Placement Three - Critical reflection The WritePass Journal

Placement Three - Critical reflection Introduction Placement Three Critical reflection IntroductionDiscrimination and empowermentLinking theory to practiceEmotional intelligenceLegislationRiskRehabilitationMulti-professional working SupervisionConclusionReferencesRelated Introduction According to Doel (2010) social work placements provide not just the opportunity for practice learning, ‘they are about a wider philosophy, linking practice to academic learning, research and continuing professional development’ (p4). Consequently, placement forms an integral part of the journey of Social Work Education.  Ã‚  My third and final placement has been within the Social work team on Thames ward, River House, Bethlem Royal Hospital which is a Medium Secure Psychiatric facility providing treatment and rehabilitation for 15 male, mentally disordered offenders with a diagnosis of mental illness and or personality disorders. Through this critical reflection on my placement I will be looking at my learning in areas such as law and policy, risk, linking theory to practice, communication and multi-professional working which have all formed an integral part of my placement. Moreover, I will also be exploring my learning and personal development in areas such as anti- discriminatory practice, reflective practice and the role of supervision in my development throughout placement.   Having successfully completed all of my academic modules as well as two practice placements I felt somewhat better prepared for this placement than I did with my first. I felt that I had grown as a professional and now possessed proven practical skills. Moreover, I felt more confident in my ability to work with service users; linking social work theories and values to my practice.  Ã‚  However, having no experience of working with this service user group I felt slightly anxious about my placement, especially as it was within a Secure Unit and that I would be working with purely male service users. This was not helped by my first visit to River House, the high perimeter fences and strict security procedures led to me feeling that I was entering a prison as opposed to a hospital environment. Upon reflection I felt that my anxiety was largely due to my negative preconceptions about mental illness especially my belief that mentally ill people are violent, unpredictable, and dangerous. These views were not only a result of a lack of knowledge about mental illness and personality disorders but also about the influence of negative media and cultural stereotypes that I had grown up with. I realised that these views were something that I would need to continually be aware of throughout this placement so as to work in an anti discriminatory manner (Unit 19). According to Thompson (2006) good practice is anti-discriminatory; therefore, being aware of avoiding assumptions which are discriminatory or oppressive can contribute positively to empowerment of service users. Mullen (2000) highlights that forensic mental health involves the assessment and treatment of those who are both mentally disordered and whose behaviour has led, or could lead, to offending (p309). Additionally, McInerny (2004) highlights that although secure hospitals are not prisons it is important that the relationship between security and therapy is properly managed. Through working as part of the clinical team I came to understand that the role of the unit is the treatment and rehabilitation of the patients with a large focus on risk management and care planning. I initially found it challenging to not look at patients from a purely medical perspective, for example by immediately attributing patients offending as a consequence of their mental illness. I benefited from a teaching session with the Clinical psychiatrist who clarified that mental illness does not cause patients to commit crimes rather, the propensity to commit a criminal offence is demographically determined. Additi onally, I learnt that certain mental illnesses gave patients the propensity to commit particular crimes for example that there is a link between personality disorders and antisocial behaviours. Discrimination and empowerment Although patients were transferred on and off the ward throughout my placement I noted that there were disproportionate amount of black African and Caribbean men on the ward. As the placement progressed I noted that that throughout River house black and ethnic minority men formed a large proportion of the patients. A number of studies including one by Harrison (2002) have found that in comparison African-Caribbean men are more likely to be admitted to psychiatric hospitals, diagnosed with schizophrenia and sectioned under the Mental Health Act. Additionally a 2008 mental health services census found that that overall rates of detention were higher than\ average among the black Caribbean and black African men by 20 to 36 per cent (Commission for Healthcare Audit and Inspection 2008). According to Harrison (2002) negative attitudes towards mental distress can be compounded by other forms of discrimination such as race for example the belief that black men are more likely to be violent than their white counterparts. The majority of staff on the ward including myself and my practice teacher were from black and ethnic minority groups and I initially wondered whether the patients took this as a positive and empowering factor in that they could identify with the nurses and social worker.   