ARTICLES

 

The experiences of social workers providing mental health services at a mental health facility in Tshwane, South Africa

 

 

Lehlogonolo Kwena Poopedi^I; Nontembeko Joyce Bila^II

^IUniversity of Pretoria, Department of Social Work and Criminology, Pretoria, South Africa https://orcid.org/0000-0003-2621-5504 poopedi.lk@up.ac.za
^IIUniversity of Pretoria, Department of Social Work and Criminology, Pretoria, South Africa https://orcid.org/0000-0003-3343-5505 nontembeko.bila@up.ac.za

 

 

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ABSTRACT

South Africa presents a high prevalence of mental health problems, with one in six South Africans being diagnosed with anxiety, depression and substance-use problems (excluding more severe conditions such as bipolar disorder or schizophrenia). The incidence of mental health problems is ranked third after HIV and other infectious diseases in determining the disease burden. Social workers are key professionals in rendering interventions and services aimed at treating persons with mental health problems. In this qualitative study, ten purposively sampled social workers providing mental health services at a mental health facility in Tshwane, South Africa were interviewed. The thematic analysis generated seven themes, four of which are discussed. The findings reveal that social workers are adequately capacitated to provide mental health services and are one of the key mental health service providers. Recommendations for practice are provided.

Keywords: Experiences; mental health; mental health services; mental healthcare user; social worker

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INTRODUCTION

Mental health is a growing area of concern worldwide with the number of people with mental health problems increasing rapidly. This rapid rise is undeniable and continues to cause immense difficulties for individuals, households and communities across the world (World Health Organisation [WHO], 2019). South Africa is no exception in experiencing a high prevalence of people living with mental health problems. It is estimated that one in six people has to deal with anxiety, depression and substance abuse as the most common problems, excluding people with schizophrenia and bipolar disorder (South Africa College of Applied Psychology, 2019). People with mental health illnesses have numerous bio-psychosocial needs and meeting these needs depends to a great extent on social workers, especially mental health social workers (Olckers, 2013). Social work is undoubtably one of the largest service provision groups within the broader field of mental health and is globally recognised as one of the five core professional groups making a significant contribution to the advancement of mental health (Bila, 2019; Cox, Tice & Long, 2019; Morris & Lezak, 2010).

In providing mental health services, social workers are confronted with several challenges including highly contested workplaces, inadequate mental health facilities, workload, safety issues and burnout. However, little is known about these experiences, since few studies have been conducted to investigate them. In reviewing the literature, the researchers noted that previous studies on social work in mental health did not directly investigate the perceptions of social workers on their experiences and involvement in the provision of mental health services. They focused rather on the role of social workers in providing mental health support or other aspects such as the lived experiences of patients with mental health problems. For example, South African studies conducted by Olckers (2013) and Ornellas (2014) both outline the context of mental health social work. However, their main focus was on the role, and not the experiences, of social workers in providing mental health services. Similarly, Conway's (2016) research explored the experiences of mental health social workers, but her specific focus was on their state of well-being and support, not on their overall experiences as in the present study. There is also a lack of literature on social work in the mental health sector within the South African context (Ornellas, 2014). Therefore, there is a gap in the literature on studies pertaining to the overall experiences of social work professionals in providing mental health services within the South African context. The present study sought to address this gap by asking the following research question: "What are the experiences of social workers in the provision of mental health services?"

The structure of this article is as follows: an overview of the literature; a discussion of the ecological systems theory as the theoretical framework underpinning the study; research methodology; research findings and discussion; conclusions and recommendations.

 

LITERATURE REVIEW

The social work profession has a dual mission, namely, to enhance human well-being and to meet the basic human needs (Bila, 2019). Particular attention is paid to the needs and empowerment of those who are vulnerable including those with mental health problems (Heller & Gitterman, 2010). Mental health problems are caused by a wide range of social and personal conditions (Nejkar, 2017). The domain of social work in mental health, therefore, focuses on the social context and the social consequences of mental health problems/mental illness. In accordance with their profession's mission, mental health social workers help with the restoration of the optimal levels of functioning especially for people with mental health problems. The main purpose of social work service provision within mental health is to restore individual, family and community well-being, to promote the development of each mental healthcare service user's power and control over their lives, and the principles of social justice (Francis & Tinning, 2014). This encompasses regularly serving mental healthcare service users with a combination of disability and substance abuse problems and collaborating with professionals across various fields of service provision including but not limited to medical, criminal justice and education (Cox et al., 2019. The literature review will contextualise social work in mental health both within the global and local contexts and discuss the role of social workers in mental health.

