Social Work and the Rehabilitation of Mental Health Patients

SOCIAL WORK AND THE REHABILITATION OF MENTAL HEALTH PATIENTS

ERNEST OSAS UGIAGBE, MSW, PhD DEPARTMENT OF SOCIAL WORK UNIVERSITY OF BENIN BENIN CITY Mobile: +2348023257639 E-mail: [email protected]

HELEN E. EWEKA MSc DEPARTMENT OF SOCIAL WORK UNIVERSITY OF BENIN BENIN CITY [email protected] Mobile: +234805590310

Dr Ernest Osas Ugiagbe lectures in the Department of Social Work, Faculty of Social Sciences, University of Benin, Benin-City, Edo State, Nigeria with research interest in gender, social policy legislation, and poverty and community development. He is a beneficiary of SWIN-P grant of CIDA and currently engaged in gender and community development initiatives and advocacy in Nigeria

Helen Ehizogie Eweka MSc, lectures in the Department of Social Work, Faculty of Social Sciences, University of Benin, Benin-City, Nigeria, with teaching and research interest in School Social Work, gender and youth development. She is a beneficiary of the SWIN-P grant. She is an active and committed member of the Girls Guide of Nigeria where she is currently involved in youth and community development programmes in addition to her academic calling. SOCIAL WORK AND THE REHABILITATION OF MENTAL HEALTH PATIENTS

Abstract

This study examines the role of Social Workers in the Social Welfare unit of the Federal Neuropsychiatric Hospital in the care, management and rehabilitation of the mentally ill people in the hospital. The methodology of data collection was the content analysis of the records made available for the study by the hospital. This was supplemented with personal observations and interactions with the medical personnel, some family members of the clients of the hospital and other stakeholders in the context of the curative and rehabilitation measures in the recovery processes of the clients. A total of 120 cases were analysed for the study using the SPSS and chi square statistic. The results of the analysis show that factors like bio-data of the individual and social capital base impact heavily on the recovery and rehabilitation of the mentally ill people. This has a serious implication for policy development and social work services in the context of concrete social policy development and advocacy by social workers in Nigeria.

Keywords: Social work, Rehabilitation, Mental Illness, Therapy, Social differentials, Social Welfare

Introduction

Mental disorders are important co-morbidities of physical illness and contributors to suicide, and they affect the financial capacity to effectively address other health problems. Mental health disorders are a problem of extreme importance, due to their high prevalence (there are estimations that suggest that between 15 and 25% of the general population suffer from them and due to the impact of suffering and disintegration in the people, their families and their closest environment (Parabiaghi et al, 2006).

Psychiatric disorders are leading causes of morbidity in the community, but most persons with such disorders do not receive appropriate care. Addressing unmet needs by increasing access and improving the quality of services are a major goal of mental health services research and service delivery system. Some progress toward this goal has been achieved through the development of effective and cost-effective social work and allied delivery interventions (Murray, 1996; Young et al, 2001; Wang et al, 2000). Current

2 challenges for health services and social work interventions are to strengthen, sustain, and disseminate prentice interventions that improve the quality of care, promote access for those with unmet need, and increase efficiency so that care is affordable for all. (Wells et al, 2000).

Mental-health conditions which include behavioural and mental health problems e.g. depression, anxiety disorders (including post-traumatic stress disorder) and disruptive behavioural disorders (such as attention deficit hyperactivity disorder, mood disturbances, substance use, suicidal behaviour, and aggressive/disruptive behaviour) are leading causes of adjustment problems in adolescents, young and old people worldwide. Attention has been drawn to global mental health moves beyond treatment-oriented programmes and service- care in health setting to include broader approaches inspired by public health and social- inclusion considerations (Horton, 2007).

Despite the fact that the main treatment for people with serious mental illness has been pharmacological interventions since they were introduced in the fifties of the last century, the partial and hinted control of the symptomatology, the short and long term side effects, and the poor treatment adherence of quite a considerable percentage of people affected pose the need to use a broader approach medical treatment is a compliment with other psychotherapeutic and psychosocial social work interventions which must be efficiently coordinated and applied to help them recover from acute episodes and from the functional deficit during the episodes and between them (Mental Health of the National Health System,

2006).

