Is abuse trauma ignored?

Sarah
Nelson, a freelance researcher, examines why mental health services are
reluctent to help female adult survivors of sexual abuse to come to terms with
their childhood ordeal.

We
began our qualitative research project in Edinburgh in 1998¹ to find
out why female abuse survivors didn’t receive appropriate mental health care.
We had assumed the main reason why was that abuse trauma doesn’t fit into
"medical model" psychiatry – organic causes for depression or
psychosis are more popular, and attract infinitely more research money.

Therefore,
we were surprised to find the biggest barrier actually came from widespread
reluctance among psychiatrists, psychologists, psychiatric nurses and social
workers to "open the can of worms". The blockage thus took place at a
very early stage of survivors’ repeated contacts with services. Many staff
decided not even to ask if clients had a history of childhood sexual abuse.
This was the case however suggestive the symptoms – like depression, an eating
disorder and self-harm.

The
Edinburgh Association for Mental Health project, in collaboration with
Edinburgh University’s sociology department, aimed to improve mental health
services to adult women survivors. We interviewed women with a range of
psychiatric diagnosis, from borderline personality disorder to postnatal
depression and schizo-affective disorder. We interviewed statutory mental
health staff and voluntary sector staff working in mental-health related
projects.

It
proved really valuable to consult all three groups, both for their helpful
ideas and because the causes of long-standing problems began to unravel in
front of us.

Staff
offered a number of reasons why sexual abuse survivors were unable to get help.
Here are some of them.

It
goes against strategic priorities
The national policy drive to return patients from acute psychiatric wards
to the community as soon as possible militates against painstaking assessment,
and work that might prolong their stay. Frustrated staff said colleagues
criticised them for destabilising patients who are normally medicated and
released.

We
need much more training, we might mess things up
This was a huge fear across sectors. As one young nurse said: "It was
always drummed into me that you have to be very careful, there is always more
damage that can be done…I always tell them (survivors)…I’m not trained and
I don’t have the experience."

There
is a clear need for confidence building and support structures for staff, but
our research challenged the need for long, complex training. Staff most valued
by survivors showed basic qualities of warmth, empathy, understanding and
courage to stay with clients, however disturbing their life histories or
symptoms.

It
would be more distressing for women to open the can of worms than to stay as
they are
This widespread belief contrasted starkly with survivors’ views. They felt
frustrated, angry or despairing at trying for so many years to be heard and
helped. Most already accepted that therapy would probably make them feel worse
before they felt better.

It
is indeed baffling that people could assume clients who dare not sleep, who
gulp drugs and drink to block the pain, eat into humiliating overweight,
mutilate their arms and suffer terrifying hallucinations of their abusers,
could be happier left as they are. It seriously underestimates the daily pain
and suffering of many survivors.

Some
had waited months on waiting lists for psychological or psychotherapeutic
treatments, only to be assessed as too distressed to take part. One irate survivor
yelled: "Of course I’m fuckin’ distressed, that’s why I’m here!" But
the rejection made others feel suicidal.

We
might encourage false memories to emerge
This was linked for some with a fear of being sued by adults accused of
abuse, especially if these came from educated middle class families. As one
psychologist put it: "We have to keep the recovered memory thing in
mind… have to be sure we’re not just planting ideas or leading the
client."

We
don’t have enough time, resources or…
The fear that sexual abuse issues were terribly complex, opened an
appalling can of worms and took enormous time, meant people did not risk
offering clients the slices of time they had. They always hoped the next agency
would have more time. Thus some women never received a service. Three weeks’
average stay in an acute ward to two months on remand was not long enough to
broach the subject. Nor were six-month postings for psychiatrists in training
long enough to trust them to work with survivors.

In
contrast, although survivors needed time for longer-term work they much valued
brief interventions that sometimes proved catalysts to changing their lives:
the night-nurse who first listened to their story with respect, the project
worker who walked the floor with them after they overdosed, or the perceptive
GP who guessed what was wrong and found them an excellent counsellor.

