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Essay: Critically evaluate tensions in Social Work law (mental ill health adults and their carers)

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  • Critically evaluate tensions in Social Work law (mental ill health adults and their carers)
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This discussion will critically evaluate the tensions inherent in the practice of Social Work (SW) law, specifically with mental ill health (MIH) adults and their carers in England and Wales. It is to be highlighted that this discussion will be concentrating upon the main legislation that associate to MIH, such as the 2005 Mental Capacity Act (MCA), the 2007 Mental Health Act (MHA) and the inclusive 2014 Care Act (CA) (Department of Health, 2014).

When it comes to the SW profession, according to the International Federation of Social Work (2014), SW is a profession ‘that promotes social change and development, social cohesion, and the empowerment and liberation of people’ (Ifsw, 2019). Cree (2002, pg. 28) substantiates this definition by stating that SW has concerns with social justice and inequalities when it comes to working alongside service users. On the whole, it is easy to assume why adults with MIH would require Social Workers (SWRs) for advocacy (CA2014): not having a ‘voice,’ feeling excluded and being stigmatised. Likewise, carers of MIH adults also have issues in their lives which can cause adversity: discrimination and oppression, human rights not being met and tensions relating to social, political and economic aspects. Thus, practitioners should indisputably be attempting to ‘remove shackles of oppression’ which could distort the lives of these service users’ (Dominelli, 1997, pg. 248). Essentially, it is evident that SWRs act as agents of change – particularly in the 21st century where there’s an increase in service user movement and increasing regulation from the HCPC (HCPC: health and care professionals council, 2018). Nevertheless, it must be considered that although SWRs aim to confront adversities in vulnerable peoples’ lives, whilst adhering to their ‘Code of Practice’ (Scie, 2010), there are unassailable challenges and tensions when it comes to handling the practice of SW law – causing problems relating to partnership working, person-centred care, oppression and the empowerment of adults.

