20 results
List of tables and figures
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Index
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six - Mothers’ perspectives
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Summary
Constructing the sample
This chapter reports on the interviews undertaken with mothers with mental health problems in the two study sites, A and B. While there has been significantly more readiness in recent years to acknowledge and identify differing professional perspectives in work with families with mental health needs (Falkov, 1998; Weir and Douglas, 1999; Reder et al, 2000a), the consequences of these differences for families have not as yet been fully explored. That research which explores the perspectives of parents with mental health needs has emphasised parents’ experiences of being pathologised by services (Hugman and Phillips, 1993) and of services being targeted on crises rather than delivered in a preventive or aftercare form (Green and Hyde, 1997). Our study aimed to interrogate service users’ experience of both mental health and child care services in more depth and to examine need alongside attitudes to services.
For this stage of the research, health and social services staff in the two study sites were asked to identify mothers whose children had been the subject of a child protection case conference in the previous 18 months and who had a diagnosis of mental illness. This could be a diagnosis provided by any health professional and could include diagnoses of personality disorder and repeated episodes of self-harm, but not diagnoses of substance misuse alone. Fewer interviews took place in site B, despite repeated attempts by local practitioners to recruit appropriate interviewees for the study. In this area, in particular, a number of practitioners from different agencies identified the same women as potential participants: this might be explained by the smaller size of the locality.
A total of 11 women were interviewed across both sites using a structured interview schedule devised by the research team. This schedule was developed with the help of the project advisory groups in each site. Representatives from service user groups were included on both steering groups, and their comments were particularly valuable in relation to the development of these interview schedules. An initial pilot interview was completed with one mother and the schedule was refined in the light of her feedback.
A second series of slightly less structured interviews was undertaken after a period of at least six months. A total number of eight second-stage interviews were completed. Three of the original sample proved unwilling to be interviewed or inaccessible (one having moved out of the area).
twelve - Conclusion
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Summary
This final chapter draws together the key themes of our research and develops some recommendations for policy and practice. The study findings have relevance for transactions between practitioners and users as well as for the relationships between different groups of professionals and their organisations. Our proposal for a dyad of keyworkers in cases where mothers have mental health problems and where there are child protection issues is designed to impact on each of these interfaces. However, some of the problems identified for mothers with mental health problems are not only confined to how professional roles are defined and played out, but also concern the availability and distribution of resources. Access to resources is increasingly determined at a national level, although new initiatives still tend to have local beginnings. Therefore, the messages here are directed at policy makers at all levels as well as at the full range of practitioners in statutory and voluntary settings.
The centrality of trust
The interviews with mothers highlighted their capacity to distinguish clearly between different professionals and their primary responsibilities. Mothers were aware that child care social workers’ predominant task was the protection of children's welfare. They resented the scrutiny of their parenting by child care social workers and experienced child protection case conferences, supervised contact and other formal processes as threatening and disempowering. Such accounts are consonant with the evidence of other research studies (Cleaver and Freeman, 1995; Farmer and Owen, 1995) that have explored families’ perspectives on the child protection process. However, for mothers with mental health problems, the alienation and powerlessness experienced in relation to the child protection system are likely to exacerbate existing feelings of low self-esteem, loss of control and stigma.
The women in this study also criticised child care social workers’ lack of availability and the attitudes they displayed towards service users. Such comments may in part be a response to the statutory role of child care social workers with its implicit threat of coercion; however, they also reflect child care social workers’ limited opportunities for the exercise of interpersonal and counselling skills in the job. These restrictions can be attributed to a combination of limited resources and an emphasis on a bureaucratic, care management model of practice that prioritises assessment and the construction of care packages over therapeutic interactions with service users.
