Applying the recovery approach to the
interface between mental health and
child protection social work
Joe Duffy, Gavin Davidson and Damien
Kavanagh
12 October 2011
Introduction
At a time when social work continues to
experience scrutiny in the wake of
several child abuse tragedies, this
workshop proposes that more positive
approaches
to
engagement,
risk
assessment and management may lead
to better outcomes in working with
families experiencing parental mental
health problems and child protection
concerns.
Objectives
In proposing that the recovery approach can inform the processes
of engagement and assessment at the mental health and child care
interface, this workshop presentation will:
1.
2.
3.
Provide a critical overview of the recovery approach which
compares it with approaches typifying interventions in child
protection work to date.
Refer to relevant research and inquiries which have provided a
range of recommendations for how to more effectively respond to
cases where there are issues around parental mental health
problems and child protection.
Apply the recovery approach to practice and critically discuss the
issues involved in its application to the interface.
Background
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The relationship between parental mental health problems and child protection is
well established (Rutter & Quinton 1984; Falkov 1996; Stallard et al. 2004).
However, we still experience serious challenges in effectively responding at this
interface (SCIE, 2009).
Many child abuse enquiries make explicit the on-going need for professionals to
improve how they work collaboratively in their responses to child protection cases
(Duffy and Collins 2010).
The benefits of multi-agency working at the interface between mental health and
child protection are also quite clear with such joined up approaches yielding more
creative pooling of skills and knowledge between workers culminating in improved
solutions, efficiencies in service delivery, cost effectiveness and alleviated stress for
workers (Darlington et al. 2005).
The Recovery Approach, underpinned by engagement principles, may offer an
alternative to workers involved in this interface at a time when existing responses
tend to be both risk avoidant and overtly managerial (Munro, 2010).
Recovery approach - definitions
• Recovery can occur in the context of continuing symptoms or
disabilities. This definition is the focus of the recovery
approach and is about recovery of hope and ambition for
living full and purposeful lives
• Deegan (1988) defines recovery as, ‘a process, a way of life, an
attitude, and a way of approaching the day’s challenges’
• Recovery may involve many stages, and inevitably setbacks
and uncertainty, and has been described as, ‘an uncharted,
unpredictable, and personal journey’ (Antony Sheehan, NIMH,
2002)
History of the recovery approach
• Roberts and Wolfson (2006) date the origins of recoveryoriented practice to the Tuke family who established The
Retreat in York at the turn of the 18th century.
• William Tuke, a Quaker and a lay reformer, set out to create a
family-like healing and spiritual environment for members of
the Society of Friends.
• The Tukes showed that moral or psychological forms of
treatment in a work-oriented, peaceful and pleasant
environment could replace physical restraint.
History of the recovery approach
• More recently, the recovery approach has emerged from
the writings of people who used services in the 1980s in the
US, and in the 1990s in the UK
• Many wrote about coping with symptoms, getting better,
and regaining a satisfactory sense of personal identity that
was not defined by illness experience
Key recovery themes
• Recovery is fundamentally about a set of values related to
human living applied to the pursuit of health and wellness.
• Recovery involves a shift of emphasis from pathology, illness
and symptoms to health, strengths and wellness.
• Hope is of central significance. If recovery is about one thing
it is about the recovery of hope, without which it may not be
possible to recover and that hope can arise from many
sources, including being believed and believed in, and the
example of peers.
Possible implications of recovery
approach for services
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•
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Role of service user
Role of multi-disciplinary team
Ethos of services
Focus of assessment, planning and
intervention
• Organisation of services
The Recovery Approach and User
Engagement
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Priebe et al. (2005), in a study of assertive outreach services, reported that people
are more likely to engage with services if they feel listened to, their views have an
effect on the care offered and they have some power to make decisions about the
services they use.
The recovery approach therefore suggests that positive engagement with clients
rather than coercion is the most effective means of reducing risk and improving
mental health and functioning. Ryan and Morgan (2004) argue “…that
(paradoxically) the best route to safety may be the one that seeks to empower
users, not control them…”” (p.ix).
