Author: Andre Coleman

This assignment follows the experiences of an immigrant Indian/Kashmiri family in their first couple of months in Australia. The family was a period of five weeks for a period of one to two hours per week in their family setting at home and once in the final week on a family picnic which they were gracious enough to invite me to. For discretionary purposes all personal information including names, addresses and any other identifiable markers have been changed in keeping with the primacy of the family’s privacy.

The family consists of five individuals, the father Mr. Fayaz Ahmad, his wife Rubina Geelani, their two children Ahmad, a boy of 10, Maryam a girl of 12 and their 5 year old nephew Abbas. The family from here on for purposes of brevity will be known as the Ahmads. The Ahmad family is from the northern most state in India, Kashmir. Mr. Fayaz used to work as an engineer in the state of Kashmir with the municipal department of the state as a civil engineer superintendent. Ms. Rubina has a bachelor’s degree in education but has never worked full time, Maryam and Ahmad were both studying in a well reputed private school and were both performing above average in academics as well as extra-curricular activities, Abbas is their nephew who was recently witness to the tragic death of his parents in a militancy related incident in their home state.

Kashmir has had a long history of troubled political activity dating back to the partition of India and Pakistan during which time the Muslim majority state of Kashmir became a bone of contention between the two newborn nations. Since then there has been a slew of political and military activity that has served only to worsen the tangled situation between the two countries with two wars being fought over the state and an armed uprising against the Indian state fueled by Pakistan which resulted in massive state sponsored atrocities as well as transgressions on behalf of the armed rebels. Several other variables, including the growing influence of China, the rise of Afghan Islamist groups, political instability etc has also contributed to the increasingly complex situation in the state. The Ahmad family immigrated to Australia following the tragic death of his brother’s family in a military encounter against suspected militants, young Abbas was the only survivor of the tragedy and was adopted by Fayaz and his wife who decided to leave the trouble torn state behind in order to secure a better future for their children. I came into contact with them through a mutual friend who is a volunteer activist for militancy affected families in Kashmir and who also helped Fayaz through the formalities surrounding immigration.

Week one:

My first encounter with the Fayaz family was on a pleasant sunny Australian Sunday afternoon the very next day after they had moved in to their home. My reception in their home was very warm and enthusiastic with Mr. Fayaz greeting me very effusively and treating me with great hospitality and warmth. I was told by my friend that the house was a temporary accommodation and was not in that great shape, nevertheless everywhere I saw I could see the efforts of Ms. Rubina and Mr. Fayaz to tidy up the place. There were boxes and unpacked luggage everywhere but Mr. Fayaz managed a comfortable couch space in the main room for me to settle down in.

The object of my research was somewhat puzzling to them as they seemed to follow me everywhere I went and it took some while for me to explain to them that this was merely an observation and not an interview, this was greeted with some skepticism and worry by Ms. Rubina who immediately wanted to know what I was looking for. The initial warmth gave way to some mistrust on behalf of Ms. Rubina who instructed the children not to play downstairs or in the open but to go to their room and play there. My initial thoughts were that the mistrust of my presence in their midst was related to their negative experiences with official government agencies that are notorious for their clandestine activities amongst the civilian population in Kashmir. The rest of the time passed by without any major incident and was spent mostly talking to Mr. Fayaz over consecutive cups of tea.

Week 2:

My second week started right after Mr. Fayaz found a part time job at a nearby retail institute as a sales executive; on my visit to the house he was not present as he was picking up a late shift that day. I used this opportunity to increase my rapport with Ms. Rubina and get to know her better, I felt that our previous encounter had not gone over the smoothest and after some initial reluctance she allowed me to observe the children playing in the yard. I had to assure her that I would not take any photographs of the children before she would allow me this. The children showed little effect of the trauma in their past, although Ahmad was showing signs of lethargy and malnutrition, upon asking Ms. Rubina about his health she replied that he was always a picky eater and had been getting progressively difficult to get him to eat properly in recent weeks.

On closer inspection of the children I saw that both Maryam and Ahmad were trying to involve Abbas in traditional Kashmiri games, a version of hopscotch and tag that somehow always ended up with Abbas winning, it was obvious that both Maryam and Ahmad were letting Abbas win these games. Later on while observing them I noticed that they shied away from me and rather spent time with their mother in the kitchen rather than stay anywhere they knew I could see them. In normal cases I would have construed this as natural shyness on behalf of the children but after seeing them play I could not imagine them being very timid by instinct.

Week 3:

My third visit marked the first time that the children had started school in Australia, I was fortunate enough to observe them coming home directly from school. Maryam seemed very pleased and satisfied with her day at school, although she spoke only in Kashmiri around her mother I could gather from the tone that she was excited about the prospect of school, Ahmad on the other hand seemed subdued and quiet, on closer observation I noticed the signs of a scuffle on the child, with a pocket torn off his new shirt, he was taken away by his mother to his room, I presumed this was to comfort him as there were no sounds of scolding from his room. Maryam was pleased enough to try and interact with me and be comfortable around me, she offered to show me her new books and notebooks, one of which bore a note by her teacher praising her drawing skills and another one which had her homework written down in her small, neat handwriting. She spoke with me in accented by fluent English asking me about why I was always in the house with them. The conversation led to the topics of her brother and little cousin, she admitted that Abbas was much sadder nowadays than in the past and he frequently wet his bed at night and as a result had to sleep with the parents in the other room instead of with them. I resolved to talk to Mister and Missis Ahmad about getting Abbas to see a child therapist.

Week 4: My fourth visit was a bit rocky as my previous suggestion of a child therapist for Abbas had not gone down well with Mister Fayaz. He felt that I was making unfair demands of him and that the child had been doing fine before I was there and even at one point tried blaming me for Abbas’s changed behavior. The majority of the time was spent trying to explain to him that it was just a suggestion and that he was in no way bound to do what I asked of him. Later on he admitted that the stress of managing finances for the household was starting to build on him and that he was worried about their future in Australia, on further questioning he informed me that his engineering degree was invalid in this country and he would be stuck with lower level jobs until he could complete another technical course here in Australia.

Week five: I was surprised by my fifth and last visit when the family decided to take me along for a surprise picnic. Although not strictly their domestic settings I decided to go along with them to observe their interaction with the Australian picnic experience. The children seemed slightly apprehensive instead of the natural exuberance that most children would show when informed about going to the beach, apart from Ahmad both Abbas and Maryam seemed to stick close to Ms. Rubina and reserved themselves to helping her pack whereas Ahmad wanted to put on his rubber wings and flippers right in the house and go to beach thus dressed. While helping Mr. Fayaz get the car ready I came to know that Ahmad has been having trouble with bullies at school who make fun of his accent, that he has been dreading school and enjoys their outings with a relish, Abbas had started his sessions with a child therapist and was no longer wetting his bed and that Maryam had already enrolled in soccer class. I provided Mr. Fayaz with some brochures and booklets regarding part time courses and short term courses that he could take.

Analysis:

There were several issues and points that I observed while with the Ahmad family in regards to their reasons for coming to Australia, their interactions with the local culture and the nature of their family relations. Most importantly I came to realize about their unique needs and perspectives, their unique characteristics in regards to what they could bring in to the community, the culture they came from and the special needs that the three children of the family that needed to be addressed. My analysis can be elaborated as:

For the greater part of this analysis the focus will be on young Abbas, then on Ahmad and on Maryam in decreasing order of significance in relation to special early care needs. The very first observations regarding Abbas were those of his interactions with the different societal settings that he had to experience. For instance his initial immigration to Australia was prompted by a drastic change in his original environment of Kashmir where he suffered the debilitating trauma of losing both his parents, in conversations with the Ahmads I got to know that Abbas was naturally a shy child and following the death of his parents he became even more withdrawn, to the point where he managed only a few sentences in conversation per day with the Ahmads and not even that with strangers. The initial experiences of the children with their societal systems were also apparent in how they treated me, a stranger in their house, the initial mistrust and fear that they projected on me was only a reflection of their past environment where authority figures or those who were in anyway related to official status were viewed with mistrust and even fear, this symptom extended not only to the children but to Ms.Rubina as well, when she forbade the children from interacting with me.

The family structure in conservative societies like that of the Ahmad family is generally constituted of only close blood relations, the adoption of children as in the case of Abbas is almost unheard of, the most that a Kashmiri family will do is provide all the necessary support and accessories to a relative but that is all the other party will remain; a relative, in this case the traditional family structure has changed to that of a typical western nuclear family model and that has put an additional load on the two adults as Ms. Rubina and Mr. Fayaz do not have the traditional family support structure in place to help them manage their children any more.

The cultural background of the Ahmad family is also an issue that has led to certain hindrances while integrating with their new environment, this was demonstrated with the trouble that Ahmad had with bullies at school and the frustration and worry that Mr. Fayaz felt at his educational qualifications not being considered eligible in the Australian work environment. The stress also showed on Ms. Rubina when she felt mistrustful of me, furthermore the bed wetting episodes of Abbas were symptomatic of elevated stress levels as Maryam informed me that he had never had this kind of problem before.

There were of course the needs of the children to take into consideration especially those of Abbas and Ahmad. The specific list of activities and processes that I recommended for the children were:

Child specialist therapy for Abbas to help address the trauma of his parent’s death and the sudden culture shock of shift from Kashmir to Australia.

Extracurricular activities for Maryam in order to enable her to come out of her shyness and gain the confidence and self-esteem she needs in order to engage in social interactions effectively.

Ahmad requires counseling as well in order to encourage better, more constructive outlets for his frustrations, bullying is always a significant issue to be dealt with in regards to early child care and Ahmad’s case is no exception but his situation is further compounded by the complexities of the previous experience in the stifling and rather constricted environment of Kashmir along with his experience in a private school in Kashmir as opposed to a public school in Australia

In addition to the counseling steps for the children I also suggested certain short term technical courses for Mr. Fayaz so that he doesn’t feel trapped in a lower level employment circle in Australia due to his degree not being recognized here.

Families where addiction is at hand are normally painful to live in, especially when a person is young. This is why individuals who live with addiction may become traumatized to varying levels by incidences. Wide changes, from one end of the disturbing, psychological, and behavioral range to the other, all too frequently characterize the addicted family system. Every member of the family is affected by the addiction. Coping with addiction can expose family members to unusual stress. Normal schedules are frequently being interrupted by abrupt or even frightening types of experiences that are part of coping with drug abuse. Addiction in the family can result in children having trauma that seriously affect growth and can have pervasive and long-term effects on them. Individuals arrive in life only partially hardwired by nature. The environment finishes the work of nature. Therefore, if an individual encounters family members who are addicted, he/she either become traumatized or live an abnormal life. Therefore, family addiction in the family affects daily living issues causing particular emotional, interpersonal, or even clinical mental health concerns. However, according to renowned research article, there available interventions, including family therapy interventions and counseling support from experts. The interventions are modified to fit the extent of addiction in the family, and the techniques and follow-ups employed vary.

Forms of addiction in the family

Substance abuse is probably the most widespread form of addiction in the family that has become chronic. According to research experts, addiction has been defined a major, progressive, unrelenting disorder with genetic, psychosocial, and ecological issues, which affects its expansion and signs. It may turn out to be fatal and progressive. The symptoms of various types of addiction in the family are a spoiled urge of the substance. Along with this worry with a certain substance and its frequent use, in spite of severe costs, characterize the same. It finally results in deformations in thinking. There has to be a complete understanding of what addiction in the family is, in order to single out problems such as drug, alcohol, and sexual addiction. This is important to seek out appropriate rehabilitation programs and addiction management to get back to normal life.

Addiction to drugs, alcohol or even sexual addiction in the family are procedure addictions and are linked to compulsive character like shopping, gambling, and eating disorders. Drug, alcohol and sexual addiction affect the victim, but also hurt those associated with them including their family members, relatives, friends, and co-workers. In addition, addiction to substance, drugs, and sex are closely related: reliance on any one can and normally does result in headway to the other. Under such situations, the addict is no longer in charge and needs appropriate rehabilitation and addiction treatment session.

Indications of addiction in the family

Some signs of various types of addiction character related to substance, drugs and sex comprise of a preoccupation with the addictive character between periods of misuse, augmented levels of abuse, a development of tolerance to alcohol or the drug in contention or a mood of dissatisfaction in the concern of sexual addiction. When the affected individual tries to stop, there are distinctive withdrawal symptoms that urge the addict to relapse to addictive behavior to shun or control these symptoms. In addition, alcohol, substance, and sexual abuse can be visible at inappropriate times while working, or when withdrawal tends to disrupt daily functioning (Henderson, 92). There is a noticeable decrease in social, work-related, and recreational involvement with the addict opting for indulgence in addictive behavior. Involvement in family matters can be disrupted by addiction in the family.

