Social Work Education Vol. 23, No. 2, April 2004, pp. 231 240 Ideas in Action The Mental Health Dimension in the New Social Work Degree: Starting a Debate Jerry Tew & Jill Anderson The Mental Health in Higher Education Project (mhhe) aims to increase networking and debate about the learning and teaching of mental health, both within and across the disciplines and professions in higher education. Despite the recent prominence that has been given to mental health in terms of policy development and new practice models, there has so far been little discussion as to what should constitute the mental health component of the new social work degree that is currently being introduced in England. This paper sets the context for the debate and reports on the outcome of an mhhe workshop on this theme held at the 2003 Social Work Education Conference in Warwick. Keywords: Social Work Curriculum; Mental Health; Practice Capabilities The transition from the existing Diploma in Social Work to the new social work degree offers an ideal opportunity to review the mental health content of professional training in England. Under the auspices of the Mental Health in Higher Education project, a workshop took place at the 2003 Social Work Education Conference to explore this issue and, in particular, to see how much may (or may not) have changed since the last guidance on the topic was produced by the Central Council for Education and Training in Social Work (CCETSW) 10 years ago. The Mental Health Content of DipSW Courses Although allowing for the possibility of specialist teaching and practice, the Diploma in Social Work was constructed around generic competences and values which were Correspondence to: Jerry Tew, Senior Lecturer, School of Social Work, University of Central England, Perry Barr, Birmingham B42 2SU, UK; Email: jerry.tew@uce.ac.uk or Jill Anderson, Senior Project Development Officer, Mental Health in Higher Education, and Tutor in Social Work, Centre for Social Work, University of Nottingham, University Park, Nottingham NG7 2RD, UK. ISSN 0261-5479 print/1470-1227 online/04/020231-10 2004 The Board of Social Work Education DOI: 10.1080/0261547042000209224
232 J. Tew & J. Anderson seen as applicable to every setting and sector of work (Vass, 1996, p. 4). There was no specification of any particular learning outcomes in relation to mental health, either in terms of a core knowledge base for all students, or in terms of what would be expected from a discrete mental health pathway, if such a pathway were to be offered (see CCETSW, 1995). Thus, although some courses provided substantial input in relation to mental health, there was considerable variability. It was acknowledged that: a wide diversity of approaches to the location of mental health in curricula is possible. Experience has shown that this may be set predominantly or even solely in a legal framework, or perhaps placed generically within sequences on such topics as Community Care, Disability or Health. In fact, it may be difficult to identify mental health inputs or clearly differentiate teaching in this area. In other instances, however, mental health may be subject to a specialist block of teaching. (CCETSW, 1994, pp. 10 11) Questions were also raised elsewhere about the content and orientation of what was taught. It was suggested that social work educational texts tended to situate practitioners in a subordinate handmaiden role with respect to psychiatry sorting out practical problems at the edges while doctors (and nurses) undertook the core work of diagnosis, treatment and management. Social work education was seen as failing to establish a viable alternative to the medical paradigm or to articulate a perspective which empowers service users rather than labelling them as sick (Braye & Varley, 1992, pp. 45 46). More recently, in order to take stock of what was actually taking place within higher education, the then professional body, the Central Council for the Education and Training of Social Workers, conducted a questionnaire survey of current practice. Of the 57 courses that responded, only 13 made explicit reference to the integration of mental health teaching across their curricula (Webber et al., 2000, p. 5). In general, students would receive input on mental health law, typically within a generic law module, less often within other policy, theory and practice modules. However, even where such teaching was mandatory, assessments would often allow students to choose between a range of areas of interest, so that they would not necessarily have to demonstrate any understanding of mental health law. Input around mental health practice was less consistent, with learning focussing more on adults than young people and teaching typically located within an optional pathway rather than within the core curriculum. Sixteen of the courses that responded offered a final year pathway option in mental health usually comprising a mental health placement linked to one or more modules of specialist teaching. The survey concluded that there is concern about what constitutes the appropriate level and depth of mental health teaching at qualifying level (Webber et al., 2000, p. 19), and that it cannot be assumed that all qualifying DipSW students have been offered teaching and learning opportunities which address the mental health needs of service users (p. 18). This may be seen as creating something of an imbalance when qualified workers of different disciplines are recruited to work in multi-professional mental health
