“ We barely survived ” : Social work students ’ mental health vulnerabilities and implications for educators , universities and the workforce

INTRODUCTION: Evidence is mounting that poverty and psychological stress among university students are common and the mental health of university students is a topic of increasing attention. METHODS: In late 2015, 2,320 social work students from 29 Australian universities completed an online survey on the impact of low income on students’ daily lives and study success. FINDINGS: Overall, students revealed financial hardships and a precarious balancing act of study, limited finances, paid work and family. Some students revealed the impact of these hardships on their mental health and wellbeing. Undertaking compulsory field placement increased students’ financial stresses and exacerbated mental health vulnerabilities. CONCLUSIONS: The qualitative findings reported here draw on students’ responses within the larger student survey data set where mental health impacts were reported. These findings have implications for universities, social work education, field


Susan Gair 1 and Len Baglow 2
A social inclusion agenda, widened access to university and a growing market economy in higher education have led to increased diversity in contemporary university cohorts.Students from a range of backgrounds, with different abilities and needs are advancing their skills to meet labour market demands and career opportunities through tertiary studies, including in social work.
Australian universities have well established student welfare services, and it often may be assumed that students from diverse backgrounds can make the required academic transitions to degree completion and aspired social mobility (Gofen, 2007;Haveman & Smeeding, 2006).However, government income support for tertiary students is decreasing, and this may contribute to significant financial and study stresses for students (Bexley, Daroesman, Arkoudis, & James, 2013;Landstedt, Coffey, Wyn, Cuervo, & Woodman, 2017;Storrie, Ahern, & Tuckett, 2010).It has been identified that juggling study, paid work and family commitments can put students at risk of mental health stresses  (Agllias, Howard, Cliff, Dodds, & Field, 2016).Paradoxically, the individualised nature of mental health stigma may deter students from seeking help during their studies (Gulliver, Griffiths, & Christensen, 2010;Newcomb, Burton, & Edwards, 2017;Stallman, 2010).A recently released report identified clear deficits in current knowledge about Australian tertiary students' mental health (Orygen, 2017).
Working-class, first-generation, Indigenous and mature-aged students, students with a range of disabilities, and those with family responsibilities collectively comprise a growing proportion of higher education enrolments in Australia (Devlin & McKay, 2017;Haveman & Smeeding, 2006;Martin, 2009).These students may already be under financial and social stresses in many aspects of their lives, often due to structural and social disadvantage, over-indebtedness, material hardship, welfare cuts, and modest available income (Byron, 2017;Krumer-Nevo, Gorodzeisky, & Saar-Heiman, 2016;Tones, Fraser, Elder, & White, 2009).There appears to be limited structural analysis in the higher education literature highlighting the everyday implications of low income for students who are members of these newer cohorts.
The purpose of this article is to report on specific findings from a larger national study on the impact of low levels of income on study success of Australian social work students.The study was informed by findings from a smaller study in 2014 of student members of the Australian Association of Social Work (AASW) that revealed high rates of student poverty when compared to Universities Australia's (UA) national study of tertiary students (Bexley et al., 2013).The unique focus of this article is on how students' limited finances (as linked to undertaking university studies) impacts their mental health and wellbeing.

Mental health of tertiary students
Growing evidence indicates that university students may represent a high-risk population for psychological distress and mental health issues (Martin, 2009;Reid & Poole, 2013;Orygen Report, 2017).According to Landstedt et al. (2017, p. 340), definitions of mental health often "are broad and complex" but can include psychiatrically defined conditions, psychological and emotional distress and "the more socially framed term mental wellbeing."The recently released Orygen Report (2017) identified ongoing deficits in current knowledge concerning young Australian tertiary students' mental health and wellbeing, while the mental health of more diverse, mature-aged cohorts appears equally under-researched.The Orygen Report identified that students may not seek help for psychological distress due to the stigma associated with mental illness.
Equally, Martin (2009) and others have reported that, increasingly, tertiary students may have a pre-existing mental health condition upon enrolment into higher education that, without adequate support, could hinder their studies.However, they confirmed that many students experienced the onset of mental illness after the commencement of their university studies, because undertaking their studies generated significant mental health stresses (Martin, 2009;Storrie et al., 2010).
Further, it has been identified that the stigma and shame of mental illness, and fears of discrimination following students through their studies and into the workplace, constitutes a powerful disincentive to revealing mental health issues and seeking help (McAuliffe, Boddy, McLennan, & Stewart, 2012).Martin (2009) argued that "many students went to considerable efforts to hide their mental health matters and in doing so struggled to meet university study requirements" (p.259).It also has been suggested that early adversity may be a factor in some students' mental health vulnerabilities (Karatekin, 2016).Interestingly, Martin (2009) found that students who disclosed details of their mental health concerns to university staff reported improved outcomes.