Effect on Family Members

According to research experts, addicted families are frequently very endangered by what they recognize to be the threatening destruction of their family. Their very position in existence is being endangered; the ground beneath them is starting to move. Denial is a dysfunctional effort to put a good look on a bad circumstance by denying the effect addiction is having on the family setting and the existence of the proverbial “pink elephant in the living room” who is consuming ever-increasing space amounts of room. Reality is reprinted as family members try to bend it to make it less intimidating; to conceal their ever-emerging despair. Family members normally colluded in this refutation and anyone who tries to turn the attention onto cruel reality of addiction may be alleged to be disloyal. They run in place to cope with appearances, to themselves as well as relatives, while reacting to a sense of despair frequently nipping at their steps, again, we observe the cycles between limits that so distinguish addicted family systems. Therefore, it is simple for family members to experience hopeless, unhappiness, and inability to believe that things can ever transform. The family is at times gripped by the memory of aggression, infidelities, and various humiliations, such as yelling, howling, intimidating, or the silent treatment. The family requires and needs aid, yet cannot access it alone. Certainly, erroneous beliefs about addiction to alcohol and other substances can derail any attempts to assist the addict.

Feelings of guilt are maximized by others

The painful experience of guilt, shame, and fear emanating from the conflict of addictive manners with the person’s own values normally develops states of unbearable inner trauma that make it tougher for the addict to restrain from resorting for to the initial addiction that is the grounds of negative feelings. Others who are prospering make this worse. The situation could worse when others start to accuse the victim starting family members to the members of the society who condemn the act of substance addiction (Barnard, 72).

Effects on children

Most accessible data shows that a parent’s drinking concern normally has a detrimental impact on children. The spouse of the individual abusing substances is probable to protect the children and neglect the parenting roles of the parent abusing substances. The impact on children is worse if both are addicted to alcohols or drugs (Digman and Soan, 100). Many mature children of addicts are at risk for a variety of psychological, social, and emotional concerns. The most notable factor is a negative self-esteem and feelings of worthlessness and disappointment. Many mature children of addicts do not attribute said dilemmas, feelings, and feelings to growing up in an alcoholic family. However, commonalities consist of failure to trust, impetuous character, and problems with violence and depression (Parsons, 2003).

Most of the adult children of addicts have difficulties with intimate associations. Because they have been habituated to distrust people throughout their infancy occurrences, they deem that if they are in love with someone they will unavoidably be hurt. These children of addicts find this disbelieves to extend into adulthood. Without being competent to belief in themselves, they deem that they are not competent in dealing with uncomfortable emotions and this creates long-term concerns with nurturing positive and healthy cherished relationships (Parsons, 2003).

The children normally feel out of control, make unfortunate career choices, and have mind-sets of worthlessness and breakdown. Many turn out to be parental breakdowns as well. Not astonishingly, some have concerns to do with abuse of psychoactive drugs or alcoholism. Such adult children have emotions of over-responsibility (Turney, 2007). Since there was such a short of responsibility in their childhood, they consider that they have to recompense it in adulthood.

Treatment and Case Management
Recovery for victims

There are various stages and phases of possible recovery for an addicted person. In all these, abstinence necessitates a decision by the victim, and recovery needs time and effort.

Physical recovery is the least multifaceted of the four recovery phases, even though it is normally the most instant. Physical recover occurs primarily because of self-denial alone. The body has an astonishing ability to mend itself, particularly when combined with medical care.

Mental recovery is more multifaceted because it encompasses not only concerns associated with brain task and brain chemistry, but with concerns of attitudes, belief settings, and lucid, abstract thought.

Emotional revival is more complex so far. In engages not only attitudes, belief settings, and lucid thought, but also idea’s first cousin-feelings. Emotional revival consist of learning to handle feelings openly, honestly, and sensibly. It encompasses learning to articulate and resolve feelings in suitable and effective ways. For most individuals in recovery, emotional recovery takes ages.

Treatment for the victim

There are two possibilities when we are examining the victims of addiction: there are the addicts themselves, who are debatably victims, and then there are the relatives, friend, and family members of that addict. The family and relatives of the addict need to support him/her in to recover or cope with stigma.

Various institutions help identify and manage cases of addictions. These include drug addiction and rehabilitation services that offer services to safeguard the health and welfare of addicts who are might have been victim drug abuse.

Evidence Based Treatments

Evidence-based practices are classified as intercessions that have depicted reliable scientific evidence of developing preferred client outcomes. The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) provide the following evidenced-based observations for substance use disorders (Miller, and Miller, M., 409).

Cognitive Behavioral Interventions- this practice consist of using awareness and skill-building roles with clients

Community Reinforcement- This practice consists of connecting the client with other required agencies and services in the society.

Motivational Enhancement Therapy- this approach entails using inspirational interviewing strategies and interventions that are founded on a “stages of change model.”

12-Step Facilitation- this is a prearranged, personalized approach for introducing addicts to a 12-step program. This can result in improved meeting turnout for a longer period.

Consistency Management- This practice involves behavioral contracting where addicts have chances to earn rewards for specific sought-after behaviors. Data shows that stimulant users react very well to this practice, remain in treatment longer, make quantifiable progress, and have better treatment results.

Pharmacological Therapies- There is reasonable evidence that medication like Antabuse, Naltrexone, and Buprenorphine when used in combination with other therapies can assist stabilize an individual’s life when their alcohol or substance use is out of hand.

Systems Treatment- this refers to treating addicts in their usual social setting. Spouses therapy, family therapy, and multi-systemic family therapy are all instances of systems treatment models. There is quantifiable evidence showing that addicts whose families are engaged in the treatment procedure show enhanced outcomes. Systems treatment seems to be especially successful with young people.

Integrated Dual Disorders Treatment- This treatment practice assists people revive by presenting mental health and substance abuse treatment cares jointly, in one setting. The same medical team provides a personalized treatment arrangement, which handles both mental health and substance abuse concerns. A wide choice of services if provided in a level-wise manner, as service needs change over the course of treatment.

Case management

There are various ways where an addict manages his/her predicament. The management also involves family members, close friends, and relatives. The following are the most common management and recovery procedures, and they are scientifically experimented.

Illness Management and recovery- Wellness self-management involves a series of strategies engineered to assist addicts manage their symptoms. Psycho-education, social skills teaching, cognitive character therapy, and survival skills teaching have shown to assist consumers handle their own mental health, minimize symptoms and relapses, and reduce the adverse effects of psychiatric illness on communal and role functioning.

Medication Management- The rudiments of a successful model to optimize the use of medications include: (1) a methodical evidence-based practice to medication selection and use; (2) measurement of treatment reaction and side effects; and (3) hard work to improve addict devotion to taking prescribed medicines.

Assertive Community Treatment (ACT), intensive Case management (ICM) – Vital features of ACT, and Intensive case management consist of the following: a little caseload, provision of services in addict’s natural environment, a 24-hour care, and organization of comprehensive multi-disciplinary services through frequent treatment team gatherings.

Family Psycho-education- Successful family intervention practices offer a mixture of education, analytic, crisis intervention, and support. Family psycho-education has been depicted to minimize relapse rate and facilitate revival of individuals who have mental sickness and/or co-morbid disorders.

Integrated Treatment for Co-Occurring Substance Use and Mental Health Disorders- Substance use treatment that is incorporated with mental health treatment and customized for persons with mental illness is more successful than detached substance use and mental health services. Successful programs also incorporate other services such as case management, medications, shelter, vocational psychotherapy, and family intervention (Ries, et al., 372).

Trauma Services- There is a rising body of evidence that timely intervention following traumatic occurrences can avoid a diversity of behavioral disorders. Successful treatment following traumatic incidents should incorporate personalized counseling taking historical relation of both current and past trauma and providing psycho-educational data about trauma occurrence. Successful treatment will encompass concurrent treatment of trauma concerns and co-morbid concerns including substance abuse when appropriate.

Support groups

Support groups help much in minimizing cases addictions and in cases of traumatized families, it helps to bring back the trust in the affected children and families. These groups are formed to reach out for mature survivors of addiction and help prevent recurring cases addiction. Dissociative disorder support groups help victims who have dissociative disorders for instance DID.

Recommended books and journals

There are various journals for traumatized victims. These help victims, parents, siblings, and families of substance addiction. In these journals, families of traumatized victims and children of addiction can find information on how to deal with the situations at hand. They can access knowledge on how to detect and probably prevent cases addiction their families.

In conclusion, addiction in the family can be painful to both the victim and the people around him/her. This is more pronounced in a family where every member is traumatized by such incidences. The most members of the family are children at a younger stage, whereby they can also become victims of addiction, and later in life have unfortunate intimate relationship. Nevertheless, early diagnosis and treatment of addiction in the family helps much in minimizing the extent of addictions, and prevent possible cases recurring addictions. Treatment takes various forms and it involves not only the victims, but also the family members. The treatment can be tailored to fit individuals and extent of addictions. These treatments range from rehabilitation to mental health treatment. It also involves case management where victims can be able to manage their symptoms. Addicted persons and members of the family can also find help in support groups. In addition, they can find helpful information in books and journals to enable them to manage trauma and related cases.

Work cited

Barnard, Marina. Drug Addiction and Families. London: Jessica Kingsley Publishers, 2007.

Digman, Carmel and Soan, Sue. Working With Parents: A Guide for Education Professionals.

New York: SAGE Publications Ltd, 2008.

Henderson, Elizabeth. Understanding Addiction. Mississippi: Univ. Press of Mississippi, 2000.

Lowinson, Joyce, Ruiz, Pedro and Millman, Robert. Substance Abuse: A Comprehensive

Textbook. 4th Ed. New York: Lippincott Williams & Wilkins, 2005.

Miller, Peter and Miller, Peter M. Evidence-Based Addiction Treatment. London: Academic

Press, 2009.

Parsons, T. (2003). Alcoholism and Its Effect on the Family. AllPsych Journal. Retrieved March

3, 2011, from http://allpsych.com/journal/alcoholism.html.

Ries, Richard, Miller, Shannon, Fiellin, David and Saitz, Richard. Principles of Addiction

Medicine. 4th Ed. Baltimore: Lippincott Williams & Wilkins, 2009.

Turney, L. (2007). Children of alcoholics: Getting past the games addicted parents play. Do It

Now Foundation. Retrieved March 3, 2011, from http://www.doitnow.org/ pages/808.html.

The introduction of the Care Quality Commission arguably fixes that which was not broken. Editorial The Trials of Marriage, The Guardian, Wednesday 1st April 2009.

The CQC came into existence on 1st April 2009. Consider the intended role of the CQC and evaluate this statement in light of the experiences of the first full year of the CQC’s existence.

“We need to see tougher action by the commission on poor providers. The commission can impose or vary conditions where older people may be at risk. It can cancel the registration if that is the only way to ensure safety. Areas highlighted as needing urgent attention include record-keeping, medication, care plans and staff supervision.”

Operating as from April 1st 2009 the Care Quality Commission (CQC) takes over from the role of the former Commission for Social Care Inspection (CSCI) as the registration and regulation body for social care in England, as well as performing the functions of the former Healthcare Commission and the Mental Health Act Commission. The CQC requires all health and adult social care providers to register their regulated activities. Regulated activities that require registration are declared in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009, Pt II, s 3(1). The intended role of the CQC is to make the general standard of care better, however concerns have been raised about the poor quality of health care for the elderly as almost one quarter of homes for older people provide inadequate care. The CQC has done a lot of juggling in its first year of existence which confirms the statement that it “arguably fixes that which was not broken”. First, its staff have had to create an organisation from the merger of the Commission for Social Care Inspection, the Healthcare Commission and the Mental Health Act Commission. In addition, it has had to continue its predecessors’ functions in assessing adult social care provision, evaluating health services and monitoring the treatment of detained mental health patients.

There are several health care regulators namely the Care Quality Commission (CQG), the Health Protection Agency (HPA), the Human Tissue Authority (HTA), the Medicines and Healthcare products Regulatory Agency (MHRA), the Medical Research Council (MRC), the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA). The CQG regulates all the health and adult social care in England and also protects the interests of those detained under the Mental Health Act. The most recently devised health care regulator is the CQC which seems to be an attempt at encompassing the role and functions of the other bodies.

The CQC has made proposals for its approach to the assessments of quality in 2010/2011 for all institutions in England that provide healthcare and adult social care services, and for the National Health Service (commonly referred to as the NHS) and local authority organisations that commission those services. The proposals were set up in accordance with the Heath and Social Care Act 2008. From April 1st 2009 all organisations that are providers of healthcare and adult social care services in England will be required to be registered by October 1st 2010 with the CQC as stated by the Heath and Social Care Act 2008. Registration is not just about the initial registration. but includes initial registration, monitoring and assessment of ongoing compliance, inspection and implementation. The CQC has to undertake registration activities as well as to perform “periodic reviews, and special reviews and studies and to publish information on its findings.”

