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Forensic Social Workers are based in a variety of settings in the UK: Special Hospitals; Medium and Low Secure Psychiatric Hospitals; and in Community based Mental Health Teams. They are employed by the NHS; Local Authorities; and the Independent Sector. ''HISTORICAL DEVELOPMENT'' Jones and Sidebottom (1962) reviewed three English mental hospitals. In the first one there were no Social Workers. The authors were told that very few “ Social Work problems” existed, and that the few which did were “dealt with by Medical Staff”. Prior (1993) described this notion of a “social work problem” as being something “sporadic” and “peripheral” to the every day confines of hospital life as one of the key notions which characterised the hospital age at the time. Psychiatric Social Work appears to have been dominated by the concept of “aftercare”. Meyer, also cited by Prior (1993) argues in 1911 that social work was necessary only for securing a healthy domestic environment for his patients. A more radical image of the Social Worker was evident from Southard and Jarratt (1922) who illustrated how Doctor and Social Worker could “co-operate” in the care of the mentally deranged”, and in so doing, says Prior (1993) also provided a new image of the patient who was seen as someone who was involved in a network of “social relations” and also as someone with a “social history”. The first appointed psychiatric Social Worker in London was in 1936.The British Association of Psychiatric Social Workers was inaugurated only in 1930.Three separate developments as cited by Prior (1993) between 1920 – 1950 encouraged the social work profession to try and establish itself as an integral part of the psychiatric team – firstly, social factors were seen as being intimately involved in the causation of mental disorder; secondly, a new ‘vision’ of psychiatric disorder as being widespread in the community, and thirdly, the expansion in the kinds and numbers of symptoms regarded as psychotic. It was this expansion of the forms of social deviance which, says Prior, inspired writers like Szasz (1960) to talk of the “myth” of mental illness. Robinson (1930) pointed out that ……”clinical experience revealed that while the starting point of treatment is the patient there may be other members of the family who are also seriously maladjusted”. Joint working is seen as important and great emphasis has been placed upon the interconnecting responsibilities of the legal, social work and medical professions Jones (1972). It would be quite wrong however, to assume that these perspectives do not overlap in any way - none of which belongs exclusively to any one profession - Barnes, Bowl & Fisher (1990). I believe it is important that the medical perspective on mental disorder needs to be balanced by a social perspective. It is essential that the Social Worker is able to identify mental distress and its potential causes, which may be located within social factors. Social Workers have worked within Psychiatric Hospital for many years but there are few of these that work directly with Mentally Disordered Offenders. Most of the expertise in England and Wales has been concentrated within the Special Hospitals. – Ashworth , Rampton and Broadmoor . It was not until the publication of the Aarvold Report (1973) that social work was officially recognised as having a valid voice in the recommendations for discharge of Special Hospital patients. In its findings, the Aarvold Committee noted the value of multi-disciplinary case conferences and expressed the hope that they would become common practice. Social work influence within the Special Hospitals system was minimal at the time – Vaughan & Badger (1995). At Broadmoor Hospital the first qualified social worker was not employed until 1969. Before this time, says Vaughan and Badger, the hospital had mainly been served by unqualified Welfare Officers. Particularly relevant was the recommendation “that wherever possible the recommendation of a Responsible Medical Officer for the discharge of a restricted patient from hospital, or for transfer from a Secure Hospital to one in the National Health Service, should be supported by the recorded views of other professional personnel, such as Nursing, Occupational, Psychological and Social Work Staff” Aarvold (1973). In the period of time since this Report, Special Hospital Social Workers have grown from “humble beginnings as minor officials with little influence to a group of specialist workers with improved status and an important part to play