Thursday, 19 December 2013

Experiences of supervision in the children's workforce: a pilot study

A pilot study was carried out via a seven-item, online questionnaire; participants (n40) were recruited through facebook , linkedin, and Chris Taylor Solutions website. The questionnaire was open for 21 days. Almost two-thirds of respondents are responsible for supervising others as well as receiving supervision themselves. Although respondents overwhelmingly value supervision as important to their carrying out their work (94%) more than a third (37%) do not receive regular supervision. Most respondents who do not receive regular supervision still value it as important for them carrying out their job well. Worryingly, perhaps, the majority of respondents who do not receive regular supervision are working in a regulated sector where supervision is a requirement to meet National Minimum Standards. Over 80% felt that supervision was important for providing emotional support, and its function in learning and development was valued equally. These qualities are usually associated with clinical supervision and might be expected to be less pronounced in line management arrangements. Given the emotional labour and complexity of working with (often vulnerable) children and young people, this is encouraging. Supervision is also widely valued for ensuring tasks are done (about 60%) but only about half of the respondents considered enhanced safeguarding as one of its functions. When it was part of their job role, respondents overwhelmingly said they had received adequate training to provide supervision, although a small number (6%) said they had not been trained adequately. Slightly more (12%) responded that they had not been trained sufficiently in receiving supervision, and it is perhaps encouraging that most had. This is a small scale study, and these data should be treated with some caution; however, as a pilot it introduces some useful themes for further research. Perhaps one of the starkest figures is that over one third of the sample does not receive regular supervision, although it is overwhelmingly valued and in some cases required by National Minimum Standards. The survey did not enquire into respondents’ emotional experiences of supervision (do they look forward to it, or perhaps dread it). Neither did it examine the contextual factors that influence its regularity. There was no examination of quality of usefulness / outcomes, and these are all aspects for further research.

Tuesday, 12 November 2013

A brief psychosocial assessment

Assessment is a process, not a single event. Done well, this process begins with a base-line assessment to decide an initial approach and develops into a virtuous cycle of intervention, review and updating so that progress is built on and obstacles are addressed. The child assessment framework described here is not a comprehensive psychological or psychiatric assessment, but a brief, systematic process to acquire an accurate, thorough picture of a young person’s strengths and weaknesses, whilst acknowledging that any assessment is to some degree a product of, and dependent on, the environment in which the assessment occurs. The framework combines the “lived experience” of residential staff or foster carers working alongside the young person with psychologically and therapeutically guided observation and recording, professional judgement, clinical interviews, questionnaires and psychometric tools. Since outcomes are not only measured in changes in symptoms or problem behaviours, but also in an improved feeling of engagement, a greater capacity to seek, accept and provide support, and increased social activity, this assessment method takes account of the young person’s strengths and soft skills as well as their difficulties and reveals protective factors, deficits, needs and risks. The assessment can also point to empirically supported intervention strategies. Although every assessment is different, usually data are collected over the period of a month. Every effort is made to complete the analysis and write-up within another month, and a completed assessment report is usually submitted two months from starting

