Summary

With the advantages of non-stigmatizing community bases in service provision, social workers in a non-government organization family service setting attempt to develop wide ranges of services for depression. A spectrum of interventions, namely prevention, early intervention, and standard treatment, is put forward in the service planning based on a population mental health approach. Service rationales and strengths of school-based prevention project, community education programmes, community based consultation service are introduced. For patients with a clinical diagnosis, the use of body-mind medicine and the pros and cons of a few approaches are explored. Clinicians are recommended to design tailor-made treatment plans according to needs and background. At the same time, values of working with patient's views and subjective meanings of depression are highlighted in the healing process. Among the different disciplines, the roles of social worker in helping individual and families with depressive disorder in integrated family service are discussed.

摘要

非政府機構家庭服務社工致力於免除標籤的社區基地，為抑鬱症的治療及預防提供多元化的創新服務。文中提及到校預防計劃、社區教育活動及精神健康諮詢服務的服務理念及優點。針對個別經診斷患者，除藥物治療外，數個正於機構內推行的治療手法及其特色的介紹，可成為制定符合個別病者需要的治療計劃時的參考。最後，作者強調病者對治療的觀點及個人主觀意義在治療過程的重要性，並介紹社工及綜合家庭服務在處理抑鬱症病者及其家人的角色及介入手法。

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Introduction

Social work practice has been characterized as an "oral culture" and the profession is still searching hard for a unifying theory to explain and guide its daily intervention.¹ It is particularly the case for social work with depressed patient. Since Hong Kong Government kept confining its role to rehabilitating the psychotic groups in its policy making and service planning in the past years, depressive disorder seldom appeared on the agenda of health and welfare planning.² So far, there are conscious efforts made by social workers in few non-government organizations (NGOs) to provide tailor-made services for this specific target group. However, the service scale remains small and funding support is limited. This paper attempts to outline our working agency's service elements, conceptual models and guiding principles in this largely underdeveloped area. Hopefully, it can stimulate more discussion among multi-disciplinary professionals to generate more advanced knowledge and practice wisdom.

A population mental health approach

There has been a paradigm shift from a traditional remedial model to a more comprehensive and holistic health approach in response to the promotion of WHO in the past few decades. A population mental health approach, which is adopted by Australian government as the conceptual framework in national policy, can be considered an ideal reference. It emphasizes the mental health status and mental health needs of the whole population. It includes population needs assessment, developing and implementing interventions to promote mental health and reduce mental illness across the whole population.³ In the model of Mrazek and Haggerty, a spectrum of interventions is put forward to service planning for different mental health needs and problems. Case identification, early treatment and standard treatment are under the category of treatment for people with some forms of mental health problems or illnesses. At the same time, a separate category of prevention is incorporated within the spectrum of interventions for increasing the well-being in a community as well as decreasing the incidence of mental health problems and mental disorders.³

As one of the major NGOs in Hong Kong, our agency is conscious in applying social work professional knowledge in meeting the mental health needs of the whole population. As an innovative project, our Family Mental Health Service was started in 1986 with an emphasis on serving the general public by filling the service gaps of existing mental health services. Compared with the psychiatric units in the public hospitals and clinics, our family service centres serve on non-stigmatizing community bases to provide mental health services. In addition, partnership and outreaching approach, such as school-based interventions, are adopted as effective strategies in service innovation.

In Hong Kong, several recently developed projects have demonstrated the commitment of local mental health professionals in preventive work. These include Understanding the Adolescent Project (成長的天空), Adolescent Health Project (成長新動力), and Emotion and Value Education Project (心智教育計劃). All of them are school-based interventions that aim to promote adolescent health. Our agency's Student Psychological Resilience and Emotional Intelligence Enhancement Project (SPREE), (少年當自強計劃) which was started in 2003, is another unique innovation with a specific theme in preventing adolescent anxiety and depression. The project aims at enhancing the resilience and overall mental health of students on one hand and reducing the risk factors that can contribute to the onset of depression and anxiety on the other hand. The programme content of SPREE which is based on a framework of Cognitive Behavioural Therapy (CBT) received very positive feedback from school teachers and students. A study of programme effectiveness of SPREE is currently conducted for establishing the evidence base and to demonstrate the cost effectiveness of local preventive practice.

Early intervention

A local survey reported that about two thirds of the respondents with moderate to severe mental health symptoms did not seek help from mental health professionals. Those people tended to believe that they could solve the problems themselves, or the disturbance did not warrant professional's intervention, or they were financially inadequate to afford for the services, or those symptoms would fade away automatically with time.⁵ These problematic beliefs discouraged many people with depressive disorder from timely intervention and treatment.

In response to the poor mental health literacy and resistance to psychiatric treatment, more community education is introduced to reduce the stigma of depression and to provide a platform for the needy to receive proper intervention. Instead of waiting for people in need to approach clinics and counselling service centres, our working agency made effort to provide accurate knowledge about mental illness and the availability of medical and community resources through mental health talks and consultation forums. The number of participants in each consultation forums was restricted to 30 and there would be more time for participants to raise questions. Early identification and timely referrals can be achieved as the needy got the chance of having personal contacts with the professionals in a stigma-free manner.