in the overall care, treatment and rehabilitation of patients” – Vaughan & Badger (1995 p141). The enquiry into Ashworth Special Hospital – 1992 – reported that Social Workers were obliged to play a marginal role in patient care and were ‘outside the mainstream of patient care decisions’. It also criticised the social work service too for being ‘professionally isolated from social work colleagues in related fields’ Marchant 1993. Role of the Social Worker The passing of the Mental Health Act, 1959, was generally heralded as a significant advance in the management and care of the mentally disordered in the modern era because it was thought to give the necessary legal framework in which to provide and develop an enlightened mental health service. Having worked as a Social Worker within the Act, I found it contained many imperfections. The 1959 Act did not ascribe particular functions to the Mental Welfare Officer (Social Worker), which were applied independent of the Doctor or relative. The result was that the Social Worker’s role was often defined administratively rather than therapeutically and little attention was paid to community based alternatives to hospitalisation. Local Authorities were not given a positive duty to provide community mental health services and they did not receive a specific grant to do so. In our experience within the social work profession since the early 1970’s, it has been the social worker who has bridged the gap between the two worlds of hospital and community. The Seebohm Report (1968) placed the psychiatric Social Worker under the authority of Social Services Departments rather than medical personnel which was partly responsible for the development of the role of the Community Psychiatric Nurse. The emphasis on “social care” perspectives has continued – highlighted by the Reed Report (1992) which emphasised the principle that the needs of Mentally Disordered Offenders should be met jointly by both Health and Social Services and not by the Criminal Justice System. This principle has continued to be supported by subsequent legislation and Government Circulars. ''APPROVED SOCIAL WORKERS. (ASW)'' The 1983 Mental Health Act, outlines a clear and important role for the Approved Social Worker. This reflects, to a considerable extent, a recognition of the significance of social factors in mental illness, extensively chronicled in the social psychiatry literature – Cochrane (1983).The ASW possesses a number of powers and duties, many of which reflect their position as a social analyst. Section 114 of the Mental Health Act, 1983, provides for Mental Welfare Officers (as defined in the 1959 Mental Health Act ) to be replaced by ASW’s This Section provides that each local Social Service Authority shall appoint a sufficient number of ASW’s to carry out the functions given to them by the Act. It is not the Authors intention to outline the ASW role in detail – this is not the purpose of the paper. However, when relatives are unable or unwilling to make application for admission it is the duty of an ASW to make an application for hospital admission of a patient if it is thought necessary. The duty, under Section 13 of the 1983 Act, is placed upon the ASW, not the Local Social Services Authority. Parliament expressly decided - Gostin (1983) that “there should be an application based upon particular statutory criteria (Section 13(2)) which would be separate from the supporting medical recommendations……. the person’s social situation and community based alternatives to hospital care must also be taken into account. Assessment of these latter factors is the ASW’s priority claim to a professional as distinct from a purely procedural role……ensuring that care and treatment are provided in the least restrictive setting possible”. ''SECTION 117 MENTAL HEALTH ACT (1983)'' The Act imposes a duty on the Health Authority and the Social Services Department, to provide, aftercare services for patients who have been detained for treatment (Section 3), under a Hospital Order (Section 37) or in hospital following a transfer direction (Section 47 or 48). The duty continues until the two Authorities are satisfied that the person no longer needs such a service. This imposed duty on Local Authorities and Health Authorities is important and affects Mentally Disordered Offenders as well as those not connected with the Criminal Justice System. “It does not specify services to be provided or confer powers to charge” - D of H Circular LAC (2000/3) Social Supervision Since the Mental Health Act 1959, Social Workers have been given