A new legal framework has been created to facilitate the new regulation system that is the Health and Social Care Act 2008 (Registration Requirement Regulations 2009). The Health and Social Care Act 2008 gives the CQC extended powers. It can issue enforcement notices, withdraw provider bodies rights to provide services entirely or can issue certain conditions of service/registration if it decides it is necessary to do so. Its enforcement options range from minor to very serious sanctions depending on the service affected degree of risk or service disruption. However the CQC stresses it wants the regulatory system to drive and support the healthcare and adult social services organisations to improve and raise standards and to be based on fairness and transparency.

On its official website the NHS describes the intended role of the CQC a regulator which “makes sure that the voices of people who use health and adult social care services are heard by asking people to share their experiences of care services. It makes sure that users’ views are at the heart of its reports and reviews. In some cases patients and their carers work alongside inspectors to provide a user’s view of services.” The reality and whether the CQC has successfully achieved the goals the NHS mentioned is arguable.

The CQC is responsible to make sure that essential common standards of quality are met everywhere health care is provided, from hospitals to private care homes and work towards improving health care services. The Commission promotes the rights and interests of people who use services and have a wide range of enforcement powers to take action on their behalf if services are unacceptably below standards The CQC brought together (for the first time) independent regulation of health, mental health and adult social care. Before April 1st 2009, these tasks were carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. The aim of the CQC is to ensure that better care is provided for everyone wherever it is provided. The Commission has greater powers and responsibilities to use and take account of people’s views and experiences of services, and this includes evidence from overview and scrutiny committees. In June 2009, a Statement of Involvement was published setting out the Commission’s approach to involving people in their mission.

Overview and scrutiny committees working on health issues have been an important source of evidence of people’s views and experiences of health services for the Healthcare Commission. The Commission wants to build on this relationship and to encourage committees to develop an ongoing dialogue with them. Scrutiny committees have a fundamental role in bringing together and articulating the views of local people who use health and social care services in their area, and to check whether their needs and concerns are being addressed by service commissioners and providers. In many ways, scrutiny committees operate like a local regulator, holding services to account.

During its first year the CQC has faced many challenges which sheds a doubt of whether the Commission has really fixed a prevailing issue or has fixed that which was not broken. The CQC has had to proceed with the roles carried out by its predecessors as stated in the Health and Social Care Bill, Part II. The CQC has also introduced a new registration system for health and social care providers in English which is the first time the NHS has been regulated in that manner. The new core standards imposed by the CQC will replace the regulations and relative National Minimum Standards under the Care Standards Act 2000 which will be void as from September 30th 2010. The regulations introduced by the CQC will apply from October 1st 2010 (the date when the providers must be registered in the new system). Under the new system introduced by the CQC, instead of being individually registered for each service, providers will have to register according to their respective regulated activity.

In September 2009, the CQC had to face a serious allegation about manipulating survey findings. The head of the Development for Mental Health, Louis Appleby, accused the CQC of trying to attract the media’s attention by portraying a distorted flattering image of the Commission’s work hence undermining the intended role of the CQC which “is to be factual and balanced and inform the public and patients”. Professor Appleby expressed his concerns about the poor performance of the CQC which the Commission did not welcome.

In December 2009, Colin Angel, the head of policy and communication United Kingdom Homecare Association and the Registered Nursing Home Association criticised the Commission’s failure to communicate effectively over the system of registration: “We are extremely disappointed about the handling of the registration process. We fear that CQC isn’t adequately prepared for the enormous communication exercise facing them.” Colin Angel also identified the fact that the CQC was “missing the opportunity to use the extensive technical knowledge available from providers’ representative bodies” which the Registered Nursing Home Association chief executive Frank Ursell approved.

Some service providers have expressed their concerns about the fact that the Commission might have embarked on a mission which was too extensive and challenging to them as stated by the joint chair of the Association of Directors of Adult Social Services standards and resources network: “It has been stretched at senior management level and we’ve had quite short notice of a number of initiatives. It’s been a bit hand-to-mouth in terms of its ability to make decisions.”

She points to the fact that final guidance on how councils were to be assessed in 2009-10 was only published three-quarters of the way through the year.

Colin Angel, head of policy and communication at the UKHCA, says: “The CQC has lost valuable time restructuring, leaving insufficient time for over 24,000 social care providers to adapt to new standards before they are required to re-register.”

But Amanda Sherlock, head of operations at the CQC, says it has “been an outstanding achievement to pull together the three commissions, deliver business as usual as well as bring in a new regulatory model”, while building a new organisation.

She says that some things could have gone better, saying that the CQC has worked on how it handles national announcements, so councils and other bodies face “no surprises” when these happen.

Norman acknowledges the CQC has “shown itself willing to listen” and “accepted the concerns that we’ve had”.

On provider registration, Sherlock says: “We are keen to hear how we can do things better and how we can tailor our approach and communication.” She says the CQC has an “absolute focus” on making sure providers are “clear what is expected between April and October” when they must register.

National Care Forum executive director Des Kelly says for its part the provider sector needs to work with the CQC to ensure registration succeeds.

Sherlock admits the CQC has “put a lot of time” into organisational development but says this has paid off in establishing an organisation that has an “absolute commitment to driving up quality and safety across health and social care without defining any sector as special”.

A year ago, many in social care, including former CSCI chair Dame Denise Platt, feared the health service’s high political and public profile would make it “special”.

And since Johnstone’s departure last autumn, there has been no one with a social care background on CQC’s executive team below chief executive Cynthia Bower, who left social services in 1995.

Sherlock insists such fears have proved unfounded, but says the CQC has been helped by adult care’s rising profile.

Sherlock, who worked for the CSCI and its predecessor, the National Care Standards Commission, points to her own centrality to CQC’s strategic direction, despite not being on the executive team. She also reveals that the CQC will soon appoint a national social care adviser, to provide “external challenge” and strengthen links with the sector.

Kelly says the issue of social care’s priority has “gone better than I would have predicted 12 months ago”.

Concerns have also been raised that the CQC would not maintain the CSCI’s focus on user involvement. Sue Bott, director of the National Centre for Independent Living, which provides users to act as “experts by experience” on inspection teams, says involvement is “nowhere near as prevalent” as it was in the CSCI.

The CQC produced a statement on user involvement last June, pledging to conduct surveys and set up consultative panels.

Sherlock agrees there is more to do but says the statement has been implemented and the CQC’s user involvement team, led by Frances Hasler, who performed the same role for the CSCI, “actively challenges all parts of the organisation”.

One of the key objectives of the CQC is to support the integration of health and social care. Kelly says he has not seen “a great deal of evidence as yet” of progress on this front. But Sherlock points to the special reviews that the CQC has been doing on issues that cross the divide, including the quality of healthcare for care home residents, which she says will identify good practice and any gaps.

These will report in 2010-11, alongside the roll out of registration for adult care providers and a reformed performance assessment for councils. It will be another busy year.

ONE YEAR OF THE CQC

April 2009

The Care Quality Commission starts work. Outgoing Commission for Social Care Inspection chair Dame Denise Platt raises concerns over its potential to sufficiently prioritise social care and involve service users.

May 2009

Former Association of Directors of Adults Social Services standards lead David Johnstone appointed director of operations at the CQC. He leaves the organisation after only a few months.

June 2009

Statement on service user involvement published. The CQC announces series of special reviews for 2009-10, including of healthcare needs of care home residents and impact of recession on services.

July 2009

The CQC says NHS trusts are failing to comply with child protection requirements in areas such as staff training in report sparked by Baby Peter case.

September 2009

DH mental health director Louis Appleby says the CQCHYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”‘HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”s portrayal of results of an in-patient survey was HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”deliberately distortingHYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”” and simply highlighted negative findings. The CQC says many survey results were poor.

October 2009

The CQC publishes draft standards for health and social care providers, and holds meeting with mental health leaders over its presentation of the results of its in-patient survey.

December 2009

Adass criticises the CQC for its treatment of eight councils labelled HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm”priority for improvementHYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm” following annual performance assessment (APA). Councils improve for seventh year running.

February 2010

The CQC says ?2bn could be saved a year from reduced hospital admissions if joint working improves between health and social care in first HYPERLINK “http://www.communitycare.co.uk/Articles/2010/02/10/113768/cqc-health-and-socal-care-integration-can-save-2bn-a-year.htm”State of CareHYPERLINK “http://www.communitycare.co.uk/Articles/2010/02/10/113768/cqc-health-and-socal-care-integration-can-save-2bn-a-year.htm” report. It promises 2010-11 APA for councils will be tougher.

March 2010

Care provider bodies slam the CQC for an alleged lack of communication of the process for registration under its new system. The CQC claims it has engaged extensively.

April 2010

The CQC is one year old. It starts process of registering adult care providers under new system. National social care adviser appointed.

This article is published in the 8 April 2010 edition of Community Care under the headline “Many happy returns?”

Intimate Relationship Violence

Della Wright

Jackson State University

Table of Contents……………..2

Abstract……………………….3

Introduction…………………..4

Victims of Crime………………4

Particular Case Study………….5

Assessment of Case……………6

Ethical and Value Issues………8

Policy Issues…………………..8

Conclusion…………………….9

References…………………….11

Abstract

This paper discusses the types of intimate relationship violence (IVP) and the likely victims of this particular type of violence. A specific case of intimate relationship violence is discussed and assessed. It also dissects the different aspects of working in the field of social work with the victims of IVP in including ethical and political issues.

Intimate Relationship Violence

Introduction

Intimate relationship violence (IPV) refers to the physical, sexual, or psychological harm caused by a previous or current intimate partner. Physical violence is described as the intentional use of physical force. This can include slapping, shoving, punching, burning, or restraining the victim. Sexual violence is defined as either: the use of physical force to compel a victim into performing or engaging in sexual acts, an attempted or completed sexual act that a person cannot condone because of the influence of drugs and alcohol or disability of some sort, or sexual contact that is abusive. Psychological abuse is defined as repeated traumatic events or coercive behavior with the intent of controlling a person’s behavior (Howard, Agnew-Davies, Feder & Howard, 2013).

Victims of Crime

According to the Center for Disease Control (CDC), one in every four women in the United States has been victims of severe physical violence where an intimate partner was the perpetrator in their lifetime (Breiding, Smith, Basile, Walters, Chen, & Merrick 2011). The U.S. Department of Health and Human Services estimates that between eighty-five and ninety percent of victims of intimate domestic partners are women. It is safe to say, then, that being a woman definitely puts a person at risk for IPV. If you add the statistic of one of every four women is the victim of sexual battery, a conclusion can be drawn that violence against women is rampant in the United States (Breiding, et. al, 2011). African Americans and Hispanics are twice as likely as their Caucasian counterparts to be the victim of intimate relationship violence, as well (Whitaker & Reese, 2007).

Particular Case Study

As we look at the impact on intimate relationship violence in a person, family and community, the fact that forty-five percent of all homicides occurring are at the hands of either a previous or current intimate partner of the victim is glaring. Take the case of John, for instance. John is a thirty-two year old white male. He has a high school diploma and works as a car mechanic. He has a long history of and has been convicted of domestic violence against his wife, Jane. Jane is a thirty year old white female who has been married to John for eleven years. They met in high school and Jane has never dated anyone else. Jane has a high school diploma and does not work outside of the home. John and Jane live in Dallas, Texas with their two daughters aged seven and three. John is currently being arraigned for six counts of murder. He allegedly killed six members of Jane’s family while he was in a rage searching for Jane, who had recently gathered the strength to leave John. Jane had a restraining order at the time alleging that when she left John, he said that if she left, he would kill her and their two daughters. Her mother, one of the deceased, had also petitioned the courts for a restraining order alleging John had choked her and threatened to kill her and others in her family a week earlier when she refused to tell him where Jane was. Jane’s mother did not have a restraining order against John at the time of her death. John allegedly went over to Jane’s sister’s house with a pistol and asked where Jane was. When Jane’s mother said they would not tell him, John shot her in the head. She died instantly. Then, John shot both of Jane’s nephews in an effort to coerce Jane’s sister and brother-in-law into telling him where Jane and his two children were and then killed Jane’s sister and brother-in-law. He was arrested less than a block away from Jane’s grandparent’s home where Jane was staying.

When assessing Jane’s case of intimate partner violence, we see a history of violence that goes back ten years. Jane stated that John started abusing her during their first year of marriage. He was also psychologically abusive by controlling her behavior and constantly degrading her. He also forced Jane to engage in sexual acts with him regularly. Jane stated although she tried to hide the abuse from her children, John would frequently degrade her in front of the children. Once, she said she was forced to perform sexual acts while the children were in the same room sleeping. She stated she stayed with John because “who else would have her?” She finally left John for the last time when he hit her seven year old daughter. She obtained a restraining order thirty days before the death of her family.

