On Thursday 8 October the Social Care Workforce Research Unit held its second annual Mental Health Social Care conference, in conjunction with Making Research Count. Joan Rapaport, Visiting Research Fellow at the Unit, was there. (2,275 words)
In her opening comments, Jo Moriarty, Deputy Director of the Social Care Workforce Research Unit, highlighted that the seminar was taking place as part of Mental Health Awareness week and that 10 October is World Mental Health Day. She observed that as well as mental health social workers, delegates from a wide range of organizations, in particular housing, were represented in the audience. This confirmed that adult mental health was not specific to one area of practice.
Enabling vulnerable adults to develop social relationships: findings from the Connecting People Intervention pilot study: Meredith Fendt-Newlin
Meredith outlined the policy background to the Connecting People study, in particular local authority duties to promote well-being and help people to contribute to their communities. Social workers are required to take a lead on community development and maximize the strengths of vulnerable individuals, their families and communities. However, within mental health, there is no established definition of social work other than the statutory functions. The case for making connections with local communities and developing a culture of evidence-based practice is therefore compelling. Could pointers from the Connecting People Intervention model help fill these role and function voids?
Social capital incorporates diverse personal and shared assets. Evidence suggests that higher access to social capital is associated with improved quality of life. In addition, people with severe mental health problems who enjoy high social capital report fewer experiences of discrimination. Trusting relationships are an extremely important aspect of helping people to access social capital.
A systematic review of the available literature on younger and older age groups in mental health and people with learning disability revealed positive findings on social participation. The Connecting People Intervention (CPI) model requires agencies to adopt strategies to promote social participation such as modelling of good practice, skill sharing, connecting with communities, local knowledge and networking and working in partnership with individuals.
The CPI pilot study set out to evaluate:
- the benefits and cost-effectiveness of the CPI model for people with mental health problems and those with learning disability,
- the implementation of the model in health and social care agencies, and to gather data for a larger trial.
The pilot worked with sixteen different third sector agencies employing mental health social care workers. The model was adapted for mental health and learning disability groups and training on CPI was provided to each of the agencies. Qualitative interviews and economic analyses were used and a nine month follow-up undertaken.
Findings
Higher fidelity to CPI was found to be associated with improved mental well-being and overall social inclusion. The role of the social care worker was identified as highly important in helping people with a range of needs. However, the ethos of the agency was shown to influence how the workers used the model and leadership, on-going training and supervision were required to embed it into practice. Significantly, the model was also shown to be cost effective: improved social outcomes did not incur greater cost.
Barriers to CPI benefits included budget cuts, high eligibility thresholds and low income and housing problems. Meredith said that whether the CPI model could be implemented in the statutory sector was an important question. In terms of next steps, given the proven benefits of the initiative, the research team was now considering its international potential.
Questions from the audience: How welcoming were the communities to the CPI? Meredith acknowledged that this was not assessed, although a valid point. Were there any individuals who failed to implement the model? Meredith stressed that implementation was heavily dependent on agency commitment rather than on that of individuals.
Mental health social care services from the perspective of staff and services users: Findings from the SCWRU Longitudinal Care Work Study (LoCS): Dr Gaia Cetrano
Gaia focused on the mental health component of a large longitudinal study of the social care workforce (LoCS). LoCS started in 2008 and is now in its third phase. The research design is unique. Its longitudinal nature allows researchers to ask staff why they have changed post and about their careers and working conditions over time. In respect of phases one and two of the sub-study on mental health, thirty-four service users, managers and care workers were interviewed.
Findings focus on:
- What are the aspects of their work that care staff are most and least satisfied with?
- Why do care staff stay and why do they leave?
- What qualities do service users want in their care staff?
Staff satisfaction: Staff were found to be generally satisfied with their jobs. They valued direct service user contact and potential to make a difference for people who had led the most impoverished lives. Establishing a relationship with people was an extremely important aspect of enabling change and challenging social injustice. Unsurprisingly, time pressures, administration and financial constraints featured as the most disliked side of their work.
Staff staying/leaving: Good staff support could make a huge difference in job satisfaction and encouraging staff to stay. Good quality supervision, regular appraisals and financial incentives were cited as important strategies. There was general dissatisfaction with pay, but this could be offset by a sense of vocation and accommodating working hours allowing for better work-life balance. Reasons for leaving included career progression, job insecurity and low pay. However, one manager in particular highlighted the importance of recognizing the importance of enabling career progression and encouraging people who had reached ‘the ultimate’ in a job to move on.
Service user perspectives: Service users valued friendliness, kindness and caring qualities, and staff they could talk to and who they could trust when they spoke to them in confidence. Having somewhere to go was important in combatting isolation. One service user said care workers should ask themselves: ‘do you like people’? From his perspective the amount of people in care work who didn’t was ‘stunning’! However, whilst he endorsed the views of others as regards the importance of the personal qualities of care workers, he also considered that they should be properly trained to help people with mental health problems.
Questions/comments: Gaia admitted that the research had probably failed to include care workers who didn’t like people! This was identified as a methodological issue. Burnout and stress: work-life balance, peer support and self-management could help offset the problem. However, self-management was also a learning process. Did people suffering burnout always recognize their situation and its impact on themselves, peers and the people they were helping?
Outcomes for homeless people with mental health problems who are resettled: Maureen Crane and Louise Joly
Maureen and Louise explained that their presentation was based on two studies: the For-Home study funded by the ESRC and the Rebuilding Lives study funded by the National Institute for Health Research (NIHR) School for Social Care Research (SSCR). The first investigated outcomes for 400 homeless people at the point of resettlement and at six and then eighteen months after resettlement. The second examined outcomes for homeless people drawn from the For-Home study five years after resettlement. Five homeless sector organizations across four areas in England collaborated with the research. About half of those resettled reported mental health problems, in some cases also exacerbated by drug and alcohol usage.