prime responsibility for the social supervision of those restricted patients presently subject to Section 37/41 of the Mental Health Act, 1983 or Section 5 of the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991 who have been conditionally discharged by either a Mental Health Review Tribunal or by the Home Secretary. Guidelines produced by the Home Office (1997) outlines this role in great detail. Working within the multi-disciplinary team is important for the benefit of the Service User or Patient. A Conditional Discharge is the tightest community power over a Patient according to Crichton (1995). It is the Social Worker who fulfills the role of the Social Supervisor who must specify suitable accommodation. The Service User can apply for absolute discharge but this is subject to favourable reports from the Social Supervisor as well as the Psychiatrist. Assessment of risk is an important part of the Social Supervisors role who is seen as a protector of the public as well as the patient. Some find this role contradictory with a bias towards the “policing“ element of the role. Mental Health Review Tribunals. The Social Worker, whether working in a community setting or hospital setting, is called upon to provide social care reports to the Mental Health Review Tribunal under their Rules (1983). The Social Worker’s views are important in the decision making process of the Tribunal. The provision of social work reports to Hospital Managers’ Review is also an important feature of the role of the Social Worker. The Review Panel in advance of the hearing ……”should obtain written reports from the patient’s R.M.O. and others who are directly involved in the patient’s care such as the keyworker, named Nurse, Social Worker and Clinical Psychologist”, Department of Health and Welsh Office Code of Practice (1999). ''CARE PROGRAMME APPROACH (CPA)'' The Care Programme Approach was introduced in 1991 and was intended to be the basis for the care of people with mental health needs outside the hospital. It applies to all people with serious mental health problems who are accepted as clients of specialist mental health services. CPA was prompted by the killing of a Social Worker by Sharon Campbell (D of H and Social Security (1988). It was introduced in the NHS in April, 1991 following the issuing of a joint Health and Social Services Circular (D of H 1990) .Despite this, however, Zito (1998) reported that the Care Programme Approach had not been implemented in a number of Health Authorities inspected by the Department of Health in 1995. The Mental Health (Patients in the Community) Act 1995 sought to improve rates of compliance with aftercare. It strengthened, under Section 25 of the same Act, powers of community teams through '‘Imposition'’ of conditions to which the patient must agree prior to discharge from hospital. Both CPN’s and Social Workers are eligible to become the named Supervisor in the Community. ''NATIONAL HEALTH SERVICE AND COMMUNITY CARE ACT, 1990.'' As from the 1st April, 1993, the National Health Service Act, 1977 was repealed by the National Health Service and Community Care Act, 1990 which represented a significant change in the delivery of health and social care services. It was preceded by the 1989 White Paper ( D of H 1989) which stated that the principle objective was to enable people to live as normal a life as possible in their own homes. Responsibility for the assessment of ‘need’ and arranging “packages of care” was given to Social Services staff. Those people moving into residential care, not under Section 117 arrangements, were also financially assessed. MDO’s are not the most popular of client groups in society and in the public’s minds unlocking the mental hospital doors had become associated with an increase in disturbed and violent patients on the streets. Since the introduction of the 1990 Act it seems apparent that the MDO has needs that often straddle the boundaries between Health and Social Services, causing agencies to look to the other for the funding of services. In my experience those patients discharged from both High and Medium Secure facilities are usually jointly funded following assessment for any residential resources. There is anyhow a shortage of such resources and those that do exist are usually very expensive which eats deeply into Community Care budgets. Standards The specific role of the “Forensic” Social Worker (FSW) is outlined in CCETW (1995) – “the key purpose of the FSW is to hold in balance the protection of the public and the promotion of the quality of life of individuals