Our community based psychiatric consultation service for families is also unique in Hong Kong. People with mental health problems but reluctant for psychiatric treatment may receive a consultation session from a volunteer psychiatrist and an experienced social worker in a relatively relaxed atmosphere. The family members or significant others, and responsible caseworker will also be involved in the assessment and recommendation of follow up plan. An internal mini-survey of those recommended to receive follow up treatment from psychiatric units in Hospital Authority, private psychiatrists, and GPs after the consultation showed that 80 percent of them had attended at least the first appointment. It proved that a community based psychiatric consultation service helped to speed up the help seeking process, and to enhance the users' acceptance for further follow up treatment.

Use of body-mind medicine

It is also preferable to apply psychotherapy for those with less severe depressive symptoms and strong resistance to medication. Compared with various approaches in treating depression, cognitive behavioural therapy (CBT) was well-known for its active, directive, time-limited and structured approach.⁶ Its strong evidence base and repeated trials in local population have demonstrated its applicability in preventing and treating depressive disorders.^7,8

CBT includes cognitive techniques and behavioural components. The former emphasizes on recognizing and challenging negative thoughts and maladaptive beliefs. The latter involves graded task assignments, pleasant events scheduling as well as other skills training such as relaxation skills, communication and assertiveness, problem solving skills.^9,10 Undoubtedly CBT is the best documented and most studied psychotherapy. However, it has not been shown to be superior to plausible alternatives.¹⁰ Although preliminary evidence suggested that patients with well-assimilated problems did better in CBT than in psychodynamic, experimental, or interpersonal therapy,¹¹ professionals may still consider other approaches or a combination of CBT and others to maximize the treatment effectiveness for different patients. Some suggested that CBT may benefit less to those with lower intelligence, a diagnosis of endogenous depression, or a comorbid personality disorder.¹⁰

Apart from the favourable outcome of individual CBT mentioned above, the advantages of group treatment as an intervention method are also well documented. Group members enjoy the opportunities to see that he/she is not alone, to learn more positive thinking from the feedback and sharing with other members, to gain support and recognition from the interactions with others.⁹ However, it is not uncommon for clinicians to face a problem of recruiting enough group members with similar problems and background. With the positive comments of ex-group participants, our agency continued to organize CBT groups in a few convenient locations in Hong Kong. The total number of CBT groups held has already exceeded 200. Our effectiveness study further showed an all around significant improvement, including decrease of psychiatric symptoms, improvement in self assessment, better and more social activities and being more able to cope with problems. The above improvement was sustained in a 3 month follow up study.⁷

In view of the above favourable outcomes in treating depression, CBT can be safely considered in the first place among various approaches in psychotherapies. However, the following alternatives may also be considered when CBT seemed unsuitable for a specific patient, or patient with low motivation or limited response to CBT. People in marital discord may have difficulties in fitting in the perspectives of CBT which are largely based on an analysis and modification of an individual's cognitions. Couples therapy and mediation service may then become a preferable choice for them.¹⁰

Art therapy promotes visual thinking, helps expressing what language cannot, and releases deep emotions.¹² It can be powerful for those with special difficulties in expressing or releasing his/her problems or emotions. Some of my clients who had joined both art therapy group and CBT group in our centres expressed their preference for the former as it allowed more spaces for them to explore their deep emotions, often related to some earlier traumatic experiences, which are relatively difficult to be resolved in CBT's systematic and logical manner. It is also true for people with less formal education and less sophisticated cognitive abilities. The above comment does not imply that art therapy is superior to other approaches but clinicians should be more open-minded to appreciate the strengths of different approaches and design tailor-made intervention for depressives.

Mindfulness, an innovative approach integrating meditation, as well as yoga and body scanning (a technique of developing awareness of body sensation), have recently been developed to help the depressives to combat their ruminative mind by learning to control their attention. Mindfulness is particularly helpful since depressive's original, habitual patterns of negative cognitive processing re-activates automatically at times of lowered mood and CBT may not be effective enough for them to find their way out. This negative thinking is then likely to intensify the depressed mood and self-perpetuating vicious cycles can lead to relapses. Mindfulness helps patients to accept what has occurred non-judgementally and to "decenter" from negative thoughts. Repeated randomized trials demonstrated that mindfulness is effective in relapse prevention for depression.^13,14

Patient's views and subjective meaning about illness

A clinical diagnosis helps mental health professionals to formulate goal-directed treatment plan. It also greatly facilitates information transfer and exchange during the intervention process. However, criticisms have been raised concerning the diagnostic classification system because suggested diagnosis can also be a hindrance to treatment. Humanistic therapists stated that diagnosis diminishes the ability to relate to the other as a person and professionals can easily be trapped to selectively inattend to aspects of the patient that do not fit into that particular diagnosis and overattend to features confirming the initial premature diagnosis.¹⁵