Social Work Education 233 teams. Mental health nurses, for example, will have followed an externally accredited specialist branch of study throughout their training, as well as undertaking generic nursing modules, so that there is clarity as to the knowledge and competence base that they can be expected to possess on qualification. By contrast, qualifying social workers may have received little or no specialist mental health input and may well not have had to demonstrate practice competence within a mental health setting. Service Developments and Implications for Education and Training During the late 1990s, a series of Department of Health policy initiatives sought to specify much more clearly the direction of a modern mental health service, recognising that existing patterns of provision were failing to meet the needs and aspirations of service users, and responding to concerns that fragmented services within the community did not provide an adequate safety net for service users and public alike. This forward direction was articulated through the publication of the National Service Framework for mental health (Department of Health, 1999), which set out a vision of a more holistic approach to mental health practice, directly addressing issues of social inclusion and discrimination, and stressing the importance of working in partnership with service users and carers. In order to deliver this vision, it was seen that professionals of all disciplines would need to review their ways of working and develop new areas of competence and understanding including how to work together in more effective ways. The influential Sainsbury Centre report, Pulling Together (1997), proposed a model in which all professions would have to learn and practise a set of shared core competences and values, as well as developing their own specific areas of expertise. Building on this, consultation exercises took place which started to give service users a major influence in determining what these core competences and values should be (NHS Executive North West Regional Office, 1998). What emerged from these developments was a focus on a more holistic approach to the needs of individuals, including social perspectives such as an awareness of cultural and gender issues in mental health and an awareness of the principles and practices of anti-discriminatory and anti-racist practice (Sainsbury Centre, 1997, p. 16). However, such radical approaches met with less than enthusiastic support from certain professional groups, so an attempt was made at a more inclusive approach in order to get these groups on board. This resulted in the Capable Practitioner report (Sainsbury Centre, 2000), which provides a more detailed development of the principle of shared values, knowledge and practice skills between professions as the core of mental health practice. However, the value of this framework was somewhat diminished by the relatively limited input of service users and the need for further consultation is acknowledged in the report (Sainsbury Centre, 2000, p. 3). Work on shared capabilities is now being taken forward by the Joint Workforce Support Unit of the National Institute for Mental Health in England (NIMHE) and the Sainsbury Centre for Mental Health. A parallel (but largely separate) initiative saw the development of National
234 J. Tew & J. Anderson Occupational Standards for mental health (Skills for Health, 2003) with the intention that these should apply across all professional groups. Unfortunately, the opportunity was not taken to build on some of the previous work in this area and specify values and competences that should be seen as core to all mental health work. Furthermore, there was little linkage with the concurrent development of National Occupational Standards for social work (TOPSS, 2002), and the opportunity was lost to produce an interlocking framework in which a basic range of mental health competences could be set for all social workers, with further competences being specified for social workers practising in the field of mental health thereby defining the learning expected of students undertaking a specialist mental health pathway. In both the benchmarking statement for social work (QAA, 2000) and the National Occupational Standards for social work (TOPSS, 2002), it was decided to retain an essentially generic specification of social work. No specific standards in relation to mental health learning were included, nor was there any stipulated expectation that students would be able to apply their generic knowledge and skill base within the field of mental health. Recognising this gap, the Department of Health introduced a requirement that courses will have to demonstrate that all students undertake specific learning in human growth, development, mental health [and] disability (Department of Health, 2002, p. 3), and it is acknowledged that this is an area where further debate and discussion needs to take place in order for more detailed guidance to be produced. The Mental Health in Higher Education Project The challenge of producing reflective and capable practitioners, well placed to function in new services and roles, is one that faces not only social work educators, but others within higher education who are involved in learning and teaching about mental health. There have, to date, been limited opportunities to articulate dilemmas, share approaches to learning and teaching and build on common ground (Anderson, 2003). This provides the context for the one year Mental Health in Higher Education project (mhhe). The initiative is funded by the Learning and Teaching Support Network (LTSN), which provides subject specific advice on learning and teaching issues across the range of disciplines in UK higher education. It is a collaboration between the LTSN subject centres for medicine, dentistry and veterinary medicine; health sciences and practice; social work and social policy; and psychology. The mhhe acts as a central point of contact for all those involved in learning and teaching about mental health in higher education and for those with an interest in what is taught and learned, such as policy makers, survivors and service users, carers, students and practitioners. It aims to enhance learning and teaching about mental health through creating opportunities for all involved to network and communicate, share questions and dilemmas, work together on solutions and identify ways forward. The project has been involved in establishing a website and discussion group,