Social work in mental health (global context)

The evolution of social work in mental health over the years led to its being identified as among the five core professional groups in this field worldwide (Francis & Tinning, 2013; Morris & Lezak, 2010). Social workers are currently recognised and appreciated for the significant contribution they make to the field of mental health worldwide (Cox et al., 2019). Moreover, there is a growing demand for these professionals within the mental health disciplines (Nejkar, 2017). This rising demand was noted by Heller and Gitterman (2010), who used a survey conducted by the National Association of Social Workers in 2006 as an example. The results of the survey indicated that 37% of American social workers worked in mental health, which is more than in any other discipline. Cox et al. (2019) concur that there has been a rapid increase in mental health social workers within the global context.

Globally, social work in mental health is divided into the public and private sectors. Its practice starts with the individual and extends to the family, social networks and broader community (Francis & Tinning, 2014; Olckers, 2013). Social work in mental health within the global context is concerned with the social context and the social consequences of mental illness as experienced by individuals, who are shaped by their social environment (Bland, Renouf & Tullgren, 2015; Francis & Tinning, 2014). The study of context mainly entails looking at the impact of mental health problems on the individual, family and personal relationships as well as the broader community; it works towards making all human services accessible and responsive to the various needs of mental healthcare service users, their families and other carers (Bland et al., 2015). The Australian Association of Social Workers (2015) emphasises that this ability of social workers to maintain a dual focus on both the individual and family domains is what distinguishes their contribution and practice from that of other mental health professionals within the broader mental health field.

Overall, the researchers detect that mental health services have undergone significant transformation globally in relation to structure, services and approaches to service delivery (Bila, 2019). This suggests the need for a comparative analysis of how social work interventions in the South African context differ from those in the global context.

Social work in mental health in South Africa

The social work profession is recognised as one of the primary providers of mental health services in this country (Engelbrecht & Ornellas, 2014). Olckers (2013) found that many social workers within the South African context deal with a client load that includes individuals with a range of mental health problems. Olckers (2013) notes that many questions and controversial issues arise when this profession is examined within the South African mental health context, such as: Are social workers adequately trained to intervene diagnostically? Is there any need for a social worker to know or use a diagnostic model? Are social workers recognised as mental health team members? What is the scope of practice for social workers in the mental health discipline? What were some of the previous debates on South African social work practice within the mental health field? Social workers also lack a formally recognised scope of practice, despite being recognised in the South African Mental Health Care Act (Republic of South Africa 2002, section 1: xvii) as mental healthcare practitioners (Olckers, 2013). In the same vein, Ashkroft, Kourgiantakis and Brown (2017) note that little is known about the scope of social work in the provision of mental health services. Aviram (2002) concurs that there is a lack of consensus among social workers and other professional groups regarding their role in the mental health field. Gajendragad et al. (2016) acknowledge this role confusion and attribute it mainly to the common roles performed by social workers and other disciplines within the mental health field. Francis and Tinning (2014) agree that there is much debate about what social workers do in the mental health field globally, but their significant contribution to mental health practice is undeniable.

Engelbrecht and Ornellas (2014) emphasise that, overall, the effects of policy changes in mental health over the past two decades in South Africa adversely have affected many social workers operating in a mental health context and that mental health social workers are vulnerable. Faydi et al. (2011)), reflecting on mental health services in South Africa, identified a significant gap between mental health needs and the availability of quality services to address these needs appropriately.

After an intensive literature review, the researchers noted many studies on mental health social workers in South Africa have not yet succeeded in exploring and describing the experiences of social workers themselves in providing mental health services. Social workers form a vital part of the provision of mental health services. While their roles and competencies seem to be understood, their experiences are not well understood nor fully known. Nevertheless, a few formal studies have been conducted specifically on the subject (Allen, 2014).

Role of social workers in mental health

Individuals struggling with ongoing mental health problems experience various challenges daily in all spheres of their functioning globally (Bila, 2019). These individuals also meet the major criteria for being classified as vulnerable and comprise a considerable proportion of South African society (Simpson & Chipps, 2012). Social workers working in the field of mental health therefore have an obligation to protect, respect and fulfil the rights of mental health care service users to ensure that they are not stigmatised and discriminated against, but are free to exercise their fundamental human rights (WHO, 2010). In accordance with their profession's mission, social workers as providers of mental health services help with the restoration of the optimal levels of functioning in various domains of life for those affected by mental health problems (Francis & Tinning, 2014). To achieve this, social workers provide various services including educating families and individuals about diagnosis and treatment options for mental health patients (Conway, 2016; Nejkar, 2017; Olckers, 2013). Other professional services rendered by social workers in mental health include counselling, advocacy, coordination of resources, case management, substance abuse treatment, supervision and programme management (Gajendragad et al., 2016).

