A long journey to rediscovery

Twelve-year-old Sabera Miah was known to the multi-agency
preventative (MAP) project, which works with young people in
secondary schools who are at risk of developing mental health
problems. She had been experiencing emotional difficulties at
school.

However, having disclosed physical abuse by her father, the manager
of the MAP project, Maswood Ahmed, was concerned that
investigations were stalling. Although its remit is not foremost
child protection, “the possibility of emotional damage and
subsequent mental health problems were sufficiently concerning for
us to push for action on this case”, says Ahmed. Sabera was then
placed on the child protection register – under two categories:
physical abuse and emotional abuse.

“We were contributing to the care and protection plan, but this was
taking time, and we began to see the situation deteriorating,” says
Ahmed. Indeed, a couple of months later Sabera took an overdose of
epilepsy medication. And a few days after discharge she was
re-admitted after taking a second overdose. “This finally made
people wake up to the seriousness of Sabera’s mental health. To us
it became clear that these acts were symptoms of someone very much
emotionally troubled,” says Ahmed.

“It was a complex situation. Sabera had clearly understood that by
displaying suicidal tendencies she suddenly commanded a lot of
anxious attention.”

Despite it being a risky step to take, all agencies agreed that it
would be best for Sabera to return home. “While the area team
social work input continued, a social worker and youth worker from
my team began working with and supporting Sabera, ensuring time and
space to express her feelings and worries,” Ahmed says.

Ahmed also thought it important to engage with the mother as the
non-abusive parent. “We started to involve her in a mothers’
support group. We found out that she was a victim of domestic
violence. This had made her feel, at times, helpless in dealing
with her own problems, which was why the children weren’t best
protected.”

Both parents admitted they needed to change their approach and
attitudes towards Sabera. “We made a specific programme to help
them recognise problems in their behaviour and how that impacts
negatively on Sabera’s behaviour,” says Ahmed.

MAP set about boosting Sabera’s confidence. “We engage young people
to participate in holiday and out-of-school recreation activities
that can improve self-esteem,” says Ahmed. “We gave her specific
but achievable tasks that gave her a sense of achievement and
self-worth. These led directly to a remarkable improvement in her
attitude and behaviour.” Home life was also improving with no
reported violent incidents.

Educationally, however, Sabera remained de-motivated and
underachieving. The family suggested that she be sent to Bangladesh
to be educated in a private religious institution with a more
discipline-oriented approach. “We were concerned about that because
this was an alien situation for Sabera,” says Ahmed. “She did not
know the country and would be in the care of extended family. She
may face difficulty adjusting to the educational and social
environment.” More worryingly, and still on the child protection
register, she would be escorted there by her father.

“We could have taken legal steps to prevent her leaving the
country, but decided ultimately to let her go,” says Ahmed.

However, Sabera was enthused by the idea. She also thought that if
she remained in Britain she would slip into drug use, as had her
friends and older brother. Also, it was felt that the family could
be trusted, given their co-operation so far.

A multi-agency case conference decided to keep Sabera’s name on the
register for emotional abuse, carry out checks on the institution
and monitor progress by telephone.

Although having reservations, Ahmed thought it might be a positive
experience. “People going from this country are seen in almost the
same regard as celebrities,” he says. This would undoubtedly
benefit Sabera’s self-esteem. To a large extent this happened.
Although Sabera returned to the UK after six months, it proved a
positive experience. Her behaviour has also improved. She did
re-engage with education, but progress was stilted, and is now
awaiting placement in a residential school conducive to her
learning needs.

The MAP project will continue to work with Sabera, helping her
settle in her placement before withdrawing. You could say that with
the project’s help Sabera’s good mental health and, indeed, future,
has been well mapped out.

Case notes

Practitioner:   Maswood Ahmed, manager, multi-agency
preventative (MAP) project. 

Field: Working with young people in secondary schools who are at
risk of developing mental health problems. 

Location: London. 