Laurance (2003) argues that engaging service users is crucial in this field, “The
most effective way to improve the safety of the public and the care of those who
are mentally ill is to devise services that genuinely engage users and meet their
desire for greater control so that they are encouraged to seek treatment and lead
stable, risk-free lives” (pxxi).
in practice, the implementation of a participatory approach may present serious
challenges for social workers, who may feel their status as expert may be
undermined (Levin and Weiss-Gal 2009). They may also be attempting to engage
service users who are reluctant to have any involvement from social work and
harbour genuine scepticism about service users’ capabilities in making choices.
What do we mean by the Interface?
•
Refers to the direct exchanges between mental health and child care and
how all of the people involved engage with service users to ensure the best
possible outcomes.
•
Darlington et al. (2005) classify the issues causing difficulties at this interface into two
main groups. The first group contains the issues relating to collaboration which could
be relevant regardless of the service user group.
The second group covers the specific challenges involved in inter-agency working
with people with mental health problems and children with protection needs. This
group includes the nature of mental health problems and the difficulties involved in
trying to balance the often conflicting needs of parents and children.
SCIE (2009), however, has attempted to summarise the possible issues and
challenges characterising current practice in the interface and has identified factors at
each stage of the process in screening, assessment, care planning, care provision
and review.
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Screening
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In regard to screening, problems can be evidenced by social workers
lacking enquiry skills in asking appropriate questions. Additionally, problems
occur in social workers not being attuned to the functions of other
professionals around mental health and child protection.
The fear, mistrust and suspicion with which social workers are sometimes
viewed can also act as inhibitors as well as the negative perceptions
accompanying mental illness diagnosis itself.
There are also issues around parents fearing the loss of parental
responsibility and children having fears about separation from their parents.
Research conducted by Stanley et al. (2003) revealed worrying degrees of
mistrust among mothers with mental health problems towards their child
care social workers: “the relationship with this service was most often
characterised as one in which trust was absent, communication was poor”
(p. 216). This absence of trust was fundamentally linked with the fear of
their children being removed into care. As a result, important information
was withheld by mothers, resulting in both inadequate assessments and a
lack of support.
Assessment
• Limited knowledge around mental health problems may
impede child care social workers from appreciating their
impact on parenting when conducting assessments. It is at
this axis where inter-professional working across the interface
would seem imperative, particularly in situations where
families are affected by a multiplicity of adversities. Stanley et
al. (2003) suggested dyadic key worker roles in mental health
and child care as a solution where: “each professional could
offer an insight into the procedures, legal provisions and
interventions specific to their service” (p. 217).
Planning
• In the context of planning, whilst closer collaborative working
may help professionals in untangling multi-faceted familial
problems, the difficulties in the perception and interpretation
of such problems at the individual level of the professional
should not be understated. With a focus on the needs of the
parent, the mental health professional may, for example,
struggle to recognise the inherent and underlying risks of
harm to the child whilst the child care social worker may
question any possibility of positive change on the part of the
parent. Some commentators also suggest that a tendency
towards ‘risk-focused and risk aversive intervention is now an
engrained feature of practice with children and families (Frost
and Parton, 2009).
Why
is
Interface
Working
Necessary?
•
Turning to how social workers respond to instances where there is an interface
between child protection and mental health concerns, Reder and Duncan (1999, p.
56) used the term ‘assessment paralysis’ to typify the uncertainty which social
workers can often exhibit in terms of determining their professional response. In such
cases, priority was disproportionately given to the psychiatric issues rather than the
child protection dimensions.
•
Consequently, these authors call for an emphasis to be placed on the behaviour of
parents as opposed to their psychiatric diagnosis. Such a refocused response would
necessarily involve examining the parents’ expression of thoughts and feelings within
the overarching paradigm of behaviour.
•
Reder and Duncan aptly call for mental health professionals to ‘think family’ when
approaching the dual concerns of mental health problems and child protection. Within
this, there is also a plea to see the service user in their ecological context of
connections and relationships to children and other family members. Such a systemic
response would necessarily entail engagement with the important interests of
significant others such as children.
Case Study
Marie (36) is a single parent with two children, Jamie (Aged 14) and Clare
(Aged 9). Marie’s relationship with her husband, Clive, ended two years ago
after she found out that he was having an affair. Clive continues to see the
children regularly and Marie continues to live in the marital home in the
outskirts of the city. Marie has been suffering from depression, anxiety and
ruminations for the past ten years and mental health services are involved.
