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Education For Community Mental Health Practice: Problems And Prospects
By Milton Wittman
Editor’s Note: This paper was presented at the annual conference of chief social workers from state mental health programs, Philadelphia, Pennsylvania, in May 1957.
The problem of professional education for community mental health practice is one that poses a number of intricate questions for both educators and practitioners. The complexity and size of the mental health problem and the growing support for mental health programs throughout the country together indicate that the field of social work must make a major effort to relate soundly to the educational needs in this field. The work of the Joint Commission on Mental Illness and Mental Health clearly indicates the need for useful data on which to assess and evaluate the current and future directions of mental health programs. There is a strong feeling among those who have some awareness of where we now stand that current efforts in mental health fall far short of meeting the vast needs. There is continued questioning of the nature and content of service available and there is a high degree of curiosity about the effectiveness of current services. We now face the disconcerting fact that we may not really be meeting these needs just by increasing the number of known and existing services; rather the implication of present-day thinking is that we need to bring about some radical changes in our working philosophy and in our practice if we are to make any realistic impression on mental health problems.
Donald Young postulates that “Ideally, a profession involves the use of all pertinent knowledge obtained from the entire range of relevant disciplines and accumulated experience for the solution of problems in research or practice.” We have not yet succeeded in selecting the most relevant elements of knowledge from related disciplines, nor have we plumbed the depths of accumulated experience for application in educational practice. This paper is directed toward the illumination of problems of education for community mental health and will suggest some prospects ahead for development of such education.
SERVICE PRIMARILY TO MENTALLY ILL
If we were to consider the sum of mental health services in the nation today, our first thoughts would turn to the work of the six hundred mental health clinics currently providing a large quantity of services to the roughly one million mentally ill and a much smaller quantity of services to the roughly eight million mentally troubled who need outpatient care and can be served while living in their own homes. A miniscule quantity of service is being provided by the core group of mental health personnel for the so-called normal population who are neither mentally ill nor mentally troubled. Therefore, it could be said that the field of practice of mental health today concerns itself primarily with the core group of mentally ill and the vast array of current services staffed with the constellation of mental health disciplines extends only in small part into the area of preventive mental health functions. This is not to deny the very useful efforts being conducted under the aegis of state and local mental health associations and is not intended to minimize in any way the very useful preventive functions currently conducted by state mental health programs. The fact remains that the bulk of mental health practice as we know it today remains related to the mentally ill or mentally troubled group.
Just as we find the core of mental health practice related to the mentally ill or troubled, so de we find the educational programs for the mental health professions geared primarily to teaching content related to pathology processes and their treatment. It is true that the conception of treatment in its most progressive interpretation implies intensive aftercare service intended to maintain the recovery of the mental patient. This quality of prevention cannot be overestimated. However, we have done little to apply the methods devoted to prevention of relapse to the prevention of illness in the first place. Educational content in the mental health professions in the main involves case material drawn from psycho- and sociopathology. Content on prevention is primarily descriptive. The fundamental problems which face teachers and practitioners in mental health today are difficult to grasp because of the intervening barrier of philosophical considerations. It is difficult to come to grips with the basic philosophical considerations which must precede any significant changes in practice and in education tending toward a vastly different methodology in mental health practice ten years hence.
Those who have perused the hearings prior to the passage of the National Mental Health Act, and subsequent testimony related each year to the Appropriations Committee hearings, will recall the immense concern with maintaining a broad perspective in the approach to the mental health problem. The high status that has been accorded mental health research is a ready indicator of the wish on the part of the National Institute of Mental Health and the Congress to provide high priority to the discovery of new knowledge directed toward a solution of mental health problems. It is possible to feel some frustration because, after so many years of research efforts, more definitive findings have not yet pointed the way toward a general solution of the problem even on a long-range basis. The basic goal of public health practice is the evolution of workable “control” programs. When we speak of control programs, we tend to think of an orderly organization of personnel and processes which will permit individuals, groups, and communities to solve their own problems, in the main, and to seek specialized help only as needed. There is some hope that mental health methods can successfully be made part of existing institutions in order that these may serve as intervening forces to prevent mental illness, or to provide for its early indication so that treatment, exclusive of hospitalization, can be used. The right approach has not yet been found. At present we cannot know whether the greatest advances in this area may yet come from physical findings, which will suggest an organic basis for mental illness, or from findings on psycho-social functioning, which will suggest effective means of fostering and maintaining mental health.