Friday, 8 November 2013

Defining and responding to complex needs

The term “complex needs” is used to convey several different ideas sometimes specifically, and most often interchangeably. They include: “multiple disadvantage”, “multiple disabilities”, “multiple impairment”, “dual diagnosis”, “high support needs” and “multiple and complex needs”. Perhaps more usefully, complex needs can be thought of as implying both the breadth of need (multiple needs that are interrelated or interconnected) and the depth of need (profound, severe, serious or intense) and a combination of both. This is captured in The Department for Education definition of children with complex needs as having “a number of discrete needs that require additional support from more than one agency. Their needs are often chronic and may be lifelong. Different needs tend to interact, exacerbating their impact on the child's development and well-being.” Rather than use the term complex needs solely to describe an individual's characteristics, we also need to think about the wider social context of their lives. These young people may also be marginalised, present as high risk, and be hard to reach, and it is useful to also consider how current service arrangements and factors of poverty and exclusion impact on meeting multiple and complex needs; that is to recognise that children with complex needs are found in a social context and that in order to help we need to think of multiple, interlocking needs that span psychological, emotional, behavioural, health and social issues. Because these children are at the extreme of a continuum of needs they pose the greatest challenges to services. The term itself may be stigmatising, restricting access to some mainstream services. The broad and deep nature of the young person’s needs is often a contributing factor in placement breakdown, school exclusion and peer isolation. Complex needs can place a child on a self-fulfilling downward cycle of: • Placement disruption; • Seemingly growing needs and greater complexity; • Greater difficulty in finding out what will help them settle; • Further placement disruption. It can also be more difficult to meet basic needs (like dental and healthcare needs) because of issues around access and motivation, and their cultural identity needs can easily become ignored. In addition, judgements of success and failure are often made without clear understanding the level of complexity that these children may present. Enduring patterns of behaviour are unlikely to be changed easily; above all, these young people require time. For young people in the Looked After system, the breadth and depth of need may be hard to see: some may have major mental health needs in addition to other impairments; others may have additional difficulties with communication; many have difficulties that result from maltreatment and unstable, fractured lives. These young people present a challenge for services and for commissioners. In general, children with complex needs are not well served by provisions established to meet more general levels of difficulty, and even within specialist services it is not simple to understand what any individual young person may need to turn their life around. What is needed is a flexible and inclusive service that is able to assess, identify and meet individual needs. As well as the willingness to tolerate some uncertainty, it is necessary to develop understanding whilst working sensitively and knowledgeably with the particular issues for each young person. This must be founded on the expectation that young people will be involved in the assessment process, recognising that they are not only their difficulties and that they also have strengths, talents, interests and abilities. Whilst careful assessment is the basis of successful work with young people with complex needs, it is important to acknowledge the often deleterious effect of multiple assessments. Ethically, the point of assessment is to lead to helpful interventions, and yet, in complex cases, assessment can become an end in itself; faced with little sense of how to help it is easy to return for more assessments, but perhaps we should first be clear how this additional burden on the young person will help. Young people with complex needs that arise from maltreatment are likely to also present with “challenging behaviours”. Agreeing appropriate ways to provide care, protection and control can be highly problematic for young people who place huge pressures on those who work with them day-to-day. It is essential that we all try to take the young person’s perspective; their welfare must be paramount, and any responses to behaviour must be in the young person’s best interest and be part of a long-term plan to meet needs and encourage recovery. When deciding on therapeutic approaches and interventions we need to consider five key questions: 1. What research is available? 2. For who does this approach work best? 3. What alternatives might be tried? 4. How is a decision made to follow one course of action? 5. How is that decision reviewed and evaluated? We also need to consider the extent to which they are settled and stable before beginning more intense work. Many young people in specialist residential care have broad and deep needs, these needs are multiple and enduring. A helpful approach is to try to understand the individual, to keep sight of their perspective, to provide care, support and protection to help them turn their lives around. It is important to acknowledge that this difficult task is likely to also be slow, and that as well as providing individual therapies and treatments, much of the work to meet their wider social and psychological needs takes place in the wider, living-learning environments of home and school. What we most want is that, overcoming complex needs, our young people are able to get a successful life of their own.

