Leeds United

In
Leeds an inter-agency initiative has seen social workers trained to provide
therapeutic services in child and family work. Team members Dawn Walker and Jan
Hext report.

Social
work has always included therapeutic practice. Over the years the emphasis on
this has varied. In the 1980s it was very popular: residential social workers
routinely used keyworker sessions for life story work; post-abuse work was
carried out by area social workers with child protection colleagues and some
area teams regularly used family therapy in their work. By the 1990s the
investigative child protection and case management aspects of the work seemed
to be emphasised over the therapeutic aspect.

In
1994 in Leeds, a joint initiative by health and social services established the
need for comprehensive therapeutic services to children and families involved
with Leeds social services department.¹ The therapeutic social work
team was established as part of this joint initiative.

Leeds
has higher than average levels of deprivation, numbers of children on the child
protection register and children accommodated. The team undertakes a range of
work including preventive and reparative work with families, assessments of
young people with sexually harmful behaviour, post-abuse work, mental health
work around issues such as self-harm and eating disorders.

There
are 13 posts in the team managed by two co-ordinators and supported by a
full-time and a part-time administration worker. Of the 130 available half-day
sessions, 40 sessions are used in Child and Adolescent Mental Health Service
(CAMHS) teams and 20 are designated for work under Quality Protects. The team
has a commitment to working jointly with the youth offending teams (YOTs) where
an assessment is needed of a young person’s sexually harmful behaviour, and
in-group work programmes for these young people. Forty-five days per year are
contracted to the social services training section to offer training in aspects
of therapeutic work to the range of staff working with children and families.

This
inter-agency collaboration has had a beneficial effect on therapeutic services
in several ways. Health and social services at strategic and operational levels
support therapeutic services for children and families. This collaborative
approach ensures coherent provision of services. Therapeutic services are seen
as being provided by all workers from both agencies across an integrated tiered
system. Field social work staff working with children and families are able to
consult therapeutic social work and health colleagues. Staff may co-work with
more experienced colleagues to develop their therapeutic skills. Social
services referrals for therapeutic work are prioritised by their local area and
considered by the monthly health and social services prioritisation panel,
which holds an overview of all the services available on a city-wide basis and
allocates services accordingly.

The
therapeutic social work team is managed centrally through the Child Protection
Section, providing continuity through assessment (including risk), reviews and
therapeutic work within the department. Referrals come from the monthly
prioritisation panel. There is an undertaking to make contact and begin the
process of intervention within 28 days of the panel referral. Work is generally
undertaken in a setting within the community in which the service user resides.

As
a newly-formed team it was helpful to have shared goals. We all agreed that we wanted
to provide quality therapeutic services to the children and families using
social services, and that these services should complement the work of other
colleagues in the department. We wanted to create an environment in the team
that would support the therapeutic services we offered. A further goal was less
explicit: to emphasise that social workers were able to offer therapeutic
services as relevant and innovative as those offered by health colleagues, more
specifically psychologists and psychiatrists.

The
creation of such a team inevitably brings tensions. On the plus side it is an
innovative way of providing therapeutic services to children and families.
Working with a social worker who does hold case responsibility can often free
the child/family up and lead to a vision of change at the same time as
supporting the role of the area social worker. The team is large and so
includes a range of skills and other attributes which can be matched to the
needs of service users. There is opportunity to share knowledge and skills as
well as co-work cases, which adds to the provision of more holistic services.

Workers
are encouraged in continued professional development, which results in many
having additional qualifications and training in therapeutic work. Despite
having a lot of experience within the team there are times when some of the
work requires external clinical supervision. The team uses a range of
therapeutic approaches including direct work, individual and group work
(cognitive, psychoanalytic and systemic) and systemic family therapy.

Some
ideas have been particularly useful in managing the difference in theoretical
orientation between team members. The idea that different ways of working fit
with different children and situations at different times has been useful. We
would hold that integrating different theoretical models enriches our practice
and creates new possibilities in our work with children and families. All team
members take responsibility for encouraging debate around the use of different
models and approaches without positioning themselves permanently within one
stance.

Some
of the specific tensions we are always working with could be the delicacy of
therapeutic work within child protection procedures and the expectations of
service users and referrers of the cure all intervention. In addition there had
been a story that long-term individual work is preferable over direct, focussed
work. Time and experience have shown that these issues are workable with as
long as we are transparent about our working practices.

The
team has a commitment to evidence-based practice supported by training, quality
supervision and consultation. Interventions provided by the therapeutic social
work team should be evaluated to measure effectiveness for referrers and
service users.

