Shaping the Future of Mental Health Policy and Legislation in Northern Ireland: The Impact of Service User and Professional Social Work Discourses

This paper explores the complex interrelationship between serviceuser and professional social work discourses and provides acritical commentary on their respective contributions to therecent review of mental health policy and legislation in NorthernIreland. The analysis indicates that dominant trends in mentalhealth care, as mediated through service structures and institutionalidentities, have tended to prioritize the more coercive aspectsof the social work role and reinforce existing power inequalitieswith service users. It is argued that such developments underlinethe need for a ‘re-focusing’ debate in mental healthsocial work to consider how a more appropriate balance can beachieved between its participatory/empowering and regulatory/coercivefunctions. Whilst highlighting both congruence and dissonancebetween respective discourses, the paper concludes that opportunitiesexist within the current change process for service users andsocial workers to build closer alliances in working togetherto reconstruct practice, safeguard human rights and developinnovative alternatives to a traditional bio-medical model oftreatment.     

Accepting and Negotiating Service Users' Choices in Mental Health Transition Meetings

Across Western welfare regimes, policies emphasize that service users should have more choices regarding their services. This article examines how service choices are presented, responded to and decided in interactions between service users and professionals in mental health transition meetings. Choice is often associated with consumerist user involvement ideas, but in mental health choice also relates to the democratic user involvement approach and to shared decision making between professionals and service users. The results of the study show that professionals construct service users as consumers by offering service options in choice making sequences, expecting users to make appropriate choices. Service users mostly act like consumers by responding to these choice options. However, the study also demonstrates that the professionals do not always accept the user's first choice but respond to them as non‐preferred. Sometimes, they also suggest choices on behalf of the users. In these ‘non‐accepting’ sequences, choices are negotiated in interaction between the parties, rather than users acting as autonomous choice makers. The sequences are based on two kinds of professional reasoning: first, the professional‐led needs assessment and, second, the structure of the service package that the user is being offered. This negotiation has elements of shared decision making and the ‘logic of care’. But it also has elements of paternalist control which challenge both consumerist and democratic service user involvement and suggests consideration of more collectively oriented service user actions.     

Do we care? Adult mental health professionals' attitudes towards supporting service users' children

The impact of parental mental health is well known, but children's very existence may fail to be recognized by adult mental‐health services. This study aimed to explore attitudes of mental‐health professionals in one outer London borough regarding support needs of mental‐health service users' children to highlight potential barriers to identifying or meeting their support needs. All statutory mental‐health teams in the borough participated in a cross‐sectional survey. The response rate was 62.8% (n = 94) out of 150. The sample consisted of a diverse range of professionals from both inpatient and community settings. The main finding was that practitioners were overwhelmingly in favour of supporting children. However, attitudes and practices were significantly associated with profession, setting and whether the respondent was a care coordinator. Demographic characteristics or experience was not associated with attitudes. Perceived barriers to supporting children are highlighted. In particular, the mental‐health professionals in our sample considered supporting children important but did not necessarily consider it their role to do so. Training is required to raise awareness about this issue.     

Capacity Building and the Reconception of Political Participation: A Role for Social Care Workers?

This paper explores a citizen-based approach to social workwhich may counter modern negative managerialist pressures onpractice. It links the discourse concerning the growth of userinvolvement in public policy with the discourse about participationin political activity and suggests a role for social workersin supporting service users in initiatives such as self-help,campaigning and community action which offer a new interpretationof community-based social work. By engaging in this activity,health and social care professionals can support people to participatein emerging forms of active and inclusive citizenship. Whileparticipation in traditional political activity such as votingand political party membership is declining in the UK, peoplein marginalized groups are finding ways to have their voicesheard about issues which directly concern them. Increasingly,groups such as disabled people, older people and mental healthservice users/survivors are taking part in activity which marksa shift of focus to include both self-help and campaigning.In contrast to their disillusion with traditional politicalactivity, people across a range of groups have gained strengthand encouragement from campaigning achievements. The paper drawson a national research study which offers fresh insights onthese issues as a basis for exploring participative approachesto social work practice.     

Pawns or Pioneers? The Logic of User Participation in Anti‐poverty Policy‐making in Public Policy Units in Belgium

Since anti‐poverty policy‐making in Belgium is embedded in a logic of user participation, social policy has shown interest in employing users with experience of poverty as experts in public policy units in order to implement and monitor anti‐poverty policies. In this article, we discuss this recent development as a relevant case for contemporary public service delivery in the European context. In the light of the ambiguous practices of user participation in Belgium, the enacted logic of involving service users in public service delivery is discussed, and potential risks and opportunities identified: do these individuals function as pawns or as pioneers? In search of opportunities for the implementation of anti‐poverty policies, we explore different ways in which public policy units can act upon the participation of employed service users in public service delivery. On the level of public service delivery, we argue that the participation of expert users risks their use as a mere blind, de‐responsibilizing those who work in public policy units in providing high‐quality services and being responsive to all service users including those living in poverty. On the level of these individual experts, we argue that the employed service users risk becoming pawns, acquiring a tragic‐optimistic outlook on life. We conclude that enabling service users to participate as pioneers requires the joint and mutual responsibility of the employed service users and those who work in public policy units for implementing and monitoring anti‐poverty strategies rather than exclusive responsibility assigned to individual service users.     

