Author: Andre Coleman

Introduction

This essay deals with the circumstances and challenges faced by 22 year old Betty, who became pregnant when she was 15, and now lives with Candy, her six year old daughter. Betty has been referred to the social services cell of the local authority for appropriate social work intervention. She has been engaging in bouts of bingeing and has in the recent past been suffering from vomiting, weight loss and amenorrhoea.

A brief case overview is provided below, followed by its analysis and its various implications for social work intervention.

Case Overview and Analysis

Betty’s mother left her father and her sisters when they were very young because of problems in dealing consumption of alcohol. The child and her sisters were thereafter sent to a home for children, where they lived for many years. Whilst the children did not have any further contact with their mother, they would occasionally receive visits from their father, who worked in a brewery and also suffered from alcohol related problems.

Betty and her sisters spent their childhood in the children’s home, from where they first attended the children’s village school and thereafter went to a comprehensive secondary school near the residence of her father. Betty began to develop truancy tendencies in her early teens and became pregnant from her relationship with an African Caribbean person, when they were both 14. She decided to keep her child who was named Candy, rather than give her up for adoption, and was placed in a foster home situated at a distance from where she had lived for many years. With the children’s home closing down, Betty’s sisters, followed by Betty and Candy, came to live with their father. All the children, including Betty and Candy, lived with their father for the next 6 years.

Betty first met a social worker when she was 22. She thereafter moved with her daughter to a small flat, which she liked and made efforts to make nice and homely. Whilst shifting to her new home proved to be beneficial for both Betty and candy, the death of her father, which occurred soon after she moved out of his home, traumatised her severely. She suffers from bouts of speaking difficulties, weight loss and vomiting and amenorrhoea. Her social service records reveal that she suffered from speech disorder episodes in her childhood as well. Betty has also spoken to her social worker about her difficult relationship with her daughter Candy. Whilst the child is doing well in school and is liked by people, she behaves very badly with her mother.

An investigation of Betty’s history reveals that she may well have been neglected during her childhood. Both her father and mother had alcohol related problems. Her mother left home when Betty and her sisters were very young, following which she was placed in a home for children. Child neglect can be defined to be a condition, wherein individuals responsible for taking care of children permit them, either deliberately or because of inattentiveness, (a) to experience suffering that is avoidable, and (b) otherwise fail to provide the environment required for the development of their physical, emotional and mental capabilities. Neglect can be physical, emotional or educational (Butler & Gwenda, 2004, p 76). Betty and her sisters were taken in the care of social services when they were young and placed in a children’s home. Whilst their physical needs were met adequately and they were sent first to the village and later to secondary school, it is very possible that they suffered from educational and emotional neglect (Grinnell & Yvonne, 2008, p 46). They certainly did not have anybody to provide them with emotional or psychological support or to help them with their school work.

Educational neglect includes the failure of care takers to acknowledge and correct acts of truancy by children, even as emotional neglect can arise from inattention to the requirement of children for emotional support and sustenance (Ghate & Ramella, 2002, p 66). It is evident that conditions in homes for children are unlikely to have emotionally or educationally enriching environments (Ghate & Ramella, 2002, p 66). Neglect during childhood can have adverse effects on the physical, social, intellectual and psychological development of young people (Ghate & Ramella, 2002, p 68). Studies reveal that neglected children are prone to development of insecure, anxious or disoriented attachments with their care givers (Howe, 2009, p 37). Such lack of security in attachment can lead to hyperactivity, lack of attention and involvement in class and lack of initiative and confidence to work on their own (Howe, 2009, p 37). Child neglect is also associated with greater incidence of substance abuse, delinquent behaviour, and early pregnancy (Howe, 2009, p 37).

Betty developed tendencies for truancy, both in her school and in her children’s home, and became pregnant when she was 14 from her relationship with a boy of her age. Teenage pregnancy is widely prevalent in UK, with the country having a highest rate for such pregnancies in all of Europe. Studies reveal that girls from social class V are at greatest risk of becoming teenage mothers. Research evidence also reveals higher incidence of teenage pregnancy in (a) young people in care, (b) young people leaving care, (c) homeless young people, (d) truants and (e) young people involved in crime.

Whilst parenthood can certainly be a positive and enriching experience for normal people, it can also bring about many negative consequences for teenage mothers (Duncan, 2007, p 307). Such problems include (a) adverse physical and mental health outcomes, (b) lesser chances of completing education, (c) greater likelihood of living in the households of others, and (d) greater probability of being lone parent (Duncan, 2007, p 307). Teenagers who become parents are known to suffer from greater socio-economic deprivation, low self esteem and greater incidence of sexual abuse (Duncan, 2007, p 307). The children of such parents tend to have lower birth weights, lesser likelihood of being breast fed, greater chances of growing up in lone parent families, and greater probabilities of experiencing poverty, poor quality housing and poor nutrition. Such people also show greater tendencies for smoking and alcohol abuse (Duncan, 2007, p 307).

“Common problems amongst teenage mothers include depression and anxiety during pregnancy, financial, social and partnership problems and more negative life events (relationship break-ups, parental separation and lack of community and family support). Teenage mothers are more likely to diet or to smoke during pregnancy. The high smoking prevalence amongst people facing social and economic deprivation suggests that smoking may be used as a stress coping mechanism. However, there is a close association between smoking during pregnancy and adverse outcomes such as low birth weight, infant mortality and delays in child development”. (DHSSPS, 2004, p 1)

Betty, whilst she has lived in a designated children’s home, and has been educated in standard schools, may have suffered from neglect during her childhood and has experienced pregnancy in her early teens. Both these experiences can result in adverse physical, emotional and psychological outcomes. A social work report reveals that she was prone to suffer from speaking difficulties in her childhood, which could well be the outcome of an emotional and mental distress at being separated from her parents. This speech disorder surfaced again when she was 22, very possibly on account of her emotional traumatisation at the death of her father, who had provided her with shelter for 6 years after the closure of her children’s home. Her other ailments namely bingeing, vomiting and amenorrhoea could also be related to her disturbed upbringing and her psychologically disturbed state, which appears to have been aggravated by the death of her father.

Methods of Intervention

Betty is emotionally and mentally disturbed because of the death of her father and the behaviour of her child, Candy, towards her. Such emotional disturbances appear to have resulted in eating disorders, vomiting and weight loss. Apart from these ailments, Betty is also suffering from amenorrhoea. She needs medical and possibly psychiatric help and should be referred to mental health professionals and the local GP for appropriate support. Betty’s basic vulnerability arises from her status as a single parent, her past of a teen mother, her lack of earning capacity and her difficult relationship with her daughter. Such problems could lead to reduction of self esteem, depression and consequent mental and physical ailments.

Social work practice in such circumstances should first focus on understanding her case and her background and thereafter formulate appropriate intervention strategies. Social workers must in the first case adopt appropriate anti-discriminatory, anti-oppressive and person centred approaches in dealing with her case (Nash, et al, 2005, p 23).Thompson, (2001, p 7), advances the theory that anti-discriminatory approaches essentially arise from personal, cultural and social (infrastructural) influences that are experienced by individuals over the course of their lives. These influences affect the socialisation of individuals and result in deeply entrenched attitudes that surface unconsciously and influence their actions and behaviour (Thompson, 2001, p 11). Social workers, many of whom come from affluent and educated backgrounds, are very likely to have developed entrenched discriminatory attitudes towards disadvantaged segments of society and could well approach the problems of service users, from different racial, ethnic, social and income backgrounds, with preconceived notions and attitudes (Butler & Gwenda, 2004, p 83). Dominelli (2005, p 41) has also time and again emphasised that discrimination is pervasive in UK society and its social work infrastructure.

Modern social work theory and practice also recommends the adoption of person centred approaches towards service users. Service users, it is now widely accepted, should be placed at the centre of the social work process; with due regard given to their need for dignity, independence and self determination (Howe, 2009, p 48). Social workers, whilst dealing with Betty, with her history of living in a children’s home, teenage truancy, and teenage pregnancy, can very likely (a) have preconceived notions about her background, upbringing, education and attitudes, (b) take little cognisance of her helpful nature, her love for her father and her affection for her child, and (c) adopt attitudes of “I know best” condescension in their assessment and intervention practice. It is thus imperative for the social worker dealing with her case to consciously overcome discriminatory attitudes, adopt a person centred approach, communicate with understanding and empathy and involve Betty in all intervention suggestions.

The social worker should in these circumstances engage Betty with open ended questions about her problems and difficulties. Betty should be allowed to express herself as completely as possible without interruption in order to obtain a more complete realisation of her physical, emotional and mental strength (Brachmann, 2010, p 1). She should be asked to explain the ways and means in which she has coped with the various crises in her life and asked to explore and discuss her various strengths and weaknesses (Brachmann, 2010, p 1). Such discussions can well help in alleviating her feelings about the difficulties and hopelessness of her situation, enable her to think about positive lines of action and formulate suitable exit strategies (Grinnell & Yvonne, 2008, p 55).

Betty should be asked to choose the different reasons for her crises, focus on one issue at a time, and thereafter sequentially explore and analyse the different challenges confronting her. Such a strategy will help her to address the different crisis factors and find effective ways to address the diverse challenges (Adams, et al, 2009, p 107). It would thus be possible for her to individually focus on her physical and emotional difficulties, her problems with bringing up her child, and her financial challenges. The social worker should lead Betty in conversations that emphasise non-directive exploration of the various crisis issues (Adams, et al, 2009, p 107). Encouraging her to open up by asking different types of open-ended questions may help in obtaining revelations or in greater realisation of the various issues, which in turn can help her and the social worker in the making of informed choices (Brachmann, 2010, p 1). The social worker, once she expresses something specific or something that she would wish to alter, can become more direct in asking her to implement such changes (Howe, 2009, p 53).

Betty is now 22 and has brought up her child for 6 years as a teen parent, doing her best at the same time to help as a non earning member in her father’s family. Whilst Betty can no longer be technically classified as a teen parent, she continues to suffer from the vulnerabilities of such people, who are considered to be among the most vulnerable members of British society. Studies consistently reveal that children born to teenage mothers are more likely to have comparatively worse outcomes in terms of physical and mental health and education. Adolescent births are also related to higher levels of mental health difficulties, violence with partners and social exclusion (Coley & Chase-Landsdale, 1998, p 152). Contemporary teenage mothers have lesser likelihoods of competing in the job market. With teenage child bearing being automatically disruptive for secondary education, it is far more difficult for such people to complete their education in the more expensive contemporary day environment (Clemmens, 2003, p 94). The children of teenage parents are thus more likely to be economically deprived and socially excluded. When adolescents become parents, their education is likely to be delayed and even discontinued. Their employment opportunities are lesser, their incomes are likely to be low and they are less likely to develop long lasting relationships. Such people often require welfare support for prolonged periods (Duncan, 2007, p 307).

Betty, it is evident, suffers from physical and emotional problems. Adequate medical attention needs to be provided to her physical and mental condition in order to ensure that she recovers from the traumatic experience of her father’s death, is able to overcome her eating disorders and develops a stable, enriching and rewarding relationship with her daughter.

The UK government’s social work policies and infrastructure for teenage mothers provide for a number of intervention programmes (Asmussen & Weizel, 2010, p 2). Social workers provide case management support by visiting teen mothers and members of their families in their homes. Such visits help in promoting problem solving behaviours, identifying personal difficulties and challenges and in finding ways and means for overcoming them (Asmussen & Weizel, 2010, p 2). They encourage mothers to find jobs and pursue their education further. Case managers also plan and hold meetings with such mothers and their family members, wherein all participants work towards developing appropriate support plans (Asmussen & Weizel, 2010, p 2).

Social workers help teen mothers by the development of mutual assistance groups, where such people can receive and give assistance between each other. Young mothers like Betty can also be appropriately educated and trained in developing and managing small businesses (Asmussen & Weizel, 2010, p 2). They are, after the completion of such training makes them ready to run their businesses, assisted to develop and formulate business plans for their projects. The funding for start up costs for such project is provided after project plans are approved by trainers (Asmussen & Weizel, 2010, p 2).

Social work programmes also provide education in life skills, which is delivered over 8 weeks in group formats (Asmussen & Weizel, 2010, p 7). Such sessions promote the enhancement of knowledge and skills in various areas associated with parenting, social understanding and behaviour management. Leadership development amongst such mothers is promoted by giving them various responsibilities and roles in different types of group activities like planning of social events and development of committees (Asmussen & Weizel, 2010, p 9). Studies on these various projects reveal that their use leads to increase in the educational achievements of mothers and lessens the chances of repeat pregnancies. It also enhances their sense of well being and reduces utilisation of illegal substances. Studies on these programmes are however yet to reveal their impact upon child outcomes (Asmussen & Weizel, 2010, p 9)

The various techniques that can be used by the social worker to make Betty open up and focus on her various challenges have already been discussed before in the course of this essay. The social worker should, in line with such techniques, encourage Betty to think and discuss about her specific challenges, namely (a) overcoming her present physical and mental difficulties, (b) establishing a stable and rewarding relationship with her daughter, (c) furthering her education, (d) increasing her earning capacity and (e) leading a more enriching and socially inclusive life. Open ended questions and discussions over different sessions on each of these issues can help Betty in becoming emotionally more positive and in finding appropriate exit strategies for her different challenges (Butler & Gwenda, 2004, p 92).

The social worker can help her in discussing various alternatives like (a) medical and psychological health, (b) counselling sessions with her daughter, (c) formulation of programmes for completion of education and / or increase of earning capacity and (d) greater inclusion in social and community life. Appropriate intervention plans can be made after obtaining taking Betty’s active agreement on specific action plans.

Conclusion

This essay concerns the social and economic and challenges faced by 22 year old Betty, who became pregnant at 15 and now lives alone with her six year old daughter. Betty has been engaging in bingeing bouts and is suffering from vomiting, weight loss and amenorrhoea.

Betty’s mother left the family when the children were very young because of alcohol related problems. She and her sisters were sent to a home for children, where they would occasionally receive visits from their father. Betty and her sisters first attended the children’s village school and thereafter went to a comprehensive secondary school. Betty began to develop truant in her early teens and became pregnant from a relationship with a boy when both of them were 14. Deciding to keep her child, Betty, her child, Candy, and her sisters spent the last 6 years with their father, following which she moved out with her child to their own small home. She was severely traumatised by the death of her father and is concerned about the negative attitude of her child towards her. She now suffers from eating and speech disorders, is losing weight and experiences episodes of amenorrhoea.

An analysis of Betty’s history reveals that she may well have been neglected during her childhood. Childhood neglect can adversely affect the physical, social, intellectual and psychological development of young people. Early parenthood can also bring negative consequences like adverse physical and mental health outcomes, lesser chances of completing education, greater probability of living in the households of others, and more chances of being lone parents. Such people suffer from greater socio-economic deprivation, low self esteem and greater incidence of sexual abuse.

Social work practice, in such circumstances, should first focus on understanding her case and thereafter formulate suitable intervention strategies. Social workers must adopt appropriate anti-discriminatory, anti-oppressive and person centred approaches in dealing with her case. It is imperative for the social worker to deliberately prevail over discriminatory attitudes, adopt a person centred approach, communicate with understanding and empathy and involve Betty in all suggestions. The UK government has a number of social work policies and intervention programmes for young mothers. The social worker should engage Betty with open ended questions about her challenges and difficulties. She should be allowed to express herself freely in order to obtain a fuller understanding of her challenges as well as her physical, emotional and mental strengths.

The social worker should discuss different options like (a) her medical and emotional status, (b) engaging in counselling sessions with her daughter, (c) formulation of programmes for completion of her education and / or increase of her earning abilities and (d) ways and means for increasing her inclusion in social and community life. Appropriate intervention plans should be made after obtaining Betty’s active agreement on specific intervention programmes.

The problem of teenage pregnancies in the UK led to the development of a National Teenage Pregnancy Strategy (NTPS) to combat it. Despite efforts put into this strategy, the UK still ranks as the highest in Europe and the lofty targets of 50% reduction is yet to be met as recent statistics show only an overall of 4.9% in reduction in rates since inception of the programme (ONS 2009).

The NTPS highlighted four key areas to be used as the basis for LA programmes which include; the use of mass media and campaigns to increase awareness, Sex and Relationship Education (SRE) in schools and community settings, easily accessible services and information on sexual health and improved assistance to young parents to reduce social exclusion (DCFS 2009). On this note, The last 10 years have seen the implementation of different programmes in the local authorities (LA) in an attempt to reach the national target of halving the rates of teenage pregnancy in the UK as well as providing means to increase by at least 60% the number of teenage mothers returning into gainful employment or education as the case may be (DCSF 2009).

