer voice to support advocacy and public education. For example, they have prepared very practical manuals for consumers engaged in public speaking or education work. They have challenged anti-stigma projects that promote positive views of some disorders such as depression while allowing stigma on other disorders to continue. Another challenge to stigma has come from the burgeoning information available to the public on the Internet where consumer voices can be easily accessed, along with good practical information about disorders and treatments by advocacy groups like SANE Australia (Bland et al. 2015). The New Zealand experience has been based more strongly on principles of the protection of human rights through specific legislation. The New Zealand Bill of Rights (1990) sets down basic rights in such areas as security including the right to refuse medical treatment, democratic and civil rights, and protection from discrimination. The New Zealand Human Rights Commission has a framework for human rights that includes: • Participation – people should be able to participate in society and decisions that affect them. • Accountability – those in authority should act justly and be answerable for their actions. • No discrimination – people should be treated fairly. • Empowerment – allowing people to use rights as a leverage for action. • Linking decision-making to agreed human rights norms. • Identification of all relevant human rights and balancing various rights (Mental Health Commission New Zealand 2007, p. 180).

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This emphasis on human rights overtakes a concern for confronting stigma. If the law can deal effectively with the impact of stigma, there is less need to address the difficult challenge of changing community attitudes and values. A concern with social exclusion provides a natural focus for social work activity in multidisciplinary team settings, offering as it does an additional conceptual and practical paradigm for social work practice. It leads social work back to core business. It represents an additional focus for work, to complement more therapeutic definitions of practice (Bland et al. 2015).

Example: Our Consumer Place – Empowerment Through Collective Action This original description of Our Consumer Place is taken from their website: Our Consumer Place is a resource centre run entirely by people diagnosed with “mental illness” (we choose to call ourselves “consumers”). We provide information, training, support and advice to consumer-run groups and projects (or more specifically, “Consumer Developed Initiatives” (CDIs)). We also support what we call “consumer perspective,” recognising that the lived experience of “mental illness” provides a crucial source of insight that is of value and must be respected. We believe that we are part of an important cultural shift, towards valuing and respecting the lived experience of “mental illness”. Our Consumer Place has been developed by consumers for consumers. (http://www.ourconsumerplace.com.au/consumer/aboutus)

The organization asserts that it is not a therapeutic resource or an advocacy group. Rather, the focus is on building the intellectual and skill base of the consumer movement and building a consumer community with the skills and resources to effect change for mental health consumers. The community building supported by Our Consumer Place is localized and contextualized. They run workshops and presentations for both professional workers and for consumers which focus on developing a distinct consumer perspective in mental health. One major activity has been the establishment of a clearinghouse of lectures, publications, and websites to resource consumers as they engage in training and contribute to the knowledge base for the mental health workforce. Leading intellectuals at Our Consumer Place such as Merinda Epstein and Flick Grey have given consumers a powerful voice in the mental health community. One of the distinctive contributions of the organization has been that of challenging and reclaiming the language of mental illness. Merinda’s cartoon drawings and deeply insightful and irreverent text offer an engaging and accessible set of ideas relevant to both consumers and professionals. The word “mad” has been embraced and promoted, featuring in such publications as “Mad Workplaces” and the “Madquarry Dictionary.” Ann Tullgren, consumer and social worker and a regular contributor to the Our Consumer Place newsletters, has produced a helpful list of stigmatizing words and alternative ways of expressing these. Judgmental phrases such as “non-compliant” are reworked to become “choosing my own

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treatment.” A constant message of Our Consumer Place is that the language we use constructs the reality of that experience, and challenging the negative, disrespectful, and pessimistic language of psychiatry is an ongoing part of the struggle to defeat stigma. How is Our Consumer Place an example of empowerment? • Providing resources. Our Consumer Place develops the intellectual property that forms the basis of education and training and makes it available to the consumer community. Individual consumers are connected with very skilled and committed activists. The quality training provided supports the good efforts of mental health workers as well as consumer activists. • Reclaiming identity – a positive view of madness. In line with the recovery task of building a positive identity, Our Consumer Place can give isolated consumers and their families a language, role models, encouragement, and hope to be able to abandon the highly stigmatized and life-limiting role of mental health patient. There is another way to be mad, and there can be some pride, and indeed some joy, in that identity. • Asserting authority and sense of agency. This is achieved through training and publication, promoting the consumer voice as a valid and important alternative to the dominant voice of mental health clinicians and academics. Our Consumer Place has been able to challenge the power of stigma and the hidden oppression of the anti-stigma campaigns. There is specific training in consumers using their experience to train others, moving beyond telling their story, and using their experience to challenge beliefs and values. Consumers recognize that they are the experts in their own experience and that that expertise is powerful when shared with others. • Establishing a sense of community. Our Consumer Place is a community of likeminded individuals, drawn together for mutual support and education. The newsletters and website provide a point of connection, pride, and identity.

Empowerment Through Challenging Orthodoxy and Promoting an Alternative Voice The Hearing Voices Network websites says that it is (https://www.hearing-voices. org/): A movement of voice hearers, professionals and carers that operates hundreds of self-help groups all around the world. Together, we are united in our mission to promote recovery and reduce the stigma associated with voice hearing. Although ‘auditory hallucinations’ are commonly understood as meaningless symptoms of biological illness, research suggests there are many explanations for hearing voices. Some people begin to hear voices as a result of extreme stress or trauma, while others find spiritual guidance in the form of their voices.

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How is the Hearing Voices Network an example of empowerment? • The Hearing Voices Network offer information, support, and understanding to people who hear voices and those who support them. The network highlights the limitations of a solely medical model in understanding and responding to hearing voices. It also provides self-help groups where voice hearers can discuss their experiences in a safe, nonjudgmental environment. • The Hearing Voices Network positions people with lived experience as experts and provides training to mental health professionals to help challenge the harmful paradigm of hopelessness and stigma that exists within the mental health system. The Network promotes hope that recovery and flourishing is possible. It also challenges stigma associated with hearing voices. • People with lived experience support, promote, and disseminate research findings into various approaches to hearing voices.

Conclusion Working with consumer groups and with family carer organizations is an important part of the community work of social workers. Confronting stigma and discrimination, and promoting the welfare of disadvantaged groups, is core business for the profession. The consumer and career organizations challenge the professional community to work effectively together. When social workers are employed in clinical services, they work as part of the powerful service structures that consumers and family carers can find oppressive. Working in respectful partnership with consumers and family carers remains a challenge for all the mental health disciplines. This chapter has explored a number of theoretical perspectives including the concept of lived experience, recovery theory, stigma, shame, and empowerment. We have worked from a definition of the domain of social work in mental health as being the social context and social consequences of mental illness. A practice focusing on these social dimensions of mental illness demands an engagement both with the broader evidence base shared by all disciplines, and a specific concern for individuals and their families, and the experience of mental illness and its consequences in their lives.

Cross-References ▶ An Overview of Social Work Approaches in Working with Families of People with Serious Mental Illness ▶ Behavior Analysis and Social Work ▶ Community, Mental Health, and Social Work ▶ Ethics, Values, and Recovery in Mental Health Social Work Practice ▶ Individual Approach to Mental Health from a Psychodynamic and Cognitive Behavioral Perspective

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▶ Legal Provisions, Advocacy, and Empowerment ▶ Social-Cultural Ecological Perspective

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Definition of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Determinants of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Definition of Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Green Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Civic Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Alcohol Outlet Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 .... Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 .... Violent Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 .... Social Work Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Abstract

This chapter review serves to present a limited number of community factors that contribute to mental ill health and well-being and when addressed can lead to improved psychological health. The community-level factors that can be addressed through social work interventions or social work-led initiatives include exposure to green spaces, civic engagement, and alcohol outlet density. The chapter proposed that actions taken at the community level such as advocacy for and usage of public parks, volunteerism, and actions taken to help regulate accessibility to alcohol consumption may have potential to directly or indirectly prevent mental ill health and improve population mental health. C. Lim (*) · R. Ow Department of Social Work, National University of Singapore, Singapore, Singapore e-mail: [email protected]; [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_24

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Keywords

Community · Mental health · Greenness · Civic engagement · Alcohol outlet density

Introduction Mental disorders are highly prevalent. According to the World Health Organization World (WHO) Mental Health Survey (The WHO World Mental Health Survey Consortium 2004), up to 26.4% of individuals surveyed, or approximately one in four persons, met diagnostic criteria for at least one common mental disorder including anxiety disorders, mood disorders, disorders associated with impulse control, and substance use disorders in the previous year. Findings from a later systematic review and meta-analysis of large-scale mental health surveys to derive global prevalence of the same set of common mental disorders, except for disorders associated with impulse control converged with the WHO (2004) findings reported above, indicating that the prevalence has not changed in recent years (Steel et al. 2014). The researchers found that 17.6% of respondents, or approximately one in five, met criteria for a common mental disorder during the previous 12 months, whereas 29.2%, about one in three participants, met criteria at some time during their lifetime (Steel et al. 2014). Several studies have been conducted to identify the prevalence of mental illness in the community. For example, the second Singapore Mental Health Study estimated that 13.9% of the adult population, more than one in eight, met diagnostic criteria for a mood, anxiety, or alcohol use disorder (Subramaniam et al. 2019). In addition, the National Centre of Social Research in the United Kingdom conducted a survey with 5000 adults and reported that 26% had been diagnosed with a mental illness. It also found that a further 18% reported having experienced a mental illness but had not been diagnosed (Bridges 2014). Given the prevalence of mental disorders, policymakers and public-health officials are increasingly concerned with ways to improve the mental health of the general population.

Definition of Mental Health Good mental health is not marked by the mere absence of mental disorder. According to the WHO (2018a), mental health enables people to realize their potential, cope with life stresses, engage in productive and fruitful work, and make contributions to the community. Therefore, the WHO mental health plan is to not only manage mental illness but also promote mental well-being. At the 13th General Program of Work (GPW13) covering 2019–2023, the WHO Director-General, Dr. Ghebreyesus, declared that the time is ripe to empower communities and individuals to attain the highest standard of health. The vision of the WHO Special Initiative for Mental Health acknowledged that mental health has to be an integral part of UHC (Universal Health Coverage). Nobody should be denied access to mental health care because she or he is poor or lives in a remote place (WHO

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2018b). Within the UHC initiative, Strategic Action 2 is defined as scaling up interventions across community-based, general health, and specialist settings. The WHO 2019–2030 initiative followed the Comprehensive Mental Health Action Plan 2013–2020 where one of the major objectives adopted at the 66th World Health Assembly (WHO 2013) was to provide comprehensive, integrated, and responsive mental health and social care services in community-based settings. The following sections will therefore discuss some areas of social work interventions across community-based and general health settings in the context of mental health.

Determinants of Mental Health Understanding the link between the community and mental health in the population is based on the ecological-systemic framework commonly used in the context of social policies and service provisions in the social care sector. The ecological-system perspective focuses on the interrelatedness of people and the environment. The ecological-systemic paradigm was first introduced by Bronfenbrenner in the 1970s (1974, 1977, 1979) based on empirical observations and evolving theories about the processes and conditions that influence the life course development of human beings in the actual environments in which they live. The general ecological model conceived of the environment as highly differentiated systems but with mutual influence across systems. Like a set of Russian dolls, the ecological environment is a set of nested structures each inside the other moving from the innermost level to the outside. The innermost microsystem consists of a pattern of activities, social roles, and interpersonal relations in the immediate environment such as family, school, and work place. The next system in the set of ecological structures is the mesosystem comprising the linkages and processes between two or more settings in which the individual is directly involved such as between the family and the school in the case of school children. In other words, the mesosystem is a system of microsystems whose interactions impact on the individual. The exosystem comprises the linkages and processes between two or more settings with at least one setting not containing the individual such as the parent’s workplace in the case of a child. Although the individual is not in the workplace, nevertheless the processes within the exosystem may also have an influence on the individual. The macrosystem, the last in the nested structures, consists of the overarching characteristics of the micro-, meso-, and exosystems such as culture, belief systems, and other factors embedded in the wider societal environment of the individual. Later theoretical developments extended the ecological parameter to the inclusion of the chronosystem where historical time is conceived as part of the environment in which the individual lives. The chronosystem encompasses any change or consistency over time in the environment such as family structure, societal norms, or place of residence (Bronfenbrenner 1994). Since the different systems interact and influence each other and impact on the development of the individual, the ecological-systemic paradigm becomes an important model for understanding the potential of the environment in shaping social functioning, mental health, and illness. The aim of social work practice is to promote the social functioning of individuals via adaptation to their environment and/or by ameliorating the environment. The

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ecological-systemic perspective allows social work practitioners to intervene at the environmental level to promote better mental health. Germain (1978, p. 542) noted that “when inputs or stimuli are insufficient, excessive, or missing altogether, an upset occurs in the adaptive balance which is conceptualized as stress: the usual ‘fit’ between the person and environment has broken down.” As such, a lack of “fit” between people and their environment can be damaging to both. An emphasis on the environmental determinants of health and wellbeing, including mental health, will reflect the importance of the “fit” between the exosystem and the macrosystem in the development and functioning of the individual.

Definition of Community One aspect of the environmental determinants of mental health that has been the focus of research is the community. The traditional notion of community as geographical locations where people carried out all aspects of their lives, where they live, work, socialize, and shop may no longer apply. Nowadays people may carry out activities in different locales outside the immediate environment where they live, work, and play. So how is community to be defined? The conceptualization varies according to disciplines. For some disciplines, community means the geophysical environment in which people live and work, but for others, community represents relationships or the social environment. In this chapter, community is defined as the social context as well as the physical environment that influence behaviors. The following review serves to present a limited number of community factors that contribute to mental ill health and well-being. The focus is on community-level factors that can be addressed through social work interventions or social work-led initiatives. These community factors include exposure to green spaces, civic engagement, and alcohol outlet density and will be discussed in greater details in the following sections. The objective is to emphasize that social work’s contribution to actions taken at the community to address these factors have potential for preventing mental ill health and improving social care.

Green Spaces An emerging body of research has focused on the relationship between exposure to greenness, which is part of the natural environment, and health including mental health. Results from cross-sectional and longitudinal epidemiological studies conducted in different countries have demonstrated the beneficial effects of the natural environment (e.g., Alcock et al. 2014; Mukherjee et al. 2017; White et al. 2013). An index of natural environment is the availability of urban green spaces. These spaces include public parks and other vegetated areas. Researchers have posited that proximity to urban green spaces improves health via increasing opportunities for physical activity, reducing heat effects, regulating pollution, and increasing access to consumable greens. Nearby greenness has been found to be associated

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with other positive health indicators such as healthier infant birth weight (e.g., Banay et al. 2017) and lower risk of cardiovascular and respiratory disease (e.g., Donovan et al. 2013). Closer proximity to urban green spaces have also been linked to more favorable psychological health. White and colleagues (2013), for example, explored the relationship between urban green space and two indicators of mental health, wellbeing, and distress. Drawing on panel data gathered from over 10,000 individuals who participated in the British Household Panel Survey, the researchers applied fixed effects analysis to compare the mental health of the same individuals at different points in time reflecting different states (e.g., when they are married, employed, living in an area with less green space vs. when they are unmarried, unemployed, and living in an area with more green space) while controlling for individual characteristics (age, education, marital status, number of children living at home, income, health status, and employment status) and area-level variables (income, employment, education, crime). Results revealed a small but beneficial effect of green space on mental distress and life satisfaction. As the percentage of green space increases, mental distress decreased and life satisfaction increased. These effects were statistically significant even after controlling for potential individual- and area-level correlates of mental health. Using data from the British Household Panel Survey, Alcock et al. (2014) expanded the aforementioned study by investigating the impact of changes in area of green space near residence on mental health. The researchers found that individuals who relocated to greener urban areas reported sustained improved mental health post move, whereas individuals who moved to less green areas reported poorer mental health in the year preceding the move, but demonstrated an improvement in their mental health following the move. The finding related to movers to less green areas may be explained by the negative impact of anticipated moving on mental health and declining mental health that precipitated the move. Similarly, Reklaitiene et al. (2014) found a statistically significant association between use of park, residential proximity, and depressive symptoms in a sample of adults residing in Kaunas city, Lithuania. Adjusting for age, marital status, education, smoking, alcohol used, and body mass index, individuals who use the parks regularly (spend more than or equal to 4 h per week) but lived further away had higher odds of being classified as having depressive symptoms than those who had residential proximity. Among individuals who did not use the park or used it very infrequently (less than 4 h per week), distance to the park was not found to be significantly associated with the likelihood of endorsing depressive symptoms. In the same fashion, Mukherjee and colleagues (2017) reported an association between park availability close to home and major depression among adults with chronic medical condition in Delhi, India. Controlling for age, sex, educational attainment, marital status, household wealth, and family size, area of the nearest park was inversely but significantly associated with current major depression. In other words, risk of current major depression was higher among participants who lived near smaller parks than those who lived near larger parks after adjusting for potential confounders. The researchers posited that smaller parks may not be as well

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maintained as larger parks, thus failing to incentivize residents to use the park for walking and social interactions, activities known to positive impact mental health and perhaps with social connectedness which will be discussed more fully in the next section. Participants who lived near smaller parks reported less physical activity per week compared to their counterparts who lived near larger parks. However, physical activity did not mediate the association between area of nearest park and current depression. Other measurements of park availability, namely, distance to the nearest park, number of parks in the neighborhood, and total area of all parks in the neighborhood were also not significantly associated with current major depression. Other aspects of mental health and the natural environment have also been studied. Using data from a nationally representative sample of community-dwelling older adults without cognitive impairments recruited from across the United States, Pun et al. (2018) examined the association between green space and self-perceived stress, depressive symptoms, and anxiety symptoms, and whether the associations were mediated by physical activity, loneliness, and social support. Adjusting for confounders (age, gender, year, season, region, educational attainment, temperature, and air quality), the researchers found that increased greenness was significantly associated with lower levels of self-perceived stressed during the previous week. The significant inverse association was partially explained by increased physical activity afforded by higher levels of greenness. Greenness has also been examined for its relationship with mental health among adolescents and young adults. With data from teenagers in the United States, this prospective cohort study examined the association between exposure to greenness during childhood, determined by participant’s mother’s home address, and depressive symptoms (Bezold et al. 2018). The researchers found that higher exposure to greenness during childhood was significantly associated with a lower risk of developing high depressive symptoms. This association was statistically stronger for participants who lived in areas of high population density and those with younger age at onset of depression, although the latter association was not statistically significant. A statistically significant association, however, was found between exposure to greenness and persistence of depressive symptoms among participants who grew up in higher population density areas. It is noteworthy that these reported associations were based on adjusted analyses performed on data gathered from more than 11,000 adolescents. Similarly, Van Aart and colleagues (2018) also found salutary effects of greenness on mental health in a sample of Belgian children. The researchers examined crosssectional associations between exposure to semi-natural and forested area and various behavioral and emotional outcomes in Belgian children and adolescents aged 9–15. After controlling for age, sex, and parental socioeconomic status, increased exposure to agricultural area was found to be negatively associated with hyperactivity but not with other behavioral outcomes (conduct problems, emotional problems, peer problems, proposal behavior, and overall behavioral difficulty). Whereas higher exposure to semi-natural and forested area was not found to be significantly associated with behavioral challenges, it was found to be significantly associated with emotions of happiness, sadness, anxiousness, and overall negative emotions. In addition to a cross-sectional evaluation, the sample of children and adolescents were followed up over several years, thus enabling Van Aart and colleagues (2018) to also examine

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longitudinal associations. The researchers found that higher levels of exposure to semi-natural and forested area in 2012 predicted significantly higher levels of happiness in 2015, partly explained by lower residential noise. There is some evidence that exposure to natural environment in care facilities may improves the mental health of residents. Browning et al. (2019) investigated whether tree canopy cover surrounding nursing homes was important for understanding the presence of depressive symptoms in residents. The researchers gathered data on percentage of tree canopy surrounding each of 9186 nursing homes across United States and percent of residents with depressive symptoms. Their investigation revealed an inverse relationship between tree canopy cover up to 3000 m away and percentage of residents with depressive symptoms so that higher percentage of tree cover surrounding facilities was associated with significantly lower percentage of residents with depressive symptoms. This association remained significant even after adjusting for variables that may impact on residents’ mental health: residents’ sociodemographic characteristics, quality of care at facilities, air quality, and population density. Notably, the association became weaker as distance of tree canopy cover from nursing home increased. The researchers offered several mechanisms for the link between natural environment and depressive symptoms in elderly residents of nursing homes. These include the facilitation of physical and social activities among residents and reduction of noise and air pollution. In addition to mental health, research has also found an association between exposure to greenness and more objective measures of mental well-being such as salivary cortisol levels in a sample of individuals living in a deprived neighborhood. Thompson and colleagues (2012) investigated whether greenness around people’s home was associated with stress, measured objectively via salivary cortisol and subjectively via completion of the self-reported Perceived Stress Scale (Cohen et al. 1983). Greater exposure to green space close to home was significantly associated with greater reduction in diurnal cortisol from morning to evening, an indicator of better mental well-being, and negatively associated with self-reported stress. Overall, there seems to be on-going evidence that availability and closeness to green spaces have a positive effect on mental health and well-being either directly or indirectly. As such, social work should consider engagement with community partners to increase service users’ exposure to greenness as part of its repertoire of skills and services. Urban planners, parks and recreation providers, and recreational groups are all part of the exo- and macrosystems in the community. They can help to generate better green spaces in the environment and incentivize residents to engage in outdoor activities, either as individuals or as members of a community group, to improve social and mental well-being.

