Mental health and evidence-based practice in social work - Essay Example

Mental health and evidence-based practice in social work Summary The article in review (Crawford & Brown, 2002) presents an assessment on how stigma is applied to the care of mental health patients residing in rural areas in the UK. The study was conducted to describe how the concept of stigma has evolved from what previous studies have first suggested some 40 years ago, where a bigger part of mental healthcare was done in hospital settings. Due to the shift in providing care from the hospital to the communities, the traditional protocol of having mental health patients receiving institution-based care has drastically changed, allowing patients to be increasingly provided care in community settings. Furthermore, current mental health care patients are being given shorter hospitalization periods and are released briefly afterwards (Edwards, 2000; Herman, 1993). The present study (Crawford & Brown, 2002) thus conjectures that, since there has been a change in the nature of mental healthcare, there could likely be a consequential change in the experience of stigma. This article makes an analysis of the traditional approach in explaining the phenomenon of stigma and demonstrates how stigma has experienced significant changes as mental healthcare has been transferred from the hospital to the community. The classic formulation of stigma—which began in the 1960s—considers this phenomenon as something that is the error of the mental healthcare system (Goffman, 1967). As such, stigma involves a person who undergoes social disapprobation as well as decreased chances in life as a result of being given an identity and diagnostic label as a patient who came from a psychiatric institution. To address the initial concept of the adverse ramifications of having a ‘psychiatric patient’ identity (Goffman, 1961, Scheff, 1966), a handful of studies has been conducted to examine how psychiatric service users and survivors regard stigma. During the initial studies, Bar-Levav (1976) found that the mere experience of seeing a psychiatrist is already stigmatizing. Later researches focused on the intricacies experienced by previous and existing psychiatric patients, such as on the different ways how the public see psychiatric users (see, for instance, Whatley 1959; Lamy 1966; Trute & Loewen 1978; Cochrane & Nieradzik 1985), the role of media (Philo, 1996), family acceptance or stigmatization of ex-psychiatric patients (Kreisman & Joy, 1974, Clausen 1981), the relationship of how society rejects or accepts former mental patients (Rabinowitz 1982), employment matters (Miller & Dawson, 1965; Webber & Orcutt, 1982), and the access to housing (Goldmeir et al., 1977). As the setting of care for mental healthcare patients transfer from clinic to the community, many healthcare workers undergo a paradigm shift in how they perceive their clients (Edwards, 2000), such as in the areas of policy and training of healthcare professionals (Audit Commission, 1994; Edwards, 2000). A collaborative culture among mental healthcare professionals has been cultivated as a result of the transfer of care from the hospital to the community, making them depend more on the close relationships they have fostered with their clients (Crawford & Brown, 2002). This healthcare provider-client relationship has implications on the manner stigma may occur in practice. As healthcare professionals become more involved in the personal worlds of their clients, they consequently must address the day-to-day problems that clients endure. Providing mental healthcare services in communities involves several particular challenges (Roberts et al. 1999), such as in ensuring non-disclosure of patient information. Likewise, the restrictions among patients, families and healthcare workers in a rural setting may likely have considerable differences than in an urban environment. Studies also suggest that communities are considered to have a propensity to succumb to stigma for psychiatric clients (Buckwalter et al. 1993, Rathbone-McCuan 1994, Hoyt et al. 1997, Fuller et al. 2000). Due to the change in focus and locus of care, Crawford & Brown (2002) argue that it is opportune to examine the concept of stigma as it relates to the delivery of mental health care in rural areas in order to determine how the concept and experience of stigma could have transformed due to the modifications to where care is provided, the changes in the orientation of health caregivers and an increasing consciousness that the social conditions that health care patients experience have an impact on how they survive in unfriendly environments. To achieve the study objectives, Crawford & Brown (2002) utilized eight focus group discussions (FGDs) with mental healthcare workers and users based in rural communities. Results from FGDs suggest that the standard concept of stigma does not immediately relate to the provision of care in rural settings. For one, the authors found that health care providers see themselves as directly seeking to address stigma within the institution. Mental healthcare workers were also actively trying to modify their professional practice to minimise the stigma of mental healthcare on patients and lessen their ‘presence’ when they provide care. This is what the authors term as making the care-giving practice as ‘like a friend going around’. Compared with other studies, Crawford & Brown (2002) indicate that health care patients express themselves in a relatively more involved fashion, such as being conscious on the potential causes of stigma as well as having the disposition to address the adverse mind-sets on their own. Finally, the study recommends that mental healthcare practice, in the future, may turn to the expertise of professionals in searching for ways to minimize stigma as well as identify ways on how to tap the strengths of patients in reducing stigma. Methods of the Study The authors mentioned (p. 231) that their study was actually a part of an exploratory, qualitative study on the nature of how mental health care is provided to clients in a rural community in the north Midlands in the United Kingdom. This particular study covered eight focus group discussions involving a total of 33 mental health personnel from statutory and non-statutory services, and 15 users of mental health services and supports. From the above, it can be said that the study employs a non-quantitative method, which deals primarily on non-numerical data. Qualitative research empowers the study participants to provide ‘richer’ responses to inquiries made by the researcher. It may also enable subjects to share important insights which could have been impossible to deduce using other methods. Specifically, the study uses the FGD tool in gathering primary data. Cooper