# Clinical Social Work Practice in Behavioral Mental Health
## Historical Changes in Mental Health Policies and Practice

The history of mental health policies and practice have changed tremendously over the last century. In the beginning of psychiatry, individuals with mental illnesses were treated extremely inhumane and neglected. Basically, anyone with a mental illness was to be institutionalized and essentially secluded from society. According to Sands and Gellis (2012), techniques used on the mentally ill included restraints, bleeding and purging, and shock therapy. Cosgrove (n.d.) describes the conditions of a mental institutions in Oklahoma that was examined and evaluated in the 1940's. These conditions included being so over-crowded and under-employed that many patients were caged in small rooms, slept on floors, had not been outside in over 10 years, wooden floors falling apart, etc. One institution housed over 1,600 patients and only had a bed capacity of around 1,100. Sands and Gellis (2012) explain the rapid growing populations in psychiatric hospitals during the early and mid 1900's being unmanageable, people were being put into institutions that did not necessarily belong in institutions. Population in United States psychiatric hospitals reached over 550,000 in 1950. Due to these circumstances reform began to take place and a focus on community mental health emerged. Many reforms took place that were influenced by medical discoveries, the Great Depression, World Wars, and economic factors.
Deinstitutionalization was a major policy and practice that changed the course of mental health practices. Once the conditions of hospitals and institutions became known, it was apparent that institutionalization was ineffective and against civil rights. This took place in the early 1970's and was the process of moving clients from institutions back into their communities. During this time, clients were to be moved to non-restrictive environments and alternatives like group homes, family care home, and half way houses were supported. This is the time when clinical social workers emerged. They began expanding and being open to new theoretical approaches and therapeutic interventions relating to social environments and systems approach.
A time line of a few policies enacted in regards to mental health.

## Mental and Health Issues in Rural Areas/Rural Social Welfare Policy

There are many social determinants rural communities experience that affect their well-being and overall health status. Examples of social determinants are availability of resources to meet basic needs, access to health care, access to job or educational opportunities, transportation, social support, socioeconomic conditions, etc. According to Glasgow, Morton, and Johnson (2004) some conditions for the population in rural areas include: increased poverty, less likely to have health care, far distances to obtain health care which could propose transportation issues, and inadequate funding put into rural health services. Glasgow et al. (2004) explain that many rural communities have a high population of elderly and low-income members, resulting in a high need of healthcare services. Additionally, rural communities are struggling to maintain their health care systems resulting in increased rates of illnesses and negative mental health outcomes. One example is that the rural suicide rates have been increasing for three decades, which could be related to absence of society, isolation, or lack of mental health services.
Policies are often created by people who live in urban areas and are not knowledgeable about rural communities, and they even neglect to think about the effects certain policies will have on people who live in rural areas (Daley,2016). This is not intentional, but many of the policy makers just do not fully understand the lifestyle of rural communities. Daley (2016) states, “Because of differences between rural and metropolitan communities, a one-size-fits-all approach to social policy may not only work well; it could effectively further disadvantage the people and community that a policy is trying to help” (p.110). Due to this issue, rural communities suffer many consequences when it comes to the services that they receive (Daley, 2016).
Rural social workers must get creative to effectively address the needs of rural communities. One way to do this is by discovering how to create resources that are not available and building strong supports with the resources that are available. Monahan (2013) expresses that the coping skill and social support mostly used in rural areas was the use of religion and being affiliated with religious activities. Almost all rural members used religious coping. He went on to explain the way churches can be a huge support in rural areas; providing support with transportation, respite care, child care assistance, support groups, and socialization.