Conversely, whether given that those who could be said to hold the ‘real decision making power’ such as the psychiatrist were white, additionally the majority of the ethnic minority staff were female, I wondered whether the patients felt disempowered by this. However as the placement developed it emerged that all professionals on the ward worked in unison and that decisions were always made by the multi professional team as a whole (Unit 17). I felt that this projected a message to the patients that none of the professional worked in isolation; as such they could attribute respect to us all as part of their care team. I found that that there was a good level of patient involvement in their own care plans as wells patients’ views being taken into consideration in decision making processes. Consequently I felt that this helped to empower the patients to a degree (Unit 5, Unit 7). Chinman et al (1999) contends participation treatment planning can also be empowering, in addition, that people with severe mental illness being able to actively participate in designing their own treatment plans could lead to an improved self-image and a greater likelihood that they will reach their treatment goals. However, authors such as Rosenfeld and Turkheimer (1995) and Linhorst et al (2002) argue, the severity of mental illness can be the main barrier to empowerment as some patients may lack the full capacity to process information, weigh choices and make informed decisions about their treatment. Furthermore, there is a danger that some patients especially those who have been in-patients for extended periods of time, may have become institutionalised or dependant on mental health services and as such do not ever have a fully desire to engage in and progress through patient recovery pathways. According to Golightley (2004) social workers need to work in unison with medical and other health professionals whilst remaining at the forefront of processes that include and empower services users. As a result I found that it was important to develop as good of a relationship as I could with each of the patients I worked with (Unit 1, Unit 2, Unit 5). According to Mason (2011) â€Å"Relationships are recognised as an integral and influential component of the therapeutic process and highly influential within service users’ care and treatment. This is even more important due to the power imbalance exists between patients and professionals† The patients on the ward engage in many therapeutic activities including groups such as understanding mental illness, index related work, substance misuse. Although patients may find it empowering to engage in therapeutic activities and groups as these would aid their recovery and rehabilitation; this for me raised questions about the power that professionals hold over the patient as well as the genuine nature of the patient’s engagement. That is because patients engagement in such activities directly correlated with the amount of progress they made towards discharge. Authors such as Lowry (1998) argue that within forensic mental health settings, patients are contained in an environment which automatically restricts choice, and autonomy. Consequently, the focus has tended to be on ‘compliance’ rather than active service user ‘engagement’ in therapeutic interventions. Rogers et al (1997), defined empowerment as â€Å"the connection between a sense of personal competence, a desire for and a willingness to take action in the public domain’’. Through my time on the ward I directly empowered patients in a number of ways (Unit 2, Unit3, Unit 5, Unit 6, Unit 10). This includes ensuring I incorporated their views in my assessments and allowed them to read my assessments and raise any concerns that they had before the final drafts were submitted (Unit 3, Unit 11, Unit 14, Unit 16 ). Moreover I ensured I gained their consent to gather information about them from their family or other services. I ensured that I provided patients informed choice over how they handle their finances as some patients’ finances were managed by their family. Additionally, I did some specific work supporting a patient to re-establish contact with his sister where he had previously no contact with any family members. I also supported another patient to make an informed decision about his relinquishing the tenancy of his flat. Although these patients have no choice about being in hospital I found that being able to make such decisions and take corresponding actions was very empowering for them. This is supported by Jones Meleis (1993) who contend that empowerment is both process and outcome, which encompass people’s rights, strengths and abilities, implying competence or the development of potential. Linking theory to practice Being in a hospital environment there was undoubted a large emphasis on the medical model in which mental health is looked at in relation to illness and illness management. However, especially where a patient was due to be discharged great emphasis was placed on the social model which included the understanding that social exclusion and stigma could present as ‘the greatest barrier to social inclusion and recovery’ for the patients (Social Exclusion Unit 2004). This is because of society’s negative perceptions about people with mental health problems can lead to them being stigmatised, labelled as being violent, and dangerous. Although at the beginning I held some of these views, working closer with the patients on my ward, as well as spending time in community hostels and community mental health teams, I came to see how difficult it is for our patients to reintegrate back into society and the anxiety that this caused them prior to discharge (Unit 19). This is bec ause they not only suffered from a mental illness but the fact that they had also been through the criminal justice system, leading to them possibly suffering discriminated on