Integrating professional social work identity and social justice advocacy: An analysis of the Australian campaign to restore Medicare rebates for accredited mental health social workers

Social action: From mobilisation to effecting change

While the literature on social workers and their involvement in social action and policy change is scant, available studies focus on two specific areas of address – exploring the drivers and motivators of social action and accounting for its effectiveness.

The first is largely concerned with exploring the impact of social workers’ professional identity and role. These studies are predicated on the rationale that identifying the social worker role as an agent of change with a mandate for public policy advocacy increases the likelihood of participation in social action and related policy work. The literature suggests however that social workers are more likely to identify with their direct practice responsibilities and advancing change at the individual, rather than social level (Gillingham, 2007; O’Brien, 2010; Schneider & Netting, 1999; Staniforth, Fouché, & O’Brien, 2011).

Staniforth et al. (2011), for example, asked 300 New Zealand social workers to provide a definition of social work. Using thematic analysis the researchers found that the vast majority of social workers continued to define their profession in direct practice terms. Social policy and social activism were considered central by less than 30% of respondents and only then as part of a general interest in social change rather than as a specific skill set to apply to their everyday practice (Staniforth et al., 2011). In a similar vein, O’Brien (2010) found that social work practitioners often draw on concepts of social justice and change, but this is generally applied to their daily direct practice with clients and is less actively considered and pursued at a macro level of change. In one Australian study, content analysis of interviews with 60 social workers undertaken by Hawkins, Fook, and Ryan (2001) found similar perceptions of the role of social justice and social change in social work practice. The researchers found social workers rarely used social justice terminology to describe their work prompting the researchers to suggest social workers’ professional discourse to be incongruent with the stated mission of social work for social justice and advocacy (Hawkins et al., 2001, p. 10).

An additional dimension of knowledge on social action in social work practice concerns the role and motives of the individual in their social action, and in particular, the influence of values and skills in determining participation. For example, Rocha, Poe, and Thomas (2010) examined the variables that promote or impede political advocacy for social workers. Feeling competent in skills such as letter writing, contacting the media, testifying before committees and strategic planning, were considered influential on decisions to undertake political social action. The ability to utilise and engage other strategic coalitions was also considered important (Rocha et al., 2010). Examining the social action activities of social work students, Swank (2012) identified already belonging to an activist network, and having an ‘activist identity’ as a social worker relate to involvement in social action.

In addition to skills, a relationship between social action and values is evident in the literature. For example, the emerging research on policy practice in social work suggests that key social justice values and associated assumptions about the social responsibility and potential influence of social workers underpin their involvement in policy activism (Gal & Weiss Gal, 2013). Additionally, knowledge and theory from the social and cognitive psychology disciplines implicate both personal and professional values as possible drivers of social action for workers, professional bodies and individual citizens (Feather, Woodyatt, & McKee, 2012; Horvath, 1999; Thomas, McGarty, & Mavor, 2009a, 2009b; Zomeren, Postmes, & Spears, 2008). On the whole, the evidence suggests that values are more likely to act as an initial ‘goad’ to action. Equally, increased education and awareness of the issues and a positive perception of their capacity to enact change appear to act as an instrument of empowerment, which then progress and scopes the effectiveness of social action (Horvath, 1999, p. 10).

In terms of successful social action for social workers, the ability to empower and encourage clients into political action appears central and is often considered an essential ingredient and core skill (Rome et al., 2010). Other researchers have emphasised collaboration and infrastructure factors, such as access to manpower and shared resources (Sherraden, Slosar, & Sherraden, 2002; Wehrmann, 2010). It has additionally been argued that social workers need to use the media in social action not only to inform and reframe definitions of social problems to the general public, but also to get the attention of governments and establish issues on the public agenda in the first place (Mendes, 2008, p. 224).

While the analysis of social workers in social action campaigns is scant in the literature, the sum of the above studies suggests acquisition of skills and competence, access to resources and the formation of collaborative alliances including the media and other social tools as avenues to explore in accounting for success. Personal and professional values and identifying social justice and social change as a social work mandate may also play a role both in initiating involvement, and in improving the efficacy of social action. Exploring whether these factors were present within the AASW campaign is a key goal of the present study.

