ARTICLES

 

Perceived challenges social workers experience in providing deinstitutionalised services to mental health care users

 

 

Portia Webb^I; Anri Gretha Adlem^II

^IUniversity of South Africa, Department of Social Work, Pretoria, South Africa https://orcid.org/0000-0002-2365-3106 portiawebbO@gmail.com
^IIUniversity of South Africa, Department of Social Work, Pretoria, South Africa https://orcid.org/000-0003-0243-1384 adlemag@unisa.ac.za

 

 

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ABSTRACT

Mental, physical and social health are vital, interdependent strands of life for all individuals. Unfortunately, in most parts of the world mental health and mental disorders are not regarded with the same importance as physical health, and are consequently largely ignored or neglected. This article aims to understand the challenges encountered by social workers in mental health care. The phenomenological design, supported by the exploratory, descriptive, contextual and case study designs, was utilised to answer the research question. Ten purposely selected social workers were interviewed by using semi-structured interviews. Thematic analysis following Tesch's model was applied. The trustworthiness of the study was ensured. Ethical principles were adhered to. The findings of this study indicated that most social workers in mental healthcare are not adequately trained and, similarly, social workers bear the burden of educating mental health care users, their families and the community at large on mental health. Authorities and policymakers need to craft customised, effective and efficient care for mental health care users.

Keywords: challenges; deinstitutionalisation; mental health; mental health care user (MHCU); mental illness; social worker.

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INTRODUCTION

Mental health should be regarded as a valued source of human capital or wellbeing in society. Good mental health is an integral part of the health of the population. It contributes towards welfare and happiness, permits social interaction and feeds labour force productivity. Therefore, everybody needs good mental health to flourish in all aspects of life (World Health Organization [WHO], 2023). As stated above, this article aims to understand the challenges encountered by social workers in providing mental health care. First, it presents a background to the study. Second, it discusses the social-ecological model that is the theoretical framework that underpins this study. Third, it outlines the research methodology followed. Fourth, it discusses the themes identified and aligns them with the relevant literature and theoretical framework. In conclusion, the article posits that social workers delivering services to mental health care users should be holistic in their interventions that target mental health care users, their families, communities and society at large.

 

BACKGROUND TO THE STUDY

Mental health is a global problem that sadly often goes undiagnosed in both developed and underdeveloped countries (Roberts, 2018). It is a basic human right, and regardless of our age, gender, race, amongst other factors, we view our mental health as a fundamental facet of individual wellbeing. Consequently, the preservation and cultivation of optimal mental health resonate as pivotal to the trajectory of personal growth, communal cohesiveness and the broader socio-economic advancement of societies (WHO, 2022a).

Mental health signifies a condition of mental wellbeing that enables individuals to cope with the stresses of life, realise their abilities, learn well and work well, and in this way contribute to their communities (WHO, 2022b). The terms mental disorder, mental illness and mental health condition are used interchangeably in this article. The cognitive, emotional, biological or behavioural dysfunction that underlies mental and behavioural functioning characterises mental disorders. These disturbances are usually associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning (WHO, 2022a).

Mental health issues are daunting and they are growing rapidly across the world. As evidenced by the World Health Organization's global mental health report (WHO, 2022b), in 2019 one in every eight people, amounting to approximately 970 million people across the globe, grappled with a mental disorder (WHO, 2022a). Among these conditions, anxiety and depressive disorders stood out as the most prevalent manifestations. During 2020, the prevalence of anxiety and depressive disorders increased substantially, a phenomenon primarily attributed to the pervasive impact of the Covid-19 pandemic (WHO, 2022a). Within the African context, the proportion of Africans who receive treatment for mental health ailments remains strikingly minimal. While the worldwide annual rate of visits to mental health outpatient facilities is 1051 per 100 000 population, the corresponding rate in Africa starkly contrasts at 14 per 100 000 (Sankoh et al., 2018). Therefore, increased attention to mental health by governments in this region is essential.

According to Nguse and Wassenaar (2021), the prevalence of mental health conditions within South Africa is substantial, with one in six individuals afflicted by conditions such as anxiety and depression. Notably, among pregnant women approximately 40% exhibit signs of depression, while 60% contend with post-traumatic stress disorder (PTSD). However, the proportion of individuals with severe mental disorders who receive treatment remains meagre, at only 27%. The World Health Organization recommends an integrated healthcare system, catering for people's overall healthcare needs, as an efficient way of preventing and managing mental disorders and other chronic diseases (Meyer, Matlala & Chigome, 2019).