Civic Engagement Civic engagement is defined as involvement in political and nonpolitical activities to address issues of public concern and promote the civic life of one’s community. Individual volunteerism, electoral participation, and charitable giving are common types of civic engagement activities that reflect the degree of social connectedness

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between the individual and the community. A body of research from epidemiological to experimental studies has explored the relationship between civic engagement and mental health. For example, with longitudinal data gathered from a nationally representative sample of adolescent followed up through young adulthood, WrayLake and colleagues (2019) investigated the bidirectional association between multiple types of civic engagement (community engagement, voting, and other political behaviors) and depressive symptoms in a sample of adolescence and young adults in the United States. They found that participation in extracurricular activities during adolescence predicted lower levels of depressive symptoms during early young adulthood holding constant levels of depression during adolescence. Similarly, service and organizational involvement during early young adulthood predicted lower depression during young adulthood. The findings that community engagement may have mental health benefits for youth are consistent with findings from the beneficial link found among older adults. The connection between these two factors is further established as reflected in the following review of research conducted in this area. Findings from cross-sectional and longitudinal studies have demonstrated that civic engagement, particularly volunteerism, is associated with lower levels of mental ill health (e.g., Creaven et al. 2018; Li and Ferraro 2005; Olesen and Berry 2011; Yeung et al. 2018). For example, Ding et al. (2015) examined the relationship between civic engagement – attending events that bring people together such as festivals, making time to attend services at places of worship, giving money to charity, and volunteering during spare time – and mental well-being, which was measured using items based on the Medical Outcomes Study Short Form (SF-36), in a representative Australian sample. The researchers found that civic engagement in 1 year predicted better mental well-being the next year, specifically life satisfaction and vitality, after controlling for age, labor force status, relationship status, educational attainment, household income, and physical health. Civic engagement was not significantly predictive of better overall mental well-being when other types of community participation activities were considered. The researchers found that among the three types of community participation examined, informal social connectedness was the strongest predictor of overall mental well-being. The researchers however found that the benefits of civic engagement were more pronounced among participants who had better mental well-being. Creaven and colleagues (2018) investigated the association between volunteering and mental health using crosssectional data derived from the sixth wave of the European Social Survey (ESS), comprising data gathered from all persons aged 15 years and older who were residents of Western Europe at the time of data collection. They found that volunteering was significantly associated with lower severity of depressive symptoms and that volunteering at any level was associated with beneficial effects over no volunteering. Tabassum et al. (2016) also found in a cohort study using data gathered from a nationally representative British population aged 15 and over that people who volunteered reported lower scores on the General Health Questionnaire (GHQ), indicating better mental well-being. People who volunteered frequently (once a week) reported the lowest GHQ score, whereas people who never volunteered

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reported the highest GHQ score. The relationship remained significant even after adjusting for potential confounders (e.g., sex, marital status, income, and general health). Empirical evidence of a positive association between volunteering and mental health is particularly strong among older adults. Using longitudinal data gathered from a nationally representative sample of adults aged 60 and over in the United States, Morrow-Howell and colleagues (2003) addressed questions related to the relationship between volunteering and late-life well-being. The researchers tested several hypotheses. Among them were that volunteers have higher levels of mental well-being than those who did not volunteer and that a dose-response relationship exists between volunteering and well-being. Results from their investigation revealed important findings, notably, that volunteering had a positive effect on late-life well-being so that older adults who engaged in more hours of volunteering reported better mental well-being. Using longitudinal data from the Asset and Health Dynamics Among the Oldest Old Study (AHEAD), Lum and Lightfoot (2005) examined the association between formal volunteering and health in a national representative sample of older people over age 70 in the United States. The researchers found that older adults who had volunteered at least 100 hours evidenced smaller increase in depression levels 7 years later than older adults who did not volunteer at least 100 hours per year. Can the relationship between volunteerism and mental well-being be explained by social connectedness? Creaven et al. (2018) investigated this association using data derived from the sixth wave of the European Social Survey (ESS), comprising data gathered cross-sectionally from all persons aged 15 years and older who were residents of Western Europe at the time of data collection. As previously described, volunteering was found to be significantly associated with lower severity of depressive symptoms and that any level of volunteering was associated with beneficial effects over no volunteering. However, this association weakened after adjusting for social connectedness, suggesting mediating effects. Measurement of social connectedness included items on intimate ties, frequency of social activities, and perceived social support. Individuals who were well connected had comparatively lower severity of depressive symptoms than did those who were poorly connected. Importantly, volunteers tended to be highly connected socially. This result demonstrates that the benefits of volunteering on mental health are better explained by volunteers’ social connectedness. Indeed, studies have found strong associations between social connectedness and mental well-being. A cross-sectional study of a random sample of adults 45 years old and older living in an Australian coastal community found that contact with friends and neighbors were associated with less psychological distress among retired people but not among working adults of the same age (Olesen and Berry 2011). Berry and Welsh (2010) found that informal social connectedness was associated with less emotional distress in a cross-section study of a nationally representative Australian sample. When this association was examined longitudinally, the researchers found the same relationship: informal social connectedness – measured by being contact with friends and relatives, chatting with neighbors, talking about current affairs with

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friends and family, keeping in touch with friends, and seeing extended family members – in 1 year predicted higher mental well-being the next year. The relationship was linear so that greater number of informal social connectedness was associated with lower severity of psychological distress. Freisthler and Maguire-Jack (2015) found that neighborhood collective efficacy, measured by neighborhood members’ willingness to intervene for the common good (e.g., if children were spray painting graffiti on a local building) and social cohesion, was associated with lower rates of child physical abuse in California. In the same fashion, Schofield and colleagues (2018) found that parents’ perception of higher levels of community social cohesion in a rural sample of White participants living in Iowa was significantly associated with lower number of adverse childhood events reported by their offspring regardless of parents’ level of exposure to adverse events during childhood. Adolescents who reported the highest number of adverse childhood events had parents who experienced high number of childhood adversity and perceived community social cohesion to be low. Whereas higher levels of social connectedness have been found to be associated with better mental well-being, findings from research suggest that the effects of political participation are less favorable. Higher levels of political participation in 1 year was associated with higher levels of mental health distress the following year even after controlling for other forms of community participation and confounding variables (Ding et al. 2015). Olesen and Berry (2011) similarly found that greater participation in political protest was significantly associated with poorer psychological health in retirees, not among employed participants. Researchers have offered several hypotheses including that individuals with poorer mental well-being are drawn to political participation and the possibility that political participation compromises mental well-being. Overall, civic engagement may result in a higher degree of social connectedness that can have positive effects on mental well-being. The association between civic engagement and mental health may be explained by the social integration theory, which posits that volunteering enhances volunteers’ sense of meaning and purpose in life, facilitates social interactions, develop social support through an enlarged social network, and introduces fulfilling and self-validating experiences, collectively bolstering mental well-being. Community participation also promotes mental health by strengthening aspects of social cohesion such as sense of belonging, social trust, information sharing. However, political participation appears to be negatively associated with mental health.

Alcohol Outlet Density As previously described, the definition of community includes the physical environment. Related to mental health, research has examined the impact of alcohol outlet density, a commonly used indicator of adverse physical environments. Alcohol outlet density refers to the geographic distribution of establishments in a defined area licensed to sell alcohol for consumption on or off premise and forms one aspect of the built environment that has an impact on the lives and mental well-being of

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individuals. Greater alcohol outlet density, a frequently used measure of alcohol availability, has been implicated in problematic behaviors that include intimate partner violence, child maltreatment, crime, and violent assaults. The following sections will review research on the exposure to these alcohol-related harms and heightened risk for mental ill health and psychological distress.

Intimate Partner Violence Research has established an association between excessive alcohol consumption and perpetration of intimate partner violence which prompted the investigation of whether alcohol outlet density also contributes to heightened risk of intimate partner violence perpetration in addition to other neighborhood socioeconomic characteristics (Iritani et al. 2013; Resko et al. 2010; Waller et al. 2013). Iritani et al. (2013), for example, examined the relationship between alcohol outlet density and perpetration of intimate partner violence among young adult women in the United States using data from the National Longitudinal study of Adolescent Health. The researchers found that young women who lived in a neighborhood with higher off-premise alcohol outlet density were significantly more likely to report perpetrating physicalonly intimate partner violence against their male partner in the previous year. This association remained significant even after adjusting for participants’ demographic characteristics (age, race and ethnicity, marital status, and experience of childhood abuse or neglect), alcohol use, and neighborhood-level characteristics. Similar relationship between off-premise alcohol outlet density and physical-only intimate partner violence was reported by Waller et al. (2013) in a study of male-tofemale intimate partner violence. Addressing the limitations of relying on police data (by including only cases brought to the attention of law enforcement and the lack of data on the perpetrator’s demographics and alcohol use patterns), the researchers sought to advance understanding of the link in a nationally representative sample of young adult men between the ages of 18 and 27 years old. Total alcohol outlet density, which combines both on-premise and off-premise establishments, significantly increased the odds of physical intimate partner violence perpetration. Building on earlier works, Cunradi et al. (2011) tested the hypothesis that higher alcohol outlet density (measured by on-premise outlets such as bars, restaurants, and off-premise outlets) would be positively associated with an expanded list of intimate partner violence events, namely, intimate partner violence-related police calls and intimate partner violence-related crime reports over and above neighborhood characteristics (poverty, unemployment, and racial and ethnic composition). Similar finding of a link between off-premise alcohol density outlet and intimate partner violence was reported in that each additional off-premise alcohol density outlet was associated with a 4% increase in intimate partner violence-related calls and 3% increase in intimate partner violence-related crime reports. The researchers, however, did not find an association between on-premise alcohol density outlet and intimate partner violence. Researchers have hypothesized that greater alcohol outlet density increases access to alcohol, which in turn result in increased alcohol consumption, a known risk factor for perpetration of intimate partner violence. Another

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plausible explanation is that higher alcohol density outlet may represent loosed social control, thus attracting individuals with heightened risk of perpetration.

Child Maltreatment According to the WHO (2014b), child maltreatment is a public health problem. Close to one quarter (22.6%) of adults experienced physical abuse during childhood; 36.3%, emotional abuse; 16.3%, neglect; and 25.6%, sexual abuse. Childhood maltreatment negatively impacts on mental and behavioral health that includes increased risk of a range of mental disorders and suicidality. Parental substance use is a known antecedent to child maltreatment or child welfare system involvement (e.g., Freisthler and Gruenewald 2013). Indeed, parents with known substance use disorder have been found to be significantly more likely to engage in child maltreatment (e.g., Freisthler and Gruenewald 2013). The availability of on-premise alcohol establishments in the community may prompt parents to spend time away from home, which results in supervisory neglect. The accessibility of off-premise alcohol outlets, on the other hand, increases the risk of hazardous alcohol consumption in caregivers at home, thus engendering risk of physical abuse (Freisthler and Gruenewald 2013). Researchers have offered several theories to explain the plausible link between alcohol density outlet and child maltreatment. The routine activities theory posits that density and types of alcohol outlets in the immediate environment influence the drinking behavior of caregivers, which in turn impacts on the probability of perpetrating abuse (Cohen and Felson 1979). With greater density of alcohol outlets, especially off-premise outlets, alcohol becomes more accessible, thus facilitating more frequent alcohol use and increasing the risk of committing child abuse or neglect given the disinhibiting properties of alcohol (Freisthler et al. 2004). However, overall findings on the association between alcohol outlet density and child maltreatment have been mixed. For example, Freisthler et al. (2014) investigated alcohol outlet density and self-report of supervisory neglect using data gathered from 3023 participants via a telephone survey from cities throughout California. The investigation revealed that higher concentration of on-premise alcohol outlets was positively related to leaving a child home alone when an adult should be present. This association remained significant even after adjusting for child and parent attributes. Density of on-premise or off-premise alcohol outlet was however not significantly associated with other types of supervisory neglect, namely, leaving a child in the car alone, leaving a child when unsure of safety, and unsafe monitoring. Using the same data, Freisthler and Maguire-Jack (2015) did not find an association between alcohol outlet density and child physical abuse. Research has also provided evidence that higher alcohol outlet density is associated with intergenerational continuity of childhood abuse and neglect. Schofield and colleagues (2018) examined the link between community environment (socioeconomic status, neighborhood services, social cohesion, and alcohol vendor density) and experience of adverse childhood events (abuse, emotional

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neglect, and household challenges) and intergenerational continuity of these childhood adversities. Results showed that adolescents living in neighborhoods with higher concentration of alcohol outlets reported higher number of childhood adverse events regardless of their parents’ level of childhood adverse events exposure. However, among adolescents living in neighborhoods with low concentration of alcohol outlets, the number of childhood adverse events was positively associated with their parents’ exposure. Importantly, these associations remained significant after controlling for potential confounders comprising parent neuroticism, parent alcohol problems, and community characteristics. This study thus provided further evidence of the association between alcohol outlet density and child maltreatment.

Violent Crime Research has provided empirical evidence that greater access to alcohol outlets is associated with violent crimes in the community/area (Campbell et al. 2009; Toomey et al. 2012). Locales such as neighborhoods with more alcohol establishments tend to experience higher number of violent crimes than those with fewer establishments. The association between alcohol outlets and violent crimes can be explained by the location of these outlets which tends to be in areas of low supervision such as socially disorganized neighborhoods (Gruenewald et al. 2006; Felson and Eckert 2016). Such neighborhoods facilitate crimes by providing motivated perpetrators avenues, like abandoned buildings, to congregate. Another explanation for the observed positive association between alcohol outlet density and violent crimes (Gruenewald 2007) posits that as alcohol availability increases via more alcohol establishments, excessive alcohol consumption correspondingly increases, which in turn increases the risk for alcohol-related harm. Types of place managers employed by alcohol outlets may also play a role. Place managers employed in on-premise establishments, such as waitresses, bartenders, and bouncers, can be more effective in preventing crime. They are not only in closer proximity to, but also are afforded longer duration of contact with potential offenders. Place managers therefore have more opportunities to intervene such as in employing de-escalation techniques. Consequently, researchers have hypothesized a stronger association between off-premise alcohol outlets and violent crimes. Similarly, Trangenstein and colleagues (2018) tested the hypothesis of a stronger relationship between off-premise alcohol outlets and violent crime exposure with more recently available data gathered from Baltimore, Maryland. The researchers examined the relationship between on-premise, off-premise, and LBD-7 (establishments permitted to sell alcohol on and off premise), and specific types of crime comprising homicide, aggravated assault, sexual assault, and robbery. Findings demonstrated a significant association between access to alcohol outlet and violence crime adjusting for neighborhood factors (percent minority, owner-occupied housing, median annual household income, population density, and drug arrest). Specifically, a 10% in access was related to a 4.2% increase in total violence crime. The

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association was strongest for off-premise alcohol outlets such that a 10% increase was associated with a 4.4% increase in total violent crime exposure, whereas a 10% increase in on-premise outlet and LBD-7 outlet was associated with a 3.0% increase and 4.2% increase in total violent crime exposure, respectively. Greater accessibility to off-premise alcohol outlet was significantly associated with all index of violent crime, namely, homicide, aggravated assault, sexual assault, and robbery. These findings thus support the researchers’ hypothesis of a stronger association between off-premise alcohol outlets and violent crimes. Zhang et al. (2015) evaluated the impact of a reduction in alcohol outlet density on violent crime in Buckhead, an affluent neighborhood in northeast Atlanta, Georgia. The neighborhood experienced considerable changes in the density of alcohol outlets between 1990s and 2000s. A growth of on-premise outlets in the neighborhood between 1997 and 2002 was followed by a reduction between 2003 and 2007, resulting in an overall decline of 6.8% in alcohol outlet from 1997 through 2007. The researchers compared exposure to violent crime in Buckhead during this period with exposure in two control sites, Midtown and Downtown, with similarly high clusters of alcohol outlets between 1997 and 2002, but experienced further increase of at least 24% between 2003 and 2007. The researchers reported a significant positive association between alcohol outlet density and violent crime exposure across all three neighborhoods. These findings also bolster those from cross-sectional studies of the link between alcohol outlet density and violent crime exposure. The findings linking alcohol outlet density directly to mental ill health has been more limited and less persuasive. Pereira et al. (2013) related alcohol outlet density to mental ill health in a population representative of the Australian sample comprised of adults aged 18 and above. Two mental health outcomes were measured: selfreport of prior diagnosis with anxiety, stress, or depression; and hospital contact (inpatient, outpatient, or emergency) for mental health within a 3-year window period from the time of survey completion. The researchers found that for every additional alcohol establishment in the neighborhood, harmful consumption of alcohol during the previous 4 weeks increased by 6%. The researchers also observed increased odds of hospital contact for mental health needs among participants with an alcohol establishment in the neighborhood compared to those without; however, this association was not statistically significant after controlling for participants’ age, sex, educational attainment, and household income. The number of hospital contacts in the sample was small, which may explain the insignificant association. Lamb and colleagues (2017) also examined the association between alcohol outlet density and two mental health outcomes, alcohol consumption and depressive symptoms, in women from socioeconomically disadvantaged neighborhoods in Australia. The researchers found associations of small effect sizes between alcohol outlet density in the neighborhood and alcohol consumption pattern, but did not find evidence of a statistically significant association with depressive symptoms. Although research on the effects of alcohol outlets density on the mental health of individuals is limited, the reasons why people drink and the consequences of excessive drinking are significant issues for social work to address. One of many reasons for drinking is to change one’s mood or mental state. Alcohol can alleviate

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feelings of anxiety and depression temporarily and are often used as a form of “selfmedication” such as to relax and sleep better and to lower inhibitions. Drinking depresses the central nervous system which can make moods fluctuate and numb emotions so that dealing with difficult issues can be avoided. While drinking does not necessarily cause mental illness, regular consumption of alcohol decreases the levels of the brain chemical serotonin which is a key chemical in depression. A result of decreased serotonin can begin a cyclical process where a person drinks to relieve depression leading to further feelings of depression requiring more alcohol to medicate the depression. Therefore, people with mental health problems may use drinking alcohol to cope with mental health issues which may make existing mental health problems worse. In an indirect manner, the density of alcohol outlets and alcohol accessibility may lead to even poorer mental health among individuals who may have existing mental health issues (Mental Health Foundation 2006).

