RCI or NCAHCP? Dilemmas About the Recognition of Psychiatric Social Work Professionals

Abstract

The training of Psychiatric Social Workers (PSW) started at All India Institute of Mental Health, Bangalore, present-day National Institute of Mental Health and Neuro Sciences (NIMHANS), in the year 1967 under the Department of Psychiatry as a two-year postgraduate diploma course in psychiatric social work. 1 After an independent department of psychiatric social work came into existence, the same course was converted to MPhil in psychiatric social work in 1978. Around the same time, the diploma course in psychiatric social work course was started at the Central Institute of Psychiatry, Ranchi, 2 in 1970, which was upgraded to MPhil in psychiatric social work (MPSW) in 1985. The Indian society of psychiatric social work (later renamed Indian society of professional social work) and the Indian Journal of Psychiatric Social Work were established at the Central Institute of Psychiatry, Ranchi. 2 Currently, MPSW is offered at 22 institutes (Table S1) under various government and private institutes across the country. Training in Psychiatric Social Work MPSW is a two-year course that involves intensive training in the areas of clinical skills and research in the field of psychiatric social work. Clinical training mandatorily includes placements to psychiatric units pertaining to adults, children, families, addiction medicine, community mental health and neurology, neurosurgery, geriatric medicine, behavior therapy, and psychiatric rehabilitation units. 3, 4, 5, 6 The exposure involves training in psychiatric and psychosocial assessments, counseling, and therapeutic interventions with patients and families under the supervision 7 of consultants from psychiatric social work, psychiatry, and clinical psychology. In this clinical training of the two-year MPSW course, trainees get hands-on experience working with persons with mental illness. This equips them with skills to undertake psychosocial interventions at individual, family, and community levels. In addition to assessments and interventions at the tertiary level, the MPSW course also emphasizes training to build the capacity of social workers 7, 8 at the secondary and primary levels. The capacity building 7, 8 extends to the grass-root level workers also. At the academic level, the trainees are also provided with theoretical inputs. In the two years, they have six theory papers encompassing mental health-related topics on assessment and interventions, apart from the case record/therapy report submissions and dissertation. 3, 4, 5, 6 The trainees are expected to participate in and make weekly academic presentations on relevant topics. This combination of teaching methodologies sharpens their academic and clinical skills. Broader Roles and Functions of PSWs in the Field of Mental Health PSWs play an important role in the multidisciplinary team of a mental health care institute and have multiple roles and functions. Clinical Services 9 Mental health and psychosocial assessment Individual psychotherapy/casework Family therapy/intervention Group therapy/work Referrals Home/agency visits Psychosocial rehabilitation Community Services 10, 11, 12, 13 Coordination for the reintegration of patient with family/discharge of patient Liaison and networking with social organizations, the judicial system, and the police department Referral for various social services Organize and coordinate community camps, extension/outreach services, etc. Organize and coordinate rehabilitation and aftercare activities, ensuring continuity of care Undertake awareness-related activities in mental health Conduct preventive and promotional activities through schools and youth/women’s groups in the community Capacity Building Programs on Prevention of Mental Disorders and Promotion of Mental Health Across the country, PSWs organize workshops/capacity building training programs 14, 15, 16, 17 on various mental health dimensions that include life skills education, stress management, student enrichment programs, family life education, family and marital enrichment programs, parent training programs, premarital counselling programs, as well as early identification, and treatment programs. Research activities 18, 19 for improving the quality of services and training and introducing culturally relevant preventive and promotive activities are also undertaken. PSWs are also involved in the training 3, 19 of lay volunteers, integrated child development scheme personnel, community nurses, Accredited Social Health Activist workers, traditional healers, National Cadet Corp/National Service Scheme volunteers, members of Panchayat Raj institutions, etc., on topics related to mental health services and rehabilitation pertaining to children, adolescents, adults, and vulnerable population such as women, disabled persons, and older adults. Recent Developments in the Field of Psychiatric Social Work in Mental Health The past decade has seen substantial growth in the number of institutions offering MPSW courses, from just five institutions in 2009 to 22 institutions. This reiterates the growing need for increased training opportunities to build a cadre of service providers to meet the gap in mental health services. So far, approximately 1500 personnel have been trained as PSW. 20 The Mental Healthcare Act, 2017 21 (MHCA, 2017) has given due recognition to MPSW course and PSWs in Chapter 1, Section 2 (x) by defining “Psychiatric Social Worker” as “a person having a post-graduate degree in Social Work and a Master of Philosophy (MPhil) in Psychiatric Social Work