What serious case reviews reveal about working with the ‘toxic trio’

For social workers, knowledge alone is not enough, writes Perdeep Gill

Photo: Chameleons Eye/REX Shutterstock

By Perdeep Gill, social care and safeguarding consultant

We often bandy around the term ‘toxic trio’ without really thinking about what it means for our practice when domestic violence, mental ill-health and substance misuse are all present in a case.

Community Care Live London 2016.

Perdeep Gill will be speaking about what serious case reviews reveal about working with the ‘toxic trio’. Her session will cover:

• Practical steps for exploring and better understanding the level of risk
• Making meaningful assessments and interventions in cases involving the ‘toxic trio’
• What lies beneath the practice failings identified by serious case reviews

Book here.

Toxicology usually focuses on a known toxin – the dose and/or level of exposure – or an interaction of ingredients that together creates a toxin.

The challenge when safeguarding children is how to make sense of the ingredients that are present:  the type, the amount, the dimensions, the context and the impact on different families.

Serious case reviews can offer us a chance to reflect on what we do in practice and why we do it (analysis and reflection that is often missing from the actual reviews themselves!).

The Daniel Pelka SCR, for example, throws up some interesting questions for our social work practice. For example:

  • There were many shared reports of domestic abuse and parental intoxication. Yet the assessments were often lamentably superficial with a singular focus on presenting incidents and shallow solutions. Why? Does this activity reveal our unconscious helplessness in dealing with these issues? Do we often do something, anything, to give ourselves a false sense of security rather than face the more difficult task of unravelling what is happening behind closed doors?
  • The SCR shows that professionals failed to explore the history, family functioning and dynamics both within and without the context of domestic and alcohol abuse. Why? Were professionals desensitised? Were danger signs normalised and minimised in our minds? What impact did that have on the children?
  • Daniel had a spiral fracture and multiple bruising and the explanation given was of an accidental injury. Although the original medical opinion said the injury involved significant twisting we gave more weight to the parent’s account when it was verified by a child. Did we ask ourselves simple questions at the time? If there was abuse, how probable was it that a child interviewed through mum’s friend would disclose? What is the likelihood, if abused, that children may be groomed not to disclose?

 
Once we discard the possibility of abuse then it is all too easy to create a mindset that in all likelihood means we will then later fail to recognise the later signs of it.

It’s not enough to see things, we must constantly ask ourselves if we understand what we see.

Learning from serious case reviews with Community Care Inform
Community Care Inform Children subscribers can use our Learn on your Lunch resources to run group sessions or for individual CPD, reflecting on the learning from serious case reviews. The session on the Blake Fowler (Child K) SCR explores how practitioners approach complex domestic violence cases and how to avoid some of the traps that professionals involved in this case fell into.

Find information about subscribing to Community Care Inform here.

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3 Responses to What serious case reviews reveal about working with the ‘toxic trio’

  1. Denice August 31, 2016 at 10:53 am #

    I don’t understand why you would not look at family history and functioning etc. Are we still not learning from SCR’s before and after Pelka?

    • Nina September 1, 2016 at 8:24 pm #

      I agree, Family history, Functioning and intergenrational family functioning etc, is fundamental to any assessments. Good social work is developing an understanding and attunement of the childs world.

  2. Ellie September 5, 2016 at 11:48 am #

    Sadly, I can say from personal experience that family history, functioning and intergenerational functioning are not always considered when it comes to child welfare cases. This can have a HUGE impact upon the life of the child (it did in respect of mine!) because all manner of contributory factors that may lead to ongoing problems in a family get missed.

    Unfortunately, this is an issue that I now understand may be much more complicated than first it appears. It is not only Social Workers who may fail to understand the importance of such information – other care workers including Nurses, Doctors, Health Visitors… may also fail to see that a comprehensive history of the family and of family functioning is crucially important. Indeed, I firmly believe that some of the biggest mistakes and failings are committed by District Nurses and Health Visitors, who are the people most likely to visit a family shortly after a baby’s birth, and who may or may not refer to Social Services on the basis of what they see.