Asking
the question would be too intrusive
In one case, this was claimed by staff whose assessment forms included
intrusive questions about numbers of sexual partners in the past month, and
criminal offences committed during that time.

There
wouldn’t be anyone to refer them to
While there is a genuine shortage of appropriate services in Edinburgh,
this phrase could also be shorthand for "anyone reliable". Many
statutory staff doubted the value of counselling, and the competence of the
voluntary sector. This infuriated charitable agencies, struggling on a
shoestring to provide care for the most damaged and distressed people – women
the statutory sector often declined to help.

We’d
be flooded if we started this work
Incongruously, below the surface of denial runs awareness that sexual abuse
is very common and that numerous survivors need support. It was disturbing that
fears of being "flooded out" if their service became known
contributed to reluctance to start one, for instance in health centres, in drug
and alcohol services or among community psychiatric nurses. Organisational
concerns were clearly being put before client need.

One
drugs service, for instance, found their former psychologist spent most of her
time working with drug misusers on their abuse trauma issues. So despite this
clear proof of client need, they decided to divert the present psychologist
from sexual abuse work into other duties, without demanding resources for
someone else to pick up the work.

Fortunately,
a significant minority of staff from both statutory and voluntary sectors in
the Lothians worked with survivors in courageous, imaginative and inspiring
ways. We hope that through our report, their example will inspire many others
to change their practice.

Sarah
Nelson is a freelance researcher and writer.

References

¹
Sarah Nelson, Beyond Trauma: The Mental Health Care Needs of Women who have
Survived Childhood Sexual Abuse, Edinburgh Association of Mental Health,
2001. Available from EAMH, 40 Shardwick Place, Edinburgh, EH2 4RT, price £7.50.

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Contracting
for care

Improving
the quality of home care is not just about legislating for higher standards.
The nitty gritty of contracts between service providers and commissioners needs
to be re-evaluated too, writes Nigel Walker, director of an independent home
care provider.

Agencies,
commissioners, users and carers have universally welcomed the implementation of
the Care Standards Act 2000¹  in
domiciliary care during the coming year. Details arising from the process are
bound to cause discussion and require refinement in the light of usage and
changing circumstance. But one question not yet widely discussed is the
importance of the contracting process to improving the quality of home care.

The
new standards are drawn from more than 90 voluntary accreditation and
registration schemes. We can assume they represent all current concerns on how
home care is delivered. It is common for accreditation schemes to be an
expression of specifications that are used as part of the local authority
contract. In theory, therefore, specifications could now be aligned to the care
standards, in which case the next consideration must be the alignment of
general contractual requirements.

For
providers of care who operate across local authority or health organisational
boundaries, attempts to devise policies or administrative systems that minimise
cost are often thwarted by the very commissioners they seek to assist. It would
help to settle a volatile market if common requirements were established
governing invoicing and payment, together with a more standardised approach to
support expectations or staff conditions. Core contractual standards would also
encourage the development of software for common use that would mechanise
routine tasks for local authorities and providers. This is almost impossible at
the moment if a provider works for more than a single commissioner.

The
role, nature and operational methods of independent providers is not well
understood by local authorities. All too often they view providers as all
operating in the same way and for the same reasons. But there are differences
to be recognised between different providers. There are, for example, private
companies needing to generate a profit from home care, others that are running
home care services at cost or through cross-subsidy in order to generate new
business, small local charities responding to local need and larger
not-for-profit organisations such as housing associations offering integrated
service packages.

A
greater knowledge of the benefits and drawbacks of working with different types
of provider (including in-house services which will be subject to the new
standards in the same way as everyone else) would help commissioners to define
what they wanted from a service. It would also better inform the debate about
public/private partnerships, which currently takes little note of the
subtleties.

