Psychiatric Social Work

JIGJIGA University
College of Social Sciences
School of Social Work
Ins. Mohamoud Mohamed
May. 2021
 Brainstorm
• Why do some people seem to be always
cheerful, whereas others are often sad?
• What is mental health? What is mental
illness?
• How do you know them when you see them?
• What do you think are risks and protective
factors for mental health problems or illness?
• What might you do as a social work to reduce
the person’s risks and enhance their
protective factors?
 Mental Health
• Mental health is a state of well-being in which an individual
 realizes his or her own abilities,
 can cope with the normal stresses of life,
 can work productively and is able to make a
contribution to his or her community.

The foundation for individual well-being and the

effective functioning of a community

An integral part of health; there is no health without

mental health
World Health Organization (WHO)
 Mental Health
• A state of successful performance of mental
function, resulting in productive activities,
fulfilling relationships with other people, and
the ability to adapt to change and to cope with
adversity.

• Mental health is indispensable to personal well-

being, family and interpersonal relationships,
and contribution to community or society.
(U. S. Surgeon General’s Report on Mental Health)
 Mental illness
• The term that refers collectively to all
diagnosable mental disorders.

• Mental disorders are health conditions that are

characterized by alterations in thinking, mood,
or behavior (or some combination thereof)
associated with distress and/or impaired
functioning.
 Mental Health Problems
• Signs and symptoms of insufficient intensity or
duration to meet the criteria for any mental
disorder.
• Almost everyone has experienced mental
health problems in which the distress one feels
matches some of the signs and symptoms of
mental disorders.
• Mental health problems may warrant active
efforts in health promotion, prevention, and
treatment. Bereavement symptoms in older
adults offer a case in point.
• Do mental disorders represent disease entities
or are mental disorders related to social
context, which affects the rates of generalized
distress, abnormal behavior, and social
deviance?
• Traditionally, sociologists have viewed mental
disorder as deviance from institutional
expectations – often referred to as social
reaction theory
MD
 Approaches to differentiate MH &MI
1. Biomedical approach
2. MI results from biological factors such as our genes and
neuro-chemicals.
3. view health and illness as opposites, as forming a
dichotomy such that one is either sick or well and fit
into a specific disease category once specific symptoms
4. It bases on Diagnostic and Statistical Manual of Mental
Disorders (DSM) to determine levels of mental disorder
in the general population.
5. The current DSM identifies more than 400 distinct
mental disorders. These disorders are assumed to be
discrete (i.e., they do not overlap with one another).
2. Mental Health Continuum
• Viewing mental health and illness in terms of a continuum,
with health and illness at opposite ends of the poles and most
of us falling somewhere in between.
• Varying degrees of healthy and sick, normal and abnormal.
• It assesses not only the problem but also its severity and
frequency along a continuum.
• Familial conditions, social causes, unknown conditions, being
a part of certain social group/in certain historic period

Healthy Reacting Injured Ill

 Risks
• Probability or likelihood of a future event given
conditions
• OR a group of people with a similar characteristic is
more likely than others in the population to develop a
problem
• Community, school, family, peer group, and
individual factors
 Risk factors for mental illness
Although the precise cause of mental illness isn't
known, certain factors may increase the risk of
developing mental health problems, including:

• Having a biological relative, such as a parent or

sibling, with a mental illness

• Social isolation or social exclusion (stigma) -

having few friends or few healthy relationships
 Cont’d

• The incidence or the impact of negative life events

and experiences (stress)
– A loved one's death or a divorce
– Long-term illness or disability
– Abuse or neglect as a child
– Abusive relationships as an adult

• The impact of deprivation, i.e. economic

disadvantage, low educational attainment, quality of
living environment
 Protective factors
Individual
• Feeling safe
• Self-determination
• Problem solving skills
• Feeling in control
• Confiding relationships
• Access to social networks
• Meaningful activity and roles
• Creativity
• Spirituality
 Protective factors
Community
• Stable/supportive environment
• Participation and influence: local democracy
• Opportunities for lifelong learning
• Networks, supports and resources
• Tolerance and trust
• Amenities and services
• Hopefulness
• Opportunity for arts and creative activities
• Access to faith groups
 Protective Factors
Societal/Structural
• Socio-economic conditions
• Participation and influence
• Tolerance and trust; Absence of discrimination
• Respect for diversity
• Economic stability
• Absence of marked social and economic
inequalities
 Assessment
Definition
“Cornerstone of effective treatment and is an ongoing process
that is interwoven with treatment” (Mueser et al., 2003, p. 49)