Assessment of Case

On a micro level, Jane was isolated from her family. She was constantly degraded and humiliated. Her shame did not allow her to be open with anyone about the consistent abuse she faced at home. Jane’s sense of self and well-being was eviscerated during the abuse. She did not think she was worth any better than what she was getting from John and thus suffered years of abuse. Coercive control is thought by some to be the defining feature of intimate partner violence (Howard et. al, 2013). After John allegedly murdered Jane’s family members, she now has feelings of guilt on top of the other issues she was already dealing with. According to the U.S. National Library of Medicine and the National Institutes of Health, the long-term effects on Jane’s physical, emotional, mental, and economic well-being can be affected. Jane’s injuries can cause her reproductive and sexual health issues. John’s constant verbal abuse could have affected Jane in ways that she does not even realize. She may think that the verbal abuse was not as bad as it was. If she accepts any part of John’s abusive behavior as normal, she is at high risk of becoming a victim again in other intimate relationship (Kaur & Garg, 2008).

On a mezzo level, we think of the effect on Jane’s two daughters. They repeatedly saw their father abusing their mother. Children of abused women are at a higher risk for suicide, drug and alcohol abuse, depression, developmental delays, attention problems, and many other behavioral and emotional difficulties (Bancroft, Lundy, Ritchie, Daniel, Silverman & Jay G., 2012). They are also more likely to be involved in violent behaviors. They are more likely to either be a perpetrator or victim of domestic violence themselves as an adult (Bancroft et. al., 2012).

In John’s case, there is apparent upset on a macro level. The murders of family members of the abused are not the norm, but are becoming more frequent according to the CDC (Breiding, et. al, 2011). During the years of abuse, Jane was isolated from her family, but they were more than likely aware that abuse was occurring even if they did not realize the extent of the abuse. Feeling helpless in these circumstances are frustrating and overwhelming. Referring to the statistics stated earlier, a safe assumption would be that everyone living in the United States knows someone who is currently or has previously been in an abusive relationship. Women are seen as weak and vulnerable by society (Kaur & Garg, 2008). Because of this view, even if society disagrees with violence against women both inside and out of the household, it has become accepted as something that just happens to women.

Ethical and Value Issues

As a social worker working with victims of intimate partner violence, there are a variety of ethical issues and value conflict that could occur. In Jane’s case, why would she stay and allow her children to be exposed to violence year after year? My values state that a child’s physical and emotional well-being should always be a high priority. Jane had a number of reasons to stay and without taking away her right and determination to make her own choice, a social worker’s responsibility is to protect and advocate for people that cannot do so.

This ethical dilemma pits self determination against the well-being of the children. Legally, social workers have an obligation to protect individuals from harm if they can by reporting the abuse to law enforcement individuals. Towards the end of Jane’s story, it is easy to see the children are in imminent danger. It is not as easy to see that in the years prior, however. When the abuse was focused on Jane, if she had wanted to stay and not press charges against her husband, there is not very much that could have been done. The state can press charges on her behalf but it is hard to prove domestic violence if the victim does not speak out against her abuser.

Policy Issues

Legally speaking women’s rights in a marriage have come a long way from where we started. Being married was actually an exemption stated in the criminalization of rape until the 1993 here in America. This was based on the English common law stating that when women were married, they gave up themselves to their husbands and that cannot be retracted as long as the two people remain married. The idea of society was what happened inside of a home was the personal business of the family.

Although we have progress in the United States, there is still the problem of one of every four women being the victim of severe violence within their home. As with the case of Jane, women who receive a restraining order may not be fully protected from their abuser. It is true that Jane did not perish at the hands of her abuser, but six members of her family was shot because in the state of Texas, where she lives, it is still legal for a person with a restraining order to own and carry a gun. Obviously, if a person wants to hurt someone bad enough, there is no stopping them, but according to womanslaw.org, John was still able to own and legally carry a gun during this volatile time obviously exacerbated the situation (2013).

Conclusion

Intimate relationship violence is a widespread problem that is not limited by race, religion, ethnicity, education level, or sex (Baker, 2010). Even though this crime is so far reaching, it is still referred to as the “hidden crime” because victims suffer in silence. Initially, intimate relationship violence affects the individuals and family that are experiencing it, but over time, the entire community is affected by the violence. To grow up in such a war zone or to suffer as Jane did is unimaginable to me. To not be able to help every Jane out there would be morally trying for me because it is human nature to protect and nurture. No one wants to see a situation like Jane’s continue for her and her children. To further prevent these situations, we need to address the policy that we have in place to prevent it. If violence is so widespread within our homes across America, we need to wage a war on the violence. Enact harsher penalties. Make it unacceptable to abuse a partner. The challenge to this is the secrecy behind intimate relationship violence. All of these policies sound good but until we as a society begin looking at intimate relationship violence as something that is unacceptable, we will continue having the problem that we do.

References

Baker, L. M. (2010).Counseling Christian Women on How to Deal with Domestic Violence. Bowen Hills, Qld: Australian Academic Press.

Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2011). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization — national intimate partner and sexual violence survey, United States, 2011. Retrieved November 19, 2014, from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm?s_cid=ss6308a1_e

Howard, L., Agnew-Davies, R., Feder, G., & Howard, L. (2013).Domestic Violence and Mental Health. London: RCPsych Publications.

Kaur, R., & Garg, S. (n.d.). Addressing domestic violence against women: An unfinished agenda. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784629/

National intimate partner and sexual violence survey—2010 summary report [Fact sheet]. (2011). Retrieved November 18, 2014, from http://www.cdc.gov/violenceprevention/nisvs/ summary_reports.html

State law overview [Fact sheet]. (n.d.). Retrieved November 19, 2014, from http://www.womenslaw.org/laws_state_type.php?statelaw_name=State Law Overview&state_code=TX

Whitaker, D. J., & Reese, L. (Eds.). (2007). Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC’s Demonstration Projects [Lecture notes]. Retrieved November 18, 2014, from http://stacks.cdc.gov/view/cdc/11488/cdc_11488_DS1.pdf

The purpose of this paper was to interview an occupational therapist who is a leader in mental health and discuss their thoughts on being a leader and their work as a mental health occupational therapist. This paper maybe added to an ebook that will act as a practical resource of best practices in mental health OT practice and leadership for students and new graduates in the field of occupational therapy. This ebook will ask act as an inspirational resource package for occupational therapy students and clinicians who are interested in mental health.

The OT leader that was chosen for this paper was Jenifer Kim, an occupational therapist working at the Centre for Addiction and Mental Health (CAMH). Jenifer Kim has worked an employment specialist in the Learning Employment Advocacy Recreation Network (LEARN). LEARN offers a wide range of services and works to integrate clients who have had a first episode of psychosis into community life through social, educational and vocational opportunities. In this role, Jenifer primarily worked with youths recovering from first episode psychosis and provided vocational training and support for these individuals. These supports include career exploration, vocational assessments, a range of structured and unstructured vocational activities (see appendix for more information about these activities), emotional support, monitoring and on going support. Jenifer acted as their main support system and assisted them in a number of activities which helped them explore, developed, and achieved their employment goals. Therefore, Jenifer was able to help these youths recovering from first episode psychosis directly by providing them one on one support.

Jenifer is currently undertaking a new role where she is working with employers and recruiters to develop new and exciting employment opportunities for individuals with mental health issues. In this role, Jenifer provides support and education to employers and recruiters about the specific needs and the importance of employment to people with mental health issues. Employment is one of the determinants to health and studies have shown that higher income and social status are linked to better health.

Jenifer is a leader in this area because she recognizes the importance of employment for these individuals and is raising awareness of mental health issues and how employers can support these individual in the work environment. Therefore, Jenifer is acting as a bridge connecting employers with individuals with mental health issues. Jenifer has made an impacted in mental illness at both the individual and societal level and will continue to advocate for individuals with mental health issues until their needs are met.

Jenifer thoughts on Leadership

Jenifer Kim is a leader in helping individuals with mental illness find and maintain meaningful employment. She believes a good mental health leader must demonstrate character and acts with personal integrity. To be an effective leader one must demonstrate values and ethics in personal behaviors and incorporates these values and ethics into their practice. A good leader acts with the courage of his/her convictions and are open with their employees. Leaders must be able to understand themselves and their employees to foster the development of others and the organization. Leaders must model honesty, fairness, transparency and show humility, they must act in the interest of both the organization and their employees and not for their own personal gain.

Another important trait of being a good leader is staying motivated. A leader definitely needs to be motivated; those who are not motivated will seem unenthusiastic about their work, which may prevent them from developing a strong therapeutic relationship with their clients. Jenifer is motivated intrinsically and receives a great deal of satisfaction when she is able to help her clients achieve their vocational goals. Jenifer believes it is important for her to stay motivated because her clients depend on her to help them achieve their vocational goals. A motivated leader can have a profound impact on a client’s performance, if he or she can motivate and keep the client highly motivated at all times.

Jenifer stays motivated by keeping updated on the latest trends in occupational therapy and mental health and is member of an international group that discuses mental health polices related to employment. Jenifer also states that her passion for mental health helps keep her motivated. Her passion for mental health started when she was involved in a work study with Bonnie Kirsh, a professor at the University of Toronto, who specializes in community and work integration for persons with mental illnesses.

Leadership is centrally concerned with people and Jenifer states that one of the challenges that can arise when working with clients is the power differential between herself and her clients. The relationship between the client and occupational therapist is by definition an unequal relationship, which results in a power imbalance in favor of the occupational therapist. This is due to the occupational therapist’s position of authority and professional knowledge in relation to the client’s health status, vulnerability, and unique circumstances. The power in the relationship may also results from recommendations made by the occupational therapist and their influence on possible benefits the client may or may not receive.

Jenifer feels that as occupational therapists we must be responsible for anticipating the boundaries that exist with our clients, as well as setting and managing these boundaries, and practice in a manner which establishes and preserves the client’s trust. Jenifer uses reflective practice and acknowledges the issues of power and control to anticipate and minimize the power differential between herself and her clients. Jenifer states that using a client-centred approach may also help minimize the power differential by taking the client’s goals and needs into consideration when developing a treatment plans.

Another challenge that Jenifer faces in her practice is gaining the commitment and acceptance from her clients. Jenifer gains commitment from her clients by helping them develop their own vocational goals. Jenifer states that clients who have identified their own goal will be more likely to stay committed to the program because the goals are meaningful and important to the client. Therefore, we must find ways to involve clients in the goal formation stage and collaborate with the client to develop appropriate goals. By collaborating with the client, Jenifer is able to establish a sense of cooperation and unity for goal attainment. Jenifer encourages ideas and input from her clients and values their contributions in the goal formation process.

Jenifer recalls a story about a client that she helped successfully return to work. The client was a young woman who experienced a first episode of psychosis. This client expressed interest in returning to work and was referred to Jenifer from CAMH. Jenifer and her client worked collaboratively to develop vocational objectives such as improving the client’s interview skills and resume. After achieving these objectives, Jenifer was able to find her client an employment opportunity as a clerk at a local supermarket. Once her client started her new job, Jenifer continued to provide support to her client and her client’s employer. The employer would occasionally call Jenifer when there was a situation with the client and Jenifer would offer advice and support to manage this client’s issues. The employer really understood that the client was a person with a mental illness and was able to see beyond the mental illness. Jenifer states that this employer was very supportive and was instrumental in helping this client maintain employment. Jenifer believes that many employers want to help others, but are unsure or don’t have the knowledge needed to aid these individuals in achieving their employment needs. Jenifer provides the support and education that these employer need to help individuals with mental illness find and maintain meaningful employment.

However, even with the proper supports and education, not all stories end with a happy ending. Jenifer remembers one client where she was unable to help them return to work. The client was a young male who experienced a first episode of psychosis and was referred to Jenifer from CAMH. This client expressed interest in finding work and Jenifer was able to help this individual find an employment opportunity at a supermarket. Jenifer noted that this client was very social, presented very well and was well liked by others around him. However, after the first week on the job, the client stopped showing up for work. The employer gave this client numerous opportunities because the employer really liked this client. Unfortunately, the client never returned to work and Jenifer was forced to terminate the client’s employment.

When asked if there was anything that you would do differently in this situation, Jenifer replied no, because in this situation the client expressed interested in this particular job and was very excited about this employment opportunity. But for some reason the client no longer wanted to go to work and there really were no signs or indication as to why the client decided not to return to work. Sometimes a number of factors can fall outside your control; you must deal with these difficult setbacks and learn from your failures. You must be strong in the face of failure and to continually work towards improving your skills as a clinician.