Many patients have queries about the effects and side-effects of the medication. It is not uncommon for patients to adjust or even stop the medication without discussing with the responsible medical professionals. In some of these cases, they may feel a bit easier to tell their social workers about their worries. However, our professional knowledge may not be adequate enough to give proper advice to the patients. Cross disciplinary exchange of case information with patients' consent is always recommended to understand patients' view of mental condition as well as their worries and questions about treatment and medication. It helps to foster necessary trust and commitment from the patients resulting in better drug compliance and enhanced recovery. Social workers may accompany patients in medical consultation sessions for case discussion with medical professionals occasionally. Phone contacts may be a more efficient way for information sharing but the use of case conferences should also be considered for extremely complicated cases involving multiple professionals.

Instead of merely talking about the depressive symptoms, it is also important for clinicians to explore the meanings of actual experiences of mental disorder. Psychotherapy, in this sense, not only help patients to recover from depression but also serves as a process for them to reexamine and adjust the core life values and assumptions. A psychiatrist who had previously suffered from the illness shared that "depression is not - as I have eventually and painfully learned - something to sweep under the carpet: to deny, to forget. It is an experience that brings great misery and causes a great waste of time, but it can be, if one is fortunate, a source of personal wisdom and worth more than a hundred philosophies".¹⁶

One of my patients who had been suffering from depression for years started to grow spiritually with the assistance of a counselling process. She found herself fall into low moods whenever she faced rejection from colleagues and relatives. It became unbearable to her as it would easily arouse her memories of being emotionally abused by carers in childhood. In spite of her outstanding work performance, she still had low self esteem and always tried to minimize or externalize her achievement in order to avoid being isolated or rejected in the workplace politics. She always strived for perfectionism to meet the expectation of others. She felt even more frustrated about other's criticism or disappointment in a single incident, regardless of the praises and outstanding comments received. She soon realized that there was a need for her to readjust her work related values and to pay more attention to her inner needs. She felt less guilty of having not "overperform" and enjoyed herself more in silence, rest and supportive family life.

An integrated family service

It should be reminded that patient's problems are interconnected with those of his/her family members. Some depressive patients are the victims of different forms of abuse while others may transmit such abusive relationship to their family members at the same time. Studies reported that about 40 percent of children of depressed mothers are diagnosed with depression. Maternal depression more than doubles the risk of a child's developing depression across the lifespan.¹⁷ It is also predictive of youth substance abuse and conduct disorder.^18,19

The reform of local family services echoes the principle of early identification in mental health promotion. It strengthens the existing outreaching and networking work to attract referrals of families-at-risk so as to intervene families with problems of at-risk youth, child abuse, battered spouse, suicide, and post-trauma victims as soon as possible. At the same time, the use of drop-in, information given, mutual help and volunteer development can serve to prevent various family and mental health problems. For example, a depressed person gets help from spending time more enthusiastically in centre's drawing or yoga classes, receiving home-based training of family aide service for improving the self-care ability and increasing activity level, gaining emotional support from the caring phone calls or visits from other volunteers, expanding social networks by joining the mutual aid group of the service centres. By the end of 2004, 61 Integrated Family Services Centres (IFSCs) will be formed by Social Welfare Department and other NGOs across the districts. Medical professionals are encouraged to make timely referrals to IFSCs and cooperate with family social workers in helping individuals suffering from depressive disorders and their family members.²⁰ The back-up of a teamwork of social service agency and other supportive services within the same service centre can avoid service fragmentation so as to improve the outcome in crisis management and enhance the overall treatment compliance and effectiveness.

Conclusion

Recently the burden of depressive disorders has aroused more attention in general public. It is believed that the needs of a depressive are complex and different forms of professions and expertise may be involved in different stages of treatment. The advantage of a social worker is that he/she is not only a counsellor but also a "professional shopper" or "resource allocator". Timely referrals to other disciplines, either within or outside the agency, will ensure a person in distress receiving proper help as soon as possible. The above discussion serves to summarize the arguments about effective prevention and treatment of depressive disorders that can be provided by social workers. There is also a challenge for different professionals to establish partnerships for promoting a more mentally healthy community.

Key messages

1. The role of social worker in depressive disorder is underdeveloped. However, a spectrum of interventions had been locally to meet different needs.
2. Local attempt in preventing depression had been introduced but its effectiveness is to be verified.
3. Community based educational activities and consultation service can improve mental health literacy and promote early intervention for depressive disorder.
4. Effect of Cognitive Behavioural Therapy in treating depression is well documented but a few alternatives are also provided in body-mind medicine.
5. . Patient's views and subjective meanings of illness are important for recovery in a holistic model.
6. . Integrated family service is currently under reform in Hong Kong and social workers have strived to meet the complex needs of depressive clients and their families.

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References