multiply grounds. Thus with regards to my role I found that the social model in addition to the dominant medical model formed the underlying rationale for the work I did. Through conducting various assessments I was able to gain a better appreciation for the need to take a multi-faceted approach in working with patients and as such developed my ability to link social work theories to practice. According to Golightly (2008) the likely cause of mental disorder is a complex interaction between a range of factors; encompassing biological, psychological and social factors (p36). Consequently, mental health should always be addressed from a perspective that ‘reflects the understanding that human beings are biological, psychological and social creatures all at the same time’ (Dombeck and Wells-Moran, 2006, p52) (Unit18). Using Collingwood’s (2005) model I noted that I used theories such as systems theory, theories on attachment and loss, as well as a biological and psychological models to inform my practice and assessments. A systemic approach takes the view that an individual is best understood through assessing the interactions within their family, community and wider socio-political environments (Payne 1997, p123). This is important especially as the majority of our patients fit within a particular demographic that being males from ethnic minority backgrounds many of who have experienced disadvantaged upbringings and disruptive family backgrounds. This is also the reason why theories relating to attachment and loss are pertinent in informing assessments. Biological and psychological models provide an important basis for the formation of understanding, treating and managing mental illness and personality disorders.   Through this placement I have learnt that it is important to combine know ledge from these theoretical perspectives in order to produce a comprehensive assessment (Unit 1, Unit 2, Unit 3, Unit 6). As well as theories which are used to inform practice there are also theories which are used to intervene, these include biological and psychological models through the use of medication and both group and individual therapies. I found that I largely took a person centred approach in working with the patients especially in the assessment process in that I strove to identify what was important to the patient from their own perspective and strove to find appropriate solutions (Brewis, 2007, p.4) (Unit 18) . In doing so, I also used task centred practice. According to Howe (1987 p82) in task centred practice, problems are defined as identifiable pieces of behaviour, goals are set and mutually agreed with service users, involvement proceeds by way of small sequential, manageable steps. Payne (1997) argues that task centred work aims for collaboration between worker and client to target problems where the goal is to utilise, extend and consolidate the service users strength and abilities (p.108). However Doel (1994) argues that although this would not be an equal partnership, in the sense that powers roles and responsibilities would differ, however, true partnership is open about these differences as ‘partnership should be based on a common understanding of the reason for doing the work’ (p30). For example after undertaking an assessment of a patient I would give them the assessment to read within a given time frame and ask them to make note of any errors or questions that they had about their assessment. As with my first placement I learnt that the process of assessment is an intervention within itself in that I was able to challenge patients to think about their overall progress as well as specific inappropriate behaviours, but also to look into their insight into their mental illnesses and index offences (Unit 9). Underpinning my use of theories are the social work values, in this placement there was a heavy focus on anti-discriminatory practice, advocacy and empowerment (Unit 19). Moreover, I learnt that as a professional I was also a resource in that I was able to communicate patient needs and concerns to the clinical team, advocate for and provide information to the patients where necessary (Unit 10). I felt that as the placement progressed and my knowledge in areas such as the Mental Health Act 1983 (as amended by the Mental Health Act 2007) and awareness of support services and agencies increased, I was able to provide a better service to the patients. Emotional intelligence During both my first and second placements I developed a greater understanding of the term ‘emotional intelligence’ as developed by Salovey and Mayer (1990). Emotional intelligence is about being an aware of my own emotions and the need to not only manage but also to reflect upon them so as to see how they might affect my interactions with patients and ultimately how they impact upon my assessments (Unit 18, Unit 20). According to Howe (2009) emotional intelligence can have an affects on behaviour, I found that this was important to note as from the onset of this placement I was aware that I held negative stereotypes about mental illness and as such was concerned as to how this would affect the way that I worked. According to Taylor and White (2000) ‘the assumptions we have about social problems and the people who experience these problems have ethical and practical consequences’ (cited in D’Cruz, Gillingham and Melendez (2007). I found that as the pl acement progressed and as I gained greater knowledge and understanding of mental illness and personality disorders I was able to overcome some of my fears and prejudices. However, due to the nature of the work I always remained aware of the potential risks and the need to manage this risk by for example carrying my ASCOM