Modernization and Devolution: Delivering Services for Older People in Rural Areas of England and Wales

The modernization of public services, with its emphasis on managerialism, choice, co‐production and outcome focused service delivery, has been implemented to a certain extent in both England and Wales. Indeed, the welfare states in both countries share a great deal, particularly in relation to policy objectives and the expectations of citizens. Devolution has chiefly meant that the instruments used to deliver policy have separated, although it remains unclear whether this amounts to formal divergence. What is also unclear is to what extent have the experiences of those living within the policy environment in both countries separated or diverged? This article addresses this question using qualitative data composed of interviews with policy actors in six rural areas of England and Wales. By focusing on the discourses of people involved in modernizing and providing services for older people in rural areas, we bring out the impact of modernization for older people. What we show is that modernization engages both service users and the wider population who may one day become service users. But the emphasis on these groups unfolds in different ways in England and Wales. In England, where there has been a commitment to a customer citizen, policy at the local level has emphasized re‐enablement, community development and individual responsibility. In Wales, where modernization has focused on collaboration and citizenship, local policies have focused on service users, and on engagement with the voluntary sector. In effect, the policy environment provides a different context for the experience of ageing in both countries.     

Subverting Social Policy on the Front Line: Agencies of Resistance in the Delivery of Services

An understanding of policy implementation issues in many of the core fields of social policy requires attention to the mode of service delivery that is characteristic of those fields: face‐to‐face interaction between frontline service staff and service users. A focus on implementation as interaction between these groups reveals the significance of ‘agency’ to the analysis of why and how certain social policy outcomes occur – and in particular why outcomes may sometimes be different from those anticipated by formal policy objectives. This article considers how the agency of workers and users shapes the processes of mediation, negotiation and adaptation that occur in different service delivery contexts, and identifies ways in which resistance to intended policy outcomes, and to the practices expected to deliver them, is formed and expressed. Drawing on a wide range of empirical research material, the article shows how agencies of resistance produce outcomes that are uncertain, fragile and contested, and whose effect can be the subversion of formal policy intentions.     

Consistencies and Inconsistencies: Mental Health, Compulsory Treatment and Community Capacity Building in England, Wales and Australia

In relation to mental health, it is clear that medicalized underpinnings,the provision of a clinically orientated evidence base for practiceand the need to contain ‘risk’ continue to be prioritized,particularly when compulsory intervention is considered. Thisis despite the increasing influence of a citizenship and socialjustice agenda which is being promoted by psychiatrists involvedin the development of ‘postpsychiatry’, as wellas by service users/survivors. These drivers are not mutuallyexclusive, but in the context of compulsory treatment, thereare clear tensions. In this article, the policy surroundingmental health and compulsory intervention in Australia and inEngland and Wales is explored. In the context of this discussion,three ways in which current government policy can be interpretedare examined and links made between these interpretations anddifferent ways of viewing the relationship between mental healthand community capacity building. With regard to social workpractice, it is argued that a response to mental ill healthwhich concentrates on an individualized ‘diagnose andtreat’ approach, which particularly comes to the foreat times of compulsory intervention, has limited capacity tofacilitate community engagement, foster social inclusion andgenerate reciprocal dynamics between positive mental healthand community capacity building.     

Rolling Out Anti‐social Behaviour Families Projects in England and Scotland: Analysing the Rhetoric and Practice of Policy Transfer

In both Scotland and England, reducing anti‐social behaviour (ASB) and building a culture of respect are key central government priorities. Accordingly, since 1997 both jurisdictions have seen the introduction of a raft of punitive legislation. Over recent years, however, there have been signs that the official ASB agenda has shifted away from a reliance on ‘enforcement measures’ towards a more balanced approach incorporating measures to address the underlying causes of problem behaviour. With their emphasis on ‘whole family’ approaches and parenting interventions, ASB family projects, pioneered by the Dundee Families Project (DFP), are seen to respond to official concerns about social exclusion and have been promoted as an effective and sustainable response to ASB. In both Scottish and English jurisdictions official endorsement of the DFP model has been marked by government‐funded programmes to ‘roll out’ this concept more widely. Drawing on findings from a recent evaluation of ASB family projects operating in Scotland combined with scrutiny of evidence from a number of English studies, this article explores, in a comparative manner, the differences and similarities in the policy discourses and models of practice employed by Scottish and English projects. More specifically, we critically appraise the role played by sanctions in evoking service user engagement.     