Contents
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five - Identifying key research issues
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Summary
The focus groups
Since no previously validated questionnaires that addressed the issues tackled by the study were available, the research team was faced with the task of developing one that was appropriate for a wide range of professional groups, spanning both mental health and child care services. Qualitative approaches have been used extensively in the pilot phase of projects, both to inform the formulation of research questions and the selection of variables for study and to develop survey instruments (Barbour, 1999). In this study, focus group discussions with health and social care staff working in an area outside the two research sites were held to assist the development of contextually relevant questions for inclusion in the survey of professionals (Dumka et al, 1998). Focus groups have been shown to be particularly effective in accessing members’ constructions and attributions of meaning (Bloor et al, 2001), and are thus ideal for testing the acceptability and interpretations of the language used in questionnaires. Since the aim was to develop a survey instrument that was relevant for a variety of professional groups, a range of practitioners needed to be involved in this stage of the study. Given the potentially large number of workers involved in service provision for families where parents have mental health problems, it was not feasible to hold profession-specific groups. Instead, the research team opted for three interprofessional focus groups. These mirrored or approximated the real-life context of case conferences and had the added advantage that they were likely to afford insights into the issues arising for professionals in the practice environment (Kitzinger and Barbour, 1999).
Since the principal reason for holding focus groups was to inform the design of the questionnaire, it was more important for recruitment purposes than is usually the case in focus group research to convene groups that were representative of the wider population to be studied (Bloor et al, 2001). Therefore, the groups involved a range of staff with different professional roles and remits, working in both the statutory and voluntary sector, and with varying levels of seniority and experience. Those recruited included representatives of the following professional groups: child care social workers; health visitors; adult psychiatrists; mental health social workers; community psychiatric nurses (CPNs); children's guardians; practitioners from voluntary organisations serving mental health services users, and from similar organisations for children; and middle managers from both community health and social services.
Child Protection and Mental Health Services
- Interprofessional Responses to the Needs of Mothers
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This book examines interprofessional work with families in which mothers have a mental health problem and where there are also concerns about child protection. Breakdowns in interprofessional collaboration, issues of risk and resources are all addressed. Mothers' views and experiences are contrasted with professional perspectives.
one - Mental health needs and mothering
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Summary
This chapter examines the ways in which the mental health needs of mothers are conceptualised within health and social care. Mothering is simultaneously identified as a prime site of origin for women's mental health problems and a key determinant of children's mental health. It is widely acknowledged that mothering is a stressful, demanding activity that offers many opportunities for failure and consequent loss of self-esteem. However, it is also defined as a cluster of psychological and practical skills which deliver nurturing and care to other family members. ‘Competent mothering’, difficult as it is to pin down, is construed in both popular and professional debates as the foundation of children’s mental health. While the successful exercise of parenting skills and the intimate relationships that mothers experience with their children can be a source of satisfaction and pride, in the context of mothers with mental health needs, research has tended to focus on adverse outcomes. Positive outcomes for parents with mental health problems and their children are rarely noted.
The dual representation of motherhood is supported by a wide range of popular media images of mothers (Coward, 1997). These include the ‘harassed mum’, the ‘dual-career mum’, the ‘stay-at-home mum’, the ‘feckless teenage mum’, the ‘glamorous Victoria Beckham mum’ and (an image popularised by Cherie Booth, the wife of the Prime Minister) the ‘juggling mum’. The juxtaposition of images and the diversity evident in these representations of motherhood reflect mothers’ subjective experience of ambivalence. Featherstone (1997) identifies this ambivalence as a key characteristic of modern mothering and suggests that, in the face of the conflict between the adult's need for autonomy and the child's need for dependence, some feminist theorists have ducked the question of how children's developmental needs are best met. Mental health and child care services have also been slow to identify the significance of this conflict for their clients, and it can be argued that services have made little progress in offering mothers solutions to the dilemmas that arise when their own mental health needs conflict with their children's needs for secure parenting.
The chapter explores the different theoretical models that have been developed to explain women's mental health needs. In particular, research that draws attention to social roles and life events, especially experience of abuse, will be discussed.