“Process of systematically collecting, organizing, and

interpreting data related to a clients functioning in order
to determine the need for treatment, as well as treatment
goals and intervention plan.” (Roberts & Yeager, 2004, p.
972)

“Thoughtful application of generalizable knowledge in the

service of understanding a clients unique experiences”
(O’Hare, 2005, p. 27)
 Why Do we Assess?
• Simply, to understand the health and
mental health needs of individuals:
 Direct assessment—interviewing client using
structured and unstructured formats.
 Indirect assessment—chart reviews; laboratory
tests; information from family, friends, and/or
significant others; and clinician-based reports.
 Cont’d
It could be applied for medical and
community-based mental health services. So in
both cases, we need to employ current and
appropriate assessment approach.

Currently, Evidence-Based Assessment (EBA)

approach is highly recommended for medical
and community-based mental health
interventions in multicultural settings.
 What is Evidence Based
Assessment?
• It is an assessment approach that is
familiar/conversant with current scientific
knowledge of human behavior.
• It focuses on contextualized, holistic and
functional explication/explanation of human
behaviors = culturally competent assessment.
 Characteristics of Culturally
Competent Assessments
Generally, culturally competent assessment and
diagnosis,
• Respects the client’s background.
• Employs problem-specific knowledge.
• Holistically assess clients’ well-being (e.g.,
psychological, social, health, and behavioral).
• Assesses the functionality of cognitive,
behavioral, physiological, interpersonal, and
social factors, and explicates their interaction
over time and across the person’s situation.
 Cont’d
• Integrates the client’s unique understanding of
the problem.
• Uses multiple data collection methods
(qualitative and quantitative) and gather data
from multiple sources.
• Focus on practical areas of change.
• Monitoring and evaluation (i.e., to enhance the
reliability and validity of the assessment).
 Multicultural Bio-psychosocial
Assessment Guide
• Corresponds with DSM-IV axes (i.e., axes I,
II, III and V).
• Sequentially but flexibly arranged in the way
the assessment process facilitates discussion
 Bio-Psycho-Social and Spiritual
• Bio (biology) refers to the physical and
medical aspects of ourselves
• Psycho (psychology) refers to the emotional
aspects of our lives
• Social refers to socio-cultural, socio-political,
and socio-economic issues
• Spiritual refers to the way people find
meaning in their lives
1. Establish Cultural Identity
– Ethnicity
– Preferred language
– Clan/tribe/faith
– Family/community identity?
– Citizenship issues
2. Cultural Explanation of Illness/Symptoms
– Use of folk/typical words to describe/explain
illness
– Meaning and explanation of client symptoms
– Context of “illness” (location, frequency, situation)
– Types of help sought
3. Cultural Factors: Level of Functioning and
Psychosocial Environment
Psychosocial & environmental problems or perceived
stressors

• Support • Legal/criminal issues

• Education • Violence/trauma
• Occupation • Access to health care
• Housing • Stigma/discrimination
• Spirituality /racism
• Others
Level of Interpersonal Functioning: Personality
Disorders and mental retardation(I and II
– Interpersonal stress or tension with
employers/family/neighbors/friends

Level of Functioning: Global Assessment of

Functioning(v
– Degree of acculturation, biculturalism, assimilation
– Level of family/community stability
4. Cultural Factors Related to Psychological
Health Status: Clinical Disorders
– Symptoms linked to traumatic event like torture,
escape, immigration etc.
– Role of substances and rituals
– History of unique behaviors/cognitions as
interpreted/reported via self, family, and
community
5. Cultural Elements of Service Provider and
Client Relationship
– Gender issues
– Age issues
– Social status
– Race/ethnicity
– Language
– Credibility within ethnic community
– Any other issues to influence how symptoms
would be expressed or how diagnosis/treatment
would be affected.
 Overall Cultural Assessment:
Diagnosis and Care
– How can cultural considerations influence
diagnosis and care?
– What is the potential for compliance to the health
care plan?
– Has the family and/or significant community
members been consulted?
 Basic Cultural Competence
• Acceptance and respect for difference
• Careful attention to dynamics of difference
• Continuous expansion of cultural
knowledge and difference
Competency Based Assessment
Competency refers to the knowledge, values
and skills to help generate meaningful changes
in the clients life.
 Cont’d
The framework for competency based assessment
involves:
1.Compassions- to have an emotional
understanding and empathetic appreciation of the
experience of clients and families.
The social worker strives to understand the client’s
unique history and circumstances, past problems,
strength and dilemmas.
 Cont’d
2. Commitment- preventing burn out and
remaining committed to mental health practices.