Different LAs have experienced both negative and positive changes in the teenage pregnancy rate with areas characterised by social and educational deprivation having a steeper rate of decline than others (DCSF 2005). Despite this steep decline, the Spearhead areas which face the greatest challenges in terms of health inequalities still have higher rates of pregnancies than others (DCSF 2009b) and Southwark belonging to this group has been worse-off than other areas in Britain. This essay attempts to highlight the process of impact assessment of the SRE programme adopted by Southwark and is intended to map the needs and examine demands of the teenagers and assess services providing SRE so as to check the gaps between these factors which are responsible for the high teenage pregnancy rate in this area despite the strategies applied in keeping with the NTPS.

SRE Programme Summary and Analysis

In 2000, the Department for Children, Schools and Family (DCSF) issued guidance on all schools to improve and ensure effectiveness of SRE in schools which is targeted at influencing young people to make responsible and well-informed choices about their lives (DCSF 2009c). SRE is meant to educate young people on sex-related issues and on making conscientious choices about their lives thereby reducing risky behaviour which might lead to unintended pregnancy. It involves mainly schools, the parents and the community at large. This is meant to be with support from the LA to ensure inclusion of comprehensive SRE programmes into PSHE in all schools (DfES 2006).

Southwark LA took the following approaches towards administering SRE which would raise the ambition of teenagers in the LA. It extended the services of sexual health professionals to beyond clinical settings to include schools and community settings. Programmes were developed outside school settings to teach teenagers about the realities of parenting and the advantages of wise choices for example: Choose your Life, L8R, Body Tool Kit, Teens and Tots, Virtual Doll Programme. Diverse needs of different ethnicities, religions and abilities were considered with programmes to meet them. In the school settings, the schools were made to develop SRE guidelines which involved parents, teachers, school nurses and teachers and vanguard staff especially those working with high risk teenagers in the schools and community were trained (NHS Southwark 2007). By this means, the Southwark LA seeks to improve the knowledge of young people on early pregnancies, direct them to making credible decisions and in turn reduce the rate of teenage pregnancies (Fullerton et al 1997).

The measures taken were in line with the aims and objectives of the programme as studies have shown that teenagers appreciated a forum to discuss sex and relationship issues and these forums were advantageous as they reduced the chances of earlier intercourse (Allen et al 2007; Fullerton et al 1997) however some local disputes existed that interfered with optimal delivery of SRE in the schools in Southwark. Not all schools had included SRE in the teaching curriculum, some of the teachers were unclear of the extent to teach and were either embarrassed or awkward about young peoples sexual issues, some schools had a curriculum that did not include social or emotional issues which play a significant role (Chambers 2002), mixed gender classes discouraged the teenagers especially females from asking questions (Stephenson et al 2004) and some parents were not totally cooperative as they withdrew their children from SRE classes (Lanek 2005).

In response to these problems recommendations by Health & Social Care Scrutiny Sub-Committee (2004) were made. The committee advised that the obligation of all schools especially faith schools towards inclusion of SRE into school curriculum should be encouraged and advocated for further training of teachers on undertaking sexual health issues with teenagers and use of different techniques that will include social aspects. They also recommended that schools attempt to increase parents’ awareness on the proactive nature of sexual health education (NHS Southwark 2004).

Health Impact Assessment Process

A Health Impact Assessment (HIA) is a blend of processes through which a project , policy or programme can be evaluated and assessed so as to identify the influence it has on the health of the population (WHO, 1999). It is a systematised way of assessing the effectiveness of a project involving different stakeholders in order to make evidence-based decisions towards improvement of the project where necessary (Lock 2000). A HIA is the ideal approach to use in assessing the effect of the SRE on Southwark teenagers as it identifies the health and inequality impacts (NHS Southwark 2004) considering the diverse nature of the young people in Southwark. Bearing in mind that this programme has been on-going, this process is regarded as a concurrent health impact to expose strengths and weaknesses in the project while making recommendations in tune with the gaps to further enhance its progress in the most cost-effective way (Bos 2006; WHO 2002).

The process of HIA involves a stepwise approach and has five core steps which would be applied towards the SRE in Southwark and any other HIA (Cameron 2000; WHO 2002). These steps which include; screening, scoping, appraisal, report and recommendation, and monitoring and evaluation may be adapted to suit the community or project being assessed (Breeze et al 2001; WHO 2010).

Screening

This process which is the first step in a HIA is aimed at exploring the feasibility and importance of the assessment, the department of health instructs on some questions to be answered to check viability of the HIA process, and the questions put into consideration the wider determinants of health which play a role in the problem of teenage pregnancy in southwark (DH 2007).

Based on the screening tool, a HIA is necessary on the SRE as Southwark LA ranks highest in teenage pregnancies in Britain despite its adoption of the programme like other LAs. In accordance with the NTPS, Southwark LA goals were to reduce teenage conception by 15% in 2004 and 60% by 2010 (NHS Southwark 2004) however the rate is still at 76.7 per 1000 and a change of 12% only has been seen since the start of the programme in 1999 (DCSF 2009a). Like the rest of Britain, Southwark included the SRE programme in its teenage pregnancy strategy and as the general consensus holds sex education has contributed greatly to the reduction of teenage pregnancies. The impact assessment will provide information and evidence on category and substance of change of the SRE programme where needed for policy makers to guarantee set targets of reducing teenage pregnancy rates are met (NHS 2007) .

Scoping

A steering group is appointed to supervise the process and also to set the geographical boundaries and profile of the population affected by the programme in agreement with the stakeholders. (Cameron 2000; Metcalfe et al 2009). As the HIA is based on Southwark SRE the geographical boundary is limited to Southwark borough and the population profile consists of about 20,000 teenagers with 37% from Black and Minority Ethnic groups (BME), blacks make up 26%, 4% are Asians, 3% are Chinese, 4% mixed (ONS 2004; Southwark Vital Statistics 2007). Issues relevant to the needs of young people in Southwark in relation to the SRE are identified and discussed to direct the appraisal step of the HIA (WHO 2002). Background information on SRE in Southwark showed the problem with the programme was multifaceted (NHS Southwark 2004). Using this information in addition to information on the SRE in other LAs where successes have been registered, proposals can be set towards addressing the issues (Joffe et al 2005).

Appraisal

“Appraisal is the ‘engine’ of health impact assessment, moving the whole process along towards practical outcomes” (Cameron 2000). This appraisal can be regarded as intermediate as the method of information collected is based on a collaboration of stakeholders, health care professionals, the teenagers and a semi-extensive literature review on the effects of sexual education on teenagers. The negative and positive impacts of the SRE on reducing teenage pregnancies in Southwark is explored by this process (Parry et al 2001) using both qualitative and quantitative data for completeness. Considering this is a concurrent HIA the past impacts are evaluated with a vision to enhance future progress. It is a multidisciplinary step as it involves all the people involved in the SRE programme (WHO 1999). Workshops organised should include the health workers, school-teachers, school nurses, community programme co-ordinators, peer-health educators, youth representatives from schools and community programmes, representatives from faith-based organisations and representatives from the LA who will provide local views of the programme (Mindell et al 2004) . The information collected from this exercise will help define the understanding of SRE amongst the different groups, inequalities existing between these groups may also be recognised and aspects of the programme which are not advantageous may be brought to light. It will also help to assess long and short-term impacts of the programme (Joffe et al 2005). Considering that data collected from this exercise are likely to be biased, robust methods are needed to contribute validity to the predictions derived from the data (Parry et al 2001). Other information should be collected by secondary analysis of existing data from the youth centres, school reports, NHS Southwark databases, and Office for National Statistics. This data collected will supply the sociodemographic and health profile of the teenagers in Southwark, and also report on already experienced impacts of the SRE.

Some challenges are expected in this stage as evidence-based information regarding the determinants of health for the different groups of teenagers may not be readily available or easily accessible. This may be daunting but should not deter continuation of the assessment rather the best available data should be used while recognising the significant gaps in the evidence used (Joffe et al 2002, Mindell et al 2003).

A sexual health needs assessment conducted on Southwark showed that high levels of need exist in relation to teenage pregnancies in Southwark and it is evident from the high teenage conception rates, high termination and repeat termination rates (NHS Southwark 2004). Another major finding which can be related to the SRE is that these high rates are disproportionately distributed as the Black and Minority Ethnic groups have higher rates (Berthoud 2001). The needs of this group are peculiar as teenage pregnancy is viewed differently with regards to the culture or religion. Teenagers of Muslim faith had different views from the wider community as younger marriage and parenthood is regarded as the norm (DCSF 2008). It is of importance to note that the ethnic inequalities in teenage pregnancy is an outcome of socioeconomic disparities (Nazroo 2003) which is evident in their representation in number looked after by LAs and in school exclusions (DCSF 2008). On the other hand, the teenagers considered sexual health services aligned to schools with some scepticism which was based on confidentiality issues (NHS Southwark 2007). Some studies carried out on the effects of sex and reproductive education on young people showed that most young people were more satisfied when the education was peer-led than teacher led and females had some inhibitions about discussing sex related issues in the presence of males (Stephenson et al 2004; Seamark et al 2005; Ross 2008). Also, despite the addition of SRE into school programmes, most teenagers cited places other than school as main source of sex related information (Allen et al 2007).

Putting all the information into consideration, the basis for the HIA can be addressed towards the different ethnicities, faiths and socioeconomic groups (Fullerton et al 1997) considering that this has been recognised as the bane of the challenges faced in maximising the impact of SRE to teenagers in Southwark. Appraisal done can relate these needs to the services available and identify the gaps where they exist to make recommendations towards satisfying the needs in the future.

Report and Recommendations

In view of the fact that the problem of teenage pregnancies in Southwark is on-going with about 289 pregnancies in U-18s yearly ( NHS Southwark 2009), it is essential that this process of report writing which will influence decision-making by the stakeholders is not delayed so as to ensure early adaptation of recommendations where implied (Joffe et al 2005). A high level of assiduousness must be assumed by the steering group to guarantee thoroughness in the recommendations proposed.

The Dahlgren and Whitehead (1991) rainbow model of health integrates biological, social and environmental factors into defining the general well-being of an individual. These factors are not constant and the degree of influence each of these determinants of health play varies for different population groups. The decision-making step of the HIA should put this model into consideration while proposing recommendations on the SRE which would adjust the proposal to take full advantage of already established positive impacts while curtailing the negative health impacts (Parry et al 2001).

Consequent upon the findings during the appraisal step of the HIA recommendations towards improving the SRE may include: establishing ethnic and faith -based SRE programmes, which will relate better with the different beliefs held by the diverse groups found in Southwark, stronger collaboration of the community, health sectors and schools in promoting SRE and further training of more peer-educators to increase the impact of the programme and thereby reduce the rate of teenage pregnancies. In addition to this, consideration of same-sex SRE classes should be made (Fullerton et al 2001) There should be a recommendation for future monitoring of the impacts seen after implementation of the revised project which would allow for necessary action towards unexpected outcomes and also contribute to the evidence base for later use (Metcalfe et al 2009; WHO 2002).

Monitoring and Evaluation

The fact that recommendations have been put forward does not guarantee implementation thus monitoring is of necessity to ensure that decision-makers put into effect agreed changes as different factors like lack of resources or political shifts could influence decisions (WHO 2010; Joffe et al 2005). The indicators which should be used in assessing the revised SRE would include rate of teenage pregnancies recorded, teenagers knowledge of sex related issues and ability of teenagers to make well-informed choices to name a few. This can be gauged using qualitative and quantitative methods (Scott-Samuel et al 2001). Long term monitoring can be used to assess accuracy of predictions made during the appraisal and recommendation (Taylor et al 2003; WHO 2002).

Three different forms of evaluation are essential. These include; evaluation of the process which acts as a mechanism of quality assurance (process evaluation), evaluation of acquiescence and execution of recommendation (impact evaluation) and outcomes of subsequent proposal (outcome evaluation) (Parry et al 2001; Scott-Samuel 1988). It is important to note that notwithstanding the extensive nature of the appraisal, the outcome may not be as predicted especially for the groups which have been identified as vulnerable groups which in this case are the BME thus the impacts in this group may be assessed and compared with other groups for more clarity (Joffe et al 2005). Other possible challenges in this stage may be budget related or due to the seemingly endless need for evaluation of a project however a defined stop-point at the onset will help to eliminate this difficulty (Thorogood et al 2000; Taylor et al 2003).

Conclusion

The concept of HIA is fairly new but then its effectiveness is extensive as it has been used in different sectors realeting to health issues and otherwise. The advantages of carrying out a HIA Can be used prospectively, concurrently or retrospectively;

_ Values a social model of health and well-being;

_ Aims for equity;

_ Uses a multidisciplinary and participative approach;

_ Works towards sustainable development;

_ Makes use of qualitative and quantitative best available evidence;

_ Encourages openness and transparency to public scrutiny;

_ Demonstrates health gain as an added value;

_ Responds to public concern about health;

_ Provides an opportunity to develop effective partnerships

The aim of this study or discussion is to analyse and discuss the impact of the labour government policy on teenage pregnancy and social exclusion in the United Kingdom, to what extent has the policy achieved its aims and objectives and if the objectives have not been met, why and how it may be improved, what are its shortcomings and constraints in the implementation process or if the policy itself was not well put together.

Barry (2002) argues that social exclusion occurs when individuals or groups are not given the opportunity to participate in society, whether or not they desire to participate.

The British Government in 2001 defined social exclusion as “a shorthand term for what can happen when people or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime, bad health and family breakdown”.(Cabinet Office, 2001)

Burchardt, Le Grand and Piachaud, (2002) identify consumption (the capacity to purchase goods and services, including health services), production (taking part in economically or socially valuable activities including voluntary work), political interaction or participation (involvement in local or national decision-making) and social interactions (integration with family, friends and the wider community) as the four key elements of social participation. These elements individually can represent an outcome measure for social exclusion or inclusion. Teenage pregnancy is a risk factor for social exclusion. Social disadvantage refers to a range of social and economic difficulties an individual can face such as unemployment, poverty, and discrimination and is distributed unequally on the basis of socio-demographic characteristics such as ethnicity, socioeconomic position, educational level, and place of residence (Wellings and Kane, 1999).

Social exclusion can happen to anybody but is more prevalent among young people in care, young people not in school and among teenagers growing up in low income households , or those growing up with family conflicts and people from some minority ethnic communities are disproportionately at risk of social exclusion. people are also most vulnerable at periods such as leaving home, care or education.

Teenage birth rates in the UK are the highest in Western Europe and pregnancy among girls under sixteen years of age in England and Wales have increased since 2006, more than four in ten girls still get pregnant before the age of twenty. Two-thirds of all students have sex before graduating from school and are exposed to pregnancy and sexually transmitted diseases. (ONS, 2009).

Social exclusion Unit (2001) in their report to cabinet said that In England, there are nearly 90,000 conceptions a year to teenagers; around 7,700 to girls under 16 and 2,200 to girls aged 14 or under. Roughly three-fifths of conceptions – 56,000 – result in live births. Although more than two-thirds of under 16s do not have sex and most teenage girls reach their twenties without getting pregnant, the UK has teenage birth rates which are twice as high as in Germany, three times as high as in

France and six times as high as in the Netherlands.

Teens that get pregnant are less likely to complete their education therefore risks making their future worse. They are more likely to be single parents and are more likely to contract sexually transmitted diseases including HIV. Every year there are new entrants into teenage world.

The risk factors that affect early teenage pregnancies are economic disadvantages, peer pressure, emotional distress, sexual beliefs, attitude and skills, family structure, community disadvantages, sexual risk taking and poor contraceptive use. (Kirby, 2007).

The main policy initiatives (750)

New Labour (1997) introduced policies that aim to reduce young people’s risks of low educational attainment, poor or no job prospects, criminality and offending, teenage pregnancy and sexually transmitted infections (STIs).

Tony Blair (PM, 2001) in a foreword to the Report by the Social Exclusion Unit on Preventing Social exclusion said “Preventing exclusion where we can, reintegrating those who have become excluded, and investing in basic minimum standards for all and we have worked in a new way – developing partnerships around common goals with the public services, communities and charities, businesses and church organisations that have been struggling with the causes and symptoms of poverty for so long.”

The policy used risk management approaches as a way of reducing risks of teenage pregnancy and sexually transmitted diseases amongst young people by using strategies that gives the individual choices , responsibilities and make them part of the solution. New Labour’s policies on teenage pregnancy centres around teenage pregnancy and sexuality using Knowledge Acquisition, Shifting Blame and Constituting Knowing Active Welfare Citizens as strategic Risk Management options.

