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Focus Group on Social Work in Mental Health Programs
In Era of Medication, Social Work
Remains Vital
In an era of advances in psychopharmacology, people who suffer from mental illness are increasingly able to live relatively normal lives. The notion of miracle drugs appears to be a reality for many individuals and their families, those who have spent years struggling with illnesses ranging from schizophrenia and serious clinical depression to bi-polar disorder.
But the idea that someone can wake up in the morning, take a pill, and
be on their way may be a gross over simplification to those who provide
the majority of mental health services. Professional social workers know
first hand the benefits of medications, yet, at the same time, they see
their clients continuing to face life and death challenges.
Fine Tuning Essential Services
What often stands between injury and safety is not the marvels of medicine
but a finely tuned eye that something is wrong; the capacity to determine
what is brewing beneath the surface, and an ability to quickly assess
the broader circumstances of a person’s life, along with the resources
that might be available to help.
In a meeting of 13 social workers at NASW-NYC recently, one social worker
recalled how she had sensed that the woman she was seeing appeared to
be more depressed than usual and that her normal level of functioning
had diminished. Quite problematically, this woman stopped attending group
therapy sessions with her psychiatrist.
Given the requirements of the program, her continuing to get medication
was tied to her attendance in this group. Her absence would put her at
even further risk if her meds were cut off.
From speaking with the woman, and as a result of the trust the social
worker had previously developed, the woman confided that the psychiatrist
looked like the man who had raped her when she was a teenager, years before.
She was very upset being in his presence, as her original trauma was re-ignited
each time she entered the group.
Once this came to light, it became possible for the social worker to help
the woman distinguish between her original traumatic experience and the
current reality. Before long, she was able to rejoin the group. If the
social worker had not perceived this woman’s change in behavior
and mood, and had not originally earned her trust, the outcome for this
woman would have been quite problematic, possibly life threatening.
Noting
Basic Facts
Another social worker who leads a mobile crisis team told of visiting
a woman who was refusing to take her medication for depression. She was
despondent, refusing to get out of bed, and hoping to die.
The first thing the social worker did was ask a series of questions in
order to assess the woman’s life situation. She quickly realized
that no other professional that had previously treated this woman took
note of some rather basic facts. The woman, who had two children, had
lost her job, was not getting unemployment benefits, and she had lost
her apartment. She was now living with her sister’s family in a
small apartment.
What did the social worker do? The social worker began by listening to
what this woman had to say. Parenthetically, she said it helped that she
spoke Spanish; otherwise, nothing else would have happened.
The worker said that she empathized with the woman’s situation but
also learned what was stressing her. As a result of what was learned,
she referred the woman to an agency that helped the woman obtain an apartment,
social security, food stamps, clothing for her children, and money for
Christmas dinner.
The woman subsequently resumed taking her medication. The social worker
made clear that when it came to this woman’s psychological state,
it was not simply a matter of taking a pill. Other basic factors needed
to be addressed but had been ignored. The woman’s life, and the
lives of her children, were on the line.
Importance Across A Broad Range Of Services
The 13 social workers that were meeting came together as a result of a
focus group convened by the New York City Chapter of the National Association
of Social Workers. NASW-NYC wanted to learn more about how professional
social workers who work in the field of mental health make a difference
in people’s lives, and more specifically, to determine whether their
interventions were actually a matter of life and death or merely a nice
but less than vital service.
Social workers in the meeting represented numerous types of mental health
services from three of the five boroughs. Programs in state psychiatric
facilities, not-for-profit agencies and acute care hospitals were represented,
as were services to Latino, Asian, and African American communities.
Saving Three Lives
One social worker shared an experience when he was filling in for someone
who was working with a man who was raising two young children by himself.
The man was receiving mental health services following a head injury.
At the time the social worker entered the picture, the man was primarily
receiving help in dealing with stress through various relaxation techniques.
The responsibility of raising his children and maintaining a home was
unquestionably taxing on him.
The social worker realized that no assessment had been done as to whether
this client would qualify for homemaker services which would substantially
alleviate a significant portion of the household burden. Although the
application for obtaining services was complicated and time consuming,
the social worker could more effectively relieve this father’s stress
through homemaker services than relaxation techniques ever could. The
result of this not only helped the father, but, according to the social
worker, enabled the children to continue living at home. Three lives were
saved.
Key Ingredients-Beyond Empathy
Key ingredients in social work practice in mental health are without question
keen assessment skills that examine the individual’s emotional and
mental states as well as the nature of the situation that they are living
in. These, along with a current knowledge of essential resources that
are available, allow a greater number of interventions to be considered
than when one is looking at mental or emotional states alone.
Knowing how to work with people to develop trust through support and empathy
are often key. There are times, however, when it’s not relevant
at all.
One social worker shared her experience of how a woman came to her who had suffered a severe blow to the head when her husband hit her with a frying pan. He then committed suicide.
The woman was clearly suffering from brain damage and trauma and was deemed
by the social worker to be suicidal.
Despite the woman wanting to go home following her meeting with the social
worker, the social worker escorted her to the psychiatric emergency room
in the hospital where she worked. She believed that this woman would be
quite angry with her and might not be willing to work with her again,
but the social worker determined that getting her into the safety of a
closed unit was the clear priority under the circumstances.
The social worker said that if she had followed a path based on empathy,
the woman would have gone home and probably have taken her life. She said
that escorting the woman to the ER was not the comfortable thing to do,
it was quite difficult, but it was essential.
Challenges to Maintaining Good Social Work - Implications for
People’s Lives
As part of the discussion about how social workers contribute to mental
health services, the participants in the focus group were asked to identify
what challenges they face in providing services. Most of them spoke about
the emphasis in their programs on increasing productivity, usually as
a result of pressures related to financial reimbursement for services.
In general, the length of time with any client is usually less than it
had been at some point in the recent past.
One social worker said that more clients can be seen, but the problem
that many pointed out is that the type of work that is often needed is
not possible. For example, being able to help a client obtain access to
things like housing, employment, health care, and children’s services
takes time. When the time is not available, people’s lives can be
put at risk.
One focus group participant said that professional social workers are
being “set up” by her program’s administration to compete
with one another to determine who is seeing the most clients. Another
social worker reported that the caseloads in her program are now so large
that each of five social workers is averaging 200 cases. When concerns
were raised following a client’s suicide, a worker was transferred.
This was extremely distressing to the workers.
Several social workers pointed out that the basic assumption underlying
many programs is that clients with mental illness only need to be given
a prescription, that the psychiatrist is presumed to be on top of the
critical issues, while serious, complicating factors go unrecognized.
It is often the social workers who pick up changes in behavior, but too
often there are not enough of them.
One social worker shared that in her facility there had been a social
work unit with a social work director. This resulted in the ability to
maintain a high degree of quality. She said that a few years ago the department
was dissolved, and there is now no director. She said that the overall
program of services is weaker, as a result.
She said, somewhat cynically perhaps, that it appears from where the program
puts its emphasis, one would presume that the definition of quality services
in mental health is merely avoiding having a death. She also said that
it feels, from the way staff is treated, that the practitioner is only
considered as good as his or her last progress note.
The last point reflects a long standing concern that there is far too
much paper work, taking time from essential client contact.
Despite the challenges and the frustrations that accompany them, the focus
group participants each appeared to remain dedicated to serving their
clients in the best way they know how.