and by working in partnership with relevant others”. More recently a set of National Standards for the provision of ‘Social Care’ services within the High Security Hospitals have been issued in August, 2001 co-ordinating the Social Workers role nationally. Recent similar standards have been produced covering Medium Secure Units Social Work Departments. The Department of Health circular – “A quality strategy for social care 2000” introduced the Social Care Institute for Excellence. There has been an interesting shift in the re-naming of these social work standards. They now appear to be called “social care” standards re-emphasising the ‘care’ component of the role. Public pressure combined with various voluntary and Carers Support lobbying have forced Political reform. These Reforms have centred on Community services. Carers have become a strong vocal body of opinion which culminated in the right of Carers to have their own independent needs assessed by Social Services (HMSO 1995). Community Reforms such as those outlined within Partnerships in Action 1998; Health Act 1999 – Modern Partnerships; and National Service Framework – 1999 appear to me to have evolved from long standing trends in social care and have encouraged new ways of doing things. ''CONCLUSIONS'' Local Authorites are the main employer of ‘Social Workers’ within this Country. Prior to Seebohm, Health Authorities employed the then named Mental Welfare Officers but Local Authorities have taken over this role. The Mentally Disordered Offender has needs that often cross the boundaries between health and social care causing each agency to look to the other for the funding of services. The funding of residential and supervisory services for the mentally disordered offender following discharge from hospital is not automatically the responsibility of the Local Authority. Following assessments, arrangements for the ‘funding’ approval of such placements are tightly controlled by Senior Managers and very often consideration is given to the joint funding of such placements between the responsible Local Authority and Health Authority. Social Workers within the Special Hospital setting are now employed by the Local Authority in whose area the hospital is placed, for example, those working within Rampton Hospital are now employed by the Nottingham Mental Health NHS Trust following the amalgamation of High Secure Hospitals with local Trusts in 2000. Social Workers within Medium Secure Units are usually employed by the Local Authority. These Social Workers co-ordinate services for the Mentally Disordered Offender, maintaining links with carers, the responsible Local Authority and other agencies. More and more Local Authorities are giving overall responsibility for work with the Mentally Disordered Offender to Specialist Forensic Teams. Many of these teams work either from a Medium or a Low Secure Hospital. This means that a more thorough approach to multi-disciplinary working can be achieved. Aarvold recognised this and so too have others - Prins (1983) who stressed the importance of mutual support, sharing of tasks and giving up notions of “going it alone”. There has been a growth of ”partnership” Authorities within the past twelve months. Social Work responsibilities have become more statutory based with suspiciously strong “policing” responsibilities. They work within specialist teams and the growth of Forensic Teams in particular has been rapid. The term ‘Social Worker’ may be redundant within the next 10 years. There appears to be a blurring of the role at a time when we see realignment of professional boundaries. The Role of the Social Worker with MDO’s has developed in line with general Political Reforms. Since the early 1900’s the psychiatric social worker has always been involved with the social perspective. Other agencies have also come to accept this. Various Community Care Development programmes have reinforced the historical movement away from care in institutions towards a greater focus on supporting people in their own homes or in, non - hospital, community settings, which has impacted upon the increased responsibilities and role of the Social Worker. == '''''References. ''''' == Aarvold Report 1973. Home Office and Department of Health and Social Security “Report of the Review of Procedures for the Discharge and Supervision of Psychiatric Patients Subject to Special Restrictions. Cmnd 5191. Barnes M. Bowl R. & Fisher M. 1990 “Sectioned: Social Services and the 1983 Mental Health Act” . Routledge. BASW 2002 Code of Ethics Central Council for Education