It is arguable that legislative frameworks, which although inform work with adults, hinder MIH adults from social justice and equality; especially in connection to adult safeguarding and SWRs empowering adults who may lack mental capacity (Department of Health, 2015). For instance, though the MCA2005 exists to empower those ‘who lack capacity’ (Department of Health, 2015) and the MHA2007 being designed to give the professionals ‘power’ to detain, assess and treat individuals with mental health disorders, it can be debated that due to the notion of power, normative social distance can develop between with SWR and MIH adult (Hasenfeld, 1987). Normative social distance in SW practice can be explained in this instance as the MIH adult making a distinction between ‘us’ and ‘them’ (‘them’ being the SWRs), causing a degree of remoteness between the groups in society (the SW profession against the service user position) (Rast III, Gaffney and Hogg, 2013). The feeling of powerlessness could emerge through a ‘decision-making process’ as the notion of professionals ‘knowing best’ could upsurge (Dalrymple, 2001) – perhaps causing the MIH adult to feel excluded and vulnerable. This can be substantiated with the argument if SWRs are unaware that they are ‘working within a social structure’ of power distribution, which excludes the minority populations, they will not challenge this issue (Hugman, 1991). Consequently, this could cause SWRs to continue to exclude sectors of society and the issue of power in SW practice could, therefore, remain, especially with BME MIH adults (Jupp, 2005). Moreover, although the SWRs Code of Practice includes respecting the ‘rights’ of the individual’ (Scie, 2010), SWRs have been ‘mandated to use powers of compulsion’ which has negative profound consequences for MIH adults (Campbell, 2010). An example of this could be mental health SWRs making decisions with other professionals, on the matter of involuntary admission to hospital (Campbell, 2010). Therefore, it can be disputed that understanding the way in which the MHA2007 legislation has been implemented in SW practice, could highlight the requirement for further law reform (Fistein et. al, 2016) – perhaps reducing the tension that may arise when it comes to oppressing MIH adults.
Although many mental health laws are intended to support adults with MIH, some have ‘offered a legal justification for discrimination and harmful social stereotypes’ (Duffy, 2017) – whilst not adhering to HCPC standards (HCPC: health and care professionals council, 2018). For instance, the ‘medical model’ is where mental health legislation emerged from and this led to an emphasis on illness and difference; along with promoting stigmatisation, separation from society and prejudice (Duffy, 2017). The use of medical diagnosis for MIH adults perpetuates stereotyping, with extensive consequences for social inclusion and human rights (Karban, 2016). However, the social model is now replacing the oppressive medical model and this characterises disability to society’s reaction to impairment, rather than perceiving disability and impairment as synonymous. Yet, it is only in current decades that other countries have attempted to reform legislation to establish it to be more patient-centred (Duffy, 2017). India’s mental health legislation is currently being reviewed to create it to become concordant with the United Nations – Convention on the Rights of Persons with Disability (Kelly, 2016). Their move towards a social model implies the rights and equalities of adults with MIH are being recognised; however, it must be considered that socio-economic disadvantage in India can be associated with mental health distress (Barbeau, Krieger and Soobader, 2004) – leading to furthering inequalities, such as higher risk of unemployment and discrimination (Karban, 2016). Nonetheless, the aspect of discrimination can also exist within mental health services themselves (Rapaport, 2008).
Although it can be debated that SW is one of the earliest disciplines to act in response to the issue of discrimination, it has been argued that SW activity has been moulded by economic and political developments (Rapaport, 2008). Even though the CA2014 promotes principles such as empowerment and protection, it can be critiqued with a Marxist view that SWRs, through acting on behalf of the state and having dominant economic interests, use their expertise to gain social influence (Hasenfeld, 1987) – implying MIH adults’ needs are not the forefront of importance. Nevertheless, the mental health workforce progressively promotes and encourages service user self-determination and handling MIH adults in the least restrictive manner possible – accordingly, in line with anti-discriminatory practice (Rapaport, 2008). Furthermore, reducing avoidable stigma and discrimination is framed within the strategy document ‘No Health without Mental Health’ (Department of Health, 2011) which promotes mental health of the nation as key to all facets of government services; besides the fact that the policy offers both a strategy for social justice and a public mental health strategy (Karban, 2016). Therefore, it is to assume that within certain policies, the needs of MIH adults are being addressed and the tensions inherent within the SW law are being acknowledged. However, though anti-oppressive practice challenges unfairness (Baines, 2007), it could be contended that suggestions declared from the SWR is more ‘service-led’ (for instance benefitting the SW profession in some way – i.e., being cost-effective) than ‘needs-led,’ implying that the voice of MIH adults are being ignored, conveying a tension with SW practice and adopting a person-centred approach. Nonetheless, relating back to ‘No Health Without Mental Health,’ it can be argued that the ‘parity of esteem’ approach enables social care services to provide a holistic response to each person who requires support, with both their physical and mental needs being treated equally (Mental Health Foundation, 2019), suggesting that the intervention implemented will be efficient for the MIH adult. But, although ‘parity of esteem’ can be defined as ‘valuing mental health equally with physical health’ (Mental Health Foundation, 2019), it can be counteracted with barriers for parity, such as stigma for MIH. The existence of stigma can prevent individuals with mental health problems from receiving treatment with the same vigour as if they had a physical illness – indicating the tension that inherently remains when it comes to the subject of MIH and policies implemented by the UK Government (Department of Health, 2011).

Moreover, according to Knapp (2006) one in four individuals experience an episode of mental illness during their lifespan, yet the ‘treatment gap’ between the receipt of, and need for, appropriate services remains wide. Though it has been disputed that excessive choice could be detrimental to MIH adults’ psychological condition, the enduring care policy in England over the past decade has pursued to promote and illuminate individual control over how requirements should be met (Department of Health, 2017). Empowerment links to the promotion of social inclusion of MIH adults and there is, for instance, many service user organisations in the UK that support and encourage the use of ‘advanced directives’ where a MIH adult specifies how they require and wish to be treated if becoming too unwell. For instance, if a MIH adult with Bipolar Disorder is experiencing a ‘manic episode,’ they would benefit from ‘Crisis Cards’ as it can be presented to the police, for example, stating details of the condition they have and how they would prefer to be supported in a crisis (Mind, 2018). Also, support for ‘advance directives’ have been reported amongst Dutch patient groups (Knapp, 2006) as they can be potentially destigmatising and empowering. However, it has been distinguished that many issues need to be incapacitated in their implementation, such as some service users’ assumption that such directives are only relevant for those who are ‘older’ or in ‘worse health’ (Emanuel et al., 1991).
In the UK, where access to social care services is means tested and selective, whilst access to health care is universal, there are practical and ideological adversities to overcome (Knapp, 2006). Whereas, in sectors of eastern Europe the issues are a different kind: the challenge of resources is that the governments cannot, or refuse to, prioritise mental health services, deserting the systems of support and causing them to become hindered in outdated practices. Evidently, this prohibits adults with MIH from obtaining social justice and equality in society, perhaps guiding towards oppressive practice. Correspondingly, a WHO (2002) report documented that ‘the concept of what constitutes mental illness varies amongst cultures based on local beliefs and practices’ (WHO, 2002). Therefore, policymakers ought to construct and create programmes focused on the national illness depictions of the population, otherwise the services will be rejected (Knapp, 2006). Furthermore, when sexism, racism and/or homophobia are combined with the experience of mental distress, along with other forms of social and structural inequalities, the resulting multifaced mix of oppression and discrimination is more likely to compromise ones’ health and wellbeing (Morrow and Weisser, 2012). The notion of social, economic and political spheres being triggers and causes of mental disorder can be supported by Karban (2016), who states that these are conditions of daily life which impact ones’ health, in which SWRs do not contemplate. In England, there is substantial evidence that the ‘social gradient of health is particularly pronounced regarding severe mental health difficulties,’ where the occurrence and commonness of psychotic disorders are nine times greater within the lowest quintile of household income (Karban, 2016). Therefore, when it comes to applying the principles of the CA2014 to MIH adults in this instance, there is the issue of being able to enforce ‘prevention’. For instance, this may be particularly difficult for the SWR to ensure when it comes to supporting a MIH adult who is homeless, as well as from a BME background (Draine et. al, 2002).