Marie has attempted suicide on two occasions in the past four years and
following these incidents has been admitted to a mental health in-patient unit.
Marie has a very good friend, Patricia, who was able to look after the children
during these times. Patricia has become concerned about Marie, who told her
recently that she was hearing voices which were telling her to “end it all and
take the children with her”. Marie doesn’t think she is going to get better and
that mental health services won’t help her. She also fears if she is not here, the
children will be taken into care by social workers. Marie is visited by a
Community Psychiatric Nurse (CPN) and Patricia has phoned him to express
concerns about what she has been told. The CPN then makes contact with his
colleagues in the Child Care team as well as the mental health social worker.
Application to Practice
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As Darlington et al. (2005) have highlighted, obstacles to effective interface
working may relate to the general organisational issues such as time,
communication and differing systems and/or to the specific nature of the
mental health problems and child care concerns.
The recovery approach suggests that if initial attempts to engage Marie
were to lead with and focus on the risks, this may undermine the
development of a trusting relationship with Marie and her family which is
needed to enable a more comprehensive assessment of the possible risks
It is suggested therefore, that in order to achieve meaningful engagement, it
is more effective to work with Marie in a way that communicates hope and
acknowledges the strengths and resilience in her and her family. This is not
to say that the risks do not need to be assessed but that the recovery
approach is potentially a more constructive way of achieving this.
Application to Practice
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Building on Stanley et al.’s (2003) suggested dyadic key worker roles, a triadic approach to
Marie’s recovery journey will help incorporate the views of Marie, her family members and those
involved in offering support and intervention.
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The welfare of the child as paramount is also core to informing intervention in this family’s life. In
supporting and engaging with the family, it is therefore important that information is exchanged not
only between all of the significant individuals in Marie’s life but also with other practitioners.
•
Partnership, as a central social work value, underpins both child protection legislation and the
recovery approach. The practitioner, therefore, in conveying honesty with Marie in a respectful and
sensitive manner, should explore her understanding of the impact that these experiences and her
thoughts could have on her family. The fact that Marie has disclosed the content of the voices she
is hearing to Patricia suggests that she is self-aware and is acting proactively in protecting her
children.
•
It is important therefore for the practitioner to understand and convey that the voices and
experiences affecting Marie form her ‘reality'. To challenge the validity of these, or to overemphasise their negative impact would exacerbate any pre-existing vulnerability.
Application
• Working in a holistic way with Marie and significant others in her life
will therefore aid the worker in developing a more robust
understanding of Marie’s experiences and support needs. An
effective plan should be developed which involves as many of those
people that Marie feels are important to her. Within this, it is
important to note the existence of arrangements for compulsory
intervention in Marie’s life from a child protection and mental health
perspective, if these are deemed necessary. Should Marie warrant
compulsory admission to mental health services, an explanation
must be offered in a humane and sensitive manner as to the nature
and purpose of such intervention. This information must also be
provided to significant others in Marie’s life, within appropriate
sensitivities around confidentiality.
Application
• Adopting a recovery approach assists in undermining
any sense of vulnerability and powerlessness an
individual may perceive. That is not to say however
that the relevant key worker for this family should
assume that once a recovery-oriented approach is
adopted, stigma and social exclusion will cease to
impact on their lives.
Adopting this approach
necessitates a sense of openness and acceptance on
the part of Marie and others of the reality of their
experiences, which can be achieved by the worker’s
skills and commitment to user engagement.
Conclusion
• Central to applying the recovery approach to the mental
health/child protection interface is the promotion of user
engagement, partnership working and a commitment to
strengths and resilience based thinking.
• The recovery approach can positively blend within existing
preventative and re-focussed ways of working with families
aimed at helping to better build capacity to sustain families
together.
• The recovery approach as a form of family support and
engagement may therefore offer a more effective means of
protecting children, through its inherent focus on an all family
perspective, where risk is assessed and managed in a spirit of
collaboration, empowerment, partnership and openness.
A New Model
• In conclusion we would therefore propose
that a ‘family recovery approach’ should be
included in any practice guidance/protocols
arising from implementation of SCIE’s Think
Family. Whilst this paper has addressed
some of the challenges that could
accompany implementation, the community
and societal context for interface working as
well as micro-level practice issues will also
require further debate and consideration.
References
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Applying the recovery approach to the interface between mental