This study focuses on role of the social workers in the social welfare unit of the

Federal Neuropsychiatric Hospital, Benin City in the treatment, management and recovering of mental health patients in the hospital. The study evaluates the roles of social workers in the recovery of mental health cases taking into consideration their activities within and outside the hospital setting geared toward the total recovering of the mental health cases.

3 Statement of the Problem

Mental health is a public health issue. Mental illness is the largest single source of burden of disease in both advanced nations and developing world. No other health condition matches mental illness, in the combined extent of prevalence, persistence and breadth of impact

(Friedil and Parsonage, 2007). Mental illness is consistently associated with deprivation, low income, unemployment, poor education, poorer physical health and increased health risk behaviour. There are large personal, social and economic costs associated with mental illness

(WHO, 2008).

Mental illness refers collectively to all diagnosable mental disorders. Mental disorders are health conditions defined by the experiencing of severe and distressing psychological symptoms, to the extent that normal functioning is seriously impaired, and some form of help usually needed for recovery. Symptoms may include anxiety, depressed mood, elation, hallucinations, delusions, obsession thinking or compulsions. Mental illness can affect an individual’s thought process, perception of reality, emotions and judgement and can result in low self esteem, poor concentration, poor organization skills and an inability to complete projects and make decisions. Individuals may also have difficulty in establishing support systems and sometimes display inappropriate behaviour. Common mental health disorders include: depression, anxiety and panic, bipolar disorder, behavioural disorders, obsessive- compulsive disorder, phobias, psychosomatic problems, schizophrenia and eating disorders

(Coyle et al, 2007).

The provision of long-term mental health care for people with mental disorders has been, and still is one of the major challenges for mental health systems in the last decades.

This is because mental disorders though have low prevalence, have huge financial and emotional toll and impact on individuals, families and society (WHO, 2008). The care of

4 mental health illness has advanced in the last decades. This entails the services of medical doctors, nurses, pharmacists, psychologists, social workers and other allied professions. This trans-disciplinary models of practice aim at providing individual-family-community centred, coordinated, and integrated services to meet the complex needs of mental health patients and their families (Carpenter, 2005). The trans-disciplinary approach has been recognised as a best practice for early intervention (Bruder, 2000; Guralnick, 2001).

Trans-disciplinary service is defined as the sharing of roles across disciplinary boundaries so that communication, interaction and cooperation are maximised among team members in the care of people with mental disorders (Davies, 2007). This brings about the facilitation of professional development that enhances therapists’ knowledge and skills

(Wamer, 2001). Social workers are part and parcel of the modern team that care for people with mental disorders. The social work profession has a vested interest in focusing its attention on the contemporary recovery paradigm in mental health problems. Social workers have played a significant role in providing care for people with serious mental disorders since the professions’ earliest years and continue to do so.

Social workers constitute one of the largest groups of practitioners in the mental health field (Bentley, 2002). Social workers, along with influential physicians, helped raise the awareness that people discharged from mental institutions were indeed in need of assistance when returning to the community as much as they need attention while on admission or institutionalized in mental health hospitals. Social workers are part of the medical team which takes care of the social-psychological aspect of the healing or recovering processes within and outside the health institutions (Schaefer Vourlis et al, 1998).

This study attempts to identify, critically appraise and evaluate the roles of the social workers in the social welfare Unit of Federal Neuropsychiatric Hospital, Benin in the treatment, care and recovery of the people with mental disorders in the hospital. This study

5 specifically evaluates the therapeutic approaches and other social work intervention methods in the care of the mentally ill people in the hospitals.

Conceptual Clarification and Literature Review

Mental illness is a deceased condition which is deemed undesirable for both the affected individual and the society because it affects adversely the normal functioning of the mental, psychological and emotional make-up of the individual and so it makes the capacity for insight, orientation, judgement, thought, mood and perception blurred (WHO, 2001; WPA,

2002). The mentally sick people constitute nuisance since their consciousness is affected, this is why they need treatment and rehabilitation. Social workers constitute an integral part of the multi disciplinary treatment team of the mentally ill people all over the world. Clinical social work specialists are actually the group of social workers that are involved in the treatment, recovery and rehabilitation of the mentally ill people.