In pursuit of rectifying the historical injustices that were directed towards persons living with mental illnesses, comprehensive global psychiatric reforms took place during the 19^th century. A shift from the practice of institutionalising mental health patients within psychiatric hospitals to an alternative approach involving the establishment of community-based institutions was central to these reforms. Addo, Agyemang, Tozan and Nonvignon (2018) posit that human rights and clinical reforms have driven the contemporary model of mental health care.

These reform efforts are characterised by the concept known as 'deinstitutionalisation'¹ (WHO, 2022a). This transformative initiative was initiated in Europe in the 1950s and subsequently gained traction globally (Shen & Snowden, 2014). However, in South Africa the process of deinstitutionalisation unfolded only after 1994, and it resulted in mental health services being decentralised and integrated into primary healthcare services at community level. This also marked a departure from institutionalised treatment alone to include resources such as community-based clinics and out-patient departments in hospitals (Selborne, 2019). Here, the terms 'deinstitutionalisation' and 'community-based mental healthcare services' are used interchangeably.

It is important to acknowledge the role of families in this paradigm shift. However, families encounter multifaceted challenges such as lack of resources for mental health care users. Selborne (2019) concurs that the pervasive stigma directed towards both mental health care users and their respective families, and a discernible imbalance across the provinces in terms of resource allocation and service distribution, attest to this view. South Africa's pursuit of an approach aligned with public health principles to enhance mental healthcare is evidenced by the reform of the Mental Health Care Act (Act 17 of 2002) (Republic of South Africa [RSA], 2002), which foregrounds the safeguarding of the human rights of individuals grappling with mental health conditions (Meyer et al., 2019).

Social workers also play a significant role in the provision of mental health care. Ow and Poon (2020) posit that because social workers understand the social and medical aspects of mental wellbeing and illness, they are at the interface between the service users and their environment, providing a critical link between the service user, the multidisciplinary treatment team and the community. In a study conducted by Mashabane (2018), the focus was on exploring the experiences of medical social workers providing mental healthcare services in a hospital-based setting in the Mpumalanga province. The study revealed that many participants expressed a sense of their inadequacy as a result of insufficient undergraduate training for mental health settings. Lack of professional support from their department, compounded by reporting to medical managers instead of social work supervisors, emerged as a challenge for the majority of them.

Another study (Ornellas,2014) aimed to explore the perceptions of social workers regarding their roles in rendering mental health outpatient and community-based care. The study identified several crucial roles for social workers in this context. These included providing therapeutic interventions for clients and their families, connecting clients to essential resources, advocating for clients, recognising the significance of social and interpersonal aspects in the functioning of mentally ill individuals, and fulfilling the role of a holistic worker within multidisciplinary teams.

In South Africa, mental health legislation is primarily defined by a few key instruments: the Constitution of South Africa (RSA, 1996), the Mental Health Care Act 17 of 2002 (RSA 2002, and the Mental Health Policy Framework and Strategic Plan 2013-2020 (RSA, 2013). The Constitution emphasises the principles of equality before the law, guiding social workers to uphold the dignity and equitable treatment of mental health care users. The Mental Health Care Act designates social workers as mental healthcare practitioners responsible for providing mental health care, treatment and rehabilitation services, with a strong commitment to safeguarding human rights. In the provinces the Mental Health Policy Framework guides the implementation of mental health services, emphasising stakeholder engagement and the establishment of specialist health teams, where social workers play a pivotal role in collaboration to ensure optimal service delivery for individuals seeking mental health care.

Research on social workers who deliver deinstitutionalised services in mental health care, particularly within a South African context, is notably deficient and therefore a research gap exists. This article sought to examine the challenges that social workers encounter in their pursuit to provide optimal deinstitutionalised services to mental health care users. Against the background of the problem statement and the short literature review, the following question has been formulated: What are the perceived challenges experienced by social workers in providing deinstitutionalised services to mental health care users? The sections below will present the theoretical framework, the research methodology within a qualitative context, and the results deduced from participants' responses.

 

THEORETICAL FRAMEWORK

Social workers encounter a multitude of challenges in providing services to individuals seeking mental health care. These challenges arise from a variety of sources encompassing the mental healthcare recipients, their families, communities and the organisations that hire these social workers. To grasp the intricacies of these difficulties, the social-ecological model pioneered by McLeroy et al. (1988) was utilised.

This model is a framework that illuminates how the distinct sources of the challenges collectively contribute to the difficulties that social workers face within the realm of mental health care. The social-ecological perspective, akin to the ecological systems theory, places significant emphasis on understanding how health outcomes are intricately shaped by a range of interconnected environmental factors at different levels (Schölmerich & Kawachi, 2016). The social- ecological model was employed to analyse the framework within which social workers formulate their decisions, provide services and navigate the factors that either facilitate or impede the attainment of optimal service delivery (Nalukwago et al., 2020). The social-ecological system is comprised of five interrelated, deeply interconnected subsystems that align and mutually synergise one another. These intricate subsystems are illustrated in Figure 1.