Social workers also attend to the experienced impacts of mental health problems as well as to the social issues influencing the problems (Heller & Gitterman, 2010). These services are an integral part of the ethos of social work to protect human rights, intervene in order to prevent or end discrimination and inequality, and protect vulnerable people from harm (Allen, 2014).

 

THEORETICAL FRAMEWORK

The ecological systems theory underpinned the study reported in this article. This theory was developed by Urie Bronfenbrenner and is based on the assumption that the behaviour and experiences of individuals are shaped by various spheres of influence (Ettekal & Mahoney, 2017; Strayhorn, 2015). The theory explains how different types of environmental systems influence the development of humans and posits that development occurs over time as part of a complex process involving a system of interactions within the individual as well as between the individual and the environmental context, they are part of (Ettekal & Mahoney, 2017). The theory additionally describes four interrelated types of environmental systems (micro, meso, exo and macro), representing ever wider proximal concentric bands to represent the settings within which individuals interact and which influence their development (Ettekal & Mahoney, 2017).

Within the context of this study, the micro and meso systems were the social workers' immediate proximate concentric bands and entailed interactions with mental healthcare service users (MHCUs), their family members, supervisors and other multidisciplinary team (MDT) members. The determination of these relationships in theory and in line with exploring and describing the experiences of social workers in the provision of mental health services help to account for the challenges they face, as well as the opportunities and capacity in ensuring quality mental health interventions. The exo system consists of policies, legislation and other events in the wider healthcare field that indirectly affect the way that social workers can provide services within the field. This was important to note, because despite not being directly linked to certain policy-making structures, mental health social workers are still greatly affected by the decisions made within those structures. Therefore, this component of the theory helped the researchers to explore, obtain rich data and decipher how such interactions contributed to the overall experiences of social workers in providing mental health services. Similarly, the macro system component gave the researchers an insight into how influences beyond the immediate sphere of the mental health social workers affected them and contributed to their overall experiences in the provision of mental health services.

The ecological systems theory therefore represents a nested network of interactions reflecting the ecology of the social worker's environment. Application of this theory provided the researchers with a holistic framework for understanding the multiple interconnected and interdependent factors directly or indirectly related to the work of mental health social workers, which may be influencing their personal experiences in the field. This theory allowed for the modelling of the way that factors in the immediate and broader context influence the social workers who are providing mental health services as they interact not only with individuals, but also the wider social, educational and healthcare environments over time (Hickey, Harrison & Sumsion, 2012).

 

RESEARCH METHODOLOGY

Research approach and design

The study employed a qualitative research approach, a descriptive research design underpinned by the interpretive research paradigm. The case study research method, specifically the instrumental case study subtype, was utilised to explore social workers' experiences in providing mental health services at a mental health facility in Tshwane. The case study method was used because of its ability to generate thick and rich descriptions, which aid the researchers in gaining insight into the phenomenon being studied (Nieuwenhuis, 2016).

Research goal and objectives

The study sought to explore and describe the experiences of social workers in the provision of mental health services.

The following were the objectives of the study:

• To contextualise the provision of mental health services by social workers internationally and locally;

• To ascertain the views of social workers regarding their role and task in the provision of mental health services;

• To determine the capacity of social workers in rendering mental health services;

• To establish the needs of social workers in the provision of mental health services;

• To suggest strategies for improving the provision of mental health services by social workers.

Research site

The study was conducted with social workers working at a mental health facility in Tshwane. This research site is a government-owned psychiatric institution that offers treatment for a range of mental illnesses. The facility is one of the most extensive mental health facilities in South Africa, accommodating roughly 5 000 annual admissions and 5 200 outpatients per annum. The researchers' decision to specifically target this facility was based on three considerations. Firstly, it is one of the largest and longest-serving mental health facilities in the whole country. Secondly, the facility has one of the biggest social work departments compared to the majority of existing mental health facilities in South Africa. Lastly, the social workers at this institution deal primarily with mental health problems, provide mental health services, and therefore fitted the inclusion criteria for the present study perfectly.

Study population and sample

Purposive sampling was utilised to select social workers to participate in the study (Maree & Pietersen, 2016). The research participants met the following inclusion criteria: the social worker had to be providing mental health services at the chosen mental health facility; be registered with the South African Council for Social Service Professionals (SACSSP); have a recognised bachelor's degree from a South African university; have six months or more experience in mental health-related social work practice; and had to give consent to participate in the study and be able to converse in English.

Data collection and analysis

Semi-structured one-on-one contact interviews using an interview schedule were used to collect data for the study. All the interviews were recorded using a digital recorder with the participants' permission. The principal researcher conducted interviews until data saturation was reached. Thematic analysis of the transcriptions of the interview recordings followed, with rich data generating seven themes, four of which are discussed in this article.