Rehabilitation services for people with a mental illness are provided in a variety of settings, from secure to residential and within the people’s own home. Mental health rehabilitation services are provided in a recovery oriented way and are informed by the framework for recovery oriented rehabilitation in mental health care (Green, 1996).

Rehabilitation services by health workers including social workers provide specialist assessment, treatment, interventions and support to help people to recover from their mental, health problems and to regain the skills and confidence to live successfully in the community.

A whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leading to successful community living through appropriate support from trained professionals and the community (Craig et al, 2004). Conceptually, this study defines rehabilitation as actions geared towards helping people to find the right combination of services, treatments and

6 supports and eliminating discrimination by removing barriers to full participation in work, education and community life is the key to the promotion and adoption of a recovery-oriented culture with mental health services.

According to the National Association of Social Workers (NASW, 2005), clinical social workers constitute the largest group of behavioural health providers in the United

States and Western Europe. More than 60% of mental health treatment is delivered by social workers. Social work involvement in the fields of substance, abuse and mental health is prevalent and expected to rise (Pilling et al, 2002; Bureau of Labour Statistics, 2010).

Social works first direct involvement in the care of people with severe mental illness

(SMI) began in the first decade of the 1900s, as the new profession started to carve out a piece for itself in mental health in the form of aftercare. Social work profession has a vested interest in focusing its attention on the contemporary recovery paradigm. Social workers have played a significant role in providing care for people with SMI since the profession’s earliest years and continue to do so. Currently, social workers are employed in multiple mental health settings and fill a variety of roles including that of case manager, therapist, crisis counsellor, programme evaluator, administrator and policy analyst (Bentley, 2002). In Nigerian hospitals, the social welfare unit is usually occupied by trained social workers who perform all the roles listed above rolled into one – social welfare officer(s).

Taylor (2006), notes that in certain social work publications, the authors condemn virtually all aspects of the medical model including biological understanding of mental illness. In the study conducted on this issue, Lalasse& Wilber (2006) concluded that a one- sided approach to mental health was being taught, with the biomedical approach dominating.

The reported Wilber’s four quadrant approach is a unifying framework for integrating various theoretical paradigms. This is because both strive for human well-being, empowerment of people, client self-determination, promotion of client capacity, emphasis on environmental

7 factors, and willingness to incorporate recognised relevant knowledge, including that which is empirically based (NASW, 1999).

Wilber’s (2006) integral approach allows for a more comprehensive form of holism than what has been available to the profession thus far (Larkin, 2006). Recently, the social work academic and practitioners community has been considering and critiquing the idea of evidence-based practice, an important paradigm shift designed to promote the consistent use of scientifically validated information and effective interventions in social work practice

(Cournoyer& Powers, 2002; Rosen, 2003; Ganbrill, 2003). Evidence-based practice may be thought of as a process undertaken by professionals wherein the scientific status of potential interventions is investigated and a thorough explication of the results is shared with clients and appropriate steps for addressing a specific problem taken (Franklin & Hopson, 2004).

Objectives of the Study

The primary aim of the study is to underscore the role of social workers of the Federal

Neuropsychiatric Hospital, Benin City in the treatment, care and recovery processes of people with mental disorders. Other specific objectives are to:

 Examine the modus operandi of social workers in the social welfare unit of the

Federal Neuropsychiatric Hospital, Benin City.

 Identify the strengths and otherwise of the intervention approaches in the handling of

mental health cases in the hospital.

 Evaluate the outcome of the intervention approaches in the context of their recovering

process and afterwards i.e. outside the confines of the mental institution.

 Assess the bio data and other social differentials and their impact on the mental health

of inmates of the hospital under study, and how these factors affect the recovering

processes and the overall outcome of the intervention process of social workers in the

8 health settings using the Federal Neuropsychiatric Hospital, Benin City as a case

study.