The New Labour government set up a Teenage Pregnancy Strategy overseen by the Teenage Pregnancy Unit and the strategy centres on reducing the rate of teenage conceptions, with the specific aim of halving the rate of conceptions among under 18s by 2010.

Getting more teenage parents into education, training or employment, to reduce their risk of long term social exclusion.

The Social Exclusion Unit was setup by the New Labour government to co-ordinate policy-making issues like school exclusion and truancy, rough sleeping, teenage pregnancy, youth at risk and deprived neighbourhoods through,

preventing social exclusion happening in the first place – by reducing the numbers who go through experiences that put them at risk or targeting action to compensate for the impact of these experiences ,

reintegrating those who become excluded back into society, by providing clear ways back for those who have lost their job or their housing, and missed out on learning and

getting the basics right by delivering basic minimum standards to everyone in health, education, in-work income, employment and tackling crime.

Critically analyse policies-SID,RED,MUD
Critical analysis of the Policy, (2000)

Action to prevent social exclusion is delivering results:

the proportion of children in homes where no-one is in work has fallen from 17.9 per cent in

1997 to 15.1 per cent in 2001;

over 100,000 children are benefiting from the Sure Start programme to ensure they are ready to

learn by the time they reach primary school; school exclusions have fallen by 18 per cent between 1997 and 1999; under-18 conception rates have fallen in four out of the last five quarters;

more 16-18 year olds are staying on in education;

the Care Leavers strategy has been introduced;

the Rough Sleepers Unit is piloting new approaches to end the fast track to homelessness from

prison and the Armed Forces;

Summary

Stakeholder Pensions will help moderate earners build up better pension entitlements from this

April. Some 18 million people stand to gain from the State Second Pension, providing more

support than under the State Earnings Related Pension Scheme (SERPS) for modest and low paid

workers, and for carers and the disabled; and

the personal tax and benefit measures introduced over this Parliament mean that by October

2001, a single-earner family on half average earnings and with two young children will be ?3,000

a year better off in real terms compared with 1997. Families with someone in full-time work will

have a guaranteed minimum income of at least ?225 a week, ?11,700 a year. And families with

children in the poorest fifth of the population will on average be ?1,700 a year – or around

15 per cent – better off.

And programmes to reintegrate people who have become excluded are recording successes:

since 1997 more than 270,000 young unemployed people have moved into work through the

New Deal for Young People;

over 6,000 people have found work through the New Deal for Disabled People and over 75,000

people had found work between October 1998 and December 2000 through the New Deal for

Lone Parents;

all Local Education Authorities (LEAs) have increased provision for excluded pupils, a third already

do so, and two-thirds plan to offer them full-time education in 2001;

between June 1998 and June 2000, the number of rough sleepers fell by 36 per cent; and

the proportion of teenage parents in education, employment or training has increased from 16 to

31 per cent between 1997 and 2000.

And changes in basic public and private services are focusing improvements on the poorest:

higher standards than ever before in Key Stage 2 English and maths with a ten and 13

percentage point improvement in each subject respectively between 1998 and 2000;

44 Local Education Authorities (LEAs) in the 88 most deprived areas2 improved their Key Stage 2

maths results by 14 per cent or more between 1998 and 2000. The most improved area was

Tower Hamlets, with an increase of 23 per cent;

24 LEAs in deprived areas improved their Key Stage 2 English results by 11 per cent or more over

the same period;

between 1998 and 2000 children from most minority ethnic communities saw a rise in

achievement of GCSEs. This includes an eight percentage point increase in the number of black

pupils achieving five or more GCSE grade A*-C, against an average for all pupils of three

percentage points;

unemployment has fallen faster than the national average in 19 of the 20 highest unemployment

areas;

the combined effects of Minimum Income Guarantee (MIG), Winter Fuel Payments and free

television licences for those aged 75 and over mean that from April 2001 around two million of

the poorest pensioner households will be at least ?800 a year better off compared with 1997 – a

real terms rise in living standards of 17 per cent.

together with tax and benefit reforms, the national minimum wage has helped to make work pay

and encourage individuals to move from benefits into work; and

by the end of 2000, all the high street banks offered a basic bank account available to all.

Preventing social exclusion

These improvements are a good start. Trends on literacy, school exclusion, post-16 participation and

rough sleeping are on track. Incomes for the poorest pensioners and families, and for low-paid

workers, have risen substantially. Where programmes have been slow to deliver results, for example

on truancy, the Government is intensifying action. But many of the programmes in this document

are only in their infancy, and are on course to deliver more substantial results over time. At the same

time, policy innovation has been accompanied by new structures and new ways of working within

Government. These have created clearer accountability for cross-cutting subjects such as rough

sleeping, neighbourhood renewal and youth policy; set the basis for a new relationship of

Partnership with groups outside Government; organised services around the needs of the client;

and helped people to help themselves

Policy can exacerbate and not alleviate
Conclusion (500)

The 1999 UK government’s report on teenage pregnancy concluded that the following were risk factors for pregnancies among teenage girls: socioeconomic disadvantage, having been oneself the child of a teenage parent, poor communication with parents, not being in education, training or work after age 16 years, peer pressure to have sex early, educational problems such as low achievement and truancy, alcohol use, low knowledge about sexual health, and learning about sex from sources other than school

However, these conclusions were based on evidence that was rather old or from cross-sectional studies, which are not the best guide to current trends

Social Work Approaches

The social work profession promotes, encourages and elicits social change in those they work with and society. This essay will examine two approaches used to support change in social work today, Task-Centred Practice and Cognitive-Behavioural Therapy, and compare and contrast these two. The essay will achieve this by applying these two interventions to Case Study Two, analysing the advantages and limitations of each method. Finally the essay will discuss any anti-discriminatory issues raised in the application of the discussed social work approaches.

Cognitive-Behavioural Therapy (hereon CBT) is a psychological approach based on a combination of theories of learning: social learning, operant and classical conditioning (Teater, 2010 p.141). The approach is a composite of behavioural and cognitive therapies, involving assessing and changing behaviours, thoughts and feelings together. CBT suggests that service user problems or difficulties are a result of thoughts, feeling and behaviours being unescapably linked, therefore how a service user views themselves or situations affects their behaviour and emotions (Vonk and Early, 2009). However, CBT only focuses on presenting problems and their current causes. The goal of CBT is to change service users’ existing faulty or negative thoughts feelings or behaviours and replace them with more socially acceptable and positive thoughts, feelings and behaviours that decrease the problem. The use of CBT derives from criticisms of Psychodynamic theory for not being evidence-based and not being effective in creating change (Howe, 2009). However CBT is not the only evidence-based approach.

Similar to CBT, Task-Centred Practice (hereon TCP) is based on strong research evidence; studies by Reid and Shyne, Reid and Epstein and Reid demonstrated planned short-term treatment using task-centred model was effective (Payne, 2005 p.99). In contrast to all other approaches TCP was developed within social work for social work practice, and is commonly used in social work today. TCP is focused on problem-solving; a versatile approach, TCP is used in a wide range of problems (Stepney and Ford 2012 p.102) including interpersonal conflict, dissatisfaction with social relations, problems in social transition, financial problems and behavioural difficulties (Ford, 1978 as cited in Stepney and Ford 2012 p.103). Doel (1991 as cited in Teater, 2010) states that TCP uses key values related to social work, for example partnership and empowerment: clients are seen as the experts in their problems; the approach builds on service users’ strengths rather than weaknesses; and finally that the Social Worker is providing help rather than treatment. TCP’s assumption of client as expert is another point of contrast to CBT. However CBT has its own assumptions.

CBT holds three basic assumptions: firstly, an individual’s cognitions mediate emotions and behaviours (Trowel et al, 1988; Vonk and Early, 2009 as cited in Teater, 2010 p.146); secondly, faulty or distorted cognitions lead to psychological distress and dysfunction (trowel et al, 1988 as cited in Teater); finally, diminishing or alleviating psychological distress and dysfunction requires modification and change to the faulty or distorted cognitions and behaviours (Trowel et al, 1988; Vonk and Early, 2009 as cited in Teater, 2010 p.146). CBT takes these assumptions and creates a structured approach to working with service users. Coulshed and Orme (2006 p.181-182) describe the CBT approach in eight clear stages; engagement, problem focus, problem assessment, teaching cognitive principles, dispute and challenge assumptions, encourage the client’s self-disputing, set behavioural homework and finally, ending. This extremely structured approach is another point of comparison with TCP.

TCP, similar to CBT, is built around a clear model, and progresses through set stages. Firstly, ‘identifying the problem’; TCP is a collaborative approach which works to tackle problems the service users acknowledge and understand (Doel, 1991 as cited in Teater, 2010 p.178). In addition the service user must express a wish to work on the problem alone or with the help of worker (Reid and Epstein as cited in Teater, 2010 p.179) Next, ‘exploring the problem’ in detail, selecting the problem that is causing the client most distress. From the problem ‘define a goal’ which diminishes or removes the problem, ‘establish tasks’ for the worker and service user towards reaching the goal, and finally ‘evaluate’ if the goal has been met and if the problem is removed (Reid and Epstein, 1972 as cited in Teater, 2010). The essay will now examine how these approaches could be applied to Case Study Two.

Case Study Two presents many key issues. The service user, Neil, is facing many difficulties at one time, which include problems with family, aggressive behaviour which has resulted in his homelessness, and lack of money, food, bedding, and household items. In addition he is also worried about moving GP. Many of Neil’s problems could be tackled using either CBT or TCP; selective eclecticism allows social workers to choose which approach would best suit each problem. The problems of homelessness, money and the want of a job are better suited to TCP; they are problems of living that may also include some social factors which CBT would not account for. The problem of behaviour where Neil is swearing in the family and the anxiety toward the change of GP would be best suited for CBT intervention, as this is proven to help with problems of behaviour and anxiety (Sheldon, 2011).

In Neil’s case, the first stages of TCP, identifying problems, exploring problem and setting goals, would need to be applied in the early meetings between Neil and the social worker. The collaborative period needs careful discussions and mutual agreement on problems and goals. A possible outcome may be tackling the problems such as homelessness, lack of money, food and unemployment in order; however, other factors may make this unrealistic. The ‘SMART’ method for goal setting is commonly applied, stating goals must be: specific, measurable, achievable, realistic and timely (Marsh and Doel, 2005 p.36). The assessment phase of CBT mirrors this early approach of TCP. During CBT’s assessment phase the service user and worker examine the links in thoughts, feelings and behaviours using the ‘A-B-C model’, as well as measuring intensity, duration and frequency of the problem (Teater, 2010 p.145). After assessment both approaches then move to intervention phases.

TCP uses tasks as an intervention. The task should be planned carefully, asking: what is the task, the reason for the task, and what the person needs to be able to achieve the task. These stages can be simplified to what, why and how (Marsh and Doel, 2005 p.55). The tasks are performed by either the service user, the social worker or by both parties in session. In contrast, a CBT intervention is classified into distinct categories of intervention including cognitive restructuring, relaxation techniques, social skill training, assertion training, problem-solving skills, aversion therapy, systematic desensitisation, reinforcement and modelling (Teater, 2010 p.149-150). The actual intervention that is selected is dependent on the problem faced. In the case of Neil, cognitive restructuring may be suitable to approach the anxiety and his false belief that his doctor is the only one who can understand him. This is done by challenging the assumption, reinforcing self-challenging and homework. Next both approaches move on to the ending phase.

The ending or evaluation phase is critically important in both CBT and TCP. Both approaches use close evaluation of the goals and progress made in the intervention; this evidence-based practice is seen as a great benefit of both these approaches. CBT uses data collected in the assessment phase as a tool for evaluating the outcome of the intervention. This is done by comparing intensity, duration and frequency of thoughts or behaviours before the intervention and after, giving a measure of success or failure in the intervention (Sheldon, 2011). TCP uses a similar process of evaluation: firstly regular assessment of the outcome of the tasks set measures change in capability; secondly, TCP monitors whether the service user’s goals have been met or the problem solved. This measurability of evidence-based approaches finds them favoured by funders and managers in social work (Payne, 2005 p.101). These are not the only benefits of these approaches.

TCP has many other qualities that result in it being commonly used: it is generic, can be used in many settings and with many different clients groups (Teater, 2010 p.189). TCP can be used easily in combination with many other approaches, such as motivational interviewing to help someone who may be unsure about change (Teater, 2010 p.189). Both CBT and TCP are highly structured and easy to use (Payne, 2005). Furthermore both interventions are brief and time-limited while remaining effective (Stepney and Ford, 2012). However these approaches have some limitations.

TCP requires that service users can make connections between problems, tasks and goals; this is not possible with all service users, as some may be unwilling or experience difficulty in making connections (Marsh and Doel, 2005). CBT also faces similar difficulty with service user commitment the approach relies on equal involvement from the social worker and the service user in changing faulty learning process or behaviours (Teater, 2010 p.155). In addition, Payne (2005) suggests another weakness in TCP is its failure to tackle the long-term individual or social problems. This is especially pertinent in Neil’s case, in which he and his family have had previous social service interventions. Another criticism of CBT is that it only focuses on the individual: oppression, discrimination, racism and poverty are not addressed in the approach (Teater, 2010 p.155). Furthermore, by not accounting for oppression and discrimination, TCP and CBT may inadvertently exacerbate both.

Thompson (2012) defines anti-discriminatory practice as an approach to social work practice which seeks to eliminate discrimination and oppression, and argues it is fundamental to social work. However, a social work intervention often places power and influence in the hands of social work, and there is scope for discrimination and oppression in social work practice, whether intended or unintended. CBT focuses on changing behaviour from inappropriate to appropriate. What is ‘appropriate’ behaviour is culturally relative and a misinformed social worker may attempt to change acceptable behaviour thus creating oppression. However, cultural sensitivity must be balanced with ability to challenge behaviour that causes discrimination in itself (Tanaka-Matsumi et al., 2005 as cited in Teater, 2010 p.156). Marsh and Doel (2005 as cited in Teater, 2010 p.191) suggests that TCP is allied with empowerment-based approaches and anti-oppressive practice as TCP takes account of power and oppression in a wider social context. The approach emphasises partnership and transparency, highlighting any power imbalance should be made explicit from the beginning of the intervention (Teater, 2010 p.191). Doel and March (2005) further argue that the client should be informed and as involved as possible. However, TCP relies on the service user accepting that there is a problem; this point may become a point of oppression whereby the social worker may force their perspective of the problem upon the service user, particularly in mandated work (Doel, 2002 as cited in Teater, 2010). However, good practice in TCP sees the service user as the expert in their problem and the social worker as helper, rather than prescriber of a course of action (Teater, 2010 p.191).

In conclusion, supporting and eliciting change is a difficult job for social work. Numerous factors play a part in a service user problem or want. No one approach will consider all the factors all the time, therefore being eclectic in choosing an intervention is a key social work skill. As shown, both TCP and CBT are very practical approaches: each has a clear structure, a strong evidence-base and uses evaluation to show the efficacy of an intervention. However each approach has weaknesses: TCP fails to address long-standing problems and asks service user to have good insight into their problems. CBT does not account for oppression, discrimination, racism and poverty, instead focusing on the individual. Like all interventions in service users’ lives, both CBT and TCP can be oppressive and discriminatory used casually or incorrectly. However, handled with care, collaboration and transparency, both TCP and CBT can be used to support service users to empower themselves into making the changes they want to make.

Reference List

Adams, R, Dominelli, L and Payne, M. (2009) Critical practice in social work, 2^nd edition, London: Palgrave.

Coulshed, V and Orme, J. (2012) Social Work Practice, 5^th Edition, Basingstoke: Palgrave Macmillan.

Marsh, P and Doel, M. (2005) the Task-Centred Book, Abingdon: Routledge.

Howe, D. (2009) a Brief Introduction to Social Work Theory, Basingstoke: Palgrave Macmillan.

Payne, M. (2005) Modern Social Work Theory, 3^rd Edition, Basingstoke: Palgrave Macmillan.

Teater, B. (2010) Applying Social Work theories and methods, Berkshire: Open University Press.

Thomson, N. (2012) Anti-discriminatory practice, 5^th edition, Basingstoke: Palgrave Macmillan.

Sheldon, B. (2011) Cognitive-Behavioural Therapy, 2^nd edition, Abingdon: Routledge.

Stepney, P and Ford, D. (2012) Social Work Models, Methods and Theories, 2^nd Edition, Dorset: Russell House Publishing Ltd.