Also available from The Policy Press
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ten - Interprofessional communication and coordination
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Summary
Identifying difficulties in interprofessional coordination
This chapter reports on practitioners’ experiences of interprofessional communication and coordination and examines their views on which services were best equipped to take a lead in work with families where mental health needs and child care concerns coincided. Our survey asked respondents to identify the frequency of difficulties in coordinating work on such cases with a wide range of professional groups. As Table 10.1 shows, 35% of practitioners reported always or frequently having problems in coordinating their work with GPs, while 27% reported the same frequency of problems with adult psychiatrists. These rates were substantially higher than the levels of difficulties identified for other professional groups. For example, only 17% reported consistent or frequent difficulties in working with child care social workers, and 12% had a similar level of problems with community psychiatric nurses (CPNs).
The professionals with whom respondents were least likely to experience difficulties were health visitors: 58% reported that they hardly ever or never had problems in coordinating work. Lupton et al (2001) report similar levels of satisfaction from other professionals commenting on their work with health visitors. The other groups of practitioners with whom respondents appeared to have fewer problems were child and family centre workers (49% reported hardly ever or never having difficulties) and child care social workers (42% reported hardly ever or never having difficulties).
Child care social workers, child and family centre workers and children's guardians (formerly known as Guardians ad Litem, this group of professionals will all have trained and practised as child care social workers) were the professional groups most likely to report frequent or constant difficulties with GPs. Over half of the respondents in these three professional groups described a high level of difficulties. In contrast, GPs did not identify similar difficulties in relation to these groups. Few health visitors and CPNs reported high levels of problems with GPs. The professionals who themselves worked in primary care settings, such as health visitors and GPs, were most likely to report very seldom having difficulties in coordinating work with GPs. About half of CPNs sometimes had difficulties with GPs. Professionals working in adult psychiatry were also likely to report that they sometimes had difficulties.
The child care social workers’ evaluations of work with GPs are consonant with the findings of both Hallett's (1995) research and Lupton et al's (2001) study.
eleven - Identifying appropriate resources
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The availability of appropriate resources will be a key factor in developing an effective response to families’ needs. In mental health services, staff time and skills are essential components of the service but are often in short supply (DoH, 2000a). Services need to be relevant and appropriate, but what constitutes a user-friendly service for one group may not succeed in meeting the needs of others. Targeting services on the specific needs of certain groups of service users is likely to increase the extent to which particular groups experience such agencies as relevant and responsive. However, this may also have the effect of limiting the potential user group for such services. These services in the mental health field might include specialist therapies, support groups for service users with needs or problems in common, training or educational programmes and domiciliary services, which aim to assist individuals with domestic and practical tasks as well as develop users’ skills. There are few examples of services that are focused directly on parents with mental health needs. Where such services do exist, they are likely to be provided by the voluntary sector. The New Parent Information Network (NEWPIN), a voluntary organisation which provides support for parents with mental health needs (Cox et al, 1991; Cox, 1993), is probably the best-known example of such a service in the UK, but none of the research sites in this study could boast such a resource. Since mental health needs fluctuate over time, services need to be speedily accessed when they are needed, with the possibility that they can be withdrawn or reduced in intensity when levels of mental health need subside.
Practitioner time is an equally important resource in child care services; Chapter Eight of this book reported the difficulties experienced by child care social workers in offering mothers adequate opportunities for ‘active listening’. Other relevant resources include those focused on strengthening or reinforcing parenting skills: these might include support groups for parents and voluntary sector services such as Home Start. The provision of good-quality childcare is a key but rationed service that is much valued by families (Statham et al, 2001). Likewise, respite care for children at times of family crisis or illness can be a key factor in keeping families intact.
seven - The mothers’ evaluations of professional support
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Summary
This chapter examines the mothers’ evaluations of professional intervention. This evaluation covers past experiences as well as any current or ongoing professional interventions that the women were receiving at the time of the study. The mothers were asked about their experiences of the full range of professionals with whom they might come into contact given their conditions and particular situations. Since one of the conditions for selecting women for interview was participation in a child protection case conference in the past two years, each of our sample had considerable experience of social services and childcare social workers. We begin by examining their views of the child protection system and those who work in it.