Scope of the Study

This study is limited to the evaluation of the effectiveness of the therapeutic approaches to the care and rehabilitation of the recovery phase of people with mental health disorders. This entails the evaluation of the paradigm of recovery and well-being in the contexts of the cases of mental illness being treated in the hospital. The processes of psychopharmacological treatments are outside the scope of this study.

Methodology

There were many sources of information for this study. This situates the methodology in a personal and social context.

Data Sourcing/Study Setting

The descriptive survey design was adopted for this study. The records of the social welfare unit of the Federal Neuropsychiatric Hospital was utilised for this study. The records details the bio data, and other personal records of the patients, the day of admission, the diagnosis and symptoms of mental illness and the methods adopted by the social workers in the social work unit of the hospital used as a case study for this study. The content analyses of the record made available for this research constitute the crux of the source and sampling method of this study.

The study was conducted in the Federal Neuropsychiatric Hospital, Benin City, Edo

State, Nigeria. The ethical issues were earlier settled with the expressed permission from the

Hospital Ethics Committee and the Research Advisory Panel. Data for the study as earlier mentioned were collected from the records of the social welfare unit and other relevant departments. The records of the in-patients and out-patients of the hospital were made

9 available to the study team during the month-long visits to the hospital. The data from the records were augmented with observations, interactions and interview of some key staff of the hospital. During the visits, the researchers participated in the therapy sessions and home visits of the clients by the hospital staff.

Data Analysis

The data collected through the primary and secondary means were analysed using the

Statistical Package for Social Science (SPSS 11.0). The data collected were resolved to their constituent components and themes, and simple percentage, means and frequencies were calculated as appropriate.

Table 1 : The Socio-Demographic Characteristics of All the Respondents

Socio-Demographic Characteristics Response Frequency Percentage SEX OF Male 57 47.5 PARTICIPANTS Female 63 52.5 Total 120 100.0 AGE OF 20 - 49 96 80 PARTICIPANTS 50 – 79 24 20 Total 120 100 MARITAL STATUS Single 66 55 Married 54 45 Total 120 100.0 RELIGIOUS Christianity 118 98.3 AFFILIATION Islam 2 1.7 Total 120 100.0 EDUCATION Primary School 12 10 QUALIFICATION Secondary School 48 40 Diploma/HND 12 10 N.C.E. 15 12.5 B.Sc. 18 15 Non-Applicable 15 12.5 Total 120 100.0 OCCUPATION Unemployment 81 67.5 Artisans 24 20

10 Working Class 15 12.5 Total 120 100.0 PARTICIPANTS BY Undifferentiated 24 20 DIAGNOSIS/SYMP Schizophrenia TOMS Several Depression 6 5 Hebephrenic 3 2.5 Schizophrenia Dependency 12 10 Syndrome Paranoid 18 15 Schizophrenia Mania with 6 5 psychotic symptoms Bipolar affective 6 5 Alcohol dependent 6 5 Delusion 3 2.5 Psychotic disorder 9 7.5 schizophrenia None 27 22.5 TOTAL 120 100.0 Source: Fieldwork, 2014.

CROSS TABULATION Table 2: There is a relationship between social capital and mental health

Occupation/Profession Status of Health Total of the respondents No Improvement Stable improvement Unemployment 21 (100.0%) 15 (100.0%) 45 81 (53.6%) (67.5%) Artisan 0 (.0%) 0 (.0%) 24 24 (28.6%) (20.0%) Working Class 0 (.0%) 0 (.0%) 15 15 (17.9%) (12.5%) Total 21 (100.0%) 15 (100.0%) 84 120 (100.0%) (100.0%) X2 = (N = 120, df = 4) = 24.762, P < .000

11 The result from the table shows that out of the respondents that did not improve in their mental health 21 (100.0%) were unemployed while there were no artisan and working class respondents. Among those respondents who had improvement in their mental health, 15 (100.0%) were the unemployed respondents and none was an artisan or working class. Those respondents who had stable mental health, 45 (53.6%) were the unemployed respondents while

24 (28.6%) were artisans and 15 (17.9%) were the working class. The implication is that the ability to have a stable mental health or not depends on the social capital of the respondents. The chi square value shows a significant statistical relationship between the social capital of the respondents and mental health status.