obtained after completion of a full-time course of two years which includes supervised clinical training from any University recognized by the University Grants Commission established under the University Grants Commission Act, 1956 or such recognized qualifications, as may be prescribed.” The MHCA, 2017 21 also recognizes PSWs as Mental Health professionals (MHPs) in Chapter 2, Section 2(r), stating that “MHPs’ include a professional registered with the concerned State Authority under Section 55 of the Act. Section 55 (l) of the Act says The State Authority shall (d) register clinical psychologists, mental health nurses, and PSWs in the state to work as MHPs, and publish the list of such registered MHPs in such manner as may be specified by regulations by the state authority. States like Kerala, 22 Tamil Nadu, 23 and Karnataka 24 have created the registry of MHPs, and many other states have begun the process. National Commission for Allied and Health Care Professionals (NCAHCP) Act 2021 In order to regulate and standardize the health care professions in India, NCAHCP Act 2021 25 was passed by Rajya Sabha and Lok Sabha on March 16 and March 24, 2021, respectively. This Act was published in the Gazette of India and came into force on March 28, 2021, after receiving the assent of the President of India. As per the Act, the commission constituted by the government will create professional councils for the ten recognized categories, and PSWs shall come under the Council titled “Community Care, Behavioral Health Sciences and other Professionals.” This Council will have the represe ntation of 14 allied health or health care professionals, including clinical and medical social workers. Initially, PSWs were not included under the NCAHCP Act. 25 It was under the recommendations of associations of social work professionals (who do not cater to PSWs only) that PSWs were later included under its purview. To the best of our knowledge, neither psychiatric social work professionals nor the institutions running the MPSW course were consulted while making this decision. Besides, the Association of Psychiatric Social Work Professionals (APSWP), the only national association in India exclusively for PSWs as defined in MHCA 2017, organized eight online consultation meetings with Heads and In-charges of various institutes offering MPSW courses. Twenty out of the 22 institutes that participated in these meetings favored the psychiatric social work profession being regulated under the Rehabilitation Council of India (RCI). The decision was intimated to RCI by the respective institutes and by APSWP, with supporting letters, following which PSWs were rightly included in the “Proposal for Amendment in Rehabilitation Council of India (RCI) Act 1992” document uploaded on the website of the Department of Empowerment of Persons with Disabilities (Divyangjan), Ministry of Social Justice and Empowerment, Government of India. 26 It is understood that later, because of the intervention of the Allied Health Division of Ministry of Health and Family Welfare, Government of India, through an official memorandum, 27 stating the inclusion of PSWs in the draft bill of NCAHP Act, 25 this decision was put on hold. Why Should PSWs Come Under RCI? MHCA, 2017 21 recognizes and provides a legal sanction to psychiatrists, clinical psychologists, PSWs, and psychiatric nurses to be called “mental health professionals.” Psychiatrists, clinical psychologists, and psychiatric nurses have as their regulatory bodies the Medical Council of India, Rehabilitation Council of India, and Nursing Council of India, respectively. Currently, PSWs do not come under any regulatory body at the national level. Placing PSWs under RCI will help bring uniform curriculum, syllabus, teaching and training methodologies, and other academic requirements across the country. This will ensure minimum expected quality among the psychiatric social work professionals as the number of institutes offering the course increases every year. The RCI has been the only approved autonomous government body that certifies training in the field of disability and related disciplines and regulates practice in the field of disability and rehabilitation. The MA Social Work in Disability Studies and Action program offered by the Tata Institute of Social Sciences, Mumbai, is recognized by the RCI; social workers graduating from this course are not trained MHPs as recognized by the MHCA. Explicit recognition of MHPs besides Clinical Psychologists by the RCI is still pending. PSWs do not have an affiliation with RCI; they are not certified and therefore have been disadvantaged in their practice in clinical and nonclinical settings. Psychiatric Social Work education should come under the ambit of RCI because it is very similar in structure and objective to the RCI-approved MPhil in a clinical psychology course. Like the MPhil in clinical psychology, MPhil in PSW is a two-year clinical-based full-time course completed under strict consultant supervision that focuses on psychosocial interventions. PSWs, like clinical psychologists, are defined as mental health professionals in MHCA 2017. PSWs also provide service to persons with mental illness who are recognized under the Rights of Persons with Disabilities (RPWD) Act 2016 28 as “people with disability.” MPSW is a super-specialty course. PSW’s training involves psychosocial assessments, diagnosis, and interventions for persons with mental illness and their families. Trainees have to undertake clinical work supervision for approximately 4256 hours in a clinical setting (psychiatric hospital/psychiatry