    ALL health and care professionals involved in a case have to comprehend the fact that it is vitally important to appreciate family history and functioning. Problems in a family may well be firmly entrenched and longstanding, and could well reflect issues that are intergenerational in nature. If this is not appreciated, then workers also fail to appreciate the impact of such issues upon a family’s functioning as a support network. In any dysfunctional family, there is likely little or no support network, because family problems distort the family members’ relationships, leading to breakdown and to haphazard (or no) contact with each-other, thus destroying any support network available within the family. When family members are raising kids, or may be at risk of abusing kids, such extended family support networks are crucial as they may provide safe havens for abused kids, and are extra eyes and ears to witness the abuse. Workers who do not find out about such things are workers doing a poor job.

    Sadly, the blame cannot lie completely with care staff themselves. Sometimes, we have to accept that abusive and potentially abusive families in which the “toxic trio” may be common are families who may be keen to pull the wool over the eyes of any care staff with whom they are involved – they become very good at lying to, and fooling, Health Visitors, Social Workers, the lot. It is important to remember that fact that what goes on behind closed doors within a family is not always the same as what goes on in public. Many abusers and their families present an idealized image in public. They also know to present this same idealized image when receiving visits from care workers and suchlike.

    The Pelka case is, in my eyes, typical of how abusive families operate. From personal experience I can tell you that abusive parents and family members who collude in abuse often do “groom” their children NOT to disclose abuse or to tell on them. This “grooming” can be subtle mind games, such as convincing a child who is being hit or slapped that such violence is “disciplinary” and “for the child’s good”. Children who are physically attacked by their parents or family members may find themselves very confused as to why it happens; abusers will frequently attempt to make the child believe that the child “deserved” such treatment because he/she is “naughty” or has some other “undesirable” trait. Children will be told this even when it is NOT true. Added to this, other parents use direct threats or scare tactics to silence abused kids, such as insisting that if the child tells anyone they “will not be believed because no adult will take a little child’s word over a parent’s”, or because “all adults know that children make up stories”. Abusers are VERY good at getting inside the heads of abused children, and making them believe a pack of lies. This pack of lies generally serves to make the abused child feel guilty, bad, and responsible for doing something that caused them to be abused. The lies also paint the abuser in a more positive light than they deserve. What abusers want is for their victims to believe that they are alone and have nobody to go to who can be trusted to help them.

    Families in which the “toxic trio” exist are also pretty good at hiding signs of this, or at obfuscation and clouding of information. It may be very difficult for workers involved with the family to get a clear and accurate picture of what is occurring within the family, or why a family member behaves the way they do. Such family members may be adept at giving “piecemeal” information, or at leaving out important facts. They may deliberately play a game in which they tell different stories to different people they come into contact with, so as to confuse people as to what the truth is. Indeed, they may even be outright liars, such as a parent with mental health problems who stops taking medication but who tells a Health Visitor or Social Worker that they are still reliably taking their pills. The impact of this on a parent’s ability to care for a child may be significant, but could go unnoticed until said parent begins showing very obvious signs of mental instability. We should be aware that some individuals with mental illnesses and/or substance misuse problems are notorious when it comes to refusing assistance and treatment, or hiding the facts of their mental health or substance misuse problem. The covert nature of their issue, and the devious behaviour that may be associated with trying to hide such a problem, makes it hard for workers to engage effectively with them because such a parent will not wish to disclose information to a care worker. Instead, they could refuse visits, act aggressively to drive workers away, deliberately choose to live a transient lifestyle in which they rarely put down roots (so as to have as little contact with regular care services as possible), or lie and present a more rosy picture of family life than truly exists.

    Workers need to be aware of all such matters – and need to be alert to potential problems that may arise because of the “toxic trio”. I cannot help but think that empathy is important here. It’s about considering how you might behave if you were a substance misuser, mentally ill, abusive and a parent. I know that this is not empathy in the sense that we usually like to consider it – in a positive fashion – but we should still be able to think about what we might do if we found ourselves in the worst case scenario. My point is that even abusive people have some kind of motivation to ac as they do. They also have thoughts and feelings that may lead them to behave in certain ways. Added to this in respect of the “toxic trio” are mental illness and substance misuse. Workers should consider the likely impact of such things in respect of propensity to cause irrational behaviour – for instance, drug taking or mental illness may lead to paranoia (which affects behaviour); a person who is regularly drunk, or high on drugs may not be in a fit state to provide adequate child care; the need to feed a drug or alcohol habit could lead to financial problems for a family… Workers should be getting family history to see if things like this have happened before. They should also be considering the possibility of them happening in the future. This does not mean automatically removing kids into care; but it does mean that workers should remain constantly alert to the potential dangers arising from the “toxic trio”.