Almost
all local authorities believe that they, and only they, have the best methods
of contracting. Even where contract managers meet on a regular, regional basis
it seems to have little impact on making cohesive local practices. And all too
often within authorities the person with the most developed knowledge is
overruled by others in more senior positions, by local political objectives or
by representations from other directorates within the authority. The reasons
are usually rooted in finance or local politics and sometimes both.

Local
authorities also find it difficult to understand what they can and cannot
control. Draconian or petty requirements are placed in contracts without proper
consultation, or contractual requirements are changed part way through without
the possibility of negotiation about the change. Partnership becomes a word
used only to symbolise the meetings held at which providers are told what will
happen next. In a fluid legislative and economic climate and with the
strictures of Best Value to obey, traditional methods of tendering are no
longer sufficient.

Independent
providers only have themselves to blame sometimes for this state of affairs as
they are secretive about their real costs and pricing mechanisms and often seek
to avoid investment in their staff or infrastructure to save costs and attract
work.

To
attain the full benefits of the new care standards there has to be greater
transparency in the pricing of meeting these. This must be a two-way process
which takes account of Best Value requirements and allows flexibility for
particular local conditions.

The
pricing of contracts is not a process well understood by commissioners of care.
Some authorities (and often those with the most stringent contractual
requirements) want to impose a price irrespective of the quality issues they
also impose. In a recent conversation with a local authority who required a
massive input to enable accreditation, but who also paid a low fixed rate, the
accreditation officer stated that any relationship between quality and cost was
"no concern" of theirs. Technically right, of course, but not a sign
of joined-up thinking in local government. Or maybe a sign of wilful ignorance
in an attempt to dispel the local authority’s financial problems at the expense
of providers, who are expected to subsidise a growing number of authorities,
and service users who have to tolerate appalling service provision on occasions.

Of
course, local authorities have real financial problems. Central government has
not matched the aspiration to modernise social services through improving the
funding regime within social services.

An
agreed framework that sets out the cost of all elements, including staff, is
easy to establish. This spreadsheet could then be completed as a part of a
tendering exercise. It should show assumptions against the standard and
illustrate the reasons for differences, both above and below costs. Such
assumptions should include management costs and surpluses for reinvestment as
well as the percentages for training and other support such as policy
development. Variations to an agreed contract required by local authorities
could then be shown as separate costs.

To
support this Best Value approach successful tenderers may be required to
present annual accounts and supporting documents. This could be a double-edged
sword as local authorities that had undervalued the service may be required to
increase costs, just as providers who had not invested according to their
declared plans may be required to compensate the authority. It can also help
establish a level playing field with councils’ domiciliary care provision.

Domiciliary
care is at a crossroads, not least because of the fall-out the new standards
will inevitably cause. It is an industry unable, in common with other caring
services, to attract staff of sufficient stature in sufficient numbers. The
trade unions are right to demand a greater recognition of staff’s role and
responsibilities, though not perhaps as part of an argument to retain services
entirely within local authority control. It is also an industry in which the
principles of commissioners are high but where the costs associated with this
are not well understood. It is an industry in which the local authorities, who
wish to tie down independent providers to contractual obligations their own
providers often cannot meet, also frequently show little sign of having any
real control over their own costs.

Yet
it is also an industry of intense value to society and one which has too often
been ignored. The care standards implementation has brought a sense of
recognition of these issues. But this in itself is unlikely to be enough if the
standards are implemented against the current background of poor resourcing,
misunderstandings and mixed (and sometimes contradictory) contractual
requirements. It would be heartening to think that all concerned could use this
opportunity of change to work together to ensure that properly run and funded
services gave quality care to those for whom it ultimately exists.

Nigel
Walker is director of home care, Housing 21.