Social Work Implications To improve mental wellbeing, there is a need to improve the social and physical environments in which people live and work. Actions taken at the community level have the potential to improve population mental health. Social work in the mental health field had long been embedded in a medical perspective where intervention and service provision had been located primarily in clinical settings within the microand meso-systems. The bio-psycho-social-spiritual framework (BPSS) has been most useful in contexts that primarily include direct interactions between the individual and the family and other more immediate social systems such as schools or the workplace. However, in the light of emerging evidence from a body of research in mental health and the community, factors such as green spaces, civic engagement and the accessibility of alcohol in the built environment, social workers need to consider expanding their role beyond clinical practice to participation in civic activities to increase their influence in preventive and ameliorative work. According to the WHO (2014a), more than 50% of the world’s population resides in urban areas, reducing access to natural environment. Since exposure to greenness is associated with better mental well-being, expansion and inclusion of urban green spaces in cities may also result in improvement in mental well-being of the population. Enhancing access to green space is a promising low-cost intervention for the reduction of depression, and disadvantaged populations may derive the strongest health benefits. Social work’s participation in advocating for investment in green space such as in care facilities may also lead to improvement in the mental wellbeing of residents. An example is the use of green care farm as a psychosocial approach to care (de Bruin et al. 2015). Green care farm offers residents access to natural environments including gardens and farm yards to encourage activity. Another example could be for social workers to participate actively in urban planning by advocating for better and more appropriate use of green spaces to help improve the mental health of residents in the community. The BBC recently reported that cities around the world are adopting a long-standing feature of Chinese public

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parks to boost exercise among pensioners and to keep them as physically and mentally healthy for as long as possible (Traverso 2019). Crowds of elderly Chinese participate in early morning exercises such as qigong, dancing, and even light gymnastics and cardio workouts. Given the ageing population across the globe, other cities in such as London, Berlin, and Toronto have also introduced playgrounds for seniors. The BBC report above also included two important observations. First, the morning exercise habit of Chinese people has a long-standing cultural tradition dating back to the Huangdi Neijing (The Yellow Emperor’s Inner Canon) in the third century where waking up early and exercising is a pillar of Chinese traditional medicine. Second, it was reported that culture was not the only factor in influencing park use among seniors. Location, design, and amenities are also important. Older adults sometimes do not feel welcomed in public parks because they are designed for younger users. Public parks may then not be psychologically accessible to them. Social work in mental health therefore has an important role to play in advocating for the availability of green spaces as well as the provision of appropriate amenities and programs for different age groups as a preventive and ameliorative strategy. Where there is no cultural tradition of exercise, social workers could be more proactive in encouraging exercise routines in available green spaces for their service users and perhaps can even conduct counseling sessions in open spaces instead of confining help to clinical settings for some service users. Social connectedness is also an important factor in developing and maintaining better mental health. Social work can include encouragement for service users to attend programs that enhance informal social relationships. Connecting with friends and relatives, chatting with neighbors, connecting with friends and family over current affairs, keeping in touch with friends, and staying in touch with extended family members leading to improvement in mental health could become part of the clinical work social workers conduct with individuals and families. Helping to facilitate and support volunteerism such as in recovery programs could provide better opportunities for service users to gain a higher level of confidence and selfesteem than just talk therapy alone. Advocating for limited alcohol availability in neighborhoods has the potential to reduce the level of harmful use of alcohol, which in turn may reduce exposure to negative mental health outcomes arising such as alcohol-related intimate partner violence, child maltreatment, drunk driving, public nuisance and fights, and violent crimes. In some countries such as Singapore, there are on-going attempts to test out different ways in which drinking-related laws and regulations could be put in place to regulate the consumption of alcohol and reduce the harmful effects of unregulated alcohol consumption in public places (https://singaporelegaladvice.com/law-arti cles/legal-drinking-age-singapore-drinking-related-laws/). The current legal drinking age in Singapore is 18 years old and it is illegal to sell alcoholic beverages to any person below the age of 18 years in licensed premises such as restaurants and supermarkets. In addition, Singapore law prohibits consumption of alcohol in public places such as parks and the sale of alcohol from retail outlets between 10.30 pm and 7.00 am. The Straits Times Forum page reported an 18-year-old Wee Yan Loong’s observation that alcohol makes young people vulnerable to being victims of crimes

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and also being criminals themselves. In addition, alcohol abuse can result in longterm repercussions such as in brain structure development which results in impulsiveness and a lack of coordination as well as become susceptible to other type of addictions. As such, he proposed that the authorities should consider raising the legal drinking age to 21 years (Wee 2019). It may be worth thinking about whether social work in mental health should be equally, if not even more, concerned than Wee (2019) on the preventive aspects of the effects of alcohol on mental well-being especially among young drinkers and therefore the need to be more participative in reviews and advocacy regarding public accessibility to alcohol purchase and consumption. Social workers can also play a role in advocating for limited off-premise alcohol outlets in residential neighborhoods.

Conclusion Overall, linking mental health and the community presents new challenges for social work. Social workers themselves need to be cognizant of factors in the service users’ environment and their effects on mental well-being. There is a need to be creative in maximizing the positive effects of certain environmental factors such as green spaces and opportunities in the community to help the service users be more socially connected. Social workers themselves need to be more participative and engaged in working with community partners such as urban planners, community leaders, concerned-members of the public in creating a community that supports maximum mental health. Social service agencies need to be more accepting that professional work in the mental health setting can transcend the medical clinical practice model and expands to an inclusion of both formal and informal work settings. One emerging model is the Connecting People Study and the subsequent Intervention Model (mgoat73 2012) where the core of practice is the principles of co-production. Co-production involves the worker and the individual co-creating and taking responsibility for the decisions made about objectives and actions to be taken in the work to be achieved in health and social care. Unlike the traditional approach of helping one-on-one, the intervention also involves developing new connections and social networks outside the worker/service user dyad as part of the strategy to achieve the co-created objectives within a supportive agency. Mental health and the community presents new challenges but also opportunities for social work to be more engaged with the exo- and macrosystems of their service users as well as expand the worker’s personal and professional expertise.

Cross-References ▶ Alcohol and Drug Use ▶ An Overview of Social Work Approaches in Working with Families of People with Serious Mental Illness ▶ Community and Mental Health ▶ Developmental Approach to Mental Health

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▶ Financial Challenges and Mental Health ▶ Legal Provisions, Advocacy, and Empowerment ▶ Qigong Practice ▶ Suicide Prevention

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Māori Social Work and Māori Mental Health in Aotearoa New Zealand

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Hannah Mooney, Andrea (Ange) Watson, Paulé Ruwhiu, and Awhina Hollis-English

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Māori (the Indigenous People of Aotearoa New Zealand) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Māori Belief Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Impact of Colonization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Services for Māori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Māori Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptoms of Mental Ill Health: A Māori Worldview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Te Whare Tapa Whā and the Meihana Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study Demonstration of the Meihana Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter is written by four Māori women who are social workers, academics, supervisors, mothers, and members of their own tribal groups. The authors write from their unique perspectives that are inevitably shaped by their histories, tribal affiliations, and social work practice. H. Mooney (*) Ngāti Raukawa ki te tonga, Te Āti Awa, Ngā Rauru, Te Ātihaunui a Pāpārangi, Massey University School of Social Work, Palmerston North, New Zealand e-mail: [email protected] A. A. Watson Te Āti Awa, Ngāti Mutunga, Taranaki, Massey University School of Social Work, Palmerston North, New Zealand e-mail: [email protected] P. Ruwhiu Ngā Puhi, Ngāti Porou, Massey University School of Social Work, Albany, New Zealand e-mail: [email protected] A. Hollis-English Awhina Hollis-English, Napier, New Zealand e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_9

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Abstract

Indigenous experiences of mental health are inevitably affected by the historical trauma experienced by colonization. Instead of looking solely to the dominant western ideas to address these issues, Māori social workers are using ancestral, cultural, spiritual, and contemporary indigenous practices to meet the health and well-being needs of Māori. This chapter presents Tā (Sir) Mason Durie’s (2001) Māori model of practice Te Whare Tapa Whā, an extension into Pitama’s et al. (2007) Meihana model, and then applies the Meihana model to a case study. There is no “one solution” or quick fix in this case study, and the authors acknowledge the variables involved when working in the area of mental health and the importance of critical reflection in practice. Keywords

Māori · Mental health · Social work · Indigenous · Meihana model

Introduction Pre-colonial Māori had belief systems in place to help understand and manage wellbeing. Kingi states: “Prior to colonization Māori did in fact have well-developed mechanisms for health protection and health promotion, and a comparatively advanced knowledge and understanding of how diseases were transmitted” (2005, p. 8). However, Māori mechanisms of well-being were significantly affected by the introduced belief systems of the British and by other outcomes of colonization eroding the Māori social and cultural infrastructure of whānau (extended family), hapū (subtribe or collection of family groups), and iwi (tribe). In Aotearoa New Zealand, much like other countries impacted by colonization, Indigenous health and well-being is measured comparatively with non-Indigenous standards of health, and the predominant medical approach is to separate mental health from physical and other elements of Māori well-being. Currently the status of Māori mental health is influenced by the trauma of colonization; however there is a reclamation of “culturefirst” or “culture-alongside” Western frameworks (Durie 2011; Pitama et al. 2007; Hirini and Collings 2005). This chapter presents aspects of this history with an emphasis on Māori belief systems and ways of viewing mental health. Readers are then introduced to Māori social work practice methods, how they work, and the values they bring to practice. These practice frameworks reflect Māori worldviews, embracing the traditional as contemporary and culturally appropriate. Māori experiences of mental health services and the advent of Kaupapa Māori mental health services are presented. The chapter explores Māori symptoms of mental ill health and areas where there could be misinterpretation and misunderstanding. The chapter then presents Te Whare Tapa Whā, a well-known Māori model of practice with an additional discussion on how extending into the Meihana model provides a critical, ecological perspective. A case

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study provides an example of how this theory can apply to practice for social workers and other helping professionals. For the purpose of this chapter, Māori words are translated into English, and when they are used, their meaning will be explained. Like many languages, Māori words cannot simply be translated into English as it does not capture the true context and the meaning can be “lost in translation.” The translations provided reflect a simple understanding.

Māori (the Indigenous People of Aotearoa New Zealand) In Aotearoa New Zealand, the indigenous people are known as Māori or tangata whenua (people of the land). Māori were (and still are) a collectivist culture, rich in oral tradition. Traditional social structures comprised of groups of families that lived together and relied on each other, known as whānau (extended family). Each whānau existed within a hapori (community) or hapū (subtribe or collection of family groups) and would belong and live within a geographic area that was important to their iwi (wider tribal group) (Walker 1990). There were, and still are, hundreds of tribal groups living within their tribal areas; however today many have moved away from their traditional communal setting (Durie 2011). Being connected to ones’ whānau, hapū, and iwi as well as to the geographical area of their ancestors is still extremely important to Māori, even to those who live in other parts of the world. Māori are now a minority within their own country (albeit the largest minority) at 14.9% of the total population (Statistics New Zealand 2013).

Māori Belief Systems The intention here is not to give a complete overview of Māori belief systems, but to provide a snapshot into a Māori worldview that shapes ideas of health and wellbeing. A traditional way of life for Māori featured strong support and belief systems, a whānau, hapū, and iwi structure embedded in Māori customs and knowledge (as mentioned above). Wairuatanga (Māori spirituality) guides the daily Māori way of life through an important familial connection to ngā Ātua (the Gods). This is nurtured from the belief that one’s whakapapa (genealogy) connects people intergenerationally to the gods and inherently to the land and environment: “throughout all procedural forms of interactions between humanity there is an intercession and dialogue between the living and the dead, the physical natural and spiritual dimensions” (Ruwhiu and Ruwhiu 2005, p. 10). A strong clue to this is found in the words “tangata whenua,” Māori are people of the land and identify strongly to significant landmarks to connect to and understand the past, present, and future. An example of this is the saying “Ko au te awa, ko te awa ko au,” I am the river and the river is me. These landmarks are Ātua; Ranginui is the Sky Father; and the land is Papatūānuku, our Earth Mother. Connected to Ātua are all living and nonliving

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things that have Mauri (life force); as such they are attributed qualities that are respected, cared for, and revered. Social balance is maintained through tikanga and kawa (customs and values) passed down through the generations that detail how one should best behave and interact and which places, people, and objects are tapu (had certain restrictions) or noa (unrestricted). Examples of these beliefs and practices are in more overtly spiritual events such as birth and death, but they also play a role in day-to-day tasks, collecting/hunting for food, travelling, and in rules of engagement (Harmsworth and Awatere 2013). Certain individuals were noted to have significant spiritual influence, connection, and standing. Tohunga (spiritual leaders) were conduits to the spirit world, guides, and healers. Others had substantial mana (prestige, integrity) either inherited or earned; these were often those in leadership positions and their firstborn children (Mead 2003).

The Impact of Colonization Aotearoa New Zealand was colonized by the British, and in 1840 Te Tiriti o Waitangi, The Treaty of Waitangi, was signed between a number of iwi and the Crown guaranteeing Māori continued rights. There were multiple versions of the Treaty, and what followed was either a complete disregard for the Treaty, as each side continued with the view that their own versions were the correct ones (English and Māori versions) or resistance by those who did not sign. Māori continued to maintain traditions while integrating introduced beliefs such as Christianity. Colonization has caused immeasurable intergenerational, spiritual, and psychological harm for many Māori. Over 170 years Māori traditions were negatively impacted, language almost lost, large tracts of land confiscated (by force or through law), and death and incarceration have been (and still are) major issues. An example of this was the Tohunga Suppression Act of 1907, which made being a practicing Tohunga illegal. An urban shift in the 1950s saw many Māori move from their rural communities into the cities, particularly in search of better employment opportunities. Around this time, Māori were expected to assimilate through informal and formal policies that became insidious nationally and in people’s homes significantly affecting the intergenerational transmission of knowledge and Māori identity. Urbanization led to significant lifestyle changes and a reduction of traditional whānau support systems. This is significant as a relationship between cultural strength and good mental health is a protective factor (Kingi 2005). Māori rates of mental ill health (as defined by western ideas of diagnosis) have increased since 1970, and Māori mental health status is a major concern. The more Māori have assimilated into “mainstream” culture, the harder it has been to utilize Te Reo Māori (Māori language) and to maintain Māori values and a connection to whānau, hapū, and iwi (traditional social structures) (Kingi 2005).

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Through loss of access to spiritual guidance and other implications of urbanization and assimilatory social policies, many Māori found themselves disconnected from their whānau, hapū, iwi, and the associated stability, “colonization has interrupted and disrupted the intergenerational transmission of tikanga (protocols), reo (language) and Mātauranga Māori (Māori knowledge)” (Pihama et al. 2014, p. 249). In recent years Maori have emphasized the importance of culture as a protective factor, which is now reflected in mental health services.

Health Services for Māori Historically, consistent with the international community, the mental health system in New Zealand had an institutionalized approach with prisons, asylums, and mental institutions providing long-term housing and “treatment” for the mentally ill and disabled. From the 1980s a deinstitutionalization process began that led to the growth of community mental health services. For some Māori, if they or a family member have mental health concerns, they will seek support through their own whānau, hapū, and iwi before accessing professional services. Currently mental health services offer a greater range of community- and government-provided services that are available to Māori. Mild to moderate mental health support is mainly accessed through general practitioners (GPs), primary health organizations (PHOs), and/or nongovernment organizations (NGOs), and Māori also have access to iwi (tribal) services or urban Māori services. Another newer initiative in policy (although not new in Māori communities) is Whānau Ora where a whānau-centered approach is promoted; this can be found in many social, community, and health services (Boulton et al. 2013). When Māori are experiencing more severe symptoms, hospital-based services can be accessed such as crisis services, inpatient services, and community mental health and addiction services. In some areas there is a separate Kaupapa Māori service, and Māori should have a choice to access this service or a mainstream service. Non-Māori are also able to access these services. According to Te Rau Matatini (now Te Rau Ora), the National Centre for Māori Health, Māori Workforce Development and Excellence (2016), the aims of Kaupapa Māori mental health and addiction services include: 1. 2. 3. 4. 5. 6. 7.

Connections with Māori whānau, hapū, iwi, and community organizations; Support by mana whenua [local hapū and iwi] and/or the local Māori community; Utilization of Māori derived beliefs, values, and practices; Staff who are predominantly of Māori descent; Aims that are consistent with wider aims and aspirations of Māori development; Facilitation of access to, and support of, kaumātua [elders]; An emphasis on whakawhanaungatanga [relationship building].

Access to these Māori-led and culturally appropriate services provides the best outcomes for whānau (Waitoki et al. 2014).

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In recent years, there has also been a focus on Māori workforce development in mental health, including Māori social workers. The aim is to grow the Māori workforce to provide better and more appropriate services to Māori. Te Rau Puāwai is an innovative and successful bursary program for Māori students, administered by Massey University and funded by the government. Over the last 20 years, they have produced 400 graduates and have a 95% success rate (Te Rau Puawai 2018). Te Rau Ora (formerly known as Te Rau Matatini) also offers opportunities for Māori to consider and work towards a career in mental health (Te Rau Ora 2019). While services are now more culturally appropriate, there are still many gaps and areas to develop and improve. A 2000 survey of 247 New Zealand psychiatrists highlighted views that Māori were particularly biologically or genetically predisposed to mental illness and several psychiatrists expressed racist views (Johnstone and Read 2000). Taitimu, Read and McIntosh’s (2018) research highlighted that Māori are likely to benefit from both clinical and cultural interventions. However in reality found Māori “spiritual and cultural constructions to be marginalised and/or pathologised within mainstream settings resulting in a survival coping strategy of silence” (2018, p. 170).

Māori Social Work Māori social workers are social workers who identify and whakapapa Māori (have Māori genealogy). For many Māori social workers, their culture is integrated into their practice. Māori social work has embraced the importance of culture in practice, leading other helping professions (Hollis-English 2015). For the majority of these social workers, their Māori identity and beliefs are congruent and integrated across the personal and professional; so, what is practiced in the workplace is consistent with what is practiced in the home and community (Hollis-English 2015). Māori social workers have embraced the reclamation of Māori ways of doing things that gathered strength in the 1980s. Māori frameworks and models of practice guide Māori social workers in the different phases of interaction and engagement with whānau. An example is mana-enhancing practice (Ruwhiu 2001), which ensures social work practitioners consider key recognition points in their practice such as the importance of historical events in Aotearoa New Zealand, the acknowledgement and promotion of one’s identity, and working with Māori using Māori concepts of well-being. Attention to the engagement phase is vitally important when engaging Māori. This is because Māori put a strong value on face-to-face contact, connection, and relationship building. Without this, rapport can be adversely affected, and the engagement can be lost, poor, or meaningless (Mooney 2012). Attention to relationship building means taking the time to engage meaningfully with the person; this includes exploration of whakapapa (genealogy). The understanding and links that can be gained from this process are very effective and create connection beyond that of “social work professional and client” to kinship (and you may in fact be working

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with your own whānau) (Ruwhiu and Ruwhiu 2005). Having this cultural lens can also ensure that misunderstanding leading to labeling and misdiagnosis is less likely to occur.

Symptoms of Mental Ill Health: A Māori Worldview Māori social workers and their allies work to challenge monocultural approaches that do not take spiritual and cultural constructions into consideration. A Māori cultural approach and recognition can be healing and respectful. This cultural approach alongside Western frameworks helps to avoid misdiagnosis. A number of “diagnostic” areas from a Māori perspective will now be discussed. Mauri mahi, Mauri ora, Mauri noho, Mauri mate Industry begets prosperity – Idleness begets poverty

The whakataukī (proverb) above talks about the Māori concept Mauri. Mauri, loosely translated, means “life force,” and here it states that someone with a productive life will be well, while someone who is inactive will be unwell. An understanding of a Māori worldview can help practitioners accurately interpret depressive symptoms and avoid misdiagnoses when working with Māori. What might be labeled as “depression” or seen as symptoms of “depression” from a Western perspective may manifest differently for Māori, and therefore symptoms can be interpreted incorrectly. Similarly, Pōhatu (2011) refers to Mauri moe, “actions and expressions of inactivity,” in this phase. This is not seen as unhealthy; it is described as a safe space that has untapped and proactive potential. The following terms are different states of Mauri moe: Kai te noho puku – being anxious and withdrawn Kai te pouri – being withdrawn and not taking part Kai te tangi – expression of hurt Kai te aue – expression of anguish and pain Kai te mamae – experiencing hurt/pain Kai te noho noaiho – not participating in activities Kai te noikore – having no energy to participate in activities (Pōhatu 2011, p. 5)

While these “symptoms” present challenges to a person’s ability to progress, there is a recognition of the reflective qualities of this state and a chance for “energies to be regathered and recomposed” (Pōhatu 2011, p. 5). While people can experience this state, it is part of a dynamic process that can change over time and has positive aspects. Another example of what depression might look like is the concept of whakamā. While this concept (like most Māori concepts) is too large to cover in this chapter, we can provide some basic understanding. Whakamā is often translated as to be ashamed or embarrassed, and there are different levels of this where Māori can feel

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shy, modest, or nervous, but at a deeper level, there are feelings of inadequacy, shame, and inferiority (Sachdev 1990). These can be experienced when outside of one’s comfort zone and when in the presence of others depending on the nature of the relationship, for example, if in the presence of a person who has power or if you are being reprimanded. Māori can also experience whakamā when someone commits a wrongdoing against them (whether intentional or not) (Sachdev 1990). Durie states that it can be in response to “a sense of disadvantage or a loss of standing” (2001, p. 25). Māori who are whakamā may present as unmotivated, non-compliant, and anxious, and they may avoid eye contact and/or be in a catatonic state. Metge (1995) describes some of the symptomology of whakamā to help understand the presentation: Someone who is whakamaa looks like a wooden post. They stand there petrified. He is frozen. It is almost as if they have lost all power of movement except the eyes moving to and fro. He just sits there. Whakamaa is loss of speech, loss of action. He stands there not seeing, not hearing, not answering. The child has switched off. He is looking downwards. He has shut off his ears, and he has got himself a bit braced too. The shutters come down. She was just struck dumb. Whakamaa is not speaking; being dumb, speechless. When they stand up, all they have thought out to say, they lost it. They become tongue-tied and dumbfounded. He is at a loss for words. They are only there in body. (Metge 1995, pp. 45–46)

Other Māori terms are used to describe someone with depressive symptoms. Mate pāpōuri is a term used to describe being in a state of sadness for an extended time. Pouritanga is another term often used to describe feelings of depression. Māori can also present with “psychotic” symptoms such as hallucinations or visions, hearing voices (speaking to ancestors), or with “special powers” of foresight. In Te Ao Māori, these are not always an illness, but a gift (Webster and Bosmann-Watene 2003). In traditional times these were more easily recognized, understood, and nurtured, as the person was viewed as being able to connect to the spiritual world or have the ability to converse with ancestors. When treated through prescription medication or drug/alcohol use, they may interfere with the natural process of being connected to the spiritual world. The Mental Health Foundation produced a report on Māori perspectives of depression and highlighted the term “whakamōmori.” This can be translated as a “deep-seated underlying sadness” or “in-built tribal suffering” (Mental Health Foundation n.d., p. 3). While it is often used as an equivalent to suicide, it refers more broadly to “a loss of alternatives that can be so overwhelming to the individual as to lead eventually to their death” (Coupe 2005, p. 10). In a NZ Psychological Society

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Conference speech, Hon. Tariana Turia (2000) highlighted the impact of tribal suffering and compared colonization and oppression with that of a home invasion, “a consequence of colonial oppression has been the internalisation by Māori of the images the oppressor has of them. . .a despair leading to self-hatred, and for many, suicide.” Turia argued that, for Māori, depression often manifests in the form of anger rather than sadness, which can easily be misunderstood by non-Māori health professionals. Ill-health can be caused by unresolved issues that originate due to an imbalance between the spiritual and physical realm (Bush and NiaNia 2012). Mate Māori can be defined as “unresolved traditional Māori ‘dis-ease’ that may result in physical, psychological, relationship and spiritual suffering or even death” (Bush and NiaNia 2012, p. 349). Pōrangi (dark night) is a form of Mate Māori and is described as a state of disconnection and darkness, an outcome of being disconnected to culture and values (Taitimu et al. 2018). In Māori mental health assessments, this should always be explored as an alternative cause for depressive and/or psychotic symptoms. When screening for Mate Māori issues, there needs to be an element of understanding of what Mate Māori is and what it might look like; historically this was the role of the Tohunga. Today, helping professionals, even if they are Māori, have variable understandings of Te Ao Māori (Māori worldview). It is helpful to have a kaumātua or cultural advisor involved at this stage or after Mate Māori issues are discovered (or suspected). Māori may find it frustrating trying to interact and communicate their perspective because it can be difficult to explain the state they are in, particularly in a predominately clinical environment where these symptoms are interpreted from a non-Māori lens. There are major concerns when the responsibility for understanding cultural difference and interpreting/translating their feelings to a different cultural group falls on the most vulnerable person in the relationship. The following Māori model of practice, and the case study that follows, provides an example of how a Māori social worker may practice in a way that integrates a Māori worldview with contemporary western approaches.