Findings
At five years, most were still living in their original resettlement accommodation or had moved to another tenancy. About a fifth had become homeless at some point and of these, some had been rehoused again. Financial problems, rent arrears, specific life events and wider social difficulties had led to tenancies failing. Of this group, a small proportion, nine per cent, cited mental health breakdown as a contributing factor. Difficulties with welfare benefit systems, dwindling/disappearing tenancy support and not having reliable contact numbers had added to the downward spiral. However, even the still-housed majority experienced similar problems. Accommodation was often poor quality and located in challenging neighbourhoods. The mental health participants were more likely to report loneliness and isolation and worries about how things were going. Significantly, increases in mental health problems amongst the younger group mainly related to financial problems and debt. This was the largest group with debts of over £1,000.
Most of the mental health group were able to cite some sort of activity and over four-fifths saw friends or relatives at least weekly. Whereas just over a fifth were receiving some form of psychological or social care, over half received medication from their GP. Yet, echoing the ‘Connecting People’ objectives, most wanted to engage in more activities, to train or get a job and a third to receive counselling, therapy and help with day to day living, such as money management and linking into work and other activities. Once again, people under thirty were less likely to be receiving treatment than their older counterparts.
Conclusion
Maureen and Louise highlighted that homeless people with mental health problems are just as likely to be able to maintain a tenancy as other people. However, they are more likely to struggle with the art of living and to have low morale. Stress could trigger or exacerbate relapse. Some formerly homeless people require substantial, possibly life-long help to keep their homes and rebuild their lives.
The full report of the Rebuilding Lives study, the summary of which is already available, will be available late November.
Questions/comments: Is too much reliance placed on giving medication and not enough on providing personal support? Ways of integrating housing workers with mental health services were required. Policy briefings to influence government were being prepared by the research team. The research team would like to follow up available participants in ten years and to reflect changes in housing policy, to introduce a new group resettled in privately rented accommodation.
Exploring the role and experiences of Approved Mental Health Professionals: Sarah Matthews
By way of background to her PhD study, Sarah described recent changes in mental health social work arising out of reform of the Mental Health Act 1983. Since the amendments under the Mental Health Act 2007 came into force, the former role of Approved Social Worker (‘ASW’) has been extended to include nurses, chartered psychologists and occupational therapists with a new title of Approved Mental Health Professional (‘AMHP’). So far only a small proportion of nurses and a few occupational nurses have trained for the role. The majority of compulsory mental health assessments, the legal core of the AMHP role, are still undertaken by social workers.
The study, still in progress, aims to explore the role and experience of AMHPs and related emotional aspects. Significantly, AMHPs are required to manage difficult situations of anxiety, risk and conflict and to reflect on how these affect themselves and others and the impact on AMHP practice. The main overarching concepts relevant to the study are Phenomenology, the lived experience, Hermeneutics, meaning and significance, and Idiography, concerning the particular. Five social workers, five nurses and two occupational therapists participated in her PhD research. Taped interviews and participants’ drawings and descriptions, designed to provide a ‘rich picture’ were used to generate data. Coding analysis was assisted by a computer software package. Theories of emotion work and the feeling rule, the display of feeling expected by the workplace and emotional labour, tensions between workplace-expected and subjugated feelings, framed the data analysis.
Emerging findings
Analysis, some richly graphic, so far suggests that the AMHP role is emotion-based work which arouses negative subjugated feelings. The work is emotionally exhausting, stressful and burnout-inducing. Drawings depicting fear of being left alone when services withdraw from the assessment venue, being time pressured and feeling pulled in all directions by multiple responsibilities emerged. However, descriptions of positive emotions, such as satisfaction arising out of a well-managed assessment and pride when praised were also apparent. Anxiety could also have the positive effect of combatting complacency and checking to ensure everything is under control. ‘Emotion reconciliation’ is emerging as the core theoretical discovery arising out of the research data (see Sarah’s slides for more on this).
Panel discussion
Benefit changes are having a serious impact on people’s lives, in particular those in younger age groups. Those affected by sanctions are losing their tenancies. People want to work to rebuild their lives. However, increasingly they are forced into jobs with zero hours’ contracts, low irregular income and job insecurity. There is no additional financial support or safety-net backup from relatives.
Benefit changes relating to eligibility on health grounds are promoting the medical rather than social care model.
People struggle with life skills and managing and keeping their tenancies. Younger people in particular are less likely to be given housing support and where it is provided, it is of a short-term nature. Some people require life-long support if they are to live independently in the community and this should be recognized.
The work of housing support workers is shaped by financial work and housing pressures. Their role is limited in terms of the support they can provide.
Housing support agencies are often working under short-term contracts. Their position is not always secure.
Loneliness and isolation is a serious problem. Some have nowhere to go. Day centres and support workers can help to alleviate isolation. However, many day centres have been closed because of the cutbacks.
Relationships and trust are crucial in helping people to connect with their communities and to move on. Frequent staff changes and discontinuance of support militate against these important aspects of care. In one case a research participant said that the homelessness study researcher had been the person most continuously involved in his life!
Social workers form 90% of the AMHP workforce. The nature of the role and possible threat to the therapeutic relationship arising out of compulsory assessments may have deterred other professions from coming forward.
It is important to compile local directories of useful community organizations.
Joan Rapaport is Visiting Research Fellow at the Social Care Workforce Research Unit in the Policy Institute at King’s.
About the Mental Health Social Care conference
The 2nd annual certified event on mental health social care from Making Research Count and the Social Care Workforce Research Unit at King’s College London took place at Henriette Raphael House, Guy’s Campus, King’s College London on Thursday 8 October 2015. It was organized by Jess Harris.