Experience of child protection system
The routes by which the families had come to the attention of child care social work varied. Three women described social work involvement commencing late in pregnancy or soon after birth, three others indicated that various individuals or professionals had referred them to child care social work, while two reported contact with the service as dating from the time of psychiatric admission. Although two of the mothers acknowledged that they had needed help at that point, five had felt angry and had found the involvement intrusive:
“It wasn't nice: I felt really angry. I said I’d never touch my kids, and then teatime I got a knock from the social worker.”
“I hated it – it was just interfering and trying to run my life for us.”
Most of the women in the sample considered that they had had little power over the events that had taken place once the process had commenced. The investigations that followed initial contact with social services evoked feelings of a loss of control, or of being judged:
“Social services want you to sign things – don't read out the small print. I didn't understand; no time to see a solicitor.”
“You get the feeling all the time you’re being watched. Makes you feel inadequate – saddened that they didn't trust us. I was never trusted as a kid neither.”
The sense of loss of control expressed by the mothers seemed to have been experienced from the early stages of their contact with the child protection system and, as discussed later in this chapter, informed the mothers’ views about working in partnership with professionals.
four - The research study
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Summary
Background to the research
This study was fuelled by a desire to understand the response of a range of health and social care agencies to two contrasting sets of needs in families. We were also aware that the organisational changes described in Chapter Two of this book were driving services for children and adults further apart. The research design for such a project was inevitably going to be multi-layered and would involve a range of different participants. Funding for the project also came from a number of sources, including the University of Hull, a NHS trust and a health authority. This chapter describes the development and details of the methodology employed for the study. We begin by introducing the findings from a small pilot study completed in 1997. The results of this pilot fed into the design of the main study, which is the focus of the second part of this chapter. The latter sections provide details of the areas included in the study and outline the methodology.
The pilot study
Before embarking on a full-scale research study, we decided to test several of our assumptions, for example, that divides between health and social care, and between children's and adults’ services, might affect professional practice with families where mothers had mental health problems. Therefore, we planned and implemented a pilot study (Stanley and Penhale, 1999) designed to examine issues of interprofessional communication and coordination. As this work provided the backdrop to the larger study, it is worth considering it here in some detail.
The pilot study was exploratory in nature and took place in a locality not subsequently used for the main research study. Detailed analysis of 13 families’ files was undertaken in one local authority in the east of England. The study explored the nature of serious mental health problems in mothers whose children were on the child protection register, and examined the extent to which different professionals worked together to meet the family's needs.
Each of the families selected for inclusion in the pilot study had been subject to a child protection case conference, and each had one or more child's name included on the child protection register. In all 13 families, which were identified for the pilot study by social work team managers, mothers were considered to have serious mental health problems.
eight - The professionals and their practice
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Summary
The sample
This chapter moves from the mothers’ perspectives discussed in the previous chapter to consider the views and experiences of the wide range of professionals involved in delivering services to children and families. The extent of their experience with families where mothers’ mental health needs and child care concerns coincide is explored here, as are their views of their professional roles and remits in relation to such families. First, however, we describe the key characteristics of the professionals who contributed to the research. Respondents were contacted in the two study sites (A and B) using staff listings provided by local services. Postal questionnaires were sent out to health and social care practitioners and middle managers, staff in voluntary organisations, including children's guardians (formally known as Guardians ad Litem), and police officers with responsibilities for child protection. Professionals were included in the survey on the basis of their involvement in work with families where mental health needs and child care concerns coincided and according to the perceived relevance of the research to their core business. Some professionals, such as teachers, were excluded since they only occasionally work with whole families with mental health needs and the survey was not considered to be sufficiently germane to their core task (see Birchall with Hallett, 1995). A group of residential child care workers who undertook outreach work with families were included in the survey in site B as their experience appeared relevant.