Te Whare Tapa Whā and the Meihana Model Māori social workers (and other helping professionals) can use Māori models of practice to better enhance their work with Māori families. Durie’s (2001) Te Whare Tapa Whā, a Māori model of practice, is presented with the additional concepts introduced in Pitama’s Meihana model (Pitama et al. 2007). Te Whare Tapa Whā is a metaphor of a four-sided whare (house). Each side of the house is represented by essential aspects of a person’s well-being: taha taha hinengaro (emotions, thoughts, feelings side), whānau (familial side), taha wairua (spiritual side), and taha tinana (physical side). Each wall of the house needs to be in balance for the house to maintain its foundations and remain upright (Durie 2001, p. 69). The examples provided for each “wall of the house” are not exhaustive; they are also not exclusive;

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while they are presented separately for practical purposes, they overlap and integrate with each other. Taha Hinengaro – this dimension refers to a person’s mental well-being, cognitive activities, emotion, and intuition. It is the female element, private and unseen, so needs to be sensitively explored (Pere 1988, 1991). Cherrington (2009) notes that this is inclusive of communication, personality, and attitude of individuals and whānau. It also takes into consideration learning difficulties and a person’s understanding of what is happening. Thoughts and emotions are investigated with the individual and whānau: How do they feel about the concerns they have, how do they feel about life in general, how do they feel about themselves and others, and how do they express their emotions? Hinengaro is often the focus of a mental health assessment where people are asked about their thoughts, feelings, and the risk and safety issues connected to these. A Māori worldview is that this cannot be assessed in isolation from the other elements. Taha Whānau – health and well-being is about being connected to others and having strong relationships with whānau (extended family). With permission, the social worker engages with the person’s whānau as they are extensions of that person, critical in their health and well-being journey. It is also important that “Kaupapa whānau” (people linked with a common purpose) and their role be explored and included as needed. This is different from “whakapapa whānau,” who will have a biological or whānau connection, and incorporates key stakeholders in a person’s life, often viewed as just as important as whakapapa whānau, particularly for those who have lost genealogical connections (Lawson-Te Aho 2010). The role of the social worker is to explore whakapapa: familial and ancestral links that connect Māori to each other, the land, and the Ātua (Gods). This may include past, intergenerational, and contemporary stories of warfare, migration, intermarriage, and links with significant landmarks. Inevitably, this identifies the person’s level of knowledge and connection to whānau, hapū, and iwi, whether the person is physically and/or mentally near or far from these. Relationships with close and extended whānau members can be explored, the person’s role and responsibility within their whānau and whether they feel they are supported and nurtured within their environment. Questions such as their connection to the marae (meeting house, place of refuge/spiritual significance) or any other cultural institutions may help to understand their interactions outside of their home and in their community. It is important to note that sometimes Māori who are “disconnected” from their cultural identity may not wish to talk about it at the beginning of the assessment, but the practitioner needs to remain open to them changing their mind. This is often the case when Māori feel whakamā about their lack of knowledge or if they do not feel comfortable sharing this with the helping professional. This can be addressed after time and process of relationship building, use of Māori frameworks, and healing. Whānau may also have their own intervention strategies of connection and support for their whānau member through practical, physical, and spiritual means. Interventions may also include the nurturing of the person’s cultural identity and might involve reconnecting them, encouraging them, or going with them to their ancestral lands, being with their people and connecting with the area (climbing their

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mountain, bathing in their river, visiting significant areas – marae, urupā (burial grounds), old and current whānau homes). There may also be some work around understanding significant historical events and how these may have impacted on the present-day individual and whānau situation, sometimes connecting with the day-today issues they are experiencing. Intergenerational relationships and historical events are considered as possible reasons for mental health concerns (e.g., whakamā and Mate Māori discussed earlier). All of these considerations to whānau connections also link into taha hinengaro as there are attached emotions and expressions shown in their various relationships. Taha Wairua – Wairua is the connection to the spiritual element and present in peoples’ values and belief systems. The use of karakia (prayer, incantation) can pave the way for spiritual acknowledgement, protection, and cleansing, carrying more weight when led by spiritual leaders and experts. Everything is interconnected; as humans we are connected to the Ātua (Gods), the whenua (land/environment), and tangata (people). It is encapsulated in the following poem: Wairua By Heather Delamere Thomson “Koro, what is wairua?” the child asked, eyes wide “Wairua, my moko is what gives us life Handed down to us from a time past At the moment of your beginning You shared with me the wairua of your tipuna: For I am your link with the past And you are my link to the future The aroha of the whānau has wairua And their words, their laughter, their tears The marae, tangi, waiata and whakapapa Have a wairua that strengthens us, gives us pride So too the sunrise and sunset The soft summer rain, the raging storm, The song of the birds in the trees, The waves on the beach The mist rising from the bush The moonlight on the water And the embracing darkness of the night To sit quietly in the wharenui or the urupa And feel the presence of your tipuna is to feel wairua Your arms around my neck, your breath on my cheek, Fills me with a special wairua For there is wairua in all things that give meaning to life To love, to the future.

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“So moko, open your mind, Let your heart love Your eyes see Your ears hear Your hands feel Give of yourself, my moko For in giving, you receive And the wairua grows.” (Thomson cited in Cherrington 2009)

The social worker will observe the person’s presence (physical and spiritual) as these can be incongruent to what he/she is reporting. They will also assess whether the person listens to their wairua or he/she experiences intuitive moments that he/she is ignoring or afraid of. Examples of these can be signs and symbols received through experiences, dreams, messages, and instinctive feelings about people and situations. As in the past, people also continue to have gifts of foresight and mediumship – harnessing these gifts can be daunting for some particularly if misunderstood or misinterpreted by self and others. An example of this is the belief that certain wildlife come with messages. There are stories about spirits that can be very significant to Māori families and are often associated with certain landmarks, transgressions of tapu, or a person’s role and placing in the families. These are tied with the ideas of tapu and noa mentioned earlier where these areas are respected so as not to bring the individual or the family negative consequences (bad luck, death). These stories need to be explored with the person and their whānau due to the sometimes very significant consequences and because it can affect a person’s ability to improve their situation generally. Additionally, wairua is also connected to personal values and worldviews where what we do and how we act have a significant effect on the way we see ourselves and how healthy our wairua is. For example, if we have done something that does not sit with our value base, our wairua gives us indications of guilt, shame, fear, and whakamā. It may not always be possible or practical to visit ancestral lands, as discussed earlier, due to geographical location, mobility, and finances, but sometimes a visit or continued visits to a beach or a walk in the bush may be enough to enhance the spirit of the person. Māori social workers and their whaiora (person seeking wellness) can utilize these moments to reinvigorate the senses with touch, smells, sights, and sounds and either have an engaging moment through discussion or silence. Some Māori find that references and connection to the different gods associated with areas and elements can help them to understand how they (or a loved one) might be thinking, behaving, or feeling, for example, exploring Tāwhirimātea (the god of the winds), the different roles of the wind, and how it can be revered or despised (see Rangihuna et al. 2018 work Mahi a Atua). The following basic questions can help the social worker understand ways to assist the person to uplift their spirit: What are the person’s strengths? How can they be enhanced? What makes them feel good? What do they enjoy doing? Taha Tinana – in mental health assessments, good physical health and development is seen as a protective factor. For Māori this is also the case; a person’s

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physical health is an important aspect to explore and is strongly connected to wairua and hinengaro. If a person is feeling satisfied with their appearance, and is fit and healthy, their wairua is most likely to reflect this too. Do they view themselves as important and tapu, not to be harmed by self and others? (Cherrington 2009). This includes substance use, self-harm, violence, and so on. The social worker will assess whether there are health issues, the person’s view of their physical self, whether there are limitations, for example, the person’s mobility is affected, and areas where the person would like to improve (and whether this is possible or not). Do they have access to the right supports? For example, do they want to quit smoking and know and understand their options? Do they want to work on their physical fitness? The tinana (the body) should be viewed in a balanced way; sometimes the issue is more in relation to overdoing things and causing stress on the body, for example, studying late into the evening and overexercising. Māori have their own interventions (rongoa), cleansing rituals, traditional medicines, herbal remedies, and massage therapies that can be used to assist the person experiencing physical, spiritual, and mental ailments. These have come from many years of research and were administered by Tohunga (spiritual leaders). The social worker may assist the person to access a healer for this intervention. Unfortunately, there are fewer Tohunga available, and often kaumātua (elders) are now in the role of spiritual guides and healers. Sometimes just having a kaumātua available to talk with can be helpful and settling for the person. The Meihana model, developed by Pitama et al., is an extension of Te Whare Tapa Whā and for use within mental health “to facilitate the fusion of clinical and cultural competencies to better serve Māori within mental health service delivery” (2007, p. 120). It is a useful framework utilized to assess the strengths of the social worker and service and also the person and whānau. It adds in two other concepts: Taiao – the person’s physical environment, their home, their community, and their support services and systems. It includes the physical environment of the service, for example, accessibility, surroundings, and respect for whaiora (person seeking wellness). Iwi katoa – the wider macrocontext, societal and political structures, values, and beliefs that dictate appropriate behaviors and policies (which also has an impact on service delivery). For the social worker, this includes an analysis of how their own worldview, value, and belief affect work with the person and their whānau. This has similarities with the popular theory used in social work, Bronfenbrenner’s (1979) Ecological System’s theory where social workers can assess the person’s level of fit with the systems around them. While this model can help those with limited cultural knowledge, for appropriate and effective application, a certain level of cultural and clinical competency is required (Pitama et al. 2007). This overall framework will be referred to as the Meihana model. Figure 1 The Meihana model designed by the authors of this chapter, demonstrating the interconnectedness of the model and how the four areas from Te Whare Tapa Whā are nested within taiao and iwi katoa The Meihana model can be utilized in numerous ways and at different stages of intervention. The model can be used as an analysis method, to reflect on an

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Fig. 1 The Meihana model

individual and whānau within their context. It can also be used alongside and with whānau to assist them to understand concerns and explore strengths, within their context. It can also be utilized as a planning or reflective tool (e.g., a debrief model) for Māori social workers and other helping professionals and services, to explore worldviews and practice.

Case Study Demonstration of the Meihana Model A case study will be presented here and then discussed with the Meihana model. In applying a Māori model of practice, theory and practice come together from a specifically Māori lens. Here is a reminder of the basic translations of the key concepts; taha hinengaro (emotions, thoughts, feelings side), taha whānau (familial side), taha wairua (spiritual side), taha tinana (physical side), te taiao (physical environment) and iwi katoa (wider macro context). The case study is an example that can be utilized by people interested in a deeper understanding of the application of this model. Parts of the story have been changed to protect the confidentiality of the whānau; however we would like to acknowledge the young girl and her whānau and the lessons learned from this scenario. The outcome of this case was tragic; however, from this tragedy there is learning and improvements in practice. A case study – Mere’s story part one: A young Māori girl, Mere (13), experienced sexual abuse for a number of years by a family member and after it was discovered she suffered from symptoms of Post-traumatic stress. Her erratic behaviour meant that she was regularly in and out of hospital (nowhere felt safe for her) because she was actively suicidal. When Mere was in the

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specialist youth hospital she continued to have distressing symptoms and she ran away a number of times. They trialled different medication and on discharge she was given a new one. The hospital was outside of the region, so immediate whānau support was not readily available. Those who worked with her (in hospital and in the community) found her behaviour challenging and many had either opted out or had started to take a judgmental approach. She made friends in hospital and this was seen as negative, influencing her behaviour and attempts to get back into hospital when she was home. Prior to the abuse Mere appeared to be high functioning, she attended school and participated in sports and cultural events.

This case demonstrates that there were significant concerns (from both a western and Māori perspective) and the need for ongoing clinical input, safety, risk assessment, and cultural input. The following tables highlight how the Meihana model can be utilized to explore aspects of Mere’s situation (Tables 1, 2, and 3). Mere’s story part two: Mere’s care was transferred to new Māori social workers from hospital based mental health services. A visit took place in the home with Mere and her mother. Initially Mere was part of the conversation but then disappeared from sight. When Mere did not return after a few minutes the social workers’ queried her absence and at this point noticed a knife block in the kitchen, this raised alarm bells because of Mere’s past suicide attempts, all access to means should have been removed or restricted. Mum kept talking; she did not seem to notice anything amiss, whereas the social workers began to feel concerned; both later reflected on an instinctive, sick feeling. Mere’s story part three: Tentatively the social workers called for Mere hoping they would be proven wrong about their feelings. They found her sitting in a sleep-out away from the house holding a large butcher’s knife. She refused to put the knife away and instead put it to her throat – she made cut marks on her throat, but stopped, momentarily distracted. A bird had appeared in the sleep-out, it was a large bird, but still covered in down. The mother and daughter worked together to try to get the bird out of the sleep-out. Once it was out Mere walked away, refusing to give up the knife. The social workers’ contacted the police for assistance. Following this Mere was again admitted to hospital. Mere’s story part four: Mere spent a week in an adult ward in hospital. When she was discharged a new safety plan was put in place to support a safe transition home, agreed to by Mere and whānau. She was due to see the Psychiatrist three days later but the night before her appointment she took her life in the same sleep-out.

Through reviewing this case using the Meihana model, we can reflect on and learn ways to improve social work practice. The case was crisis-based, and on reflection the support from services was primarily based in a medical model, focused on diagnosis, medication, and hospitalization. The whānau was left with the devastation of the loss of Mere and the whānau member (the abuser) still among them. The Māori concept of whakamā was evident from both Mere and the abuser (Table 4). This case was not absent of a cultural approach, but the argument is that there was not enough “culture-first” or “culture-alongside” at all points of engagement. The aim is not to dismiss the medical model; it is to show that taking a broader view, inclusive of the cultural lens, applied in a meaningful way, can benefit social work practice with Māori. This is an important commitment for the mental health sector and beyond.

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Table 1 Mere’s story part one Taha hinengaro

Taha whānau

Taha wairua

Taha tinana

Taiao

Iwi katoa

Mere and her whānau experienced many emotions, i.e., whakamā, grief, anger, self-hatred, and other negative thought processes Mere had to deal with the aftermath and mixed emotions of the exposed abuse and people viewing the behavior of the abuser as wrong and disgusting Although Mere struggled with what had happened, she was trying to improve her situation A crisis occurred for the whānau (the abuse) The whānau had to consider how to support Mere and cope with the information and changes in her (managing her emotions and risk) Relationships were redefined, for example, with the abuser, for Mere and the whānau Mere’s father was not in her life Mere felt that she had betrayed the abuser. This person was a trusted male member of the whānau The whānau rallied to support Mere Mere had a strong, trusting relationship with a female member of her whānau Mere had new friendships (mostly dismissed as negative by the adults around her) Issues of transgression of tapu (the body is sacred) – Mere and her whānau were victims of wrongdoing and an extreme violation of trust Attachment, connection, and relationships with close loved ones were impacted The trauma associated with the abuse and the discovery by her family led to a post-traumatic stress response and she did not feel safe anywhere Physical and sexual violation of Mere’s physical body Physical safety (suicidal ideation, self-harm) Mere excelled at netball and hoped to continue with this in the near future, although this was now fragmented Mere’s ability to attend school was impacted Her cries for help were minimized as “behavioral” by support services. She experienced judgment from individuals and services Mere had wraparound service support, including local iwi services This impacted upon her youth culture, as normal developmental behaviors (i.e., sexuality development, relationships with adults and peers) were distorted and her identity damaged The abuse was a breach of cultural norms, expected rules of encounter/society norms, and a crime Society views the behavior of the abuser as wrong and disgusting Absence of father is a concern for many families in New Zealand Māori stories of the Ātua (Gods) can help to explain actions, feelings, and emotions connected to sexual abuse. The following pūrākau (story) about the transition of Hine-tītama to Hine-nui-te-pō shows how she reinvented herself in response to the abuse and betrayal she experienced. Aspects of resilience, respect, and hope are present in this story, as well as the clear message that physical and sexual abuse and incest are shameful and unacceptable The story of Hine-tītama and Tāne Hine-tītama is the daughter of Hineahuone and Tāne. In childhood she became separated from her father and was unaware her father was alive. They met later in life, and while Hine-tītama was not aware of Tāne’s identity, Tāne was aware of Hine-tītama’s identity and did not reveal his identity to her. They fell in love and had many children. On discovering Tāne was her father, Hine-Tītama drew support from her women relatives to leave him and created a new life in the underworld. After reciting an incantation to prevent him from pursuing her, she transformed herself to become Hine-nui-te-pō, guardian of the underworld, to prepare for her children (and humankind) in death (Smith et al. 2002 cited in Le Grice and Braun 2016)

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Table 2 Mere’s story part two Taha hinengaro

Taha whānau

Taha wairua

Taha tinana Taiao

Iwi katoa

Initially Mere was open to engaging with the social workers and welcomed them into her home alongside her mother There had been no overt indication that Mere was upset, and she had not said anything when she removed herself from the meeting An initial meeting was held with Mere and her mother Whānau supports and relationships were explored Whānau management of risk became a concern, for example, the knife block Mother’s apparent disconnection with understanding of risk needed further exploration Māori social workers experienced an instinctual response and sick feeling; this added to risk assessment concerns Gauging the mauri or energies in the room and reading non-verbal communication such as body language helped to attune to this Mum appeared to be desensitized to Mere’s behaviors and was therefore desensitized to the unseen energies that communicated to the social workers Mere leaving the meeting was a concern for the social workers Social workers discussed services that were involved and supporting Mere and her whānau Services needed to improve collaboration and provide better support to Mere and whānau The meeting was held in the whānau home Societal expectation for whānau to protect and nurture their tamariki (children) and keep them safe at all times Societal expectations that mothers predominately carry the sole responsibility to protect and nurture the whānau Societal and developmental view that young people can demonstrate difficult behavior and are to blame for it

Conclusion While the experiences of indigenous groups around the world differ, similarities are apparent. Like Māori, other indigenous peoples have experienced the effects of colonization. Like Māori, other indigenous peoples are significantly represented in low socioeconomic groups, suffer similar patterns of disease, and engage in similar battles for recognition of rights. Indigenous peoples are more at risk of developing mental health and addiction problems, and cultural alienation can provide some explanation of this (Durie 2005). There are also similarities in experiences and worldviews in relation to WesternEurocentric treatments and ongoing issues of diagnosis, misdiagnosis, and mismanagement that are related to culture (Durie 2005). To counteract these and advance health and well-being, indigenous peoples around the world share a common purpose to retain their own distinctive cultural identity and exercise selfdetermination (Durie 2008 cited in Te Rau Matatini 2016). This would mean that the communities of indigenous peoples advocate for their own traditional models of practice to be a part of or all of the assessment and intervention planning. This chapter contributes to the pursuit of this goal.