Australian social work and the AASW

The AASW is the professional social work association, which promotes the professional identity of Australian social workers; enhances practice and ethical standards; develops social work education, knowledge and research; and promotes social justice for service users (AASW, 2012). The Association represents social workers in all fields of practice, and covers the whole range of practice interventions from casework to group work to community development to policy and research.

Social work in Australia is not a registered profession with legal professional boundaries in contrast to both the mandatory registration of social work in most English-speaking countries, and the registration of most other allied health professions in Australia. Though its past attempts have been unsuccessful, the AASW is currently advocating for registration under the Australian Health Professionals Regulatory Agency. All social work graduates from AASW accredited university programs are eligible to join the AASW, but many elect not to join because membership is not a requirement for professional practice. Consequently, the AASW has only about 6,600 members, which they estimate to be about 30% of eligible social workers. This relatively small membership appears to have negative implications in terms of the social work profession’s profile and influence (Cintio, 2010; Lonne & Duke, 2009). Additionally, until recently the AASW has not routinely employed senior staff with skills and experience in social policy, advocacy and government relations, whether from a social work background or not.

Various studies suggest that the AASW has long had a strong commitment (at least in principle) to social action, but that in practice the Association has often failed to meet its stated objectives. It appears that a number of factors including the AASW’s small membership and its corollary limited resources have minimised the reach and efficacy of these activities. Social policy has not always been a high priority for the Association (Gillingham, 2007; Mendes, 2003) due to the demands on the Association to ‘self-regulate’ the profession. This is a similar position to other professional social work bodies that also have a small membership and a minor impact on social policy debates (Dickens, 2010, 2011; Payne, 2002).

The Better Access to Mental Health program

In 2004, the Australian Government began to fund primary care treatment plans involving a range of allied health professionals to provide more affordable and accessible care for people with complex mental health conditions. One of the programs which emerged from this initiative in 2006 was the Better Access to Mental Health Care Scheme which provides a Medicare subsidy for focused psychological strategies. Social workers were included in this Scheme on the condition that the AASW establish suitable assessment guidelines to determine the eligibility of individual mental health social workers for accreditation (Harries, 2009).

The Better Access Scheme is an early intervention program, which enables members of the community (via a referral and mental health care plan from a General Practitioner) to access subsidised time-limited private mental health care. The service user can receive six sessions with an accredited mental health social worker, accredited occupational therapist or psychologist. With GP support, they can access another six sessions, and in exceptional circumstances a final six sessions. All these sessions are eligible for a Medicare rebate which means the client only has to pay the gap between the Medicare rebate and the amount charged by the counsellor (Allen-Kelly, 2010a; Charikar, 2010; Lonne & Allen-Kelly, 2010; Sommerville, 2010). In effect, this provides a low-cost treatment and support plan for those that need it most.

Social workers have traditionally been one of the leading professions in mental health service provision in Australia – participating in hospital and community mental health services, non-government agencies and private practice. Social workers have been represented on the board of the Mental Health Council of Australia since its establishment in 1996. The development of competency standards for mental health social workers was funded by the Commonwealth Government as part of the education and training agenda of the National Mental Health Strategy in 2002 (AASW, 2011; Bland, Renouf, & Tullgrent, 2009). About one in five (1306) of the approximately 6600 members of the AASW are Accredited Mental Health Social Workers who are approved by a formal AASW assessment process (Sommerville, 2012), and many other members work in public or community mental health settings.

In May 2010, the AASW was suddenly informed by the Commonwealth Department of Health and Ageing that social workers and occupational therapists would be withdrawn from the BAMH Scheme. The only explanation given was a concern to reduce costs, and to divert resources (and social workers) to services for people with the most severe mental health disorders via Flexible Care Packages. This was despite the fact that social work mental health services had cost less than AUD$9 million in 2008–2009 out of a total budget of AUD$666 million, and the proposed savings would involve only 4% of the Better Access program budget (Australian Institute of Health and Welfare, 2009).

The announcement of the decision to remove social workers from the list of registered providers provoked considerable shock within the AASW and anger amongst many of its members. The Association and many of its members were immediately concerned that such a move would effectively shrink the scope and access to support available to clients in addition to reducing the income of accredited mental health social workers in their private practice (AASW, 2010c). The AASW immediately launched a public campaign to have this decision reversed. Through a variety of strategic political meetings and an increasingly ‘public’ education campaign on the implication of the decision for vulnerable client groups, the AASW was successful in having the decision revised.

