INTRODUCTION
"Little if anything that the helping professions do for their patients and clients takes place outside a context of the values, rules, opportunities and constraints of the contemporary social system. This is nowhere more evident than in the field of psychiatry, and any mental health worker who is unaware of it is
potentially dangerous."
Hudson, B. (1982), Social Work With Psychiatric Patients, London: Macmillan, p. 1.
In this essay I shall deal with the problematic nature of the social worker role, especially within the mental health field. I shall begin by outlining some theoretical background and then move on to examine some examples in detail which highlight particular areas of ethical dilemmas. I have chosen to use examples from work with an individual, a family and in the community. I tried with these examples to show how ethical considerations manifest both on a 'high' ideological level and on a day-to-day practical level.
THE ROLE OF SOCIAL WORKERS
Social workers are professionals who see it as their duty, and whom society expects, to intervene in other people's lives in order to help those who for one reason or another are, or have been, disadvantaged. At times social workers have to make decisions concerning lives which their clients do not agree to. In all cases, social workers have to grapple with ethical considerations as to whether their actions are indeed the best possible course for the client, as well as examine how they fit within their own perception of reality and their expected
obligations towards their agency and society at large.
"To what extent am I my brother's or sister's keeper?... How do we balance the freedom of the individual with the freedom of those with whom he or she interacts?"
Stevenson, O. (1989), 'Taken From Home', in S. Shardlow The
Changing Values of Social Work, London: Routledge, p. 157.
Are social workers agents of society, guardians of law and order, a soft version of the police forces? Or are they protectors of the weak and disadvantaged sections of society, representing the rights of those who are not able to do so themselves? Or are they agents of change, empowering individuals to make more of their lives? The answer to these questions is problematic and any attempt to formulate a 'correct' response would have to encompass both ends of the spectrum as well as that which takes place in between.
Which ever position individual social workers occupy along this spectrum they will encounter questions as to what are they doing and how they are doing it.
THE NATURE OF HELP
"Fundamental to this perspective is our belief that the adoption of a 'helpful' role is beset with difficulty."
Timms, N. and R. (1977), Perspectives in Social Work ,London: Routledge, p. 5.
The assumption that social work interventions can be termed as 'help' is one that must be looked at critically. First of all, it assumes that the client has a problem which the social worker is equipped to solve better then the client, and/or their relatives/friends themselves. This assumption highlights the danger of creating a problem where one did not exist simply to justify the intervention of the social worker in someone's life situation to justify the worker's/the agency's/society's moral position towards that individual.
A recent example for this has occurred in a community home in Nottinghamshire (where I worked last year), where two residents were interrupted during their love-making in the privacy of the man's bedroom during the day by a woman worker who ordered them to stop what they were doing and later told them off for doing
it. This couple, a man and a woman, were known to be in an intimate relationship with one another. It was clear to the worker that both were consenting adults from her long-standing acquaintance with both individuals. The query would not have arisen, in my opinion, was it not for that worker's views condemning sexual contact between men and women who suffer from mental health problems unless they were married.
INSTITUTIONALISATION - HIGH LEVEL INTERVENTIONS
There are of course many instances where the social worker can offer skills, information, support and access to resources which might be helpful to the client. But in offering these skills, it is important to be aware of the danger of disallowing the client from using and developing their own skills and resources to deal with their unique life situation.
This is highlighted in social work with people with enduring mental health problems who have been receiving psychiatric care for a number of years and have probably spent most of their adult life in one institution or the other. Even the process of closing down the big psychiatric hospitals which is in progress in Nottingham, still leaves more then 1,700 people who are dependent in one way of the other upon hospital or hospital-related services. This client group is one which has received very high levels of interventions in the past. They were seen to be needing so much help to cope with their lives as to be hospitalised for many years. Perceptions have been changing about what is appropriate level of help for psychiatric patients and this client group, generally speaking, is a prime example to the damage which excessive amounts of 'help', benevolent or
otherwise, can do in terms of self-motivation and independence.