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Table 3 Mere’s story part three Taha hinengaro

Taha whānau

Taha wairua

Taha tinana

Taiao

Iwi katoa

Although there was a clear risk history, she had presented as engaging and willing to build a relationship; however a moment later, she was less able to manage herself, seemed uncomfortable in her own skin, and desperately looked for escape Although Mum had a slow initial response, she actively undertook to remove the knife from her daughter and protect her from self-harm Mother and daughter worked together to remove the bird from the sleep-out The incident in the sleep-out was demonstrative of the erratic nature of the issues Mere and her whānau were experiencing. There seemed to be limited boundaries between a crisis and “normality” The “gut feelings” and an intuitive wairua feeling of the social workers associated with the crisis experience were significant; events, signs, and symbols showed that all was not right or “tika” with Mere These signs are significant to Māori and other cultures and can be overlooked if there is not an openness to be aware of them. For example, at the time the presence of the bird seemed bizarre, while it may have been a welcome distraction, it was just for a minute, and the incident with the knife continued. Perhaps it gave Mere a brief reprieve from her own distress and helped to avoid a more serious injury from occurring in the sleep-out that day Mere was communicating a strong message by removing herself from the meeting and waiting in the sleep-out with the knife Immediate safety issues/self-harm behavior Safety concerns of those around her as Mere was carrying a large knife around The sleep-out was significant; it was separate from the home. It may have been a place of refuge for Mere Police support and de-escalation of crisis Admission to hospital Ongoing support by social workers Police did not initially view the situation as requiring further input from them however responded to the social workers’ concerns Māori worldview of significance of signs and symbols, for example, the presence of a bird can be associated with death

Māori development in the Māori mental health field has been to build the Māori workforce and develop in the area of dual competency, specializing in the areas of both clinical mental health and cultural mental health. The pervasive impact of colonization and symptoms that are “treated” or caused by alcohol and other drug use can create a difficult assessment environment, because cultural issues may be not recognized or may be overlooked or masked. For Māori and non-Maori social workers, culture is viewed as an important element of practice, and to varying degrees, they will be influenced and guided in their practice by Māori theories and models of practice that are based on a Māori worldview. It is essential that “culturefirst” or “culture-alongside” assessment and interventions continue to grow and develop and that these are supported by attitude changes and policy. The Meihana model was presented and applied to a case study, highlighting how each area can be explored, ensuring that this cultural lens is genuinely considered.

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Table 4 Case review Taha hinengaro Taha whānau

Taha wairua

Taha tinana Taiao

Iwi katoa

How could Mere have been supported to be more physically and emotionally safe? Did the whānau feel resentment to services and individuals? How could Mum have been supported to address relationships, emotions, attachment with daughter, and possible desensitivity to risk? Social workers needed to have more of a sense of whānau dynamics and Mere’s identity and changes of these over time (and in response to the abuse and discovery of abuse) How can whanaungatanga (building relationships) be practiced in crisis situations? The significance of the bird How could Mere have been supported to be more physically and emotionally safe? Addressing risk and safety better, for example, better planning to keep Mere alive, access to means Organizations, services, and policy need to examine their worldview, practice, and judgments pertaining to those accessing (or not accessing) services What changes need to be made to service delivery and attitudes? Consistency of support for Mere and whānau Analysis of the support to staff who were working with Mere and whānau (during and after her passing) Organizations, services, and policy need to examine their worldview, practice, and judgments pertaining to those accessing (or not accessing) services Suicide and youth suicide is a major concern in New Zealand Mental health issues and suicide are also a concern particularly for Māori. Māori are overrepresented in negative statistics The need to protect young people from being victims of sexual abuse. How to recognize abuse has happened (or is happening)? How to address it and support the victim in the best way possible, taking into account their cultural identity? How are whānau, hapū, and iwi included in the mahi (work)? Services are now focusing more on understanding trauma and providing traumainformed interventions; need to ensure this is culturally appropriate for Māori. How are social workers prepared to work with trauma?

Cross-References ▶ Trauma-Informed Social Work Practice with Children and Youth ▶ Social-Cultural Ecological Perspective ▶ Suicide Prevention

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Part IV Contextualized Practice with Individuals and Families

Trauma-Informed Social Work Practice with Children and Youth

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Childhood Exposure to Violence: A Global Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma-Informed Care, Systems, and Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evidence-Based Trauma-Specific Treatments with Children and Youth . . . . . . . . . . . . . . . . . . . . . . . Cognitive Behavioral Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Group Cognitive Behavioral Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eye Movement Desensitization and Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child-Parent Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evidence-Informed and Practice-Informed Trauma-Specific Treatments . . . . . . . . . . . . . . . . . . . . . . Somatic Trauma Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachment Focused Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Life Story Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expressive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preventative Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nine Practice Guidelines for Working with Traumatized Children and Youth . . . . . . . . . . . . . . . . Practice Principle 1: Ensuring Safety and Creating a Safe Environment . . . . . . . . . . . . . . . . . . Practice Principle 2: Teaching Children and Youth About Emotional Literacy and Emotional Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Principle 3: Giving Back Control and Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Principle 4: Preparing Children and Youth for Critical Transitions in Their Lives and Giving Them a Voice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Principle 5: Increasing Their Support System and Including Their Significant Others in the Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Principle 6: Actively Deploying Resources and Anchors . . . . . . . . . . . . . . . . . . . . . . . . .

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Y. Munisamy (*) Child Protective Service, Rehabilitation and Protection Group, Ministry of Social and Family Development, Singapore, Singapore e-mail: [email protected]; [email protected] D. E. Elze (*) University at Buffalo School of Social Work, Buffalo, NY, USA e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_10

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Practice Principle 7: Ensuring Predictability and Structure, Continuity, and Repetitiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice Principle 8: Designing Trauma Response Plan with the Child or the Youth . . . . . Practice Principle 9: Consolidating Coherent and Honest Narratives of the Children’s Lives with Them and Their Significant Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges in Developing Trauma-Informed Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tuning in to the Impact of Trauma Work on the Social Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Self of the Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preventing Vicarious Trauma, Secondary Traumatic Stress, and Burnout . . . . . . . . . . . . . . . . . Reflective Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annex A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annex B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Human rights violations and other traumatic events imperil the lives of millions of children worldwide, jeopardizing their physical, emotional, mental, spiritual, and social development, health, and well-being. Childhood trauma is a global public health problem. Untreated childhood trauma can impose lifelong negative consequences on children’s health, well-being, and life chances. Children and their families urgently need access to trauma-informed systems of care and trauma-specific interventions. Given the social work profession’s focus on social justice, advocacy, and facilitating access to resources, an in-depth understanding of trauma-informed social work practice is critical for direct practice with children and youth, program development, research, and policy. Trauma-informed social work intervention and advocacy will optimize the chance of achieving good outcomes in adulthood for vulnerable, traumatized children and youth. This chapter provides an overview of trauma among children and youth and its consequences on their lives. This chapter also describes principles of trauma-informed service delivery and evidence-based, culturally appropriate trauma-specific interventions with children and adolescents. Keywords

Trauma · Trauma-informed care · Children and youth · Trauma-specific interventions

Introduction Childhood trauma is a global public health problem (Stark and Landis 2016). Human rights violations and other traumatic events imperil the lives of millions of children worldwide, jeopardizing their physical, emotional, mental, spiritual, and social development, health, and well-being (World Health Organization [WHO] 2014). Child maltreatment (i.e., physical, sexual, and emotional abuse), child neglect,

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trafficking for forced labor and sexual exploitation, armed conflicts, natural and environmental disasters, exposure to domestic and community violence, life-threatening injuries and diseases, forced displacement and migration, and terrorism blight children’s lives and life chances (United Nations Children’s Fund [UNICEF] 2016a). In the United States and Singapore, exposure to traumatic events often precedes children’s involvement in child welfare, juvenile justice, behavioral health, homeless services, and primary healthcare systems. Untreated childhood trauma can impose lifelong negative consequences on people’s health, well-being, and life chances. Children and their families urgently need access to trauma-informed (TI) systems of care and trauma-specific interventions (Substance Abuse and Mental Health Services Administration [SAMHSA] 2014). Given the social work profession’s focus on social justice, advocacy, and facilitating access to resources, an in-depth understanding of trauma-informed social work practice is critical for direct practice with children and youth, program development, research, and policy. Trauma-informed social work intervention and advocacy will optimize the chance of achieving good outcomes in adulthood for vulnerable, traumatized children and youth. Additionally, professional development for social workers through a trauma-informed lens will enhance social workers’ competency, retention, and rejuvenation. This chapter provides a brief overview of trauma among children and the consequences of traumatic stress on their lives. This chapter also describes the principles of TI care; initiatives to develop TI service delivery systems; evidence-based, culturally appropriate trauma-specific interventions and promising TI practices with children and adolescents; and nine practice guidelines for social work practice with traumatized children and youth. The chapter concludes with the challenges in implementing trauma-informed care and attention to self-care for social workers to prevent vicarious trauma and burnout.

Definitions Discussions of childhood trauma must distinguish between trauma, traumatic events, traumatic stress, post-traumatic stress disorder (PTSD), and complex trauma. Trauma, as defined by SAMHSA (2014), “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual wellbeing” (p. 7). The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) more narrowly defines trauma as direct or indirect exposure to actual or threatened death, serious injury, or sexual violence (i.e., a criterion A trauma) (American Psychiatric Association [APA] 2014). Not all children exposed to traumatic events experience traumatic stress. Child traumatic stress refers to persistent distressing reactions, of short or long duration, which overwhelm a child’s ability to cope, following exposure to a traumatic event, thus affecting the child’s daily functioning. Such adverse reactions may be physiological, emotional, psychological, or behavioral and may

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emerge immediately or with delayed expression (National Child Traumatic Stress Network [NCTSN] 2013). Most children exposed to trauma exhibit resilience and do not suffer from prolonged trauma-related difficulties (Miller-Graff and Howell 2015). A subset of children, after a traumatic exposure, may meet diagnostic criteria for post-traumatic stress disorder (PTSD) if they experience characteristic symptoms (e.g., intrusive memories; avoidance behaviors; negative changes in cognitions, mood, arousal, and reactivity) that last longer than 1 month, which cause them clinically significant distress or impairment in functioning (APA 2014). An array of individual (e.g., developmental stage, prior trauma, co-occurring mental health problems, perceived threat to life, fear), family (e.g., domestic violence, caregiver response, culture), and community (e.g., neighborhood violence, lack of social support) risk factors influence a child’s likelihood of developing PTSS or PTSD post-trauma (Miller-Graff and Howell 2015; Trickey et al. 2012). A meta-analysis of PTSD rates in trauma-exposed children, ages 2–18, found that 15.9% developed PTSD following exposure to a criterion A trauma, with girls subjected to interpersonal trauma (e.g., violence, war, terrorism) showing the highest rate (32.9%). Approximately 10% of the children developed PTSD following exposure to a non-interpersonal trauma (e.g., life-threatening disease, death of a loved one, disaster) (Alisic et al. 2014). PTSD prevalence and symptom severity in children, ages 5–18, appear to spontaneously decline during the first 6 months and 3 months post-trauma, respectively (Hiller et al. 2016). Another meta-analysis revealed a strong association between negative appraisals of trauma and PTSS in children and adolescents (Mitchell et al. 2017). A study of multiple trauma exposure of 721 Singapore children in out-of-home care revealed that 63% experienced at least one interpersonal trauma and 35% experienced multiple trauma exposure (Liu et al. 2016). The children with multiple trauma exposure had poorer psychosocial functioning with higher number of lifefunctioning needs, behavioral and emotional needs, and risk behavior needs. Complex trauma refers to the pervasive impact on children of multiple, chronic, and recurrent adverse traumatic events, usually beginning in early childhood within the caregiving system, and the deleterious developmental and biopsychosocial problems associated with those experiences. Children with complex trauma histories may experience impairment in one or more developmental domains: (a) emotional and behavioral self-regulation; (b) neurobiological processes; (c) self-concept and self-esteem; (d) cognitions, such as attention regulation and information processing; and (e) attachments and relationship formation (Kliethermes et al. 2014). The PTSD diagnostic classification, which conceptualizes trauma as a single event, is limited in its applicability to children who experience complex trauma. Researchers and clinicians have long advocated for a “developmental trauma disorder” (DTD) classification, which would incorporate the pervasive effects of complex trauma on children’s functioning across multiple domains (e.g., affective and behavioral dysregulation, cognitive deficits, self-perception, and relational problems), symptoms not captured in PTSD or co-occurring diagnoses. The debate continues, as DTD was not included in the DSM-V (Denton et al. 2017).

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Research in developmental neuroscience, endocrinology, immunology, epigenetics, and developmental traumatology has revealed that prolonged exposure to trauma and “toxic stress” cause dysregulation of neurobiological stress systems, with subsequent alterations in brain structure and function, and adverse consequences on children’s emotional, cognitive, social, and behavioral functioning (see reviews: De Bellis and Zisk 2014; Hein and Monk 2017). Toxic stress occurs with severe, prolonged, repeated exposure to adversity (e.g., abuse, neglect, violence, caregiver mental illness/substance abuse, family economic hardship) without sufficient adult support. While positive (i.e., brief increases) or tolerable (i.e., time-limited) stress responses are normal aspects of healthy development, “toxic stress responses” involve excessive, prolonged activation of stress responses systems, potentially undermining healthy development and well-being across the life span (Center on the Developing Child 2016). The duration, severity, proximity, and age of trauma onset and individual and environmental risk (e.g., neighborhood violence, poor schools) and protective (e.g., family cohesion, social support, safe neighborhoods) factors may intensify or attenuate the effects of toxic stress on neurobiological stress systems (McLaughlin et al. 2015; Shern et al. 2016). Home environments with toxic stress exposure to children and youth are also evident in Singapore. A study of the family profiles of 440 maltreated children in Singapore classified the families by four types: large household group, high criminality group, harsh parenting group, and low disadvantage group. The high criminality group consisted of half the parents of children who were abused in this class having mental health issues and three-quarters having a criminal history (Chng et al. 2018).

Childhood Exposure to Violence: A Global Epidemic Trafficking, armed conflicts, displacement, child maltreatment, disasters, and other traumatic events affect millions of children and youth worldwide (UNICEF 2016a, b). More than 25% of detected trafficking victims in 2014 were children, with rates ranging from 8% to 64%, depending upon the region (United Nations Office on Drugs and Crime [UNODC] 2016). Nearly 250 million children live in areas affected by armed conflicts (UNICEF 2016a). These conflicts subject children to “six grave violations” of their human rights (i.e., abduction, recruitment as combatants, denial of humanitarian access, sexual violence, killing and maiming, and attacks against schools and hospitals) (Office of the Special Representative of the Secretary-General for Children and Armed Conflict [OSRSG/CAAC] 2013). Children under 18 years of age comprise half of the world’s refugees and 15% of all migrants. Displaced children, particularly unaccompanied minors, risk sexual, physical, and psychological abuse; human trafficking; murder; torture; exploitation by smugglers; separation from family members; detention; kidnapping; slave labor; illness; and death (U.N. Department of Economic and Social Affairs 2016; UNICEF 2017a, b). In destination countries, they face discrimination, stigmatization, violence, racism, xenophobia,

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detention, economic deprivation, and poor living conditions (UNICEF 2017a, b; Murphey 2016). Globally, child maltreatment is a pervasive public health problem (WHO 2014). A synthesis of several meta-analyses of global prevalence rates determined that 12.7% of adults had experienced childhood sexual abuse (7.6% of boys and 18% of girls); 22.6%, physical abuse; 36.3%, emotional abuse; 16.3%, physical neglect; and 18.4%, emotional neglect. Prevalence rates for maltreatment were largely similar across continents, except for sexual abuse; females in Africa, Australia, and North America reported the highest rates of sexual abuse (i.e., approximately 20%) (Stoltenborgh et al. 2015). In Singapore, it was reported in Channel News Asia online that the number of child abuse cases are on an upward trend with 894 child abuses investigated by the Ministry of Social and Family Development in 2017 compared to 343 in 2014 (Ong 2018).

Trauma-Informed Care, Systems, and Service Delivery Responding to demands for systems change from women trauma survivors and other mental health consumers, SAMHSA, in the early 1990s, embarked on a long-term commitment to fund and promote TI systems of care (DeCandia et al. 2014; Jennings 2008). Since then, SAMHSA, in partnership with other federal agencies and national associations, has spearheaded multiple initiatives to integrate TI care across publicly funded systems serving children, adolescents, and adults (Berliner and Kolko 2016; DeCandia et al. 2014; Hanson and Lang 2016). Trauma-informed care (TIC) promotes: (a) safety (i.e., physical, emotional, psychological); (b) trustworthiness and transparency in organizational practices; (c) peer and family support; (d) collaboration and mutuality (i.e., sharing power and decision-making); (e) empowerment, voice, and choice for staff and clients; and (f) attention to cultural and gender issues, and historical trauma. Trauma-informed (TI) systems and organizations recognize the far-reaching impact of traumatic experiences on individual, families, groups, organizations, and communities and integrate this knowledge into policies and practices to promote recovery. Providers recognize the signs and symptoms of trauma, the pervasiveness of trauma exposure among client populations and staff, and avoid blaming and re-traumatizing clients during service delivery (SAMHSA 2014). TI systems routinely screen for trauma exposure and trauma-related symptoms, and, when indicated, conduct thorough trauma assessments (Child Welfare Information Gateway 2015; Ford et al. 2007), although they may refer clients elsewhere for trauma-specific treatments. TI systems for children and their families utilize a strengths-based approach that engages families, supports resilience, builds protective factors, and promotes continuity of care and collaboration across systems (Rozzell 2013). TI systems require the availability of mental health practitioners skilled in delivering evidence-based, culturally appropriate treatments and community- and system-wide trauma education (Henry et al. 2011).

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Among its child-focused initiatives, SAMHSA has administered, for nearly two decades, the National Child Traumatic Stress Network, the mission of which is “to raise the standard of care and increase access to services for traumatized children and their families across the United States” (NCTSN 2013, p. 1). NCTSN supports the development and dissemination of evidence-based, culturally appropriate assessments and interventions; provider training; research and evaluation; community awareness campaigns; and advocacy for TI practices and policies across multiple child-caring service sectors (NCTSN 2007). Over the last two decades, the vast majority of states have integrated TI practices and policies into their behavioral health systems for children and adolescents (Jennings 2008). Through its position statements, technical assistance provision, and the development and dissemination of TI best practices and policies, the National Association of State Mental Health Program Directors (NASMHPD), since the late 1990s, has kept trauma at the forefront of an agenda for state mental health systems’ transformation. The NASMHPD convened multiple national meetings of trauma experts to develop criteria for building a TI mental health system, and disseminated TI activities, best practices, and model policies to state mental health agencies (Jennings 2008). The Children’s Health Act of 2000 (P.L. 106-310), subsequent rules issued by the Centers for Medicare and Medicaid Services, and standards of the Joint Commission on the Accreditation of Healthcare Organizations, boosted efforts to restrict the use of seclusion and restraint (S/R) in children’s psychiatric settings (Azeem et al. 2015). Recognizing that S/R are inherently violent, coercive, and traumatizing practices, NASMHPD issued specific guidelines to reduce their use in inpatient behavioral health settings (Huckshorn 2006). The guidelines identified six core strategies: (a) leadership that prioritizes TI organizational transformation; (b) data collection to assess implementation efforts; (c) workforce development; (d) TI risk assessments and intervention strategies integrated into organizational operations and policies; (e) inclusion of children, families, and advocates in implementing TI principles; and (g) rigorous debriefing of incidences (Huckshorn 2006). Implementation of these guidelines reduced S/R in a pediatric inpatient setting (Azeem et al. 2015) and in children’s residential programs (LeBel et al. 2010). Statewide, interagency, and site-specific initiatives have successfully integrated alternatives to S/R into organizational cultures and operations (LeBel et al. 2010). Together, the Children’s Bureau within the Administration for Children and Families (ACF), SAMHSA, NCTSN, and NCTSN’s affiliated Chadwick Center for Children and Families have advanced the development of TI child welfare (CW) practices, policies, and models and integrated TI-CW and behavioral health systems. The Children’s Bureau issued policies and provided funding to support statewide initiatives to develop TI-CW systems (Berliner and Kolko 2016). ACF designated TI-CW system development a child welfare funding priority and supported approximately 20 state and tribal TI-CW initiatives (e.g., Akin et al. 2017; Bartlett et al. 2016; Kerns et al. 2016). Although far from universal, TI practices or models have also been integrated into US juvenile justice, pediatric healthcare, behavioral health, homeless, and

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education systems (Ko et al. 2008; DeCandia, et al. 2014; Jennings 2008; Rozzell 2013; McInerney and McKlindon 2014; O’Grady 2017; SAMHSA 2014; U.S. Interagency Council on Homelessness 2015). Comprehensive recommendations exist for integrating TI approaches into juvenile justice systems (Attorney General’s National Task Force on Children Exposed to Violence 2012), including juvenile and family courts (Marsh et al. 2015), and law enforcement practices (International Association of Chiefs of Police and Yale Child Study Center 2017). Advocates have called for an end to practices that further traumatize children and youth (e.g., incarceration for nonviolent offenses, seclusion and restraint, strip searches, solitary confinement, physical/sexual abuse by staff and youth) (Branson et al. 2017). The NCTSN Medical Traumatic Stress Working Group (2004), the American Academy of Pediatrics (2014), and the Center for Pediatric Traumatic Stress (2015) have developed comprehensive toolkits for families and healthcare providers to advance TI pediatric healthcare and address pediatric medical traumatic stress (PMTS). The Integrative Model of Pediatric Medical Traumatic Stress provides a conceptual model to guide pediatric healthcare professionals in preventing, assessing, and treating PMTS, with TI approaches (Marsac et al. 2016; Price et al. 2016). The US Interagency Council on Homelessness, under the Obama Administration, emphasized trauma and the urgent need for TI service delivery in its federal strategic plan to prevent and end homelessness (U.S. Interagency Council on Homelessness 2015). The National Center on Family Homelessness has created organizational assessments, toolkits, and curricula to guide homeless programs in developing TI practices and policies for homeless and displaced children and families (Clervil et al. 2013; Guarino et al. 2009). Noteworthy TI guides or models for education systems are NCTSN’s Child Trauma Toolkit for Educators (2008); the Washington State Compassionate Schools Initiative (Wolpow et al. 2009); the Trauma and Learning Policy Initiative in Massachusetts (Cole et al. 2013); and the Sanctuary Model ®, an organizational transformation model, which was first implemented in children’s residential treatment programs (Bloom 2013). In TI schools, school personnel understand the impact of trauma on learning, integrate TIC principles to create a TI culture, foster school connectedness and positive behavior in children, utilize restorative practices rather than punitive disciplinary procedures, and provide tiered support based on students’ needs (Walkley and Cox 2013; Wolpow et al. 2009).