The AASW campaign commenced the day after the Budget decision was announced. The campaign was led by the CEO (a social worker with long practice experience in health and post trauma services in rural and remote Australia) and coordinated by the Senior Manager for Advocacy and Communications in the national office. The national office staff established the key aims, tools and ideas for action, but also sought to facilitate action by social workers in all states and territories at the local level. The ultimate campaign success came in November 2010 when the Labor Government announced a complete reversal of the original decision, and committed to working with the AASW to deliver high quality mental health care services (Roxon & Butler, 2010). Four months later, the Better Access Evaluation report was released. The report included a section on social work services, based on consultations with 458 mental health consumers, which confirmed that social workers were providing high quality and accessible clinical care leading to positive health outcomes (Ftanou et al., 2014; Pirkis, Harris, Hall, & Ftanou, 2011).

The present study

The Australian Association of Social Workers campaign for the reinstatement of social workers to the Better Access to Mental Health Scheme provides an excellent opportunity to explore the factors that enhance or inhibit social workers’ participation in social action and policy advocacy in Australia. The campaign itself is quite extraordinary on several fronts – making it highly suitable for the present analysis. First, it effectively overturned a government decision after it had been made and then announced. This outcome is a rare event in the social policy history of Australia. Second, although Australian social workers are notorious for a lack of collective action (Gillingham, 2007; Mendes, 2005) and demonstrate some ambivalence regarding professional boundaries (Healy, 2009), their exclusion from the BAMH program clearly struck a chord with social workers and the AASW, prompting them to organise in unprecedented numbers and take decisive and sustained political action. The campaign provides a unique opportunity to account for these anomalies and utilise the learning to improve the future performance and participation of social workers in policy development, advocacy and larger scale social change.

Findings

The literature review and the consultations with respondents provided a wealth of information about the background to and details of the AASW campaign, and how this contributed to the success of the campaign.

Strengths and weaknesses of the campaign

The campaign was clearly a success both in terms of outcome and mobilising the Associations member base. A core strength considered central to success highlighted by the sample was the skill and experience of the AASW staff in organising the action. They understood the methods and strategies of effective social action, effectively utilised political processes, and were supported by up-to-date technological infrastructure. This finding in particular aligns with previous research highlighting contextual factors such as building awareness, knowledge and skills that are critical to successful social action (Feather et al., 2012; Gillingham, 2007; Horvath, 1999).

Another factor of success identified in this study was the careful scripting and control of messaging, ensuring that the campaign was perceived as an issue of social justice (meeting the needs of disadvantaged service users) and service accessibility (ensuring that mental health services were targeted to disadvantaged consumers and those living outside the cities), rather than a narrower concern to protect the jobs and livelihood of individual social workers in private practice. This clearly had resonance with policy makers and the general public, but was less popular with some rank and file members.

This strategy seemed to be effective in asserting the legitimacy of social work concerns, and gaining the attention of media and government. In general, the AASW and its members also seemed to effectively use the core social action skills that are taught to all social workers (Haynes & Mickelson, 2003). The campaign was characterised by organised action, the distribution of a core set of ideas and messages, the employment of collaboration and networking skills to facilitate the inclusion of a wide range of practice experiences and case studies from varied locations, and the priority allocation of resources by the AASW to support the campaign. In addition, the campaign achieved a side benefit of serving to educate government and the general public about the core skills and knowledge base of social workers as a distinct discipline in the mental health field (Allen-Kelly, 2010a, 2010c, 2011).

In line with some of the key influences and factors of success highlighted in the literature, the competence and knowledge of lobbying and political process and the utilisation of the social justice mandate of social workers appear to have also been decisive. The Association and its members were able to gain the attention of media and decision makers and provide appropriate levels of education and political pressure to overturn the decision. Capacity building through communication tools, templates and messaging guidelines housed on the Association website and social media channels, further enabled a wider groundswell of members to become involved and active within their own spheres of influence.