The collected data were analysed in accordance with the six steps of the thematic analysis process as proposed by Clarke, Braun and Hayfield (2015:222), namely, "familiarisation, coding, searching for themes, reviewing themes, identifying and naming themes and writing the report".

The researchers ensured trustworthiness by considering the four constructs used for assessing the quality of qualitative research: credibility, transferability, dependability and confirmability (Lietz & Zayas, 2010). Strategies used to ensure trustworthiness included peer debriefing, thick descriptions, data triangulation and an audit trail (Korstjens & Mosser, 2018; Leedy & Ormrod, 2010; Lietz & Zayas, 2010).

 

ETHICAL CONSIDERATIONS

This study received ethical clearance from the Research Ethics Committee of the Faculty of Humanities at the University of Pretoria (Reference Number: HUM044/0620). The researchers ensured the protection of all research participants by employing appropriate ethical principles applicable to qualitative research (Arifin, 2018:30). Specifically, the avoidance of harm, voluntary participation and informed consent, no deception of participants, anonymity and confidentiality, publication of the findings, and competence of the researcher were applied in the study. Permission to conduct research at the chosen research site was granted by the CEO of the selected mental health facility.

The researchers did not anticipate any physical harm inflicted by the study. However, contracting the COVID-19 virus posed a threat of physical harm, meaning that any negligence and or poor compliance with the lockdown level 1 requirements and the mental health facility's restrictions could compromise the participants and put their health at risk. Therefore, researchers always ensured strict compliance with the pandemic precautionary measures such as health screening, sanitising and maintaining social distancing to protect themselves and the participants. Avoidance of emotional harm was ensured by firstly briefing the participants about the main focus areas of the study upon recruitment to provide them with an opportunity to decide whether they would be willing to participate in the study, and secondly by making an arrangement with a registered social worker from another organisation to provide debriefing or counselling should the need arise. No participant indicated a need for such services following the interviews. Voluntary participation and informed consent were ensured by adequately informing the participants about what the research study entailed, allowing them to ask questions and leaving informed consent forms at the mental health facility for those interested to review and sign for a period of five days. This was done to give potential participants enough time to read through and understand the details of the study and to decide voluntarily whether they would like to participate or not. Any form of deception was eliminated by being honest with the participants and not withholding any information pertaining to the study from the participants both during the recruitment and data-collection process. Confidentiality was ensured by using numbers for each participant (e.g. participant 1) both in the analysis of data and reporting of the research findings to protect the identity of the participants; data captured were electronically password protected. Data obtained through this research were used for academic purposes only as the researchers are both academics with adequate experience, skills and knowledge applicable to research studies.

 

RESEARCH FINDINGS AND DISCUSSION

The research findings are outlined in two sections, namely key participants' biographical information, followed by a presentation of four themes and sub-themes.

Biographical information of participants

The demographic background of the ten research participants is presented and explained in this section.

Four of the research participants were below the age of 40 years and six participants were 41 years and older. The age range shows that the social workers in the present study were generally middle-aged or older. All participants in the study were female in this mental health facility when this study was undertaken.

Seven participants had the undergraduate Bachelor of Social Work degree as their highest educational qualification. Two obtained a Master of Social Work in Healthcare qualification and one had a doctorate. Four participants had 3 to 5 years of experience as social workers at a mental health facility, forming the most represented duration of experience in the study. Three had experience which ranged from 6 to 10 years and three had experience ranging from 21 to 30 years. In addition, two participants had less than five years of experience, while one had 11 to 20 years of experience. The remaining participant had 31+ years of experience in the provision of mental health services.

The findings revealed a wide range of employment periods and experience at the hospital. This is reflected in the rich data insights that were obtained in this study.

Theme: Mental health services provided by social workers

This theme was mainly focused on contextualising the services provided by social workers at the chosen mental health facility. Three subthemes from the research findings are discussed.

Subtheme: Assessments, rehabilitation and re-integration of mental healthcare users (MHCUs)

The assertions of the research participants show that social work in mental health services provision is primarily concerned with the assessment, rehabilitation and re-integration of MHCUs at the selected mental health facility.

... recovery, the rehabilitation, to integrate the person again in the community.

... it's about assessment in the first place; So, you have to assess the whole time.

... assessment, assessment remains key because assessment is everything.