## Indigenous Population in Rural Areas
#### Health related and social problems

Glasgow, Morton, and Johnson (2004) discuss some of the leading causes of death among the Indigenous population in rural areas. First, cardiovascular diseases are one of the leading causes of death, and it is attributed to lack of physical activity and bad eating habits. This raises the question if Native reservations have opportunities on the reservations for physical activities? Next, Glasgow also informs that the rates of unintentional deaths is another leading cause of death for Indigenous people up to age 45, and that the rate is twice as much as the general population. The reasoning given behind this, is low socioeconomic status and alcohol abuse. That brings us to the problem of alcohol and substance abuse. According to SAMHSA (2012), the need for alcohol or drug treatment among Indigenous population is about two times more than any other ethnic or racial group. The suicide rates among the Indigenous have been increasing for the past sixteen years (Leavitt et al., 2018). Leavitt et. al (2018) examined data from eighteen states between the years 2003-2014, and within that data, they found that the Native American population has higher rates of suicide than any other ethnic or racial group in the United States. The American Psychiatric Association (2010) informs that suicide is the second leading cause of death among Native Americans ages 10-34. Sands and Gellis (2012) add that primary behavioral health problems for Native's are co-occurring substance abuse and mental disorders and post-traumatic stress disorder. Lastly, Disproportionate numbers of Indigenous population have low incomes and suffer from poverty.
Glasgow, Morton, and Johnson (2004) discuss that overall the Indigenous population has numerous health disparities and a lower health status when compared to the general population, with the reasons being genetic predispositions, individual risk behavior like alcohol and drug use, and socioeconomic and environmental factors.

#### Culturally Competent Mental Health Practice With Indigenous Population

Sands and Gellis (2012) display the importance of cultural competency with all cultural backgrounds. With the indigenous population it is important to ask the client to what extent they identify with their tribe, what their traditional practices and beliefs are, and how they have been impacted by tribal history. Although each tribe will have their own unique practices and beliefs there are some universal themes that are important for a Social Worker to be aware of. These themes are holism, harmony, and community. They usually value the welfare of their group over the individual. Natives do not separate mind and body, in other words it is all related and connected in some way. Mental health problems can sometimes be related to supernatural forces or external causes.
Mental health practices should reflect values of each tribe to be most effective. Traditional healing practices within the tribe could also be beneficial to become aware of.

## Evidenced-Based and Best Practices for Behavioral Mental Health
#### Psychosocial practices for treating depression

* Cognitive Therapy
* Interpersonal Therapy
* Problem-solving Therapy

#### Cognitive-behavioral approaches to treat anxiety disorders

* Systematic desensitization
* Flooding and implosive therapy
* Response prevention
* Thought stopping
* Cognititve restructuring
* Stress inoculation

#### Psychosocial approaches for individuals with severe mental illnesses and their families

* Illness management and recovery
* Family psychoeducation
* Cognitive rehabilitation

#### Co-occurring substance use and mental illness

* Motivational Interviewing
* Integrated dual disorders treatment (IDDT)

## Reflection on Information for Social Work Practice

This knowledge is beneficial for Social Work practice for a multitude of reasons. First, understanding the development of the field and how mentally ill clients used to be treated can show the progression in society. It also shows the importance of advocacy, because several of the policies that got passed to benefit the circumstances of the mentally ill were influenced by social workers who conducted research, discovered problems, and created solutions. Social Workers must advocate and promote social change. The historical changes also show that this field will continue to change and transform.
Next, Learning about rural health issues and the indigenous population is critical, to have a better understanding of what that population experiences. Being a member of an urban area, rural issues were unknown prior to this knowledge. If someone is wanting to work in a rural area, it is important to realize that it could involve playing many different roles. The Indigenous population (and other cultural/ethnic backgrounds), have their own set of beliefs, experiences, traditions, etc. This knowledge has taught me to always explore and ask a client for all these details. They are the expert and can teach the clinician about the culture, so that the clinician practices with cultural competency. It was beneficial to become aware of some of the major themes and general ideas. For example, Native's communicating and being comfortable with silence or lack of eye-contact. This is not something that a client would typically say during their first visit, so it's important to know some of these generalizations among all cultures then discover more in-depth from the client.
Finally, There are many evidenced-based and best practices for behavioral mental health. It appears that Social Workers explore and implement different approaches to discover what works best for each client and each circumstance. Clinical practice is not a "one size fits all". Each person is unique, each situation is unique, and the same approach will not have the same outcome for every individual. Learning about all the different practices is helpful in knowing that if one approach does not work, there are other options. Research is constantly being conducted with new practices being developed and implemented. Learning the basic models assists new social workers in building a solid foundation for their clinical work to build upon.