Individual placement and support model (IPS)a use CPPF (enter/initiate, set the stage, assess/evaluate, agree on objectives and plan, implement plan, monitor/modify, evaluate outcome, conclude, exit)

Using the Individual Placement and Support (IPS) model, Jenifer Kim has helped individuals with mental illness find and maintain employment. Jenifer likes the practical approach of the IPS model and how it helps direct her through the various steps need to help her clients achieve their employment goals. She feels that the IPS model creates a very client-centered approach and it makes it so much easier for clients to be successful. Jenifer thinks the IPS model has been successful at CAMH because of how they integrated their health care team into the program; this makes it really simple for the client because they can meet with all their mental health professionals in one place.

The IPS was developed from the supportive employment model and is widely used as an employment model for people with mental illness in the United States. There is significant body of literature that supports the effectiveness of the IPS model. It has been extensively researched and found to be effective at achieving integrated community employment for persons with mental illness.

The IPS model is based on several defining features including competitive employment, a zero-exclusion policy, rapid job search, the integration of mental health and rehabilitation services on a single team, consumer preferences as the basis of employment, and individualized support of any needed duration.

Competitive employment is the main goal of IPS. Employment specialists help clients obtain competitive employment that is available to anyone in the community and pays at least minimum wage. The focus is always on jobs that are in integrated work settings, rather than on intermediate activities or sheltered work experiences because low expectations lead to poor outcomes. Competitive employment, at least part-time, is a realistic goal for almost everyone who desires it.

The IPS model promotes a zero exclusion policy. An important component of the IPS is the philosophy that anyone with a psychiatric disability who expresses interest in competitive employment is eligible regardless of their diagnosis, symptoms, skill level, history of substance abuse, or other criteria that have been used by professions to exclude people from employment services. The client ultimately determines if and when to participate and does not have to be deemed “work ready” in order to receive these services. Clients who believe they are ready for work are often able to overcome these and other barriers.

A rapid job search is also utilized when implementing the IPS model. In this model, lengthy prevocational assessment, evaluation, training, practice and preparation will not be used to prepare the client for work. Instead, a competitive job will be sought and that position will be used to assess an individual’s ongoing support needs. Typically, the employment specialist or the client begins contacting employers about jobs within one month of starting to work together. Again, the job plan, the pace of searching for a job, and the method of finding a job are based on the individual’s choices.

Supported employment is integrated with mental health and rehabilitation services. Rehabilitation is considered an essential component of mental health treatment rather than a separate service. Employment specialists join and meet regularly with the mental health treatment team to insure that services are seamless and coordinated. Team members develop a consistent plan in close collaboration with clients as part of integrated services. Communication between all practitioners is critical in help clients achieve their employment goals.

A focus on consumer’s preference to ensure the job fits the individual. Clients are assisted in finding jobs that match their preferences, values, skills and goals rather than jobs that are available in a pool. If the employment specialist is unable to find a compatible match between the client and the job, it can greatly affect the client’s job satisfaction, tenure and success.

Individual supports are not time-limited. Individualized supports provided by team members cater to each client’s specific needs and these follow-along supports continue for a time that fits the individual, rather than terminating at a set point after starting a job.

Applying the Canadian Practice Process Framework to Practice

Enter/initiate: Clients are referred to Jenifer from CAMH, this is important because it emphasizes the integration of the client’s mental health treatment team and the employment specialist. In this stage, Jenifer works collaboratively with the client to help identify the vocational challenges and needs of the client. Jenifer and the client must then decide whether to continue or not with the program. When making this decision the client must acknowledge that they understand and consent to the agreed upon plan and Jenifer has to reflect on her own experience and determine if she has the knowledge and skills to take on the referral.

Set the stage: In this stage, Jenifer develops rapport with the client and engages them in discussions about their values, beliefs, assumptions, and uses this opportunity to establish ground rules and expectations. Jenifer works with the client to determine how they can work together and start to identify vocational goals.

Assess/evaluate: Jenifer does not use any prevocational assessments or evaluations as it may discourage client who want competitive employment and is not the goal of the IPS model. However, Jenifer works with her clients to identify their unique preferences in order to find employment opportunities that match their specific needs.

Agree on objectives and plan: In this stage, Jenifer encourages the client to participate and power-share as much as possible to help minimize the power differential between her and her clients. She collaborates with her clients to identify and prioritize vocational goals and a plan on how to achieve these goals.

Implement the plan: Jenifer implements the agreed upon plan by coaching and supporting clients to help them achieve their vocational goals. In order to achieve a client’s vocational goals, Jenifer may need to assist clients in preparing for an interviewing, resume writing, job search and career exploration. Jenifer may also advocate for the client with the employer to identify ways to help the client maintain work and cope with the symptoms.

Monitor and modify: Jenifer would often follow up with her client and their employers to review and monitor the client’s progress at the workplace. Afterwards, Jenifer would provide support to both her client and their employers as needed, but states that many clients are able to manage their new role with very little support.

Evaluate outcome: Jenifer says the main goal for her clients are to find meaningful employment opportunities. Jenifer is responsible for helping her client’s meet this goal and assists them in a number of ways to ensure that they are successful in achieving their goal. However, at CAMH the only outcome measure that they use is the number of clients that successfully achieve competitive employment. They do not track or measure job tenure or how much support is required by each client.

Conclude/exit: Since the IPS model states that individualized supports are not time specific, Jenifer offers support to her clients even after they have successfully achieved competitive employment. Jenifer believes that this is not always realistic and may cause issues with workload balance, but feels that it is necessary and important part in helping her clients maintain employment.

I was inspired by Jenifer’s passion for helping others and the commitment she has made to helping those suffering with mental illness. This interview helped me realize the effects of unemployment on an individual’s health and the value of occupational therapist in advocating for individuals with mental health issues.

Another important message that Jenifer conveyed in one of her stories was to stay positive, even when faced with a difficult situation. We may not always succeed, but we are always given an opportunity to learn, even from our failures. We must be resilient even in the face of failure and must constantly work towards improving our skills because our clients are depending on us.

Jenifer uses mock interviews to help her client practice answering questions. Jenifer would take on the role of the recruiter and attempts to make the interview as realistic as possible by asking questions that are typically asked in an interview. After the interview is over, Jenifer would provide constructive feedback on both the client’s verbal and non-verbal communication skills and strategies on how to improve.

Jenifer also offers some advice when preparing your clients for an interview. Preparation is an important step that is overlooked and often leads to poor results. To prepare for an interview, Jenifer recommends that you learn about the organization, review the job qualifications and your resume, practice an interview with a friend and most importantly arrive early for your interview. When you are in the interview try to stay relaxed and answer each question concisely and promptly. Try to use proper English and avoid using slang at all times, also be enthusiastic and use body language to show interest. Lastly, remember to thank the interviewer when you leave and follow-up with a letter to thanks the interviewers for taking the time to interview you.

Jenifer says that with very little effort, you can create a resume that makes you stand out as a strong candidate for a job. Jenifer offers the following tips when writing your resume, always spell-check your resume, make sure that your resume has proper punctuation, grammar, and spelling. You should always include a cover letter with your resume; this allows you a chance to express why you believe you’re the best candidate for the job. Lastly avoid using paragraphs or long sentences, try using bullet points and action words to condense and summarize your sentences.

Jenifer helps her client explore different career opportunities to help find jobs which fits their interest, skills and abilities. One of the exercises that Jenifer uses to help her clients explore different career opportunities is through job research. This gives the client specific information about the job such as the requirements and qualifications required for the job. The client can then evaluate if this job meets their unique interest, skills and abilities. If the client expresses interest in the job, but does not have the skills and abilities to perform the job, Jenifer would help the client make vocational goals to work towards achieving job. Jenifer also uses different career exploration sites to help identify employment opportunities that fit her client’s individual preferences. A list of these sites can be found in Appendix D.

Introduction

Various intervention strategies have been implemented to try and reduce the risk of sexual abuse in those persons with a learning disability. There is a general consensus that education programmes directed towards the perpetrator are least effective and that techniques aimed at fostering assertiveness and communication in the learning disabled adult are the best preventative measures. In this review I found there to be a significant lack of research that measured the effectiveness of these interventions and further support and investigation is needed into researching these intervention strategies, advocacy and community awareness studies.

Methods of obtaining research

In recent years the number of articles on ‘sexual abuse in people with a disability’ found in databases such as Medline and Proquest have increased although there is still a considerable lack of quality statistically significant research. Political and media exposure has unsurfaced the need for this group to be protected. For example, the European ‘Valuing People’ agenda unsurfaced serious inequities.³ Some of the most in-depth studies come from research in which women with learning disabilities have been interviewed directly about their experiences including the ground breaking work of Michelle McArthy.³

A number of factors can limit the disclosure of abuse and lead to an underestimation of the extent of this problem. For example, an individual that has had limited exposure to prevention programs and sexuality education may not recognise the abusive nature of sexual contact they have experienced.⁴ Disclosure may also be inhibited by feelings of confusion, guilt or denial especially if the abuse occurred from a care-giver or a person that was trusted by the victim.⁴

This paper aims to criticize interventions and assess the most appropriate methods used to help educate those with learning disabilities about sexual abuse and foster prevention rather than looking at ways to support post-abuse. I haven’t addressed the issue on whether sterilization is appropriate in this review as it steers away from the autonomy of the mentally disabled adult and it is more appropriate to concentrate on education as a tool of prevention and looking at the efficacy of training methods.

Method of obtaining papers for literature review

All papers in ‘British Journal of Social Work’, Medline via PubMed and Medline via ProQest from 1995 – 2005. Keywords used were ‘learning disability’, ‘sexual abuse’, ‘mental handicap’, ‘prevention’, ‘intellectual disability’, ‘consent sexual relationships’, ‘learning disabilities’, ‘sexual act’, ‘sexual malpractice’. Search terms were grouped as follows:- ‘education, sexual abuse, disabled’, ‘education, sexual abuse, handicap’, ‘education, sexual, disabled’, ‘assertiveness training, sexuality, disabled’ and ‘sexuality, training, mentally disabled.’ Papers found that concentrated on adults only were used and those articles found on sexual abuse pertaining to children were omitted apart from one paper that examines the use of a Computer-Based Safety Programme that could be useful in educating mentally disabled adults. Papers that addressed interventions used to prevent abuse from occurring were included in the review.

Definitions

A ‘learning disability’ is defined as “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the reduced ability to listen, think, speak, read, write, spell, or to do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia.”² Disorders not included are “learning problems that are primarily the result of visual, hearing, or motor disabilities or mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage.”² It is not necessarily the person’s learning disability that makes them more vulnerable to the sexual abuse as to the situation they are placed in so that if we took a person of normal mental capacity and placed them in the same environment the risk of sexual abuse for that person would be greater as well.

Sexual Abuse refers to any form of sexual contact to a vulnerable party and violates the victim’s rights as they are not fully aware of the situation. Sexual exploitation is evident when done by anyone in a position of trust or authority towards a person or where the victim has a relationship of dependency with the perpetrator.

There are various definitions of sexual abuse used in the literature and widely diverging definitions tend to be used in studies of adults with intellectual disabilities.⁵ Brown and Turk (1992) also distinguished between non-contact and contact abuse. Another definition of sexual abuse was “any sexual contact which is unwanted and/or unenjoyed by one partner and is for the sexual gratification of the other”.⁶ This is still ambiguous as sometimes sexual contact is misunderstood and it could still be enjoyed it is just that the victim is unaware of what the full extent of the act means. I believe that a better definition of sexual abuse is any sexual act performed on a victim in a position of vulnerability. That is one party is not fully aware of the act being performed and there is an imbalance in power. Could this then exclude those persons with an intellectual disability from having a relationship with a person of normal mental capacity? Perhaps, if there is balance in the relationship and the learning disabled adult can make decisions in other aspects of the relationship this would be a more equally distributed balance of power and this person may be able to fully make decisions on relationships at their own accord. There are varying degrees of mental handicap and this makes research difficult as ethical dilemmas on whether there is full consent and understanding of sexual contact can be ambiguous. However, there are also clear cut cases such as when a disabled person is institutionalized or the primary care-giver is the perpetrator. For the purpose of this review it is important to move more onto preventing the abuse in those that are vulnerable and critiquing methods used to empower those with disabilities rather than focus on the definition of abuse. Protection of those that are in a more vulnerable position and empowerment of individuals already victims of abuse should be fore-front in the social literature.