Several authors, namely Conway (2016), Olckers (2013) and Nejkar (2017) identify assessment as one of the main services provided by social workers within the mental health field. MHCUs often present primary psychiatric disorders that are not demonstrably caused by one or more clearly verifiable medical conditions (Pollak & Miller, 2011). Assessment is therefore key in guiding social workers, doctors and other members of the multidisciplinary team in the diagnosis and selection of an appropriate treatment for mental health conditions. Using information gathered through assessment further enables social workers to conduct interventions that are centred on rehabilitating MHCUs to ensure that optimal levels of functioning in various domains of their lives are restored before reintegration with their families and communities (Francis & Tinning, 2014). Ornellas (2014) also describes psychosocial rehabilitation; assisting in the adequate reintegration of MHCUs into society and the needs associated with these as some of the key services provided by social workers in the mental health field. The responses indicate that social work services are first rendered at a micro level with the focus specifically being on the MHCU and later expanded to the broader community.

Subtheme: Advocating for and protection of MHCUs

The participants mentioned advocating for the protection of mental healthcare service users (MHCUs) as one of the main contexts of the social workers' functions at the mental health facility. The following verbatim quote is representative of participants' responses confirming this theme:

Being an advocate is also very important, like advocating very well, because sometimes some things happen to you like, no one is hearing my patient, or no one is hearing the story of the family very often because we are the ones who usually speak to the families and other team members like the doctor and the psychologist and the occupational therapist, they don't really deal with the family.

The narrative indicates that social workers are responsible for advocating for MHCUs and their families. MHCUs comprise a considerable proportion of the South African population and have been identified among the most vulnerable people in society (Simpson & Chipps, 2012; WHO, 2010). They are often subject to stigma and discrimination and tend to experience high rates of physical and sexual victimisation (McBratney, 2007). Research findings from Conway (2016) and Olckers (2013) emphasise that mental health social workers have an advocacy role and an obligation to protect, respect and fulfil the rights of MHCUs to ensure that they are not stigmatised and discriminated against, but are free to exercise their fundamental human rights. This indicates the importance of social work intervention in ensuring adequate protection of the rights of MHCUs; delivery and access to appropriate services; and preventing discrimination against them as well as the inequality they might be subjected to (Allen, 2014). Advocating for policy change to ensure that needed changes with respect to MHCUs are addressed also forms a critical part of mental health social work (Cox et al., 2019; Gajendragad et al., 2016; Nejkar, 2017). The advocacy role can be explained in the micro-system level of the social workers' lives, where proximate interactions are with the patient and the family, as well as the meso-system level of interactions among the micro-system components in the ecological systems theory (Eriksson, Ghazinour & Hammarstrom, 2018)

Subtheme: Making family contact and to educate

Participants asserted that contacting family members and providing education to family members are some of the contextual roles associated with social work. The following comments are representative of this subtheme:

From my side, I'll say it's all... about us a social worker nhe... it's a helping profession whereby you empower users, families... because of more especially, is to psycho educate, because people doesn't have a background in mental health. When it comes to this, especially us as Africans. They interpret it as witchcraft, most of the instances, so I would say that the emphasis is to dwell more on psycho education, educating them about mental illness.

We make contact with families and also provide psychoeducation, that is our most important role, because it is the essence of what we do, because also the psychoeducation and support, if we didn't do those services, the patient would not necessarily be able to function in the community.

Another participant mentioned that educating the family extends to explaining feedback provided by other members of the MDT such as doctors in terms that they can easily understand. She said:

I would say an educator, with the families a lot of times the doctors you know they don't bring it down to a level that a normal uneducated person, or not even an uneducated person but that someone else would understand necessarily. So, it's important for us to educate the family. To say okay this is what it actually means.

Roestenburg, Carbonatto and Bila (2016) assert that social work focuses on a person-inenvironment perspective and uses relationships as the basis of all interventions. This is because MHCUs' connections with their families and broader social environment are critical in the recovery process. Therefore, social workers are the professionals most likely to engage the family in mental health settings (Inspectorate of Mental Health Services, 2012), because they are perceived to be key in the care, support and recovery of MHCUs (Wilberforce et al., 2020). Moreover, their connection to the MHCU and understanding of mental health can impact positively or negatively on the treatment and recovery outcomes. This can be observed in the above comments, where the participants alluded to making frequent contact with MHCUs families. Contact is made to educate them about mental health conditions, provide them with updates on the condition of the MHCU and from other members of the MDT, and to support them.

The National Association of Social Workers (2011) identifies the importance of family and patient education on diagnosis and treatment options among other services provided by mental health social workers. Engelbrecht and Ornelas (2014) further aver that making contact facilitates and ensures effective communication between patients, families and healthcare teams in ways that mitigate barriers caused by poor health knowledge. Conway (2016) also notes that contacting families to educate them is beneficial in helping social workers to gain greater insights into family functioning, which can by extension have a positive impact on the MHCUs' outcomes and help prevent further crises linked to relapse. Families adequately educated about mental health can be valuable sources of support for the MHCU and a moderating factor between the MHCU and the community. Eriksson et al. (2018) emphasise the need, within the ecological systems theory, to educate parents on multiple contextual knowledge areas in terms of the proximate context of interaction at the micro-system level and its influence and how the community can impede or help in the human development of the MHCU.