 

 

As illustrated above, the social ecology model identifies multiple levels of influence as the intrapersonal, interpersonal, organisational, community, and public policy levels. At the individual level, social workers focused on the mental health care users' personal attributes such as knowledge and beliefs about their condition. The kind of support from family and friends at the interpersonal level contributed either positively or negatively to the users' wellbeing. The general perception of the community about mental health has the potential to enhance or hinder users' wellness. Rules and regulations in organisations that render services to mental healthcare are also significant towards maintaining the wellbeing of users. Lastly, at the public policy level, legislation and laws determine protocol for mental health services. Efforts to enhance mental health service delivery are more likely to succeed when various levels of influence are addressed concurrently (Okoye, 2016).

In conclusion, the social-ecological model advocates for a cohesive approach encompassing individuals, families, organisations, communities and policy-makers. The model underscores the imperative of nurturing environments on individual, social and structural domains to ensure the holistic wellbeing of mental health care users (Wold & Mittelmark, 2018).

 

RESEARCH METHODOLOGY

A qualitative research approach was adopted. It is described as an interpretation of the reality that participants ascribe to their social world, and an investigative process whereby the researcher gradually makes sense of a social phenomenon by contrasting, comparing and classifying the object of study (Creswell & Creswell, 2018).

The exploratory design was adopted to gather information about the social workers' challenges in providing services to mental health care users through interviews, as little is known about this (Meneses, 2022). Concurrently, a descriptive research design was applied to present a picture of the specific details of these social worker's challenges (Neuman, 2014). A contextual design was utilised as well to encapsulate not only the content of participants' narratives, but also the spatial dimensions within which these narratives unfolded (Bayeck, 2021). Case study research was also utilised to explore in depth the lived experiences of these social workers. The author collected detailed information using interview guides (Creswell & Creswell, 2018). This assisted the author to derive an in-depth understanding of a few cases, set in their real-world contexts (Maree, 2016).

The population under consideration for this study encompassed the entire group of social workers engaged in the provision of deinstitutionalised services to mental health care users in the North West province. The author drew a sample from this population of interest and transferred the results from the sample to the whole population (Majid, 2018). A group of ten social workers was chosen for interviews. The author employed purposive sampling to select this sample on the basis of its convenient accessibility, and chose participants who possess knowledge about, and are actively involved in providing, services to mental health care users, as outlined in Neuwman's work (2014). The author specifically included participants from institutions that offer deinstitutionalised mental healthcare services.

In this inquiry the author utilised face-to-face semi-structured interviews. The author maintained an open perspective regarding the information sought, allowing concepts and theories to emerge naturally from the collected data (Bryman, 2016). A set of predetermined questions outlined in an interview guide was employed to gather data from a cohort of ten participants. The point of data saturation indicating where recurring patterns and themes became evident in the participants' responses was empirically confirmed (Fusch & Ness, 2015).

After transcribing the interviews, the author engaged in an independent analysis of the transcribed data. To facilitate a systematic and structured data analysis, the author adhered to Tesch's framework (as cited in Creswell, 2014). This approach facilitated the methodical identification of overarching thematic constructs which constituted the foundational narrative that emerged from the data. The strategies utilised to ensure the trustworthiness of this study are indicated in Table 1.

 

 

ETHICAL PRINCIPLES

The Department of Social Work Research and Ethics Committee at UNISA sanctioned the study (01/02/18/07900295_18). The ethical principles upheld included obtaining informed consent, maintaining anonymity and confidentiality, voluntary participation and debriefing of participants should a need arise.

 

LIMITATIONS INHERENT IN THE STUDY

According to Miles (2019), limitations are defined as constraints to the study based on the research methodology and design elements that one cannot control. The following limitations are noted here.

• Obtaining permission

This research is situated within the realm of healthcare. Navigating health protocols to secure authorisation for access in institutions posed a challenge. Seeking approval from multiple professional organisations to endorse the study was required. Permission to continue with the study took too long to be granted. Consequently, this process caused a delay in the initiation of the study.

• Access to participants

The area where the study took place is geographically widely spread. Transportation to all designated locations emerged as a notable hinderance in the study. In addition, the identified social workers were not always available due to work commitments. This resulted in a small sample size.

• National lockdown

The global onset of the Covid-19 pandemic precipitated the enforcement of a national lockdown, encompassing stringent restrictions on human mobility and communal activities.

This situation posed substantial obstacles to traveling to various participants' locations for data collection and resulted in a small sample size.