Evidence-Based Trauma-Specific Treatments with Children and Youth There is a myriad of evidence-based and evidence-informed treatments for trauma that aim to improve the child’s quality of life, ensure daily functioning, and help the child enhance self-regulation and coping skills.

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Cognitive Behavioral Therapies Silverman et al.’s (2008) review of evidence-based psychosocial treatments for children and adolescents exposed to traumatic events evaluated 21 randomized controlled trials (RCTs). Two cognitive behavioral therapies (CBTs) met either well-established or probably efficacious criteria for improving child and adolescent outcomes such as post-traumatic stress symptoms (PTSS), depressive symptoms, anxiety symptoms, and externalizing behavior problems. Trauma-focused cognitive behavioral therapy (TF-CBT) was rated as well-established. Six studies tested individual CBT with parent involvement, four of which tested TF-CBT specifically. Only two of the TF-CBT studies in the Silverman et al.’s (2008) review included children younger than 5 years. Five of the six studies focused on sexual abuse as the main traumatic event. TF-CBT treatment includes approximately 10–12 separate child and parent sessions, with parents and children receiving the same elements. Some sessions are conjoint. Treatment elements include psychoeducation about trauma exposure and PTSS; coping skills (e.g., affect identification/modulation, relaxation, cognitive coping); imaginal exposure (i.e., explicitly recalling details, thoughts, and feelings about traumatic experiences; often through drawings, writing, or other creative mechanisms); in vivo exposure (i.e., through confronting innocuous trauma reminders); cognitive restructuring of maladaptive, trauma-related cognitions; and safety skills training. Parents are taught parenting skills (e.g., praise, contingency management). Eight-session versions of TF-CBT were more effective than an eightsession non-CBT community treatment approach. Cohen et al. (2011) concluded in his study that TF-CBT effectively improved children’s interpersonal partner violence-related PTSD and anxiety.

Group Cognitive Behavioral Therapies Group CBT is a common treatment approach for symptoms of childhood trauma. Children and adolescents are the main participants with minimal parent involvement. Group CBT usually consists of 10 treatment sessions which include psychoeducation, coping skills, and cognitive restructuring (Layne et al. 2008) and commonly tested in schools. Some approaches include imaginal and/or in vivo exposure, problem-solving, and focus on social support. In Groupwork CBT with parent involvement, children and parents typically meet concurrently but separately over 16 sessions, with a few joint sessions. Treatment elements are similar to those in individual CBT with parent involvement. When the trauma is from physical abuse, treatment focuses equally on parent outcomes, such as parenting behavior, preventing physical abuse recidivism, and the mental health impact of trauma exposure. Treatment involves content relating to parent’s commitment to non-violence on their children or spouse.

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Eye Movement Desensitization and Reprocessing EMDR intervention involves guided imagery and relaxation to enhance coping skills; cognitive restructuring; imaginal exposure; and simultaneous bilateral sensory input, such as eye movements. Treatment involves 8–12 individual therapy sessions. A number of studies provide evidence for the effectiveness of EMDR in treating trauma symptoms in children (Silverman et al. 2008).

Child-Parent Psychotherapy Several randomized clinical trials have shown that Child-Parent Psychotherapy (CPP) is effective in helping children aged 3–5 recover from trauma. The intervention promotes affect regulation in the child and focuses on the dyad to provide a joint trauma narrative. This intervention reduces inter-dyad conflicts and has shown to improve the mother-child relationship. This intervention prevented child trauma symptoms and behavioral issues and also ensured that mothers would not avoid the issues and engage in sessions to help the children (Keeshin and Strawn 2014).

Evidence-Informed and Practice-Informed Trauma-Specific Treatments Somatic Trauma Therapy The premise of this intervention is that PTSD has somatic components. Somatic Trauma Therapy (STT) focuses on psychobiology and neurobiology. This integrated trauma therapy utilizes tools for identifying, understanding, and treating trauma effects on mind and body. Rothschild (2000) writes on bridging the gap between talk therapy and body therapy to help the client heal from trauma. She posits three phases in trauma recovery: (a) safety and stabilization, (b) trauma narrative, and (c) integration. She also proposed eight keys for the individual’s own safe trauma recovery: (a) plot your course with mindfulness; (b) begin with your epilogue. . .you made it; (c) remembering is not required; (d) stop flashbacks; (e) reconcile forgiveness and shame; (f) take smaller steps for bigger leaps; (g) get moving; and (h) make lemonade.

Attachment Focused Family Therapy Hughes (2007) posits that childhood trauma, when addressed with this model of family therapy, can result in benefits for children and parents who were traumatized

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in their childhoods. He highlights how the principles of attachment and intersubjectivity help with dysregulation and interpersonal family conflicts. Hughes outlines seven steps in attachment-based family therapy to facilitate the exploration and resolution of childhood trauma: (a) The social worker/therapist be the source of attachment security. (b) As pockets of safety emerge, the social worker deepens intervention with the parent-child dyad by moving to mildly stressful themes and facilitates intersubjectivity exploration. (c) Primary intersubjectivity is established and the social worker moves to secondary subjectivity. (d) Co-regulating the affect associated with the event in the sessions. (e) Child is no longer dysregulating in shame or terror and is co-creating new meaning of the traumatic event. (f) Child is able to integrate the event into his or her autobiographical narrative. (g) The event is assimilated into a coherent narrative.

Life Story Work Life story work is an established social work approach with roots in practice with children and reminiscence work with elderly clients. Social workers have done life story intervention with children in out-of- home care, providing them with a factual narrative of their lives about significant events in their lives, and significant people in their lives. This helps children formulate a coherent narrative that provides integration and a sense of settlement as they embark on the next stage in their life. The child’s voice is a key focus in life story work, which attempts to answer the “what, when and why” questions about the child’s life experiences in a gentle and creative manner. This approach allows the child to “unravel confusion and discard negative emotional baggage” (Conner et al 1985) cited in Rose (2012). Rose shares that the life story therapy also consolidates the strengths and triumphs of the child in the face of adversity.

Expressive Therapy Expressive therapy is a psychodynamic approach which utilizes a blend of expressive personal growth and counseling methods (Pearson and Wilson 2001). The intervention focuses on emotional healing and involves a range of experiential approaches including sandplay and symbols work. The aim is to help children develop inner-life skills and access enhanced resilience. Each task in this activity-based approach supports integration of body, mind, and feelings, and activates innate healing potential. Expressive therapy is a client-centered, strengthsbased approach and assumes an invitational stance.

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Preventative Interventions Marsac et al. (2014) discuss early interventions to prevent PTSS or PTSD in children exposed to potentially traumatic events. They discuss a range of skills taught at an early stage after traumatic events. Early interventions aimed at increasing efficacy in survivors, focus on building problem-solving skills, promoting positive activities, managing reactions, promoting helpful thinking, and rebuilding healthy connections. Pharmacologic interventions have been used in clinical trials with adults and now more with youth to prevent PTSD after a physical injury. Morphine was the first medication shown to be effective in preventing PTSD in youths and children in hospitals after an acute burn injury.

Nine Practice Guidelines for Working with Traumatized Children and Youth Nine principles, drawn from literature and from the authors’ social work practice with traumatized child and youth in Singapore, Australia, and America, are (a) ensuring safety and creating a safe environment; (b) teaching children and youth about emotional literacy and emotional regulation; (c) giving back control and pacing; (d) preparing children and youth for critical transitions in their lives and giving them a voice; (e) increasing their support system and including their significant others in the intervention; (f) actively deploying resources and anchors; (g) ensuring predictability and structure, continuity, and repetitiveness; (h) designing trauma response plan with the child or the youth; and (i) consolidating coherent and honest narratives of the children’s lives with them and their significant others.

Practice Principle 1: Ensuring Safety and Creating a Safe Environment Safety is always first in trauma-informed interventions (Herman 2001). Rothschild (2000) highlights that resolving trauma could mean releasing defenses. If the current living environment is unsafe, children and youth will not be ready for trauma work. Social workers have an ethical responsibility to work in a safe manner with vulnerable children and youth. Safety ranks as the most basic need in Maslow’s hierarchy of needs. Without safety, there can be no recovery. In the Child Safety Commission’s publication, From Isolation to Connection (2009), the spiral of healing framework is shared with clients, and safety is reinforced by ensuring that abuse, neglect, and other traumatizing events have stopped. Children may rate their sense of safety differently for different people in their lives and in different contexts, such as the home, the foster care and residential placement, and the school. This

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creates the need to invite children to share their varied ratings of their felt sense of safety. Fisher (1999) warns that if the social worker listens empathically to the patient’s account of a flashback, they may risk worsening their intrusive symptoms. Retelling one’s story can be re-traumatizing for clients if safety has not been established. Protective interrupting of the intrusive thoughts and flashbacks is needed. Social workers should be attuned to physical signals of autonomic system arousal transmitted by the client’s bodily responses and tone of voice. When a client turns pale, breathes rapidly or hyperventilates, has dilated pupils, is shivering or expresses that he or she is cold, his or her sympathetic nervous system is aroused. Presence of such symptoms should indicate to the social worker the need to calm the client down first. Grounding and centering skills are imparted during safety stage to help children and youth be connected to the present moment. Grounding can be in different forms such as placing one’s feet to the ground firmly and breathing deeply. Touching items from nature such as a stone or grass can be grounding as with the kinesthetic activities such as gardening, swimming, and cooking. It is important to identify the ones that resonate with the child or youth.

Practice Principle 2: Teaching Children and Youth About Emotional Literacy and Emotional Regulation Neurobiology and somatics are important in trauma intervention. Traumatic stress can impact the child’s emotional ability to identify and express core emotions. Perry (2012) shares that for someone who is traumatized, the brain is set with associations that are like landmines. Stress or distress resulting from triggers can result in changes to cognition, affect, behavior, neurophysiology, and physiology. Co-regulation ensures that the child’s amygdala is not triggered. Co-regulation empowers the primary caregiver to help children learn to manage their own arousal and the intensified emotions (Van Der Kolk 1994). Matching tone, rhythm, and sound and matching intensity (Hughes 2007) is also helpful in this process. The children or youths’ learnt behavior and response to trigger is like an established highway route. The new behavior response to trigger, learnt during intervention, needs repeating and re-testing for it to become an established response. It thus takes time for these new behaviors to embed and new routes of behavioral responses to form. As part of psycho-education for children and youth around emotional literacy, affect identification is paramount. For instance, using the thermometer picture to ask children to indicate their intensity of feelings can help with affect and emotional regulation. For youth, helping them chart their behavioral responses to various emotions can be extremely helpful. Somatically, teaching children and youth a range of balance and muscle strengthening exercises helps to build containment measures. This could reduce hypervigilance and managing hyperarousal states.

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Practice Principle 3: Giving Back Control and Pacing As part of establishing safety, social workers should avoid having children access their trauma memories prematurely because such premature recollections could trigger flashbacks. Trauma results in loss of control for children and youth. As such, the focus is on helping them gain back control by making decisions, starting with simple ones such as choosing what colors to use or where they would like to sit in sessions. Pacing allows social workers to titrate the intervention while paying attention to the somatic responses of the children. Levine (2008) writes that a key principle in renegotiating trauma in children is to allow the child or youth to “control the pace of the game.” The social worker needs to respect children’s wishes and never compel them to do what is not within their ability and willingness. For youth, exercising control can be part of identity development. Adults can expect that teens might resist adult intervention as a way of asserting and maintaining control (Fahlberg 2012). Nevertheless, social workers and other adults need to ensure that youths are supervised for their safety.

Practice Principle 4: Preparing Children and Youth for Critical Transitions in Their Lives and Giving Them a Voice Children face many critical transitions, and social workers can help them negotiate these transitions in a meaningful way. Some examples of transitions include being brought into statutory care from birth family, a sudden death of a family member, loss due to incarceration, sudden homelessness, or coming out to family around their sexuality. Children and youth feel deeply about these transitions. Some of these transitions can be traumatic for them if they have insufficient resources for coping. Social workers need to facilitate safe space for the children to express their feelings. The flooding of emotions may result in dysregulation or behavioral and psychosomatic symptoms. Preparing children for transitions with significant support network people in their lives helps mitigate sense of overwhelm and maladaptive behaviors. The effects of “repeated transition” can be “profound” on children or youth, as each transition “always brings some type of loss” (Department of Safety 2006, p. 1). Minimizing the number of changes for a child is necessary and keeping some aspects of their lives constant is essential. Youth transitioning from care to community are often at a disadvantage compared to their peers. They are more likely to be unemployed or underemployed, less likely to further their education, more likely to have lower incomes and greater financial problems, and more likely to suffer from social and mental health problems (Forbes et al. 2006). They are less likely to seek assistance independently and need a support system to facilitate their connection with needed services to meet their care needs. The authors propose a model of transition for children moving from one placement to another to guide the social worker in their intervention work with children

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and their caregivers pre-, during, and post-transition (Annex A). The model also outlines interventions to use at each stage to facilitate transitions effectively.

Practice Principle 5: Increasing Their Support System and Including Their Significant Others in the Intervention Peter Levine (2008) shares that “trauma is about loss of connection to ourselves, to our bodies, to our families, to others and to the world around us.” Connection is a key principle in trauma-informed care (National Child Traumatic Stress Network 2013). Quality care and strong support trigger release of oxytocin and keep the amygdala from activating the fear/stress/defense systems (Hughes 2007). Hughes (2007) in facilitating developmental attachment highlights how the involved parent or caregiver creates depth and greater meaning to the therapeutic process. The intervention emphasizes and focuses on emotional attunement and empathy. Attachment-based family therapy (ABFT) is conducted based on the belief that strong relationships within families can buffer against the risk of adolescent depression or suicide and help in the recovery process. Attachment theory posits that when parents and caregivers are responsive and protective, children develop a healthy sense of self, trust in others, better capacity for independence, and affect regulation. Some children have no attachment or disrupted attachment with their primary caregivers due to abuse or desertion. Significant others and support network is essential and focused in practice approaches used in child protection such as Signs of Safety, Partnering for Safety, as well as Protective Behaviors. “Constructive working relationships” among family members, and between the professional network, are “the heart and soul of effective practice” in working with children and youth who have suffered abuse (Department for Child Protection 2011). The Signs of Safety framework paper in Western Australian child protection points to the fact that best outcomes for vulnerable children arise when constructive relationships exist in both these arenas. The rationale behind “involving an informed naturally occurring network around the family” is to “break the secrecy and shame” that are common in child abuse or youth abuse cases. Interpersonal positive relationships are resources for a traumatized children or youth. Connection and help-seeking and a steady network of trusted adults can help traumatized children and youth feel settled and assured.

Practice Principle 6: Actively Deploying Resources and Anchors Resources can be “anything that helps you feel better” (Miller-Karas 2015). It can be from past or present life. A resource makes the individual feel peace, calm, comfort, happiness, relief, and well-being. Resourcing the child or youth is

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important and involves tracking what the resourcing does to regulate and calm the body. Anchors are specialized resources that integrate Levine’s SIBAM (Sensation, Image, Behavior, Affect, and Meaning) elements and concrete observable resources that can be tapped on during trauma work as a “good braking tool with any trauma therapy” and prevents arousal level from being “out of control” (Rothschild 2003). Annex B outlines the five types of resources: practical, physical, psychological, interpersonal, and spiritual that social workers can help their clients identify during intervention. Tapping on their resources and anchors can also help with regulation.

Practice Principle 7: Ensuring Predictability and Structure, Continuity, and Repetitiveness Children or youth’s exposure to traumatic events “overwhelms their usual adaptation in everyday life” (Herman 2001). As such, one goal for supporting children and youth after a traumatic event is to ensure predictability, structure, and continuity to daily life. It is important that the child and youth resume their previous routine and rituals as soon as possible. If the child or youth needs to adapt to new routines, they should be preempted. There also needs to be consistency in these new routines for a period of time. Skuse and Mathew (2014) reinforce the need for structure and routine in the trauma recovery intervention where the child presents behavior that is “instable and chaotic.” Perry (2012) shares how plasticity is not uniform in all parts of the brain and that the lower parts such as the brainstem are harder to change as it protects itself from too much changes. There is a need for more repetitions of positive behaviors to effect the needed change. He suggests the use of repetitive rhythmic activities such as poetry and songs which can be soothing to children. Structure and consistency by the professionals and the caregivers is important (Child Safety Commission 2009). Traumatized children sometimes have little internal structure and, therefore, need firm boundaries, rules, expectations, and consequences. Professionals create safety by being reliable and consistent, being firm but nonpunitive, and ensuring good boundaries between caregivers and children and youths. Helping children and youths recognize who are the safe and unsafe people around them, and respecting their personal spaces and choices help them to have a sense of predictability. Intervention by the social worker in the various ecosystems of the child includes building daily routines; talking to parents/caregivers on house rules and structure; building in support and resources during transition time (e.g., waking up and bedtime); talking to the school and ensuring calmer classroom responses; and setting up rituals for the child or the youth such as prayer times as a family, sleep rituals, and one-on-one carer-child time. Repetitive expressive therapies and play can be helpful for the child. Many children who are introduced to sandplay and other play mediums do engage in repetitive play until they achieve mastery over the situation in their play.

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Practice Principle 8: Designing Trauma Response Plan with the Child or the Youth The plan should be clearly explained to the child when he/she is calm. Children can also be actively involved in developing the plan as it would give them a sense of control and predictability. They can be given a written copy (using words and/or pictures) of the plan. This will be useful as initially, it may be difficult for them to remember the plan when distressed. To facilitate the implementation of this plan, the school and carers should keep each other informed of changes so that both can be supportive of the implementation of the plan. The trauma-informed plan could be organized in the following subsections: (a) Identified presenting issue. (b) Identified behavior. (c) List of possible triggers and signs that situation is escalating. (d) Location of intervention. (e) Goal of intervention. (f) Who would the child like support from? (g) Words and actions to use to regulate and de-escalate. (h) Words and actions to avoid. (i) Child’s resources and special interest activities. (j) Follow-up action. (k) Evaluation and review date.