## Glossary

* Institutionalized: place or keep (someone) in a residential institution.
* Reform: make changes in (something, typically a social, political, or economic institution or practice) in order to improve it.
* Social determinants: Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes
* Native reservations: Area of land that is owned and managed by a Native American tribe
* Cultural competency: the level of knowledge-based skills required to provide effective clinical care to patients from a particular ethnic or racial group.
* Interpersonal therapy: A form of psychotherapy in which the focus is on a patient's relationships with peers and family members and the way they see themselves. Interpersonal psychotherapy (IPT) is based on exploring issues in relationships with other people.
* Systematic desensitization: a treatment for phobias in which the patient is exposed to progressively more anxiety-provoking stimuli and taught relaxation techniques.
* Response Prevention: A means to prevent reinforcement (and, thus, continuation) of anxiety reduction through repeated, ritualistic behavior. Determent for carrying out compulsion.
* Stress Inoculation: A form of cognitive-behavioral therapy that helps clients develop skills in coping with stress.
* Cognitive rehabilitation: Aims to remedy deficits in information-processing skills such as vigilance, memory, recall, and conceptual abilities
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Sands, Roberta G. (2012). Clinical social work practice in behavioral mental health : toward evidence-based practice. Gellis, Zvi D. (3rd ed.). Boston: Pearson Allyn & Bacon. ISBN 9780205820160. OCLC 682896753. https://www.worldcat.org/oclc/682896753.
* ↑ "'Epidemic Ignored': Oklahoma treats its mental health system without care". NewsOK.com. Retrieved 2019-07-25.
* ↑ "Social Determinants of Health | Healthy People 2020". www.healthypeople.gov. Retrieved 2019-07-25.
* 1 2 3 4 5 6 Glasgow, N., Morton, L. W., & Johnson, N. E. (2004). Critical issues in rural health. Ames, IA: Blackwell Pub.
* 1 2 3 Daley, Michael R.. Rural social work in the 21st century. New York, NY. ISBN 9780190615567. OCLC 990059365. https://www.worldcat.org/oclc/990059365.
* ↑ Monahan, Deborah J. (2013-1). "Family Caregivers for Seniors in Rural Areas". Journal of Family Social Work 16 (1): 116–128. doi:10.1080/10522158.2012.747461. ISSN 1052-2158. http://www.tandfonline.com/doi/abs/10.1080/10522158.2012.747461.
* ↑ "The NSDUH Report: Need for and Receipt of Substance Use Treatment among American Indians or Alaska Natives". www.samhsa.gov. Retrieved 2019-07-26.
* 1 2 Leavitt, Rachel A.; Ertl, Allison; Sheats, Kameron; Petrosky, Emiko; Ivey-Stephenson, Asha; Fowler, Katherine A. (2018-03-02). "Suicides Among American Indian/Alaska Natives — National Violent Death Reporting System, 18 States, 2003–2014". MMWR. Morbidity and Mortality Weekly Report 67 (8): 237–242. doi:10.15585/mmwr.mm6708a1. ISSN 0149-2195. http://dx.doi.org/10.15585/mmwr.mm6708a1.
* ↑ Sands, Roberta G. (2012). Clinical social work practice in behavioral mental health : toward evidence-based practice. Gellis, Zvi D. (3rd ed.). Boston: Pearson Allyn & Bacon. ISBN 9780205820160. OCLC 682896753. https://www.worldcat.org/oclc/682896753.