The 500 practitioners (327 in Site A and 173 in Site B, the smaller site) who responded to the survey from both areas covered a wide range of professionals (Table 8.1). As in any locality, the different groups are not equally represented, but the power wielded by any one profession within a local network derives less from their numbers and more from their relative status. The overall response rate for the two areas was 50.5%, with little difference in the interest evoked by the survey in the two areas.
The response rates of the different professionals varied considerably, with most groups ranging from 42% to 70%. High response rates (>75%) were achieved from community psychiatric nurses (CPNs), child and adolescent psychiatrists and occupational therapists (OTs) in mental health services. Low response rates (<5%) were obtained from GPs, nurses on mental health units and wards, and accident and emergency staff.
two - The service context
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Summary
In the UK, mental health services for adults and child care social work both owe much of their current structures to a preoccupation with risk. Mental health services are principally concerned with the risks that their user group may pose to the general public. In contrast, child care social work focuses on the risks to which children, the service's primary client group, are exposed by others. The development of both services can be depicted as a struggle between the demand that risk be contained or reduced and normalising ideologies such as community care and family support. Recent emphasis on the rights of users and their families in the face of professional expertise and authority has also contributed to the dynamic process of service development.
Beck (1992) defines the preoccupation with risk as a key feature of modernity. Whereas in other settings risk taking may have positive connotations, in the context of health and social care, risk tends to be defined negatively and its outcomes are conceptualised as harm or danger (Alaszewski, 2002). A social policy analysis traces the centrality of risk in both child care social work and mental health services to the influence of a series of public inquiries during the last two decades of the 20th century (Stanley and Manthorpe, 2004). At the time of writing, the capacity of inquiries to shape services is apparent in the anticipated organisational changes in child care services that have been stimulated by the inquiry into the death of Victoria Climbié (Laming, 2003). The extent to which inquiries and the public response to them have driven policy is analysed in depth elsewhere (Parton, 1985; Parton, 1991; McCulloch and Parker, 2004: forthcoming; Munro, 2004: forthcoming). However, the influence of the inquiries has had to contend with other imperatives, including concerns about the intrusion of the state into the private sphere and an emphasis on the community or family as the locus of care for vulnerable individuals.
Introduction
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In the context of family life, children are usually portrayed as dependent and as more vulnerable than their parents; their needs are accorded some priority in recognition of their rights to protection. When parents themselves are vulnerable, agencies’ standard responses to families are called into question.
This book is concerned with the professional response to families where mothers have mental health problems and there are concerns about the children's welfare. It presents the findings of a research project which, alongside an exploration of mothers’ perceptions of their mental health problems, examined the ways in which professionals conceptualise and try to meet those needs. Since the mental health problems of mothers may pose risks for their children, both adults’ and children's services are likely to be involved. Therefore, interprofessional collaboration and communication are key themes of this book.
While the needs of children and adults interact in complex ways, the close relationship of the two is not reflected in the organisational structures of health and social care services. General Practitioners (GPs) are one of the few healthcare professionals with a remit to work with all family members; the majority of health professionals work with either children or adults. In social care, practitioners also have a primary focus on either children or adults, and agency structures reinforce this divide. Although a range of national and local developments have aimed to promote interprofessional and interagency work between health and social care services, such shifts have been located within adult services or within services for children. Increasingly, adult mental health services are provided by joint trusts or teams in which the work of social services and community health staff is integrated. In child care, the emergence of Children's Trusts (DWP, 2002) signals a shift towards similar models for the delivery of a range of health and social care services. The gulf between children's and adults’ services remains difficult to bridge. While both mental health and child care practitioners may acknowledge and recognise the contribution of other family members to the welfare and health of their primary client group, service structures will render those providing services to other family members more distant and less accessible. Professional identities and allegiances may act to reinforce structural divisions.