Early
in 2000 the therapeutic social work team began working with the Centre for
Evaluation Studies in Huddersfield which offers single-case evaluation. This
methodology allows a social work practitioner to track their progress systematically
with a service user using the scientific realism model which seeks to evaluate
practice within the realities of society.²

Some
areas of the country have chosen to employ psychologists and psychotherapists
to work alongside social workers. Leeds has chosen to develop the skills of
existing social workers to offer therapeutic services as relevant and
innovative as those offered by colleagues in health. Their training and
emphasis on child protection ensures that consideration is given to the safety
and timing of therapeutic work with service users. Collaboration with health at
a strategic and operational level ensures integrated services for children and
families and promotes the positive working relationships essential for quality
therapeutic services. Additionally, the Social Service Inspectorate commended
the team in 2000, commenting that it was "an example of focused
professional work and had achieved measurable outcomes".

Jan
Hext and Dawn Walker are the team’s joint co-ordinators of theraputic services,
Leeds social services department.

References

¹
D Cottrell, D Lucey, I Porter and D Walker, "Joint working between child
and adolescent mental health services and the department of social services:
the Leeds Model", in Clinical Child Psychology and Psychiatry, Vol
5 no. 4 pp481-489, 2000

²
M Kazi "Putting single-case evaluation into practice" in Cheetham and
J & M Kazi, The Working of Social Work, Jessica Kingsley, 1998

Background
reading

1
See the work of the Safeways Group, Leeds, 1989 and Trafford Metropolitan
Borough Council, 1986; and Oldham Metropolitan Borough Council, 1989

2
D Jones & P Ramchandani, Child sexual abuse: Informing Practice from
Research, Radcliffe Medical Press, 2000

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Reminiscence
– the art of remembering

Mabel
Mowatt discusses how helping older people to reminisce about their lives can
help them overcome memory loss, the scourge of old age.

Anyone
over 70 will admit that one of their greatest fears is losing their memory.
Every time they mislay the keys or forgot what they were going to do, they are
filled with terror that they are suffering from early dementia.

Anyone
supporting an older person to remain at home will have seen the devastating
effect of forgetfulness, from the mild and spasmodic confusion of time and
place, to the life-threatening situation where gas is left unlit. Those who
suffer memory loss on a regular basis find their confidence shattered and their
self-esteem reduced, as simple tasks become difficult. As incidents multiply,
people find that their subsequent anxiety increases forgetfulness.

For
residents of nursing and residential homes their fears of memory loss may have
already been realised and are the main reason for the loss of their home and
independence.

Both
these groups of older people find that memory loss reduces the quality of the
life that they can enjoy. These difficulties are compounded by western society’s
habit of relating to them as old people, not individuals, losing sight of
anything they may have achieved in their lives. Reliving memories may put the
elderly person back in touch with their past life but often the listener
dismisses the "ramblings" as boring and unproductive.

Reminiscence
is the art of reflecting on the past in the company of others, with the aid of
individual memories, photographs and artefacts. When properly facilitated, this
is an enjoyable and stimulating experience, emphasising the value of
experience. Revisiting memories often means experiencing again the emotion
related to them, and can bring back their joy.

Most
reminiscence work takes place in groups, with a trained facilitator who by
using artefacts and photographs encourage participants to share their knowledge
and experiences. The role of the facilitator is to help group members to value
each other’s contributions and to encourage those who are timid of speaking in
a group. Using artefacts helps to stimulate all the senses and often holding an
item releases forgotten memories. The use of items relating to particular
events, such as weddings or World War II, often unlocks memories and allows
listeners to get in touch with the person who has become masked by age and
infirmity. The experience for carers is insightful as they learn more about the
person, but the most profound change can be for the one who remembers as they
feel their contribution valued and life experiences affirmed.

My
personal experience has highlighted the power of smell. The aroma of pipe
tobacco gave me, long buried, mental images of my paternal grandfather. I was
instantly transported to his tobacco pouch, which I illicitly used to sniff,
and I saw him so clearly.

Many
museums now have memory boxes and there are many books and packs available to
encourage reminiscence. Age Exchange, the reminiscence centre in Blackheath,
London, is an important resource for items and training courses. Although group
work requires an experienced facilitator the aims of reminiscence can be
applied to individual conversations, either between carers and residents or at
home. Employers of carers should value time spent encouraging reminiscence,
providing it is aimed at increasing self-esteem and reducing the negative
effect of forgetfulness. Education of care assistants and home helps is
essential if this is not to deteriorate into idle chitchat masquerading as
reminiscence.