In relation to the tensions that there are with MIH adults, there is a current estimate of 1.5 million people in the UK caring for an adult with MIH (Carers Trust, 2015) – indicating that inevitably there will be difficulties within this group of individuals too. Those with MIH may need a carer if they begin to feel their mental health is decreasing; yet caring for someone with MIH can be particularly challenging for many reasons: difficult behaviour in the unwell individual, finding the support that suits the MIH adult and the carer, as well as if the carer is from a BME community they could encounter discrimination, with their cultural needs unfulfilled (Healthtalk, 2015). However, the recognition of the contribution that carers give to supporting MIH adults has been around since 1990s UK social care policy (Maher and Green, 2002); for instance, the 1995 Carers (Recognition and Services) Act authorised caregivers to an assessment of their needs and ability to care, along with further legislation, Carers Equal Opportunities Act (2004), extending carers rights. The latter also proposes that statutory institutions must work concurrently to establish services that meet carers eligible, assessed requirements (Seddon, 2015). Furthermore, the Carers Strategies for England and Wales (Department of Health 2010, Welsh Government 2013) identifies holistic assessments as chief to depicting the strategic envision for carer support; this is where individuals are: ‘recognised for the work they do, are involved in decisions that affect them and are supported to maintain their health and well‐being’ (Department of Health 2010, Welsh Government 2013). However, despite the continuous efforts to strengthen UK policy framework which underpins carer support, the assessment of needs for carers is problematic. Repper et al. (2008) have recognised that there are tensions when it comes to the intersection of a ‘service user focused personalisation agenda’ and the formal acknowledgement of carers subjective needs and rights. Hence, it has been recommended that support for carers should be reflecting their unfolding needs, yet practitioners report that this is problematic on the basis of the data gathered during the assessment, to create personalised action plans that embody carers social and employment aspirations (Seddon, 2015). Furthermore, the conduct of carer assessment has the issue of relying on problem-focused, structured assessment protocols – again failing to perceive the diverse and complex lives of carers (Seddon, 2015). So, it can be disputed that assessment tools which encourage a narrative approach to assessments for carers, could capture the emotional aspects of caregiving; overall supporting the carers individualistic needs.
Another issue that can be contended is that although it was the MCA1995 which allowed for carers to have more equity, and was a significant achievement for carers institutions, its values were more symbolic than real (Parker and Clarke, 2002). This is not surprising as no extra resources were dedicated to local authorities to fulfil the prerequisites of the legislation (Cavaye, 2006). While, SWRs should aim to promote ‘social inclusion’ (BASW, 2014), a tension that may occur with this aspect within SW law is the lack of funding in the current economic state (Wenzel et al., 2018). Even though in practice much of this shortfall has been reduced by informal care, the lack of funding restricts MIH adults and their carers from accessing services – implying that SWRs are unable to fulfil their role of upholding public trust in social care services (Scie, 2010). Nevertheless, the need for an improved provision of social care advice, for carers in the UK, has grown immensely over the past 3 decades (Department of Health, 2010). The CA2014 marked the start of systematic changes in how England social care is imparted; including increased recognition of carers rights, and improved responsibility for local governments to tackle the needs of carers (Meyer, 2018). Furthermore, the UK’s CA2014 shift to support carers rights and needs, emulate those transpiring in other counties (Meyer, 2018); for example, in the USA the National Academies of Sciences, Engineering, and Medicine (2016) published a report highlighting the significance of person and family-centred care when it comes to supporting MIH adults in society.

