Identify an intervention with a service user or service users from your own practice. Discuss the theories for practice that informed the chosen intervention. Illustrate your answer with examples from your practice and evaluate the outcomes of the practice.
Any names used have been anonymised and I have used pseudonyms throughout to ensure confidentiality.
In this essay, I will discuss a discharge group which I ran jointly with an occupational therapist and psychologist whilst on placement on an NHS adult mental health ward. I worked within a multi-disciplinary team on a discharge ward for twenty working-age people who had been detained under the Mental Health Act 1983 Section 3 (MHA 1983s3). Following service-users expressing concerns about their discharge in Ward Round Meetings, it was agreed by staff that a small group should be run to discuss these concerns for those at similar stages of transition. For some service-users, the routine and boundaries of the hospital environment that they had initially fought against had now become a sense of security and the thought of living alone or in supported living increased their anxiety. In this essay I will explain how through groupwork theory (Morgan, A, 2016) I was able to see how; the dynamics of the group due to different values impacted on individuals, the paradoxical nature of empowerment and whether person-centred theory could be incorporated (Rogers,C (1951) cited in Daniel, B.(2013)). How collaborative working is vital and how the intervention was intended to be dissonant with the medical model which was present on the ward and the challenges faced. Groupwork theory is a method used within social work to work with a group of people either virtually or in-person to enable desired change, growth and development (The Open University 2019a). For people with mental health illness who may have previously felt isolated or excluded from their community, working as a group can provide a ‘sense of belonging’, that comes from sharing an identity (Doel, M, 2013). Although the staff’s focus and purpose of the group was ‘discharge’ it became apparent that each service-user had their own individual goals. It was important to recognise this and incorporate person centred planning into the sessions where appropriate. The groupwork used a mixture of different approaches, relational-cultural where the aim was to build self-esteem and encourage empowerment, but also a narrative approach where service-users spoke about their individual ways of approaching labelling and stigmatisation in society and shared strategies (Galvani,S, 2013). As the group developed over the weeks it went through stages of forming, storming, norming and performing (Tuckman and Jensen, 1977). The service-users already knew each other so the forming stage consisted of clarifying roles and boundaries within the group. It also consisted of expectations of behaviour and commitment to attend each session. During the storming stage ideas and perspectives as to how the group should run was discussed. Even though the group knew each other it took time for the group to recognise each other’s strengths and appreciate that others had faced similar experiences. The group appeared to move between this norming stage and storming stage depending on each session and failed to reach the performing stage. On reflection, this could be because the power imbalance between staff and service-user was already apparent and therefore a person-centred and empowerment approach was lacking. This was also evident as the agenda was already decided by staff and the service-users were spoken to rather than included in the planning of the sessions (Tuckman and Jensen,1977) This was partly due to the bureaucracy and policies in place including time restraints and logistics of running a session for an hour. As Connors and Caple (2005) state groupwork theory is influenced by the interactions within the group and by the external environment. The external factors of the staff’s young age in comparison to the service-user and the clinical environment, as the meeting was held on the ward, had negative connotations on the individuals and impacted on the dynamics of the group. The hierarchical environment made service-users feel positive regard was conditional and put pressure on them to behave in an expected way and was hegemonic.
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It was important to work collaboratively both within the group and on the ward to benefit the service-users. Sessions were task led and they were disseminated depending on professional’s skills. Although pre-planning ensured everything was covered in the sessions it left little room for variation. For the group to be successful it was important to understand individual’s needs and adapt the group task accordingly. Evaluation of the ‘life course’ (The Open University, 2019b) and each session was required to improve outcomes for each service-user. Working alongside colleagues who had a different role allowed the group to benefit from diverse skills and perspectives which is not possible when working alone. But pressures and barriers such as different priorities dependent on each person’s role impacted on collaborative working and at times caused a strain on the group dynamics (Gorman 2000 pp93-95). Overall the group worked well and over the weeks the service-users appeared to develop a degree of trust within the group and were able to talk openly and honestly. This counterbalanced to some extent the disempowerment from a dominated hierarchal environment on the ward and the service-users provided an insight into their life experiences that is available through groupwork. Open discussions that followed, even if they competed with others beliefs and values, provided a balance of power which is conducive to collaborative working and was an advantage of groupwork (Sarson and Lorentz p110). However, when service-users were reluctant to join the group or when other staff took them to other appointments or organised non-urgent tasks with them this showed a lack of commitment. This made me feel demoralised and almost jeopardised the group sessions. A lack of commitment by managers due to the risk associated with the unpredictability of groupwork, including liability and accountability which can be heavily scrutinised due to policies, procedures and legal responsibilities can prevent groupwork taking place. (The Open University 2019c.) However, I did not experience this as the ward manager was not risk-averse. This could be because group activities already occur on the ward and as the service-users all live together the dynamics of different personalities have already been resolved.
