The ClearFear Game: Using fun to tackle social anxiety

Connecting with other people is one of the ‘five ways to well-being’. Many people with mental health problems have small social networks and experience difficulties in making positive social connections. This is the main reason why we are exploring in the Connecting People study how health and social care workers can most effectively help people with mental health problems to connect with others.

One of our findings so far is that many people encounter difficulties in making the first step to connect with others because of a fear of social situations, or social anxiety. Of course, many people like me are shy or introverted. I am not ashamed to admit that I prefer solitary pursuits like blogging to parties, but at least I have a choice. If I would like to engage with other people in social situations, I can. I don’t fear being scrutinized by other people. I don’t worry for days about finding the right words to say to people. I don’t actively avoid social situations or suffer panic attacks when I’m in them. But many people do. Many people unreasonably expect others to be evaluating them negatively. Many avoid social situations or find them intolerably stressful. Many people suffer from social anxiety in various degrees of severity.

An American study found that 5% of the general population experience social anxiety disorder (at the severe end of the social anxiety spectrum) at some point in their lives. Although cognitive behavioural therapy can help, over 80% don’t receive any help. For many, it simply goes undetected. For others, the stigma of asking for help prevents them from doing so. However, we believe that it needs to be openly tackled to enable people to make social connections which can help them to get on with their lives. And we aim to do this using fun.

The Connecting People study team are teaming up with Kingston Recovery Initiative Social Enterprise (RISE) and Playmakers Industries to create the ClearFear Game. Last week, the RSA Catalyst fund – which provides small grants to RSA Fellows to develop innovative solutions to solve social problems – announced an award of £2,000 to help us to design and pilot the game.

The ClearFear Game will be a non-virtual game which will immerse people in social interactions which they would be otherwise fearful to engage in. Using the principle of ‘flow’ from positive psychology and gaming theory, the game will use fun as the active mechanism in relieving fearful situations.

The ClearFear Game will be developed by the Connecting People study team, members of Kingston RISE, Playmakers Industries, RSA Fellows and other experts during a ‘game camp’ on 6th-7th March in London. I’m not really sure what this involves, but judging by the YouTube videos, it looks like a lot of fun! We are actively involving people who experience, or have experienced, social anxiety during these two days to ensure that the game will be playable and fit for purpose.

Once it is designed, we will invite colleagues in Kingston RISE to pilot the ClearFear Game with people experiencing social anxiety to see if it helps at all. We will evaluate their progress before recommending it is used more widely. If the findings of the pilot are promising, we will aim to conduct further experimental evaluations of the outcomes of playing the game.

The development of the ClearFear Game and the results of the evaluation will be published online. The game itself will be made available using a Creative Commons licence. I’ll keep you updated on our progress on this blog and on the Connecting People study website. In the meantime, have fun!

  

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Social work doctorates: let’s share the knowledge

I am passionate about integrating research into practice in social work.

Research has the potential to transform social work practice if it is robust and relevant. It can help practitioners to be more effective; it can provide new knowledge to enrich social work practice; and it could suggest which interventions are most likely to lead to the best outcomes in different contexts.

But, as we know, research is not always disseminated very effectively. For example, I often hear complaints from community mental health teams that researchers come in, interview practitioners or service users, and leave without ever being seen again. This isn’t acceptable. Findings of studies should always be fed back to participants, however mundane or revolutionary they might be.

The transformation of social work practice by research is also hindered by practitioners having insufficient opportunities to either undertake research or read journals in which it is published. It is not part of our professional culture to set aside a bit of time each week for continuing professional development (CPD) or to undertake practice-based research (as it is in medicine, for example). The CPD requirements of registration with the General Social Care Council has provided a little time for this, but it is still not enough.

Some practitioners are able to undertake research as part of a post-qualifying programme, like our MSc Mental Health Social Work with Children & Adults. Many undertake interesting studies – like Janine Hudson’s national AMHP survey – and others are successful in getting their studies published. But few local authorities sponsor students on advanced level post-qualifying programmes leaving most practitioners to self-fund. 