Theme: Perceptions of social workers regarding their roles and tasks in the provision of mental health services

In ascertaining the views of social workers concerning their roles and tasks in the provision of mental health services at the mental health facility, three subthemes that emerged from the interview findings are discussed in the subsections below.

Subtheme: Social workers as the link between the patient and the mental health provision system

The participants posited the practice as being the link between the patient, the patient's family and the mental health service system. Participants asserted the following:

We are the link between the family and the team. It's basically, social work is the link between the family and the hospital, the community, the patient.

We have to link them to other resources outside. Let's say they go outside, we link them to other resources, maybe SASSA [South African Social Security Agency], Home Affairs and things like that.

From the commencement of their interaction with the MHCU, social workers integrate individual recovery with other helpful services available across the community. The focus is not only centred on strengthening relationships between people, but on linking them to the resource system too (Olckers, 2013). Social workers, in addition to monitoring MHCUs' needs, also link them to relevant resources and treatment where necessary (Ornellas, 2014). The respondents in Kirschbaum's (2017) study similarly posited the social worker to be the link between the MHCU, family, mental health system, social networks and wider community resources. In the researchers' view, assisting clients to obtain supportive competitive employment and referring MHCUs for other outpatient services as mentioned by Cox et al. (2019) and Nekjar (2017) is an aspect of their role of linking patients to the resource system. The ecological systems perspective involves considering an individual and the environment around them (Eriksson et al., 2018).

Subtheme: Lack of recognition of social work in mental health service provision

Participants' responses on their perceptions in mental health services cite the lack of recognition of social workers in their provision of mental health services. Participants made the following assertions in this regard:

At times you feel that your profession is not like taken... taken seriously.

I feel like our role all day we do everything and anything, usually work that no one wants to do, social workers do.

The unaddressed concerns and lack of understanding of the social workers' roles by other professionals related to mental health service provision is viewed by the research participants as a sign of a lack of recognition of their profession as a critical part of the mental health service system by other professionals. Social workers serve as MDT members to provide coordinated care to the patient (Conway, 2016). The British Association of Social Workers (BASW, 2010), however, emphasises that managers and practitioners from other disciplines do not always value the skills and expertise of mental health social workers. Social workers further experience high competition for authority within MDTs; they are perceived to possess a poor mental health knowledge base and are less specialised than the rest of the MDT members (Bland et al., 2015; Roestenburg et al., 2016). The perceived lack of seriousness about their role is observed to be negatively affecting social workers. This is corroborated by the BASW (2010) through its emphasis on the need for human beings to feel understood and their roles clearly understood by others in work and social settings. Without such role clarity, people can feel dissatisfied and undervalued. Eriksson et al. (2018) note that the attitudes and cultures within the macro system should ensure that there is employee satisfaction for the social worker as a recognition of the contribution of the profession in the provision of mental health services. This is because the macro system is responsible for policy governance and therefore has oversight over the planning and designing of a facilitating environment for providing enhanced mental health services by the social workers.

Subtheme: Role conflict with the mental health service system

Participants indicated that role conflicts can be prevalent in mental health service interventions, because there is no clear distinction between their roles and those of other mental healthcare service professionals. Participants asserted the following:

You will hear issues of fighting, a patient needs to go shopping, they are like it's social work, and we are like no, our job is not to take, that is OT [occupational therapisty it is rehabilitative, it's not us.

We lose the focus on the patient, we lose what's in the benefit of the patient and that makes me angry, and that is the mostfrustrating because is it my role? Is it your role?

You first have to have an hour, organise a consultation or argument about whose role is it, but at the end of the day no one wants to do.

Another participant further mentioned that their roles with other members of the MDT often overlap and that communication with other members of the MDT in such instances is important to reach an agreement on a way forward. She said:

All our way I would say our role is communication with the members of the MDT. You know I am very team orientated, and you will find that it overlaps, because it's not to say it's specifically this is the occupational therapist, and she may not move one inch out of this. I mean, if we communicate and then we can agree it's fine in this case you do this, I do this.