alarm at all times whilst on the ward, ensuring I sat close to exits and alarms when alone with patients in the interviews rooms etc. (Unit 13). I felt that my ability to manage and reflect upon my own emotions and those of others was tested during this placement especially on one occasion when I felt caught in an ongoing issue between a challenging patient and his family (Unit 20). In this instance in as much as I could understand the family’s concern about the patient, who was spending his money erratically, I tried to impart on the family the many difficulties I was faced with in working with the patient. However it soon emerged that, as I continued to liaise with the patient and his family, both parties were challenging to work with. This was due not only to the patient’s perception that decisions were being made about him without his involvement but also the families concerns that the patient was being allowed to spend his money despite there being a ward policy in place allowing only  £40 weekly. In this situation I found it difficult to manage the patients emotions (especially as he was quite unwell at times became verbally aggressive), those of the family as well as my own and had to turn to the multi disciplinary care team to help me to deal with the situation (Unit 17). My ability to manage and contain the emotions of others was also tested whilst shadowing my Practice Teacher in her capacity as an Approved Mental Health Professional. In this instance a decision was made to assess a man under section 2, Mental Health Act, (1983, amended in 2007), who was felt to be suffering from a mental disorder. The police were called due to the fact that he had assaulted one of the assessing psychiatrists and he needed to be safely conveyed to hospital to minimise further risk to others. I found the whole experience quite difficult to handle emotionally, especially as I spent the majority of the assessment with his mother who became quite very distressed at seeing her son being taking away by police even if it was to hospital for treatment. I found remaining calm and professional in this instance very difficult in that dealing with the emotions his mother as well as the chaotic manor of the situation was quite overwhelming. Upon reflection I feel that this situa tion highlighted some of my initial reservations about working with mentally ill service users but it also highlighted to me the impact that mental illness can have on the families of the patients. The situation also highlighted that I needed to continue to build my emotional resolve as I would undoubtedly experience more distressing situations in my role as a qualified social work practitioner (Unit 20). Legislation Similar to my first placement I quickly learnt how legal and policy requirements direct practice, with the Mental Health Act (1983) as amended by the Mental health Act (2007) being the main legal instrument in use in this setting. The Mental Health Act (1983) covers the detention of people who are deemed to be a risk to themselves or others. The Act sets out the legal framework for the care and treatment of mentally disordered persons, by providing the legislation under which people suffering from a mental disorder can be detained in hospital to have their disorder assessed or treated against their wishes (Unit 18). The Act gives powers for Crown or Magistrates Courts to remand an accused person to hospital either for treatment or for a report on their mental disorder. It also provides powers for a Court to make a hospital order for the detention in hospital of a person convicted of an offence who requires treatment and care; this is done on the basis of two medical recommendations. A restriction order under section 41 may be imposed at the same time which places restrictions on movement and discharge of a patient detained under section a 37 hospital treatment order; all movement is then subject to agreement   from the Ministry of Justice this is necessary to minimise risk to the public. Moreover, the Act also contains powers to transfer prisoners to hospital for treatment of a mental disorder under section 48/49. Patients may apply to Mental Health Review Tribunals (First Tier Tribunals) who consider whether the conditions for continued detention are still present and have the power to order a conditional or absolute discharge. Patients can also apply to the Hospital Managers to review their case. Throughout this placement I was continually developing an understanding of the application of the Mental Health Act (Unit 18). I became especially interested in the effect of section 41, I found it interesting that for some patients this provided impetus for them t o work towards their own recovery and discharge by engaging fully in their care plans, through partaking in therapeutic groups, not using illicit substances, or posing as management problems in order to evidence to the Ministry of justice that their overall risks had decreased. However others appeared content to remain in hospital and were not actively working towards their discharged. This led to me considering whether some patients had become dependent on institutional care. Risk In my first placement in a Children’s Services safeguarding team I found the concept of ‘risk’ difficult to fully understand. I found it difficult to identify risk and as such address how it could be minimised and managed. In my second placement work with The AIDS Support Organisation in Uganda, risk was an obvious concept to appreciate. Throughout this placement I feel that I have really developed a greater understanding of the concept of risk and as such I have gained greater confidence in the identification of risk and assessment of how it can be managed (Unit 9, Unit 12, Unit 13). According to Scott (1977) ‘risk’ is defined by an assessment of a particular behaviour, the potential damage or likely harm from that behaviour and the probability that it will occur and under what circumstances. Moreover, following research on mental illness and violent behaviour Mossman (1994) argues that past behaviour can be used as the best predictor of future behav iour. I was able to use this knowledge whilst working with the patients on a daily basis but crucially I used this knowledge to inform my assessments so as to be able to identify and assess risks posed by the patients using past and present behaviours.   