Some practitioners undertake professional doctorates or PhDs to gain research training, but these are often self-funded. Without employer buy-in into higher degrees (either Masters or Doctorates), it is less likely that research findings are disseminated back into practice. The research becomes an adventure for the individual concerned, but it has limited impact on practice because of its disconnection with the world of social work.

The College of Social Work is planning a Community of Interest for workforce development and research. One way we can help to improve the dissemination of social work doctoral research – and to help maximise its impact on practice – is to make it available to practitioners in this forum.

As a starting point Jane Shears (jane@changingmindsenterprisecic.co.uk) has offered to collate abstracts of social work doctoral research and compile a narrative. Therefore, if you are a social worker, have a doctorate and are interested in sharing its findings, please email Jane your PhD or professional doctorate thesis abstract and any publications which may have been come from your research. She would be most grateful if you could do this by 5th March 2012.

I’ve just sent her mine. If you are interested in reading my PhD thesis, here is the full version. For the potted version, here is the abstract:

Access to social capital and the course of depression: A prospective study

Depression is a significant clinical problem. Social factors such as poverty and unemployment, interpersonal difficulties, poor housing conditions and the absence of positive events are related to lower rates of recovery. Social capital, defined as resources embedded in social networks, may also be related to recovery. However, social capital research methodologies are in their infancy and little evidence of positive associations currently exists. This study extends our knowledge by validating a measure of individual social capital and testing the hypothesis that people with depression with access to more social capital will improve more over six months than those with less.

Focus groups, an expert panel and a series of field tests validated the Resource Generator-UK for use in the UK general population. This instrument is a measure of access to network resources across multiple domains. Item reduction and scaling using item response theory and standard psychometric testing demonstrated the instrument to be valid and reliable for the UK.

A prevalent cohort of people with depression was recruited from primary care (n=173) and followed up for 6 months (follow-up rate = 91.3%). Depression was measured using the Hospital Anxiety and Depression (HAD) scale alongside a large number of potential covariates. Multivariate analysis of covariance found that a univariate association between improvement in HAD scores and access to expert advice became non-significant. Baseline HAD scores, emotional support and level of education were predictors of change in depression scores in the multivariate model. When change in subjective quality of life was used as the outcome, a different model emerged in which an interaction of access to social capital and attachment style was significantly related to change in quality of life alongside multiple covariates. Results are discussed in the light of existing findings and recommendations are made for clinical practice and further research.

 My PhD was a small piece of social epidemiology – that is, it investigated the effect of social factors on the course of a health problem (depression). The measure of social capital that I developed in the study has been subsequently used in a number of studies including the evaluation of Time to Change phase two; the evaluation of the Capital Volunteering scheme; and the validation of a measure of social inclusion. The findings of my PhD have been used to inform the Connecting People Study, which is developing an intervention for social workers and social care workers to help people connect more effectively with the community in which they live.

If you have a social work doctorate, please share your knowledge today!

Good practice in personalised care in mental health services

Personalisation has become a defining feature of adult social care services. Direct payments and personal budgets are set to become default methods of funding local authority care as they are believed to provide service users with enhanced choice and control over the services they use. This agenda has widespread support from organisations commissioning or providing social care services in the UK.

So far, the personalisation agenda has had minimal impact on mental health services. A number of barriers exist to the full implementation of personalisation in mental health services including organisational cultures being unable to respond to new ways of working; concern about the management of risk which may constrain risk-taking in the context of increased choice and control over care; difficulties in disentangling ‘social care’ and ‘health’ needs to justify funding; or bureaucratic obstacles to setting up personal budgets or direct payments. Although all local authorities have met the performance target of having 30% of social care service users in receipt of a personal budget by April 2011, notional personal budgets have been used in some cases (particularly for mental health service users). This raises questions about the extent to which meaningful choice and control is being provided within the nomenclature of a personalised service. 