Aviram (2002) indicates that there is a lack of consensus among social workers and other mental health professionals regarding their role in the mental health field as well as the boundaries of their domain. This is attributed to the increased inclusion and involvement of social workers within the wider mental health system, which has led to the gradual blurring of professional boundaries between them and other professionals. Gitterman (2014) notes that role conflicts date back to the early years of the historical development of social work, where the strong link social work had with psychiatry almost damaged its role in the mental health field. Gajendragad et al. (2016) explain role conflicts as arising from the overlapping of the roles performed by social workers and those of other mental health disciplines. Roestenburg et al. (2016) similarly acknowledge that the majority of the services predominantly offered by social workers are the same as those provided by psychologists. These commonalities result in conflicts, leaving social workers to defend and fight for their distinctive role within mental healthcare MDTs. Boland et al. (2019) point to the lack of clarity regarding what social workers do as compared to other professionals as arising from the generic roles that social workers are often pressured to undertake, thus gradually eroding their traditional roles and opening them up to others. This makes it more difficult to articulate the unique contribution social workers make to the mental health field.

Despite acknowledging the role conflicts among social workers and other mental healthcare service providers, Gajendragad et al. (2016:90) argue that

specific to the domain of social work are roles of building partnerships among professionals, caregivers and families; collaborating with the community, usually with the goal of creating supportive environments for clients; advocating for adequate service, treatment models and resources; challenging and changing social policy to address issues of poverty, employment, housing and social justice; and supporting the development of preventive programs.

Theme: The capacity of social workers in rendering mental health services

The capacity of the social worker in providing mental health services generated three subthemes, which are discussed next.

Subtheme: Lack of adequate resources for mental health service provision

The majority of the research participants mentioned that there is a gap in resource allocation and availability, which in turn has an impact on the capacity to provide mental health services. The following comments substantiate this subtheme:

We don't have enough resources I'll start there. Like, for example, at times the phones are not working. I use my cell phone.

Firstly, its resources, we don't always have the resources to deliver the services that we want to.

The findings indicate the lack of adequate resources for the social workers to be one of the major challenges affecting social workers. The literature also confirms these findings, not just in South Africa but globally (Docrat et al. 2019). Mental health is usually not prioritised, leading to funds not being allocated to address it, especially by African governments (Roestenburg et al., 2016). Similarly, government policies - more specifically the deinstitutionalisation policy - is identified as one of the factors that resulted in inadequate resources for social workers operating in the mental health field (Engelbrecht & Ornellas, 2014). The lack of resources affects the expansion of social work services in mental health service interventions, resulting in an inability to meet the high service demand adequately (Roestenburg et al., 2016). The exo system consists of immediately contiguous and proximate social systems and contexts within which the individual does not necessarily participate directly, but which affect their career development (Eriksson et al., 2018). Therefore, lack of adequate resources does not directly involve social workers, but affects their ability to provide quality services and interventions effectively.

Subtheme: The scope of social work interventions in mental health services

Participants asserted that the lack of a clearly set scope of practice for mental health social workers has a bearing on their capacity to provide services, because it subjects them to undertaking many roles which fall outside of the social work scope of practice. The following comments represent this subtheme:

We need to have structure in terms of our scope, because we really get drained out and burned out because we are doing everything. There needs to be a defined structure.

We are always fighting for our place, and I feel it is so unnecessary because everybody has a place in a patient's life. Everybody has a place in the treatment plan, but we find ourselves fighting about roles, and fighting about defining our roles, we're fighting about who provides what service.

The challenge with defining the scope of work of the social worker in mental health service interventions is highlighted in these comments. Ashcroft et al. (2017) indicate that there is little known about the scope of social work, particularly in the provision of mental health services. The observed absence of a comprehensive and explicit scope of practice for social workers in mental health service provision is also mentioned by Olckers (2013) as one of the main issues affecting their capacity to render effective interventions within the South African context. This absence still prevails, even though social workers are recognised as mental healthcare practitioners in Section 1: xvii of the Mental Health Act 17 of 2002 (Olckers, 2013; RSA, 2002).

Subtheme: Supervision of social workers in mental health

All participants agreed that supervision is a critical support function that greatly enhanced their capacity in providing mental health services as social workers. Participants attributed this to the fact that through supervision they get to impart more of what they learn from academia and field practice to enhance their mental health service interventions skills.

Participants stated the following on the adequacy and importance of supervision:

Supervision [is] very important, hey... it equips you; it gives you more knowledge that you didn't have before. Like, what like I said...I started here, 2016, I'm not the same person as when I started here, because I've been acquiring lots of information, given lots of knowledge. So, they are very, very, very important.

So, we have supervision on a monthly basis. As I said we have an open-door policy. Uhm, our seniors are always available if there's a problem that we, you know, as juniors maybe cannot manage.... She checks up on us and ensures that we have the tools and the skills to do the job.