• Representation of the study

The findings of the study are limited in their generalisability. Although the author sought a diverse pool of participants, the study is not representative of mental health social workers in the whole of South Africa. Future research could be extended to other provinces because this study is limited and delineated to cover social workers who are employed at organisations that provide deinstitutionalised services to mental health care users in the North West province only.

 

BIOGRAPHICAL PROFILE OF PARTICIPANTS

The demographic details of the ten participants of the study are presented and explained in this section. Participants were selected from organisations delivering mental health services in the North West province. Specifically, out of the total of 10 participants, 7 were young adults (1839 years), while the other fell into the middle adulthood stage (40-65 years). The average age was 42 years, reflecting a relatively mature group. In terms of gender distribution, 6 participants were female and 4 were male. This gender composition corresponds with findings by Khunou et al. (2012), which note a predominance of women in traditionally nurturing professions such as social work and nursing.

The professional experience of participants varied, with 5 having 10 or fewer years of experience, while the other 5 possessed over a decade of experience. More than half of participants managed caseloads that exceeded the recommended ratio by the Department of Social Development, which stipulates one social worker per 60 cases. Caseloads often surpassed 300 cases or more (Engelbrecht & Strydom, 2015).

 

RESEARCH FINDINGS

The four main themes derived from the analysis of the reflections provided by the participants on the topical questions posed to them are presented in Table 3.

 

 

 

 

In the next section, the themes that emerged from the data analysis will be substantiated by storylines and compared with the literature from the adopted theoretical framework.

Theme 1: Challenges in working with mental health care users

Participants were asked about the challenges they faced in working with mental health care users. From their responses, two significant subthemes emerged, which will be explored below.

Subtheme 1.1: Quality of life for long hospital stay patients

In cases of protracted hospitalisation, certain patients experience a deterioration in fundamental social skills. Accordingly, participants underscored their inherent obligation to preserve these elemental functional proficiencies among patients. One participant elucidated:

Remember, you are working with patients who have been in an institution, some of them for close to almost 60 years. They came here as young patients and they grew old within a structured secure environment. Now, you want to introduce these patients to life outside. It is our responsibility to make sure that before we send these patients outside, they know basic things. We need to educate them at their level because they never went to school, and intellectually, they don't understand many things. (Participant 10)

Because they only know life inside the hospital grounds, we also remind staff to be cautious when driving inside the hospital grounds as there are patients who sometimes wonder around, and the speed limit is 40 kper hour you understand? It's your responsibility as a social worker to make sure before you send this patient outside that they know such things. (Participant 7)

Corroborating these narratives, the literature underscores the point that elderly individuals grappling with mental disorders, particularly those who have experienced prolonged institutionalisation, encounter substantial difficulties during the transition to community-based facilities. This encompasses an erosion of self-sufficiency and mastery of essential daily life competencies (Silva et al., 2017). As the social-ecological model posits, at this intrapersonal level the model addresses the vulnerability of individuals living with mental disorders. Their compromised physical and cognitive functioning can be attributed to factors such as extended institutionalisation. Therefore, social workers need to take cognisance of these factors.

Subtheme 1.2: Difficult mental health care users

This subtheme pertains to mental health care users who exhibit behaviour (by state patients³) that is incongruent with societal norms when granted the opportunity to visit their families' residences. Such behaviour places a substantial burden on the family members hosting them. One participant gave an account that illustrated this. The participant expressed that recidivism⁴contributes to the way that families and communities react towards state patients. The following storylines attest to this.

The other challenge is that the family would accept the patient. Fine, they take him. The very same patient rapes someone again. This is now the second rape. Now, the family blames you as a social worker. They say it's you who have been calling them, saying he is coming home and is rehabilitated. (Participant 4)

One of the participants articulated the complexities associated with patients displaying challenging behaviour as follows:

That's one thing I find challenging, because you would want to send patients home for leave of absence, and they would be telling you straight that I'm not going to stay there. If you take me there, I will leave. Indeed, that is what they do, they come back here, hence there's always readmissions, readmissions, or relapses. (Participant 4)

The views above correlate with the findings of various scholars (Marais & Subramaney, 2015), who confirm the point that at times state patients are released back into the community with the aim to treat and reintegrate them back into their communities. But when this is done, they re-offend (Marais & Subramaney, 2015). Drawing on the social-ecological model, social workers need to identify factors that perpetuate this behaviour and educate the community about risk factors. As Shishane et al. (2023) explain, recidivism indicates that there are challenges within the system where members of our society are trapped in a cycle of crime, but state strategies to address this are not as successful as hoped. The lack of holistic approaches in investigating what contributes to recidivism among South African offenders creates and maintains fear. As a result, communities at large become trapped in a downward spiral, where crime increases fear, which increases isolation and lack of trust among community members, which in turn leads to more crime.