Present mental health practice is dominated by a philosophy evolved from a combination of social and psychological theories of human behavior. Current knowledge of culture and society and the psychological impress of events during the life cycle of the individual form the basis for existing mental health services. When mental illness strikes, the social and health resources of the community are devoted to the ultimate task of restoring the individual to normal functioning. In most of our communities this task can be carried forward only under the most difficult circumstances. A foremost reason for this is the lack of social and health planning which intervenes as an obstacle to early diagnosis and thoroughgoing treatment following immediately upon the onset of illness. Too frequently the patient is subjected to damaging delays preceding diagnosis and treatment which tend to reinforce the illness and make recovery all the more difficult. There is frequently too little interpretation to the spouse or relatives which would permit an understanding of the illness and an appreciation of the intensely important supportive role it is possible for families to play. Our philosophy governing the care of the mentally ill suggests an immediate separation from the family and from society until an appropriate stage of recovery has been attained. This is in contrast to the type of philosophy in other countries which move instead toward maintaining the sick person in his family and in his community with the burden of direct care falling upon the immediate family. Current thinking in Great Britain suggests the open hospital as the pattern for service with direct involvement of the community in hospital program and procedure.
At another order of thinking, one might consider the importance of social and health resources in assisting the remedial handling of individual and family crises at the point of their occurrence. It is readily evident that any American community contains within its social structure a number of crisis-handling agencies such as the general hospital, the court, the police department, the school, and the church, all of which at various times encounter individuals and families under emotional stress. In a very few instances these resources are prepared to deal with crises on the basis of mental health knowledge. The present goals of the national mental health content in medical, legal, and theological professional education represent one move toward the better preparation of professional persons for dealing with mental health problems among their usual clientele.
The philosophical considerations which must be faced in general planning for education in community mental health suggest two avenues of approach. One is the extension of existing numbers in the core mental health professions. A second is through the medium of improving mental health functioning of existing community resources and structures so that “problems will solve themselves” at an early stage in their development and a “buffer zone” will be established between the individual and the mental hospital. It is in the nature and definition of the “buffer zone” that we have the greatest need for research and evaluation. At this point we are not certain how much can be handled by such an important social institution as the school system, for example, with a minimum of help from the “outsider” from the mental health field. To what extent should psychiatric personnel be introduced into the school system and to what extent can teachers and school personnel be prepared to take action on mental health problems on a purely independent basis?
If the same questions are applied to the field of social work education we might give some thought to two main questions. The first is: How can education for psychiatric social work be directed toward meeting the needs of community mental health programs? The second question is: How can the education of all social workers provide for the kind of knowledge and skill that will have preventive mental health insurance in everyday social work practice? It must be granted that for the present we can only conjecture on how these problems are to be met. Social work practitioners and educators both have an important concern for reducing the dissatisfaction currently found when the requirements of mental health positions are measured up to the capacities of recent social work graduates. The most frequent comment heard from mental health administrators relates to the deficiencies of social work graduates in the areas of community organization, work with groups, consultation, public relations functions, ability to use and conduct research, and unfamiliarity with the common aspects of inter-and intraprofessional collaboration in providing normal social and health services. The following has been said about the current status of social work education:
…The ability of schools of social work to prepare students for highly individualized casework practice and for the group work field is generally acknowledged, but it has been questioned whether the schools at present are adequate for preparing personnel with knowledge and skills in policy making, administration, and community welfare organization, or are geared to meet the staff requirements of the large public welfare services.
It must be granted that the uneven character of the development of professional education will inevitably lead to greater emphasis in one part of the field as compared with others. In the case of social work education, the development of education for community organization is seriously behind education for group work and casework. Building this part of the curriculum will be an important task over the next few years.