The comments indicate that the participants have access to regular and good-quality supervision. They seem to understand the importance of accepting advice and support, and know how and when to seek advice from their supervisors (Department of Health UK [DOH UK], 2015). Social workers engage in supervision and social work/clinical consultation with other community health workers and other social workers involved in mental health service delivery (Gajendragad et al., 2016). Engelbrecht and Ornellas (2014) stated that social workers require structured and professional supervision, because the effects of policy changes in mental health over the past two decades in South Africa have adversely affected many social workers operating in the mental health context and left them vulnerable. Access to regular quality supervision, therefore, supports social workers' emotional resilience as well as their emotional and physical well-being (DOH UK, 2015). Supervision relates to the mesosystem of the ecological systems theory in that it provides for interaction between contiguous microsystem elements such as the social worker and their immediate supervisors to effect support and guidance for quality mental health service provision (Eriksson et al., 2018).

Theme: The needs of social workers in the provision of mental health services

Research findings generated two subthemes from the interviews pertaining to the needs of the social worker in mental health provision. These include danger allowance and addressing low salaries, social worker caseloads and the aspect of resource availability that could enhance the quality of mental health service interventions.

Subtheme: Danger allowance and low remuneration

Three participants thought that they deserve a danger allowance and to be better remunerated, just like their counterparts in the health services such as doctors, nurses and others. The following two participants underlined this point:

... working in this institution and not getting danger allowance.

... obviously, we are very much underpaid ... but compared to other professionals ... you know if you compare to the occupational therapist, to Psychology, our salaries are much lesser, and I mean that also has an impact, because I think it also kind of demotivates you at times.

Social workers are mentioned as being among professionals to receive danger allowance in case they experience a genuine risk to their lives in the course of employment (Department of Public Service and Administration, 2016). However, the above comments indicate that the social workers at this facility do not receive this allowance as other professionals within the same field do. The participants also perceived themselves to be the lowest remunerated professionals in comparison to their counterparts within the mental health service provision system. Naidoo (2004) found that social workers are demotivated because of their low priority on government agendas and with their low salaries relative to other professions. The lack of funds allocated to the field of mental health in most African countries, as noted by Roestenburg et al. (2016), was also identified as one of the major challenges affecting social workers providing mental health services. Interactions at the meso system level must take into account the micro-system concerns about remuneration, as this has been shown to have a negative impact on the motivation of social workers in providing good quality services (Zhang, 2018).

Subtheme: Social worker caseload and burnout

Participants noted that they were working with high caseloads in mental health service interventions, therefore making them susceptible to fatigue and burnout:

Like I'm saying, like my caseload is 100, I must manage that 100, and in doing that, doing admin and doing everything and doing home visits. I must multitask and some other things, it takes your like I said, your money, your time, your family time, everything, you know.

I think that our caseloads sometimes are very high, and you know, the services we provide is quite ... an exhausting field and you can burnout quite easily.

Hussein (2018) asserts that social workers are increasingly being identified as suffering from stress and burnout compared to those in other human service occupations. Inadequate staffing, excessive workloads, poor leadership and lack of support for skills development and negative public image are identified as the main causes of burnout among all social workers (Hussein, 2018). Alpaslan and Schenk (2012) similarly emphasised high caseloads as one of the main challenges experienced by social workers across South Africa.

 

CONCLUSIONS AND RECOMMENDATIONS

The researchers concluded that social workers have an important role to play in the provision of mental health services and are at the centre of interactions in the micro- and meso-system levels of patient services when it comes to mental health interventions. Core to the role of social work within the mental health field are the services of assessment, rehabilitation and reintegration of MHCUs. Social workers further advocate on behalf and for the protection of MHCUs, and contact their families to educate them about mental health problems of their loved ones. Despite this, their role is undervalued, while their roles and tasks in the provision of mental health services indicate high caseloads at any given time. The lack of seriousness in recognising social workers as an important part of the mental healthcare service provision system is also identified in the research findings as a precursor to the demoralisation and demotivation of social workers.

The researchers further concluded that there are gaps in policy for social workers in that their roles and interventions within the mental health service provision system are not clearly defined. This can be attributed to the lack of a clearly recognised scope of practice.

Several needs of the social workers are not addressed in time, while the resources meant to enhance social work service provision and interventions within the mental health field are inadequate compared to what is available for other mental health service providers. One example of this is the lack of danger allowance for social workers, whereas some MDT health professionals receive such allowances.

Based on the findings and conclusions of the study, the researchers recommend that the scope of the role of a social worker in mental health service provision should be explicitly defined. In addition, it is recommended that social auxiliary workers assist the social workers in the provision of mental health services. This is because the high caseloads that each social worker is typically burdened with is a precursor to mental fatigue and consequent decline in effectiveness. Moreover, adequate resources such as halfway houses should be made available to social workers so that they may render effective and efficient mental health services.

 

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Article received: 16/2/2023
Article accepted: 6/6/2023