Table 3: Social differentials like sex has strong impact on mental health

Sex Status of Health Total No Improvement Stable improvement Male 21 (100.0%) 15 (100.0%) 21 (25.0%) 57 (47.5%) Female 0 (.0%) 0 (.0%) 63 (75.0%) 63 (52.5%) Total 21 (100.0%) 15 (100.0%) 84 (100.0%) 41 (100.0%) X2 = (N = 120, df = 2) =56.842, P < .000

The result of the above table shows that more males 21 (100.0%) than females 0 (. 0%) of respondents have no improvement of mental health while male 15 (100.0%) than female 0 (.0%) had improvement of mental health and as against males 21 (25.0). and females 63 (75.0) respondents who had stable

12 mental health. The chi square test value shows a significant relationship between sex and stability mental health.

Table 4; Social differentials like age has strong impact on mental health

Age Status of Health Total No Improvement Stable improvement 20 – 49 21 (100.0%) 15 (100.0%) 60 (71.4%) 96 (80.0%) (Younger respondents) 50 – 79 (Older 0 (.0%) 0 (.0%) 24 (28.6%) 24 (20.0%) respondents) Total 21 (100.0%) 15 (100.0%) 84 120 (100.0%) (100.0%) X2 = (N = 120, df = 2) =12.857, P < .002

In the table above, the respondents’ ages were divided into two, the younger respondents and the older respondents. To get each of the groups, those respondents whose ages were between 20-49years belong to the younger respondents while those who were 50years and above were the older respondents.

The result from the table shows that out of the respondents that did not have mental improvement, 21 (100.0%) were younger respondents while none was an older respondent. Among those respondents who had improvement in their mental health, 15 (100.0%) were the younger respondents and none was an older respondent. For those respondents who had stable mental health, 60

(71.4%) were the younger respondents and 24 (28.6%) were the older

13 respondents. Therefore, the ability of the respondents to have stable mental health or not is dependent on the ages of the respondents. The chi square value shows that age has an impact on mental health of the respondents.

Table 5: Social differentials like age has strong impact on mental health

Marital Status of Health Total status No Improvement Stable improvement Single 21 (100.0%) 15 (100.0%) 30 (35.7%) 66 (55.0%) Married 0 (.0%) 0 (.0%) 54 (64.3%) 54 (45.0%) Total 21 (100.0%) 15 (100.0%) 84 (100.0%) 120 (100.0%) X2 = (N = 120, df = 2) =42.078, P < .000

The result from table 5 above shows that out of the respondents that did not have mental improvement, 21 (100.0%) were singles while 0 (.0%) was married. Among those respondents who had improvement in their mental health, 15 (100.0%) were the singles and none was married while those respondents who had stable mental health, 30 (35.7%) were the singles and 54

(64.3%) were the married. Therefore, the ability of the respondents to have stable mental health or not is depends on the marital status or stability of the respondents. The chi square value shows that marital status has impact on mental health of the respondents.

Discussion and Finding

The results of the analysis of the data show that majority of the mentally ill people in the hospital are Christians, unemployed and artisans. The singles i.e.

14 without committed partners are also in the majority. The people with low level of education are also in the majority. The import of these results is that the people who suffer more mental breakdown belong mainly to the lower class.

This may not be unconnected with the harsh socio economic conditions in of

Nigeria where the poor are becoming poorer by the day and the fortunes of the lowly are waning and declining every day. Depression, schizophrenia, manic attacks, bi-polar effects amongst others easily develop as a result of the poor coping mechanisms and social capital base of the individual are unable to withstand the onslaught of severe economic deprivation and emotional trauma.

The functional causal factor of schizophrenia is thereby justified and proven.

The dwindling economic fortunes of Nigerians result in individualistic lifestyles whereby rich people avoid the “extra” responsibility and hence the poor lonely and jobless are further isolated and the social exclusion further compounds the psyche order of the people.