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The Orygen Report (2017) identified that tertiary students experiencing mental health issues were more likely to exit their course before completion and they highlighted that non-completion was a costly loss for students, families, universities and the professional workforce."High risk" groups listed by the Report (2017, p. 14) are international students, students from rural/regional areas and low socioeconomic backgrounds, students studying law and medicine, first-generation students, Aboriginal and Torres Strait Islander students, and students with a physical disability.While the Orygen Report focused on younger university students, Stallman (2010) found female students with financial stresses, aged under 34 and in a subsequent year of their degree were at higher risk of psychological distress than other students and the general populations.Stallman (2010) argued that, without support and intervention, these students were at risk of severe mental illness.Earlier research by Lo (2002) similarly identified a combination of inadequate finances, study requirements, family, and health concerns as impacting some student cohorts.

Inadequate student fi nances
In Australia, the government income support system predominantly is allowances distributed through Centrelink to eligible recipients.In 1997, the payment rate for the unemployment allowance was 92% of the Aged/Disability Pension rate.By 2013 the rate was 67% of the pension rate and declining (Klapdor, 2013).Youth Allowance and Austudy/Abstudy allowances (allowances for youth, and non-Indigenous and Indigenous students) are paid at lower rates than the unemployment allowance.At the time of writing, Youth and study allowances were the equivalent of 54% of the pension rate.This minimal rate of available government income support for eligible tertiary students helps to demonstrate the context for current students' lived experiences of trying to juggle paid work and study.The UA's student finances study (2012) reported that, among the 80.6% of domestic full-time undergraduate students in paid employment, the average hours worked had increased over the previous four years, and 50% of students indicated that their paid work adversely impacted their studies.UA also found that 18.2% of full-time domestic students reported regularly foregoing necessities including food and required medications (Bexley et al., 2013).Elsewhere, much higher rates of food insecurity are reported in tertiary cohorts than in the general population (Gallegos, Ramsey & Ong, 2014).
Australia's attrition rate is comparatively low and re-enrolment data identify that university students who withdraw from studies frequently re-enrol; however, low-socioeconomic students and firstgeneration students are least likely to return to studies (Cardak & Vecci, 2016;Harvey, 2017;Spiegler & Bednarek, 2013).Equally, students are aware of the "rising bar" of competitive employment and labour market demands, where a tertiary degree increasingly is required to gain entry to, or maintain employment (Orygen, 2017, p. 22, cited in Vic Health andCSIRO, 2015).Overall, it seems that a range of issues, including social and structural disadvantage, financial constraints and study requirements may contribute to mental health stresses for tertiary students.

Social determinants of health, wellbeing and social mobility
It is acknowledged that socioeconomic factors including low levels of education, employment and income, gender, age, cultural background, low-socioeconomic status, geographical location, and disability are important determinants of wellbeing and social mobility (Graham, 2000).However, Landstedt et al. (2017) argued that it remains difficult to unravel how social and structural conditions interact to impact students' mental health, and their recent research suggests students from middle-income backgrounds may be more vulnerable.Nevertheless, Landstedt et al. (2017) acknowledged that a combination of study, work and financial hardship, particularly if hardship continued over several years, could contribute to poor student mental health, with students who support themselves and who have inadequate finances being at most risk.