departments). Similar to clinical psychologists, an entry-level qualification is a Masters’ Degree in the respective discipline (social work). The current course structure and syllabus (three theory papers each in the first and second year) are also like that of the clinical psychologists. The roles and functions of PSWs include working with persons with psychosocial and neurological disabilities toward prevention/promotion activities, assessment, diagnosis, treatment, and psychosocial rehabilitation of persons with mental illnesses. MPSW training makes them well qualified to work in various settings like psychiatric or mental health centers, District Mental Health Program, child and adolescent mental health centers, rehabilitation centers, institutions for persons with developmental disabilities, family therapy centers, and nongovernmental organizations (NGOs) working in the mental health sectors, to name a few. The training also equips PSWs to practice psychosocial interventions and therapies independently. With the training on individual, group, family, and community-level interventions, PSWs will be able to contribute to quality services envisaged by RCI and under the RPWD Act, 2016. 28 The RPWD Act, 2016 28 mentions the provision of social security measures (disability pension, financial assistance, insurance, etc.), undertaking community-based approved surveys, investigations and research on disability, conducting awareness programs, developing programs for NGOs, skill development and employment initiatives, incentives to private sector employers, provision of legal aid, and so on. The human resource development for such activities is implemented through the RCI/Social Justice Departments. As mental health professionals, PSWs are involved in the rehabilitation process of persons with mental illness, encompassing all the above provisions. If RCI recognizes the psychiatric social work profession, the rehabilitation interventions by PSWs also would be recognized as per the RCI Act 1992/2000, 29 which allows anyone to practice as a “rehabilitation professional” with its registration only. Also, lack of registration prevents PSWs from holding office as rehabilitation professionals, authenticating any disability-related certificate, and giving evidence in any court despite being a recognized mental health professional under MHCA, 2017. 21 Section 2(j) of NCAHP Act 2021 25 says “health care professional” includes a scientist, therapist, or other professionals who study, advises, researches, supervises, or provides preventive, curative, rehabilitative, therapeutic, or promotional health services and who has obtained any qualification of degree under this Act, the duration of which shall not be less than 3600 hours, spread over 3 years to 6 years, and divided into specific semesters. The minimum required qualification for PSWs as per the MHCA, 2017 21 is two years MPhil degree. The hours of training are well within what is prescribed in NCAHP Act 2021, 25 but the course duration is less than what is needed to be recognized as a “health care professional.” RCI, hence, is the option for PSWs as it does not specify the duration of the professional course. What is the Way Out? To ensure that the gaps in mental health care in India are met and the practice by PSWs is sustained and protected, it is critical for PSWs to be recognized by an approved authority to practice therapy and rehabilitation. Further, in today’s context, the absence of such certification or recognition puts private PSW practitioners and therapists at a disadvantage, especially in medicolegal situations or court cases. Not having the certification or recognition limits the scope of PSWs and has the potential to reduce the already low mental health professional and mental health service user ratio. At present, the duration of the MPSW course in India does not meet the criteria for “health care professional” as stipulated by the Commission. 25 The Commission, 25 which is of a recent origin, with its emphasis on the course duration, is not aligned with the current MPSW course offered by the existing institutes. This strips the profession of its status and scope. The MPSW course and training in its current form is a good fit for the RCI’s training stipulations. Hence, aligning with the RCI would give PSWs the recognition and the required approvals for practice in clinical, nonclinical, and rehabilitation settings. The authors, who are also the office bearers and members of APSWP, strongly feel that RCI should consider the inclusion of the MPSW course and the trained professionals under the RCI as per Section 11 (2) of the RCI Act, 1992. 29 The formation of Commission and Councils under the NCAHP Act 2021 25 is in a preliminary state. It is understood that an amendment in the schedule under NCAHCP Act 2021 25 is possible under clause 70 (1), subject to an assurance from RCI to accommodate PSWs under its purview. There is a way out of this situation if the two ministries, namely, the Ministry of Health and Family Welfare and the Ministry of Social Justice and Empowerment, cooperate and collaborate and engage with the other stakeholders like the associations and training institutes to reach a collective decision on this matter. This would be in the best interest of the psychiatric social work profession and that of the persons with mental illness. APSWP and the representatives of the 20 institutes are seeking RCI regulations and registration for PSWs and call for the support of our fellow mental health colleagues—psychiatrists, clinical psychologists, and mental health nurses to make this possible.