Legislation and policy
The Mental Capacity Act 2005 (MCA 2005) defines the legal framework that is applicable to social work in the area of mental health practice. The MCA 2005 provides the definition of mental capacity as well as provides the statutory powers and duties in situations which provide the need for intervention for the best interest of such persons. Mental health conditions such as autism, severe and clinical depression, psychological, schizophrenia, etc. would be considered to be subject to the provisions of the MCA 2005 under specific situations (NHS, 2016). For a person to come under the purview of the MCA 2005, it has to be seen that the person lacks mental capacity. Here, lacking of mental capacity is defined under the MCA 2005 as someone an inability of a person to make decisions for himself due to an impairment in the mind or brain or any disturbance in the mind or brain, even where such impairment is temporary, provided that at the time such decision needs to be made, there is an impairment (MCA 2005, s.2).
The Health and Social Care Act 2012 has also ensured that parity is given to physical and mental health (Allen, et al., 2016). However, despite the passage of this law, it is considered that mental health issues are remain marginalised and stigmatised in both the social services as well as society (Allen, et al., 2016). It is also considered that mental health services are not given as many resources as given to other areas of health and care (Allen, et al., 2016). It is also observed that people with serious mental health needs may be more likely to live in poorer housing and have poorer physical health, be unemployed or socially isolated (Allen, et al., 2016).
The Care Act 2014 provides that adult social care should involve helping people seek support in anticipation of their needs. The aim of the law is to prevent and reduce dependency on higher intensity care and support services by tackling the problem at an earlier stage.
The Children Act 1989 puts together law and policy with respect to care and safeguarding of children and young people. The duties with respect to the child under the Act are underpinned by the principles that require placing the welfare of the child as the paramount matter of interest (Walker, 2012, p. 30). Moreover, the Act provides that the children should be taken care of within their families as far as possible. The interventions designed for the safety of the children should be with the intention of ensuring prevention of risk to the children. It is also important that even though children are not the decision makers regarding their treatment, they should be informed to the level of their understanding as to the treatment decisions that are being made for them. With respect to the Local Authorities, section 17 makes it a duty to safeguard and promote the interests of the children who are in need. The Act also considers and defines mental disorders.
In the context of social work policy and practice, the best interest regime under MCA 2005 is pertinent. The best interest regime comes into practice when a person is incapable of taking decisions in his own interest. Whether a person comes within the purview of the MCA 2005 for the purpose of application of the best interest regime depends on the determination by the relevant authorities as per the tests that are laid down by the MCA 2005. The MCA 2005 provides a two stage test, in section 2. In the first stage, the question that is asked is whether the person suffers from an impairment or disturbance in his mind or brain. In other words, the impairment can be due to psychological or physical factors. In the second stage, the question that is asked is whether such impairment is of such a nature that it impacts the ability of the person to make decisions (NHS, 2015). If the answers to these two questions show that there is an impairment affecting the brain and that such an impairment impacts adversely the capacity of the person to make decisions for himself, the two stage test of section 2 MCA 2005 is positive for the person to lack mental capacity.
For social workers it is essential that the two stage test provided above is seen to be followed properly. Not only that, social workers must also have regard to the jurisprudence developed by the courts in the application of MCA 2005 to individuals where the family of the individual is also involved or is contesting the application of the MCA 2005 to the individual. It is important to note that the application of MCA 2005 may lead to the deprivation of liberty for individuals and at times deprivation of liberty safeguards (DOLS) may apply to individuals and this may be contested by the family. Therefore, regard to the law as well as the jurisprudence of the courts is important to ensure correct practice.
There may be situations where the DOLS authorisation may need to be taken for an individual who is in parental care. In such situations, the DOLS authorisation can only be taken by the Local Authority from the Court of Protection (NHS, 2015). Therefore, the DOLS framework can be used by either the Local authority or the Court of Protection. Ethical dilemma in DOLS process are seen because there may be conflicts between the social workers’ and family’s viewpoint about the individual’s subjection to DOLS, especially where detention is to be done of the individual.
Evidence-based practice (EBP) refers to “health practitioners applying the best currently available research evidence in the provision of health services. In other words, EBP challenges practitioners to “do things right” and to “do the right things”” (Waddell & Godderis, 2005, p. 60). In other words, evidence-based practice involves a process wherein the practitioner uses well-researched interventions as a background with which he combines his own clinical experience and ethics, the preferences and culture of the individual for the purpose of identifying the appropriate treatment and interventions for the individual.
Research in this area involves research relating to improvement of services designed to support the mental health and well-being of children and families (Palinkas, et al., 2008) and need and encouragement for innovative practices in mental health (Mendel, et al., 2008).
