This chapter will examine some of the key issues in mental health services. One of the most important developments in mental health services is the belated and far from complete recognition of the importance of service user perspectives. The chapter begins by a consideration of these issues and then goes on to examine a range of contemporary concerns within services and mental health social work.

Surviving psychiatry

Sick role

Parsons (1975) identified four main elements to the ‘sick role’. One approach to understanding service user responses to the psychiatric system is to regard them, whatever form they take, as a challenge to Parsons. He outlined four key elements to the role:

• • The person is not responsible for assuming the sick role.

• • The sick person is exempted from carrying out some or all normal social duties (e.g. work, family roles).

• • The sick person must try and get well – the sick role is only a temporary phase.

• • In order to get well, the sick person needs to seek and submit to appropriate medical care.

The sick role is a binary, paternalistic model. Modern medicine takes a rather different approach to the causes of ill health. There have been significant changes in societal and professional attitudes. For example, being sick is no longer necessarily a temporary phase but also it does not exempt one from usual social obligations. Shifts since Parsons outlined the sick role include the fact that there is greater ambiguity about responsibility for the adopting the sick role. For example, public health campaigns emphasise that diet, exercise, smoking and drinking are all potential factors in the development of long-term conditions. Patients have a much greater role, including the exercise of choice, in the management of illness. The idea that the patient must simply submit to the treatment regime that is outlined by the medical profession is an outdated one in almost all areas of medicine. Wagner et al (1996) outlined a Chronic Care Model and the changes that the health care system would be required to undergo to produce a health care culture and delivery system to promote patients’ priorities. This model flips the doctor-patient relationship and the patient becomes the expert.