In 2010 we set up a research group which brought together leading researchers, service users and carers to develop research proposals to investigate some of these issues. The group was successful with a bid for an NIHR Programme Development Grant on personalised care in mental health. This grant provides funding for a one-year project to investigate the feasibility of conducting a programme of studies to evaluate the effectiveness and cost-effectiveness of personalised care in mental health services. The first step of this is to identify places where personalisation is working well in mental health services.

We are keen to hear from you if you know of examples of personal budgets being used innovatively to meet the social needs or aspirations of people with mental health problems. We are interested to learn about practitioners empowering people to have genuine choice and control over their care and support in mental health services. We would like to know where the bureaucracy around personal budgets has been streamlined to facilitate the process. We also would like to hear about mental health services which have fully taken on board the principles of personalised care. In short, if you are a user of services, carer, practitioner, manager, commissioner or otherwise know of good practice in personalised care in mental health services, we would like to hear from you. 

If you have some good practice which you are willing to share with us, please email linda.parker@kcl.ac.uk with the following information:

  • Your name
  • Your daytime telephone number
  • Your email address
  • The name of local authority / NHS mental health trust concerned
  • A few sentences about the example of good practice you wish to share

 A researcher will be in touch with you sometime during March or April to gather further information. The research team will then collate all this information to develop a ‘gold standard’ exemplar of personalised care in mental health services. We will share examples of good practice on a new website (with the permission of the local authorities or mental health trusts involved). The exemplar we develop will then form the basis of the second phase of the feasibility study. This will explore whether NHS mental health trusts can genuinely achieve personalised care and whether or not we can evaluate its outcomes.

 Any contribution to our search for good practice will be most welcome. Thank you!

Social workers need to define their practice

Published by The Guardian Social Care Network on 30th January 2012:

If I was an undergraduate social work student writing an essay on what mental health social work is, I might cynically answer: “It’s what you’re told to do”. To date, we have been too reliant on others – employers, policy makers and health services – to define our practice.

At a time when the prime minister is talking about integrating health and social care, the opposite is happening in NHS mental health services. Social workers are increasingly being pulled out of integrated mental health services by their local authority employers to concentrate on policy priorities such as safeguarding vulnerable adults and setting up personal budgets.

There is nothing new in these developments. If you explore the history of mental health social work in the UK, it has largely been shaped by policy or statute. For example, mental health social workers have been defined by their role in assessing people for compulsory detention, until 2007 when this role was opened up to other mental health professionals under a reform of the Mental Health Act.

Mental health services are now being increasingly shaped by the National Institute for Health and Clinical Excellence (NICE) clinical guidelines, which recommend interventions with randomised controlled trial evidence of their effectiveness. This approach to policy makes sense, but has led to evidence-biased practice with more easily-measurable medical and psychological interventions taking provenance over ‘messy’ and complex social interventions.

Our difficulty as a profession to define our identity and role has had a profound impact on my career in social work. As a practitioner I saw how psychiatrists and psychologists in the community mental health team I worked in had a clear professional identity and could justify their practice on the basis of evidence for its effectiveness.

Social workers, however, typically work with the most complex cases where either medical or psychological interventions don’t tend to work, or social factors such as poverty, poor housing or ineffective social networks are predominant. The effect of evidence-biased practice in mental health services is that social workers are increasingly being appointed on their ability to deliver psychological interventions rather than their ability to solve social problems.

Almost 10 years ago I left frontline practice to help to develop evidence about the effectiveness of social work and social care interventions. I see this work as important in helping us to define our own future. However, if we want to be able to articulate and evaluate our interventions in a way which would be recognised by NICE guidelines, this means undertaking randomised controlled trials of social interventions.

Many social workers baulk at this idea, but we should again look at our history. Although by no means commonplace, trials of social work interventions did take place in the UK in the 1960s and 1970s.

My journey from practice into academia has brought me to a point where I’m about to pilot a social intervention which, pending positive evaluations and success with future funding bids, may lead to perhaps the first social work-led randomised controlled in mental health services for many years.

The Connecting People Study (funded by the National Institute for Health Research School for Social Care Research) is developing and articulating an intervention model for workers to help people to improve their social connections. Based on principles of co-production and social capital theory, the model emphasises a shared focus for a worker and an individual on the goal of engaging beyond mental health services.