Implementation of individual placement and support in a first‐episode psychosis unit: A new way of working

The aim of this study is to explore the IPS implementation process in a first‐episode psychosis (FEP) mental health service team in Sweden. More specifically, the study explores how integration processes and critical situations are perceived over time by team members who originated from two diverse welfare organizations. A serial interview design was used (initially, at 6 and 12 months) to describe experiences of 16 team members. Material was analyzed using a constant comparison grounded theory approach. Team members dealt with the ambivalence of sharing mental health information, and whether the new way of working was a risk or benefit for users. They gradually learned new perspectives and knowledge, built trust and shared common views. After a year, the team workload perceived reduced and became person‐centred. Some members described remaining unclear roles and requested further support. Negotiated goals for integration and early knowledge transfer are critical. Organizational change and trusting team relationships have to be facilitated. Anticipated gains of integration should be clearly described and discussed early on, and continuous support for sustainability should be considered. This study confirmed the importance and potential of integrating IPS into FEP teams.     

Practices of activation in frontline interactions: Coercion,persuasion, and the role of trust in activation policies in Germany

Following Michael Lipsky's well‐known argument that policy is made in the daily encounters between street‐level bureaucracy and citizens, a growing body of research emphasizes that actors and organizations delivering social and labor‐market policy play a crucial role in welfare‐state politics. Using qualitative data collected at three local employment agencies in Germany, this article explores worker‐client relations as a crucial mechanism through which activation policies are translated into practice. The analysis investigates how caseworkers define their role and their relationships with clients. The findings show that it is essential for caseworkers to achieve client compliance. In such a context, building relationships of trust is a strategic instrument in overcoming possible barriers to co‐operation in the caseworker‐client interaction. Caseworkers develop strategies to create the impression of trustworthiness and to motivate both unemployed clients and employers to become trust‐givers in the caseworker‐client relation. While research has often stressed the dichotomy between disciplining and enabling elements of activation policies, our explorative study shows that persuasion and trust‐building are a further important dimension of the frontline delivery of activation policies. These strategies reflect the importance of emotional aspects of frontline work.     

A critical review of mental health and mental health‐related policies in China: More actions required

In China, there are over 170 million people suffering from mental illness. However, there is a lack of a critical review of the policies governing the provision of mental health services. Drawing on the framework of mental health policy developed by the WHO, this article critically examines mental health policies regarding legislation, financing, model of care and delivery, as well as manpower and the training of mental health professionals in China. This analysis raises a number of policy‐related questions concerning the lack of community‐based psychiatric services, inadequate coverage of mental health services in the rural areas, poor standard of education and an insufficient number of trained mental health professionals, and insufficient protection of the human rights of people with mental illness. The article ends by urging the various levels of governments to make a firm commitment to improve mental health care for people with mental illness in China.     

‘Problematising’ Australian policy representations in responses to the physical health of people with mental health disorders

Australia, like other jurisdictions, is recognising the poorer physical health of people with mental health disorders. This paper explores policy responses to this issue through discourse analysis of 22 Australian Federal and State government policy documents published in 2006–2011. The paper utilises Bacchi's ‘what's the problem represented to be?‘ approach to explore policy solutions in relation to the representation of the issue, enabling identification of issues which are not problematised and policy solutions that have not been considered. The poor physical health of people with mental health disorders is attributed in policy to poor lifestyle habits and limited access to monitoring of physical health care. Three policy solutions are offered: collaborative care delivery involving greater use of fee‐for‐service primary care to manage physical health; the monitoring of physical health status by mental health teams; and the promotion of lifestyle change. These solutions fail to address ongoing issues with collaboration between specialist mental health and primary care services. Reliance upon fee‐for‐service primary mental health care may, in fact, reduce rather than increase access to services. The strategies are discussed in light of neoliberal ideals of governance and personhood which are underpinned by informed consumer choice and personal responsibility for health.     

Middle‐Class Political Activism and Middle‐Class Advantage in Relation to Public Services: A Realist Synthesis of the Evidence Base

Since the late 1960s social policy scholarship has been concerned with the distribution of the resources or benefits across social gradients. This article presents a review of the literature on one mechanism by which inequity might be produced – activism by middle‐class service‐users enabling them to capture a disproportionate share of resources. The review used the methodology of realist synthesis to bring together evidence from the UK, the USA and Scandinavian countries over the past 30 years. The aim was to construct a ‘middle‐theory’ to understand how and in which contexts collective and individual activity by middle‐class service‐users might produce inequitable resource allocation or rationing decisions that disproportionately benefit middle‐class service‐users. The article identifies four causal theories which nuance the view that it is the ‘sharp elbows’ of the middle‐classes which confer advantage on this group. It shows how advantage accrues via the interplay between service‐users, providers and the broader policy and social context.     