The assumption behind such high levels of interventions is that once a person suffers from mental health problem they are helpless and need to be protected, and protected from. Whether this general impulse to protect is a benevolent one, ie to support vulnerable individuals, or a destructive one, ie to control and restrain individuals who don't 'fit in', is debatable and I would suspect that the answer lies somewhere in the middle.
THE CHOICE TO CARE
I am making this point, which might seems too obvious, in order to emphasis that these choices are made by society in order to maintain some kind of inherent ideal of how it should function. It is conceivable to talk of societies where the caring for disadvantaged individuals would be the domain of other individual
members or of no interest at all (the Nazi regime was an extreme example where needy individuals were 'cared for' by being , on the whole, eliminated)Cocks, G. (1985) Psychotherapy in The Third Reich, New York: Oxford University Press.
By delegating the caring responsibilities, those agents acquire certain levels of social power over other members of society, at least in some areas. The exercise of this power is an ethical and problematic process central to the work of social workers. Social workers should be therefore aware that they are operating within a normative value system which may often be in conflict both with their own and with their clients. Whose value system should they respect in cases of conflict? Are they representing society at large or the clients? Or should their own judgment be dominant?
The ethical issue of exercising this delegated caring responsibilities becomes more desperate if we accept that the individuals and groups receiving it are, as Rhodes put it, 'The desperate and the untreatable'Rhodes, M.L. (1986), Ethical Dilemmas in Social Work Practices, Boston: Routledge, p. 2.and are therefore less likely to be able to be advocates for themselves and for their own
different value system. They are more in danger of being swamped by the dominant value system which the worker imposes on them.
WHAT IS MENTAL HEALTH
The first difficulty that social workers in the mental health field face is recognising what is a mental health problem. Fisher et el explore the extent to which a person is in need of receiving attention from professional carers by defining the term "mentally ill" as those
"where impaired social functioning was accompanied by impaired mental state and where the impairment of social functioning could not be wholly attributed to circumstances other then impaired mental state". Fisher, M. Newton C. and Sainsbury E. (1984),Mental Health Social Work Observed, London: George Allen, p. 4.
They acknowledge that their definition of mental illness could be contentious and is formulated for the purpose of their particular study and is not comprehensive nor exhaustive. They show how certain cases would not be 'worthy' of professional attention unless certain conditions occur.
The issue of what is mental health has been discussed widely by many professionals, most of which were psychologists or sociologists. People like Szasz Szasz, T. (1961), The Myth of Mental Illness, New York: Harper and Row.
c, Goffman Goffman, E. (1968), Asylums, Harmondsworth: Penguin.
Sedgwick Sedgwick, P. (1981), Psycho-Politics, London: Pluto Press.
and Laing Laing, R. (1960), The Divided Self, London: Tavistock.
amongst others, have all debated whether mental health is indeed a medical condition or a socially constructed one. This essay does not allow me to go into any detail of their work. Suffice to say that their arguments contributed to questioning of psychiatric services all over the world, hopefully leading practitioners to develop approaches which are integrative of both models.
CODE OF ETHICS
To ensure that the caring professionals do provide a service which is helpful and appropriate, a body of ethical guidelines is laid down. The BASW Code of Ethics declares its objective to be 'the protection of clients'.BASW (1985), A Code of Ethics For Social Work, in D. Watson (ed.) A Code of Ethics For Social Work, London: Routledge, p. 1.
"The importance of a code of ethics lies in the provision of a standard against which the actions of a profession can be judged, and puts constraints both on the power of the established ideology to dominate and control the individual and on the inclination of the unrestrained individual to do as he pleases." Wilkes, R.(1985), 'Social Work: What kind of Profession? in D. Watson (Ed.) A code of ethics for Social Work, London: Routlegde, p. 45.
Rhodes takes the view that every decision a social worker makes inevitably involves ethical considerations. She groups these into five main groups and asserts that in each of these an ethical consideration arises as the result of a conflict of interest between any two or more of these groups: the client, their
family, the social worker, their agency and the society in which they all live. Each of these holds a value system and set of needs which may be in contradiction with one another.