Mullen (2000) argues that mental health services have a responsibility  to do all that they can to provide appropriate care and support  to those mentally disordered people with the aim to identify and manage risks before they manifest  in violence. Throughout this placement I have had to be conscious of ‘risk’ on a daily basis, I have learnt that in as much as the patients could pose a risk to themselves as well as others, their mental illness also leaves them vulnerable and at risk of harm themselves (Unit 12). Rehabilitation Throughout this placement risk was strongly linked with the concept of rehabilitation. As with everything else on this placement I found that rehabilitation was a multi faceted exercise that involved a variety of professionals, treatments and approaches. This includes medication for the treatment and management of the symptoms of mental health, therapies such as art and relaxation, groups to improve social functioning and provide patients with greater insight not only into mental illness but also issues such as substance misuse. A theory that I found that was used whenever the term ‘rehabilitation’ was mentioned was the ‘Recovery Model’. The Recovery Model is an approach to the treatment of mental illness that emphasizes and supports an individuals potential for recovery. Recovery is seen as a personal journey as opposed to a destination that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion , coping skills, and meaning (Jacobson and Greenley (2001). Due to the complexities of need presented by service users within the setting of the medium secure unit, it is important that a range of approaches and treatments is taken in order to aid recovery. As I have previously stated this includes therapeutic group-work such as the managing mental health group which I co-facilitated (Unit 8). I learnt the importance of constantly reviewing the therapies and services that are provided to the patients in order to measure their effectiveness for example in the group I facilitated at the end of the group sessions I was involved in writing individual patient evaluations where I looked at each patients’ engagement to see what they were gaining from the process (Unit 15). This is important as authors like Heinzel (2000) argue that it cannot be forgotten that groups although therapeutic they are also cost effective as they allow for the delivery of relevant support to a larger numbe r of patients at the same time, consequently reviewing their performance is of grave importance. Social work also played a role in this by ensuring that patients’ social needs were met through liaising and facilitating visits from family and friends and ensuring patients were receiving the correct benefits etc. This was more important for patients that were due to be discharged as I was involved in looking for appropriate accommodation and daytime occupation for patients all of which are fundamental part of rehabilitating patients back into the community.   Moreover, I learnt that giving patients leave from the ward and hospital premises was also important in allowing them to become reintegrated back into society. According to Mullen (2000) rehabilitation is a preventative process as striving to decrease the risk posed by an individual is not only beneficial for others but also for the individual themselves in enabling them to move closer to living safely in the community. The focus on treatment, care and rehabilitation highlighted to me that despite being a secure envi ronment unlike prison, the aim is not to confine and contain offenders as punishment but rather to treat and provide care. Part of rehabilitation involves being reintroduced back into the community, I was involved in an in numbers referrals to hostels as well as accompanying patients to their assessment visits. Also when the facilitation of a move into a community hostel placement broke down, I was also involved in gaining new funding for a new placement as well as completing the referral to the new provider in a short space of time (Unit 4, Unit 15). Multi-professional working Risk management, rehabilitation and care planning are all heavily reliant on effective multi professional working (Unit 17). A great example of this that I took part in during placement was the Care Programme approach (CPA). Section 117 of the Mental Health Act (1983) places a duty on health and social services to provide after care to patients detained under the Act. The CPA was originally developed as a response to poor after care services in mental health services and provides a framework for care coordination and resource allocation. Consequently, CPA is essential to providing seamless care for service users. Within this framework multi-disciplinary working is seen as the main vehicle for the assessment, planning, organising, delivering and monitoring of services (Wix and Humphreys 2005). This is because the CPA focuses on both the health and social care needs of the patient with the aim to ensure that service users have access to the full range of community support they need in order to promote their recovery and integration (Unit 5, Unit 7, Unit 14, Unit 16, Unit 17). Consequently, I have learnt that multi-disciplinary work and multi-agency working plays a central role in producing comprehensive assessments and care plans (Unit 11).   