We will be piloting the intervention model and associated training in twelve agencies in England and evaluating both its effectiveness and cost-effectiveness. Although results will not be available until 2014, you can keep up to date with the study on its the website or here on my blog.

If I was to take a less cynical approach to the question ‘what is mental heath social work?’, I could say that it is the only profession working in NHS mental health services which holds social justice as a core value. I see my contribution to the profession as developing and evaluating interventions aimed at reducing social inequalities in mental health.

Systematising practice in this way may be an uncomfortable culture shift for social work, but it may be necessary in order to demonstrate the effectiveness of our practice. Championed by The College of Social Work, we perhaps now have a unique opportunity to shape our own professional identity and role.

Approved Mental Health Professional Survey update

We have received an excellent response to the national Approved Mental Health Professional (AMHP) survey in the first month of its administration. Almost 350 AMHPs have completed the survey so far.

The 2012 national AMHP survey is evaluating whether levels of stress and burnout have changed for this group of professionals in the last decade. Also, as it is the first national survey since the widening of the statutory role to other mental health professionals, it will allow us to compare levels of stress and burnout between social work and non-social work AMHPs for the first time.

To enable the survey to provide important data to inform AMHP policy and practice nationally we need a high response from AMHPs across England. We have had a great start, but there is still a long way to go. In particular, we would like to hear from more non-social work AMHPs as all but 17 respondents are social workers so far. Therefore, if you know a non-social work AMHP, please ask them to take the survey (please see link at the bottom of this post).

The survey is being promoted via social media and AMHP leads across the country. We are very grateful to the support of everyone who have helped to spread the word about it. Particularly, we are grateful for the following sites who have  posted information about the study:

Community Care news

Community Care blogs

Masked AMHP

The not so big society

The Care Guy

Care Training

We still need your help to achieve a high response over the next two months. There are a number of ways in which you can help to promote the survey:

1) If you are an Approved Mental Health Professional working in England, please take the survey if you have not done so already. The link is below.

2) If you know an Approved Mental Health Professional working in England, please email them the link to the survey.

3) If you don’t know any Approved Mental Health Professionals working in England but want to help distribute the survey, please use social media tools such as twitter, facebook, linkedIn, blogs or whatever you use to connect with other people, to send the link around.

The online survey takes only 10-15 minutes to complete and an information sheet containing further details about the study is displayed on the first page. If you would like to read more about and/or complete the survey please click on the link below:

https://www.surveymonkey.com/s/stressandthestatutoryrole

This study is being led by Janine Hudson, an experienced AMHP studying the MSc Mental Health Social Work with Children & Adults programme at the Institute of Psychiatry. The survey questionnaire has been pre-tested by AMHPs and other social workers. The survey will remain open until the end of March 2012.

Thank you in advance for your time and support.

Ruby Wax and co-production

Today I had the pleasure of meeting Ruby Wax, probably the best campaigner for the elimination of stigma against mental health problems. Although I am a critic of the cult of celebrity, when it is used as a force for good I am suitably impressed.

Ruby was the guest speaker at a Hestia seminar on co-production. She used some of the material from her ‘Losing it’ tour to promote her latest initiative. In February she is launching a new website – blackdogtribe.com – to create a ‘tribe’ to challenge mental health discrimination. Learning from gay pride, Ruby has a vision of people with mental health problems coming out loud and proud about their experiences. It will culminate in a momentous celebration on World Mental Health Day in October 2012.

Ruby is using her celebrity to empower people to find the confidence to talk about their experiences and share it with others. Like most social networking sites, blackdogtribe.com will build social capital and should be a force for tremendous good.

It is rather difficult to follow a performer such as Ruby Wax, but that is exactly what seminar organiser Elvis Langley asked me and others to do. I was a member of a panel to take questions from seminar participants and discuss some of the issues arising from the day. I was in esteemed company, sharing the platform with Peter Beresford, Mike Seal, Stephanie Royston-Mitchell, Mimi Nunez Trejos and Anthea Sully.