Social Work Education 235 collating case studies of learning and teaching, producing good practice guidance and in a range of other areas of activity. Workshops have provided a means for educators to meet face to face, and for the exploration of key issues both within and across disciplines. One such took place at the 2003 Joint Social Work Education Conference, with the aim of exploring what should now constitute the mental health dimension of the new social work degree. Setting the Context for the Workshop The development of the new social work degree provides an opportunity to review previous CCETSW guidance on the mental health dimension in social work (CCETSW, 1994). The latter emerged during a period of relative neglect of social perspectives in mental health, and of the potential distinctive contribution of social work (Tew, 1999). However, more recently, coinciding with the arrival of the National Service Framework, there has been a flurry of activity in this area. One expression of this has been the formation of the Social Perspectives Network (Duggan, 2002; Social Perspectives Network, 2002). This is now formally linked in to the National Institute for Mental Health in England and has a remit to pull together knowledge and research in relation to social perspectives, and to use this as a basis for influencing mental health policy and practice. These developments have been accompanied by articles drawing out implications for the education of social workers (Tew, 2002; Karban, 2003). As well as such shifts in thinking, account was taken of other current and future developments in policy and practice, including the implementation of the new service models embodied in the National Service Framework, the potential reform of the Mental Health Act, and the integration of social work with other professions within combined mental health trusts. It was suggested that social work roles are, in the future, likely to become defined less by the duties of an Approved Social Worker (as potentially, the Approved Mental Health Practitioner role may be taken on by a range of disciplines), and more by the ability to bring expertise in relation to social models and perspectives to the work of multi-professional teams. Alongside a recognition of these developments within specialist mental health practice, account was taken of what may be the priorities, in terms of a foundation level of mental health learning, for social workers practising in other fields, such as work with children and families, older people and people with disabilities. While it has to be accepted that, within the confines of a three year degree, it is impossible to train social workers to be specialists in all areas, nevertheless effective practice with other groups of service users may be seen to require a significant level of understanding of mental health issues in order to appreciate how these may intertwine with issues of, for example, parenting or disability. In the light of these considerations, workshop participants were invited to discuss what may be expected of qualifying social workers in terms of their practice capabilities in mental health both now and in the future and what may be the implications of this for the mental health component of the new social work degree.
236 J. Tew & J. Anderson In order to provide a framework for this discussion, participants were invited to revisit CCETSW guidance from 1994 on the mental health dimension in social work, and look at how this may need to be revised and updated. 2.1. Abilities of DipSW qualifying students The underlying themes of this guidance are that all social workers at the point of qualification should, at a minimum, be able to: (i) theorise about the possible presence of mental health factors as a dimension to all situations, needs and problems encountered; (ii) practice with the self-awareness and confidence to acknowledge the reality and impact of mental illness, for individuals, families and the wider community as well as on self; (iii) demonstrate a basic understanding of psychiatric diagnoses, causes, symptoms and treatments, and be basically familiar with the psychiatric vocabulary; (iv) recognise when people are becoming mentally ill; (v) show a basic awareness of the need to promote mental health and of the social work contribution to the prevention of breakdown in mental health; (vi) apply a basic knowledge of mental health legislation and of mental illness in order to know whether, when and how to consult others including ASWs/ MHOs, other social work colleagues, or medical personnel; (vii) understand racism and discrimination in relation to mental health, and the care and treatment of people who are mentally ill. (CCETSW, 1994) Outcomes from the Workshop Workshop participants were divided into small groups and each produced what they saw as key areas of capability for qualifying social workers. Although there were some differences of focus between the groups, proposals were seen as complementary and there emerged a strong consensus across the groups in support of the final listing. It was recognised within this discussion that there would be value in specifying both the foundation of mental health learning that should be demonstrated by all students undertaking the new degree as a pre-requisite for practising with any potential service user group, and the more advanced level of mental health learning and practice competence that would be expected of any student following a specialist mental health pathway. Thus, for each of the areas outlined below, learning outcomes might need to be specified at two levels: Social workers at the point of qualification should, at a minimum, be able to: (i) understand mental health holistically, and consider mental health factors in relation to all situations, needs and problems encountered;