Client: Sabera Miah is a 12-year-old girl, living with her
parents and brother.  

Case history:   Sabera, who has special education support, was
referred to the MAP project – a multi-agency team comprising social
workers, youth workers and clinical psychologists – just after she
started at secondary school. Teachers, who were familiar with the
MAP project’s work, felt she would benefit from one-to-one support
to help with some emotional difficulties. An initial assessment
identified some problems at home but remained inconclusive. Soon
after this assessment, Sabera arrived upset at school one morning
and disclosed that she had been struck by her father with a hockey
stick. She had some bruising on her body.  

Dilemma: As the complexities of the case were revealed it became
clear that although she had been physically abused by her father
and emotionally abused by both parents, Sabera had a strong
attachment to her home environment. As a result she would refuse
placements in foster or residential care.  Risk factor:  Permitting
Sabera to remain in the care of her father (in particular) and her
mother put her at risk of further abuse.  Outcome: Sabera’s
relationship with her parents is improving and she is awaiting a
residential school placement.

Independent comment   

The MAP project appears to be a good,  co-ordinated, assertive
and proactive service with a mix of youth workers, social workers
and clinical psychologists, writes Eric Davis.  

Probably the most important factor facing Maswood Ahmed was that
Sabera was referred to a service that was culture- and
youth-friendly and which appeared to communicate well internally
and externally with other youth-connected agencies. Lack of
communication where there is a known element of risk often results
in a poorer outcome for the at-risk individual.  

The MAP team was faced with difficult decisions connected to
Sabera’s care and well-being. Sabera wished to remain with her
family despite clear evidence of physical and emotional abuse. The
dilemma for the MAP team was to foster a sense of alliance with the
family while keeping in mind child protection issues.   

Sabera travelling to Bangladesh also raises complex issues. The
element of risk remains, not least because of her father’s
presence. Here, the father could be seen as trying to exert more
control from a dominant position. From Sabera’s viewpoint several
advantages accrued.  

The MAP team weighed up the risks well. For the future, the MAP
team should be encouraged to assemble a risk management plan which
indicates the risk factors for Sabera and which attempts to specify
the conditions under which she may remain with her family. 

Eric Davis is consultant clinical psychologist with
Gloucestershire NHS Partnership Trust. 

Arguments for risk 

• While unhappy about her parents’ traditional attitudes Sabera
  had a strong attachment to home and, by working with the parents on
  changing their attitudes and approach to parenting, she could
  remain at home with safeguards in place. 
• Sabera had serious emotional deficits and these needed to be
  repaired by working with the family together. To move Sabera out
  would be counter-productive and add to – not mend – her sense of
  physical and emotional isolation. 
• Work on Sabera’s self-esteem and confidence was seen as crucial
  for her emotional self-worth. While venturing somewhat into the
  unknown, the proposed move to Bangladesh, although fraught with
  concern, could offer positive benefits. Also Sabera herself was
  enthusiastic about the idea and to deny her might cause
  resentment.  
• The only way to prevent Sabera from leaving would be through
  legal action and this was felt excessive given the positive
  developments made with the family.     

Arguments against risk 

• With the father’s history of domestic abuse, it is difficult to
  see how Sabera can ever be placed at home safely. A traditionally
  male-dominated household, discipline and obedience are seemingly
  physically enforced. 
• Similarly, it appears that the father was the main mover behind
  the plan to send Sabera to Bangladesh. The fact that he escorted
  her alone also raises concerns. Seeking to isolate his daughter and
  keep her with unknown (to social services) members of his extended
  family could be seen as a plan to silence Sabera and to bring her
  into line.  
• That the education she was to receive was to be provided by a
  religious institution with traditional ways of discipline and
  compliance might not be conducive to promoting self-esteem and
  confidence. The potential social and educational isolation of being
  in a foreign country – albeit the family’s heritage country – could
  be seriously damaging to Sabera’s frail mental health.