Practice Principle 9: Consolidating Coherent and Honest Narratives of the Children’s Lives with Them and Their Significant Others Children and youth who have experienced trauma may have fragmented memories of their lives (Rose 2005). If they have had multiple moves and disruptions in attachment and connection, it becomes even more difficult for children to develop a strong sense of self and for them to understand how the past influences their present behavior (Fahlberg 2012). Rose (2012) shares that storytelling and narrative sharing reminds children and youth of where they belong. He describes life story work process as “a powerful, regulating, anchoring, reassuring, rewarding neurophysiological effect.” Through intensive research into the child’s past, life story work enables the child to understand what has happened, when and where they have lived, who has cared for them, and most importantly decisions that have impacted on their lives. Sometimes, adults might hold back from sharing information about the past with children or youth, and thus suggesting that the past is too much to cope with or something to be ashamed of. The premise of this intervention is that no matter how traumatizing past experiences were, the child has lived through them and survived, and so can live with the truth. “Truth can be presented in a harmful way that lowers the child’s self-esteem or in a way that helps the child to understand and accept his

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past and thus raise his self-esteem” (Rose 2005). Children need to be consulted in the process to give voice to their experiences and allow alternative identity consolidation. Critical to life story work is the involvement of significant others. An important consideration for the social worker is the stage of trauma work in which this intervention is done. Life story work is done in the trauma narrative stage or integration stage. This should not be done in the safety stage as it could destabilize the child or teen further. Resources and anchors need to be established first so that the child can go to his/her safe space or engage in resourcing activities when the trauma material gets tough. The child needs to have a lot of control in this process and the social worker needs to titrate the pacing of the child for the intervention to be effective and healing.

Challenges in Developing Trauma-Informed Systems Researchers and practitioners have identified multiple challenges in implementing and sustaining TI practices in child-serving systems (Hanson and Lang 2016). Professionals across the different systems lack clarity on how to operationalize TI care (Branson et al. 2017; Donisch et al. 2016). Systems experience high staff turnover (Bartlett et al. 2016), heavy caseloads, limited resources (Kramer et al. 2013), and insufficient evaluation of TI initiatives (Hanson and Lang, 2016). Workers hesitate to conduct trauma-impact assessments with children (Kerns et al. 2016), receive insufficient training in implementing TI practices (Donisch et al. 2016), lack access to trauma assessment tools and evidence-based treatments (Donisch et al. 2016; Kramer et al. 2013), and, when trained, are no more likely to refer children to evidence-based treatments than untrained workers (Dorsey et al. 2012). The field urgently needs research that will determine whether identified children actually receive trauma-specific treatments, and whether assessment and treatment result in improved child outcomes (Berliner and Kolko 2016). The lack of universal routine screening of children entering service systems means that many traumatized youth go unidentified. Even if there is routine screening, children and youth may be in a state of shock when they enter the care system and may not be exhibiting trauma symptoms at that point of screening. They may be assessed as not needing trauma interventions. Trauma symptoms surface for some children and youth once they are in a safe and settled placement. Close communication between caregivers and professionals is essential so that children and youth can access trauma interventions at any point in time. Embedding trauma-informed care in any system requires a good analysis of the implementation fidelity. Carroll et al. (2007) discuss implementation science and the need for implementation fidelity to be measured using the five elements: adherence to intervention, dosage, quantity of delivery, participants’ responsiveness, and program differentiation to establish essential components. Ensuring traumainformed care delivery fidelity can help link client outcomes to intervention. This

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can help justify continuation or expansion of trauma-informed care as a modality in a system.

Tuning in to the Impact of Trauma Work on the Social Worker The Self of the Worker Trauma recovery work with children and adolescents can have an emotional, physical, and social impact on the social workers. It is therefore important that social workers working with this special population have strategies to maintain their own mental health and well-being. “It is the painful stories of the . . .child that can hurt the adult working with them” (Child Safety Commission 2009). Clear boundaries, consistent boundaries, and self-care enhance social workers’ ability to be “empathetic, compassionate and helpful” (Rothschild and Rand 2006). Another crucial aspect in trauma work is the social worker’s values and beliefs. If the social worker believes that health is bigger than trauma, the social worker will work toward healing and growth with persistence and confidence and will build on the positive health and functioning of the child or the youth. It is with this belief that social workers will approach their own self-care by focusing on the physical, social, emotional, and psychological health by resourcing self adequately. Dyregrov (2010) explains why trauma work can be exhausting. Social workers in the helping profession have a lot of empathy and strong sense of social justice to help vulnerable populations. Children and youth can be helpless and innocent and when they become the subject of serious harm and even fatality, it can make the social worker feel life is unfair and might threaten the social worker’s perception of a safe world. Dyregrov postulates that this can contribute to feelings of helplessness, fear, anxiety, anger, and irritability as well as intrusive images and thoughts from secondary traumatization.

Preventing Vicarious Trauma, Secondary Traumatic Stress, and Burnout Rothschild and Rand (2006) outlines four areas of risks faced by professionals regularly working with clients who have been traumatized. The four areas are vicarious traumatization (Terr 1985), secondary traumatization (Stamm 1995), compassion fatigue (Figley 1995), and burnout. Vicarious trauma refers to changes in the social worker’s inner experience, beliefs, and thoughts resulting from long-term exposure and empathetic engagement with traumatized clients. Secondary traumatic stress occurs when the social worker listens to the abuse or traumatic experiences of children and youth and experiences an emotional toll, such as PTSD symptoms. Compassion fatigue is related to the change in cognitive schema of the social worker therapist and exhaustion from being in the helping profession.

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Burnout refers to emotional exhaustion and depersonalization and reduced sense of personal accomplishment. It is also seen to be caused by context of work such as workload, interpersonal issues and non-supportive organizational culture. Poor physical health, work avoidance, and negative outlook on life are symptoms of burnout. Reflection, regulation, relaxation, and participating in a care team approach can help mitigate the stress faced by professionals (Child Safety Commission 2009). The use of the social worker’s “brakes” are helpful in “reducing in-session hyperarousal” and “protecting against the direct impact” of traumatic “client material” (Rothschild and Rand 2006). The main goal of applying the brakes in therapy session is for the social worker to become calmer and think with clarity. This would require the social worker to be aware of his or her autonomic nervous system responses and arousal patterns and apply the brakes when the arousal goes beyond the optimal range. Social workers need to self-regulate in order to regulate others.

Reflective Supervision Supervision is essential for social workers working with traumatized children or youth. Supervision builds competent and confident social workers and ensures good client outcomes and service standards. Supervision provides a space to talk about the needed “emotional distancing” and boundary-setting that helps the social worker not be overwhelmed (Dyregrov 2010). In supervision, rituals can be established to help for the social worker to disconnect from work and have clear boundaries as they transition from work to home. When multiple social workers have been impacted by the same incident, critical incident stress debriefing can also be done in a group supervision session. In supervision is also when the social worker can take stock of their anchors using SIBAM concepts and discuss ways to recharge self. Supervision also allows for the celebration of small successes and movement towards healing in child or youth clients. Dyregrov shares that inputs from team feedback on “practical aspects of the work” and “recognition and praise from others help raise morale.” Supervision is also a helpful space to look at social workers’ personal growth and glean insights and integrate them through appreciative inquiry.

Self-Care The steady grounding of self and having strong resources and anchors helps the social worker working with traumatized children and youth be able to support them and contribute to positive adult outcomes. Dyregrov (2010) also reinforces the need for the social worker’s self-care and suggests that relaxation techniques, leaving the situation, and seeking social support from family and friends can help in managing

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“cumulative stress” of the helper. Rath (2015) discusses keys to energizing work and life and describes how connection and positive interactions boost oxytocin levels and open up the prefrontal cortex and allow for expanding thought and increase ability to “trust others.” Social work practice with traumatized children and youth can be challenging while being rewarding and meaningful. It is important that social workers and their organizations have sound strategies to ensure that they can recharge and become increasingly competent in working with this vulnerable yet resilient client group.

Conclusion The building of TI service delivery systems for children, youth, and families, and the dissemination of trauma-specific treatments, require continuous, long-term, neverending efforts by policy makers, funders, administrators, clinicians, parents, and community advocates. Given the vast and persistent disparities in the United States, in health, wealth, and income, access to basic resources and life options, and institutional treatment, based on race, socioeconomic status, and other social identities, the realization of universal trauma-informed systems and the elimination of the treatment gap are aspirational goals. Troubling is that half of the US children with a mental health disorder are not receiving necessary treatment, with gaps in treatment varying widely among the states (Whitney and Peterson 2019). In Singapore context, children and youth statutory services as well as medical and social service sector professionals are steadily building competency, frameworks, and infrastructure to contribute to a sound TI service delivery for the clients and TI organizational culture for professionals. Existing research suggests needs for further consensus on the meaning of “TI approaches,” and implementation and impact studies to identify organizational- and systems-level components and the conditions necessary for integrating and sustaining TI approaches (Melz et al. 2019). Multiple barriers exist in implementing TI approaches and disseminating evidence-based treatments. However, systems are changing and the use of trauma-specific interventions is expanding. We can draw inspiration from the resilience of children, youth, and families affected by traumatic events, and the countless professionals, paraprofessionals, parents, and other community members involved in creating TI service delivery systems and actively disseminating TI approaches.

Cross-References ▶ Ethics, Values, and Recovery in Mental Health Social Work Practice ▶ Theories on Mental Health, Illness and Intervention

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Annex A A working transition model for child(ren) with planned placement changes Pre-move stage

Post-move stage

Actual move

C

Yoges Munisamy (2011)

Transition time frame Decision is made about transition

Crucial closure with previous carer and family Pick up of child by new carer

Meeng between old and new carers Case Manager, Carer support worker and Transion worker

Child Session 1 Explain move with houses puppets

 Collation of routine, eating, likes dislikes, regulation methods, behaviour  Making a joint transition plan that is well-paced for child ..not carer’s timeline only  Discuss contact

Child Session 2 Bear cards to talk about feelings and transition plan -calendar Goodbye plan

 Work with carers on their loss and grief  Document what he/she /they have given to this child.  Joint memories  New carers’ dreams & expectations  Observation of child @ visits with new carer

Child Session 3 Collage-by child /joint piece with carer Photos of critical symbols in house

1 month Review Meeng with new carers , Case manager, Carer support worker and Transion worker

Child Session 4 Actual move Name emotions facilitate transition Thank you and affirmation

   

Joint collage Transition object School goodbye A meaningful closure plan that is significant for the child and carer and other family members  Discussion with new carer on trauma

 Support to new carer  Impact on old carers and the children left behind  Ensure contact is occurring where possible and assessed to be helpful  document in care plan

Child Session 5 Joint session with new carer and child to talk about the move

 Review of how the month has been..  How has the attachment development been ?  PACE process (Playful, Acceptance, Curiosity and Empathy

Annex B Self-care for the social worker: Resource Categories Resource type

Present

What are they?

Not present and can be developed

Practical

hysical Physical

sychological Psychological

nterpersonal Interpersonal

piritual Spiritual

Developed by Yogeswari Munisamy from content from Babee Rothschild’s Somac Trauma therapy training in Cambridge, UK (2016)

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Van der Kolk BA (1994) The body keeps the score. Harv Rev Psychiatry I:235–265 Walkley M, Cox T (2013) Building trauma-informed schools and communities. Child Sch 35(2):123–126 Whitney DG, Peterson, MD (2019) US national and state-level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Ped 173:389–391 Wolpow R, Johnson MM, Hertel R et al (2009) The heart of learning and teaching: compassion, resiliency, and academic success. Washington State Office of Superintendent of Public Instruction Compassionate Schools. http://www.k12.wa.us/compassionateschools/pubdocs/TheHearto fLearningandTeaching.pdf. Accessed 5 May 2017 World Health Organization (2014) Global status report on violence prevention. http://www.who.int/ violence_injury_prevention/violence/status_report/2014/en/. Accessed 7 Aug 2017

Application of Mindfulness-Based Approaches in the Context of Social Work

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Si Ying Tan and Shian-Ling Keng

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Roots of Mindfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mindfulness: Definitions and Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existing Mindfulness-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mindfulness in the Context of Social Work and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mindfulness and Mental Health: Marginalized Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mindfulness and Mental Health: Social Work Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mindfulness and Mental Health: Social Work Pedagogy and Training . . . . . . . . . . . . . . . . . . . . . . . . Development of Mindfulness-Based Interventions in Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Rooted in the spiritual tradition of Buddhism, mindfulness-based practices have proliferated in medicine and psychology for the past few decades through secularized adaptations of its fundamental tenets into various psychosocial treatment modalities. The extension of the applications of mindfulness-based practices to different types of social work interventions is on the rise. This chapter discusses the application of mindfulness-based practices in the context of social work from three angles. First, we review the applications of mindfulness-based practices among marginalized population groups who are often excluded from the S. Y. Tan (*) Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore e-mail: [email protected] S.-L. Keng Division of Social Science, Yale-NUS College, Singapore, Singapore e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 R. Ow, A. W. C. Poon (eds.), Mental Health and Social Work, Social Work, https://doi.org/10.1007/978-981-13-6975-9_11

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mainstream institutions. We apply social justice framework which emphasizes on fairness and inclusivity of access toward social resources for all segments of population in the society in our analysis, examining both the micro and macro practices of mindfulness-based interventions. Following that, we discuss the way in which mindfulness-based practices can be harnessed as an internal resource to strengthen social workers’ capacities as helping professionals and to increase their capabilities for self-care. Finally, we examine the extent to which mindfulness-based practices have been adopted in social work curriculum and pedagogy as part of the social work trainings in different cultures. We conclude that there are great potentials for the application of mindfulness-based practices in social service settings, particularly in an integrative manner with many existing social work interventions. Keywords

Mindfulness-based practice · Social work · Marginalized population · Practice · Pedagogy and training

Introduction In recent years, there has been a huge increase in the interest in the application of mindfulness-based interventions in a variety of contexts. Mindfulness, commonly defined as a way of paying attention to the experiences in the present moment in an open, intentional, and nonjudgmental manner (Kabat-Zinn 1994), is a practice that has its roots in Buddhism and other spiritual traditions. In recent years, much work has been devoted to understanding the effects and mechanisms through which mindfulness training influences physical and psychological functioning (Baer 2003; Keng et al. 2011), as well as exploring potential adaptations and application of mindfulness-based approaches in various contexts, including the practice of social work. In this chapter, we attempt to provide a discussion of various ways in which mindfulness-based approaches have been applied in the context of social work. We began by providing an overview to the history, definitions, and operationalization of mindfulness. Following this, we elaborated on selected existing mindfulness-based interventions and discussed three major contexts in which mindfulness-based interventions are applied in the realm of social work. We concluded the chapter by discussing the development of mindfulness-based interventions in the Asian context, as well as providing suggestions for future work and research on the intersection between mindfulness and social work.

Historical Roots of Mindfulness Historically, mindfulness has its roots in several eastern philosophical and spiritual traditions, such as Taoism, Chuang-Tzu’s school of philosophy, and Krishnamurti’s teachings (Kabat-Zinn 2003). However, mindfulness has been most systematically

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articulated and emphasized in Buddhism, a spiritual tradition that is at least 2500 years old. The Sanskrit root word for “mindfulness” is sati, which connotes attention, awareness, and remembering. In Buddhism, meditation is a key spiritual vehicle aiming at cultivating the qualities of mindfulness and concentration, which are considered as crucial for one to develop insight into the nature of reality and one’s experiences. Starting from the 1960s, a number of Western psychotherapists became interested in meditation and wrote some books surrounding the theme of meditation and psychotherapy. A few examples were Zen Buddhism and Psychoanalysis (Suzuki et al. 1960), Psychotherapy East and West (Watts 1961), and A Psychiatrist Discovers India (Boss 1965). In addition, some research studies also began to examine the physiological states associated with mindfulness meditation. Brain wave activity of individuals engaged in mindfulness meditation showed very brief periods of alpha blocking, which suggested that these individuals did not habituate to distractions and that each distraction was experienced as if it was experienced for the first time (Kasamatsu and Hirai 1966). Mindfulness began to be more broadly applied in the field of medicine and psychology beginning the work by Jon Kabat-Zinn, who developed an 8-week mindfulness-based stress reduction (MBSR) program based on intensive formal and informal practices of mindfulness meditation in the early 1980s. Subsequently, other treatments based on mindfulness practices and principles were also developed, such as mindfulness-based cognitive therapy (MBCT) (Teasdale et al. 2000), dialectical behavior therapy (DBT) (Linehan 1993), and acceptance and commitment therapy (ACT) (Hayes et al. 1999).

Mindfulness: Definitions and Assessments In an attempt to operationalize this construct further, Bishop et al. (2004) proposed a two-component model of mindfulness. The first component is self-regulation of attention, while the second is orientation to experience. Self-regulation of attention involves non-elaborative observation and awareness of thoughts, sensations, or feelings from moment to moment. This aspect of mindfulness encompasses the ability to voluntarily sustain one’s attention as well as switch attention from one object to another. The second component – orientation to experience – concerns the attitude toward one’s experience. Through mindfulness practice, one maintains an attitude of curiosity toward any sensations, thoughts, or feelings that arise at any moment. Such an attitude is accompanied by a sense of acceptance, which is characterized by being open and receptive to whatever that occurs in the present moment, without imposing judgments on the experience. Various measurement scales, such as Kentucky Inventory of Mindfulness Skills (KIMS) and Freiburg Mindfulness Inventory (FMI), have been developed to assess trait mindfulness and its related constructs (Baer et al. 2004; Buchheld et al. 2001). Baer et al. (2006) reviewed five existing mindfulness self-report questionnaires and derived five clear and interpretable facets of mindfulness through factor analysis.

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These facets include the ability to describe one’s experience with words, the ability to engage in daily activities with awareness, the ability to notice and observe one’s moment-to-moment experience, as well as the ability to remain nonjudgmental and nonreactive toward one’s experiences. Research has demonstrated that these facets of mindfulness traits work synergistically and are predictive of more adaptive psychological functioning, such as reduced symptoms of depression and anxiety (Baer et al. 2006).

Existing Mindfulness-Based Interventions To date, a number of interventions have been developed based on principles and practices of mindfulness and adapted for a variety of populations and settings. Examples of these interventions include mindfulness-based stress reduction (MBSR), mindfulness-based resilience training (MBRT) (Stonnington et al. 2016), MBCT (Oken et al. 2010; Teasdale et al. 2000), mindfulness-based feminist therapy (Crowder 2016), and mindfulness-based interventions that adopt a social justice approach (Hick and Furlotte 2010). As highlighted earlier, one of the earliest mindfulness-based interventions developed was MBSR, previously known as the stress reduction and relaxation program (Kabat-Zinn 1982). MBSR was first introduced in a behavioral medicine setting for patients with chronic pain or stress-related problems. A standard MBSR program consists of an 8-week course, in which a group of up to 30 participants meet for about 2 or 2.5 h per week for mindfulness meditation instruction and training (Baer 2003). Several mindfulness-related practices, such as body scan exercises, sitting meditation, hatha yoga, and walking meditation, are taught in the program. During these exercises, participants are instructed to pay attention to the object of observation (such as breath or bodily sensations) and to observe them nonjudgmentally. Whenever the mind wanders away from the object of observation, participants are instructed to gently bring their attention back to the present moment and the object of observation. Participants are required to practice these skills for at least 45 min a day, outside of group meeting times. With repeated training, mindfulness practice is intended to enable one to recognize one’s habitual pattern of thinking, feeling, and cognition and to take a more nonjudgmental and decentered attitude toward these mental constituents. Since its first application on chronic pain patients, MBSR has been used to alleviate symptoms of a variety of medical problems, such as fibromyalgia, psoriasis, and cancer (Kaplan et al. 1993; Kabat-Zinn et al. 1998; Speca et al. 2000). Research has also demonstrated the beneficial effects of MBSR in treating a variety of psychological disorders, such as eating disorders and anxiety disorders (Kristeller and Hallet 1999; Kabat-Zinn et al. 1992). Similar to MBSR, a number of other mindfulness-based interventions incorporated a myriad of skills training and psychosocial and experiential components, with sitting meditation, walking meditation, and gentle yoga being among the most commonly taught mindfulness practices (Crowder 2016; Oken et al. 2010; Stonnington et al. 2016; Whitebird et al. 2013; Zhang et al. 2015). One study also incorporated

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components from other notable interventions such as acceptance and commitment therapy (ACT) and stress management and resilience training (SMART) and integrated them into the traditional MBSR training for transplant patients and their caregivers. For instance, psychoeducation that imparts knowledge on the neuroscience of stress and resilience and skills training that aims to cultivate gratitude, compassion, and meaning is actively integrated into the traditional mindfulness training exercises (Stonnington et al. 2016). Audio recordings with guided meditation practice are also distributed to the participants, and homework and activities are assigned to the participants to be practiced at home in order to achieve optimal benefit (Crowder 2016; Stonnington et al. 2016; Whitebird et al. 2013; Zhang et al. 2015). Some studies have demonstrated that mindfulness-based interventions have shown similar efficacy as some of the pre-existing psychosocial training and treatment protocols, such as standard training (Whitebird et al. 2013) and standard psychoeducation (Oken et al. 2010) for caregivers of patients with dementia.