IMPLICATIONS FOR EDUCATION
Present educational programs in social work are composed of personnel, didactic content, and field resources. Basic professional education at the master’s level provides for preparation in theory and practice which is imparted over a two-year period in various combinations of class and field experiences. The ideal curriculum provides for a carefully planned balance of education in human growth and behavior, social work practice, and social services. Research and administration are taught as enabling processes and feature as important parts of the curriculum. The graduate emerges as a practitioner who has been seen as needing supervision over at least a year before he can attain accepted basic competence in practice. At present, it could be said that there is very little content in either the master’s or post-master’s program related to theory and methodology of prevention. The leading development of such theory has emerged from the public health field but this has been incorporated in social work education in only rare instances. Education for psychiatric social work consists for the most part of content in casework practice in mental hospital or clinic settings. It is the rare hospital that carries on a planned program of preventive activities. More frequently such activities are found in mental health clinics as part of the ongoing program but these are rarely seen as an appropriate part of the student’s field experience. Therefore, education in application of preventive functions must be inculcated in the post-training experience.
At the post-master’s level, the situation is somewhat better. Here there has been a substantial development of program content more directly related to community health functions. In at least two schools of social work there has been a conscious effort to develop class and field content related to community mental health programs. While only a very few students have completed these programs, it is possible now to examine them at their early stages of development to see if they contain what we really need to develop skilled practitioners in community mental health. The third-yearstudent brings to the advanced program a master’s degree in social work and on the average, from six to nine years of social work practice in one or more agency settings. He has mastered basic competence in social work practice and is now prepared to undertake a learning experience involving more complex field instruction responsibilities and involving a level of thinking requiring an approach to theory-building and application. He must be prepared to view the complex aspects of the social worker as community organizer, administrator, consultant, and researcher. The complexities of this program have been set forth by an administrator who has undertaken field instruction on the advanced level
The field work content must basically be oriented to principles whereby a state mental program is, can, or may eventually be implemented. This means in the first instance that there must be developed a clear orientation to the historical perspective of the current program in which the field placement is made. In the development of this perspective the content of the program is learned and inevitably some comparative illustrations of other state programs are developed. This orientation also brings in many specifics, e.g., the legal sponsorship of the program and its development, the state interdepartmental relationships and the public and voluntary relationships. Concurrent with this broad base there is the need to understand the local pattern of government, e.g., county, town, etc., and how these units relate to state government. These interrelationships will be the base on which policies must be formulated to be compatible with all interested parties from whom support of the program can be promoted. The policies are of course vital content since they are the baseline against which a grant program or a direct (or indirect) service program will be administered.
It can be readily seen that this experience is one which would be difficult to view at the master’s level. Moreover, we have few faculty members in any of the schools of social work who have had practical experience at this level of operation. It would seem important to provide an opportunity for seasoned administrators to become involved in social work education. Likewise, it would seem important that as rapidly as possible we should produce teaching material which can be made available to programs which do not have an opportunity to establish advanced field instruction in community mental health. Another approach would be to permit senior educators to have a year of practice at the advanced level so that their experiences could be other than academic. The National Institute of Mental Health Senior Stipend Program will provide a practical means for pursuing this objective.
IMPLICATIONS FOR PRACTICE
There is a serious need to analyze and assess current social work practice to estimate present and potential contributions to preventive mental health. The notions of “preventive social work” needs definition and testing. Perhaps the closet approach to prevention in present-day practice is found in the activity known as “family life education” which is aimed at promoting understanding of life processes and emotional growth. A second level of prevention is the goal of recently organized specialized social agencies to co-ordinate social work functions aimed at the “hard-to-reach” groups. The effective use of social data to establish reliable lines of prediction of human behavior offers on favorable developmental prospect. Social workers need to devote more of their time to refinements of practice which permit an application of their skills and methods in work dedicated to strengthening individuals and families and to very early case-finding. Thus they will come closer to the ultimate goal of effective preventive social service. It is conceivable, for example, that long-range prevention goals might be served better in the community if the caseworker interviewed clients one day a week and spent four in such other essential activities as consultation, research, work with groups, education, and interpretation. A major shift in philosophy from the primary objective of treatment to that of prevention must precede any significant changes in social work practice.