(ii) (iii) (iv) (v) (vi) (vii) Social Work Education 237 identify how stigma and social exclusion, and oppression on the basis of race, gender, sexual orientation, age and other factors, may impact on people s mental health, and the care and treatment they receive and implement strategies to start to redress this; contribute to the promotion of mental health and the prevention of breakdown in mental health; demonstrate an awareness of the impact of mental health problems on individuals throughout the life-cycle, on families and on the wider community; recognise when an individual s mental health is deteriorating, or is under threat due to external pressures or circumstances; use different models and frameworks for understanding mental distress, including service user and carer perspectives, social models and differing cultural understandings; practise with awareness of the impact of mental health issues on oneself, and the confidence to be clear about what one does not know, as well as what one does; (viii) apply knowledge of mental health policy and legislation, and of the nature and impact of mental health problems, in order to know whether, when and how to consult with others (including service users and carers, social work colleagues and those from other disciplines and services); (ix) (x) acknowledge the contested nature of mental health, tolerate uncertainty and make judgements in complex situations, seeking further information where appropriate; demonstrate an awareness of, and ability to work within, a multi-professional and multi-agency context. As may be seen from this list, some of the themes of the earlier CCETSW guidance are still considered to be relevant. However, certain shifts of emphasis and approach may be noted. The language of the medical model is less dominant, while the perspectives, concerns and expertise of service users and carers take a more central place. There is a profound shift away from a scientific paradigm of (medical) knowledge and predictability, to an acknowledgement that mental health is a contested area, with differing understandings of mental illness and distress. It is seen that a holistic practice must involve working with a range of competing and potentially contradictory perspectives with an emphasis on social and cultural viewpoints and service user knowledges. And it is made explicit that the negotiation and promotion of such a way of thinking is to take place within the context of multi-disciplinary and multi-agency working. Mental distress is seen more to be part of mainstream experience and is located within contexts of growing up and ageing, and of family and community life. There is evidence of some erosion of us and them distinctions between professionals and those suffering mental distress, with the acknowledgement that mental health issues may impact on workers as well as those who use services. And there is an increasing
238 J. Tew & J. Anderson confidence that social workers must be able to see, and work with, the big picture not just being involved in managing individuals distressing feelings and behaviours, but being able to locate and respond to people s experiences of distress within a wider context of cultural complexity, social pressures, discrimination and social exclusion. All this suggests a need, 10 years on, to reorientate both the content of the mental health curriculum in the new degree, and the ways in which it is delivered. There needs to be space for new models of thinking, such as developments within social perspectives (Duggan, 2002; Tew, forthcoming) and service user perspectives on recovery (Coleman, 1999; Turner-Crowson & Wallcraft, 2002), hearing voices (Baker, 1996; Coleman & Smith, 1997) and self-harm (Pembroke, 1997; LeFevre, 1998). Course design and delivery will need to embrace service users and carers as full partners in all aspects of the process (Beresford, 1994; Took, 1997; Barnes et al., 2000; Tew et al., 2003), and lived experience will need to be valued as a primary source of knowledge (Beresford, 2003). This implies the need to facilitate reflective learning (Gould & Taylor, 1996); and problem- or enquiry-based rather than didactic approaches to learning may be appropriate in enabling students to work with a range of perspectives. Finally, interprofessional learning opportunities will be essential if students are to become confident in negotiating new ideas and perspectives with colleagues from other disciplines (Whittington & Bell, 2001; Department of Health, 2003). The workshop, and this paper which arises out of it, may be seen as the start of a process of dialogue and consultation about mental health teaching within the new social work degree that needs to take place not only within the social work community (both practitioner and academic), but also with wider stakeholders, principally service users, their families and other carers, mental health professionals and educators from other disciplines, and those charged with the planning and development of the mental health workforce. The Mental Health in Higher Education project, if funded beyond its initial pilot year, will be well placed to ensure that this debate can draw on current and best practice in learning and teaching about mental health within other disciplines and subject areas. Although the framework for social work training, and the policy and practice contexts, may differ, this debate will be enriched by the perspectives, insights and experience of social work educators, and others involved in learning and teaching, across the whole of the UK. Further information about the Mental Health in Higher Education project can be found at www.mhhe.ltsn.ac.uk.
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