Theme 2: Challenges in working with families of mental health care users

Participants emphasised that there are instances where families are reticent about actively participating in the restorative journey of their mental healthcare beneficiaries. However, participants have stressed the need to educate these families on effective strategies for engaging with their mental health care users. The narratives shared by participants distinctly highlight this requirement.

Yeah, when I do a home visit, it's not only for patients. It is also for family support. Yes, for instance some patients with depression will tell you that they don't appreciate me at home. I'm being labelled, I'm being called names. You need to psycho-educate the family to understand his condition. We need to educate family members because they sometimes reject them, and when they do, where do they want the social worker to take this person? That's when the social worker plays a huge role to explain to the family that this person is not well. (Participant 1)

Mabunda et al. (2022) add that a considerable proportion of family members of mental health care users state that they are ready to be involved in the care of their relatives. However, such involvement is burdensome. These authors also suggested that families could participate in support groups with similar families where they share experiences, challenges, and suggest coping mechanisms for one another. On the interpersonal level, the social-ecological model addresses a person's relationships with family and peers. The social workers should support families in taking care of their mentally ill relatives.

Theme 3: Challenges experienced in the community

This theme pertains to the hurdles encountered by social workers while rendering mental healthcare services to individuals at the community level. Participants emphasised the salience of stigma, the intricacies of the schooling system, and the challenges of acquiring disability grants. These factors are addressed in the subthemes below.

Subtheme 3.1: Stigma

Within this context, stigma manifests as an adverse response to individuals grappling with mental health conditions, engendering a pessimistic perception of self, or eliciting unfavourable judgments from external parties (Matsea, 2017). The manifestation of this challenge was vividly exemplified in the narratives:

It's difficult for them to even find work, because immediately they mention that they are psychiatric patients, they are stigmatised. So, it's very difficult for mental health care users to find work. The other thing is that we need to make sure that the support system is strong enough for the patient so that at the end of the day he should be valued as a normal person as well. We attempt to so away with the stigma of labelling people as 'mad'. We explain to people that they need to understand that the patient's condition is just a state of a mind that has been disturbed and the person would come back to reality again. (Participant 1)

The literature corroborates these narratives. Stigma plays a pivotal role in the tribulations and economic repercussions associated with mental disorders, and individuals living with mental illnesses encounter victimisation and discrimination (Kakuma et al., 2010). In comparison with a multitude of other afflictions, mental illness is beset with a heightened degree of stigma, which compromises the fundamental rights of MHCUs (Minty et al., 2021). At the community level, as advocated for by the social-ecological model, the social worker should address the community norms and values regarding persons with mental illnesses through activities such as community awareness campaigns, radio talks, social media etc.

Subtheme 3.2: The school system

While the Department of Basic Education has formulated policies for the inclusion of children with mental disabilities, substantive evidence on their effective implementation is scarce. This deficiency is exemplified through the follow comment.

It becomes very difficult, because within the education system there is a gap. Some of the learners are slow learners, they don't fit within the school structure because they don't perform as expected, but they are above the level of the intellectually disabled children. So, at a certain point, they end up discontinuing school and coming here to the training centre, because there's no specific area where they fit. So, yes, it becomes difficult. I think that's also a challenge that it's not all special schools that have specially trained teachers that know how to handle kids with behavioural problems. I also think that their policies don't accommodate kids with behavioural problems. (Participant 8)

The literature substantiates this account. The placement of children with learning disabilities in special educational institutions calls for the availability of educators equipped with the requisite competencies (McKenzie et al., 2020). However, while avenues for enhancing teachers' proficiency in addressing impairment-specific obstacles are provided by nongovernmental organisations (NGOs), there is a reluctance among educators to use these opportunities.

Theme 4: Obtaining disability grants

People living with mental illnesses are eligible to obtain social grants as they might not be able to work. Social workers play a significant role in the application for a disability grant for people living with mental illnesses. This is explained by one participant:

Yes, if they are South Africans we make sure that the grant is there, the birth certificate is also there, that is our role as social workers in the hospital. You make sure that you also apply for the grant, even if the patient is still institutionalised, we make sure that they get the grant. (Participant 1)

Individuals with physical and mental impairments encounter many obstructions across social and environmental dimensions, effectively hindering their active participation in the conventional labour market. In recognition of this, the South African government extends "social grants" to these individuals as they exhibit a relatively diminished capacity to engage competitively within the open labour market (Kelly, 2019). For those confronted with limited employment prospects, these social grants are their sole viable recourse for securing a stable household income (Kelly, 2019).