It was important to recognise the medical model that dominated the setting and how it was utilised and practised whilst challenging the ethical dilemmas such as intimidation (Shah, 2000). The medical model considers poor mental health to be a physical ailment which can be treated and presumes social, cultural and environmental issues are as a result of the medical condition and not a part of it (Bogg.D,2008 pp41-53). This could be utilised as labelling and stigma and emerge as barriers for service users, it was important these were addressed and overcome within the group. As I was older than the occupational therapist and psychologist as a mature student I was less afraid to speak up and challenge decisions. Being aware that values are internalised and may appear invisible can create obstacles when working with others so clear communication was vital (Crawford, K 2012 pp67-91). It was crucial to have an understanding of power and authority and how it was understood on the ward. As a member of staff, I was seen as having more authority and power by the service-users. This was confirmed in many subtle ways; for example, I had the key to the activity room and therefore service-users could not enter until I arrived. As the distribution of power in a hierarchal manner undermines trust it could impact on service-users self-esteem and confidence (Plaskoff, 2006).Using the social model theory I recognised the discriminatory and oppressive response is from society and the environment and not a characteristic of the individual (Adams, R. et al 2013 pp261–269). It was important that I became a participant in the group as well as a facilitator to displace the dominant power and build trust (Das and Teng, 2001). As group work seeks to empower others and is a sharing of power the service-users needed to have an active role within the group and in their future. It was important I did not make service-users feel coerced into discharge as they may have felt about their medication and they were involved in their discharge plan to enable them to feel valued and empowered which is conducive to person-centred planning.
Communication skills are vital not only when working collaboratively with other professionals but with a range of service-users. It was important to ensure I modelled good communication both verbal and non-verbal, that I was non-judgemental, sensitive and understanding of their experiences to develop rapport and promote change where desired (Trevethick, 2008). Through the groupwork, I was able to develop interactional techniques such as responding to feelings and keeping the group focused (Doel, M 2013) which will benefit my practice in the future. The communication needed to be jargon-free, not condescending or patronizing, paraphrasing helped to ensure I had understood clearly the point each service-user was saying. But the environment was quite formal and not relaxing, hard chairs around a large table could easily have been seen as a ‘them and us’ situation. The person-centred concept still applied to the group including listening sensitively to each individual, empathetic and unconditional positive regard. Some service-users spoke very quietly and although it was important they were heard asking them to repeat it several times would have made them very self-conscious. It was also important to accept silence, as long as this did not demonstrate resistance and therefore individuals were not coerced to participate. An awareness of non-verbal expressions was essential as this can portray more information than verbal communication (Trevithick, 2008). Being ‘group aware’ (The Open University, 2019c) allowed me to see how the power dynamics within the group changed over time or dependant on the topic as service-users became more confident and felt empowered. According to Payne ‘the objective of groupwork is to develop the democratic mutual aid system and simultaneously help group members to carry out (“actualise”) their purpose’ (The Open University 2019d). To empower the service-users it was important that I helped them to help each other, recognised the worth of each individual and the skills each brought to the group. (International Association for Social work with Groups, Inc.).By removing the dominant power openness, exchange of knowledge and learning were possible. Numerically the service-users outnumbered the staff in the group and therefore appeared to have more power than the staff and this could bring about a sense of empowerment. Having the freedom to speak and be heard within a group can raise unexpected emotions and therefore groupwork comes with an element of risk. Mary was a ‘monopolizer’ (The Open University 2019d) and took a disproportionate amount of the group’s time to the detriment of other members. However, she initiated conversations and spoke openly and honestly about her experiences and by sharing this, it gave others strategies on how to cope with isolation and poor health. As she dominated conversations this demonstrated a power imbalance between her and her peers. But by sharing her experiences she demonstrated she had experienced similar stigma and helped others feel less isolated. While addressing power with Mary it was important to do this delicately to encourage empowerment rather than appear controlling.
Although the idea of empowerment was central, in practice the paradoxical ideal of empowerment was inhibited due to professional values and policies to manage risk and protect service users. Therefore professionals remained in control both of the process and how much service-users were involved and contributed (Harrison and Mort, 1998). During one session Mary spoke up when another service-user said about the fear and stigma when ‘signing on’ at the job centre when discharged. Mary could relate to this but instead of speaking about how she manages this feeling of discrimination at the job centre she instead spoke about how she had previously earned money as an escort as an alternative to ‘signing on’ so she did not have to face this stigma. The other facilitators tried to close her down and address the issue raised about benefits. This further demonstrated disempowerment; instead, it was important she was not judged by me or others and those views did not override interventions. That she was able to talk within a safe environment; but this was not seen by others as a solution or strategy to financial discrimination. Therefore communication both verbal and non-verbal was imperative as to not make her feel devalued but to ensure she was not seen as vulnerable to the male service-users. As a female and a member of an all-female staff team in this group, I became aware that Mary may be at risk from males on the ward. In hindsight, I may have imposed my values as a female patriarchy within the group by assuming males would think she was promiscuous and females exclude her. It was important for me to recognise how my own experiences and emotional reactions may influence my professional judgement and subsequent behaviour. Although I had not experienced the same as the service-users and had been fortunate enough never to have to attend a job centre I could empathise with the worries of insufficient money and getting an extra job to increase the income. It was also important to recognise that this disclosure may indicate that Mary has some unresolved issues about her past that needed further exploring on a one to one basis. As well as recognise the social injustice that needed challenging at a higher level.