References

¹
Care Standards Act 2000, Stationery Office, 2000, available at www.hmso.gov.uk/acts/acts2000/20000014.htm 

Background
Reading

1
D Brand, P Fletcher, A Guide to the Care Standards Act 2000 for Residential
and Domiciliary Care Providers, The 
National Housing Federation

Websites

1
National Care Standards Commission implementation project at www.doh.gov.uk/ncsc/carestandardsorder.htm 

2
Further review of standards and web links at UK Home Care Association website
at www.ukhca.co.uk

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One
for all

The
NSPCC is proposing new multi-agency child protection teams. Rhian Stone, policy
adviser for the NSPCC, explains the approach

In
too many tragic child protection cases professionals are not effectively
sharing their concerns about individual children. But what is needed is not
exhortation for people to work together but a radical approach that will ensure
multi-agency working.

The
NSPCC is circulating a set of proposals for strengthening the child protection
system with the aim of generating debate about the way forward prior to the
Victoria Climbie inquiry’s report in the spring. Someone To Turn To¹
proposes a multi-agency team structure, similar to the youth offending teams
model, for the delivery of services to vulnerable children. The NSPCC believes
the YOTs approach would be one way of ensuring more effective working together
between the key agencies. Debate is invited on the scope and responsibilities
of the teams, in particular whether the model would work for all children in
need or should focus on children in need of protection.

The
main elements of the NSPCC proposal are that local authorities should be required
to discharge their duty to provide child protection and welfare services in
partnership with the health authority and the police authority and other
relevant local agencies. The staff of different agencies should work as an
integrated team under single line management rather than working, as now, on a
co-operative basis while managed by their own agency.

At
operational level, we propose that the children in need or child protection
teams should include social workers, education and health authority staff,
police officers, and possibly the voluntary sector. The teams would exercise
the local authorities’ duties under the Children Act 1989, undertake the
requirements of Working Together ² for handling individual
cases and carry out integrated needs-led assessments using the Framework for
the Assessment of Children in Need and their Families.³ They
would be responsible for commissioning family support and therapeutic services
where needed.

Having
professionals together would enable a more flexible approach to children and
their families. It would also help to resolve some of the commonly held
complaints and difficulties that professionals raise. Teachers consistently
highlight difficulties referring their concerns to social services and complain
of lack of feedback when they do. Social workers experience difficulties and
frustrations with the referrals they receive from teaching staff. Common
complaints are that referrals are unclear, poorly timed and that staff are
unfamiliar with their responsibilities for safeguarding children.

If
there were multi-agency teams, education representatives could perform a
liaison role and ensure that schools pass on relevant information, receive
feedback and be aware of their responsibilities in the investigation and planning
process.

Similarly
the presence of health representatives on the teams would provide a vital link
with health services leading to an improved understanding of roles,
responsibilities and systems, particularly in relation to paediatricians and
adult psychiatry.

The
other major benefit of a multi-agency structure would be to play to the
strengths of the different agencies. In certain circumstances, such as when a
crime has been committed, the police could take the lead, whereas a joint
social work and health approach would be more beneficial for another child.
Joint working of course occurs at present but would be greatly strengthened
through the multi-agency team structure.

The
approach would also build trust between professionals and between professionals
and families, offer families a one-stop service and support, ensure the
involvement of all relevant agencies throughout the process and allow for
focused prevention and therapy.

Victoria
Climbie’s death was not an isolated act, as the deaths of Lauren Wright and
John Smith illustrate. This is the right time to make changes to the system to
prevent more such deaths. The creation of multi-agency teams to undertake the
investigations, assessments and interventions with children and families could mean
a more effective approach to safeguarding children. We owe it to children to
try. CC

–
Comments on the proposal should be sent by 30 November to: Rhian Stone, Policy
and Public Affairs Department, NSPCC National Centre, 42 Curtain Road, London
EC2A 3NH.

Tel:
020 7825 1322; or e-mail: rstone@nspcc.org.uk

Rhian
Stone is child protection policy adviser, NSPCC.

References

¹
NSPCC, Someone To Turn To, NSPCC, 2001

²
Elizabeth Hallet and Christine Birchall, Working Together in Child
Protection, The Stationery Office, 1995

³
Department of Health, Framework for the Assessment of Children in Need and
their Families, Stationery Office, 2000