The name of the service user has been changed
Practitioner: John Ball, therapy consultant.
Field: Young people who display challenging behaviours and mental health problems.
Location: Southern England.
Client: Dwight Johnson is now 19. His parents split up soon after he was born. He stayed initially with his mother.
Case History: There were concerns about Dwight from birth but nobody was sure why. He seemed autistic and his development was slow. It was not until several years had passed that it was discovered that Dwight was deaf. His notes revealed that the deaf nurse visited, gave his mother some leaflets and wasn’t seen again. When Dwight was 10, his mother decided to move to another European country with her new partner. Dwight was invited but being deaf in a non-English speaking country with a different deaf language would have been problematic, so he stayed with his father, with whom he had a difficult relationship. Dwight had never been challenged about his behaviour by his mother, but his father challenged him a lot. With his school unable to cope, Dwight was moved to a residential school for the deaf. His father would pick him up every weekend. The situation was becoming more stable when his mother returned permanently. Then his behaviour worsened.
Dilemma: Dwight fitted the criteria for several services, some of which argued over who should take on his case.
Risk Factor: Dwight’s behaviour is escalating to attempted suicide.
Outcome: He is now living in his own house with support from a team of six care staff.
Sometimes, despite the best efforts of the care system, there will remain young people for whom services fail. They are the ones at the end of the road, with nowhere else to go.
One such young person is Dwight Johnson. A traumatic childhood, strained parental relationships and his deafness – which took several years to diagnose – contributed to his challenging behaviour. Referred to a specialist child and adolescent mental health service in London as a teenager, he was rejected after three months for being “too difficult” – and because of his “borderline personality disorder”. So he went to a specialised service dealing with borderline personality disorders – and it couldn’t deal with him because he was deaf.
He moved to another provider which coped but which felt that it was only “warehousing” him. After several suicide attempts (he strangled and scratched himself, ate glass and jumped out of windows), Dwight was moved to a secure unit.
The unit asked private provider New Forest Care, which specialises in working with young people when all else seems to be failing, to assess him.
Dwight’s case was overseen by consultant therapist John Ball. “For the first week or two I do research on young people. I go and view their original social services files. I talk to parents and other people who have known them since they were small. I go to placements that have been important to them. I’m looking for what the potential is rather than what the situation is.”
New Forest Care does not assess young people to fit into a regime. “They are assessed to find out what needs they have and what service could be configured by the organisation to meet those needs,” says Ball.
Dwight’s assessment recognised the possibility of an emerging personality disorder but was complicated by the communication factor. “In order to get your attention a deaf person might grab your hand or get hold of your face and point it towards them – because unless there is eye contact they can’t talk to you.”
But Ball needed to consider emotional communication. “As a hearing person, if you want to show somebody that you are fed up you might sigh heavily and look out of the window, or drop a pen to make people look at you. You take action rather than say ‘I’m fed up’. How would a deaf person do that? It would seem to me entirely reasonable for a deaf person to throw something, or scratch their arms, or put something around their neck: they’re saying, ‘Look at me, I’m not happy’.
“You could see that as a symptom of an emerging personality disorder or you could see that as completely disordered communication. If you see it as the former – all you can do is wait until he’s 21 and place him into a therapeutic community. If you see it as the latter, you can work on communication.”
It was a conclusion that took about six weeks. Ball says: “It’s actually about sitting and watching people and working out what is going on: making and testing hypotheses – all this very old, low-tech stuff that we’ve been doing over 30 years.”
Dwight, now 19, is in a single occupancy house with a staff team of six. “New Forest Care doesn’t use agency workers so Dwight knows all his staff,” Ball adds. They are all learning British Sign Language (BSL) stage 1. “My therapy sessions are always covered by an interpreter – and we’re noticing after four months that we’re just beginning to talk about feelings mainly because there are no specific signs for specific feelings in BSL. There is a sign for ‘sadness’ but it depends on how demonstrative the person is as to what sort of sadness they are talking about. It can then take an interpreter two months or so to know how a person signs their feelings.
“It’s amazing the paucity of language in deaf language about emotion. For example, it took some time to get an interpreter to teach me the signs for ‘how are you?’. Usually you ask ‘OK?’ with a thumbs-up. But I’m interested in how you feel, not whether you are OK.”
Although this is Ball’s first experience of deaf psychology in his 35 years of practice, he has seemingly identified the source of Dwight’s behaviour centres on communication – and the somewhat ironic notion of a deaf young person’s inability to be heard. If we can communicate, we can understand. If we understand we can start to do something that helps. And for Dwight Johnson, such understanding is finally beginning to arrive.
Arguments for risk
● People are always worth fighting for. Ball says: “If we believe the idea, as we ought to do in this business, that young people are born more or less OK and it’s only things that happen to them that make them behave badly, then our questions should always be ‘what happened, how did it happen and how can we ameliorate the effects of that?’. My feeling is that the system doesn’t do that really.”
● New Forest Care’s approach was perfect for Dwight. All his life he’s been moved because the service he was using could not cope with aspects of his characteristics and needs. Dwight was assessed and the services he needed were set up specifically for him.
● As a drama therapist, Ball’s interests lie in the play and socialisation that occur early on: “If you know about them you know what their potential was. You can then look at what the events did to mess it up.”
Arguments against risk
● Such a bespoke service – own house, six support staff – will inevitably be expensive. Looking at people’s needs individually requires a lot of one-to-one time in assessment and researching the history of the case.
● The non-intervention programme to deal with Dwight’s suicidal tendencies is controversial and one that Dwight is unhappy about (as he says that only by direct and immediate intervention can staff show they care about him). “We’ve told him that we’re not going to intervene if he puts a ligature around his neck – until he is showing signs of distress,” says Ball. “We’re not going to stop him from scratching – we’re going to supply him with things to cover his arms if he wants to. We’re saying we’re very happy to talk to you about this and think about why you feel like this and what you should do. But what we’re not prepared to do is go along with you doing an action and we have to automatically jump into an emergency response.”
As a lecturer, I spend a good deal of time teaching about the importance of a needs-led approach to social care provision, but as a practitioner I am painfully aware of how rare such an approach really is, writes Patrick Ayre.
The need to constrain costs inevitably means that we find ourselves trying to hammer the square pegs of assessed need into the round holes of existing service provision. How refreshing, then, to encounter a service which actively seeks to adjust itself to fit its users.
Furthermore, John Ball’s assessment techniques, based on patient observation, reflection and creative analysis, seem to capture precisely the characteristics required if we hope to get a handle on the infinite complexity and variety of human behaviour and personality.
Unfortunately, the climate of blame, fear and mistrust which characterises much of today’s child safeguarding provision means that few of us, and few of our managers, have the self-confidence and faith in ourselves to encourage the development of such client-centred approaches.
Taking down a one-size-fits-all assessment checklist from the shelf and squeezing into it those we assess is much safer, much more predictable but much less effective.
In Dwight’s case, it is inconceivable that any standardised assessment would have suggested the conclusions perceptively reached by his therapist. Standardised assessments can see only what they are devised to see and they filter out and discard everything else.
Patrick Ayre is an independent child care consultant and senior social work lecturer at the University of Bedfordshire
This article appeared in the 23 March issue under the headline “A victory for reflection”