Conversely, participants shared a concern that mental health patients are subjected to prejudice when they apply for a disability grant. The following comments attest to this.

Sometimes, when it comes to engaging with relevant stakeholders, like SASSA, I do have a problem when it comes to disability grants. I've even written a letter to the manager of SASSA, requesting him to review the grant application of a certain client, because the client did not have a chronic condition but had an intellectual disability, so his application was declined. He started school in a normal school, but later realised that he had an intellectual disability. I took this client to Tshepong Hospital to be assessed by a psychiatrist. The psychiatrist confirmed that he has an intellectual disability, but still the doctor at SASSA disapproved the grant application. (Participant 8)

My experience is that most of the doctors working for SASSA are too strict at times, especially with mental health patients, because after the patients are discharged, they go to SASSA to apply for grants, but because they are stable at the time, then the Doctor would reject the application. (Participant 9)

The disability grant is an intrinsic part of care for the mentally ill individuals, because of their inability to get jobs in the labour market. This could cause a relapse or hospitalisation because they are not able to collect medication, buy food etc.

In congruence with the social-ecological model, social workers would judiciously consider community variables, including those afore-mentioned when devising and implementing apt interventions. This aligns with the model's framework and recognises the multifaceted dynamics influencing individuals and communities (Schölmerich & Kawachi, 2016).

Theme 5: Challenges relating to service provision

Social work roles within the sphere of mental health differ vastly based on the organisational contexts within which social workers are situated. The political, economic, societal and cultural factors impact on their roles in these domains (Hussain & Ashcroft, 2020). Participants' challenges in this regard are discussed below.

Sub-theme 5.1: Multidisciplinary team's expectations of social workers

Social work is a collaborative profession that transcends individual efforts to function as a strong team effort in the context of mental healthcare. Social workers' education emphasises the value of inter-professional cooperation and collaborative practices (Roth et al., 2021).

However, the role of social workers in mental health care has not been well defined. Their status and authority within multidisciplinary settings has sometimes been undermined, and opportunities to realise professional potential have been underdeveloped (Allen, 2014).

Participants expressed their frustrations about working in multidisciplinary teams. They felt pressure from other professionals to do things that they would necessarily not do. The following comment highlights this frustration.

For instance, if a patient is discharged and the family doesn't want to come and take the patient, the team discusses the patient. I would try to plead with the family to take the patient home. But the family would still refuse. Then when I attend the MDT meeting I would be reminded that the patient is discharged, but is still in hospital. This issue would then become my burden alone. (Participant 1)

In addition, participants felt that other professionals were not clear on the role of social workers within these teams, which is evident in the following comment.

Even the doctors call social workers for everything. Apparently, they think that anything that has to do with family has to do with social work. Even when a patient is being prepared for surgery, they want us to call the family. What are we going to tell the family? Because we don't even know the medical terms or even the procedure, and even the reason for the operation for that matter? So, ja, that's one thing that I think they are confused about. Even when a patient has passed away, they want us to be the ones who inform the family members. I think that's not fair. (Participant 4)

As evident in the literature, multidisciplinary team functioning is complex and requires a deeper understanding of the different professions in teams. Boundaries between professions can act as a barrier, can influence communication and coordination negatively, and this can impact on service user safety and care integration. Unclear role allocation and lack of clarity regarding leadership can also hinder team functioning (Roth et al., 2021).

Ambiguous work-related role expectations from different stakeholders have been found to contribute to individual social worker stress and strain (Graham & Shier, 2013). Likewise, the absence of clearly delineated work role expectations, in some social work practice settings, can result in decreased job satisfaction (Graham & Shier, 2013). At this organisational level, efforts to foster positive relations among staff members, building close relationships with colleagues and working collaboratively can increase efficacy.

Sub-theme 5.2: Unsupportive management

Normally, working with people who are seriously ill evokes a variety of emotions among care givers at the workplace including sadness, frustration, grief and guilt. These negative feelings get worse when employees perceive management to be unsupportive. The participant's account below illustrates this.

Debrief? We do not get opportunities to debrief. We are expected to move from this scenario to the next. Sometimes I would feel that I am down the drain and management would be pressurising me, 'I want stats, I want stats every month. How many did you discharge this month? Give me the reasons why you did not discharge? Why did you do that? You are under your target'. That, for me is stressful and difficult to handle. We are not able to adhere to their rule to discharge patients after three months, because there are too many factors at play. (Participant 5)

The above storylines allude to perceived organisational support (POS), which refers to employees' perceptions regarding the extent to which their organisation takes measures to protect their physical and psychological wellbeing, which is related to job satisfaction, organisational performance and absenteeism. A challenging work environment, characterised by increased work demands and lack of organisational or colleague support, may be linked to the deterioration of mental and physical health among healthcare workers. It is therefore important for organisations to identify the organisational needs of their employees and to ascertain the impact of organisational aspects on employees' mental health (Chatzittofis et al, 2021).