The part of this paper that deals with prospects rather than problems must concern itself with what is happening in mental health research and its possible impact on mental health practice. Research in mental health is directed toward producing new knowledge which will permit the primary group of professional people in mental health to do improved work and which will lay some groundwork for an improved role in mental health for the secondary group of professional personnel. This implies the design and testing of new patterns of service involving new constellations of personnel. It involves a careful analysis of the structure and function of existing resources to determine which methods work and what methods do not. It implies pilot and demonstration activities which will extend mental health services into communities where they are not now found. It implies exploration of existing social institutions as these tend to create the caseload of mentally ill or mentally troubled people and it will delve into the nature of psycho-and sociopathologies in their several forms. This means that social work must move from the role of helper in research projects to that of designer of research projects. It means that more people must become prepared in research so that they can add a measure of knowledge to what is now known in content and method of mental health practice.
The immediate future should produce a number of developments which will help ease the problems we now face. The prospects are that:
- The social work role in prevention will become better known and will take more of our professional effort. New social inventions beyond the social agency and the child guidance clinic may pave the way for such a development.
- The transition of preventive practice into educational programs will be facilitated as theory becomes perfected and case materials increase.
- More faculty from the social sciences will be employed in social work education. These should aid in the professional equipment of social workers for the tasks of research and demonstrations.
- The pressure for increased range in field experiences for students at the master’s and post-master’s levels will involve mental health programs in professional education to a greater extent.
- Mental health research will point to new uses of the several professions and consolidation of practice may lead to an extended generic base.
- Definitions of practice levels will earmark those functions which may be carried by sub-or semiprofessional personnel. Thus the social worker may in time be more important as consultant, teacher, supervisor, or administrator than as basic practitioner. Education may need to prepare for this eventuality.
In general it may be said that the field is in flux and changes in methodology and philosophy may be required at several stages in the professional life of the present generation of social workers.
This paper has outlined in summary form the problems and prospects for professional education for community mental health practice. It has pointed out and highlighted the deficiencies in preparation which make it difficult for social work to provide a maximum contribution in community mental health. The need for developing a sound philosophical base for social work operations in mental health is critical. This means much more work on an organizing principle or concept which can place more definitive meaning in the “prevention” construct. It has been said by one author that “the preventive phase of mental hygiene is most frequently only relatively preventive” and if this is so, it is obvious that much effort is needed to establish the validity and reliability of preventive programs. A sound philosophical base cannot be developed without much improved communication between educators and practitioners in social work. It does no good purpose if educators meet alone to discuss and review their problems. In order to make any practical progress in modifying social work education, it will be necessary to direct more attention to reducing the obstacles to collaboration between education and practice. It will be necessary to launch more collaborative long-range research and to involve educators in pilot and demonstration programs. Only as such intercommunication can be soundly established will it be possible to foresee effective education for community mental health practice.
 MILTON WITTMAN, D.S.W., is training specialist, psychiatric social work, National Institute of Mental Health, National Institutes of Health, Public Health Service, U.S. Department of Health, Education, and Welfare, Bethesda, Maryland. This paper was presented at the annual conference of chief social workers from state mental health programs, Philadelphia, Pennsylvania, in May 1957.
 Donald Young, “Universities and Cooperation among Metropolitan Professions” in Robert Moore Fisher, ed., The Metropolis in Modern Life (New York: Doubleday & Company, Inc., 1955), p. 291.
 H. L. Lurie, “The Development of Social Welfare Programs in the United States” in Russell H. Kurtz, ed., Social Work Year Book 1957 (New York: National Association of Social Workers, 1957), p. 42.
 Myron J. Rockmore, personal communication, April 23, 1957.
 George Stevenson, “Psychiatry,” Encyclopedia Britannica, 1955 Edition, Vol. 18, p. 667M (emphasis not in original).
Source: Milton Wittman Papers. Box 24. University of Minnesota, Twin Cities, Social Welfare History Archives. Minneapolis, MN.