Nevertheless, the campaign was not without its challenges. One missed opportunity in the campaign was the limited success in gaining service user involvement or forming extensive collaborative networks (Rocha et al., 2010; Rome et al., 2010). Although the AASW made a proforma letter available for practitioners to share with their clients (AASW National e-bulletin, 12 May 2010c), only a few consumers seem to have contacted MPs or the media directly. This is perhaps not surprising given that mental health consumers may find it stigmatising and stressful to discuss their condition in public. But it also seems to confirm the argument of Rome et al. (2010) that social workers are generally wary of encouraging client political participation.

Another potential flaw that may have undermined the success of the campaign was the sometimes limited communication given to the membership base on the strategies and progress. On closer analysis however, this perception may have been influenced by a considered reduction by the Association in the information shared with the general membership based on confidentiality and prudence. According to the AASW CEO, there was advice that was given by parliamentarians of all political persuasions and some in the bureaucracy that was unable to be provided to the membership given its political in-confidence nature. This meant that there were occasions after the initial decision to defer any changes to the Better Access Program that the campaign at the AASW end moved more quietly. While it created a sense of insecurity in members (and in some cases overlap or restriction of effort) it may have ultimately benefited the campaign and the final outcome.

There also appeared to be mixed motivations and agendas to get involved in the campaign in the first place, which had the potential to undermine the effectiveness of the campaign through mixed messaging. Though most respondents did include some discussion of both personal and professional values systems in their reflections, some placed more emphasis on one or the other. Motivations for taking action included a sense of professional injustice, a social justice concern for disadvantaged clients, and also some personal/professional self-interest. For example, one respondent had previously noted their motivation for taking action was a matter of professional integrity: ‘The decision was experienced as an insult to the profession itself … This action by the government seems to have drawn a deep sense of being misunderstood and mistreated as a profession to the surface’ (Allen-Kelly, 2010a, pp. 247–248).

Other respondents emphasised a sense of broad duty to the profession and its longevity:

 … I do feel very very strongly that if we don’t collectively do (this) social action we are not going to exist in public mental health I can assure you in ten years’ time. (Interview No. 6)

The sample also noted a sense of unfair competition with other professions such as psychologists. This may not have been entirely unfounded. There was no suggestion made by the government that psychologists, who claim the Medicare rebate in far greater numbers than social workers, be excluded from the Better Access Scheme. At present psychologists are also able to claim a higher rebate than social workers (AASW, 2011). However, this prioritising of psychologists’ skills does not seem to be based on any evidence of higher competence.

For this reason, social work claims of differentiation to psychologists on the basis of social work’s commitment to social justice outcomes for poor and disadvantaged groups, was firmly represented in the campaign. A number of social workers interviewed in the media supported the overall social justice platform by emphasising that their private practice clients were low-income and disadvantaged people including deaf or hearing impaired and single parent families who could only afford to access services that offered bulk billing. One worker commented: ‘If you have to choose between putting food on the table for your family, or buying a new pair of shoes, and counselling, you wouldn’t choose counselling’ (Evans, 2010). It is important to note that the many social workers in private practice do not charge above the scheduled fee to allow clients to be totally bulk billed.

While most agreed on the importance of the above premises some private practitioners involved in the campaign seem to have also been driven by a personal concern that their jobs and livelihood were under threat. To be sure, they also held a strong belief that the service they were providing was essential. But it is unusual for such large numbers of social workers to get involved in a public campaign, and there is no doubt that the potential loss of income drove much of this passion. One private practitioner commented:

I can tell you on the year before that alone I had spent sixty thousand dollars on my business. We’re talking about a lot of money here … Some of us were going to lose our houses over this. That’s not right and it’s not fair. (Interview No. 2)

However, the actions of the private practitioners may have reflected a frustration that the existing AASW structure did not properly represent their concerns. One mental health social worker, who works in both private practice and public health, commented:

We felt that because we were in private practice that there was some sort of belief that we were not true social workers so we were a little bit on our own. We always felt they were sort of on the fence about that … There are a lot of insinuations around people in private practice. (Interview No. 5)

Finally, there was also tension between mental health social workers in general and the remaining groups of general AASW members. Although significant numbers of general AASW members participated in the campaign overall, many chose not to become involved. Some appear to have resented the exclusive focus on the mental health group, asking why the AASW was committing so much of its scant resources to one specific field of practice and one small group of members (Focus Group; Hutchinson, 2011).