COMPULSORY ADMISSIONS TO HOSPITAL
The highest level of intervention which a social worker in the mental health field can deploy is through their statutory obligations under the 1983 Mental Health Act. By applying for compulsory admission to hospital, the Approved Social Worker (AS) is participating in a process in which the individual is
deprived of many of their rights. The law states quite clearly that this is to be done in order to protect the individual from themselves or to protect others from the actions of the individual who is deemed to be unable to take responsibility for their own actions.
What are we to make of compulsory admission? Are we to take Szasz's view who, quoting Alexander Solzhenitsyn who condemned the admission of Refusinks to mental institution as a 'spiritual murder', says
"If the compulsory admission to psychiatric hospital of 'healthy people' is so abhorrent, what then makes it medically and morally justifiable when it is imposed on 'sick people'"?
Olsen, R.M. (1984), 'Historical Analysis' in M.R. Olsen (Ed.), Social Work and Mental Health, London: Tavistock, p. 18.
I shall now move on to discuss in some depth the case of M. in whose compulsory admission to hospital I was present.
ŠM. a 38 years old Afro-Caribbean woman, has been brought to the awareness of a mental health team through reports from one of the hostels for the homeless in Nottingham. M. made allegations against one of the workers (English male) in the hostel of being sexually interfered with by him. Her allegations were investigated by the police who decided to make a compulsory admission under section 136 of the 1983 Mental Health Act and removed M. to 'a place of safety', a police station. Several hours later she was seen by the consultant and the ASW.
The white male Scottish consultant recommended that M. will be admitted to Hospital under Section 2 of the 1983 Mental Health Act, after consulting briefly with the police surgeon. The white female ASW agreed and made the application. During the interview, where all three professionals, as well as two PC's and myself were present, the ASW made several attempts to communicate with
M. but was told by M. not to talk to her.
M. was unhappy about being held in a police station. She said she didn't want to go to hospital and didn't feel that she was in any need of help. She qualified her allegations of rape after being questioned by the consultant and admitted that she had felt interfered with mentally in a sexual way but that no physical contact with a anyone was made. She elaborated about her psychic perceptions and felt that harm was being done to her by people who were close to her, through the use of 'black magic'. At one point, she turned towards me and accused me of transmitting thoughts into her mind.
What are the ethical considerations the ASW should have been aware of in this case? Several points become clear if we review the sequence of events.
INTER-AGENCY ETHICAL CONFLICT
Both psychiatrist and ASW were from the same sector team and had a good working relationship. They knew each other's method of work and assessment and have got on well in the past. Does that work in favour of the client? According to the 1983 Mental Health Act, the consultant should only make a psychiatric recommendation to the ASW who is then in position decide whether the client
needs hospitalisation. How easy would it have been for the ASW to challenge the consultant's recommendation, considering the power relationship between them (the consultant being the clinical head of the team)?
A different perspective is provided by the Nottingham branch of NALGO which has stipulated recently that in light of the shortage of ASW's in this area, ASW's should not undertake duty work in areas which are not familiar to them. This position is justified by the importance of having a good working knowledge of available community resources in order to offer alternatives to hospitalisation.
If ASW's work with psychiatrists whom they work with daily, are they in danger of rubber stamping their recommendations? Or are they likely to feel deskilled if they work in geographical areas with which they are not familiar?
ASW's are coming under increased pressure from G.P.'s and psychiatric to be available for immediate assessment. Recently, G.P.'s in Northumberland have threatened that they will stop calling out ASW's as their response was 'slow', complaining that it took ASW's up to five hours to come out for an assessment. Millar, B. (1992).
The G.P's intend to use the authority given under the Act to the nearest relative as the person who can make the application for compulsory admission. The implication is that clients would be deprived of a possible advocate. Compulsory admission could then become a device by which families remove a member without the full investigation into the circumstances being carried out by a social worker.
SPEED VS. THOROUGHNESS
All three professionals interviewed M. at the same time. Has that allowed any of them to reach an independent opinion about M.'s condition? Would it have better for three separate interviews to take place, as is the letter of the law? Would that have caused the distressed client further suffering as she would have had to undergo three interviews rather then one?