Sub-theme 5.3: Insufficient training

In South Africa a lot of social workers receive generalist training rather than specialised training in mental health. They unintentionally end up in mental health facilities because they applied for a job. Hence for some certain people, the dearth of specialised training in mental health presents difficulties for them. Participants shared the following experiences.

When I started to work here, I was getting confused on how to intervene with a mentally ill client. You know, it's sometimes not easy even for a sane person to express themselves. So, what about a mentally ill person? When I had sessions with patients, sometimes I would take their word for it because I did not know what to do. (Participant 4)

I worked at the Department of Social Development before I worked here. When I started I would get confused most of the time. When I had sessions with the patients, I would sometimes take their word. Then when I asked the nurses, they would say no that is not what the patient meant. On a certain occasion, I did not realise that the patient had relapsed, and I did not understand why he was rude because I was never trained to assess these situations. (Participant 4)

The challenges faced by social workers in managing complex situations involving patients with mental health conditions are illuminated by their narratives and resonate with insights from the literature. Concerns have been raised internationally about the gaps in social work education and training in mental health, and the discrepancies between what is taught in the classroom and what is needed in the field. This disconnect echoes the narratives of social workers who experience challenges beyond what their university education prepared them for (Kourgiantakis et al., 2019).

The literature also notes that therapists may experience emotional responses when they perceive the patient as difficult. Therapists' emotions may include guilt, tension, anxiety, frustration, avoidance and anger towards patients. Therapists may manifest negative attitudes, act erratically and respond non-therapeutically to a patient perceived as difficult (Fischer et al., 2019). The training of mental health social workers is a systemic issue that universities need to address on an organisational level, because it affects the efficiency of social workers in their service delivery.

Sub-theme 5.4: Remuneration

Participants expressed their discontentment regarding their remuneration, emphasising their lack of specific allowances extended to their professional counterparts. They expressed their views as follows,

What are our challenges? We don't even have a danger allowance, you know. What if a patient could injure you and you don't have a danger allowance? But we are exposed to danger, regrettably. The doctors and the nurses are getting it - why not social workers? If a doctor and a psychiatric nurse can get a danger allowance, why can't I get it? Because I'm a social worker? (Participant 1)

You know, staff shortage is a problem and we are overworked. Ifeel that social workers are treated unfairly. For an example, all other members of the multidisciplinary team are getting rural allowances and even provincial workers, but we don't. (Participant 3)

Owing to the nature of their practice and their work environment, social workers experience high levels of stress and burnout from exposure to their clients' stressful experiences, and from facing elements of risk and danger, including actual and threatened violence (Graham & Shier, 2013). All these factors, in addition to the inadequate salaries they are forced to accept, bear heavily on practitioners (Graham & Shier, 2013). Discussions at policy level should take into account these concerns among social workers, as this affects their productivity.

 

CONCLUSION

This article has delved into the intricate field of challenges faced by social workers in delivering deinstitutionalised services to individuals with mental healthcare needs. Through the narratives and insights shared by participants, it became evident that the realm of mental healthcare presents multifaceted challenges that extend beyond the clinical context. This interplay between individuals, families, communities, institutions and societal perceptions shapes the realities encountered by social workers in their endeavours.

Findings from this study underscore the importance of recognising the broader ecological context within which mental healthcare services are provided. The social-ecological model provides a lens through which these challenges can be understood, and the inter-connectedness of individual and interpersonal interactions, community dynamics, institutional frameworks, and societal attitudes is highlighted.

The narratives of social workers portray the tensions between their professional aspirations and the practical constraints. The disparity between classroom education and real-world demands, coupled with the intricacies of working with individuals in vulnerable states, underscores the necessity of comprehensive and contextually relevant training.

Importantly, the struggles elucidated by the participants not only shed light on existing obstacles, but also point toward potential avenues for improvement. As the mental health landscape evolves, it is imperative for institutions, policymakers and educators to heed the call for comprehensive and updated training that bridges the gap between theory and practice. Acknowledging the holistic nature of mental healthcare underscores the importance of collaborative efforts in multidisciplinary teams, as well as the empowerment of social workers to enable them to apply their expertise in inter-professional contexts.

As the field of mental healthcare continues to evolve, this study serves as a reminder that addressing the challenges faced by social workers necessitates a comprehensive approach. The narratives shared by participants and the insights drawn from the social-ecological model implicitly advocate for a dynamic and contextually sensitive framework that acknowledges the intricate web of factors impacting on mental healthcare service delivery. By recognising and addressing these challenges, we will be taking significant steps toward enhancing the wellbeing of individuals with mental healthcare needs and fostering a supportive and inclusive society.