I felt ambivalent about joining a panel such as this as it implied I had answers to delegates’ questions. I mentioned this quandary when I introduced myself and instead posed a question to the floor. How do we break down professional barriers to achieve true co-production in services at both a macro and micro level? I don’t know the answer to this, but I think it requires changing people and challenging worldviews. Easier written in a blog post than achieved in reality…

I had in mind the intervention model we are developing on the Connecting People study when I talked about ‘micro co-production’ during the session this afternoon. This refers to workers and individuals co-designing interventions and its outcomes to achieve user-defined goals. In reality, this means workers sitting alongside individuals and exploring their assets – what they are good at or passionate about. They then use their assets to achieve goals the individual sets for him or herself. It is only after we developed the intervention model that I realised it embodied co-production principles. It has social capital at its heart, as well as one of its anticipated outcomes.

One questioner challenged the panel to name four co-production values (to help distinguish the concept from others such as ‘user involvement’). I suggested that it embodies equality, genuine partnership, empowerment (of both worker and individual) and adds value to existing services. The man who posed the question noted that we did not mention reciprocity. I kicked myself under the table for not being clever enough to come up with this myself.I should have mentioned this because reciprocal relationships are at the heart of co-production, right as they are at the heart of the Connecting People intervention model.

I left the seminar invigorated. I had met a celebrity who is genuinely doing good; I had met up with some great people from Hestia I know through the Connecting People study; I had met the commissioner of Kingston RISE as well as its director; I had met people I didn’t expect to see there; and Elvis, the seminar organiser, had told me that the idea for the day came from a conversation I had had with him ages ago (flattery goes a long way…). Perhaps most importantly, I came away with two more potential research projects to engage in. If only there were more hours in the day…

Social workers’ learning about empirical research methods: a problem of pedagogy or epistemology?

In common with other social science disciplines, the debate about what constitutes knowledge in social work is located in the wider divisions between positivist and constructivist perspectives about the nature of social reality [1]. The former finds expression in the evidence-based practice movement which argues that social work interventions should be based on the best available evidence derived through empirical research. In contrast, constructivists challenge notions of the objectivity of knowledge, arguing that it is socially constructed.

Social workers draw upon knowledge derived from a range of perspectives to become effective practitioners. Mental health social workers, for example, who work alongside psychiatrists and psychologists whose practice is largely defined by evidence derived from randomised controlled trials about the effectiveness of interventions, need to be able to articulate their own evidence base to justify their role in mental health services [2]. However, technical knowledge alone is insufficient for the complexity of social work practice, which frequently draws upon unconscious tacit knowledge which practitioners create themselves [3].

Advanced post-qualifying education in social work draws upon a range of epistemological traditions to assist the professional development of advanced practitioners. For example, it both supports practitioners to articulate their tacit knowledge and enables them to contribute to the profession’s evidence base through original empirical research [4]. However, our experience on the MSc Mental Health Social Work with Children & Adults at the Institute of Psychiatry is that practitioners frequently find learning about empirical research methods to be the most challenging aspect of the programme.

Social workers are more likely to have backgrounds in the humanities rather than the sciences, making them less familiar with empirical research methods at the beginning of their social work training. When they are included in social work curricula, empirical research methods are taught alongside other methods, such as participatory research, reflecting the discipline’s diverse epistemological paradigms [5]. It even appears that teaching empirical research methods to social work students has been a long-standing pedagogical challenge for many educators [6]. The result has been that social workers gain only a limited understanding of empirical research methods through their qualifying education and early post-qualifying training, which inhibits their ability to read, appraise and implement research in their practice [7, 8].

Our previous research with experienced social workers suggests that the quality of their learning is influenced more by their prior knowledge of empirical research methods than by the teaching modality used to deliver it [9], reflecting Ausubel’s [10] theory of assimilative learning. Understanding students’ prior knowledge structures through concept mapping can assist educators to more effectively engage with their students’ learning [11]. Concept mapping methodologies also permit students and educators to share knowledge structures and to make explicit any variances in their epistemological perspectives, which may act as barriers to both learning and teaching.