M.'s liberty was already curtailed as she was under Section 136.
In a sense, she had to prove to the psychiatrist that that decision was either mistaken or no longer appropriate. Is it reasonable to expect a woman who was under considerable emotional stress due to her life circumstances, to be able to preform in such a way in a police station?
Was it the responsibility of the ASW to make sure that M.'s right to be assessed independently was observed?
ADVOCACY VS.STATUTORY OBLIGATIONS
" The approved Social Worker carries the responsibility for looking after the liberty of an individual." Millar, B. (1992), 'Cross Section', in Social Work Today, 30th January, 1992, p. 9.
according to BASW's Assistant Secretary. From that it seems that the advocacy
responsibilities of the social worker are at least as important as the statutory ones she carried.
As M. refused to communicate with the ASW, it was very hard for her to carry those advocacy duties. She failed to make contact with M. who clearly did not want her to be her advocate. The ASW was faced with a situation where her advocacy was not wanted by the person for whose benefit it was intended. She was neutralised by M.'s hostility towards her.
From that point on, she had to carry on as an advocate relying on her assumptions and perceptions on what would be M.'s best interests without being able to check it out with M.
VALUE SYSTEMS IN CONFLICT
Most of what was seen as M.'s disturbed behaviour was due to her belief in occult forces. She felt persecuted by forces which she admitted were not visible. She was conscious that what she was complaining about was not evident to other people. And yet, she was clearly disturbed by it. She held a value system which was not shared by anyone in the room. Her statements about the occult were taken as symptoms of her illness, rather then as religious believes, which she claimed they were.
The value system she held as a black woman who believed in the power of magic was very alien to those held by the white people in the room. Nobody was therefore able to take a position alongside her and their stigmatising interpretation of her behaviour was increasing her sense of isolation and despair, causing her verbal behaviour to become more and more hostile.
What position does this cultural alienation place the ASW in? The ASW was facing the dilemma of having to make quick assessment as to whether the symptoms which M. was exhibiting (feeling invaded by unseen forces, connecting to her aura etc) were indeed psychiatric 'symptoms' or genuine religious beliefs.
REPRESENTING AN INADEQUATE SYSTEM
In Nottingham, there are no alternatives to hospitalisation in cases of individuals whose mental state requires them to be removed form a situation which is potentially dangerous to themselves or to others. M.'s social situation was indeed very unstable. She had no permanent address and had been asked to
leave by a couple of hostels in the city, no relatives of hers were known at that point, and the ASW feared that if she was allowed to retain her liberty, she would sooner or later engage in a violent conflict, although there have been no signs that that has happened in the past.
The compulsory admission was obviously against M.'s own wishes. The ASW and psychiatrist were saying that they knew what was best for her and could not at that time take much note of what M. wanted for herself. This was justified by the fact that she was 'ill'. Her illness was viewed as a total and absolute factor which justified depriving her from her rights of self-determination. In other words, the need to care for her was perceived as greater then her rights of self-determination.
The dilemma which the ASW faced was clear. She acted against the wishes of the client in protection of her perceived need. She had to assume that her professional judgment of the situation was accurate and that M. really needed to be in hospital. It was a difficult to assess later whether it was justified. M.'s behaviour continued to be disturbed in the hospital and she complained about being forced to remain there and to receive medications against her will. Nevertheless, she refused to have contact with the ASW who came to see her on a couple of occasions within a week.
Morally, the situation remains unresolved. M.'s perceived behaviour 'improved' to the extent that she was referred to day care while in hospital with view to her discharge. She seemed to be accepting that she needed the kind of help she received but was doing so reluctantly. Whether that was because she really needed that treatment and benefited from it or because she simply adjusted to the social and cultural expectation placed upon her remains an open question. What is clear though is that in this case the social worker acted as an agent of society dealing with one citizen whose behaviour was challenging to the social
worker's values and the values of the dominant culture.
AUTONOMY VS. SAFETY
The move from care in the hospital to care in the community places further responsibility upon social workers. Clients living in the community do not have the high level of supervision which they received in hospital. While not a bad thing in itself, it does mean that clients who may be neglecting their own care, are less likely to be noticed at the same speed as they would have done in the hospital.