 

RECOMMENDATIONS

In the light of the social-ecological model pioneered by McLeroy et al., (1988), at the intrapersonal level social workers should continuously educate and engage mental health care users to determine their understanding of their condition and coping skills; at the interpersonal level, they should educate family and friends on mental health issues as they are crucial for managing the day-to-day stressors and adverse conditions for users; and on the community, organisational and policy levels, social workers should advocate for equality, social justice, human rights and equal access to mental health services.

Recommendations that would strengthen interventions aimed at optimal deinstitutionalised service delivery to mental health care users can be made based on the study results. First, children's mental health is a significant but neglected sphere in mental healthcare. This calls for social workers to intervene at policy level to advocate for the rights and wellbeing of children facing mental health challenges, including those with conditions such as intellectual disabilities and autism. Social workers could lead in establishing consultative platforms that engage a range of stakeholders.

Second, people living with mental illness face significant barriers in attending school and finding employment. The exclusion of children with mental and psychosocial disabilities from education leads to further marginalisation of this already vulnerable group. Poor educational outcomes also lead to poor employment opportunities. People with these disabilities experience the highest rates of unemployment. Because of these factors, people with mental and psychosocial disabilities are much more likely to experience impairments and die prematurely, compared to the general population (National Health Mission, 2016). Continuous community education with the aim of breaking the perpetual cycle of stigmatising mental health care users is paramount.

Third, social grants are another issue that needs interrogation at the policy level, with special reference to disability grants for mental health care users. Social grants constitute a notable and often essential income source for numerous individuals who are mental health care users. However, it is apparent that these individuals encounter obstacles that impede their access to these vital grants. According to October (2022), the disability grant is an intrinsic part of the package of care in a way. The struggles that come with economic hardship from a person's inability to access the grant could cause a relapse or hospitalisation. For beneficiaries, having to repeat this process every 6 to 12 months is nerve-wracking. Given the complexity of this issue, it is recommended that further comprehensive research be conducted on the issue.

Lastly, employers situated across diverse settings where social workers engage in service provision to individuals who are mental health care users should demonstrate an acute awareness of the intricate nature of this professional domain. Management should extend meaningful and practical support to these professionals, acknowledging the multifaceted challenges inherent in such work. A noteworthy step in this direction would involve the recognition and acknowledgement of the demanding nature of these roles by remunerating social workers in a manner that reflects the complexity and significance of their contributions. This recognition coupled with reasonable remuneration could serve as a motivating factor promoting a sense of value and job satisfaction among social workers. Organisations need to foster an environment that values and supports the endeavours of these professionals and this should in turn contribute to the overall well-being of both the workforce and the patients they serve within the mental healthcare sector. According to Smith and Shields (2013), satisfactory pay is no doubt a "statistically significant predictor of job satisfaction". Joseph (2017) concurs that although unlimited negative factors within a job would not be nullified purely by an increased salary, remuneration is a contributing factor to a sense of self-worth and job satisfaction.

In the ever-evolving landscape of mental healthcare, the resilience and dedication of social workers stand as beacons of hope, embodying the commitment to surmount challenges, drive change and usher in a future of compassionate and effective deinstitutionalised services for those in need.

 

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Article received: 06/03/2024
Article accepted: 22/07/2024
Article published: 13/06/2025

 

 

1 Deinstitutionalisation: A shift in the locus of care for severe mental health conditions away from psychiatric hospitals towards community-based mental health services and closing long-stay psychiatric hospitals (WHO, 2022a, p. xix).
2 The author used pseudonyms to protect the identity of participants.
3 State patients are individuals who have been charged with offences involving serious violence and who have been declared unfit to stand trial because of their mental illness, and they are referred by the courts for treatment, rehabilitation, and detention at a forensic psychiatric facility (Marais & Subramaney, 2015).
4 Recidivism refers to one who after release from custody for having committed a crime, falls back, or relapses into former behaviour patterns and commits additional crimes (Morgan & Del Fabbro, 2018).
AUTHOR BIOGRAPHY
Portia Webb was a Master's student and a lecturer in the Department of Social Work at the University of South Africa. Her field of specialisation is mental health. The article is derived from her Master's dissertation, based on research conducted from January 2019 to December 2023.
Anri Adlem, a doctoral graduate from North-West University, is currently an Associate Professor in the Department of Social Work at the University of South Africa. She supervised the study from January 2019 to December 2023 and assisted with support and conceptualisation of the article.