A focus on mothers’ mental health requires some explanation. Despite their increasing participation in the workforce, mothers have retained their primary responsibility for child care (Ferri and Smith, 1996).
three - Interprofessional work
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Before examining the evidence for the extent to which services succeed in working together, it is useful to consider why interprofessional coordination is generally considered a goal worth pursuing. As Corby (2002) has pointed out, communication and coordination can be costly and the outcomes for service users have not been formally evaluated. The benefits need to be enumerated. One clear advantage of interprofessional communication is that the information base for a particular client or family is broadened across the dimensions of activity, knowledge and time. So, by obtaining information from a health visitor about a child's early development, a child care social worker can gain access to information that is both historical and covers areas of expertise, such as child health and physical development, which are outside a social worker's immediate range of tasks and competence. Data on different family members will be held by different agencies; for example, information relating to a new partner's history of mental health problems may only be accessed by a child care social worker through contact with mental health services. Coordination and communication between professionals will also allow families to be monitored more effectively. Should the health visitor share her weekly observations of the child with the social worker who is also visiting once a week, a fuller picture covering a wider range of circumstances and situations can be constructed.
The need for information that is reliable and comprehensive (Sheppard, 1990) becomes particularly acute when risks are perceived to be significant. Guidelines on professional codes of confidentiality recognise this and allow for information to be disclosed to relevant agencies without clients’ consent when risks are assessed as high. However, judging whether or not the risks are high enough to warrant breaching professional codes of confidentiality may vary according to individual assessments of the level of risk, the value attached to confidentiality and users’ rights by different professional groups, and the client orientation of the practitioner making the decision.
Even when information is available, professionals may experience difficulties in collating, sifting and interpreting it (Sheppard, 1990; Waterhouse and Carnie, 1992; Farmer and Owen, 1995). These tasks, and the decision making which ensues, are likely to involve the assessment of risk, and much of the process is undertaken in multi-professional forums such as child protection case conferences, ward rounds or Care Programme Approach (CPA) reviews.
nine - Conceptualising needs and evaluating risk
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Summary
This chapter explores the ways in which the professionals surveyed in our research conceptualised mothers’ mental health needs. We were particularly interested to compare practitioners’ views with those of the mothers that we interviewed. The survey also utilised vignettes to examine practitioners’ assessments of risk in families where mothers’ mental health problems coexisted with child protection issues. This approach allowed us both to identify the key factors associated with high risk and to compare the assessments of the different professional groups surveyed. This chapter also addresses the role of training, which is often invoked as the means by which practitioners’ attitudes and skills in this area of work can be developed.
Conceptualising needs
The survey asked professionals to list what they considered to be the three most important needs of mothers with mental health problems. In response, we received a wide range of answers. These were grouped into four broad categories (Figure 9.1). Two thirds (276) identified resources to support and maintain parenting. Such resources included provision of childcare, contact with absent children, respite care, practical support, financial support and assistance with parenting skills. For instance, one practitioner described a need for “practical hands-on help with children”. Another suggested:
“appropriate care for children when experiencing particularly difficult times, eg nursery placements, childminders.”
A similar proportion (274) identified the mothers’ needs for professional intervention or treatment for their mental health problems. This cluster of responses was relatively specific and included such answers as “appropriate and effective medication and treatment” or “professional interventions such as therapy”. The mothers interviewed were less likely to emphasise their need for formal treatment, although talking therapies were valued. Some of those interviewed were unhappy about taking drugs and expressed an interest in coming off their medication.
In the third category of responses, just over half of the professionals indicated the importance of emotional support for mothers. This support, therefore, was treated as a separate category, distinct from the more practical forms of support emphasised in the first grouping, although it is necessary to be aware that ‘emotional support’ covered quite a broad spectrum in terms of the responses given. For example, some practitioners identified a need for “opportunities to talk and someone to listen and believe”, without identifying the source of support, while others focused on the role of family and friends in providing emotional sustenance.
Frontmatter
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References
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- 10 September 2003, pp 123-140
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