Vonk, M, E & Early, T, J. (2009) Cognitive-Behavioural Therapy, New York: Oxford.

“Write a case study illustrating a social work intervention with an individual or family drawn from your current practice placement. The case study should illustrate the application of a social work method / approach (such as crisis intervention, systemic approaches, solution focused approach, CBT etc) to a practice situation and should contain a critical analysis of the chosen methodology.”

Within this assignment I will discuss a case that I am managing within my placement by providing details of the case and other professional bodies that are currently involved. In relation to this case I will discuss the relevant theories and methods that I have used with this client and critically analyse my choice of method. I will also mention other methods or approaches that I feel may have been beneficial to my work with the client. In order to provide evidence of this session with my client I will also attach a process recording to illustrate my chosen method.

Michael is a 47 year old male that is a service user of the Mental Health Team in Ballyfermot. Michael has been diagnosed with schizophrenia and a mild intellectual disability. He currently lives alone in the community with the support of the Mental Health Team. I am managing this case with the supervision of my practice teacher. At the moment Michael has the support of the outreach team in which they manage his medication and food shopping, whereas the social work department manage his finances in regards to his bills and give Michael a daily allowance each week. I am currently working one to one with Michael on a weekly basis in regards to the goals he has set for the following weeks. Each week Michael and I meet to discuss relevant issues that may have arisen for him during the week. Michael and I worked in partnership to complete the recovery star and made a plan to tackle some of the areas in his life that he would like to improve on. An example of this would be attending literacy classes, learning how to text and learning how to cook at home and also finding a job. I am working in partnership with Michael to achieve these goals.

For this session, I planned to discuss and start the recovery star with Michael in order to understand his lifestyle at this present time. In order to complete the recovery star I used a task centred approach. The theory that I used for this session was behaviourism. Behaviourism is based on the theories of Pavlov, Skinner and Watson (Trevthick.P, 2005). According to Trevthick.P (2005) it was seen that through observable and measureable responses that behaviours are learned and in result behaviours can also be unlearned (Trevthick.P, 2005). According to Trevthick.P (2005) it also states that there are four types of techniques which are systematic desensitization, aversion therapy, operant conditioning, and modelling. In regards to working with Michael in this session, I used one of these techniques which were operant conditioning. “Operant conditioning is a technique where ‘the environment has been specifically programmed to support certain behaviours and discourage others’ (Sheldon, 1995) by altering the consequences that follow” (Trevthick.P,2005:P.96). While working with Michael and arranging to have our sessions in the civic centre every week it is evident through our sessions that the environment around him would have an effect on his behaviour. For example if the civic centre was busy Michael would sometimes seem a little anxious, whereas if the centre was quiet, Michael’s mood would be quite calm. Through operant conditioning it also discusses the possibility of reinforcements in regards to behaviours. Through this it is evident that through our weekly sessions, Michael would understand his reinforcement by participating within the session would be his daily allowance. This has become clear on a number of occasions as Michael has become quite engaging in regards to the sessions that would take place on a weekly basis. Whereas before if Michael received his daily allowance before his weekly sessions he would become disengaging and would abandon the session. Through this theory I then decided to use the method of task centred work with Michael.

According to Adams, R et al (2002) “Task centred casework was described as a method to help people with problems of living.” (Adams.R et al, 2002). According to Payne.M (1997) task centred work looks at problems with the client and ensuring that the client accepts and acknowledges the problems that they have. Also understanding that their problems can be resolved by their actions outside the ongoing work they may have with the social worker and that the problems can be defined clearly. While also having certain issues in the clients lives that they feel that they can change and that these problems are realised by the client and not others that are in the client’s life (Payne. M, 1997). It is also discussed that it should be assessed of the “direction and strengths of clients wants” (Payne. M, 1997), this is explained in regards that the clients want can start an action, although the clients belief system can shape the want while also providing an acceptable way of accomplishing those wants. In result according to Payne. M (1997) a belief can steer an action and by completing certain cognitive therapies these beliefs can be changed. According to Payne. M (1997) this was called a point of leverage. A point of leverage is accuracy, scope and consistency. Accuracy is when a social worker would discuss how accurate a client’s belief is then discuss the scope in which they discuss the range of beliefs that client has and explored with the client when they think these beliefs are limited. And lastly consistency in which the social worker would tackle misrepresentations due to a disagreement between one belief and another in which the social worker would be able to remove these and discuss it with the client. Through this emotions can arise for the client when there is a collaboration of their belief and want. This can then follow onto an action which would be shown by a behaviour which would be carried with intent which then follows on to a plan (Payne. M, 1997). A plan is a portray of intentions which is formed from the interaction of the belief, want and emotion (Payne. M, 1997). Through this a plan can be set in regards to exploring alternative options that may not have been tried by doing so this can give feedback to the client and social worker to understand if the method was successful or not. Through this method it also allows the client to resolve any problems they may have while also providing them with the skills for situations that may arise in the future. In result the client would be able to tackle a future issue that may arise without the need of the social worker.

As cited in Payne. M (1997), Reid (1978) discusses the various stages of task centred practice. These are as follows step one “identify potential problems” (Payne.M, 1997) identifying specific problems the client is having and allowing them to express these problems in their own words in order to gain a full understanding of the situation. Step two is “reaching tentative agreements” (Payne.M, 1997), by doing this you can explore the main problems the client may be facing. Step three is “challenge unresolvable or undesirable problems” (Payne.M, 1997) by completing this with the client the social worker can challenge these problems so the client will not be encouraged to obtain an unrealistic goal. Step four is “raising additional problems” (Payne.M, 1997), through this step the social worker can challenge and allow the client to realise other problems they may be having. Step five is “seek others involvement” (Payne.M, 1997) through this it may be beneficial to seek others that can be supportive or can contribute to finding a solution. Step six is “jointly assess the reason for referral” (Payne.M, 1997); in this step it would be useful to discuss the reason why the client was referred to the service especially if the client was forced to do so. Step seven is “get precise details” (Payne.M, 1997), it would be very important for the social worker to get accurate details into when and where the problems are occurring for the client. Step eight is to specify the problem for the client, step nine would be to identify the clear baselines and lastly step ten would be to decide on the changes the client would like to make (Payne.M, 1997).Throughout this process it is vital that the client and social worker have a similar understanding of what needs to be achieved and also provide feedback at the end of each session in order to understand if certain aspects of their work is not proving successful. Adams. R et al (2002) discusses this that task centred work is a systematic model which examines what works well for the client and what doesn’t work so well in regards to achieving the desired goals that are put in place (Adams.R et al,2005).

In regards to this the main reason why I used this approach with Michael was because he has a mild intellectual disability and it can be difficult to engage Michael in activities for a long period of time. So when starting the recovery star I explained to Michael that we would complete three sections and then continue the rest the following week. Throughout this session Michael became agitated and annoyed as he wanted to receive his daily allowance and leave. Although when continuing to proceed with the recovery star and using the task centred approach it became clear to myself and Michael what improvements he would like to make in the different areas of his life. With this new knowledge, Michael and I were able to set a basic map. While working in this session with Michael, I decided to use the basic map of task centred practice that is discussed by Trevthick.P (2005). The reason I used this specific map instead of the other process described by Payne.M (1997) was because the basic map overall described four basic steps that would be beneficial to the sessions I had with Michael. According to Trevthick.P (2005) a basic map of a task centred approach consists of four steps. These steps are as follows, step one would be targeting three main problems the client has. Through the recovery star there were certain areas Michael wanted to improve on, which was his living skills i.e. cooking and cleaning and also his literacy skills. Step two consisted of a contract which was setting up a plan to achieve these goals successfully and set a time frame for when these would be completed. This was competed by researching the resources that were in the community in regards to the literacy classes and possible cooking classes and looking at the time scale of when Michael would like to accomplish these goals. Step three consists of problem solving which would be solving any problems that would arise for me or Michael in regards to the sessions that take place. For example while working towards improving Michaels literacy skills it was evident that Michael would need one to one tutoring and this wouldn’t be possible for several months, although Michael was adamant to start in which he decided to start in a group. In result as the student social worker I know I will have to support, encourage and motivate Michael in this process as he may find it challenging to be part of a group of sixteen. Finally step four is termination in which will commence when I start to finish up in my placement and hope that Michael will continue with his goals with his own social worker. At this present time because of Michael’s background and his diagnosis this method has been successful to date. I have also been able to use a person centred approach along with the task centred approach with Michael throughout this process in order to allow Michael to open up about his feelings and be honest about what is going on for him at that time and in result has allowed Michael to achieve positive outcomes within our daily sessions.

In regards to the task centred approach that I have undertaken with Michael, at present it has been successful as it looks at the three main problems that he would like to improve on within the short space of time that I will be working with him. By using this approach it was evident that Michael felt motivated to complete these goals as he focused on the three main issues he had in his life. According to Trevthick.P (2005) it can be very difficult to engage in the underlining issues that may be present. In my opinion and the evidence from conducting sessions with Michael this is quite accurate as it can be difficult to engage Michael in certain difficult conversations from his past from a task centred approach. Although by using a person centred approach when discussing these difficult conversations can be suitable as this approach allows him to discuss these issues calmly and reflect on the situation that he may find difficult. For example by using this approach, it allowed Michael to open up about his daughters and the relationship he has with them and how he wants it to improve. He was also able to realise that he wanted to do something about his literacy skills and how this issue could be a barrier for him when searching for a job. By conducting a task centred approach and completing the recovery star I discovered this about Michael and was able to use the person centred approach to discuss it in more depth. Although even though it is discussed that a task centred approach is chosen because it allows the goals to be achievable, it can be difficult for those who may suffer from a mental health illness. Some individuals may find it difficult to achieve the goals that have been set, although at that time it is important for the social worker and client to be able to feedback any difficulties that have arisen and be able to change in accordance with the individual. For example while working with Michael it can be difficult for him in regards to his mental health, so throughout our sessions I ensure that near the end of each session Michael is able to understand what was discussed and his understanding and ensure that he is still motivated in regards to the goals that he has set for himself.

In conclusion, it is evident that the ongoing weekly sessions with Michael have been beneficial in regards to a task centred approach. The reason for this is that Michael can concentrate on three specific goals at a time and doesn’t feel overloaded. From working with Michael on a one to one basis, his history and mental health status, this approach is working in a positive way in regards to what Michael wants to achieve. From previous case notes it has been noted of other methods that have been tried and failed to motivate and encourage Michael. This approach does have its limits for example it doesn’t allow the client to discuss their issues in detail, although that is when the social worker can incorporate other approaches into their work with the client. Throughout my work with Michael this approach has been favourable as with this client it has achieved positive results, while I am also aware that this may not be the case with every client that I encounter. Although while managing this case I plan to continue with this method and incorporate various approaches as needed in order to work in partnership with Michael to achieve his goals while anticipating a positive outcome.

References

Adams. R, Dominelli, Payne.M (2002). Social Work: Themes, Issues and Critical Debates. 2nd ed. Hampshire: Palgrave. P191-199

Teater. B (2010). An Introduction to Applying Social Work Theories and Methods. Berkshire: Open University Press, McGraw – Hill Education. P178-193

Nelson – Jones. R (1992). The Theory and Practice of Counselling Psychology. London: Holt, Rinehart and Winston LTD. P107-120

Payne. M (1997). Modern Social Work Theory. 2nd ed. Hampshire: Palgrave. P104-112

Trevithick. P (2005). Social Work Skills: A practice handbook. 2nd ed. Berkshire: Open University Press, McGraw – Hill Education. P95-98, P275-277

Recovery Star

Demonstrate your understanding of the main principles of TASK CENTRED PRACTICE. Consider the strengths and weaknesses of the theory in its application to anti discriminatory practice.
Introduction

The International Federation of Social Work states that:

“The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work”^[1].

The best kind of social work is that which places the client or service user at the centre of everything it does. This is a core principle of task based social work, rather than working with a set of preconceived ideas the social worker has to negotiate the legal framework within which she/he is obliged to operate in order to achieve the best results for the service user. Task based social work is therefore first and foremost ethical and anti-oppressive social work which takes as its foundation the Human Rights Act of 1998 that each person should be dealt with in terms of the concept of the inherent worth of the individual.

This assignment will first give some definition of the role and responsibilities of the social worker. From within this framework it will then look at the main principles of task centred practice and will use imaginary scenarios to consider the strengths and weaknesses of the theory and its application to anti-discriminatory practice.

Social Work

People looking for a career as a social worker usually have more luck if they have had some experience of dealing with individuals in the community. This could involve work placements or being involved with voluntary work, both of which seen as good practice and background to engage in social work practice. Prior community involvement is seen as a valuable asset for anyone wishing to become a social worker. Social services is set against a background of voluntary charity work in the late nineteenth century and people who get involved in community work are seen to have the right kind of spirit, or an interest in social justice that is a valuable part of social work (Moore, 2002).

Tasks and Roles Within the Legal Framework

The social worker’s role is outlined by what was the personal social services. The overall aim of social workers is a concern with individuals and the care they may need. Under Government legislation and the Code of Practice, social workers have to act in accordance with the 1998 Human Rights Act, the 1990 NHS and Care in the Community Act (a result of the 1988 Griffiths Report), the Chronically Sick and Disabled Person’s Act of 1970 and the 1995 Disability Discrimination Act. More recently social workers are legally required to be involved in partnership working with other agencies (ref) and this has been extended to include the service user/service provider relationship. There is, arguably, some truth in the fact that this takes what is at heart a charitable search for social justice and puts it on a par with businesses and at the mercy of market forces.

The primary work behind task centred practice is the identification of social systems, what they might be and what they do. Thus the properly qualified social worker needs a good deal of sociological knowledge with regard to things like class, gender, race and religion. He/she would also need to be aware of Parson’s work on social systems and socialisation because this gives an insight into the boundaries from which a service user may be operating (Payne, 1991). Once social workers are aware of social systems and how they operate then it is possible to be able to define any imbalances within a working relationship (Payne ibid). This last is a necessary part of anti-oppressive and anti-discriminatory practice, however, we shall see that task centred practice can be a two edged sword for the social worker.

Payne’s (1991) systems analysis is essential to task centred practice because it provides the social worker with a conceptual basis to start breaking a problem and its solution into manageable pieces.Task centred practice is based on the idea that people learn by doing and that when they have a success this then improves their performance (Hanvey, 1994). Task centred theory is further premised on the view that tasks are a series of steps that a professional would take in order to help a service user achieve a goal. This goal would need to take into account the rights and responsibilities of others as well as those of the service user.

There are three key parts of task centred practice the first part of this process focuses on the problem or situation that the social worker is faced with, for example a young mother who has been hospitalised with mental health problems and now wishes to look after her child herself. In this situation the social worker would have to break the problem down for example what might the risks to the child be if it was left unsupervised with a mother from a difficult client group? The social worker would begin by looking at the whole picture and then focus on particular aspects of the situation that could be problematic. Added to this as the social worker investigates the problem further he/she may find the shape and scope of the problem changing (Hanvey, ibid). Thus the social worker has to establish certain parameters e.g. the urgency of the problem and the chances of failure or success as well as any support the service user may have. In the case of a young mother with mental health issues for example the following problem might occur:

If the social worker needs to make a visit and the service user refuses to allow entry this could cause problems with regards to any future assessment, something which is required by the legal framework. According to the terms of the Community Care Act of 1990 (circular LAC (92) 12, any needs assessment would have to take into account that persons current living situation, any help or support from friends and relatives and what she herself hopes to gain from the assessment. Because of mental health needs this client would be entitled to a specific type of assessment.^[2]

A task centred approach involves looking at what the service user wants (in this case to have parental rights and control of her child), what the problems might be. If an earlier assessment has shown that family and friends would be able to offer little in the way of help and a young child is involved then the social worker has a duty to search for alternatives. If the mother’s care of the child is erratic and she is posing a problem for other people around then it would be the social worker’s duty to call in the medical officer of health who then has to obtain an order from the magistrates’ court. This would allow the social worker to gain entry and to assess the situation and the needs of the child, however, this could bring the social worker into a value conflict situation (this, I think is one of the problems with the task centred approach).

Task centred social work means that once the social worker has defined the problem and the hoped for outcome, he/she then has to decide whether the outcome is really attainable and what the consequences might be if it were achieved. With the imagined scenario used here achieving what the client wants could involve the social worker in a variety of problematic situations.