and Training in Social Work 1995 Forensic Social Worker. Competence and Workforce Bluglass R. 1992 “The Special Hospitals – should be closed” British Medical Journal Volume 305 p323-324. Chiswick D. &Cope R. (ed) 1995 “Practical Forensic Psychiatry” R.C.P. Cochrane R. 1983 “The Social Creation of Mental Illness”. Longman. Crichton J.1995 “ Psychiatric Patient Violence: Risk and Response” Duckworth Dale C. & Storey L.1999 “Nursing in Secure Environments”. London UKCC Dent S. 1997 “The Home Office Mental Health Unit and its Approach to the Assessment and Management of Risk” International Review of Psychiatry Volume 9, p265-271 Department of Health and Social Security 1988. Report of the Committee of Inquiry into the Care and Aftercare of Miss Sharon Campbell Cm 440 Department of Health 1990 The Care Programme Approach for People with a Mental Illness Referred to the Specialist Psychiatric Services HC (90) 23 LASSL (90). Department of Health 1999 Local Authority Circular LAC (99) 23 Department of Health and Welsh Office 1999 Code of Practice Mental Health Act.1983 Chapter 23.14. Department of Health 2000 “After Care Under the Mental Health Act, 1983”. Circular LAC (2000) Eastman N. 1995 “Anti Therapeutic Community Mental Health Law” British Medical Journal Volume 310 p1081-1082 Farrar M. 1996 “Government Policy on Mentally Disordered Offenders and its implemetation” Journal of Mental Health Fook J. Ryan M. & Hawkins L. 1997 “Towards a theory of Social Work Expertise” British Journal of Social Work. Volume 27 No 3. Gostin K. 1983 “A Practical Guide to Mental Health Law”. London, Mind. Gostin K. (ed)1985 “Secure Provision” Tavistock, London. HMSO Carers (Recognition and Services) Act 1995. Home Office 1990 “Provision for Mentally Disordered Offenders” Circular 66/90 Home Office 1997 Mentally Disordered Offenders Survey of Inter-Agency Arrangements (Circular MNP 97) Home Office and Department of Health 1997 Mental Health Act 1983 “Supervision and After Care of Conditionally Discharged Restricted Patients: Notes for the Guidance of Social Supervisors”. Home Office and Department of Health 1997 Mental Health Act 1983 “Supervision and After Care of Conditionally Discharged Restricted Patients: Notes for the Guidance of Social Supervisors”. James D. 1999 “Court Diversion at 10 years : Can it work, does it work, and has it a future?” – Journal of Forensic Psychiatry Vol.10 No. 3 Jones K. & Sidebottom R 1962 “Mental Hospitals at Work”. Routledge and Kegan Paul. Jones K. 1972 “A History of the Mental health Services” Routledge and Kegan Paul. Marchant C. “Secure Hospitals”. Community Care 2 Sept. 1993. McClelland N. 2002 (Lecture) “The Historical Aspect of the Development of the Role of the Specialist Mental Health Nurse”. M.Sc. Psychiatry Univ. of Birmingham. Mental Health Act. 1983 HMSO Mental Health Review Tribunal Rules. The 1983 HMSO Mental Health Act 1983 Section 73 (2) HMSO Mental Health Act 1983 Section 42 (2) HMSO Prins H.1983. “The Care of the Psychiatric Prisoner – Discharge into the Community and its Implications” – Medicine, Science and the Law. Vo. 23 No. 2. Olsen M.R. (ed)1984 “Social Work and Mental Health – a guide for the Approved Social Worker” Tavistock. Prior L. 1993 “The Social Organisation of Mental Illness” Sage, London Reed Report 1992 Department of Health and Home Office Robinson V.P.1930 “A Changing Psychology in Social Case Work” University of N.Carolina Press. Seebohm Report 1968 “ The Committee on Local Authority and Allied Personal Social Services” Shepherd M. 1990 “Mental Health –the Role of the Approved Social Worker” Sheffield University and Community Care. Social Services Inspectorate 1994 “Inspection of Social Work in Medium Secure Units –The Reaside Clinic”. Department of Health Social Services Inspectorate 1999 “ Inspection of Ashworth Hospital Social Work Service” Department of Health Southard E.E. & Jarratt M.C. 1922 “The Kingdom of Evils “ MacMillan Szasz T. 1960 “Myths of Mental Illness” Harper Taylor P.J. & Gunn J. 1996 “Forensic Psychiatry : Clinical , Legal and Ethical Issues” Butterworth Heinemann Vaughan P. & Badger D. 1995 “Working with the Mentally Disordered Offender in the Community”. Chapman and Hall. Wix S. & Cushing H. 2001 – “Diversion from Custody”. Ed Forensic Nursing and Mental Disorder in Clinical Practice – McClelland N. Humphries M. Conlon L. & Hillis T. Butterworth Heinemann Zito J. 1995 “Victims of Community Care” Mental Health Nursing Volume 15 No 6 Zito J. 1998. “ Lessons From the Outside”. Nursing Times. 28.1.94. |
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