The result of the analysis also reveals that schizophrenia and other related mental ailments like depression, dependency and delusions dominated the ailments of most of the patients of the hospital (see Table 7). For example, undifferentiated schizophrenia is 20% while hebephrenic schizophrenia and psychotic disorder are 2.5% and 7.5%.Respectively

The medical action and social work intervention models show that those tested with drugs, therapy and counselling were 81 (67.5%) while those treated

15 with drugs, admitted and counsel thereafter were 15 (12.5%). Those treated with drug only were 24 (20%).

On the issue of their health statutes after a period of treatment and intervention by the social workers and other health professionals, most of the patients responded positively to the treatments, rehabilitation, etc. For example, those with stable health were 84 (70%) while those who have improve considerably were 15 (12.5%) of the total in-patients. However, 21 (17.5%) of the patients did not show any significant improvement in their health status.

This shows that the combined team of medical, pharmaceutical, psychological and social work personnel interventions show positive results in treating mental health patients.

Specifically, social work intervention models outcome is also remarkable.

The combination of problem solving/family therapy and rehabilitation is the main approach/model of the social workers in the social welfare unit of the hospital used for this study. The effectiveness of this model and the crisis intervention in the rehabilitation of the mental health patients is a pointer to the effectiveness of a compendium of community/family therapeutic approach in the rehabilitation of mentally ill people. The involvement of the family and community appears to be a more veritable rehabilitation model because of the tenets and positive sides of multi therapeutic/counselling approach of this type.

The working members of the patients according to the cross tabulation manifest stable health because of perhaps their social networking and capital base and the

16 hope of bright future outside the confines of the health institution. The status of health of the sexes also manifests some puzzle; while the health of the females remains relatively stable there were adulation in the health recovery process of the males. This may be as a result of the societal value systems which place more burden of catering for dependants on the males members of the society.

While all the 63 (75%) of the inmates were females and experience stable health, 21 of the male inmates and 15 males show no improvement while only

21 (25%) manifest stable health status.

The younger members of the inmates of the hospitals were in majority and their health status also varies from no improvement (20), improvement (15) to stable 60 (71.4%). On the other hand, all the older patients manifest stable health. This may be attributed to the worry about life issues and the fear and apprehension of failure and stigma. Similarly, the married patients also manifest stable health status after a period of time. This may be as a result of comfort and assurance from their spouses unlike singles who suffer isolation, social exclusion and trauma as a result of stigma and abandon anxiety. This perhaps explains why all the 54 (64.3%) of the married patients manifest stable health as against 30 single patients who manifest stable health while 21 inmates show no sign of improvement.

Implication for Policy Development and Social Work Service

The results discussed above lend credence to the positive side of psychosocial counselling and community rehabilitation approach to mental

17 health treatment and recovering processes. There is therefore an urgent need to fully incorporate the other social health practitioners into the main stream of mental health policy in Nigeria. The present situation in Nigeria where too much emphasis is placed on medical treatment and the social aspect of individual health is neglected. A lot of gains are always made when there is team work in the treatment of medically ill people, but in Nigeria ‘power’,

‘knowledge’ and ‘authority’ revolve round the Doctors, Pharmacists and Nurses to the detriment of Social Workers. This is not the case in advanced nations of

Europe and North America. There should be policy and paradigm shift to include social workers who actually ensure that healing and recovery processes are concluded positively.

In the teaching and education of prospective social workers, emphasis should be placed on practical and on the job learning backed up by strong theoretical orientation. Clinical social workers should be given specialized training to handle effectively the demands of complex mental ailments of the modern human society especially Nigerian society that is characterised by hardships and trauma.

Conclusion

Mental ailment is unarguably on the increase in Nigeria. The medical personnel alone cannot and have never effectively treated mental health disease in recent times. The medical social workers are specially trained to ensure total

18 recovery and rehabilitation of mentally ill people. The intervention models of social work encompass the individual, family and community. This is why the government needs a rethink in the present dispensation and to involve social workers from the on-set in the treatment and recovery of mentally ill people.

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