Prevalence of Sexual Abuse

There is an increase in the prevalence of sexual abuse in children with learning disabilities. A study conducted by the US National Center on Child Abuse and neglect (1993) found that caregivers abused children with disabilities 1.7 times more than children without disabilities.¹¹ The violation of children can foster the development of low self-esteem and lead onto abuse into their adult lives. A research study by Sobsey found that the risk estimate of abuse of people with disabilities may be as high as an increase of five times greater than the risk for those that aren’t disabled.⁸ A study by Zemp (2002) found that 64% of female and 50% of male participants were sexually exploited and that disabled room mates were the predominant group of perpetrators for the male and third important for the female participants in the study.⁹

The statistics in the current literature does vary and “the wide variation in the figures is due to differences of abuse, the differences in the populations sampled and differences in research methods.”⁷

Vulnerability

For children with disabilities the risk factors for sexual child abuse are increased. A child with a learning disorder has more difficulty in understanding and communicating and has an increased level of vulnerability. As they are unable to understand tasks as well as other normal children of the same age they are often brought up with low self-esteem as their care givers perform more of the tasks for them than they would for other children. This also leads onto a greater vulnerability and increased risk of sexual abuse than what is seen in children of the same age and normal development.¹ This low self-esteem can continue into adulthood resulting in the learning disabled adult also possessing low-self esteem and greater risk factors of vulnerability in comparison to other adults.

For those adults with intellectual disabilities there is a difficult balance to be met between empowering the individual to make their own sexual choices and to be leading more of a normal life and to claim their sexual rights and protect them from sexual abuse.⁴ Murphy et al (2004) suggests that services should be guided as to whether a person has the capacity to make their own sexual choices, however, the ability to assess this capacity to consent hasn’t been clearly defined. It is obvious that a caregiver would be taking advantage of their position of trust and it would be defined as sexual abuse. However, relationships outside this sphere are much more difficult to assess. Sexual acts between two adults of diminished mental capacity for instance and with adults outside the care-giving role. A more appropriate definition in this case may be “where a person is used by another in order to satisfy certain needs without being informed or giving consent”. This focus is more on the perpetrator as satisfying their sexual needs while the victim does not gain anything by the relationship so the victim is in a position of vulnerability and may not be able to represent themselves.

Review of Intervention Techniques as a method of preventing Sexual Abuse in the learning disabled adult

Lobbying the Government and changes to policy

The manner in which sexual abuse is dealt with in a community reflects the way disabled people are regarded by in society. A report was released in 2004 that spoke about the changes the government is try to initiate as part of the ‘Valuing people: Moving Forward Together’ project.¹² According to the Health and Social Care Act 2001, an annual report must be given to Parliament on learning disability. The Leaning Disability Task Force report for 2004 was called ‘Rights, Independence and inclusion’ and addressed the Sexual Offences Bill. Part of the Bill that talks about capacity and consent was changed to reflect the rights of people with learning disabilities to a full sexual life. The British Home Office is now working on helping others understand the Sexual Offences Act fully. Change has taken place and inclusion in helping to form government policy can be considered ‘morally and ethically the most appropriate form of education’. The acceptance of the disabled person as an individual is important not only at school level but right through to parliament.

Behavior modification in the learning disabled adult; empowering the victim

It has been suggested that programs aimed at re-educating the perpetrator have had little success and interventions aimed at modifying the behavior of the victim have a much greater success at reducing the risk of sexual abuse in adults with learning disabilities (Bruder et al, 2005). To be able to protect themselves against perpetrators, the adult with learning disabilities needs to learn how to assess whether a situation is inappropriate, must have the assertiveness to say no and seek help and to report the event. The eleven papers chosen for review are listed in Table 1 in the Appendix.

Burke et al, 1998, suggested that one way a care provider can lower the risk of sexual abuse in a learning disabled adult is to help provide functional communication skills. The adult may use their own form of communication whether this be symbols or words and their form of communication should be encouraged so that they are able to express their needs. Communication is empowering to the individual and enables them to be able to get a message to their Caregiver. Often those with intellectual disabilities are hard to understand and the carer should ask themselves if they have tried to read non-verbal behavior or begun to establish an alternative form of communication. Burke et al, 1998, also suggested that it was the Carer’s role to provide sexual education to limit the risk of abuse. This education then becomes a way of communicating the common language of sexual health. It is important that the individual understands what appropriate sexual behavior is and understands how to trust their feelings by ‘validating, rather than dismissing or minimizing, them’. The person also needs to be made aware of the appropriate forms of touch so that they can maintain and understand personal boundaries. Burke has suggested that these adults need to have a plan for when somebody doesn’t obey their personal boundary rules so that they are able to get themselves out of the situation and avoid sexual abuse altogether. It doesn’t mean being afraid of strangers but learning how to remain safe. Burke has suggested ways of empowering the learning disabled adult and reducing the risk of sexual abuse. These methods may not be useful when the caregiver is the perpetrator and it could be suggested that a teacher outside the carer role provide this type of education so that the individual is then able to recognise when a person in close association with them has crossed personal boundaries. It does not give ways to avoid abuse altogether and aims to reduce the risk when the person knows what types of behavior is inappropriate and requires reporting. The main downfall of Burke’s research was that she didn’t quantitatively measure the reduction in risk of introducing a communication skills program so further research is needed to assess whether the implementing education on sexuality and encouraging communication strategies actually lower the incidence of sexual abuse.

Earle, (2001), agreed that those with learning disabilities are especially vulnerable to sexual abuse due to the disabled person’s dependent environment, difficulty in articulating their abuse and understanding when abuse has taken place. She suggested that ‘whilst disabled people have the right to be protected from sexual abuse and exploitation, it could be argued that a concern with this risk should not be used as a smokescreen to deny disabled people their sexual identity.’ Earle also postulated that by not discussing sexuality and creating an atmosphere where ‘sexuality is taboo’, this may in fact increase the incidence or worsen the experience of the sexual abuse. Earle also found that nurses tended to think of their disabled patients as asexual and in denial did not address the sexual needs of the patient at all. She also found that disabled individuals have been unable to access information and services on sexuality. Earle admits in this paper that ‘the purpose of this paper has not been to provide answers’,’ nor has it been possible to explore all of these issues in depth’ but to show that the issue of sexuality should be given greater emphasis in a holistic health care framework. The missing link is whether empowering the disabled individual to make their own sexual choices and discover their own sexual identity actually reduces the incidence of sexual abuse.

Teaching refusal skills to sexually active adolescents was introduced in a study by Warzak et al (1990). The training was given to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays were used to help teach effective strategies using ‘the who, what, when and where of situations which resulted in unwanted sexual intercourse.’ The skillfulness and effectiveness of the subjects’ refusal skills were judged to be improved as a result of the training. This study did not have a control group. The research did have a long-term follow up after 12 months and this showed a decrease in sexual activity for each girl.

Singer (1996) introduced a programme to seven intellectually disabled adults that lived in a residential group home. The programme consisted of weekly sessions of assertiveness training, group exercises, role-plays and information giving. The participants had previously been subjected to verbal, physical and emotional abuse by previous members of staff and Singer aimed to teach them how to respond appropriately and assertively in situations of abuse. The trainers assessed each client individually to evaluate how they would initially act in a situation of abuse and also measured their social behavior, assertiveness skills, use of verbal and non-verbal behavior and reading and writing skills. They were given ratings on assertiveness in each role play and it was found that after the training was implemented, the participants did not show improvements in scores where authority figures were the perpetrators but that an overall general improvement in assertiveness scores was established. The staff did comment that the residents showed an increase in confidence, communication and positive attitude post-intervention. This type of study would be great implemented on a larger scale. The difficulty in establishing whether this research has been effective is due to the small numbers. The long-term effects of the trainings are also unknown as there has not been any follow up study. The research study is lacking statistical analysis and a control group so it is difficult to assess whether the trainings actually reduced the risk of further sexual abuse.

Mazzucchelli (2001) introduced a ‘Feel Safe pilot study of protective behaviors programme for people with intellectual disability.’ The programme was designed to increase personal safety skills by teaching ways of recognizing unsafe situations and developing a range of coping and problem-solving skills. This research study implemented the use of a control group. There were ten participants in each group. This intervention program was originally developed in the 1970s for children and was then used in this research study with learning disabled adults. Another main focus of the training was “Nothing is so awful that we can’t talk to someone about it.” The training programme involved the research group participating in role-plays and then evaluating how they behaved to promote self-regulation of behavior as well as using the role-plays in real, everyday situations. Questionnaires were used to evaluate quality of life and protective behavior skills and conducted by assessors that weren’t involved in delivery of the programme. The experimental group did show a statistically significant increase in performance on the Behavioral Skills Evaluation in comparison to the control group from pre-test to follow-up suggesting that the programme did improve favorable behavioral skills but did not improve the participant’s quality of life. The six-week follow up may have been too soon to appropriately evaluate any change in quality of life. Mazzucchelli also had a small number of participants which led to difficulties in showing statistical significance for the research. The themes which showed the greatest increase from pre-test to post-test were “we all have the right to feel safe”, “it is acceptable to be non-compliant or ‘break rules’ during an emergency and self-assertion skills.

The researchers Lee et al (2001), examined the effectiveness of a computer-based safety programme for children with severe learning difficulties that could be implemented into an adult training programme. Three groups were established. One group was offered the safety programme, one was a control and the third group was given the intervention programme much later in the study. All of the participants were tested for cognitive ability and knowledge of personal safety concepts pre-training. Two post-tests were conducted 1 week and 2 weeks after the safety programme. There were 18 candidates in the control group and 31 children in the experimental group. None of the schools had previously implemented formal personal safety training programmes although some of the teachers had started to discuss personal safety with their students. The computer programme went through role-plays illustrating types of behavior and the experimental group was divided into ‘less able’ and ‘more able’ depending on cognitive ability. The researchers used two interviews to establish the student’s perception of authority figures and their knowledge of personal safety. MANOVA analysis found authority to have an independent effect on the respondent’s safety scores and this authority awareness was independent of the participant’s cognitive ability. These researchers found that those involved in the safety programme have significantly improved their knowledge of safety concepts and maintained this increase in knowledge for 15 weeks. There was also a statistically significant result in those going through the programme for the skill of ‘being able to tell someone’ and the study illustrated that they would repeatedly tell someone even after being dismissed the first time and they could also provide a reason for this disclosure. The research showed that there was no significant increase in knowledge attained by the control group leaving these untrained students as potential targets by perpetrators. Lee et al (2001) also found that the increase in knowledge post-training was greater in the ‘more able’ group so that training may need to be repeated for those with lower cognitive ability. By the end of the programme all the students were able to produce a list of people that they would tell if they experienced an incident. The researchers also explored the importance of acknowledging authority issues when designing a personal safety programme. This research illustrates that learning disabled students can benefit from training programmes on personal safety. The implementation of these programmes with adults may prove beneficial.

Education of teachers, health care providers and caregivers

Howard-Barr et al (2005) explored the beliefs in teachers regarding sexuality training of mentally disabled students. The researchers also investigated the range of sexuality topics they would teach and their professional preparation. The participants in the study believed that sexual education should be taught, they rated their current delivery as inadequate and expressed that they needed much more preparation. The number of participants was moderate (n=494) although only 206 candidates actually returned the questionnaire resulting in a response rate of 42%. There were 36 sexuality topics presented and out of the top 6 most important skills, the concept of personal skills was rated the highest. Teachers of mentally disabled students rated personal skills topics such as finding help, assertiveness, communication and friendship more important than human development topics such as reproduction, anatomy and body image. Subjects such as masturbation, human sexual response and shared sexual behavior were the most neglected topics. The limitations of this study included the inability to assess the quality of teaching and whether the teacher was actually addressing any specific areas of the 36 topics. This research topic did not address the effectiveness of education as a risk reduction method for sexual abuse however it did examine the beliefs of the teachers in the type of topics covered in sexuality education of mentally disabled students. It also revealed a general feeling of professional inadequacy in this area.

Fronek et al (2005), conducted a research study that examined the effectiveness of a Sexuality Training Program for patients post-spinal cord injury. They found that there was evidence to support consideration of the client sexuality and a lack of training given to caregivers in this area. This study evaluated the attitudes of staff before and post-sexuality training. The researchers based the training on the Specific Suggestions and Intensive Therapy (PLISSIT) model. The sample group (n=89) was divided into a control group and experimental group randomly. A series of one-day workshops were conducted to the experimental group. Topics covered included identification of professional boundaries, limit setting, maintaining boundaries, development of sexual identity and case studies. This training programme was not focusing on the prevention of sexual abuse, rather the education of staff to being able to be open and teach their patients about sexuality. The staff assigned to the treatment group showed a significant improvement on all subscales of the KCAASS (Knowledge, Comfort, Approach and Attitudes towards Sexuality Scale) post-training and these changes were still significant three months later. In comparison, the control group did not show any significant changes on the KCAASS. Those patients suffering from spinal cord injury are not necessarily affected cognitively and may be only physically affected so this study is limited in assessing how sexuality training of staff could benefit the needs of people with a learning disability. The training was conducted over a one day period and a longer programme may be more beneficial to staff. There was a reporting bias shown by the control group as they were not assigned to receive training initially and the researchers believe that feelings of resentment and a tendency to over-estimate knowledge resulted from being assigned into the control group. Whether improvements can be maintained for longer periods of time (>3 months) is uncertain and refresher courses may be necessary. The research did not examine the effect this education has on the patient in improving their own sexual identity and further studies would be useful in examining whether this limits the risk of sexual abuse. The PLISSIT model has been widely used to implement staff training and sexuality rehabilitation interventions within various clinical disciplines and could be an effective model to use to train carers of mentally disabled people. This model also allows for staff involvement according to level of comfort, previous knowledge and counseling skills.