Ethically speaking the interests of the service user should take priority. However the social worker has a duty to bear in mind the BASW guidelines on ethical practice, Boulton (2003) has said of this:

In exceptional circumstances where the priority of the service user’s interest is outweighed by the need to protect others or by legal requirements, make service users aware that their interests may be overridden (Boulton, 2003 p.10).^[3]

Where it has been estimated that a child may be at risk then a social worker has a duty of care under the 1989 Children’s Act. At the same time there is a requirement to act within a framework that is informed by the Human Rights Act of 1998 and the rights of the mother have to be taken into consideration. There is a dilemma here for the social worker because a wrong decision could result in harm occasioned either to the child or to the mother as a result of her own actions. In such circumstances a social worker is bound to make an assessment of risk, and also probable harm. If harm is occasioned then the social worker could be held to account.

The (system we are in now is almost ready to treat every death as chargeable to someone’s account, every accident as caused by someone’s criminal negligence, every sickness a threatened prosecution. Whose fault? Is the first question (Douglas, 1992:15-16).^[4]

Clearly this situation needs a multi-agency approach including the social worker, his/her immediate superior, someone from the child protection scheme, the mother’s GP, the health visitor and the mother. Putting the child on the child protection register with regular reviews may help alleviate the situation and is in line with the requirements of the 1989 Children’s Act. This could therefore become a case where the service user’s rights will be overridden because the primary duty is to the child. This is where a social worker would be faced with a conflict of ethics and values which may lead to a practice situation where, as a practitioner, the social worker cannot be right. The final part of a task centred approach is to define just how long a social worker can give to a particular case and this is almost impossible to define, particularly in the imagined scenario above. A case like this could go on for years with different levels of professional involvement.

Conclusion

Task centred theory, I believe is a good starting point for social workers as it provides some sort of framework for dealing with some of the problems service users may present. While the theory is meant to support anti-oppressive and anti-discriminatory practice, this relies on a thorough understanding of social systems and how they operate. On the other hand there are some situations where a social worker has to weigh the needs of one person against another and this can result in apparent oppression and neglect of a service user’s human rights. The fact of the matter is that there will always be cases where someone is the loser and this is a sad fact of social work experience.

Bibliography

http://www.gscc.org.uk/NR/rdonlyres/30BC32F2-20B2-4D90-ABAB-3666D5BB44EB/0/Rolesandtasksconsultationpaper.pdf accessed 31st March 2007

Boulton, J 2003 Code of Ethics for Social Work available at http://www.basw.co.uk/articles.php?articleId=2&page=14

Hanvey, C and Philpot, T. 1994 Practicing Social Work New York, Routledge

Kemshall, 2002 Kemshall, H. 2002. Risk, Social Policy and Welfare Buckingham, Open University Press p.9

Payne, M. 1991 Modern Social Work Theory. A Critical Introduction, London: Macmillan.

The Care Programme Approach Policy: towards integrated care programme approach and care management (2000) South London and Maudsley NHS Trust

1

Select a social work intervention, evaluate its theoretical roots and influences and compare it to at least one other approach. Describe briefly how you would apply your chosen approach in work with a service user or carer group and evaluate its effectiveness. Use at least one piece of research to inform your evaluation. You will need to demonstrate the ability to detect, understand and evaluate potential for discrimination generally with particular emphasis on two specific areas.

This paper will evaluate the theoretical roots and influences of two psychological social work intervention theories – task-centred and crisis intervention. They will be applied to practice with a children and family setting. The potential for each intervention to discriminate on the grounds of age and race will be demonstrated and evaluated. Both theories will be contrasted and evaluated in terms of their strengths, weaknesses and effectiveness, by use of informed literature and research.

Theories can provide social workers with a safe base to explore situations and understand complex human behaviour (Coulshed and Orme 2006). Used wisely, they can promote effective, anti-oppressive practice (Wilson 2008). Theory underpins the social work degree (Coulshed and Orme) and the growing emphasis on evidence-based practice ensures theory is at the heart of the profession (Corby 2006).

The most significant theory within social work is Freud’s psychodynamic theory (Daniel 2008). Payne (2007:80) goes say far as to suggest that “psychodynamic work is social work”. It was the original theory social workers drew upon to understand complex human behaviour (Coulshed and Orme 2006). It is also the theory from which many others have been developed or as Payne (2005) suggests, opposed. For these reasons, it can be difficult to understand other theories without knowledge of psychodynamic (QUOTE, QUOTE).

Psychodynamic is a major underpinning base of crisis intervention, more specifically, ego psychology, developmental psychology, and cognitive behavioural approaches and systems theory (McGinnis 2009). These theories provide an understanding of the “particular psychological characteristic of people in such situations” (Beckett 2006, p110).

By contrast, task-centred was established within social work. Stemming specifically, from Reid and Shyne’s (1969) research into the profession (McColgan (Lindsay ed.) 2010). Reid and Shyne claim the roots and influences of task-centred were not derived or borrowed from any other discipline (Parker and Bradley, 2010; Watson and West, 2006). Therefore, Trevithick (2005) suggests task-centred should be referred to as a “work or practice”, rather than an approach. However, many writers contest this, including Doel (2009) and Marsh (2008) who assert association lies with behavioural and problem-solving approaches to social work. On reflection there are stark similarities between problem-solving tool and behavioural.

Crisis intervention was developed by Caplan from Lindeman and Caplan’s work into loss and grief (QUOTE). It “is not a single model in the way that task-centred casework is a single model, but rather a group of models for short-term work with people at points of acute crisis” (Beckett 2006, p110).

A crisis is a “precipitating hazardous event” which is “meaningful or threatening” to oneself (Payne 2005:104). Crises are often caused by “sudden loss or change” (McGinnis 2010:39). However, it is not the event that defines a crisis, but rather the service user’s perception and emotional interpretation (Parker and Bradley 2010). What may present a crisis for one may be considered a challenge for another because people have different life experiences, cultural backgrounds, coping strategies and levels of resilience. Crises can be predicable, as in Erikson’s psychosocial model (which views developmental conflicts as part of the life course), or unpredictable crises which cannot be foreseen for instance, a natural disaster, ill health and poverty or even a burglary (Hamer 2006) (ONLINE).

Crises reduce the psychological coping ability by challenging the homeostasis (normal equilibrium) (Thompson 1991). When one’s usual coping resources are unsuccessful in responding to their problem and they cannot adopt alternative internal strategies or find another way to cope, they are likely to find themselves in crisis (Hamer 2006).

Caplan argued, that “people act as self-regulating systems” (Trevithick 2005:267), in that they strive to retain homeostasis. He believed that “in addition to the occasional crises caused by unpredicted events” people experience developmental crisis throughout the life course. He further argued that “preventative work, offered at the time of such developmental crises, might be effective in reducing symptoms of psychiatric illness” (Wilson et al. 2008: 361). Unsuccessfully resolved crises can lead to psychologically incapacitating experiences such as “regression, mental illness, feelings of hopefulness and inadequacy, or destructive action” (Wilson et al. 2008:362).

Equally, crises can stir up repressed feelings (Coulshed and Orme 2006). For example, a marriage breakdown may reactivate repressed feelings of rejection and loss from being taken into care as a child. This can add “to the sense of feeling overwhelmed and overburdened (a double dose)” (Coulshed and Orme 2006:135). While this may provide the opportunity to address a repressed event, the more unresolved crises one has, the more vulnerable they are to future crises (Hamer 2006). Similarly, if unhelpful coping mechanisms are employed during a crisis, this has the potential to create another crisis (Watson and West 2006).

Crises produce “biological stress responses” whereby the “fight or flight mechanism is activated”. CHINESE MODEL This energy can be fuelled into developing new coping strategies and resilience for now and the future (Thompson 1991, p20).

Thompson (1991:10 citing Caplan 1961) uses to his three stage model to understand the characteristics of a crisis. “The impact stage” is short-lived and “characterised by stress and confusion” where the event can appear unreal. The second is the “recoil stage”. This is “characterised by disorganisation and intensity of emotion”. For example, emotions can be directed externally (anger), internally (guilt) or both concurrently. There may be psychical symptoms as well such as, “fatigue, headaches (and) stomach disorder”. The final stage is “adjustment and adaption”. Crises take on average four to eight weeks to resolve and it is during this final period that a crisis can be resolved as a “breakthrough or breakdown” (Thompson 1991:10). If unhelpful coping mechanisms are used during this stage, they have the potential to create another crisis (Watson and West 2006). As such, skilled crisis intervention during this time can lead to a “breakthrough” (Thompson 1991:10).

For application to practice, Roberts 2000 cited in Wilson et al 2008:366

Uses a seven stage model:

Assess risk & safety of service user
Establish rapport and appropriate communication
Identify and define major problems
Deal with feelings and provide support
Explore possible alternative responses
Formulate action plan
Provide follow up service

IN APP:

Try to find trigger – but don’t get lost in it
What is happening to them?
How do they normally cope internally/externally?
Do they use just psychological or social and community resources to good effect?
Opp to help back to homeo but also to improve
Min danger enhance risk
Mobilise support system – advocate
Calm, reassure, rapport, interest
Develop new techs of coping thro counselling
Remember person open for limited period
Get SU to set goals – give beginning and sense of control
Short term incremental to build confidence and new learning
Don’t set up for failure

If using the example given above, the situation does not constitute a crisis, but rather a series of/or large problem, task-centred can be utilised to address these. Task-centred practice involves five structured steps which are essential to its effectiveness (HOWE BOOK):

The first step is for the social worker to understand the problems faced, the methods used to respond to the problem and the preferred situation. These are defined and expressed by the service user (Thompson, 2005). Anna expresses she is feeling low since the recent birth of her son, she is worried she does not have the natural mothering ability and cannot remember the last time she last had an adult conversation. She doesn’t know where to turn for help. The social worker explores cultural and structural XXXXX it becomes clear that Anna cannot tell her family how she is feeling because it is frowned upon by her culture. She would love to feel happy and in control again. Using feminist perspectiveaˆ¦.. Her cultureaˆ¦.. Ageaˆ¦..

During the next stage the social worker encourages Anna to prioritise which parts of the problems she would like to work on first. With support she breaks the problem down in manageable chunks. This process helps Anna to see that her problem is not insurmountable; it gives her hope and a focus. It is essential during this time that the social worker remains empathetic and builds Anna hopes.

The following stage is based upon negotiation in partnership. Together, Anna and social worker agree a maximum of three problems for desired change. Each goal must be “specific, measurable, achievable, realistic and time-bound” (Doel AND WHO YEAR p36) to ensure Anna is not set for failure. The first of task might be for Anna will visit the local Children’s Centre next week to find out what services they offer. The second step could be attending a session as the Children’s Centre. A timeline for the tasks (usually 12 weekly sessions), together with agreement of who will complete which tasks will form a written contract, signed by both parties.

The agreed contract is implemented and monitored until evaluation or termination. This allows for flexibility should this be required (such as extension of time or reorganisation of problems).

Anti-oppressive practice lies at its core of task-centred and the values of social work practice are integrated.

Partnership working promotes social justice and seeks to reduce the power imbalance between worker and service user. Thompson (2007, p50) agrees stating “user involvement and partnership working are part of a political commitment to promoting social justice, social inclusion and equality.” These aspects are further supported by the British Association of Codes of Practice, Codes of Ethics for Social Work (DATE) (24 October 2010).

The promotion of choice for service users by their own identification of the problem and prioritisation of their goals empowers. It also views the service as an expert in their situation. The nature of breaking down problems (often considered insurmountable) builds a sense of hope for service users to overcome them (QUOTE)

The simplicity of the model means it is easy to understand and apply and enables service user to use it for future problem solving (Doel and Marsh 1995). This builds resilience and empowers service users.

The model recognises and builds upon service users strengths because it considers they have the personal resources to solve their problems with limited support. This empowers by enabling service users to take control and ownership (McColgan, (Lindsay ed.) 2010).

A contract provides transparency and clarity. It places the focus on the problem, rather than the individual. It also allows for flexibility for the level or duration of support to be increased or goals to be reorganised.

Because the model is time-limited it decreases the risk of dependency and creates motivation to respond to tasks (Doel AND WHO, DATE, p36).

The successful completion of tasks, lead to personal growth of the service user, in terms of confidence and self-esteem for now and for the future.

For the worker and agency it offers a time and cost effective intervention. It also saves on future resources by building service users to solve their own problems in the future.

A note of caution is that it would be oppressive and ineffective if used with service users with limited cognitive functioning (such as poor mental health, learning disability or dementia). The model is also incompatible where there are complex underlying issues because it cannot address them. Additionally, it may not consider structural oppression such as class, poverty, ill health, gender or racial oppression.

Because of the nature of partnership, service users need to be willing to participate for the model to be effective (Trevithick 2005).

A written, signed contract may encourage a power imbalance between social worker and service user, placing the social worker as the expert.

Marsh (Davies ed. 2008) warns that while task-centred practice may be the most popular theory among social work students, perhaps owing to its simplicity. The quality of its application is often undermined. Many believing they are carrying out task-centred practice work, when actually they are not. PAGE 121

BBB

In applying crisis intervention the social worker must establish a rapport with Anna using skills of empathy and active listening, while also assessing the risk of harm to Anna and her child (Mc Ginnis 2010). Importance should also be given to the non-verbal communication of the service user.

Anna should be supported in exploring the problem (the objective facts) and her emotional response to the problem (the subjective) (Beckett 2006). The social worker can assist by asking sensitive open questions (to ensure it remains Anna’s story) and responding by showing acceptance. McGinnis (2010, p45) claims “showing acceptance is key to effective relationship building”. It can also promote anti-oppressive practice and social justice by not judging the service user. The information collected should focus upon the here and now, although the past should be acknowledged.

The social worker should find out the attempts Anna has made to respond to her problem, while at the same time reassuring Anna. McGinnis (2010:45) suggests achieving reassurance by “gently reframe(ing) the client’s perception of self and events into a more realistic understanding of the situation”. Therefore, the social worker could say ‘I imagine you feel isolated’; ‘It sounds as if you have had a lot to cope with one you own’. Empathy should be shown the entire intervention by the social worker, by use of lexis and non-verbal communication.

If the service user is assessed as being in crisis the social worker can explain the concept of crisis intervention and agree the nature of the work to be carried out.

Arguably crisis intervention is also anti-oppressive. It seeks to effect positive change in behaviour now and for the future, through the building of resilience and coping mechanisms. It can also release service users from their past by addressing repressed issues. All of which results in empowerment of service user.

Integrates with codes of practice – WHAT CODES – Active listening and empathy

Crisis intervention provides a safe structure of intervention for social worker, service user and use by voluntary agencies in addition to statutory. QUOTE

The time limited nature is anti-oppressive because it reduces the risk of dependency for the service user. Additionally, it provides an economical intervention for the social worker and agency. This is supported by research undertaken by the NCHaˆ¦. (QUOTE)

Factors such as individual culture, values, gender, race, class and age can be taken into account because the service user is the expert and defines their own experience. (QUOTE)

Crisis intervention can be applied to many situations, namely, predictable crises in line with Erikson’s ego psychology model and unpredictable crises. (QUOTE)

Conversely, there are many criticisms.

The service user must be committed to working with the social worker to effect change (QUOTE)

The very nature of the word ‘crisis’ can lead to the theory being used inappropriatelyaˆ¦.. sw may assume su in crisis due to event

There is an imbalance in the power dynamic between social worker and service user because of the vulnerable nature of the service due to the crises. Moreover, the social work is considered the expert. This can leave room for unethical behaviour on the social workers part (QUOTE)

As crisis is short-lived, many social work agencies may not be able to respond fast enough to take full advantage of this window (Wilson et al. 2008). KEYWORD the brevity of the intervention may not be long enough to resolve a service users issues fully (QUOTE)

Research suggests that people respond to crises differently and at varying speeds, due to age, culture and cognitive impairments. Thus the model may need to be adapted to suit the service user and the situation, although, adaptation may render it unsafe for practice (Wilson et al 2008).

The theory involves active listening and empathy on behalf of the social worker. As the intervention involves use of active listening and empathy on behalf of the social worker, this may provoke many emotions. The social worker must remain empathetic and professional with an awareness of self.

Crisis intervention is also criticised as being Eurocentric. Ignoring different traditions and cultures and being concerned simply with fixing the problem as quickly as possible (Wilson et al. 2008). This can lead to oppressive practice.

In conclusion

Psychodynamic as discussed, was the theory of the day. It provided according to Howe (2009), complex, inefficient, open-ended intervention. In comparison, task-centred offered an effective, simply structured, easy to understand, time-limited approach, which dealt with the here and now (Howe, 2009). Reid and Shyne’s concluded through their research, that short-term intervention was effective (Trevithick 2005), and that problem-solving was more likely to be successful if a deadline was in place (Marsh Davies ed. 2008).