3. Collaboration- having the ability to relate to

mental health clients, families, and other
providers in a way that conveys respect and
appreciation for their legitimacy and perspective.
 Cont’d
4. Competency- having current knowledge
about mental, emotional, and behavioral
disorders. Also updating information on
psychopharmacology, use of effective
interventions, and professional confidence to
direct the helping process.
5. Creativity- using professional imagination
and integrate somehow art in the helping
process.
 Mental Health Treatment

“Why Deviant Behaviors are labeled as

‘ILLNESS’ and managed MEDICALLY?”
 Prologue

The case of Catherine Benincasa(1)

“Catherine Benincasa was a woman
of 26….Refused to eat nothing…
for it causes her to vomit… after a
while she simply refused and
starved to death”…
 Cont’d
Catherine was a saint and she lived during
1373 in Italy.
The fact that she refused to eat was
perceived as a ‘Symbol of her holiness’
[Serious Commitment to Fasting] among
her superior religious leaders.
Those people around her never considered
her as ill or disordered and she never got
the chance to be diagnosed as Anorexic.
 Diagnosis of Anorexia Nervosa
1. The Person refuses to eat enough food to
maintain the minimum normal weight of her
age and height and her body weight is 85
percent less of what is expected
2. The person has intense fear of gaining weight
or becoming fat even though far underweight
3. The Person denies the seriousness of low
under weight or has a distorted sense of the
body; for example, believing she is too fat
even though she is underweight
4. The person misses at least three consecutive
menstrual periods because of her low weight
(Diagnostic and Statistical Manual of Mental
Disorder,1994).
The Case of John Hinckley(2)
 John Hinckley was a man who attempted to
assassinate Ronald Reagan in 1981.
 Hinckley was found to be Mentally Ill and
committed to Mental hospital than being
sent to jail or incarceration.
 The crime he committed was a consequence
of his mental illness- an action which he
could not control.
Simply put, his “Crime” was taken as an “Illness”.
So What’s the Lesson?
Today Catherine Benincasa would have been
diagnosed for Anorexic in 1373 and John Hinckley
would have been labeled as a criminal and would
have also been murdered.
This shows us from the time of Catherine to
Hinckley, the way society see as “Deviance
behavior” have been altered.
 Cont’d
• Nowadays, Mental Illness which has used to
be believed as demonic possession has been
diagnosed and treated using Bio-Medical
Model.
• People used to cut the skull of a person in
order to help the sprit escape the mentally ill
person.
Trepanation – drilling a hole through skull to
allow evil spirits to escape.
 Controlling Deviant Behavior
Deviant behavior can be defined as behavior that
violates norms and role expectations, violation
that has disapproved.

 Labeling theorists specify that behavior is deviant

when other people react to and label the behavior
as such.

However the definition of specific deviant

behavior changes over time.
 Why Do We Control Deviant
Behaviors?
 Violation of behavioral standards are usually met
with attempts to control them for two main
reasons:-
1. For the Stability of Social System
2. Maintenance of position of social
advantage and dominance

 Deviance behavior is controlled by informal social

sanctions or formally by specific social institutions
Formal institutions that control deviant behavior:
The medical system
Criminal justice system (state)
Religious institution

•Social system operate successfully only when everyone in

that system does their job, Illness is regarded as a form of
deviance.
•The social system works smoothly when each of its members
fulfill their roles. E.g. As parent, spouse, friend, employee.
 Cont’d
• Since roles are collections of norms, failure to fulfill
this roles fits the definition of deviance. And one of
the way in which individuals fail to fulfill their roles is
when they lose the capacity to perform normative
activities or in other words when they became sick.
• Illness can be conceived as a form of deviance
because it interferes with ones ability to fulfill role
expectations.
• As a result, the medical system has become a means
for social control of deviance.
 Cont’d
• Based on where responsibility lies, society tried to
control deviance using a therapeutic or punishment
approach.
• Illness is morally neutral and brings more
compassionate use of therapy and treatment.
• Therefore, unlike criminal deviants, individuals are
not held responsible for the deviance related with
illness.
• Punishment and treatment are not always
completely opposite because Szasz (1994) argues,
treatment can involve punishment.
 Cont’d
• According to Szasz, Treatment in a mental hospital,
consists the coercive control of the treated person’s
liberty, property and life.
• There has been an obvious shift in the involvement
of formal institutions in cases of social control.
• With regard to mental illness the shift that occurred
involve:
– Change in the attribution of responsibility for
control of deviance from the family to a formal
organization
– The interpretation of deviance as medical concern
 Cont’d
• Medicalization has its roots in the general
development of western society.
• We trust physicians and provide them a wide
autonomy in how they practice medicine even
when they don’t really have good explanation
for illness.
• Therefore, we have to acknowledge the
tremendous cultural authority and legitimacy
of the enterprise of medicine.
 Cont’d
• Mental illness do not have the same
symptomatic characteristics as physical illness.
• And this ambiguity of diagnostic criteria
makes the effectiveness of physicians who
deal with mental illness more questionable.
 The Medicalization Process
Medicalization is a process of delivering
treatment or therapy for an ill status of a person
so as to restore his/her normal way of
functioning.