According to Wigfall and Moss (2001), multi-agency work is ‘about bring various professions together to understand a particular problem, in this sense they afford different perspectives on issues at hand’ (p71 cited in Walker (2008) p13). Unlike my first placement I felt a greater part of the multi professional team and that the professionals were able to work in unison for the benefit of the patients. Supervision Supervision formed an integral part of this placement. According to Noble and Irwin (2009) supervision is underpinned by a shared commitment to fostering a learning-centred partnership and that this learning partnership becomes an essential component of professional development. Similar to my first placement I found this statement to be true as supervision enabled me develop reflective as well as reflexive practice (Unit 18, Unit 19, Unit 21). However, due to the unfamiliar nature of this placement setting, supervision became even more important as â€Å"a bridge across the education-practice gap† (Tsui, 2005) in that it was in supervision that I received teaching around mental illnesses and other related areas such as law. This was especially important as unlike my first placement where I had already undertaken an entire academic module on assessment in Children and Families, I had not received as much focused learning on mental health. Consequently, supervision became a valu able tool in not only increasing my knowledge in this area but also for my overall professional development (Unit 18). Supervision also enabled me to think about research and best practice guidance and to work towards incorporating evidence-based methods into my practice. Through supervision I felt that I was able to develop what Urdang (2010) refers to as ‘centred and stable professional self’ (p.525) ensuring that I did not become overly-involved with the patients but maintained professional boundaries, keeping in mind risk and safety procedures whilst maintain a good working relationship with patients. Moreover I was able to work toward promoting values of best Social Work Practice, especially ensuring that I worked in a holistic manner as authors such as Kadushin (1990) argue that ‘the myth of sameness can result in oppression’. Additionally, Thompson (2009) argues that â€Å"treating everybody the same’ simply has the effect of reinforcing exis ting inequalities’ (p.140). That was very important to bare in mind as the patients had been already labelled and categorized as ‘mentally ill offenders’, I had to work to ensure that I treated them all as individuals. Additionally, supervision provided the opportunity to think about the ethical issues that were raised in working with the patients for example balancing my own feelings about some of the clients’ offences and ensuring that this did not impact on the working relationship I had with them (Unit 20). Thompson (2009) highlights that such considerations are important because of the tension that balancing care and control creates in such a working environment. Conclusion Reaching the end of this placement has allowed me to reflect back on my personal and professional progress not only in this placement but also throughout my studies as a whole. I feel that this placement has afforded me greater understanding and knowledge of mental illness and has made me less anxiety about working with mentally ill people in the future. In my first placement I identified a future learning goal as increasing my capacity to manage stress as well as prioritising my work so as to be more effective. I felt that I was able to achieve this more within this placement than before and I can attribute that to the great amount of support I received not only from my practice teacher but from the entire multi-professional team on Thames ward. This placement has also provided me with the opportunity to work with groups of individuals in order to achieve positive change; I was able to refine my skills in presenting information and engaging individuals in group discussions and debates. I felt that overall I found it easier having already completed two placements to link theory and academic learning to my practice and felt that this was demonstrated in the assessments that I undertook as well as my direct work with patients (Unit 3).   Unlike the first placement I felt a greater sense that I was part of a multi professional team and felt that I had greater involvement in the decision making processes including Hospital Managers meetings and Mental Health Review Tribunals. In as much as I learnt a lot on this placement I have identified some future learning needs. Although, this placement was not as emotive as my first placement I feel that I will need to continue to develop my emotional resilience and ability to manage stre ss and stressful situations including dealing with difficult clients and their families. I feel that as I go on to practice as a qualified social worker I will need to continually strive to be a reflective and reflexive practitioner, I will need to continue to use evidence based practices and promote best social work practice. Overall I have thoroughly enjoyed this placement; I feel that my practice teacher provided me with interesting and varied learning opportunities which enabled me to get a comprehensive understanding and experience of forensic mental health social work. 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