Community awareness

Rogow (1998) discusses the impact of different forms of abuse in two case studies and expresses the need for comprehensive preventative or pro-active intervention strategies. The author discusses the release of an education campaign that consists of a video, handbook, workshop series and public service announcements for broadcast media that is aimed as a preventative to educate people involved with disabled youth. These publications are not specifically addressing prevention of sexual abuse in mentally disabled persons although, these forms of media could be used to help foster community awareness of this subject. The effectiveness of these media releases has not yet been evaluated and requires research. The video and handbook is being supported by government and private agencies and made in co-operation with parents and organizations advocating for the rights of people with disabilities.

Advocacy

Leicester & Cooke (2002) expressed a need for further advocacy to those individuals to whom the giving of informed consent is difficult (individuals who are most likely to be among those labeled as having ‘severe learning disabilities’). These researchers also suggest that advocates, in representing other people, must attempt to work out what the learning disabled person would choose and not necessarily what they would choose. Advocates needs to have high levels of empathy and the ability to know when and how to set their own beliefs and values aside. Assessing the ability to use advocacy to reduce the risk of sexual abuse in learning disabled persons is yet to be researched.

Recommendations for social work practice at local level

There are several great projects currently in place that foster the empowerment of the learning disabled adult to help them protect themselves and also to be able to make their own choices about sexual relationships. For example, The Disability Pride Project explores avenues that promote safety and support by promoting awareness within the community and developing healthy sexuality workshops for people with disabilities.¹⁰

This group teaches community specific advocacy and self-advocacy skills, organizes workshops for personal attendants and institutions about sexuality in the lives of people with disabilities and creates opportunities for young women with disabilities to be mentored by older women with disabilities.¹⁰ These educational sessions could be implemented by Social Workers, carers and other educators internationally to foster empowerment in the learning disabled adult to help prevent abuse and instill confidence and responsibility in both the disabled adult and the caregivers. In this review I have critiqued papers that have researched the effectiveness of education of both the carer / teacher and the learning disabled adult and it is evident that there is an extreme lack of research in this area and there is a need for more statistically significant, large numbered studies that investigate the effectiveness of intervention strategies.

Conclusion

The studies on interventions used to prevent sexual abuse in those with a learning disability are limited. There is some suggestion from the research that advocacy and changes to policy will help to encourage greater understanding of learning disabled people in the community. Greater awareness can foster independence and boost self-esteem which may then lower the risk of sexual abuse in this minority group. Some of the research papers presented in this review have shown that intervention strategies such as improving communication skills in the learning disabled and education of both staff and carer may be beneficial. The implementation of behavioral strategies including role-plays may help the intellectually disabled person gain an increase in confidence, assertiveness and develop a strategic plan if placed in danger of a sexual predator. These training programmes could be introduced by the social worker or some other authority figure apart from the actual care-giver as there have been cases where the carer is actually the perpetrator of the abuse. More studies of greater numbers using both an experimental and control group are necessary to determine whether these intervention strategies will be successful at significantly reducing the risk of sexual abuse in the learning disabled adult. Although, an increase in confidence and assertiveness in these people would also be a great benefit so even if the studies are unable to show significant risk reduction of sexual abuse the training could positively influence other aspects of their lives.

References
Abuse of Children with Disabilities. NCFV. Public Health Agency of Canada. www.phac-aspc.gc.ca
http://curry.edschool.virginia.edu/sped/projects/ose/categories/ld.html#defin
Brown, H. 2004. A Rights-based Approach to Abuse of Women with Learning Disabilities. Tigard Learning Disability Review. Volt 9, Is 4, pp41-44.
Murphy, GH and O’Callaghan, A.2004. Capacity of adults with intellectual disabilities to consent to sexual relationships. Psychological Medicine, Volt 34, Is 7, pp 1347
Brown, H and Turk, V. 1992. Defining sexual abuse as it affects adults with learning disabilities. Mental Handicap Volt 20, pp 33-55.
McCarthy, M. 1993. Sexual experiences of women with learning disabilities in long stay hospitals. Sexuality and disability Volt 11, pp 277-286.
McCarthy, M and Thompson, D.1996. Sexual abuse by design: an examination of the issues in learning disabilities services. Disability and Society. Volt 2, pp 205-224.
Subset, D. 1994. Violence

Evaluate the evidence base for and against early intervention in the lives of children and families to forestall the development of Criminal behaviour.

Methods of early Intervention

After decades of rigorous study in the United States and across the Western world, a great deal is known about the early risk factors for offending. High impulsiveness, low attainment, criminal parents, parental conflict, and growing up in a deprived, high-crime neighbourhood are among the most important factors. ‘It is the accumulation of risk factors that characterises this much smaller group’s persistent extreme violence.’^[1] There is also a growing body of high quality scientific evidence on the effectiveness of early prevention programs designed to prevent children from embarking on a life of crime. Preschool intellectual enrichment, child skills training, parent management training, and home visiting programs are among the most effective early prevention programs. ^[2] Friedrich Losel, director of the Institute of Criminology at the University of Cambridge has researched that “Conduct problems often start by the age of five and about 40 per cent go on to become more serious and persistent as the child gets older. This is why it’s important to develop and implement measures to stop it relatively early.”^[3]

Therefore, assessing the risk factor behaviour before offending occurs or become persistent is imperative. The Youth Survey suggests that the most common age for first time offending is between the age of 11-12 for mainstream pupils and 10-11 for those that have been excluded. If someone has not committed an offence by the age of 14 they will generally not do so. An early onset of delinquency prior to age 13 years increases the risk of later serious, violent, and chronic offending by a factor of 2–3. Also child delinquents, compared to juveniles who start offending at a later age, tend to have longer delinquent careers.^[4] Rolf Loeber and David P Farrington advance that the protective factors in the individual, family, peer group, school, and neighbourhood affect the development of delinquency.^[5]

The risk factors that have been well researched are varied. ‘There is no easy link of cause and effect between the factors associated with youth crime and actual offending.’^[6] The risk factors may be counteracted by positive influences such as good parenting.

Notable risk factors include, being male; being brought up by a criminal parent or parents; living in a family with multiple problems; experiencing poor parenting and lack of supervision; poor discipline in the family and at school; playing truant or being excluded from school; associating with delinquent friends; and having siblings who offend. Research has illustrated that ‘two important influences are persistent school truancy and associating with offenders, but the single most important factor in explaining criminality is the quality of a young person’s home life, including parental supervision.’ ^[7]

The National Public Health Service for Wales issued an en evidence briefing so as to discuss interventions surrounding crime and the fear of crime in June 2005. The paper is as a result of studies relating to adult and juvenile offenders. As well as protecting against future criminal activity early intervention arguably promotes health. Building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and re structuring health services are thought to help prevent against crime also.^[8]

The family factor of risk concerns ideals such as poor parenting, family history of offending and family conflict. For families, Behavioural Parent Training for anti social child behaviour acts as an effective strategy to modify child anti social behaviour and improve parental skills. Parenting programmes provide parents with an opportunity to improve their skills in dealing with the behaviour that puts their child at risk of offending. They provide parents/carers with one-to-one advice as well as practical support in handling the behaviour of their child, setting appropriate boundaries and improving communication. Pre school children who fall within one or more of the risk categories should also be placed into day care, establishing a supportive environment for both the child and the parent. The outcome of this method of intervention appears to be increased employment, lower teenage pregnancy rates, higher social class status and decreased criminal behaviour in intervention population. Trials have established some weaknesses, but the potential population effective impact is very broad. To prevent youth violence specifically, it has been researched that interventions applied between the prenatal period and the age of six appear to be most effective. Community based programmes that target high risk behaviour is seen as beneficial. Family and parenting intervention for conduct disorders and delinquency for those aged between 10 and 17 years also have beneficial effects in decreasing criminal activity. High quality pre school supervision has been seen to decrease arrests and arrests specifically for drug dealing. Time spent on probation is also decreased in this way. It is a cost effective method of intervention ad can be implemented within pre school education and programmes within day care and nursery.^[9]

The School factor of risk flags up cases of low achievement, lack of attendance, lack of commitment, aggressive behaviour and bullying. Safer school’s partnerships provide a much focused approach to address the high level of crime and antisocial behaviour committed in and around schools in some areas – crime committed by and against children and young people. There are now 370 police officers based in selected schools in areas with high levels of street crime. This is a joint initiative between the Department for Education and Skills the Youth Justice Board and the Association of Chief Police Officers which aims to reduce criminality, antisocial behaviour and criminality.^[10] Academic and vocational interventions in order to educate those with a lesser capability than others are seen to be effective in reducing recidivism. Behavioural and skill orientated classes for those showing risk are among the most successful interventions to reduce crime and recidivism. To prevent offending, the Youth Justice Board set up schemes such as the Youth Inclusion programme. Under this programme young people who are engaged in crime or at risk of offending are identified by youth offending teams and the programme gives young people somewhere safe to go where they can learn new skills, take part in activities with others and get help with their education and careers guidance. Youth Inclusion and Support Panels aim to prevent antisocial behaviour and offending by 8 to 13-year-olds who are considered to be at high risk of offending. Panels are made up of a number of representatives of different agencies such as social services and health. The main emphasis of a panel’s work is to ensure that children and their families, at the earliest possible opportunity, can access mainstream public services. ^[11]

The community factor of risk revolves around community disorganisation, neglect and community tolerance of crime and drugs. The individual, personality factor of risk includes early problematic behaviours surrounding drugs and alcohol and the notion of criminally active friends. ^[12] Positive Activities for Young People provides a broad range of constructive activities for 8 to 19-year-olds at risk of social exclusion. It builds on the success of previous school holiday programmes such as the Youth Justice Board’s Splash and Connexions’ Summer Plus. The programme aims to reduce crime and to ensure that young people return to education, have opportunities to engage in new and constructive activities, and can mix with others from different backgrounds. This cross-government initiative aims to develop young people’s interests, talents and education, and engage them in community activities so they are less likely to commit crime. Activities based on arts, sport and culture take place both during the school holidays and out of school hours throughout the year. Positive Futures is a national sports-based social inclusion programme aimed at marginalised 10 to 19-year-olds in the most deprived areas. By engaging these young people in sport and other activities, Positive Futures aims to build relationships between responsible adults and young people based on mutual trust and respect, in order to create new opportunities for alternative lifestyles.^[13]

One method which many may overlook is the punishment of offenders once they have offended at whatever age. If a young person is convicted of an offence, there are a number of community and custodial sentences. The community sentences currently available include, Community Rehabilitation and Punishment Order, Supervision Order, Action Plan Order Attendance Sentence Order, Referral Order, Reparation Order, Fine, Conditional Discharge and Absolute Discharge. Young people can also be given an Intensive Supervision and Surveillance Programme as part of an order. ISSP is the most rigorous non-custodial intervention available for young offenders. It combines high levels of community-based surveillance with a comprehensive and sustained focus on tackling the factors that contribute to the young person’s offending behaviour. The programme targets the most active repeat young offenders, and those who commit the most serious crimes.^[14]Punishment does afford deterrent effects but it is no clear how much in cases of increased severity. As this is not always cost effective, this is one reason why possible alternatives should be considered

Although some of the methods I have just discussed are effective, the effects may be limited. For example, Behavioural Parent Training for anti social behaviour in children is a short term procedure and for long term sustainability it will require other methods to supplement the training. Changes within the environment and the community are also seen as a potential short term effect because it is proven that changes do reduce criminal activity and fear of crime but there is little information on whether this has been a long term deterrent. Cognitive behavioural multidimensional programmes to prevent youth violence can be effective but the main area of weakness within youth crime prevention is that the approaches for youth crime have not been well evaluated. Controlled studies are needed regarding diversion programmes, counselling and therapy in order to see their preventative quality. Family and group treatment has also worked in the short term but seems to decrease dramatically as time passes. If communities can build home visiting programmes to prevent crime, that are comprehensive, continuous and family focussed these are most likely to succeed long term. This is dependant on other services on offer in the community and the scope of the programmes facilitated. Physiological and social skill training of children is seen to prevent adolescent aggression but not for the duration. All those involved with a child’s upbringing are required to show them what is right and what is wrong and the consequences of their behaviour. This is seen as effective so as not to cause inadvertent damage. The social skill training for children has prevented criminal behaviour and aggression but the success of the effectiveness is different in different settings and for different personalities.