The social worker could be faced with the dilemma of having to decide whether a person right to self-determination is greater then society's proclaimed regard towards the protection of vulnerable individuals.
Bates and Pidgeon outline a case where B., a 40 year old English man who had a long psychiatric history of obsessional personality behaviour had locked himself into his newly acquired flat and refused to open the door for six weeks.
"Was he legitimately exercising his right to be alone in his own house, celebrating the acquisition of a front door key? Or, alternatively, was he locked into a self-destructive state of mind - powerless and helpless? How was the balance between his rights to autonomy and his vulnerability to be assessed?" Pidgeon J. and Bates, P. (1990), 'Intervention: Protection or
Control?' in Social Work Today, 11.1.90, pp 18-19.
The social workers had recourse to various statutory solutions such as Section 1375 of the 1983 Mental Health Act allowing to police to forcibly gain access to make an assessment, or Section 47 of the 1948 National Assistance Act and its 1951 Amendment allowing compulsory removal if lives were at risk. A third option
was to use the Public Health Act which would have allowed the environmental health department to gain access to the flat in order to clean it. The social workers were aware that using the later would have both violated B.'s rights and been very costly. Was that justified?
They continued to explore non-compulsory measures and B. was finally persuaded to leave his flat and be admitted to hospital after another worker spent an hour shouting through his letter box. Later, B. admitted that he wished that they acted sooner and got the police to break down his door and got him out...
MEN NOT CARING ENOUGH?
In conversation with one of the two workers involved in this case, I learnt about a discussion they had about what should be done. The male worker was arguing for holding back for as long as possible, careful to respect the client's autonomy, while the woman worker was arguing for an earlier intervention, even if it meant infringing upon the client's liberty. She was concerned that the client was acting out some delusion and is incapable of
seeking help although needing it.
According to several writers, this gender is significant. Male and female workers respond differently to ethical dilemmas concerning the conflict between the rights of the individuals versus their safety. According to Gilligan, this difference is entrenched in learnt gender stereotyping. Stevenson quotes Gilligan as saying:
" The moral imperative that emerges repeatedly in the woman's interviews is an injunction to care, a responsibility to discern and alleviate 'the real and recognisable trouble' of this world. For the men Kohlberg studied, the moral imperative appeared rather as an injunction to respect the rights of others and thus protect from interference the right to life and self fulfilment."Stevenson, O. (1989), p. 189.
AFFLICTING THE COMFORTABLE?
N. is a 58 years old English man who took early retirement 13 years ago as a result of increasing conflicts with his boss in the factory where he worked as a quality inspector. Since then, he suffered from bouts of depression and obsessional behaviour, often creating great deal of marital tension between him and his English wife and occasionally hitting his teenage sons. He was admitted to hospital twice, reluctantly but as an informal patient, where he had medical treatment including two courses of E.C.T. He had been able to return home every time where his wife, who by now was running a busy local shop, took over his care. They had little support over the years from social services as the level of care he was receiving at home seemed adequate. His wife received no support at all and had to rely on other members of the family for it. Over the last 18 months, N.'s condition is seen as a stable. He visits two day care centre but in neither is he doing very much. Both him and his wife admit that he comes to day care just in order to avoide sitting at home, doing nothing and being a burden on his busy wife. He has no social worker working with him, and his only contact with psychiatric services, apart from the day care staff, is the six-monthly visit to the male Asian psychiatrist. The psychiatrist's opinion is that N. is
better and needs no increase in therapeutic intervention.
WASTING RESOURCES?
As a student in one of the day centre, I was asked to evaluate the situation. I was asked to consider the financial cost of keeping N. occupied five days a week in two day centres where he seems to be disinterested in any activities. The question was asked whether his placement is justified in light of his stable
home condition and improving psychiatric condition.