What is apparent from the above analysis is a rather mixed set of motivations and worker perceptions for getting involved in the campaign in the first place. Members also appeared to have a variable approach to social action. Some respondents were mobilised by the potential injustice to client groups yet all the private practitioners in this sample also emphasised to varying degrees the direct impact of the decision on their chosen career path and livelihood. While these are not trivial concerns, the majority of the public and political messaging of the Association tended to emphasise the macro social justice issues, reinforcing to both the AASW members and the general public that the policy decision would be extremely damaging for vulnerable groups and the maintenance of social justice.

Discussion

The AASW appears to have completed a very effective social action campaign to restore Medicare rebates for accredited mental health social workers. The campaign was successful in educating government and the general public regarding the qualifications, experience and distinct therapeutic skills that social workers bring to mental health services. Organisationally, the campaign reinforced the importance for the AASW of employing high quality professional staff with skills in policy activism who are able to speak promptly and publicly on behalf of the Association. The early development of technology and communication platforms was central to the Association’s success in rallying support and stewarding a strong and unified message for the campaign.

The active role played by many social workers in this campaign was also central but it does contrast with a general apathy and ambivalence examined within the profession for social policy debates and professional recognition. The personal threat to the livelihood of many activists may have played a decisive role in the numbers of members active in this campaign. To be sure, some individual practitioners (and groups) were less likely to construct the issue as one of social justice beyond their personal spheres of influence. However, such arguments were unlikely to be as effective in persuading the government to reconsider and may have potentially undermined the success of the campaign. It appears in this case, it was indeed the ‘facts’ and the social justice platform that proved decisive to success and the ultimate reversal of the original policy position.

This case study suggests that professional associations might increase the efficacy of future lobbying via forming alliances with other key stakeholders and influencers (Horvath, 1999; Payne, 2002) and articulating the implications of policy decisions in terms of social justice and equity outcomes with accompanying case studies. This is a skill in itself and must be reinforced in social work education (Heidman et al., 2011).

Finally, while social work interventions disproportionately assist disadvantaged groups and individuals the collaborative nature of this campaign suggests that narrower professional social work identity and broader social justice advocacy can indeed be reconciled and synthesised to good effect in social action campaigns. Such campaigns would arguably be more effective if social workers can form more active partnerships with service users and promote the notion of a common concern in ways that mobilise the broader client groups and community to action. The reflections from respondents in this study further reflect some common understandings of the role played by values and identity in mobilising social action.

Study limitations and further research

Although our methodology has provided rich data on the AASW campaign, this study had some obvious limitations. First, the sample included only nine social workers in total, all of whom were based in Victoria. While small sample size is a practical limitation to generalisability in most qualitative research, in this study, the sample was both small and homogenous in that it did not include perspectives outside Victoria or include those social workers who were not AASW members. Future research on this campaign would benefit from a wider if not larger sample including social workers from a range of geographical areas both within and outside the Association membership.

Future studies should also include views from general practitioners, occupational therapists and psychologists who chose to join the campaign, in order to assess their motives for becoming involved, and to contrast and compare their agendas with that of the ‘social worker’ activists. Another group worth targeting would be non-mental health social workers (e.g. general members of the AASW and other social workers from other fields of practice) who did not take any action. Equally, surveys of service users would be useful to determine whether social work clinicians informed them of the campaign, and the potential for their participation. There is some evidence to suggest that this is not a mainstream social action strategy of social workers despite its potential efficacy (Rome et al., 2010). Finally, interviews with decision makers in government including the Minister for Health would have been useful for determining the key factor(s) that actually overturned the decision to exclude social workers and contrast that with the findings from the sample.

Conclusion

The BAMH campaign is an exceptional example of effective social work action and advocacy. The campaign itself was remarkable not only because it was one of the few historical examples of the social work profession coming together to lobby and advocate for change, but because of the campaign’s unmitigated success in overturning a high level Government decision already announced and approved as part of the Federal budget.

Understanding the levers of success in this campaign provides an opportunity to contribute to, and develop, best practice social action and advocacy frameworks for social workers. The analysis of this campaign suggests that adoption of a social justice, macro issues approach is pivotal to success. Future analysis of this campaign and others of this nature will be critical to deepening the profession’s understanding of social action efficacy.