Thursday, 22 August 2013

Why We Might Be Curious

Perhaps our work with vulnerable young people is not so much a job as a belief; a belief that the young people we work with can and will make progress and have decent, fulfilling and satisfying lives. It seems to me that one of the most useful ways we can contribute to this belief being true is though our own curiosity about our young people. When we observe a young person behave a certain way we often explain their behaviour based on a kind of certainty about their motives or intentions. Hit hard by an angry child, we might think to ourselves “they want to hurt me,” or even “they didn’t want to hurt me”. Same action, perceived in different ways, and our response to this action is likely to be highly influenced by our thoughts about their intentions. Unfortunately, even if we know the person well (and often in our work we do not) we may well be wrong. And if we are wrong about their mental state, we may not respond effectively. Additionally, we might happily say why (in our opinion) a young person acted as they have, even though they may not really know why themselves. I’d like to suggest that such certainty is not likely to be helpful. What we believe about ourselves and others can become a self-fulfilling prophecy because we tend to act in accordance to what we believe. Further, our inborn potential to give more weight to information that confirms what we already think than we do to information that contradicts it (called confirmation bias) means we often experiences our beliefs as being supported by the evidence before our eyes. It may be more useful to be curious about their mental and emotional state than to be certain, and that to be curious about why a child does certain things and cannot do others is one of the most helpful things we can do. There is something special about curiosity, to really sense, hear, feel what life is like for the child, and showing genuine interest in their thoughts, values, beliefs and intentions. Previously, drawing on John Bolwby’s suggestion about how therapists may best help their patients, I suggested that in our work we may help our young people not so much by interpreting things for them, but by being a “companion for…exploration”. A key tool to this companionship is curiosity. The American psychotherapist Dan Hughes highlights how the first shared state between an infant and their primary caregiver is one of acceptance and curiosity, love and playfulness. Murphey & Joffe said that “creating a caring relationship requires genuine curiosity.” It is through shared curiosity that the child first experiences being in the mind of their attachment figure, who is curious enough about the emotional tone of the child’s communication to respond in an attuned way. Being curious frees us from the need to always having to “solve” difficulties. This can take enormous pressure of us, and can be hugely validating for the child. This does not imply we do nothing, but that what we can do is to be curious about the meanings of events and behaviours and curious about possible causes of action. For me, to genuinely be curious is one of the great skills of our work; it is our genuine interest in our young person’s thoughts and feelings and respect for their perspectives. Curiosity sits in the long tradition of therapeutic working. The approach applied in therapeutic communities, which employ the planned use of social interactions and processes, is founded on a “culture of enquiry”. Without curiosity, the child’s behaviour means only what they act out. Curiosity allows us to not lose sight of the efforts the child is making to build a relationship with us. Also, curiosity is the anti-dote to avoidance (a common response to trauma). Our curiosity about the child in the here-and-now builds a bond of trust, respect and reliability and provides the foundations for new, healthy attachments; when someone is genuinely curious about us, it causes us to be reflective, to wonder about ourselves, and we have a sense of being special, and our genuine curiosity in the here-and-now expresses our attempt to think into the inner world of our young person. Rather than being certain about why a child has acted a certain way, we might be curious about many things: • Why things are the way they are? • How it is that this person came to be in this situation? • How one might we help? • What will happen if you do something (or do nothing)? • To wonder about who this person is • What their experience of themselves is? • What it is like to be them? • What are their intentions, motives, goals and thoughts? • What are they feeling? • What am I thinking and feeling, and why am I? It is also useful to be curious about outcomes. How can we be confident enough that our young people are making progress? Change is often messy, and a young person’s recovery from the difficult circumstances of their life is unlikely to be a smooth, constantly improving path. It is much more likely to me a rollercoaster, sometimes moving forward, sometime going back; sometimes progress might unlock previously unseen difficulties. An example of this might be a young person who for years has turned anger about their experiences inwards and only expressed it by hurting themselves beginning to express their anger more outwardly (but still not appropriately) by acting it out more directly on the world around them. This uncertainty about progress and outcomes is one important reason why we need to try and measure change through some objective means.

Resilience in Residential Childcare and Fostering

If our work is somehow walking alongside the child as they explore their inner world (Bowlby’s “companion for exploration”) then we need to be as well-equipped as we can be. However, at this point we need to acknowledge a difficulty. Training and personal development programmes should provide the skills and knowledge to do the task (the explorers’ tools), but the hard emotional labour of looking after our young people also requires some personal qualities. This is the “stuff” of explorers that is beyond any training programme. This “stuff” includes a deep emotional pool on which to draw; ability to step outside the immediate feelings brought up by the child’s difficulties; insight to see their behaviour for what it is...communication; and capacity to come back in the face of repeated rejections (“stickability” and “bouncebackability”). These qualities (there are undoubtedly others) might be referred to as resilience. Resilience is usually thought of as having three layers. First there is an inner layer of personal qualities and inner strengths, including a secure sense of our own identity, healthy self-esteem, belief in our ability to influence the world, and beliefs and experiences of success. As adults, this is largely our own “stuff”; our own individual responsibility, and we cannot reasonably look outside ourselves to be given these things. We have acquired them, to a greater or lesser degree, as part of the trajectory of our own lives. Those of you interested in attachment theory will no doubt reflect on the role that a secure childhood attachment can play in providing the foundation for this. Resilience is not just these personal qualities, it is also produced and supported by the connections we have to other people. In other words, an individual’s capacity to “stick with it” and to “bounce back” depends in part on their character and in part on their network of close and supportive others (families and friends). It is a sad fact that the anti-social hours of the work can take its toll on our families and friends, but knowing this can encourage us to work hard enough to maintain these much needed connections. The third layer of resilience is usually called community. This is the degree to which we are connected to something wider than our immediate supportive circle, the way we feel we have a place in the world and feel that we belong, that we have a purpose and are fulfilled by our daily lives. It is important that we connect with our own work community and with communities beyond our own work place. This is in part the stuff of the therapeutic community, but it is also the stuff of teams, of working together, of integrating and sharing with colleagues from different disciplines, and the stuff of looking outside our own organisation to the wider community of childcare (a helpful social worker, a conference, journals and magazines, web-discussion forums, and so on, all connect us to the wider community, even, perhaps, helpful blogs). It is also management structures, supervision, mentoring, buddying systems and formal and informal networks of colleagues. It’s worth mentioning here that, as well as receiving support and developing our resilience in these community contacts, we are also there to provide support and sustain the resilience of others in these communities (that’s what a community is) and to be as ready to give support as we are to need it. Perhaps these are rare things, although I see them daily in the people around me in my own organisation. If you know people with this “stuff”, and they like children and want an interesting and varied career, perhaps you should think about recruiting them to a fascinating and rewarding career. If you see gaps in this stuff in yourself or in your colleagues (and gaps will appear for none of us is unbreakable) then perhaps you could think about how to help.