SUMMARY

While both interventions are suitable for differing situations, there are several similarities. Both are individualistic-reformist in that neither truly addresses social change.

Both have the potential to oppress and discriminate, but this can be overcome if assessments are sensitive to anti-oppressive practice (Wilson et al. 2008:366).

They are both time-limited.

Payne (2005:105) quoting James and Gilliland (2001) purports there are three crisis intervention models: “The equilibrium model – Caplan’s (1965) original approach.” Individuals are seen as experiencing disequilibrium.

The focus is upon return them to equilibrium enabling them to respond effectively to their problems.

Secondly, “The cognitive model – Associated with Roberts (2000)”

Ego psychology developed by Erikson, views the course of life as a series milestones through which conflicts occur. Developmental psychology considers early experiences shape personalities in adulthood.

(Daniel ed-Davies 2008); “cognitive behavioural approaches and systems theory” (McGinnis 2009:37).

3.3 Strengths (pay attention to AOP and values)

Time limited – reduces risk of dependency

In line with codes of practice – WHAT CODES

SU more open to help and change at a time of crisis (for a limited period)

The Application Of Systems Theory

To a Case Study

Introduction

The following case study will detail an intervention with a 32-year old service user who was referred with a range of presenting issues and needs. It was apparent that a complex array of family, social and agency networks existed, indicating that the focus of any intervention would necessitate the addressing of these various components and their role in the service user’s functioning. It was decided that employing systems theory would be the most efficacious approach in managing the service user’s needs.

General systems theory was first proposed by von Bertalanffy (1968) as a universal theory of the organisation of parts into wholes. A system was defined as “a complex of interacting elements”. Although this paradigm was initially applied to the physical world (mathematics, biochemistry, etc), it was adopted by the therapeutic community in order to formulate an understanding of systems comprising individuals and organisations. Some of the ideas and concepts systems theory has brought to the field include:

Families and other social groups are systems having properties which are more than the sum of the properties of their parts.
Every system has a boundary, the properties of which are important in understanding how the system works.
Changes within systems can occur, or be stimulated, in various ways.
Communication and feedback mechanisms between the parts of a system are important in the functioning of the system.
Events such as the behaviour of individuals in a family are better understood as examples of circular causality, rather than as being based on linear causality.
Systems are made up of subsystems (e.g. parental, marital, siblings) which are themselves parts of larger suprasystems (e.g. extended family, the neighbourhood, hospital).

(Beckett, 1973).

The service user was a 32-year old male of Afro-Caribbean origins, with a diagnosis of schizoaffective disorder dating back to his early teens. He had been residing in a semi-secure forensic unit for more than two years and was detained under Section 3 of the Mental Health Act. In terms of family history, he had been conceived through rape and fostered by distant relatives in Trinidad. Upon the death of his foster mother, his natural mother arranged for him to leave Trinidad and enter the UK. Shortly after this, he became involved with the mental health system and the criminal justice system. Subsequently, his mother had refused all contact with him and would not engage with any of his care. The sole family contact had been his maternal grandmother.

A genogram is a useful adjunct within assessment and treatment when utilising systems theory (e.g. Guerin and Pendagast, 1976), in that it gives a concise graphic summary of the composition of the systems surrounding an individual. A genogram depicting DE’s particular systems was prepared and is illustrated in Figure 1.

Within the genogram, DE’s familial relationships are illustrated, showing the existing subsystem with his maternal grandmother. Other subsystems include, DE’s relationships with the criminal justice system, mental health services and with myself, his social worker.

With regard to using systems theory in my assessment and intervention of DE, this would encompass developing a hypothesis concerning the nature of the relationships DE has with aspects of his system and how this impacts upon his functioning. In addition, circular questioning would be employed to test this hypothesis and promote change (e.g. Selvini Palazzoli, Cechin, Prata and Boscolo, 1980a). Each of DE’s presenting needs will be explored within the context of his wider system and the methodology inherent to systems theory employed in my intervention.

Figure 1: A genogram of DE’s case.

The Referral

DE was a statutory referral which was accompanied by a challenge from his legal representatives to the local authority, claiming that they had failed in their duties towards DE as he was medically fit for discharge and did not need to be detained under Section 3 of the Mental Health Act. Although discharge from Section 3 was agreed, no plans were presented to the mental health tribunal by the local authority regarding the arrangement of appropriate accommodation. From the perspective of the social worker, plans were therefore required to implement Section 117 and organise appropriate after care and accommodation. In order to do this, it was necessary to identify DE’s wishes and preferences as far as possible, in addition to managing any risk perceived by the multidisciplinary team and the mental health tribunal. A transfer CPA to the community team was organised in order to maintain DE in the community and facilitate his recovery. Adhering to the notion of “goodness of fit”, inherent to systems theory (Payne, 2002), that is enhancing the match between the individual and their environment, ways of developing, maintaining or strengthening supportive interventions and reducing, challenging or replacing stressful systems were explored.

Assessment

An assessment of DE’s presenting needs was conducted in order to formulate a hypothesis based upon the information available which would then provide a starting point and guide to subsequent interventions. According to Selvini Palazzoli et al. (1980a), a hypothesis is “neither true, nor false, but more or less useful”. Therefore, it was important to maintain this stance when considering the circumstances surrounding DE’s case. By seeking information from DE and others within his system, I was able to obtain as many perspectives as possible and construct an understanding, or story, as to how he had come to be “stuck” and enable him to move in a more helpful direction.

Both DE and the multidisciplinary team involved in his care agreed that he required 24 hour residential care, as previous supported accommodation had not been able to facilitate his needs and he had relapsed, leading to his admission to hospital under section. Additional presenting concerns reported by DE included an impoverished family support network and poor finances. Drug and alcohol misuse were also evident, acknowledged by DE and verified by a positive test for cocaine. DE’s keyworker recounted how DE frequently disengaged with him and displayed challenging behaviour, including breaking rules of the care home and absconding. Indicators of relapse described by staff included a preoccupation with insect infestation, delusions of the devil attacking him and homophobic fears of male staff sexually assaulting him. In addition, non-compliance with his care plan was recognised as a precursor to relapse.

Using circular questions to derive new information about DE’s situation and the interconnectedness of the system’s components, a pattern emerged which suggested possible indicators of relapse. A principal feature of circularity is the capacity of the therapist to consider feedback from the systems involved and to invite each part of the system to relate their perspectives of other subsystems, thereby metacommunicating (Selvini Palazzoli et al. 1980a; Byng-Hall, 1988; Cecchin, 1987). Further crucial principles of circularity are asking about specific behaviours that occur, rather than feelings or interpretations and ranking behaviours in order to highlight differences (Barker, 1998; Dallos and Draper, 2000). So, for example, DE’s keyworker was asked: “what does DE do when he breaks the rules in the house”, “when you believe DE is relapsing, how do you know? What does he say or do?”, “who is most worried about DE using drugs/alcohol?”. Similarly, DE was asked such questions as: “when you abscond from the care home, who is most concerned? … and then who?”, “when you are worried about the devil attacking you, what do you do?”, “what would your keyworker say was most important for you to get sorted out?”.

A specific use of circular questioning is to define the problem (Bentovim and Bingley Miller, 2002). Hence, members of DE’s system, including his key worker, other multidisciplinary team workers, available family members and DE himself were questioned as to “what is the problem? What do you think DE/keyworker/etc would say is the problem? Who agrees with DE? Who disagrees? Who is it most a problem for?…” etc. Such information served to enrich the hypothesis that was being formulated of DE’s needs.

Over time, a systemic hypothesis evolved which incorporated the role of impaired family functioning and an early sense of abandonment by DE’s natural mother combined with the loss of his secondary, foster mother contributing to the development of a schizoaffective disorder. A further contributing factor may have been DE’s move to the UK following his bereavement and the sense of confusion and alienation this may have instilled. A pre-existing vulnerability to his mental health problems may have been activated by DE’s use of drugs and alcohol, possibly his coping mechanism to manage the previously described stressors.

In terms of DE’s behaviour within his care home, it would be important to consider physiological factors many of the concerns reported. The literature associated with schizoaffective disorders has suggested that the onset of the illness can produce cognitive deficits, including memory impairment, planning, social judgement and insight (Randolph, Goldberg and Weinberger, in Heilman & Valenstein, 1993; James and Murray, 1991). These deficits, combined with the lack of family support and underlying psychological issues, could have resulted in the issues with compliance and rule-breaking reported by the professionals involved in DE’s care.

However, within a systemic approach, it is important to consider the dynamic interplay between the individual and the various components of their system when conceptualising the problem. In DE’s case, it appeared that the effects of his drug and alcohol use and of rejection issues had not been fully considered by staff at the care home and therefore the consequences of these had been able to escalate into relapse. Furthermore, it may have been that an over-critical attitude towards DE prevailed within his care home, as has been described in the concept of expressed emotion (Leff, 1994). This has generally been reported as existing within the families of those with schizoaffective disorders and is thought to represent deficits in communication and overinvolvement.

The function of the problem is also a vital element within a systemic formulation (Reder and Fredman, 1996; Bilson and Ross, 1999) and in DE’s case his presenting issues appeared to represent both a communication of internal conflicts (loss, abandonment, etc) and as a solution to the problem perceived by him as inappropriate accommodation. Thus, his behaviour could be conceptualised as an attempt to resolve both internal and external discordance. However, clearly DE’s perceived solution only served to escalate and maintain the essential difficulty, that of his lack of engagement with help and disruptive behaviour.

Intervention

There were various strands to my intervention with DE, within which I attempted to address the issues outlined in the above hypotheses. Initially, the issue of accommodation was addressed. In concordance with a systemic approach, DE’s needs and preferences, as well as opinions derived from members of the multi-disciplinary team, were matched with available accommodation. Three suitable placements were identified which were concomitant with the needs identified in DE’s care plan, that is: 24 hour residential accommodation with staff to supervise his medication, encourage independent living skills and monitor his activities and behaviour to identify relapse indicators. DE’s opinions on the three potential placements were sought and a decision reached on the most suitable. In view of DE’s history of lack of engagement with keyworkers, it was felt that regular meetings with his care co-ordinator would be vital in exploring his concerns and potential barriers to compliance with his care plan. The use of circular questioning could be usefully extended in such meetings, in reframing DE’s perception of his concerns and enabling him to recognising the effects of his behaviour on himself and others.

Specific aspects of DE’s presenting problems were managed by referral to appropriate agencies, thus widening his system of support. For the substance misuse reported he was referred to a drug and alcohol worker. A referral to psychological services was made to address his rejection and bereavement issues. The involvement of DE’s grandmother and uncle was also an integral part of discussing his difficulties and it was postulated that at some point in the future, systemic family therapy might be helpful in providing some cohesion to DE’s family structure and enabling communication with this part of his system.

Once the initial concerns had been addressed, my role turned towards care management and a reasonable price for the accommodation was negotiated, along with the development of a comprehensive care plan which was presented to the agency’s funding panel. The funding was agreed and a discharge and transfer of care CPA was arranged. Throughout the ensuing discussions of plans, DE’s opinions were sought. In order to best meet the needs identified and ensure an optimal rehabilitation programme, DE’s care plan incorporated day care activities, psychological and community forensic input.

In accordance with the principles of a systems intervention, a non-judgemental stance was maintained throughout (Goldenberg and Goldenberg, 2004) and the notion of partnership was promoted (Dallos and Draper, 2000). Additionally, the strategy of facilitating sustained change whilst not being an expert about the system was adopted (Fleurida, 1986), although this presented certain challenges as will be discussed in the following sections.

In terms of implementing DE’s placement, it was agreed that a gradual transfer which allowed him to adjust to the new setting would ameliorate his opportunities for rehabilitation. Therefore, overnight stays and extended stays for a week prior to discharge were arranged. Initially, difficulties were experienced with DE’s compliance with some house rules and I arranged a meeting with DE and the house manager in order to discuss and negotiate these in order to prevent a breakdown of the placement. Once more, circular questions were used to elucidate the problem and identify possible routes for change. For example, DE was asked, “when you don’t comply with this rule, who is most upset?” and “what prevents you sticking to the rules?”. The house manager was asked questions such as, “What does DE do instead of sticking to the rules?” and “what reasons do you think he has for not complying?”. Consequently, specific barriers and obstacles were identified and it was possible to negotiate a way in which DE could assert his individuality within the placement setting, whilst behaving in ways which were acceptable to staff and other residents. Thus, the “fit” between DE and this particular system was enhanced.

Review and Ending

During my work with DE a dynamic, fluid hypothesis was formed which was based on systemic principles, in that it was circular, addressed relationships, was expressed in terms of what people do and believe rather than what they are and included all members of the system (Reder, 1983). The hypothesis was continually monitored and reframed during the intervention phase, which facilitated change and enabled new perspectives and solutions to be considered.

Other parts of DE’s system were also modified by posing circular questions as they allowed the various professionals and agencies involved to consider how helpful or unhelpful the strategies they employed to manage the exigencies of DE’s case were and to gain different perspectives. It is important to note that this approach is distinct from merely providing instruction or information, in that it facilitates change through the process of thinking and reasoning.

The initial focus of intervention – to provide appropriate accommodation – was successfully completed. This was rendered smoother by the gradual transition to his new setting. By the end of the intervention, I believe that DE was able to engage in a more useful way with the various components of his system and was more settled in his placement as a result. Reports from the house manager and other professionals also indicated that this was the case.

Referrals to other agencies (psychology and drug and alcohol services) which comprised a vital component of the intervention, enabled an expansion of DE’s systems and the meeting of previously unconsidered needs. His progress with these agencies was ongoing. DE’s engagement with community forensic services was valuable in gaining further perspectives into his care.

Discussion

Within systems theory, the questions themselves form a substantial part of the intervention (Tomm, 1988), as they are believed to lead towards a constructive change in the problematic experiences and behaviours of service users. In addition, questions constitute a much stronger invitation for users to become engaged in a conversation and process than do statements, instructions of information and provides stimulation to think through problems alone, thus promoting autonomy and a sense of personal achievement (Payne, 2002).

In continually seeking the views of DE and perspectives from other parts of his system, it was possible to create a clearer picture of the characteristics of the problem and to foster a sense of ownership on the part of DE. That is, because he felt part of the process of change, he would be more likely to feel comfortable with its parameters. A further part of promoting DE’s compliance with his care plan was to use positive connotation, another important principle of systems theory (O’Brian and Bruggen, 1985). Positively connoting DE’s behaviour consisted not only in reinforcing and praising his attempts to change, but also in acknowledging that his problem behaviour was serving to express his dissatisfaction with the situation he was in. An important aspect of intervention therefore was to communicate an understanding of how things had come to be the way they were. Only through doing this was it possible to challenge the existing belief system, suggesting new and different definitions of relationships. Therefore, by acknowledging the pain of DE’s abandonment by his mother with a referral to a psychologist, it enabled him to explore a different way of interacting with this part of his system. Similarly, by considering the role of drugs and alcohol in mediating his distress and enabling him to cope with his situation, other means of coping were explored.

The use of systems theory was congruent with mental health policy guidance for CPA in that it was person focused, involved all relevant agencies and required a recognition of needs in order to facilitate the movement of service users through CPA. The identification of unmet needs in DE’s case, as well as involving multiple agencies was crucial in managing his care effectively. As DE was on enhanced CPA, it was important to consider multiple care needs and to recognise that he was more likely to disengage with care. Once more, a holistic assessment and a comprehensive, multi-disciplinary, multi-agency plan which encapsulated his wider system was necessary.

Systems theory requires strategic thinking about the possibilities and limitations for change in the different systems affecting the user’s environment, as well as an understanding of the possibilities for intervention in each system (deShazer, 1982; Penn, 1982), therefore considering DE’s behaviour in specific settings and with specific individuals and agencies was a useful strategy. In addition, possessing an understanding of the possibilities for intervention within each system enabled me to think creatively about different courses of action and potential outcomes (Byng_Hall, 1988).