Several interviews with N. and a couple of home visits established that N. seeming apathy is a defence to his deep sense of confusion about his identity. The crisis which he underwent after his early retirement had never been acknowledged by any of the workers who had seen him in the past. He was hiding deep feelings of anger towards the system. These feelings would surface in his behaviour towards his wife, whom he saw as having taken over from him as the bread winner. This has clashed strongly with his patriarchal values of gender roles. He was not able, nor willing, to make the adjustment that was necessary for the role reversal which had taken place.
I was faced with the dilemma of a seemingly stable, but stagnant, situation where N. is likely to continue to waste already-stretched day care facilities as well burden his wife as long as the core issue surrounding his breakdown and his relationship with her were not explored through psychotherapy and marriage
counselling.
N. himself was reluctant to engage in any depth exploration of the core issues. He exhibited a high level of mistrust of social workers and felt let down by them. His wife was very enthusiastic about the possibility. Both felt that N.'s mistrust is an obstacle that could be overcome, if they received adequate
support.
MAKING A CRISIS OUT OF A DRAMA
Was it justified to increase the level of intervention in this case to challenge N. on his passive-aggressive behaviour towards his family and the day care? Such an intervention might lead to a psychiatric crisis which would be seen as regressive. It would not have been supported by the psychiatrist who saw such an
increase as inappropriate as well as a waste of resources, considering N.'s age and the level of informal care he enjoys. The psychiatrist would not see that the stress placed upon N.'s wife was an issue concerning the psychiatric services.
The outcome was a compromise. N.'s English male key worker in one of the day care centres took it upon himself to began an intensive counselling contract with N. to explore issues of domestic behaviour and identity with him. N.'s wife was in infrequent private counselling contract which she was encouraged to continue. Both have been encouraged to make a demand for more active social work intervention if and when the need arose.
THE FEAR OF NEGLIGENCE
The importance of not allowing a seemingly stable situation prevent an active intervention was made clear to me upon reading in the newspaper about a woman who had stabbed her husband after being provoked by him, following ten years of frequent battering by him. She was cleared by a Court of Appeal who recognised her predicament. The detail that caught my eye in this instance was that the husband suffered from deep depression following a long illness and had been a receiver of psychiatric services during those ten years. Mills, H. (1992), 'Woman who killed violent husband freed', in The Independent, 3rd April, 1992, p. 4. After reading this, I had to ask myself whether it was possible that N., who had been physically violent towards his wife during periods when he was depressed, would drive her to an act of violence against himself as a result of insufficient social work intervention. Although the cases were quite different and I didn't feel that it was appropriate to draw too many comparisons between the two, I was nevertheless confronted with the dilemma of having to check whether I have done enough for the couple.
My approach in this case was psychodynamic and humanistic. I believed that N. and his family would benefit from an intervention which would allow and support them to explore the tensions in the family. This assumption was based on my view of human potential that sees crisis as a point for further development, rather then an occasion that needs to be pushed away and simply contained. I was also aware that pushing such an intervention would not be through consent of both N. and his wife and that I was in danger of creating a crisis which may have left
them both in an unsupported situation. I had to control my intervention accordingly.
I also had to ask myself who was the client in this situation. Was it N., who pretended that there was no problem? His wife who was expressing the need? The family as a whole? I was conscious that the cultural assumptions within this society allow such a situation to carry on unchallenged, N.'s wife would not be the first woman to support a dependent male without any support herself. Was I to challenge this particular instance of gender inequality, knowing that the psychiatric services on the whole do not practice the approach I was advocating?
CONCLUSION
In this essay I tried to show the ethical complexity of some social work interventions. The term social work itself and the level of intervention each worker feels justified in employing are not free of value judgment.
Social workers in the mental health field are no longer specialised workers. Their generic training often puts them in a less informed position from other mental health workers such as psychiatrists and community psychiatric nurses. They have to work in teams where their particular model of mental health may differ radically from the rest of the workers. At the same time, they are expected to contribute significantly in a time when more of the care for psychiatric patients in moving into the community.
I would consider that good practice in this area would have to consist of careful consideration of the values which are loaded into the relationship between social workers and their agency, social workers and the clients and with the values that social workers bring into their own work.
Written in 1992