Neoliberal infl uences
Neoliberalism has been identified as a set of political beliefs, values, and practices informing heightened regulation, accountability and competition, greater justification of public expenditure, the extension of business strategies across public, social welfare and educational sectors, and increased assertion of individual rather than state responsibility (Strauss & Hunter, 2017).The collision of unprecedented expansion of higher education, a restructured higher education sector, neoliberal values influencing social policies, and widened access to adult education, may have rendered some students vulnerable and without adequate ongoing support (Pitman, Roberts, Bennett, & Richardson, 2017).Layton (2009) identified that the corporate culture espoused by neoliberalist ideology promotes superficiality and a denial or minimisation of the structural positioning and wellbeing vulnerabilities of some individuals.Other authors have cautioned that social work education and practice have not escaped the impacts and implications of neoliberalist thinking (Morley, 2016;Wallace & Pease, 2011).

Social work students, emotional exhaustion and mental health
Some studies have looked at the specific experiences of social work students juggling paid work and studies.Collins, Coffey, and Morris (2010) identified a relationship between emotional exhaustion experienced by UK social work students and necessary employment in part-time jobs, although they reported that students with family commitments appeared to be coping with multiple demands.
In a similar, Australian, study by Ryan, Barns, and McAuliffe (2011) across three social work programmes the researchers found that, while the benefits of paid work were acknowledged, 76% of students identified fatigue and reduced time for study.In a more recent Australian study, and in contrast to the earlier-noted UK study, Agllias et al. (2016) identified that many social work students struggled to balance studies, work and family commitments, with the situation being more precarious during field placement.Elsewhere, Reardon (2012) identified that the stressful balancing act for social work students of juggling studies, job and family may trigger or exacerbate mental health issues, while Ying (2011, p. 280) argued that tertiary study "exacts a cost" on social work students' mental health (p.280), including a "disequilibrium" during field education that may not be restored by graduation (p.288).Johnstone, Brough, Crane, Marston, and Correa-Velez (2016) called for urgent collaborative efforts from multiple key stakeholders to help address the hardships that can make students more vulnerable to psychological stresses.
Of interest, Ketchen Lipson, Zhou, Wagner, Beck, and Eisenberg (2016) suggested that social work students may be more likely than engineering or business students to seek help for mental health stresses.However, highlighting the complexities, Newcomb et al. (2017) found that, while some social work students were motivated to study because of their service user status or lived experiences, they feared disclosing their own use of services due to perceived shame and stigma.
Similarly, research by Rubio-Valera et al. (2016) revealed almost one third of social work students participating in workshops on mental health stigma had experienced mental health concerns themselves.Yet Covarrubias and Han (2011)  In this article, specific findings from a large national survey on the financial and study circumstances of Australian social work students are reported.While broader findings have been published elsewhere (Baglow & Gair, 2018;Gair & Baglow, 2017), here the impact on students' mental health and wellbeing of studying with insufficient income is revealed, and strategies for change are recommended.

Design and method
The primary aim of the larger study, from which the mental health data reported here were drawn, was to explore the impact of low or insufficient income on the lives and study success of Australian social work students.At the time, no previous large national study of social work students' experiences was identified.The study proceeded as a partnership between the AASW and a regional university.The research design comprised a national web-based survey.Data collection occurred during the second semester of 2015.The survey enabled the collection of both quantitative and qualitative data (Creswell, 2013).
The survey consisted of 23 questions covering demographic information, government allowances received; hours of, and reasons for, paid work; and whether students' families supported them financially.Other questions sought to ascertain the impact of insufficient income on students' lives and studies; the experience of studying while meeting family responsibilities; hours spent studying; income; savings; and any added impact of compulsory field placements.The study received University Human Ethics Committee approval and was overseen by a national reference group.To participate, students read online information about the study and then progressed to voluntarily complete an anonymous online survey.A total of 2,320 students completed the survey, constituting approximately 25% of all enrolled social work students at the time.