In other words it is an explanation of illness and

producing workable treatment.
 (Conard and Schneider, 1992 p.144)
According to them there are 5 sequential
stages of medicalization.
1. Defining of the behavior as deviant.
2. Prospecting
3. Claims: making
4. Legitimacy
5. Institutionalization of the medical deviance
designation
 1. Defining the Behavior as Deviant

• The behavior that becomes medicalized is

already considered as a deviant.
• It validates the search for a way to control the
behavior.
• Medicalization can be seen as one way to deal
with social problems created by the existence
of deviant behavior.
 2. Prospecting: Medical Discovery

•Medicalization is a political process. Because

specific behaviors are already known as
deviant, it is possible that there are pre-
existing ways of dealing with it.

•Medicalizing the deviant behavior requires a

rationale for incorporating it under the
umbrella of medicine.
3. Claims: Making- Medical and Non - Medical
Interests
• Claiming refers to actively promoting the
recognition of the problem in medical terms
so that its discovery can be legitimated in
the public arena.
 4. Legitimacy: Securing Medical Turf

• It is not always necessary for formal

political bodies (State legislature)to
officially authorize the medical system as a
legitimate system to achieve and control
over some deviant form of behavior.
• E.g., the insane action must be officially
recognized and defined at the federal level
of government.
5. Institutionalization of the Medical Deviance
Designation
• The deviant behavior status as a medical
issue can be better secured if it is
incorporated in to standard classification
system of the medical setting (Diagnostic
and statistical manual)/institutionalizing.
• Therefore, among others the deviant
behavior is recognized to be within the
legitimate scope of medicine.
 Cont’d
• General practitioners therefore use the
designation because it is officially available
and increases the chance for identification of
new cases.
• Therefore, as a process it/medicalization/
transforms the deviant behavior in to illness
and medicine and as a social institution the
medical setting becomes the dominant and
exclusive institution for the control of the
particular form of deviant behavior.
 Cont’d
• Even it is not necessary for medicine to have
an effective explanation of cause or
effective cure, but what matters is they have
succeed in convincing the general public and
political actors that the medical claim is
valid.
 Benefit of Medicalization
1. Humanitarian Response to Deviant Behavior
Being treated at the medical setting might be
kinder or gentle form of social control of
deviant behavior. But some times medical
treatment is seen as a punishment (Szasz).
2. De-stigmatization
As a form of illness, mental illness will be seen
as a motivated form of deviance to be punished
and more as a form of physical illness.
 Cont’d
In medicalization, the sufferer is not
responsible for what he did or less. He/she is
allowed to enter the sick role, the problem is
treated therapeutically and the stigma of the
mental illness label is reduced.
3. Optimistic medical Model
From medical point of view deviant behavior is
treated as illness from an optimistic point. It
encourages recovery and rehabilitation.
 Costs of Medicalization
1. Discouraging the understanding of social
conditions leads to Disorder.
• There is a tendency to regard individualization
of illness and treating those illness at individual
level.
•The logic of medical treatment puts more focus
on individual. Thus, this way of treatment over
looks social conditions the cause of illness in
general and mental illness in particular.
 Cont’d
2. cloaking/hiding the imposition of values
and biases in Neutrality of medical terminology.
• E.g. The classification of homosexuality as a
mental illness since the 1980 and abandoning as
the public attitude changes about it shows
importance of the biases and values to the
definition of a certain behavior as illness or not.
 Cont’d
3. Harmful treatment provided by medical
techniques. E.g. treatments like: Lobotomy ,
psychoactive drugs , ECT(electroconvulsive
therapy) have proved to be potentially
harmful.
• Lobotomy ( surgical removal of a portion of
the brain or cutting some part of the brain)
results in behavioral changes in personality,
memory loss.
• Psychoactive drugs – prolonged use of the
drugs causes side effects like tardive
dyskinesia, loss of muscular control especially
facial muscles.
• Electroconvulsive Treatment- denoting the
treatment of mental illness by applying electric
shocks to the brain.