Social workers pioneer new approach to personality disorders

On a suburban street in Holloway, behind a shopping centre, sits a small building that resembles a nursery with its clean, light rooms and abundant toys, photos and cots.

In fact, that’s exactly what it used to be, but the building is now the focus of a new way of working between mental health services and social workers in Islington.

Minna Daum, one of the project leads and a family therapist with the Anna Freud Centre in London, says social workers often become paralysed when faced with parents who are hostile or intimidating – or, in clinical speak, show signs of personality disorder.

“It’s hard to see the child and what the risks are because they are having to deal with the immediate problem of the parents and their anger,” Daum says. “The system becomes paralysed because there’s a lack of services for these parents, so social workers are faced with closing the case or escalating it into a child protection issue.”

Co-project lead Dr Duncan McLean, a psychiatrist, worked with adults in mental health services at the Maudsley Hospital day centre and became keenly aware that services for parents with mental health problems were minimal.

“Adult services don’t cater for those with children but if you have a child under five what are you supposed to do with them while you go for treatment? It’s a massive gap and effective transitions between child and adult mental health services are non-existent,” he says.

Shadowing social workers

The pair’s belief that parental problems could be resolved much earlier in the process prompted them to apply for government funding to set up the Early Years Parenting Unit (EYPU) under a service level agreement with Islington’s children’s social care.

The EYPU only takes referrals from social workers who believe children are at risk of being taken into care. Anna Freud therapists were allocated to social work teams after shadowing them and undergoing IT and data-sharing training so they could have (read-only) access to files.

Psychologist Nicola Labuschagne says the team still work closely with social workers and will go out on joint visits with them, “so we know what the social worker’s concerns are and what needs to happen or change for their concerns to be reduced”.

In the year since the unit opened 15 families have entered the programme. In four of the families the risks have reduced to the point where children who were about to be taken into care have instead been placed on the child-in-need register.

Labuschagne admits the commitment – two days a week for 18 months – feels overwhelming for many parents, but says once they start most understand the need for it and enjoy the visits. What makes the EYPU unique, according to McLean, is that the same staff deal with all three presenting issues in one place – the parent’s own problems and mental health, their parenting and the child’s developmental problems.

However, the unit’s funding will come to an end in April 2013. The team is applying for more, but there are concerns for its future with cash-strapped local authorities reluctant to take on extra spending.

A parent’s perspective:

Two years ago Ray Holloway, then recently released from prison and living in a one-bedroom flat, faced the awful prospect of his three children being taken into care because their mother could no longer cope. “I’d missed my children so much while I was in prison,” says Ray, now 29. “I realised they gave my life meaning. My father had never been around so I was determined I would be there for them now.”

The children’s social worker was unsure, however, because even after a 13-week parenting course Ray still had anger issues. It was suggested he should attend the Early Years Parenting Unit and he agreed “because I would do anything for my children”. He admits he was a bit overwhelmed at the size of the commitment but is adamant it was worth it. “My previous parenting course was only 13 weeks and really you don’t learn anything from 13 weeks. But being in this place has made me a better parent.”

A social worker’s perspective:

For Gavin Swann, operational manager at Islington’s children-in-need service, the unit has been incredibly valuable, not least because it’s led to changes in social work practice and the council’s complaints procedure.

While social workers agree not to close a case for the 18 months of treatment, in return the unit’s therapists provide training for social workers on techniques to handle hostile parents. “I don’t think we appreciated just how big this issue was for all of us,” says Swann. 

“The Anna Freud centre has given us the tools to manage it, which has completely changed our way of working. Not only are we dealing with parents better, and coming up with better care plans and child protection plans, but we’ve changed our complaints system too because hostile and intimidating parents are often voracious users of it.”

Although the team has only been working like this for a year – not quite enough time to be able to demonstrate concrete outcomes – Swann believes it is the future.

Case study: How cost-effective is the EYPU?

SL is a 34-year-old West African woman whose son was subject to a child protection plan because of neglect from birth. Her early life in Africa was traumatised by sexual abuse, rape and physical violence until she was trafficked to the UK as a sex worker in 2004.

Before the birth SL had already been a regular user of mental health services after numerous attempts to commit suicide. Attempts to abort her unborn child meant the boy was placed on a child protection order as soon as he was born. SL was pessimistic about her ability to look after her child, but following 18 months of treatment at the EYPU the risk has reduced. Her son is now on a child-in-need plan requiring just one visit from social workers per month.

An 18-month programme costs £39,750 per parent. Below is a breakdown of the estimated costs, and savings, of SL’s treatment.

The unit can also predict the possible savings of SL’s treatment. Had her son been taken into care at birth, the social care and legal costs could have been as much as £208,600. Had he remained on a child protection plan before being taken into care aged four, the costs could have been as high as £814,000.

Figures sourced by Anna Freud, Early Years Parenting Unit and Islington Borough Council