Respondents
In all, 87% of respondents identified as female and 13% male.Of these, 31% were under 25 years of age, 33% were aged between 25 and 34 years and 36% were over 35.These figures reflect, in general, the gender and age profile of social work students in Australia.A total of 75% of students indicated that they had a full-time study load, 14% had a part-time load and 9% identified they were studying externally by distance education.A majority (64%) of students lived in a metropolitan area, 27% in a regional area and 9% in a rural area.All Australian states and territories were represented in the study.Some 4% of respondents identified their cultural background as Aboriginal and/or Torres Strait Islander, representing a higher rate than population percentages.A total of 47% of students received government financial assistance in the form of allowances or pensions.Respondents were drawn from the 29 Australian social work programmes accredited at the time of the study, and represented multiple year levels within Bachelor and Masters Qualifying programmes.

Data analysis
The quantitative data analysis and findings, and specific qualitative findings are presented

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elsewhere.Three questions on the survey that enabled both quantitative and qualitative responses specifically focussed on financial hardship impacting studies.Question 5 asked about insufficient finances for necessities whilst studying (see Table 1).This question attracted 829 qualitative responses.Question 7 asked how their studies were impacted by lack of sufficient financial support.This question offered multiple options and attracted 330 qualitative responses.Question 11 asked students about juggling student placement and paid work.This question attracted a total of 614 qualitative responses.No question on the survey asked students to comment on mental health concerns or experiences.However, as revealed below, the qualitative data analysis process provoked further, specific analysis in relation to this topic.
During the broader, qualitative data analysis process, responses were read multiple times and recurring patterns and concepts were documented.Themes were named and then renamed during a process of sorting and synthesising until a point of saturation was reached with key themes linked back to questions asked (Liamputtong, 2009).However, after a primary level thematic analysis of the qualitative data, it seemed apparent that mental health may be a unique and important code, and further analysis could assist in illuminating it.Liamputtong (2009, p. 282, cited in Miles & Huberman, 1994) identified several reasons for "counting" within a qualitative analysis, including "to see rapidly what you have in a large batch of data".Liamputtong argued that identifying the number of times concepts appear across the data can add to meaning-making and take the researcher into "unforeseen areas" (2009( , p. 282, cited in Altheide, 1996( , 2004)).In this instance, a specific, content analysis component within the larger qualitative analysis process was used primarily to help render visible a new code for further focussed thematic analysis within the large volume of textual material.
As noted, no question on the survey asked students about mental health issues, mental illness, stress, anxiety or depression.Yet it was evident that, for some students, these were important concepts -a word-use frequency count revealed 317 instances where these terms were used.This step helped researchers capture important common threads in some students' narratives around mental health.The thematic analysis process resumed.Responses containing the identified concepts were read multiple times and a synthesising process of identifying and naming patterns resulted in four key themes.It is these specific findings in relation to mental health and wellbeing that are presented here.

Results
In the following section, brief quantitative data from Question five from the national survey provide a contextual backdrop for the qualitative data reported here.Table 1 illustrates quantitatively the range of ways a lack of finances was impacting many students' lives.

Qualitative data
The themes below represent dominant patterns and sentiments in the qualitative responses related specifically to students' mental health.These themes are: i) financial hardship impacts mental health and wellbeing; ii) forced decisions to gain necessities; iii) insufficient funds hinder mental health management; and iv) field placement increases ill-health/ burnout.Given the complexity of the topic, some longer quotes help capture the multifaceted dynamics.