Research has shown a variety of different models have been proposed to summarize factors at multiple levels of the social and organizational context that potentially influence the process of translating research into effective improvements in practice (Glisson & Schoenwald, 2005). Some models focus on the importance aligning community stakeholders with the inter-organizational agency environments (Glisson & Schoenwald, 2005).
One study emphasizes on the importance of using evidence-based practice for the purpose of dealing with childcare in mental health contexts. The study finds that agencies servicing children and families are pressured to demonstrate service effectiveness and accountability by government funders but there is a lack research evidence being used for responding to or creating programs for responding to social care issues in mental health (Archer-Kuhn & Greco, 2014).
Another study discusses impact of use of evidence-based treatment in therapeutic foster care wherein the combination of evidence-based practices with mental health services was provided for treatment and intervention. The study suggests that the evidence-based practice model was successful in improving outcomes for children as well as their families (Murray, et al., 2014).
Despite the scholarly research that suggests that evidence based practice is beneficial, there are also criticisms against it, particularly, that evidence based practice is difficult to implement (Waddell & Godderis, 2005). In social work, there are criticisms against evidence-based practice which emanate from the difficulty for social workers to transform the research into viable practices (Bellamy, et al., 2006). In context of social work and mental health, the barriers against evidence based practice relate to the time taken between research development and dissemination of evidence and the transformation of the information to practice settings (Bellamy, et al., 2006). There is also a problem with the lack of support and training social workers and practitioners (Bellamy, et al., 2006). At the same time, there are also evidence of effective interventions but there needs to be a dissemination of programs and other research findings which can prove to be beneficial to the social work practitioners (Bellamy, et al., 2006).
A recent report that adds to the evidence base for practice was funded by the King’s Fund and it provides an analysis of integrated care for mental and physical health from the perspective of the patient or service user; an overview of areas where integrated care is needed; innovative service models being developed at this time and also information on the barriers at for the implementation of certain models (Naylor, et al., 2016). As per this report, integrated care is essential so as to provide health and care services so that the various needs of an individual are met in a manner that is co-ordinated. This is especially significant in mental health care because, in this area, the co-ordinated effort is required to answer the medical, social and psychological needs of the child of family in question (Naylor, et al., 2016). At the same time, the evidence base for health and social care agencies remains sparse at this time (Cameron, et al., 2014). This impacts on the outcomes for social care work in the area of mental health and children.
The Deprivation of Liberty Safeguards (DOLS) provide legal protection for those vulnerable people who are, or may become, deprived of their liberty under the MCA 2005. There are safeguards that are meant to provide legal process and protection where DOLS becomes imperative in the larger interest of the child. These safeguards themselves provide a framework and are created for the purpose of ensuring that DOLS is not applied in an arbitrary manner which leads to the separation between parent and child. Therefore, there are five key principles of the MCA 2005 that are to be followed as safeguards. Richards & Mughal (2015) state the key safeguards that are applicable to the safeguarding of the individual as follows:
A person must be presumed to have capacity unless it is proved otherwise. Therefore, there will onus on the person claiming lack of capacity to prove it.
If a person makes an unwise decision, that by itself does not indicate a lack of capacity.
Decision made under the DOLS must be in the best interests of the person.
The person making the decision should choose the least restrictive option.
A theoretical framework that is applied in mental health work is the bio-psycho-social approach. This approach emphasises on biological elements and grants a subordinate role to social and psychological factors (Tew, 2011). This approach is holistic and is applied in cases where people have to be detained under DOLS for the safeguarding of their interest. The bio-psycho-social approach helps create a holistic and supporting environment for people who are detained under the DOLS process (Hewitt, 2009). Recently, the bio-psycho-social approach has been suggested particularly for practice involving social care involving mental health because health is the product of biological, psychological and social processes, and therefore, the assessment and management of mental health should be from that perspective only (Naylor, et al., 2016). An integrated approach suggested for this purpose (Naylor, et al., 2016).
Practitioners also need to conduct their work with cognizance to UN Convention on Rights of Child 1989. The theoretical framework offered by this approach is that of making social work child-centric. The Convention provides that welfare of the child is of paramount importance as per Article 3 of the Convention and Article 19 of the Convention provides that maltreatment or neglect of children should be avoided (Walker, 2012). In the UK, the theoretical framework presented by this approach has been seen in legislations such as the Children Act 1989, which have made the welfare of the child paramount and has underpinned the values of child welfare and need for the child to be taken care within family settings as paramount. These underpinning values of child rights have allowed the structuring of social care in a way that ensures that the child or family suffering from mental health issues will not see an intrusion or intervention by the Local Authority in a way that is oppressive. One area where oppressive practices may be seen is in social work in multi-ethnic contexts. Social work practice in multi-ethnic settings requires a theoretical framework that allows social workers to work within such settings with sensitivity to issues involving human diversity (Dominelli, 2002).