Social workers' perspectives on parental engagement when children are at risk in Romanian society

This paper presents the findings of a study that looked at social workers' perspectives on parental engagement in making the difficult choice of either taking the child into care or keeping the family together. The paper first explores the specific context of children at risk in Romanian society and explains that in this middle‐income nation there is an absence of evidence‐based risk assessment tools, which prompts social workers to use their own ‘common sense’ risk assessment indicators. The findings of this small‐scale, non‐representative study on several public non‐voluntary child protection services in Romania suggest that social workers' perceptions of specific dimensions of parental engagement in non‐voluntary child protection may influence service delivery decisions and outcomes.     

Planned telephone support for disadvantaged parents in North Wales: perceptions of service users

This paper draws on the findings of a qualitative evaluation to examine user perceptions of a planned telephone support intervention based in a disadvantaged area in North Wales. Telephone support services are tailored differentially to offer information, advice and/or counselling on a crisis‐led or planned‐intervention basis. Research focusing on telephone support, for the most part (and particularly in the UK) has examined crisis‐led as opposed to planned support services. The findings of our study resonate with earlier research findings about telephone support that suggest provision of non‐visual support in social care can overcome some practical and financial difficulties for users with little discernible loss to their experience of satisfaction with the service. In addition, the paper suggests that planned support may provide a valuable service to users who are most disadvantaged and marginalized and who have found traditional forms of support unsatisfactory. For such users, planned telephone support can offer one‐to‐one communication tailored to specific client needs. Moreover, it can enable the development of user trust in the service which empowers users to operationalize strategies in the context of a reliable, sustained, unthreatening (and thus minimal risk) relationship.     

Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years

The deinstitutionalization of mental health care has changed the responsibilities of involved authorities and has led to a continuous need for new treatment forms and interventions. This article describes this development in Europe, and in particular how these new conditions have been handled in Sweden over the past 20 years at the level of governmental policy‐making. Three major policy documents from 1994, 2009 and 2012 were included in this study. To increase our understanding of the policies' contents, we have used theoretical concepts concerning governance, implementation and political risk management. Although our main interest was to find out how the government handles interventions for users of the mental health care system, we found that the policy work is progressing stepwise. The first document, from the deinstitutionalization era, did not discuss interventions clearly. Instead, it was mainly concerned with both practical and economical areas of responsibility. The second document, from the post‐deinstitutionalization era, was more focused on what services should be delivered to the users, while the most recently published document to a greater extent addressed the question of how the support is supposed to be designed. The trend in European community mental health policy has been to advocate services in open forms that are integrated into the society's other care systems. This is also the case in Sweden, and continuous work is being done by the government to find strategies to support the development, and to meet the needs at both political and local levels.     

The assembly of active participation by parents of children subject to a multi‐agency model of early intervention in child and family services

The Common Assessment Framework provides a model of early intervention, which is familiar in local authorities throughout England, and asserts a participatory framework of child and family engagement. This paper is based on a qualitative study of parents and children who were subject to a multi‐agency process of early intervention in children's social care in a local authority in the Midlands of England. I advance the concept of assemblage to consider the basis of an active service user participation as rather more a struggle to achieve than something that has been granted by practitioner agencies. Interview extracts are used to show the enrolment and assembly of participation as a process of service users developing their active human agency in a multi‐agency setting. The article explores the assembling of skills in administration and management of meetings and plans, accessing knowledge and expertise through service user networks, and challenging professional expertise and institutional space while developing personal qualities of confidence and voice as a means of marshalling an effective participation in a multi‐agency setting.     

Domestic violence and child protection: exploring the role of perpetrator risk assessments

This article explores the issue of severity in relation to domestic violence and provides a number of reasons for the necessary engagement by workers with such a contentious issue. The specific role that the assessment of the risks posed by the perpetrator which has now developed in some police forces in the United Kingdom is examined, and its relevance to child welfare intervention discussed. A range of factors are identified that heighten the risks of increased violence. These include prior sexual assault; stalking and controlling behaviour; substance misuse and mental‐health problems; separation and child contact disputes; pregnancy; escalation including the use of weapons and psychological abuse; attempts and threats to kill; child abuse; isolation and barriers to help‐seeking. The ways in which perpetrator risk assessment can be used to inform the filtering of referrals to the statutory child care agency, enhance multi‐agency working, provide a structure for the assessment of the perpetrator, enhance partnership‐working with survivors (usually women) and inform the protection strategies for workers are explored.