Financial hardship impacts mental health and wellbeing
Many students in this study identified how financial constraints impacted their everyday survival while studying.As exemplified by this student and their partner, studying parttime was taking a mental health toll: …my partner and I were studying full time via distance education, no support from parents… we're on Centrelink benefits.We barely survived.After those six years, we could no longer cope with living in poverty as it had a significant impact on our health, mental health and general wellbeing.
For the next student, and many others, affording medication, food, fuel and secure accommodation was difficult, and going without these items impacted their health, study results and mental health: I … had to get medication … and owe pharmacies for scripts, eat toast for days, borrow money for petrol etc, postpone specialist appointments … trawl through op shops for clothes appropriate for work, go … without textbooks … and my mental health and grades have suffered as a result.
For the first three months of semester one this year I was couch-surfing until I could find affordable stable accommodation.
Equally, this student identified that financial constraints across their whole degree had impacted their health:

Forced decisions to gain necessities
This second theme gives further depth to the daily juggle evident in the first theme.The students provide examples of their need to choose between necessities or make reluctant decisions so necessities can be secured.
This student revealed how a financial shortfall forced them to make choices between essentials that, in turn, aggravated their mental health circumstances:

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Often I must choose between food or transport, frequently late with rent payments and have had to forgo my medication I take for depression and anxiety to get food, fuel etc which serves only to exacerbate the situation and my condition.
The below student identifies how they reluctantly borrowed from friends to afford necessities including food, medication and textbooks: I am a type 1 diabetic with depression and anxiety.I have … been incapable of buying medical supplies, textbooks, food and clothing … I have borrowed from friends but I feel like a burden.
Equally, this student felt compelled to move back home with parents to finance their studies and help juggle paid work and mental health: I had to move back in with my parents… on top of this, I am doing my second degree currently, and so Centrelink will only cover 1.5 out of the 5.5 years … so I have been saving as hard as I can for the last couple of years and will have to keep living with my parents until I finish the degree (I'll be 31 then).I have been very lucky to find a job that works around my uni timetable ... while maintaining my (fragile) mental health.I have struggled to afford medical expenses in the past … as I have a chronic medical problem.
These narratives serve to exemplify social work students' experiences expressed in multiple qualitative responses concerning ongoing financial hardship that for some, impacted their studies, health and mental health.

Insuffi cient funds hinder mental health management
Previous themes identify a complex balancing act for students of study, paid work, securing necessities and maintaining mental health.This theme specifically highlights how personal management of mental health was constrained by students' financial realities.This student identified struggling to afford mental health appointments while studying: … at times [I] had insufficient funds to access my regular psychologist sessions and am unable to afford access to a psychiatrist.
Similarly, this student prolonged the time between appointments beyond what was desirable because they were unaffordable.
I regularly attend appointments to help manage my mental health, sometimes I will cancel them because I can't afford to go.I find myself spacing them out more than I would like to, just so I can afford to get some help.
Mental health medication was a requirement that could not always be prioritised, as this student explained: There's times where I go without so at least my children are taken care of in relation to food and medication.I have refrained from buying some of my medication or even following up on specialist appointments for myself as I live with a mental illness and severe arthritis.However, I always make sure my children have their medication and required treatment.
As noted earlier, UA found a growing number of full-time domestic students regularly going without food or other necessities including required medications (Bexley et al., 2013).

Field placement increases ill-health/ burnout
Social work field placements provide the vital link between classroom learning and real world practice.Students enrolled in accredited Australian programmes undertake a total of 1,000 supervised hours

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of placement, most commonly in two, 15week blocks (AASW, 2012, Guiding principle 1.2).Across the entire data set, students repeatedly identified how the financial and personal burden of placement contributed to hardship, and for some, declining mental health: In order to achieve 500 hours of placement, where my current job requires me to work two days a week, my placement happened over three days a week.This was very mentally exhausting… my mental wellbeing deteriorated … my circumstances meant I needed to continue employment, no matter how tough and unbalanced my life became.
Some students saw emerging signs of mental distress on placement, implicating a lack of designated time for reflection and self-careas this student articulated: Lack of time to properly reflect on my placement and work experience, always working at placement or paid job, not enough time for self-care, starting to notice impacts on my mental health.
Similarly, this student outlined her thoughts that current placement arrangements did not facilitate self-care: … it is unreasonable to expect students not to need days off for sick leave or life events ... no ordinary working conditions prohibit time off for illness and life events … On both placements I have been at the office more often than staff members, ... I don't think students are … enabled, to practi[s]e [self-care] during placement.
For the following student, burnout was the result of trying to juggle paid work, family and placement: Working part-time as well as family commitments while on placement nearly killed me.Even doing a parttime placement was hellish … and I was totally burnt out at the end of each one.
Students' experiences on placement reflect previous research findings (Hemy, Boddy, Chee, & Sauvage, 2016;Johnstone et al., 2016) that students endure severe hardship juggling studies, paid work and field placement, while Robins et al. (2017) identify student burnout as a growing workforce concern.