Review and Evaluation

In general, systems theory was a useful tool in working with DE, in that its principles guided many aspects of the assessment and intervention towards a beneficial outcome. The basic tenets of systems theory, of being respectful of all perspectives and attempting to empower the service user to implement change, are congruent with the CPA model of working. However, the principle of maintaining neutrality (i.e. forging an alignment with all parts of the system) and a non-judgemental, non expert stance (Selvini Palazzoli et al. 1980a; Fleurida, 1986) proved to be more challenging. As DE’s care co-ordinator it could be expected that a greater alliance would be formed with him and also that I would possess, in this role, information and knowledge pertaining to a variety of issues, such as financial assistance available to him. Clearly in this case, I was unable to maintain a non-expert stance. Furthermore, being non-judgemental in relation to all DE’s presenting needs (for example, his drug and alcohol misuse) was very difficult and whilst my approach could encompass the evolution of a shared understanding of this behaviour, ultimately the negative impact on DE’s mental health and stability of his placement would need to be acknowledged. Therefore, it could be said that there was a juxtaposition between CPA care management and using systems theory. However, it was possible to separate the two aspects of my role with DE and apply systems theory accordingly.

In terms of what I would do differently, I believe that a greater involvement of DE’s family would have been beneficial in order to assist him in constructing a different story or narrative around his history, which would have enriched his and perhaps others’ understanding of why problems were presenting themselves.

Applying systems theory to a service user such as DE, who may have the cognitive deficits previously described, raises some important ethical issues. Firstly, regarding the ability to give consent to such an approach being employed and to the seeking of perspectives from other parts of the system, such as family members and other workers. The potentially harmful influence of labels has been described in the literature of systems theory (e.g. Benson, Long and Sporakowski), however the use of labels such as “schizoaffective” and “enhanced CPA” would seem unavoidable when working within a multidisciplinary team which necessitates communicating with equivalent language. However, the use of systems theory creates space for thinking about the meaning and impact of these labels and is, therefore, at the very least a valuable and functional adjunct to the repertoire of strategies for managing complex cases.

Summary and Conclusion

The work carried out with DE attempted to illustrate how individuals function as a part of many systems – they are affected by these systems and they, in turn, affect the systems. I believe that the circular nature of DE’s presenting issues and needs was highlighted effectively and the intervention took into consideration this dynamic interchange and the consequences that changes in one part of a system will have for other parts. Fundamentally, I have learned that many problems arise due to a mismatch between individuals and the systems of which they are a part and the role of a social worker is to enhance the fit between the individual and the systems affecting them.

References

Barker, P., 1998. Basic Family Therapy, 4^th Edition. Oxford: Oxford University Press.

Beckett, J.A., 1973. General Systems theory, psychiatry and psychotherapy. International Journal of Group Psychotherapy, 23, pp. 292-305.

Benson, M.J; Long, J.K. and Sporakowski, M.J., 1992. Teaching psychopathology and the DSM-III R from a family systems therapy perspective. Family Relations, 41 (2), pp. 135-140.

Bentovim, A. and Bingley Miller, L., 2002. The Assessment of Family Competence, Strengths and Difficulties. London: Pavillion.

Bertalanffy, L. von, 1968. General Systems Theory: Foundations, Development, Application. New York: Braziller.

Bilson, A. and Ross, S., 1999. A history of systems ideas in social work. In, Social Work Management and Practice. London: Jessica Kingsley, 2^nd Edition.

Byng-Hall, J., 1988. Scripts and legends in families and family therapy. Family Process, 27, pp. 167-179.

Cecchin, G., 1987. Hypothesizing, circularity and neutrality revisited: an invitation to curiosity. Family Process, 26, pp. 405-413.

Dallos, R. and Draper, R., 2000. An Introduction to Family Therapy. Buckingham: Open University Press.

de Shazer, I., 1982. Patterns of Brief Family Therapy: An Ecosystemic Approach. New York: Guildford Press.

Fleurida, C. et al., 1986. The evolution of circular questions. Journal of Marital and Family Therapy, 12 (2), pp. 112-127.

Goldenberg, I. and Goldenberg, H. , 2004. Family Therapy: An Overview, 6^th Edition. London: Brooks/Cole.

Guerin, P.J. and Pendagast, E.G., 1976. Evaluation of family system and genogram. In, P.J. Guerin, ed. Family Therapy. New York: Gardner Press.

James, P. and Murray, R.M., 1991. The genetics of schizophrenia is the genetics of neurodevelopment. British Journal of Psychiatry, 158, pp. 615-623.

Leff, J., 1994. Working with the families of schizophrenic patients. British Journal of Psychiatry, 164 (suppl. 23), pp. 71-76.

O’Brian, C. and Bruggen, P., 1985. Our personal and professional lives: learning positive connotation and circular questioning. Family Prcess, 24, pp. 311-322.

Payne, M., 2002. Systems and Ecological Perspectives. In, Modern Social Work Theory, 3^rd Edition. Basingstoke: Palgrave MacMillan.

Penn, P., 1982. Circular questioning. Family Process, 21, pp. 267-280.

Randolph, C., Goldberg, T.E. and Weinberger, D.R., 1993. The neuropsychology of schizophrenia. In, K.M. Heilman and E. Valenstein, eds. Clinical Neuropsychology, 3^rd Edition. Oxford: Oxford University Press.

Reder, P., 1983. Disorganised families and the helping professions: “Who’s in charge of what?”. Journal of Family Therapy, 5, pp. 23-36.

Reder, P. and Fredman, G., 1996. The relationship to help: interacting beliefs about the treatment process. Clinical Child Psychology and Psychiatry, 1 (3), pp. 457-467.

Selvini Palazzoli, M.S., Cechin, G., Prata, G. and Boscolo, L., 1980a. Hypothesising-Circularity-Neutrality. Three guidelines for the conductor of the session. Family Process, 19 (1), pp. 3-12.

Selvini Palazzoli, M., Boscolo, L., Cecchin, G. and Prata, G., 1980b. The problem of the referring person. Journal of Marital and Family Therapy, 6, pp. 3-9.

Tomm, K., 1988. Interventive interviewing: part III. Intending to ask lineal, circular, strategic or reflexive questions. Family Process, 27, pp. 1-15.

Reflective Diary Analysis

I applied the theory of psychoanalysis to the practice situation in order to explore underlying issues which had made ME so dependent upon her partner, JM. This appeared appropriate as it would provide an opportunity to gain information about any past experiences which had contributed to her present state, in particular, the nature and origin of her anxieties and fears. Uncovering this information would then inform my practice with ME and JM and provide structure to any intervention.

The overall purpose of psychoanalysis derives from the Freudian assumption that psychopathology develops when people remain unaware of their true motivations and fears and they can be restored to healthy functioning only by becoming conscious of what has been repressed (Bower, 2005). Freud believed that the unconscious conflicts he uncovered – in dreams, in memory lapses, in neurotic symptoms – always referred to certain critical events in the individual’s early life. His observations of his patients led him to conclude that all human beings experience a largely similar sequence of significant emotional events in their early lives and that it is this childhood past that shapes their present (Freud, 1905).

Although Freud cautioned against the use of psychoanalysis in schizophrenia, as he believed that sufferers of schizophrenia had regressed to a state of “primary narcissism”, a phase early in the oral stage before the ego has differentiated from the id (Freud, 1905), more contemporary psychoanalysts have adopted a different approach. Primarily followers of Melanie Klein, they have taken the position that the schizoid position, or splitting between “good” and “bad” objects, was a normal stage of development and that schizophrenia was the late consequence of not negotiating this stage properly (Salzberger-Wittenberg, 1970). Thus, the flow of unconscious material (e.g. delusions, hallucinations and thought disorder) were actively encouraged, explored and participated in.

In ME’s case, a formulation of her presenting issues included the role of specific anxieties and fears. Anxiety has been conceptualised psychodynamically as a state of helplessness and “psychic pain”, which results from the perceived discrepancies between one’s ideal self (or ego ideal) and one’s actual self (Freud, 1926, cited in Brown and Pedder, 1991). These painful discrepancies cannot then be easily assimilated into our conscious view of ourselves and the world because of the anxiety they arouse and the consequence is a “defence mechanism” activated to subdue this psychic pain.

Using open-ended questions with ME, such as “how are you feeling?” and allowing her to respond freely revealed a little of her state of mind, ie. “very low, always tired and very sad”. It was interesting to note ME’s partner, JM’s, explanation of ME’s low mood, “the weather”, a subject he had mentioned at the outset of the encounter. This may indicate an attempt to avoid, or defend against, speaking of difficult issues and furthermore, may represent his own coping strategy. Further questions to elicit ME’s emotional state included “has it made a difference?” (regarding the use of anti-depressants) and “how do you feel about quitting smoking?”

An inherent principle of psychoanalysis is the use of transference and countertransference within any clinical encounter (Casement, 1985; Salzberger-Wittenberg, 1970). Transference is the conveyance of past feelings, conflicts and beliefs into present relationships and situations, spe

Discussion Paper on Quality Service and Impacts on Poor Service Quality in terms of reputation, Accountabilities of private and public sector and Stakeholders

Written by:

Eva Michelle S. Baculi
Shela Mae Sabanpan
Gynievel Ondasan
Epifanio Jr. Montajes
Elangkovan Balakrishnan

INTRODUCTION

Kindly Residential Care Rest Home had experienced problems regarding the quality of care of its services, in so doing, as a Geriatric Healthcare Specialist; I am tasked to organize a group of caregivers in order to produce a paper that discusses Quality Management Approaches and Techniques. Such research work will be disseminated to all health staff so that it will be implemented and eventually will improve the services of the rest home in serving our geriatric clients.

As we all know, New Zealand, like all other countries, faces the same challenge in the rapid increase in the ageing population. With this, health sector is greatly affected as it provides greater services to varieties of conditions, such as arthritis, heart disease, and even dementia, thereby health facilities, such as hospitals and rest homes have also increase their workload. Being in the health sector, it is our vital role to ensure that all our clients are given the best quality care. But then, how do we define quality service? What will be the impact if we give poor quality service in the organization with regards to reputation? What will happen to the stakeholders? And lastly, what are private and public accountabilities with regards to poor quality service? As mentioned above, it is then necessary to answer these questions to have better clarity on what it means to give quality care so that we, ourselves, could give the best quality service to those people suffering from dementia and other geriatric conditions.

What is Quality Service?

Service quality is viewed as “the degree and direction of discrepancy of the client’s perception and expectations and are influenced by five gaps” (Parasuraman et al, 1985):

Tangibles as seen on the facilities, equipment, health care workers and some communication materials such as patient’s folders, prescription forms and requests forms
Reliability or the hospital’s ability to perform the promised service accurately and dependably.
Responsiveness or health care workers willingness to aid the patient and give prompt service
Assurance or the competency, knowledge and courtesy of the health care workers and their ability to inspire patient’s trust and confidence towards the hospital services
Empathy or the caring, undivided attention given to patients by the health care workers.

Therefore, the quality of health care depends upon on the how the patient perceives. Patient perception of quality ranges from their desired health outcome, relationship with health care workers, health care workers qualifications and performances and healthcare access and choice.

To provide service quality among the clients the aim of the organization must be achieved while service performance and client’s satisfaction must be met. As we talk about service quality in health care there are many questions that would pop-up in our minds. Everyone deserves a good service quality especially in a healthcare setting or any residential care where mentally impaired clients are being taken care of. Sometimes understanding the opposite concept of good service quality will enhance your knowledge to do well on the services you provide to your clients. Especially if you are a healthcare provider, you must do your very best to provide the proper care that your client needs.

Poor service quality has a big impact towards any organization. It is because it could affect the internal and external aspects of your business. Client satisfaction must be a priority at all times. Giving poor quality service to clients could pull any business or organization down. It could negatively impact the stakeholders and shareholders because they are the ones who would be affected by poor service quality. For example in the hospital or any home care, if the doctors, nurses and other medical teams who are involved in the care are showing poor quality service to the clients, it could affect not just the hospital and the employees themselves but the organization as a whole.

IMPACTS OF POOR SERVICE QUALITY IN TERMS OF REPUTATION:

The reputation of any business or organization will be affected if poor service quality is practice. Reputation is how your organization is being perceived through the eyes and judgment of your clients, suppliers, employees and other parties that are included in your organization. An organization engages in various activities such as rendering proper quality care, responding to the needs not just to the clients but also to the significant others and their families, attending to queries and complaints if there is any in an appropriate approach, and by taking any feedback or concerns in a positive way. Through these things a strong reputation can be built by the organization which could attract and retain our clients. The organization’s reputation is the biggest and most important determining factor in the long term success of your efforts. Your reputation is recreated each day with each client that you are taking care of. In reality, however, you are not only dealing with the organization’s reputation in general but also other considerations that arise from the minds of the clients or to significant others who deal with you during the organization’s activities. Therefore, reputation is very much important because this is a key factor that determines the trust and confidence that clients will have on us. We must keep in mind that our clients will talk about us about the services we give them. If we provide poor service quality they can negatively influence the public’s perception on what our company is all about through word of mouth.

ACCOUNTABILITIES OF THE PUBLIC SECTOR:

PUBLIC SECTOR

The declining quality of service of Kindly Residential Care Rest Home led to a negative impact that resulted to a liability to the public sectors accountability and the results are the following:

Low client patronage. Because of the poor quality service, client’s family members opt to avail services of other health facilities instead of Kindly Rest Home.

Jeopardize the Rest Homes reputation. Public perception would be sour due to the above mentioned infarction, and it will taint the reputation of the health services of New Zealand. Some might think or generalize the idea that other health facilities in the area have similar problems. That is why, the District Health Board have continuously monitoring the services of all its health institutions to ensure that standardized health practices will be adhered.

Increase in staff turn-out. Since patronage of the public will be minimized of the Kindly Residential Care Rest Home, low income earning of the rest home will affect the increases in wages/ other benefits to the employees. As a result, employees will opt to transfer to other work to seek a much better wage offer and equally, recruitment will be affected considering that Kindly rest home can no longer afford to pay additional workers.

Loss of profit. With few client patronage and tainted reputation, obviously, will result to decrease in profit, not to mention that the facilities operational funding allocation will be greatly affected.

Under scrutiny of government health organization. As mentioned earlier, the District Health Board ensures that health facilities under its jurisdiction will adhere according to the standardized health practices formulated by the board. Any health institution that will violate health standards set will be sanctioned by the DHB. Possible measures will be imposed such as fines, withdrawal of public funding support, closures, reprimand and other government actions.

Leads to poor services. Poor quality of care will result to accidents due to equipment malfunction such as defective bed side rails and wheelchairs and legal actions against facility personnel will be made as a result of such negligence. Another is possibility of infection outbreak resulted from lack of disinfection materials or even poor hygiene practices and finally, contamination will affect not just to other residents, visiting family member and also to home staff.

ACCOUNTABILITIES OF THE PRIVATE SECTOR:

It is always expected that if the management is poor the quality of service to be rendered is also poor. In New Zealand there are private sectors who are also handling the health care of patients with dementia and the other common geriatric diseases. If this private sectors are not well-prepared to assist these patients, there will be a great impact on the kind of institutions they have and because of poor service quality, the patients will be affected so much. The medical staff of these private sectors should attend training on health care program. So as to widen their knowledge, skills and attitudes on the health care program. The government should not permit private sectors to start giving assistance to patients with dementia and other common geriatric diseases if not ready because they are adding more problems to the patient and to the health care program in general. It is advisable that all the medical staff of this private sector should be well informed of all the best practices in the health care program. The New Zealanders also want their country to have the best health care program. The patients need special care and attention, likewise, it is needed for this home care private sector to know well the cause and effect of the ailment of this individual patient, so the management will be able to give them the proper assistance needed, thus, giving the patient the feeling of belongingness and acceptance. That is they are accepted as individual in the society where they live. These patients with dementia will not feel insecure because of their illness or personality, but instead, have that feeling of joy and happiness. So this kind of behavior will be enjoyed by the patient with dementia if the medical staff in private sectors are well trained and are ready to assist patients with dementia and other common geriatric diseases.

There is really a need for a thorough screening of medical staff for private sectors so as to avoid poor service to their clients. These dementia patients need to be understood so it is the management to make adjustments so as to understand each other. They need a loving assistance so as to give them a comfortable life despite of their ailment. The better quality of service the better will be the result. You will lessen the stress of the patient and helping the individual a wholesome member of the community. The New Zealanders are health conscious. Therefore, private sectors should work hand in hand with the health care program of the government. There is a need for the private sectors to establish the best practice quality management health care for the benefit of the individual with dementia and other common geriatric diseases.