Moreover, it can be contested that carers of MIH adults also face obstacles and struggles in their everyday life with aspects of oppression and prejudice from society. Although there is evidence that declares good practice by SWRs when it comes to supporting MIH adults, there is a requirement for a change in cultures, attitudes and the understanding of the impact on carers. There are reports on issues when it comes to carers expectations of a SWR, along with the complexities of integrating the role of carers and the rights of the service user (Campbell, 2010). Carers relationships with mental health services have been described as tense and problematic, as relatives occasionally feel resentment, hostility and dissatisfaction towards professionals who fail to comprehend their needs. For instance, although a study in Rome declared that there was satisfaction with services expressed by MIH adults and their carers, this was substandard when it came to information of the condition, the level of family-carer involvement in programmes, as well as cultural understanding (Knapp, 2006).

Furthermore, it is estimated that between 40-90% of MIH adults live with relatives who provide them with long-term emotional and physical support (Knapp, 2006). This evokes the sense that it is the relative carers who undertake adversities and additional responsibilities where inadequate resources have been ‘transferred to community-based mental health systems’ (Knapp, 2006). However, in the UK the system of carer support is idiosyncratic in granting beneficial cash to carers, which implies an acknowledgement of their involvement (Cavaye, 2006). Likewise, in Germany, Long-Term Care Insurance was established to encourage and support informal caregiving. Also, NHS England (2016) declare that carers should have a choice in whether they want to provide care of not, besides how much they will provide if so (Department of Health, 2014). Nonetheless, whilst the English carers policy strategy has focused on numerous carer-specific problems over the last 2 decades (Department of Health, 2014), the issue of choice remains underdeveloped. This concern has been concentrated upon by developments in policy to identify carers as individuals whose requirements should be deemed on an ‘equal footing to the care recipient (Rand, 2019). Nevertheless, it can be argued that it does not recognise the possible tensions between care-recipients and their carers needs and outcomes (Rand, 2019)

When it comes to carers and the access, or lack of, services provided for them when it comes to supporting MIH adults, the NHS Information Centre (2010) reported that 26% of informal carers found it ‘very difficult’ to access advice and information on support and services which could have assisted with the caring role (Cavaye, 2006). Meyer (2018) also states that her study found that ‘materials were presented in a one size fits all manner’ which was not useful for the diverse needs of carers, for example, information that was presented for carers lacked relevance and were not tailed to different levels of comprehension. Furthermore, in Meyers (2018) study it was expressed that carers were not interested in social care services due to the experience they had of formal services not being culturally appropriate. For instance, a participant researched into ‘meals on wheels’ but found that the ‘universal’ service did not provide or cater Punjabi meals that her father in law would eat (Meyer, 2018) – demonstrating the lack of cultural diverse options available for carers and care recipients within UK society. However, although under CA2014 there is the necessity of ‘personalisation’ of the services (Cornes, 2016), it can be argued that SWRs do not have the duty to provide every cultural type of food – but to essentially, just allow for the service to be provided. Thus, it could be debated that it is the MIH adult’s ‘choice’ to eat or not, and that overall the SWR is providing an adequate service. Nonetheless, it could be argued that ‘food options’ associates to an individuals health and wellbeing, as well as their culture and identity (Jung, 2014). So, not providing diverse food options for all cultures could disputably be oppressive and discriminatory towards the service user – implying the failure of the SW profession from empowering and ensuring social justice to all service users in society (Ifsw, 2019).

To conclude, it is clear that there are many tensions inherent when it comes to the practice of SW law while ensuring to support MIH adults and their carers. Although legislation, within England and Wales, such as MCA2005, MHA2007 and the CA2014 has been inaugurated to support MIH adults, these cannot be implemented comprehensively as there are continuous issues of oppressive practice in SW (Artazcoz and Rueda, 2007; Arber and Ginn, 1993). Even though SWRs must adhere to their Code of Practice (Scie, 2010), this is a difficult task to accomplish as there remain underlying issues towards MIH adults and their carers, such as discrimination, stigmatisation and issues of trust that MIH adults may have towards the SW profession. Thus, though the HCPC is encouraging an increase in service user collaboration (HCPC: health and care professionals council, 2018), with the aim of promoting empowerment and person-centred care, this is essentially problematic to ensure when there is a lack of diverse services for individuals in society (Seddon, 2015; Meyer, 2018). Overall, although SW legislations and policies have improved over time, to certify that MIH adults and their carers receive equal rights and support (, 2019; Ifsw, 2019; HCPC: health and care professionals council, 2018; Scie, 2010), tensions will continuously persist when social and economic problems occur; together with issues of race and ethnicity within international countries too.

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