As a social work student it’s important to promote social and economic justice, the experiences the group relayed at the job centre demonstrated oppression and it’s important that I worked with the service-users to promote anti-discrimination as Mary’s way of avoiding this discrimination does not affect system change and may increase her vulnerability in society. Social change for oppressed and disadvantaged people is a large part of social work and without this group, I would have potentially been unaware of this discrimination. Being aware of the stigma and discrimination ensured the focus was service-user led (Petch et al, 2013). But by advocating for a community to be treated as equal requires groups to work together to ensure their voice is heard. But media coverage and programmes such as ‘Benefit Street’ promotes stigma and further ostracism and means the majority of society is unaware of the stigma people with a mental health problem face (Cutliffe and Hannigan, 2001 pp315-321).
This example shows how within a group setting, individuals may not receive the support they need especially if there is one individual who monopolises. It can be harmful if the advice service-users give to others increases their vulnerability, but also how empowerment is controlled by professionals. A core principle of the person-centred theory is to reduce the power and authority gap and enable the service-user to be the expert. It was important that I respected that each individual’s experience of mental health is unique to them, some service-users in the group suffered from severe depression, others from schizo-affective disorder or drug and alcohol abuse. Each person’s identity was unique to them and it was important to recognise this when working with the group and to be aware that they had also had to constantly redefine their identity as their life situation changed. It was important that they did not feel stigmatised within the ward or within their community once discharged whether they returned to their home or moved into supported living.
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Rather than focusing on one individual as in person-centred planning, it was important to be aware of the interactions within the group, between staff, staff and service-users and the process of each session. It was important to be aware of how each person’s behaviour influenced the group. Even within the small group members had already aligned themselves with allies who they felt shared the same values. Mary and Bob were both returning home but each situation was unique. Mary was returning to her home within an affluent town however, the area she lived in was in the outskirts of the town and had become an area dominated by people who had suffered from mental health and were now living in housing associated property and had formed their own community. This concept of ‘Othering’ (Thompson, 2005) is where groups who are marginalised by society form a community, here she felt comfortable and felt a part of the community, she was not stigmatised as being different and therefore was not at risk of isolation or exclusion. It appeared that friendships had developed between service-users with different social classes, ages, ethnicity etc. based on the same experience of the mental health system.
As a student social worker I needed to build on service-users individual strengths and the strength as a group, it was important that I was not seen as an ‘expert’ but as a facilitator of empowerment. Empowerment is not professionals giving service-users power but service-users realising their own strength (cited in Törrönen,
M et al, 2001). As Social workers have the authority to make decisions and were initially involved in the service-users being detained in hospital this can make service-users feel there will never be equal sharing of power. Groupwork can help others feel empowered by feeling part of a group and through a process of self-discovery. The ability to draw on resources gained from their own experiences, rather than depend on professional intervention, is the foundation from which empowerment and resilience develops. Service-users often enter psychiatric hospitals feeling demoralised; they are unable to help themselves let alone others. The experience of being valuable to other service-users enhances their sense of self-worth.
As Preston-Shoot states groupwork creates a ‘sense of belonging and mutual identity’ (Seden, J. pp356- 365). The group made people feel less isolated, and by sharing experiences helped to build self-worth. Feeling valued and connected to others help individuals to challenge discrimination and oppression, only by working together can changes begin (Piven and Cloward, 1993). By sharing experiences service-users became more resilient and able to resist personal blame about their illness or present circumstances. Within the group, individuals were able to develop relational strategies. Although I was working with a group it was important to recognise and understand the diversity and different characters and human experiences that have formed individual identities. Culture refers to more than someone’s ethnicity and is unique to each person’s life experience and this can include oppression, poverty, marginalisation and exclusion. It was vital I recognised how although each person in the group was different they may experience some similarities for example through their diagnosis they may have experienced discrimination socially, economically and been oppressed and marginalised by society. But in groupwork, issues of power are central, and many people participate in groups because they feel they lack power. Groupwork has a place in social work but power imbalance can impact on individuals and the group as a whole. Groupwork provides opportunities for service-users to share their expertise but this comes with a risk, a combination of groupwork and person-centred may provide the best outcome for service-users.
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