Discussion
Some 20 years ago, Ife (1997) asserted that legitimising the voices of marginalised groups is an important, perhaps the only way, to challenge existing structures and develop an alternative based on social justice.In this article, we sought to raise the voices of social work students as a marginalised group.The findings presented here align with the assertion by Landstedt et al. (2017) that a combination of study, work and financial hardship, particularly if hardship continues over several years, contributes to poor student mental health.
Although the student survey did not ask students about mental health impacts, respondents identified they had insufficient financial resources for necessities including textbooks, food, fuel, accommodation and required medications that, for some students, in turn impacted their mental health.
Poverty, a feature of many of the students' accounts, is an example of structural injustice.Such injustices are considered difficult to correct, because government system change is needed, as well as individual and institutional action to agitate for and support change.Increasingly, writers highlight the influence of neoliberal ideologies (Morley, 2016), yet critiquing neoliberalism alone will not facilitate strategic future direction.
It seems evident that universities, social work academics, and relevant professional associations, all of whom have greater privilege and power in the higher education sector than students, have a compelling responsibility to undertake collective advocacy for struggling students.The

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quantitative (discussed elsewhere, Baglow & Gair, 2018) and qualitative data from this study provide evidence for reconsideration of the minimal level of government financial support currently provided to tertiary students (also see Gair & Baglow, 2017) Overall, these findings align with evidence elsewhere in the literature that collective action by all stakeholder bodies is needed to help ensure students succeed in their tertiary studies (Johnstone et al., 2016).Equally, representative stakeholders, including the higher education sector, professional associations, human service organisations and social work educators can increase their investment in a more positive mental health and wellbeing culture, recognising the many stressors students are juggling.Students may then feel more enabled to seek help when required.
Limitations of this study include that the focus of the larger study was exploring the impact of low levels of income on students' study success.Therefore, students with manageable study circumstances may not have felt prompted to complete the survey or comment on levels of income and impacts on their daily lives.It is acknowledged that from these findings it cannot be argued that all tertiary students would report similar circumstances to those discussed here, or that social work students necessarily have unique study circumstances.Further research is recommended.

Conclusion
These findings help confirm evidence elsewhere in the literature that juggling financial hardship and tertiary course requirements can impact students' study experiences, wellbeing and mental health.There appears to be an urgent need for universities, the sector and professional associations to be more receptive to acknowledging that many students may be experiencing precarious mental health.A united approach seems called for in advocating for reform, including increased government financial support and targeted early-intervention strategies that contribute to a mentally healthy student body and professional workforce.Further research may illuminate unique study circumstances for social work students.Equally, current findings may have implications beyond the Australian context and social work student experience, to a national and international professional helping workforce.

Table 1 .
As a Student Have You Had at Any Time Insufficient Money for Any of the Following?

Percentage of students answering in the affirmative Number of students answering in the affirmative
(Martin, 2009)ontext, Australia is a signatory to the United Nations Convention on the Rights of Persons with Disabilities, including mental illness.It upholds people with disabilities as equal citizens with rights to an inclusive education and lifelong learning.As such, universities have an obligation and responsibility to support students' mental wellness(Martin, 2009).The social inclusion agenda and widened access to higher education has heralded welcome diversity to university campuses and to many helping professions including social work -but only if diverse cohorts complete their courses and enter the workforce fully able to engage in demanding professional practice.While interventions focussed on youth mental health are emerging, these study findings suggest diverse student cohorts may have different support needs and social work students might be another group to add to the abovementioned "at risk" list(Orygen  Report, 2017, p. 14).It seems clear that further research is needed regarding social work students' mental health.