An effective empirical research methods module will equip students with the skills to appraise empirical research and integrate relevant findings into their social work practice. However, a higher order learning outcome would be that practitioners adopt empiricism as a practice paradigm. Popper [12] maintained that the mission of science is to disprove hypotheses. Translated to social work practice, this requires practitioners to be aware of evidence that runs counter to the theoretical assumptions on which they are basing their decisions and actions [13]. A study of social workers found that they tended to use confirmatory search strategies when finding information about cases, but when they were asked to justify their use of information they adopted less biased strategies and were more open to contradictory information [14]. This suggests that practitioners can use deductive as well as inductive methods of acquiring information to inform their practice. This higher order learning outcome could be achieved through a constructive alignment [15] of module learning and teaching with an assessment of students’ ability to use empirical methods in their day to day social work practice.

An understanding of how experienced practitioners learn (many of whom have been out of formal education for a number of years) may help to inform the pedagogy of empirical research methods modules. Further, integrating new knowledge with what practitioners bring to the classroom may help to avoid students adopting surface learning strategies, which can result in ‘non-learning’ [16]. Notwithstanding the irony of using constructivist methods to inform the learning and teaching of empirical research methods, there are undoubtedly many pedagogical and epistemological challenges facing social work educators who aim to enhance the quality of learning of empirical research methods for experienced social workers.

References

1. Pease, B., Challenging the dominant paradigm: social work research, social justic and social change, in The SAGE Handbook of Social Work Research, I. Shaw, et al., Editors. 2010, SAGE: London. p. 98-112.
2. Nathan, J. and M. Webber, Mental health social work and the bureau-medicalisation of mental health care: Identity in a changing world. Journal of Social Work Practice, 2010. 24(1): p. 15-28.
3. Schon, D., The Reflective Practitioner: How Practitioners Think in Action. 1983, New York: Basic Books.
4. Nathan, J., The making of the advanced practitioner in social work, in Reflective Practice in Mental Health: Advanced Psychosocial Practice with Children, Adolescents and Adults, M. Webber and J. Nathan, Editors. 2010, Jessica Kingsley: London. p. 29-45.
5. Shaw, I., et al., eds. The SAGE Handbook of Social Work Research. 2010, Sage: London.
6. Epstein, I., Pedagogy of the perturbed: Teaching research to the reluctants. Journal of Teaching in Social Work, 1987. 1(1): p. 71-89.
7. Morago, P., Dissemination and implementation of evidence-based practice in the social services: A UK survey. Journal of Evidence-Based Social Work, 2010. 7(5): p. 452-465.
8. Pope, N.D., et al., Evidence-based practice knowledge and utilization among social workers. Journal of Evidence-Based Social Work, 2011. 8(4): p. 349-368.
9. Webber, M., et al., Social workers can e-learn: evaluation of a pilot post-qualifying e-learning course in research methods and critical appraisal skills for social workers. Social Work Education, 2010. 29(1): p. 48-66.
10. Ausubel, D., The Psychology of Meaningful Verbal Learning. 1963, New York: Grune & Stratton.
11. Novak, J.D., Learning, Creating and Using Knowledge: Concept Maps as Facilitative Tools in Schools and Corporations. 1998, Hillsdale, NJ: Lawrence Erlbaum.
12. Popper, K., The Logic of Scientific Discovery. 1959, London: Hutchison.
13. Munro, E., The role of theory in social work research: A further contribution to the debate. Journal of Social Work Education, 2002. 38(3): p. 461-470.
14. Osmo, R. and A. Rosen, Social workers’ strategies for treatment hypothesis testing. Social Work Research, 2002. 26(1): p. 9-18.
15. Biggs, J. and C. Tang, Teaching for Quality Learning at University: What the Student Does. 3rd ed. 2007, Buckingham: Open University Press/McGraw Hill.
16. Kinchin, I.M., S. Lygo-Baker, and D.B. Hay, Universities as centres of non-learning. Studies in Higher Education, 2008. 33(1): p. 89-103.