and Schindler (2001, pp. 142-146) mention that ‘focus group discussion’ originated in sociology but became widely used in market research during the 1980s and is used for increasingly diverse research applications today. It dates back a long way in the social sciences apparently used by Malinowski (in 1922) in his anthropological research. It used to be called focused interview (or group interviews), first proposed in a systematic fashion in the social research carried out by Merton et al. (1956) to study the impact of political propaganda. A focus group is a panel of people, led by a trained moderator, who meet for ninety minutes to two hours. The facilitator or moderator uses group dynamics principles to focus or guide the group in an exchange of ideas, feelings and experiences on a specific topic. Typically the focus group panel is made up of six to ten respondents. Too small or too large a group results in less effective participation. Creswell (1998, p. 124) explains that focus groups are advantageous when the interaction among interviewees will likely yield the best information, when interviewees are similar and cooperative with each other, when time to collect information is limited and when individuals interviewed one on one may be hesitant to provide information. Ethical considerations were observed prior to the actual conduct of FGDs in the present study. The approaches in selecting subjects varied based on whether one is a caregiver or patient. This ensured each participant will likely provide valid responses. The authors also secured initial validation on the participants’ readiness to partake in the study. Likewise, to ensure that the identity and privacy of participants are protected, the audio-taped FGD sessions were transcribed and the audio recordings were destroyed. This approach also allowed openness from the participants. Reliability and validity of research were also observed by the study proponents, as these ensure the rigour and trustworthiness of the undertaking. Reliability illustrates the extent a specific research tool, test or procedure or tool will result in similar outcomes in different instances, supposing nothing else has been modified. Validity refers to how close a study has achieved its actual results compared to those planned (Roberts et al., 2006). Analysis and interpretation of the resulting transcriptions followed the grounded theory approach, as outlined by (Glaser & Strauss, 1967, Strauss & Corbin, 1998). Grounded theory refers to the generation of a theory or concept closely related to the context of the phenomenon being studied (Creswell, 1998, p. 56). In grounded theory, the central phenomenon might be identified, although it is likely to change or be modified during data collection and analysis (Ibid., p. 97). There has been a tendency for researchers to ‘adopt and adapt’ grounded theory and to use it selectively for their own purposes. As Glasser (1995) himself acknowledges, there is an almost inevitable process where the original idea gets transformed through the way that people interpret it, the way they apply it, the way they selectively use bits of it alongside other methods and the way they might try to develop the idea further. For the present study, there are two resulting themes—stigma reduction and resistance. Disciplinary triangulation was also adopted to further advance reliability and validity (Denzin & Lincoln 1994). This allows further examination of the different variables of the study (such as the statements made prior and after making the formal audio-recordings and the familiarity of the researchers on the locality) to ensure integrity of the data set. Findings The authors presented the results based on the narrative of stigma derived from the FGDs, in a succession divided into three different sub-sections which match the various facets of stigma as defined by the participants. The first is on the preliminary definitions of the phenomenon of stigma. Mental healthcare professionals suggest that the problem of stigma comes from the intervention of other people, or those outside the mental healthcare system. This contradicts the classic principle of stigma, which avers that stigma comes from within the mental healthcare system. Based on the resulting anecdotes from the FGDs, the professionals in this study seemed to suggest that it is very hard to maintain privacy and anonymity in rural areas. The professionals also shared on the complexities which may arise when members of the community become aware that someone from their neighborhood has been a mental patient. Thus, the authors infer that since the mental health problem is actually the cause of the leakage, the professionals are responsible in helping the patient deal with the resulting social problems. The second section discusses the probability that the ‘cautionary tales’ made by mental healthcare workers regarding stigma may have even worsened the already intricate issue. Based on the narratives, these ‘cautionary tales,’ which typically points to another person other than the real source of the story, can actually help express valuable local information regarding good practice and even paint a good image of the storyteller, as an individual who could not make mistakes of this nature as due to his/her sensitivity to stigma-related issues. There were also stories which underscored particular approaches in how to protect users from stigma. The last group of narratives is on the approaches to minimize and address the problem of stigma—which presented ways of using secrecy to avoid stigma. The different approaches of stigma-avoidance were described by the professionals so as to ensure that the client’s neighbors will not discover why mental health professionals visit their clients. These approaches may include the caregiver wearing plain clothes when making house visits or providing the care in the clinics instead of the client’s home. Discussion Biases in research can take different forms, which are influenced by the type of research method used. Both qualitative and quantitative research designs have inherent biases. For qualitative studies, biases will be on the exclusivity or limitation of the sample, while the quantitative research will be the predisposition to cover as much data, making the ‘richness’ of each data suffer. There are also various categories of bias that influence the validity of a study, such as selection biases (like having an unrepresentative sample of the population), measurement biases (issues concerning the method of estimation employed), and intervention or exposure biases (the disparities in the use of the method or the manner the subjects were exposed to ‘factor of interest’) (Hartman et al., 2002). The present study by research design can likely suffer a selection bias considering