Mental Health Social Work: Perspectives on Risk, Regulation, and Therapeutic Interventions

As we write this editorial, the Australian Government has launched a major reform of the Australian mental health system. According to Professor Ian Hickie, one of the National Mental Health Commissioners, these reforms constitute a “radical departure” from a model that funds individual practitioners “to do what they're trained to do” to one that is funded on the basis of the needs of people with mental health problems (Australian Broadcasting Commission (ABC), 2015). Media releases tell us that services in the redesigned system are to be integrated and well-coordinated, locally situated, and responsive to the people using them (ABC, 2015). Yet, these ideals of individualised care provision are not new. Mental health policy development in Australia has appeared very progressive since deinstitutionalisation with its focus on the human rights and social inclusion of people with mental disorders, and an emphasis on the “active” participation of service users and carers in treatment decisions, “recovery,” and service planning (Commonwealth of Australia, 2009). However, the translation of these principles into practice has been contentious (Sawyer, 2011). Since deinstitutionalisation, national surveys have reported significant areas of unmet need and user and carer dissatisfaction with services (Mental Health Commission, 2012). The new reforms aim to address these issues, to prevent people “falling through the cracks,” by providing services in new ways.

Mental health social workers often occupy complex and contradictory spaces that are shaped by a range of legal, policy, and societal drivers. Although there are broad, commonly understood definitions of mental health social work in Australasia, the United Kingdom, and North America, practitioners often need to adjust their interventions to take account of the particularities of local and national politics. The articles presented in this Special Issue illuminate a range of challenges and dilemmas in contemporary mental health practice in the broader context of intersections between the imperatives of recovery-focused practices and the risk and regulatory regimes that shape and constrain these practices. The issue opens with Mike Titterton and Helen Smart's paper on the challenges confronting mental health social work in Eastern Europe and Central Asia, particularly the increased burdens of mental illness experienced by people as a consequence of political and social upheaval, together with the very recent development of community care in these areas. Titterton and Smart emphasise the need for culturally-specific models of risk and resilience in these very distinctive forms of “risk society” and for “narratives of positive risk-taking and resilience.” The subsequent papers concentrate on the Australian context and cover the themes of legal/involuntary contexts of care, diagnosis and therapeutic treatments, and community-based practice.

Mandated roles associated with mental health law in the UK and Australia have been subject to considerable debate. For example, whereas a prescribed set of functions has been reserved for mental health social workers in Scotland, Wales, and Northern Ireland, a generic role, that of the Approved Mental Health Professional is now in place in England (Morriss, 2015). In this respect the English system mirrors the Australian one, where a range of professions is involved in the delivery of Community Orders (Campbell, Brophy, Healy, & O'Brien, 2006). Of course mental health social workers occupy many other, nonmandated spaces that are no less challenging. This is often where uncertainty prevails because of disputed claims to knowledge about mental health best practice, questions about who is best positioned to deliver these practices, and whose interests are privileged and disadvantaged through existing and emergent practice models. It is amidst this backdrop that Karpetis provides an example of mental health social work attempting to build its therapeutic evidence base, in this instance by deploying the concept of “reframing” in psychodynamic-based practice.

Sawyer and Green (2013) have argued that community-based practitioners must navigate a range of, often contradictory, responsibilities and regulatory pressures, including policy and service imperatives of individualised care, risk management procedures, check-lists, and other reporting requirements. This point is well illustrated by Shevellar and Barringham, who examine how mental health interventions, particularly those enacted in community settings, raise complex ethical and moral dilemmas that create particular vulnerabilities for both mental health service users and practitioners. Stanford (2010) has demonstrated the need for social workers to “speak back” to the “fear” that such dilemmas ignite through moral risk-taking, a stance which Shevellar and Barringham encourage through having “risky conversations” about boundary issues in community mental health practice.

Despite optimism about the use of technical approaches to risk management, often shared with other mental health professionals, social workers in this field tend to struggle to find a balance between principles of parens patriae and service user autonomy. Organisational commitment to actuarial approaches in measuring risk may assuage government and public concerns about relationships between mental health, dangerousness, and vulnerability, but the evidence suggests that, all too often, professionals make too many false positives and false negatives using such approaches to measuring risk (Large, Ryan, Callaghan, Paton, & Singh, 2014). Such discourses often mask hidden costs, not just in terms of investment in the technocracy of risk measurement, but perhaps more importantly in risk to the relationships between mental health professionals and service users. Lemon, Stanford and Sawyer's article on suicide risk assessments undertaken in nongovernment mental health services found that lack of trust could be a barrier to undertaking these risk assessments. This suggests the need to understand the risks of mental health practice in more nuanced terms than is currently presented in debates about how best to assess suicidality.

Pressures from above (government and policy makers) are matched by pressures from below (service users and their families). Given the marginalised circumstances of many mental health service users there is an understandable expectation that social workers attend to issues of social justice and social change, a point that is strongly argued by Ferguson in her article on working with people diagnosed with Borderline Personality Disorder. Aspects of more inclusive practices in working with service users, their families and social networks are partially captured in recovery approaches that are being mainstreamed in mental health services across many jurisdictions around the world. O'Donahoo and Simmonds discuss the challenges of recovery approaches in forensic mental health services where issues of risk loom large. However, as Davidson, Brophy and Campbell point out in their article, the ethos and practices of recovery have the potential to help reshape how to engage with and respond to risk. Recovery approaches to risk emphasise: the need to promote positive aspects of risk-taking; to find a balance between risk and recovery thinking that is strengths-focused; and the importance of clarifying how to work in partnership with people when risks to self and others are apparent. However, a recent Australian study found that, despite overlaps between principles of recovery and social work practice, to date social work academics and practitioners have made few contributions to the evidence base and theory development in this area (Hyde, Bowles, & Pawar, 2013). Meanwhile there is much work to be done in terms of elaborating notions of recovery in everyday practice. If these notions of recovery are to have resonance, especially in the context of resolving tensions between risk and recovery, relationships of power should be revealed to allow the building of meaningful alliances between mental health social workers and service users.

As academic researchers with social work practice experience in mental health, we have been alarmed at how the subjective experiences of harm and loss are rendered redundant and inconsequential within neoliberal welfare regimes. Yet, as the articles in this issue illustrate, researchers and practitioners are striving to find spaces they can occupy to construct practices that enhance the lives of service users. Between them, the articles in this Special Issue identify the need to: acknowledge risk management requirements, but to not apply them unilaterally without giving due thought to other relevant contextual issues; prioritise relationship building over procedural interventions that are risk focused; and focus on people's “recovery,” their autonomy, decision-making, and opportunities for social inclusion. Risk is a necessary aspect of recovery and learning; some “mistakes” will inevitably occur, but we argue that establishing good “rapport” can be risk-reducing in itself. At the core of these practices should be an awareness of the contested nature of “risk disputes” that are a feature of mental health social work, and the significance of the way that professional discourses do not just shape our understanding of the social work role but also sometimes adversely affect service users’ lives. Hence it is important that perspectives about mental illness and disorder are interrogated and interventions designed in tandem with service users that take into account their views and needs.