Rebuilding a life

    Social worker Philippa Havill talked to Mike George about her
    decision to admit a teenage girl who had been abused to psychiatric
    care rather than allow her to be subject to possible
    recriminationsfrom her mother and siblings.

    Can the lengthy, ongoing debates about the relative values of
    family-centred preventive work and the child-centred focus of much
    child protection work ever arrive at a satisfactory conclusion? For
    as social care staff know only too well, the answer is usually,
    “well it depends on the circumstances”. And in some circumstances,
    the urgency and importance of child-centred child protection work
    overrides broader family-oriented support.

    Philippa Havill, a senior practitioner in an NCH project, has
    had to take this view in her work with teenager, Amanda Harris (not
    her real name), despite the fact that her family appears to be in
    great need of some form of intervention.

    Amanda was sexually abused by her father for many years before
    she disclosed this, and from Havill’s subsequent work with her it
    seems that her mother might have been aware of the abuse.

    However, her mother has learning difficulties and so had been
    unable to give her daughter any protection. She also had her own
    emotional needs arising from her husband’s abuse of her
    daughter.

    After disclosure and a subsequent investigation the father was
    prosecuted, and convicted. But Amanda was extremely distraught at
    the time, and after gaining her consent, social services referred
    her to Havill for both pre-trial support and subsequent work to
    help her process the trauma of abuse. The strain of the lengthy
    delay before the case came to court, and the court proceedings
    themselves, added significantly to her distress: among other things
    she had suicidal thoughts, nightmares, disturbed sleep, and eating
    problems.

    Havill says that at the time she was so worried about Amanda’s
    vulnerability that she had no option but to help arrange an urgent
    psychiatric assessment. “She was crying almost uncontrollably and
    was basically unable to function, meanwhile I found that her mother
    couldn’t intellectually or emotionally grasp how her daughter was
    feeling. I didn’t really want her to be admitted into psychiatric
    care, because I was afraid that this would lead her to label
    herself, something she really didn’t need at the time, but I felt
    that her immediate safety was more important.”

    At first, the risks associated with Amanda’s subsequent
    admission to a residential psychiatric facility for young people
    loomed large. “She was terrified,” says Havill. “I worked very
    closely in the initial stages with the unit’s therapeutic staff,
    and contacted her frequently to try to help reduce her fears. I was
    also worried that she might be exposed to, and perhaps learn
    self-destructive behaviours from other young residents.” However,
    these concerns receded, as Havill could see that Amanda was
    responding positively to the boundaries, and the types of
    acceptable relationships and behaviours she encountered there –
    none of which she had experienced before. She was also, for the
    first time in her life, living in a safe, protected
    environment.

    Havill attended the regular reviews of her progress, together
    with a social worker from a children’s team and an educational
    social worker – both of whom worked with her throughout. This
    multi-agency work proved effective; after several months, with
    Amanda’s agreement, she was discharged back home; she had also
    agreed to a programme of work with the project.

    Before discharge, Havill and her colleagues carried out a
    comprehensive risk assessment. They were concerned about the
    possible impact of her mother’s attitude towards her; her mother
    was essentially blaming her for breaking up the family. There were
    also worries about her older siblings’ behaviours, which was
    putting them, and possibly Amanda, at risk – again her mother was
    unable to protect her.

    She explains that they eventually decided that any serious
    attempts to persuade Amanda to leave the family home would
    reinforce her sense of loss of control. For while she had
    progressed substantially, and was beginning to be able to “rethink”
    what happened to her without being overcome by the emotional
    turmoil caused by the abuse, she had not really been able to start
    addressing the loss of her parents. So despite the fact that living
    at home could undermine her new-found sense of self-worth, this
    risk was judged to be outweighed by effects of another stressful
    and distressing event.

    This decision appears to have been the right one, says Havill.
    For while she continues to be concerned about the family, Amanda
    has subsequently gained emotionally and psychologically from their
    regular work together. Although there are still some problems in
    her relationships with peers, she has managed to form some good
    relationships, not only with adults she trusts, including Havill,
    but also with a few friends. Not surprisingly, she is very behind
    with her education, and this continues to exercise Havill and her
    colleagues, though together they are beginning to map out a
    training strategy for the future.

    “She still has flashbacks and nightmares, but is now much more
    able to cope with them. She has also developed a healthy sense of
    self-respect, and is learning very well how to interact with the
    wider world. At a personal level she is a bright and delightful
    person, and we all admire the way in which she has managed to cope
    with, and move beyond, the terrible traumas she has
    experienced.

    “We have reached a point where Amanda wants to consider
    independent living options, though it seems likely that this will
    at some point lead her into having to confront feelings of
    emotional abandonment, especially by her mother,” Havill says.