STAKEHOLDERS:

Stakeholders are individuals or group of individuals who are afflicted by or can control a company or product throughout its life. Without the continuing participation of these stakeholders, it would find it difficult for a company to get through, because a company and the stakeholders are mutually co-dependent. Their involvements are vital in company’s expression of values, execute its mission, establish strategies and enhance relationships continuously. Also, they are also important for involvement in performance-based sense. If the company establishes long term relationships with these stakeholders, it runs smoothly and has a better chance of earning profits, can increase production and harvest the word-of mouth benefits. However the stakes are high once a company establishes the long-term relationship with them. In this section, we will categorize these stakeholders into two:

Internal Stake Holders:

These internal stakeholders include

Clients

Clients are categorized as the consumers and patients. Since they are the final user and the payer of the health care system, they become the most valuable stakeholder; thereby, they also must be participative in their own care. They have to be informed about their illness, the kind of medical treatment and as well, be accountable of their health. They also have the right to voice out any concerns of the company.

Family Members

Family members are often said to be partners, joining forces with the health care staff in ensuring the best health care needs of the client/patient. They have the right to question any misdemeanors or wrong choice of treatments and even medications that are prescribed to the patients. It has become a common knowledge that many of this establishment face lawsuit mainly because of miscommunication between the family and the establishment. This can be reduced and corrected by giving the right information, discuss better recommendations to the patients and inform of the establishment’s policy rules and regulations. This will give a better understanding to both parties concerned and there will be a connection between them to work together for the benefit of the patient admitted there.

Care providers

Who knows the patients suffering dementia better than the care providers? Hence, the importance of the care giver is of vital importance to the patients and more so to the establishment. Nurses, aides, medical staffs, dietitians, pharmacist are all part of the category. Each and every employee takes their positions seriously as any cause of carelessness would affect the lives of the patients. It is not only essential to attain good quality care givers but they must also be protected by the establishment. There are many numerations that can be given to the care providers as incentives to take their job more seriously and also give them the aspiration that they can depend on the establishment if any crisis arises. The establishment can also furnish the care providers with better trainings and information on how to deal with the dementia patients at every level and treat the Geriatric patients with using the latest skills and equipment’s to make the treatment less stressful for the patient.

External Stakeholders:

Medical equipment supplier

Medical equipment suppliers may seem insignificant but indirectly they hold a major stronghold in the establishment. Medical equipment comes in all shape, size and functions and is one of the factors the patients depend on heavily. In this case, medical supplier has to be prompt in delivering their stock according to their records. Any equipment malfunctions must be reported immediately to the suppliers to be replaced or repaired so there will not be any disruption to the patient’s physiotherapy or exercises. It is also their role to explain the benefits of equipment and how it will benefit them in the long run. Any new products in the markets are introduced to the Health care and proper and detailed information must be given to the patients and also the therapists

Food supplier

Food is equally important factor in this establishment as it is a basic human necessity. Not only that, patients need their food on time so they can consume their medication on time therefore, the food chain cannot be broken or interrupted in any time or else dire consequences will happen. If the food supplier is not a reliable one or produces poor in quality or not in the dietary list should be terminated and a reliable one should be tendered in immediately. The establishment should check the timing and quality (freshness) of the food items at all times. This also means it has to be under the Food Act.

Care Home Building maintenance supplier

The building material supplier is also one of the many major factors that need constant reviewing. Especially in the Kindly Residential Rest Care home it is vital that all building structure is secure, safe and durable in any case of natural disasters. Safety of the patients must be the first priority. Many criteria must be given attention to, including proper and good lightings at the home, hand rails for support, and many more. Injuries and damaged grounds of the building will bring a questionable reason to the safety of the patients as well as the establishment. It is advisable always to keep in check of building maintenance and cleanliness at all times. Other stakeholders like the patient’s families are sure to note of this.

D.H.B ( District Health Board )

Every Health care facility is automatically registered under the District Health Board which is a requirement bonded by the Government to ensure the delivery of quality health care services. This procedure is done so that any legal complaint against the Home can be done through the District Health Board. The Kindly Residential Rest Care home is for the benefit of the elderly patients, patients going through Dementia and Alzheimer and other Generics illness. So the environment and the premises must always be in good conditions and abiding all the rules and regulations that will encourage more patronage to the health care. If any faults are filed against the care home, warning letters will be issued by the D.H.B. to make the changes according to the rules and regulations. If the warning letters are neglected, the D.H.B. has the right to cancel the license to run the rest home care. This will affect the entire Rest Home business and image in the health care business will be tarnished.

CONCLUSION:

In today’s world where there is an outgrowing number of ageing population and the advances in sciences that increases the life expectancy of people, the demand of health care increases. Therefore, there is a need for continuous improvement so as to satisfy the ever-increasing market. To be able to do this, it needs good quality management. If a certain organization exhibits poor quality management, it can lead to negative impacts affecting both the internal and the external aspects of the business. The company’s reputation is damaged and many would be greatly affected, the clients, the employee, caregivers, employees and worse, its existence. To avoid this from happening, it is then important that we render good service particularly to the clients, family members. Not only that, we should also need to work as a team that can lead to a long lasting improvements. We should also ensure that we adhere to the policies and procedures. With this, the result would be good quality, efficiency and profitability.

This report reflects on the care needs of 67 year old Kingsley, at 55 he was diagnosed with Type 2 Diabetes then at 65 Kingsley suffered a stroke. After a lengthy stay in hospital he was moved to a nursing home where he currently lives, he is not happy in the nursing home and wishes to be discharged and return home to the care of his wife. He displays his unhappiness to care staff with bouts of anger and frustration. He has a social worker assigned to his case who is currently undecided if Kingsley should return home to his wife, he questions the layout of the home and his wife’s ability to cope with Kingsley’s care needs. Kingsley and his wife have some difficult decisions to make and should be able to discuss these with the social worker as these will have a fundamental impact on where he lives as this will be instrumental to his wellbeing.

Living with a long term health condition can have its challenges when receiving health care, its paramount that a care user receives the correct level of support and information available. A psycho sociological perspective offers a holistic approach which addresses an individual’s needs and an anthropological perspective which offers a biological study of the human being.

A psycho sociological perspective addresses an individual’s psychological health and wellbeing needs which are individual to functioning within human society. This perspective highlights that factors such as age, gender, environmental living conditions and the individual differences that people face are to be considered in health needs and care issues.

A psycho-social approach to public health aims to incorporate the environment which will address the health of groups of people by social context, social class, location and how accessible they are to local resources. In the past this has been referred to as the social model of health (K217, Learning Guide 2, p43).

The structure of the social model of health aims to make health services more affective, accessible and acceptable to individuals. The components are as follows (K217, Learning Guide 2, p43).

To acknowledge the influence that health has on political, economic, social, psychological, cultural and environmental factors and also biological factors.

To improve health a focus must be placed on the socio-economic environment.

To achieve community participation with shared decision making between lay people and practitioners.

Health services to collaborate with other government agencies and sectors.

Commitment to equity and accountability in health.

The use of evidence which is qualitative and quantitative.

The concept of this perspective is that the focus of social causes are linked to illness rather genetics. If the social causes which are causing a detrimental effect on health are addressed then a better quality of life and sense of wellbeing are to be achieved. In Kingsley case he is not socially active because of the environment he is currently living in, which is restricting him from participating in any social networks, which gives the practitioners power over him so he is then not part of the decision making regarding his wellbeing.

Holism perspective

The practice of holism is to recognise that each person’s needs are unique to one’s own identity. It acknowledges that focus is to be given to lifestyles and choices which have an impact on health and illness. The approach links all aspects of a person’s physical, mental and emotional state to create a composition of a state of health and illness.

The approach of a biomedical perspective will address medical conditions with a biological, anatomy, and a physiology view but ignores an individual’s needs, as a holism approach would address the individual’s needs which would have an effect on lifestyles and choices.

So a Biomedical perspective has a place in some health conditions such as Diabetes which will address the medical needs such as insulin. But a holistic approach will identify the whole person combining their mind, body and spirit. This can be helpful for practitioners to understand how a Diabetic may be feeling with effects of injecting insulin, are they coping with self management of the condition. The whole person approach to care is to give service users the ability to move on from the professional dominance in the doctor centred model and to achieve the self care model which is to encourage independence. (K217, Learning Guide 2, p42).

Discussion.

The contribution of theory.

Do theories have a place in health and social care services and how can they help people like Kingsley who is suffering from a long term health condition.

Theories in health and social care are developed from two perspectives

Good research and medical engagements which results in theories from evidence.

Generalised practice and an understanding of experience within a profession, these theorises are developed from practical experiences.

Theories in understanding long term health conditions can be found in two perspectives bio medical and the social model of health. The bio medical approach is that the body functions normally but when things go wrong a specialist can repair the body; its focus is that biological problems can be addressed with medicine. The social model of health recognises biological factors but also includes the recognition of the influence of health being a matter of psychological and social addressing the wellbeing of an individual.

If just a bio medical approach to theory was taken of Kingsley’s situation he would have been diagnosed with two long term health conditions a stroke and type two diabetes by a practitioner then undergone biological treatment in hospital, were tests were taken and symptoms were controlled with medication. He is now living with two conditions controlled by medication. Bio medical may adapt mechanical metaphors which presume that a practitioners approach is to be an engineer and to fix what is malfunctioning with medication (K219, leaning guide 1, p36). The N.H.S. point out that a stroke is a medical emergency and should be diagnosed as soon as possible this would be in a bio medical environment. A bio medical view would be taken to determine the emergency treatment needed and also for after care with medication, therapists, physiotherapist and G.Ps. The N.H.S also highlight that the social model of health should be incorporated into a patients social care needs social workers would assess a patient and their carers needs and offer services such as meals on wheels and home care services (N.H.S. 2011).

A purely social view of theory to long term health conditions would offer Kingsley and his with sociological support in dealing with his conditions addressing needs for his wellbeing. Kingsley has experienced a change to his identity, because of his illness he feels he can no longer contribute in society. Kingsley’s illness has made it impossible for him to work so he now relies on the welfare benefit system so his identity has changed from a working man providing for his family to the sick role. The sick role can be identified when an ill person becomes exempt from a social role of responsibilities examples are because of illness, a sick person will not get better without being taken care of and the sick person will want to overcome illness and should be obligated to seek the correct professional help to deal with an illness (Parsons, 1951, p.294). This theory of the sick role has an element of social care and bio medical, society will address an ill persons needs with benefits and care issues and a biological factor will be present with medication.

What can be learnt from research and practice guidelines?

Research show that suffers from a long term health condition such as a stroke may face physical disabilities and suffer from social exclusion which can lead to spoiled identities. The Stroke Association commits approximately two and a half million pounds per year in to research of stroke prevention and treatment .Two key achievements are (The Stroke Association 2011).

Staying physically fit after 40 cuts risk of a stroke. People who are physically fit after the age of 40 can lower their risk of stroke by as much as 50 percent, ‘compared to people who aren’t as physically fit’ (The Stroke Association 2011).

The benefit of occupational therapy for stroke care home residents. A recent study funded by the Stroke Association has shown how beneficial even a small amount of occupational therapy can be to residents in care homes who have had a stroke. The study, carried out is extremely significant as the care home population is an understudied and extremely vulnerable group (The stroke Association 2011).

The research suggests that prevention can reduce the risk of a stroke and that life style changes and rehabilitation will help with the recovery process, learning to deal with the effects that the stroke has had on them and learning to adapt to the limitations caused by stroke. Rehabilitation would also address the need for any support in dealing with social, emotional and practical issues.

A government report on long term health conditions and self care (Your health, your way, 2009) is aimed at promoting discussion between health and social care professionals and people with long term health conditions, it addresses what options, support and information are available for health care users who wish to self care. The N.H.S. and social services want to encourage people with long term health conditions to self care, its shared aims and values for the transformation are to ensure that service users and their carers are not discriminated because of illness or disability and are supported to be able to:

Live independently and be able to sustain a family unit, which will avoid children taken on inappropriate caring roles.

To stay healthy and to be able to recover quickly from illness.

The ability to exercise control over their own life and if appropriate the lives of family members.

To participate economically and socially as active and equal citizens.

Have the best quality of life, irrespective of illness or disability and retaining respect and dignity.

(Your health, your way, 2009, p.4)

Self care is build around a holistic process that places the service user at the centre of their own care but also recognising that different issues can impact on an individual’s health and wellbeing so the process is supportive, individual, flexible and non-judgemental, the focus is solely on enabling the individual to achieve the outcomes that they want for themselves.

People who use services completed a survey prior the transition to self care and after the changes had occurred the findings are.

(Your health, your way, 2009)

(Your health, your way, 2009)

The results show how being empowered to take a more active role in health and well-being can improve quality of life. People who are living with a long term condition can benefit enormously from being supported to self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and be more active and independent (Your health, your way, 2009, p.6).

Theory and practice.

The social model of disability (K217, Learning Guide 6, p43) plays a significant part in a care service user’s life, such as Kingsley. This theory accepts that people will experience differences in life because of health issues such as stroke and diabetes, but questions that the difference is the problem when society does not adapt to such differences. The theory was introduced in the 1970’s when disabled activists debated that society is the problem that faced disabled people not the individual’s disability. This approach has a commitment to improving the lives of disabled people, by promoting social inclusion and removing the barriers which oppress disabled people (Tom Shakespeare, 2006, p 9).

The biomedical paradigm ignores the differences between individuals and is criticised for overlooking social influences which have an effect to health care (K217, Learning Guide 2, p40). This is clear in the case of Kingsley; he has received biomedical treatment in the past for type 2 diabetes and now for a stroke from medical practitioners. Kingsley is now experiencing differences in life to an able bodied person as well as a change to his identity to being disabled because he cannot walk or use his right hand without being aided. The nursing home were Kingsley now lives accepts his disabilities and provides care for him such as assistance to walk and use his right hand. Two people assist Kingsley to get out of bed, shower and dress him. The environment is restricting his independence and making him disabled relying on assistance and there are no aids he can use himself which would give him control of his care.

Empowering people who use services (K217, Learning Guide 10, pp28-34) is a theory which would allow Kingsley to become involved in his health care needs. The focus of the theory is the concern regarding the need for people to participate in their health care needs, and that empowerment will encourage them to use services and empower them to participate within them. People need to be encouraged to use health care services but also need to empower themselves to participate within a service. Health and social care services encourage users to become empowered; this can be with support groups with people who share similar experiences (Diabetes NHS, 2011). Key factors of the theory are that power and control should be equally divided between service provider and user, several options will be available to the user which there will have knowledge on, information supplied to assist in making decisions and if the user is dissatisfied with the system has the option to decline any further use of the system and make a complaint. Involving people who use health and social care services with empowerment gives them achievement by (K217, Learning Guide 10, p30).

Having control and being engaged with services.

Equal share of power with practitioners.

The contribution of planning individual services and the development of good practice.

Including all members of society.

Empowerments goal is to involve participation at all levels in care services allowing users to have a say and to be engaged in their care needs working with practitioners to satisfy care needs. Empowerment is a ‘way of equalising the distribution of power between users of services and practitioners’ (Tuner, MacKian, Woodthorpe, 2010, quoted in Learning guide 10, p.30).

Kingsley’s care needs are being dictated to him by the care home and his social worker if he was to be empowered to use care services and was to empower to participate in services he may be more actively contented with his care needs.

Conclusions and recommendations

Who cares for Kingsley and where he receives care are now important decisions to make. The decisions will influence his care needs and his future wellbeing. This report highlights the concerns that people who have long term health conditions face with care needs and the services that provide care.

Clearly when a person suffers from an illness such as a stroke or diabetes an emergency response for care is received from a medical practitioner who will offer a biomedical diagnoses and if needed medical treatment and medication. As was the treatment Kingsley received, the next phase in the care process is how after care support and treatment is provided for people with a long term health condition.

Kingsley’s individual care needs have not been addressed; he may be adequately receiving biomedical care in the nursing home and his basic fundamental needs for living such as shelter, food and warmth are being provided his individual needs are not being considered.

Kingsley wishes to return home to the care of his wife, a psycho sociological perspective will identify that his individual psychological health and wellbeing in society is not being fulfilled. The care home environment is restricting him from participating in main stream society; he cannot be active within society because he has no access to social networks. This will be a fundamental reason for his bouts of anger and frustration as before his illness he was social active and provided for his family. Kingsley’s care needs are unique to his new identity as a disabled person with a long term health condition, along with a psycho sociological perspective a holistic approach will help to identify the impact this is having on his health, lifestyle and wellbeing.

The social worker assigned to Kingsley is concerned that his wife would not be able to cope with his care needs, one option is to recognise what difficulties in society will be restricting Kingsley because of his disability (The social model of disability). The care home is disabling Kingsley because of its lack of practices and environment.

If the social worker was to work with Kingsley and his wife to identify the support needed to provide a self care package such as direct payments (K217, Learning Guide 10, p29) this would allow them to be independently in control over which services they use. Allowing them to live independently as a family and able to participate economically within society.