Reminiscence
lessens the impact of everyday lapses of memory, revisiting moments of
enjoyment. It is not by chance that the media are fascinated with nostalgia; it
reflects the pleasure of reliving the past and reminds people they were not
always old and should not be defined by age. For the elderly person, at a stage
of life where there is often loss of abilities, reminiscence increases
confidence and self-worth, because others are stimulated by what they say.

It
is not enough to feed and clothe our elderly population. There is much more to
learn from the history of residential child care, where institutional care
failed to nurture the child. As individuals become increasingly infirm and
require help we must aim to care for the whole person, offering holistic care,
which includes giving them the opportunity to be affirmed as individuals.

Mabel
Mowatt is a freelance tutor specialising in psychological issues in illness and
loss, and a part-time hospital-based social worker in Edinburgh.

———————————————————————————

The fight for safety

Social
services director Liz Railton describes how her department has improved its
child protection system and come off special measures, but also reveals the
difficulties of maintaining progress.

Social
services departments have rarely been more in need of good news stories than
they are now. The lifting of special measures from Cambridgeshire social
services is a good news story for staff and users – but it has a chillingly
familiar background. The stories emerging from the Climbie inquiry and from
Norfolk evoke the starkest of memories – the death of a child who should have
been protected, the mounting numbers of case files containing stories of
potential risk that are never properly evaluated, the shortages of staff and
the sheer sense of overload, pressure and chaos. That was Cambridgeshire
throughout the late nineties.

It
is possible to come through this and earn the confidence of external
scrutinisers. "We judged that the foundation had been laid for a safe
child protection service that would continue to work hard on developing
services and practice" is the verdict recently delivered by the Social
Services Inspectorate. Today the service spends less than it did but, according
to the recent star-rating system, has earned 74 stars out of a possible 81.

However,
the notes of caution are loud. It has taken more than three years of focused
effort to reach this point and yet every day we question the sustainability of
our position. We are conscious, as are children’s services across the country,
of the fragility that lies behind any concept of safety. We think recruitment
of social workers is going relatively well – but only because we have learned
to live with the constant level of vacancies. Experienced staff are at a
premium and as they retire or move on we do not replace our losses of such
staff at anywhere near the same rate. The commitment of other agencies seems
vulnerable. Schools and health services are under enormous pressure. Their
staff attend conferences and do contribute to the core group work that lies at
the heart of multi-professional support to children, but we are on the watch
for backsliding, and constantly patrol the boundaries of their commitment.

The
position in Cambridgeshire now is that we look after 25 per cent fewer children
than we did in 1998 and we have more than a third less children on our at-risk
register. Many more children receive intensive support without resort to these
interventions and a third of our resources are devoted to family support.
Although the council was already a relatively high spender on children’s
services a decision was made to inject more funds into the service on a
short-term basis in order to improve family support services. These services
were simultaneously reviewed in order to ensure that they could be used to best
effect within a refocus strategy. As this strategy began to bite significant
savings accrued from reductions in legal proceedings and in the numbers of
looked-after children. In the longer term these savings have more than covered
the increased investment in family support.

However,
the scale of change required was immense and placed at risk the commitment of
staff in a situation that was already fragile because of recruitment and
retention difficulties. Staff experienced significant organisational and
practice changes intended to transform assessment and care planning and ensure
a much stronger focus on improving the lives of children. These changes have
been accompanied by regular audits to check on the impact of these changes and
to identify further improvements. Staff have felt the presence of a large
family of "big brothers" constantly watching them.

These
changes made little sense at first. They added to the pressure of work,
heightened the sense of risk and the fear of getting things wrong. It is only
relatively recently that there has been evidence that front-line staff feel a
greater level of confidence in the strategy, in the support from senior
managers and in the ability of the service to cope with demand and complexity.

Nevertheless,
we worry. Morale is relatively high but the pressures at the front line are
relentless. We struggle to find enough foster carers, and budgets could be
busted as we fork out money we do not have in order to pay for the skilled care
that many of our children need. Today, as I write this, we have a very troubled
young person, subject to a secure order, whose behaviour is such that no secure
unit in the country will take him.

Our
message is – we may be doing well on all the objective criteria and we have
addressed a huge agenda of cultural change and performance improvement, but we
think children’s services everywhere are in crisis because they are
underfunded, undervalued and very complex to deliver. No amount of
modernisation will conceal this fact. 

Liz
Railton is director of social services, Cambridgeshire Council.