Social Control Theory

There is a widely held, informal theory of child development that unwanted behaviours will somehow be “switched off” if they attract sufficiently disadvantageous responses, a kind of informal, social learning approach. However, there is little empirical support for this idea. One of the ideas put forward by the Chicago School in the 1920s & 30s is that violating social norms is potentially so pleasurable that we should perhaps be more interested in finding out what constrains people from doing so more often than they do. Social Control Theory (Hirschi) suggests that individuals are constrained from anti-social behaviours by four types of control: 1. Inner controls that result from internalizing pro-social beliefs and values. I would add to this the idea that pro-social values take root more readily when the individual has an internal representation of themselves and others as worthwhile. 2. Outer controls, which are typically social and economic sanctions. I would add to this the point that many traumatized children will not experience typical social sanctions as unwanted. One example would be that negative attention from a telling-off might be preferred to no attention at all 3. Indirect controls that arise through identification with, for example, a victims discomfort or a parent’s disapproval. I would add to this the idea that such identification requires a degree of empathy that may be inhibited in traumatized children 4. Satisfaction of needs. Anti-social behaviour may arise as a way of satisfying needs, from material needs for possessions though to internal needs such as power, revenge and control. If the individual can satisfy these needs in legitimate ways then the need for anti-social behaviour is reduced. The imposition of outer controls (sanctions) may well increase a need for revenge, power and control, and therefore increase rather than decrease unwanted behaviour. Outer controls and indirect controls can only be effective at “switching off” unwanted behaviour if an individual has a degree of self-control; they clearly cannot be effective if there are significant impulse control difficulties. This also applies to earning rewards and privileges, or gaining levels. We also know (e.g. from the Cambridge Study of Delinquency Development, Farrington, 1990) that delinquent behaviour is more likely when an individual’s social bonds are weakened or diminished. The combination of low levels of affection and the failure to adequately protect a child is both traumatising and associated with weak bonding, and so children who are traumatized in their families are at high risk of exhibiting a wide range of unwanted behaviours. The problem with social learning approaches for this group of children is that both the earning of rewards and the loosing of privileges weaken, rather than strengthen, bonds. Another reason sometimes put forward for reward-punishment approaches to unwanted behaviour is that all children need opportunities to learn about the consequences of their actions. This is undoubtedly true, but we have to be careful what the child is learning. From the exertion of adult power they may learn that they are small and powerless and what they really want is revenge. But there cannot be a problem with exerting some level of discipline; the question is more of how it is done, and why. Getting a child to help clear up a mess they’ve made, or making them wait a little for something they want to do, can help them make amends, teach as sense of consequence, promote experience of delayed gratification, and distinguish wanted behaviours from unwanted. However, it is essential that the use of consequences is accompanied by good quality explanation and genuine, authentic warmth. Explanation promotes the child’s ability to generalize to other situations, and authentic warmth allows the child to experience discipline as a supportive intervention for their benefit, rather than the exercise of adult power.

Friday, 1 June 2012

Emphatic Care for Children with Disorganized Attachments

A new book by Chris Taylor, Emphatic Care for Children with Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-Informed Care is published by Jessica Kingsley Publishers in July this year. Disorganized attachment is the most extreme form of insecure attachment. This book is a practical guide to caring for children and young people with disorganized attachment and related emotional and psychological difficulties. Synthesising attachment, trauma and mentalization theory into a useful practice model, Empathic Care for Children with Disorganized Attachments proposes ways of meeting the needs arising in children and young people with disorganized attachments. Focusing on the importance of interpersonal bonds to facilitate the child's capacity to mentalize, it aims to equip the reader with the appropriate skills to provide effective, sustained and, most importantly, empathic care to the most vulnerable and troubled children. This structured psychotherapeutic approach to caregiving will enable the development of child–carer relationships and can be used to create informed, safe environments that support both the young person and the caregiver. This useful guide is invaluable to health and social care professionals including residential carers, therapists, counsellors, and those working with vulnerable and troubled children and young people including those supporting foster and adoptive families.