Mindfulness in the Context of Social Work and Mental Health Even though the concept of mindfulness took root in Buddhism as an ancient philosophy and spiritual practice, as discussed above, it has been widely applied in modern medicine and psychology over the last few decades through secularized adaptations of its fundamental tenets into various psychosocial treatment modalities. As an interdisciplinary field that has traditionally integrated theoretical concepts from various fields in social sciences which include psychology, social work scholars and practitioners, following the footsteps of psychologists, started borrowing the therapeutic elements of mindfulness practices into the practice and pedagogy of social work heavily in recent years. The rise of empirical studies in the social work literature to examine the efficacy of mindfulness-based interventions in clinical settings and the adaptations of mindfulness principles into social work pedagogy are testimonies of that. Unlike what some may believe to be primarily a practice of self-reflection and introspection, mindfulness practice, when adapted and applied in social work settings, is multifunctional and has broad, inclusive, and encompassing scopes. Besides serving as a tool to self-regulate one’s feelings and emotions, the utility of mindfulness practice in social work reverberates in many dimensions of social relations and could effectively be applied by social workers at many levels of practice. In this respect, Hick (2009) proposed a conceptual model which suggests that mindfulness practice in social work can occur at three different levels: within the person (or inner dimension); in micro practice (through direct interventions with individuals, families, or groups); and at the level of mezzo/macro practice (through community work, advocacy, and policy). This model suggests that the role of mindfulness in social work is multidimensional and multifunctional. At the individual (self/ inner dimension) level, mindfulness could be harnessed as an internal resource to strengthen the helper’s own capacity and development; at the micro practice level, it could be implemented as an intervention to support clients through their problems. At the

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Self/ Inner Dimension

• Present-moment orientation. • Inner peace and calm. • Practices to cultivate self-compassion and self-acceptance. • Changed relationship. • Stress reduction and self-care.

Micro Practice

• Present-moment orientation. • Methods to develop deep listening and interpersonal presence. • Open and nonjudgmental. • Practices to cultivate compassion and empathy.

Mezzo/Macro Pracrtice

• Present-moment orientation. • Attentive to process. • Open-minded and non-dogmatic. • Analysis of structural causes of injustice. • Attentive to intentions of social change.

Fig. 1 The role of mindfulness in social work. (Adapted from Hick 2009)

macro level, it could be utilized as a soft skill approach to create open-mindedness and flexibility in navigating the complex terrain of social work leadership as well as the policy world, forging effective engagement and negotiation in order to facilitate social change (Hick 2009) (Fig. 1). The therapeutic effects of mindfulness-based interventions have been documented in a wide range of populations in a diverse range of human service settings. The literature on the application of these interventions has exhibited positive effects of mindfulness-based interventions to cancer patients (Carlson 2016), transplant patients (Stonnington et al. 2016), people with substance abuse problems (Chiesa and Serretti 2014), survivors of intimate partner violence (Crowder 2016), youth with or without mental health conditions (Borquist-Conlon et al. 2017; Zack et al. 2014), family caregivers of patients with various medical conditions (Oken et al. 2010; Stonnington et al. 2016; Whitebird et al. 2013; Wood et al. 2015), elderly populations with Parkinson’s disease (Cash et al. 2016) and chronic insomnia (Zhang et al. 2015), as well as people with various mental disorders (Keng et al. 2011). Taken together, these studies point to the potential benefits of mindfulness-based interventions for a variety of populations and offer promise to clinical social workers that mindfulness is a form of therapeutic approach that they could apply to benefit their clients. In the below sections, we discuss in greater depth several ways in which mindfulness-based interventions have been applied in the broader context of social work. These areas include mindfulness applied in the context of supporting or treating socially marginalized populations, mindfulness as a form of self-care tool to enhance internal resources for social workers, and mindfulness as applied in social work pedagogy.

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Mindfulness and Mental Health: Marginalized Populations The effects of mindfulness-based interventions in hospital clinical settings targeting different subpopulations that are diagnosed with different medical conditions have been well-documented since MBSR was first introduced in the late 1970s (KabatZinn 1994). Over the years, mindfulness-based interventions have gradually made inroad to many other arenas, including mental health and social service settings. This section focuses on the application of mindfulness-based interventions in treating various mental health conditions, as well as more generally in social service settings that mainly target socially marginalized populations. Within the domain of mental health, mindfulness-based interventions such as MBSR and MBCT have been found to be effective in alleviating a range of psychological symptoms. For example, MBSR was found to be comparable to group cognitive behavior therapy in terms of improving quality of life, mood, and functionality among patients with generalized social anxiety disorder (Koszycki et al. 2007). MBCT, an intervention developed based on the integration of mindfulness meditation and cognitive therapy, has been shown to be effective in preventing relapses among patients with recurrent major depressive disorder (Ma and Teasdale 2004; Teasdale et al. 2000). In the later study, the effects of MBCT in reducing the rate of depressive relapses are found to be comparable with those of maintenance antidepressant medication (Kyuken et al. 2008). The effects of MBCT have also been examined among patients with bipolar disorder. In a study by Williams et al. (2008), MBCT was found to be more effective than a waitlist condition in reducing depressive and anxiety symptoms among patients with unipolar and bipolar disorders. Meanwhile, DBT is a clinical intervention that incorporates teaching of mindfulness skills as a core component and has been found to be efficacious in reducing the rate of nonsuicidal self-injury and improving psychosocial functioning among patients with borderline personality disorder (e.g., see Linehan et al. 1993; Verheul et al. 2003). It is believed that these interventions work in part by increasing individuals’ ability to decenter from their experiences and thereby disengage more effectively from maladaptive cognitive and behavioral patterns (e.g., rumination and avoidance) that trigger and maintain psychological distress (Keng et al. 2011). While the effects of mindfulness-based interventions on severely marginalized populations remain under-researched in many countries, preliminary evidence suggests that mindfulness training may be a promising approach in supporting oppressed and economically disadvantaged populations (Crowder 2016; Hick and Furlotte 2009, 2010). This approach is particularly important in community social work that places emphasis on espousing the principles of social justice to promote fairness and inclusivity in the society, including having equal access toward social resources for all segments of the population. Renowned Vietnamese Zen master Thich Nhat Hanh, for instance, is one of the leading voices that promotes social justice using peace and silence, in line with his teachings on mindfulness, to address sensitive issues such as racism civil rights violation in his capacity as a spiritual leader (Gomez 2015). For instance, social workers and researchers in Canada adapted the standard MBSR program

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and integrated it with critical social theory, which espouses the importance of addressing social exclusion. The result of this integration is a group intervention that specifically targets severely economically disadvantaged populations (Hick and Furlotte 2010). Examples of target populations include individuals who are homeless in drop-in centers, beneficiaries of social welfare schemes, and recipients of the sheltered home programs. This intervention, known as “radical mindfulness training,” addresses individual, interpersonal, societal, and structural issues in addition to teaching formal mindfulness practices. As part of the group work process, the researchers developed an exercise that encompasses nine specific instructions (e.g., (i) notice, pause, and breath; (ii) accept yourself, but not the situation; (iii) clarify with clarity; (iv) think creatively; (v) opening to fear; (vi) take action; (vii) smile; (viii) work in solidarity; and (xi) be persistent) to overcome experiences of oppression. Twenty-two participants were recruited from a local community health center for a study evaluating the effects of this intervention, and seven participants who completed the survey revealed an overall increase in self-compassion and satisfaction with life following completion of the program (Hick and Furlotte 2010). Further, existing work has integrated mindfulness approaches to engender feelings of empowerment and liberation for survivors of intimate partner violence (Crowder 2016). Mindfulness-based approach encourages the gradual detachment of self-identification on one’s past traumas and restores the ability of inner healing through the promotion of self-compassion and letting go. This practice, which encourages inward looking and acceptance of all phenomena – including painful events – as part of ever evolving human experiences can be leveraged to bring about greater sense of interconnectedness of all beings in the world, foster compassion, and increase awareness about how our individual and respective roles in the society can perpetuate or influence oppressions and injustices that affect our collective well-being in the world (Crowder 2016; Hick and Furlotte 2009, 2010). Mindfulness-based interventions have also been shown to be an effective treatment approach for youth and young adults at risk. For young adults with history of substance abuse, mindfulness-based interventions were shown to be effective in preventing relapse or reducing the frequency of substance use (Bowen et al. 2014; Chiesa and Serretti 2014; Witkiewitz and Bowen 2010). A systematic review reported that mindfulness-based interventions, which encompass Vipassana meditation, MBSR, MBCT, mindfulness-based relapse prevention (MBRP), spiritual selfschema therapy (3S-Therapy), DBT, and acceptance and commitment therapy (ACT), were effective in reducing the consumption and misuse of substances such as alcohol, cocaine, amphetamines, marijuana, cigarettes, and opiates to a significant extent, compared to waitlist control participants (Chiesa and Serretti 2014). Two other randomized control trials investigating the effects of MBRP also reported positive results, whereby MBRP participants reported fewer days of alcohol and other substance use compared to control group participants at 4-month follow-up (Witkiewitz and Bowen 2010) and 6-month follow-up (Bowen et al. 2014), respectively. In one of these studies, MBRP was shown to be superior to cognitive-behavioral relapse prevention (RP) with regard to longer-term outcomes;

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in particular, results at 12-month follow-up showed that MBRP participants had fewer days of alcohol or drug consumption as compared to participants in both the RP group and the control group (Bowen et al. 2014). In contrast to many other psychosocial approaches that centered on addressing symptomatic behaviors and providing psychoeducation to the participants, MBRP seeks to address the root of the substance use, such as negative mood and craving that revolved around individual values and needs. This approach teaches participants to observe their physical, emotional, and cognitive conditions of their craving whenever they arise and learn to sit with these uncomfortable feelings without attempting to habitually reacting on these negative states of mind (Bowen et al. 2014; Witkiewitz and Bowen 2010). The use of intensive guided meditation sessions, experiential sessions, and discussion during the intervention, coupled with the use of audio-recorded guides to facilitate daily practice at home, ensures that participants could sustain their practice beyond the immediate settings where they were taught mindfulness practices (Witkiewitz and Bowen 2010). In prison settings, the efficacy of mindfulness-based interventions has also been widely documented. Prisons are among one of the most challenging environments to implement such interventions, due to the fact that the structure and environment in prison settings can often times be extremely dehumanizing. This is often exacerbated by the inherent hostility, command, and control exerted upon the prisoners, which often render them feeling dejected and powerless. Meanwhile, it is precisely due to the fact that implementation of mindfulness-based interventions is challenging that successful implementations can often be extremely rewarding (Lyons and Cantrell 2016). A recent systematic review and meta-analysis that examined the effects of yoga and mindfulness meditation programs in prisons across the United States, United Kingdom, India, and Taiwan reported modest effects of these programs on psychological well-being and behavioral functioning. Further analyses indicated that programs with longer duration had a slightly larger effects on behavioral functioning as opposed to more intensive programs (Auty et al. 2017). Smaller-scale studies that involved smaller sample sizes in the United States (Samuelson et al. 2007) and in China (Xu et al. 2016) demonstrated positive effects of these interventions as well. In the United States, MBSR programs concurrently rolled out to several correctional facilities in Massachusetts were shown to be effective in reducing hostility and mood disturbance, as well as improving self-esteem among the inmates, especially those in minimum-security, pre-release facilities (Samuelson et al. 2007). An adapted version of this program was similarly tested in prison facilities in Beijing, China. Results were largely positive, pointing to reduction in aggression and improvement in emotional health among the inmates who received the intervention (Xu et al. 2016).

Mindfulness and Mental Health: Social Work Practice Mindfulness has long been advocated as an effective psychosocial interventions for clients with different medical and psychosocial conditions. The above section documented how mindfulness-based interventions have been effective to many types

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of socially marginalized populations. However, scholars have argued that helping professionals can only be both effective and authentic facilitators of mindfulnessbased interventions when they are able to truly embody the qualities and practice of mindfulness in their everyday life (Shapiro and Carlson 2009). Embarking on a mindfulness journey is important for social workers interested in experiencing the benefits of this practice and effectively utilizing mindfulness as an intervention approach to help their clients. The journey of mindfulness can start only when mindfulness practice is weaved into one’s daily life as part of self-care. This is important to achieve a healthy balance between addressing the sufferings of others and attending to one’s needs and well-being, both of which arguably function in a synergistic manner. Across most cultures, social workers constantly face challenging and constraining circumstances at all levels – systematic, organizational, and individual. At the systemic level, the need to adjust to the ever-changing realities on the ground and the pressure to keep abreast with constant social policy changes could create a heightened sense of duty that compound mounting work stress. This is even more so for social workers who are already wrestling with high caseloads. At the organizational level, there are managerial expectations on keeping up with performance in a wide range of portfolios that often span both functional and operational aspects. Besides, the nature of social work often predisposes social workers to difficult situations, in which social workers have to make resource allocation decisions. As resources are always scarce, having to capitalize on the limited funding to meet both organizational goals and clients’ needs always requires careful deliberations on the trade-offs. These demands can be overwhelming and potential stressors for social workers. At the individual level, the hypervigilant and hyper-attentive emotional states that social workers are prone to – especially when managing crises events and challenging situations – can take a toll on their personal well-being. Under these circumstances, social workers, like many other helping professionals, risk facing occupational stress such as burnout, compassion fatigue, and professional self-doubt (Lloyd et al. 2005). It is thus important for social workers to put self-care at the center of their profession. One common problem in the helping profession is too many of those in the helping positions see clients’ needs and their own psychosocial needs as separate entities and, very often, place the clients’ needs above their own needs and fail to attend to their own well-being (Shapiro and Carlson 2009). Mindfulness practice, grounded on the development of awareness of presentmoment experiences in an open and nonjudgmental manner (Kabat-Zinn 1994), can be applied by social workers to create a safe haven for themselves in a work setting that tends to demand much emotional energy. Altering one’s mental state from the default mode of “doing” to simply “being” (Hick 2009) helps build up capacity for deep introspection and creates room for personal self-care and mental rejuvenation. Further, mindfulness practice helps to create emotional space for social workers to accept their foibles and limitations and to let go of preoccupation with external criticisms or self-judgment. Incorporating elements and principles of mindfulness to social work practice settings serves to enhance social workers’ internal capacity to work effectively with clients and to be more at ease with the notion that even if

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they are not able to help generate immediate solutions for their clients, being wholly present with them and facilitating the acceptance of uncertainty with their clients can also bring about positive effects of healing (Birnbaum and Birnbaum 2008). Incorporating mindfulness principles in the social workers’ practice settings has started to gain momentum in the West, notably in North America. While mindfulness practice in social work settings is far from establishing itself in the core operations of human service organizations, social workers have started to develop individual or group initiatives to practice mindfulness meditation as a routine and consciously impart the element of mindfulness to their professional work. Studies have shown that incorporating mindfulness principles in social work practice in the form of group contemplative practices and group discussion helps social workers to enhance awareness, develop attentional capacities, cultivate a deeper sense of attunement to the therapeutic relations and interconnectedness with clients, and increase empathy (Birnbaum and Birnbaum 2008; McGarrigle and Walsh 2011; Shier and Graham 2011; Turner 2009). These studies ranged from conceptual and review studies (Birnbaum and Birnbaum 2008; Turner 2009) to empirical studies such as intervention trials (McGarrigle and Walsh 2011) and mixed-method study (Shier and Graham 2011). In one small-scale, pre-post intervention study involving 12 human service officers as participants, an 8-week contemplative practice group consisting of mindfulness-based practices such as meditation, yoga, body scan, and relaxation exercises were taught by an experienced yoga and meditation teacher, who was also a social worker. Post-intervention assessment indicated significant increases in trait mindfulness and decreases in stress levels (McGarrigle and Walsh 2011). This study also showed that social workers perceived incorporating mindfulness practices within the organization, which serves to protect the well-being of workers, as an act of accountability to both clients and organizations (McGarrigle and Walsh 2011). This sense of accountability stems from helpers realizing the need to first care for themselves before they could reach out effectively to those needing their help. Failing to keep their personal emotional wellbeing in check may negatively impair the quality of their work with clients. Another mixed-method study that incorporated mail survey and in-depth semistructured interviews examined ways in which mindfulness practices benefitted social work professionals (Shier and Graham 2011). Findings highlighted several key benefits of mindfulness practice to social workers. These benefits include reduced stress and increased clarity of the realities faced by social workers both internally and externally. Further, mindfulness practice also allows social workers to reflect on pivotal moments in their personal lives and ascribe deeper meanings to those moments, which helps them achieve greater balance between their personal and professional lives (Shier and Graham 2011). While current findings point to the potential benefits of incorporating mindfulness practice in social worker’s personal and professional development, it is important to note that the studies are limited in sample size and lacking control groups. Therefore, future work should examine the effects of mindfulness practice on various dimensions of social workers’ lives, through the use of larger sample sizes and more rigorous methodologies, such as randomized controlled trials. Overall, however, the

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findings do offer promise that mindfulness practices could be utilized as effective strategies for self-care and addressing burnout.

Mindfulness and Mental Health: Social Work Pedagogy and Training In recent years, there has been an increase in the incorporation of mindfulness principles and elements into the training of social work students. Mindfulnessbased practices have been shown to improve quality of life, enhance positive emotions, facilitate emotional regulation, increase awareness toward the perception of reality, as well as increase knowledge and self-efficacy (Birnbaum 2009; Bonifas and Napoli 2014; Botta et al. 2015). These benefits directly improve strengths and capacities of the students to meet the challenging demands in both their study and life pursuits (Birnbaum 2009; Bonifas and Napoli 2014; Botta et al. 2015). The incorporation of mindfulness training in social work pedagogy has been done in both experiential and didactic forms. These trainings are either implemented as a standalone curriculum or integrated into other mainstream, existing curriculums. Studies have shown that most of the institutions which have adopted mindfulness training implemented it in the form of experiential workshop (Birnbaum and Birnbaum 2008) or as experiential teaching elements integrated into mainstream curriculum designed as active listening skills training (Goh 2012), foundational social work practice course (Gockel 2015; Thomas 2017), and mindfulness group work (Botta et al. 2015; Newsome et al. 2012). Some other institutions designed it as a full semester-long elective course with the aim to enhance clinical skills and stress coping capabilities for social work students (Bonifas and Napoli 2014; Wong 2013). In addition, mindfulness training was also incorporated as part of the supervision exercise for social work students during their fieldwork placement (Birnbaum and Birnbaum 2008). In a full elective course designed specifically to promote quality of life and stress coping abilities among Master of Social Work (MSW) students in a public higher institution in the United States, readings and mindfulness exercises were designed to cover eight domains: (i) establishing personal boundaries; (ii) developing environmental awareness; (iii) eating healthfully; (iv) caring for the body; (v) recognizing inner strengths; (vi) restoring life balance through rest, relaxation, and recreation; (vii) building supportive relationships; and (viii) discovering passions and envisioning goals (Bonifas and Napoli 2014, p. 473). The other full elective course that was designed as an elective summer course known as “Spirituality and Critical Social Work” applied the framework of “interbeing” of the person and environment – a concept taught and propagated by renowned Zen master Thich Nhat Hanh – to advance students’ ability to harness mindfulness principles when engaged in a broader context of advocacy and advancing social justice (Wong 2013). Both courses integrated a diverse range of experiential learning activities such as weekend silent retreat, guided mindfulness meditation, in-class discussions on the reading materials, and research presentations on a wide ranging of mindfulness practices for different

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clienteles and their relations in enhancing quality of life (Bonifas and Napoli 2014; Wong 2013). A reflective mindfulness journal was also incorporated as part of the curriculum in which students were given opportunity to keep personal journals on their applications of mindfulness practice in their daily lives (Bonifas and Napoli 2014). In some instances, mindfulness practice was integrated as part of the elements of mainstream social work curriculum. In Smith College, a prominent institution for training social workers in the United States, instructors incorporated MBSR techniques and training exercises such as mindful walking, mindful stretching, mindful play, body scan, open awareness, walking meditation, and loving-kindness meditation for 15-min period in 28 sessions of a 10-week foundational social work practice course for beginning social work students (Gockel 2015). In another social work program in Singapore, instructor inculcated mindfulness principles to encourage individual reflections of habitual mental activities among a cohort of social work students (Goh 2012). A self-assessment tool was used to track 12 common mental habits, and daily reflections were captured on alternate weeks to record students’ experiences of becoming aware with these mental habits. Besides, students were divided into several groups that met fortnightly to discuss their experiences of practicing mindfulness and to brainstorm strategies on overcoming distractions that hindered active listening when attending to the clients. In Israel, mindfulness practices were applied in the form of group work and as a tool for individual observation of their fieldwork experiences and supervisory relationship (Birnbaum and Birnbaum 2008). These exercises were designed as means to enhance self-awareness, facilitate self-inquiry, and increase emotional support. Through mindfulness meditation, students were taught to observe their mental chatters nonjudgmentally and develop nonreactive patterns to the existential threat of anxiety over the uncertainties in life. From these practices, it is envisioned that students would learn to develop a broader world view and adopt a more open perspective toward their identity as a person and as a helper in the world (Birnbaum 2009)