the nature of the research (qualitative, grounded theory approach). However, this ‘shortcoming’ can likely be ameliorated by the fact that the present study is actually a part of a bigger study covering a rural region in the north Midlands in Great Britain. Likewise, the authors have been conscientious of the limitations of the study that they have always made qualifications that study results are best considered as indications and are, in nature, suggestive. In essence, the study opens several avenues for future research challenging the classical notion of stigma, particularly in the rural setting. For one, future studies can further investigate the intricacies experienced by professionals in addressing local prejudices and exclusionary practices. This may involve identifying effective practices to help clients face or eliminate anxieties in going to public places or in making acquaintances. While efforts have been made to effect mass education to minimize the effect of stigma (Bryne, 2000; Britten, 1998), further studies can also be done in searching for ways on how professionals involved in community care can help clients with stigma on a daily basis. The present study has identified strategies that can be utilised in the practice of professionals in community settings. Although there may be inconsistencies when generalizing good practices and sensitivities that arose within the focus groups, the mere instance that such practices have been identified indicates that mental healthcare providers are already attempting actively to know the actual experiences of a mental healthcare user and that the long-unattended sentiments of activists and clients regarding stigma are already becoming priorities of mental healthcare providers. Thus, existing and upcoming information on stigma can be made as potent tools in enriching practice and policy to effectively make sense of the experiences of stigma sufferers as well as to plan services and daily activities to ensure that disapprobation by the public may be prevented. Institutional practices may also be fine-tuned to address the issue, in a way that the healthcare system shifts from being a passive player into becoming very active in addressing the issue. Concealing the identity of professionals may help in minimizing stigma, but in a larger social context, more considerable efforts must be initialised. The paper provides an excellent source for evidence-based practice. Through the application of scientific approaches that investigate the ramifications of particular practices on the stakeholders in the mental health care system, the knowledge base is created. As suggested by Hoagwood, et al. (2001), ‘evidence-based practice is a shorthand term that denotes the quality, robustness, or validity of scientific evidence as it is brought to bear on these issues.’ The ‘top-down’ approach can be effective in designing policies but is impossible when there is a lack of evidence, efforts or resources (Evans & Weist, 2004; Wiltsey-Stirman, Crits-Christoph, & DeRubesis, 2004). Thus, the absence of available data gives merit to the ‘bottom-up’ strategy, such as what this study aims to provide. By conducting small-scale studies in a portion of a larger community mental healthcare environment, evidence-based practices can be formulated, fine-tuned and eventually adopted in actual settings. This is what is being done in developing evidence-based health interventions that will be used in school settings (Langberg & Smith, in press). When adequate information have been collected, large-scale evidence-based policy initiatives are then implemented (Biegel et al., 2003; Chamberlain, 2003; Chorpita et al., 2002; Goldman et al., 2001). The paper in review provides the potential for undertaking a small-scale community initiative that sets the ground works for large-scale change. Presentation and Style Generally, the paper is logical in the way information has been presented. Beginning the discussion with the classical notion of stigma—the origins of the concept and how developments were achieved—has positively helped in shaping the author’s argumentation and inferences. Arguments and counter-arguments on previous and present findings on the area of stigma and mental health care were effectively elaborated and this has contributed considerably in the paper. The paper does display a good level of coherence and accessibility of language, although, as I have observed in most technical papers, it would greatly help in achieving clarity in the discussion if, in the initial parts of the paper, paper-specific terms are operationally defined as per description and coverage. In my opinion, although it helps to utilise different terms when discussing a single concept to achieve some levels of diversity and stylistic tones, further clarity will be achieved and ambiguity will be eliminated if employing nuances are prevented. For instance, the somewhat randomly interchanging use of mental healthcare providers, professionals, caregivers and workers can elicit some ambiguous understanding, as well as when alternately substituting mental healthcare users, patients, clients, sufferers, etc. I know that these were used by the authors according to particular unique contexts, but I think there were some instances when the above terms have been somewhat used confusingly. I am speaking from the point of view of beginners as well as non-technical people. This may be of little merit (as the paper is published in a trade journal targeting professionals in the field of health and social care in the community) but this is how I see it. The paper made effective use of headings and subheadings. For one, the results are discussed under several subheadings which correspond to the various facets of stigma, which arose from the focus group discussions. Using sequential discussion, the authors went on with the discussion as how the participants talked about the phenomenon of stigma. As I went through the paper, I have made frequent checking on the corresponding citations and found everything to be in their proper places and have complete entries to facilitate future study and correlation. The quantity of citations is also quite substantial for the scope and topic of the paper. Overall, I do commend how the paper was conceptualised and executed, especially, of course how the study was conducted. The paper is a rich source of information which can be valuable for future studies aimed to further enhance the practice of community healthcare workers and users alike. References Audit Commission (1994) Finding a Place: A Review of Mental Health Services for Adults, HMSO, London. Bar-Levav, R. (1976) ‘The stigma of seeing a psychiatrist,’ American Journal of Psychotherapy, vol. 30, pp. 473–482. 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