     

    Case notes

    Social worker Philippa Havill

    Field: Senior practitioner in an NCH project.

    Location: North Wales.

    Client: Amanda Harris (not her real name) is in her mid teens.
    She had been sexually abused by her father since early childhood,
    and disclosed this a few years ago. The subsequent investigation
    led to a prosecution. Her mother, as a result of having learning
    difficulties and other problems, was unable to support her either
    before or after the trial. Similarly, she has received no
    understanding or help from her siblings.

    Case history: Social services referred her to the project for
    pre-trial support and subsequent work to help her process the
    trauma arising from the abuse. She was having suicidal thoughts,
    severe difficulties in sleeping and was in other ways experiencing
    major emotional problems.

    Her father was convicted, but the trial process itself had added
    to her trauma. Consequently Havill became even more worried about
    her emotional state and arranged for a psychiatric assessment.

    She was admitted to an NHS residential psychiatric facility for
    young people, and after initial trepidation she began to make
    relationships, learnt about appropriate and inappropriate
    behaviour, and the value of boundaries. Meanwhile Her mother had
    been offered support, but did not take it up. Havill kept in
    regular contact, and after Amanda agreed to be discharged some
    months later she undertook a long-term programme of work with the
    project. Her emotional state improved, her symptoms of distress
    abated gradually, and she began to develop self-esteem.

    Dilemma: Should her mother’s difficulties be addressed more, or
    is it better to support Amanda to become independent?

    Risk factor: The family home environment has severely hindered
    her emotional and psychological recovery, but if she left this
    could add separation trauma to her problems.

    Outcome: She is discussing independent living options with
    Havill and her local authority social worker.


    Arguments for risk

    – Throughout most of this period she has been living with family
    members who are totally unsympathetic to the problems she has
    faced, and Amanda has responded by being overly-responsible towards
    them; it is very unlikely that she will experience anything other
    than extremely dysfunctional family relationships.

    – Despite the considerable efforts made to support her, the
    betrayals and feelings of loss associated with both parents have
    and will continue to affect her emotional development.

    – She continues to be afraid that her father will return. Her
    education has been severely disrupted and she still hates going to
    school; some peer relationships are difficult.

    – Her gradual recovery has depended largely on the trusting and
    completely open relationships she has had with Havill and her local
    authority colleagues; she is less likely to experience this as she
    moves into the wider world.

    Arguments against risk

    – Since experiencing the original traumas she has shown a
    remarkable degree of resilience in the face of many very
    distressing episodes. She appears able to cope with destructive
    family members.

    – She has developed the capacity to trust others, as long as
    they are being honest and open.

    – Her intellectual and emotional functioning has improved very
    substantially, and this seems likely to improve further in the
    future: similarly, she has developed self-respect.

    – She has now developed an independent social life, and has
    other out-of-school interests.

    – She has been capable of making a considered decision to move
    out of the family home.

    – Havill and her colleagues will continue to support her, if she
    wishes.

    – Despite her poor educational record she is bright, capable and
    interested in many aspects of the “outside world”


    Independent comment

    The dilemmas here include the question of whether practitioners
    should work with mothers whose willingness or ability to be
    protective are compromised, writes Marie Lebacq. Practice in this
    area is underdeveloped despite knowledge that mothers who are
    supportive are contribute greatly to their child’s recovery.

    Meeting Amanda’s emotional and psychological needs regarding
    self-esteem, identity and separation from her mother as she reaches
    adulthood cannot be delayed during work to enhance her mother’s
    potential as a nurturing parent.

    There is ethical and therapeutic justification in focussing the
    work on independence based on Amanda’s stated wishes, her life
    stage and her experiences of powerlessness. The foundation for this
    work established through Havill and the residential psychiatric
    facility’s intervention. Havill’s concern about such placements
    remains important, even though the intervention worked for Amanda.
    It offered multi-agency work involving a consistent group of
    practitioners in regular contact and the development of
    significant, stable relationships with Amanda. Is it possible to
    access the same in a less stigmatising environment?

    Continued multi-agency involvement is required to provide
    education and therapeutic work within a practically supportive
    environment to complete Amanda’s transition to adulthood.
    Educational success enhances general life chances and helps to
    establish an identity beyond being a survivor of sexual abuse.
    Neither a residential childcare placement nor supported housing is
    ideal, illustrating a gap in suitable “half-way” provision for
    vulnerable young people.

    Amanda’s status raises key legal and policy issues. The council
    has the power to help her as “a child in need”, but few statutory
    obligations. Her level of vulnerability in respect of long-term
    outcomes is comparable to those of a “looked-after child” but she
    is not entitled to the same level of support.

    Marie Lebacq is senior lecturer, Institute of Social
    Work and Applied Social Studies, Staffordshire
    University.

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