In case of multi-cultural social work, a theoretical framework for “multi-cultural social work needs an overarching theory that allows the different theoretical models to be applied and integrated. Therefore, a synthesis is required between systems theory and social work practice” (Walker, 2012, p. 162). Different theories are required because simply ethnocentric and Eurocentric explanations of emotional and psychological development will not provide the adequate solutions to the problems associated with the development of the ethnic minority groups (Walker, 2012, p. 162).
Social workers can use an empowerment model of practice that is also anti-discriminatory with the work involving a multi-disciplinary approach that enables the social workers to create a practice model that is culturally inclusive in nature (Walker, 2012). There is a need to create a social work practice for the ethnic minorities that challenges stereotypes and racism, where the social work staff is encouraged to stop and think about their assumptions so that they can rise above these assumptions in trying to help the families and children dealing with mental health issues (Walker, 2012).
Good practice in mental health, especially under the MCA 2005 involve taking into consideration the interest of the individual concerned as well as the family. At times, this may require a balancing of interests as between the individual and family.
Social workers must have regard to any signs that there is physical and mental abuse that the individual may be subject to at the hands of family and care takers. Here, signs of injuries or bruising must be taken seriously and properly reported. In case of adult safeguarding, unexplained bruises or injuries may be a sign of a possible physical abuse (SCIE, 2015). There may even be a tendency for the individual to self-harm. In any case, such signs are to be taken seriously by the social worker. Due to possibilities of self-harm as well as possibilities of abuse being both present in cases involving persons lacking mental capacity, social workers have to be careful and diligent in their reporting to the authorities. In one case, the Local Authority processed a DOLS authorisation for a person who was living at home at the time and did not apply for an authorisation from the Court of Protection. The social workers had noticed some injuries on the person but did not inform the Local Authority of the self-inflicted nature of the injury. The parents of the person applied for relief against the DOLS authorisation and the court held that the DOLS authorisation by the Local Authority violated the rights of the individual under the European Convention of Human Rights. The court also considered the lack of reporting of the injuries to the Local Authorities as a systematic failure due to which the DOLS authorisation was seen to be compromised and the court ordered the person to be removed to the care of his family (Somerset v MK (Deprivation of Liberty: Best Interests Decisions: Conduct of a Local Authority), [2014] EWCOP B25, 2014).
Social workers must also have regard to the Mental Health Act Code of Practice (2015) while dealing with a person who lacks mental capacity. The Mental Health Act Code of Practice (2015) provides five important principles, each of which is to be considered before important decisions relating to an individual’s treatment or care can be taken (Jackson, 2016). The first principle provides that the least restrictive option must be chosen for the individual and the purpose of the treatment should be to maximise the freedom of such a person. In other words, the decision to detain a person under DOLS authorisation must be the last option to be applied only if it is not possible to treat the person without detaining them. The second principle provides that there must be a focus on empowering families, carers, and other responsible people and increasing their involvement in the treatment of a person. In other words, removing children or adults that need safeguarding from the society of their family should be the last option to be applied only if best interests of such a person demands it. The third principle is that the respect and dignity for the patients and their families should always be considered first. The fourth principle is that the best practices must guide the process of DOLS authorisation. The fifth and final principle is that different social services should work in tandem with each other in the interest of efficiency and equity (Jackson, 2016, p. 324). In general, non-restrictiveness in the management of behavioural disturbance is considered to be a good practice (Department of Health, 2015).
Good practice in mental health social work involving families and children requires that the interest of the child should be of paramount consideration. The child should not be made to suffer any neglect or maltreatment. At the same time, there may be times when the social workers realise that the parents of a child are not co-operating in child protection assessments. In such situations, social workers will need to create a balance between the need to protect the best interest of the child and the need to ensure that the intervention that is conducted by them is not unnecessarily intrusive and oppressive. Although Section 43 of the Children Act 1989 allows the social workers to apply to courts for the child assessment order in such situations, best practice demands that the social workers apply a balancing rationale in assessing whether the situation demands the application for such an order (Walker, 2012). It is noteworthy that in child care and family settings social care, good practice emphasizes on the mental health and the emotional well being of the child and the social worker will have to balance the risk assessment criteria under the Children Act 1989 with the systems nature (Walker, 2012, p. 33).
In social work practice, an area of oppressive practice may be the drive to completing forms within specified guidelines and oppression may be provided by the pace of assessment being beyond what the family can cope with at the period in time (Walker, 2012, p. 122).
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