There are a variety of ineffective methods of intervention. Namely, community crime prevention programmes have insufficient evidence to state that such interventions can alter the behaviour of individuals who do not see crime as wrong. Even juvenile offender programmes have come under scrutiny due to the abandonment of recreational programmes, guided intervention, social case work and detached worked programmes as they are seen as ineffective. There is a wide variability in the reported effects and so even if more behavioural and skilled orientated programmes were introduced it would need to be done area by area. Mentoring pairs a volunteer adult with a young person at risk of offending. The adult’s role is to motivate and support the young person on the scheme through a sustained relationship over an extended period of time. Youth Offending Teams have been set up to work with young offenders and young people at risk of offending. These are multi-agency teams made up of representatives from social services, police, health, housing, police, probation, education and dug and alcohol workers and this will be set up in every local authority area

However, Mentoring and peer counselling are see to be less effective in order to prevent youth violence from an early age. Intensive casework to prevent youth crime has evidence that argues against this approach as more often than not it has had negative effects.

The review conducted by the Wider Determinants & Inequalities (2005) Interventions: Crime and Fear of Crime, found that there was little evidence of effectiveness for any intervention and the evidence that does exist is described as ‘slight, inconsistent and of questionable reliability.’^[15]

A Summary and critical commentary on history of early intervention attempts in the UK and it’s continual development.

In the 1990’s there was a huge increase in the number of children engaging in criminal activity and caught up in the youth justice system. The labour party wanted to reform the youth justice system in 1997 to stop the increase. The focus was on parental responsibility and new parental responsibility orders in order to ‘force parents face up to their responsibility for their children’s misbehaviour.’^[16] Labour introduced the Crime and Disorder Act 1998 and the Youth Justice Board was set up to drive the reforms forwards. ’The aim of the YJB is to prevent offending among under-18s and it delivers this by setting standards and monitoring performance, promoting good practice and diverting young people away from crime through early identification and prevention programmes.’^[17]The act implemented proposals such as the Child safety order, designed to protect children under ten who are at risk of becoming involved in crime or who have already started to behave in an anti-social or criminal manner. The local authority can require a child to be at home for a number of evenings a week, stay away from certain people and prohibit conduct such as truancy.^[18] Also, the local child curfew for those under ten, is proposed to protect children, to prevent neighborhood and to promote supervision of young children, unsupervised late at night. ^[19] Schemes such as those outlined above have provided an effective immediate method of intervention. The Children Act 2004 also placed much emphasis on joined-up working and early intervention. It aimed to divert young people away from crime and ensure parents are responsible for their child’s behaviour.

The Government then planned a Draft Bill, building on the responses to the September 2003 consultation ‘Youth Justice: The Next Steps.’^[20]It introduced better sentencing of juveniles with a sharper focus on preventing offending and simplification of sentences. Rolf Loeber and David P Farrington were in agreement with the ‘preventive and remedial interventions in the juvenile justice system, families, peer groups, schools, and neighbourhoods, and makes a case for improvement in the integration of services for child delinquents.’ ^[21]The premise of action by those working within juvenile justice, mental health and child welfare has been supported alongside policy recommendations. The youth crime strategy looked at targeting risk factors and those most at risk.

The ‘Every Child Matters’ and ‘Children’s Bill’ afforded structural reform to children’s activities within the early years.^[22] The joint Home Office and youth justice board issued guidance alongside this with the supporting aim to prevent children and young people being involved in criminality in the first place.^[23] Through identifying early those most at risk and commencing intensive target programmes they hoped to decrease the number of children that turned to criminal activity. Research by the Home Office has shown that those most at risk of offending have not entered into criminality where the have participated in preventative programmes. The lack of successful implementation of these programmes has meant that prevention of very young children growing up and turning to crime is inadequate. The early years influence children greatly and the age at which children begin to ‘offend’ the more likely they are to continue offending^.[24]

Presently, measures tackling prevention of children becoming involved in criminal and anti social behavior are insufficient. The Government should not and will not dictate how children should be raised or the running of a family home, but parents hold the primary responsibility for giving children the love and care they need, ensuring their welfare and security and teaching them right from wrong. Intervention methods, still fail to adequately address the parent, child and criminal activity connection.

When discussing the potential of continual development regarding early intervention, the thesis of Friedrich Losel, considers it necessary to look at three categories of programme to act as a means of early intervention. Firstly, there is Universal Prevention which requires social services to be in contact with all families in the UK. This would also act as a technique for access where the family requires a more intensive and interactive service. The obvious problems with this theory are that although thorough and highly stringent, social service may not have the resources funding or manpower to carry out this proposal as well as it should be. Secondly, there could be Selective Prevention where social services focus on families at risk, such as young, single mothers and those who already have crime within their families. This is close to the system that the government, police and local authorities agree with but it is also close to the system that we have at the moment which is insufficient. The problem is whether the option typecasts people too much and does not look at the bigger picture or new risks surfacing. Thirdly is the theory of Indicated Prevention, where social services make a clear assessment of the child’s development when they have already shown some aggressive behaviour, such as fighting, disobeying parents, or fire setting. “If the child shows these behaviours in more than one social context, such as at school and at home, then this is an early indicator,” says Losel. “The problem is that these families often think this is normal which is why professionals have an important warning function because they are more neutral in recognising the problem.’^[25] Again this is also close to the current system, and although more resource friendly, it still waits until there has been an affirmative action before any form of intervention occurs. This is the deficiency with the system at present. From these three ideals, we are no closer to providing a uniformed means of intervention unless all three are used and applied on a case by case basis.

There is consensus with Losel in that research has provided a relatively sound knowledge of risk factors but there are a number of programmes requiring better evaluation about which ones are successful in the long-term. There are only a few specialist services available and because of the scarce specialist provision at an early age, such as residential school placements, foster care, family placements, therapeutic input, assessments or forensic advice, professionals have been unable to respond to the behaviour of the children before it gets so serious in adolescence. It is then for the already overworked, under funded and under staffed Social Services who end up trying to sort the problem. The risk factors are known but it can be ‘difficult to distinguish which child will go on to be extremely dangerous. So it can be difficult to get funding for specialist resources] on the basis that you are predicting something that hasn’t happened yet.”^[26] It is argued that early intervention is the key rather than the present strategy where it is only when a child does something as extraordinary or dangerous as this that they get a response. Further,” the inability to respond and prioritise some cases over others, early on, means we end up with these extreme behaviours.” ^[27]

Diversities, contradictions and debates in public discourses of early childhood convey only a fraction of the challenge, when set in context of (generally unarticulated) diversities in beliefs, ideas and experiences that shape individual children’s lives. Any close study of young children reveals the complexity of the worlds they inhabit, the very different pressures on parents, caregivers and others on whom their wellbeing depends. Starting points for policy development are very different where early childhood is dominated by extreme poverty, inequality or discrimination, or by ethnic struggle, civil or cross-national conflict, or by malnutrition, preventable diseases or HIV/Aids, by family or community breakdown and forced migration, or by weak or corrupt infrastructures of care and education, health and social support. Asking about young children’s perspective on their own unique early childhood is arguably the most crucial starting point for policy and practice. It is argued that none of the strategies implemented or proposed will “magically work” unless the general problems are made right first and ‘every child needs – consistency of care and education – before you can give them anything more specialist.“^[28]

Upon this, programmes should be structured well and detail casework for each individual case. Staff should be trained, supervised and be representative of the workload in order to match demand. The remedy requires ‘adequate endurance and intensity – this is not quick fix.’^[29]The longer it takes to intervene, the more intensive the problems become and the more it costs to deal with. Estimated costs include special pre-school, school, intensive foster care, residential care, psychiatry, social services, health services, involvement with criminal justice and damages to others. In conclusion, within the climate of today, everyone appears in agreement that although it is never too late to turn a child’s life around, “As they reach adolescence the probability of changing the course of their life gets less and less.”^[30]

Although I am in agreement with early intervention, in order to progress development successfully, an integrated policy is required so that a trial and error strategy can be avoided. There seems to be no shame in admitting that we ‘need some indicators to show what kind of programme is needed for what kind of family at what time.”^[31]

Bibliography
Articles

Submission from the Association of Chief Police Officers (ACPO) (2005) Every Child Matters- Education and Skills Select Committee.

Wider Determinants & Inequalities (2005) Interventions: Crime and Fear of Crime.

Lane B, (2005) Youth Crime Prevention- An Overview. Home Office Publications.

Cambridge University Press, (2000) Young children who commit Crime, Cambridge University Press Online.

Boyd, J (2007) Children and crime: early intervention is the key.

Government Publication: (1997) No More Excuses: A new approach to tackling youth crime in England and Wales.

Jerrom, C (2007) Youth Justice: The Bigger Picture on the youth justice system.

Jenny Boyd, Renuka Jeyarajah-Dent and Vivian Hill talk to Natalie Valios (2007) Children and crime: early intervention is the key. P.1

Text Books

Feldman, M.A (2003) Early Intervention- The essential readings. Blackwell Publishing.

Farrington, D.P & Welsh, B.C (2006) Saving Children from a life of Crime – Early risk factors and effective interventions. Oxford University Press.

Burke, R.H (2003) An introduction to Criminological Theory. Willan Publishing.

Galvin, K.M & Byland, C.L & Brummel, B.J (2003) Family Communication (6^th Ed). Person Publishing.

Lemert, C (2002) Introduction to Sociological life (2^nd Ed). Rowman & Littlefield Publishing.

Maguire, M & Morgan,R & Reiner, R (2002) Handbook of Criminology (3^rd Ed). Oxford Publishing.

Statutes

Crime and Disorder Act 1998

Children Act 2004

Draft Bill building on responses to the September 2003 consultation ‘Youth Justice.

Websites

www.communitycare.co.uk

www.publications.parliament.uk

www.Homeoffice.co.uk

Top of Form

1

Presenting Problem

The case is about an adult woman’s struggle to get over her trauma for the sexual abuse she suffered in her childhood. Apparently, her painful memories of such a traumatic experience were triggered when she and her workmates visited a friend’s farm in the country. While in the farm, she had flashes of her painful childhood memories which she thought she has forgotten over the years. However, the sights, smells, sounds, etc. of the farm only made the flashbacks more vivid.

Sherry was only four years old when her grandfather began sexually molesting her in his barn. He did this to her until she was nine years old when she and her family had to move to another city due to her father’s employment. Sherry used to adore her grandfather because he brought her on trips around the country side and had ready treats for her every time she and her parents came to visit him and her grandmother. It is in the barn when he would sexually abuse her in the guise of pretend play. Sherry did not enjoy that kind of play at all and felt uncomfortable with her grandfather’s touch. Even if she was already toilet trained, she would sometimes soil her underwear in the hope that her grandfather will not rape her. Although he told her that it was their secret and she was not supposed to tell anyone, she tried to tell her mother when she was five years old, and in response, she was spanked, in the belief that she was lying. She never told anyone again.

Bowlby’s Attachment Theory (1969) is one theory that explains the development of attachment of children to their significant others. It posits that a person’s real relationships in the earliest stages of life shape his or her survival functions as he or she grows and develops throughout the life span. To Sherry, her attachment relationships to both her grandfather and mother may have been shattered by her disappointment in them. Ringel (2012) contends that children like Sherry develop disorganized attachments alternating between ambivalent and avoidant behaviors as well as dissociative behaviors like freezing and repetitive behavior. The dissociative processes used by the child have been developed from his or her dysregulated, traumatic interactions with the people they are attached to. These provide protection from overwhelming and unacceptable affects like being fearful or angry towards the significant other. Dissociation can also mean adopting alternate and disconnected identities, developing bodily sensations and conflicts in relationships. The individual may realize that such dissociative behavior is very unlike his or her character (Ringel, 2012). In Sherry’s case, if she developed dissociative behaviors (such as soiling her underwear when she was with her grandfather), it was to cover up the fear and anger she keeps for her grandfather, who violated her, and her mother, who did not believe her and instead, rejected her.

Trauma theories point to the victim trying to control the resurfacing of the memory of the painful event and stashing it away in some part of the brain to enable him/her to focus on living day to day. However, such memories can still be triggered by physical factors from the environment causing the individual to react physically to the memory, be it conscious or not. Nonverbal messages are conveyed by facial, gestural body language (Jacobs, 1994).

Recently, with the old pain being resurrected, Sherry always felt stressed out. She would feel palpitations and sudden episodes of intense fear that makes her unable to concentrate on her work. She also felt worthless, as if she is “damaged goods”. Her self-esteem became so affected that she feels she has lost the former confidence she exuded. She does not feel like socializing with others and would rather be alone. That was the reason why she sought professional help.

Proposed Intervention

In designing the most appropriate intervention for Sherry, who has been through such an intense trauma and is in need of more understanding and less judgment from a counsellor or therapist, it is important to remember that gaining her trust necessitates a more humanistic approach such as the one advocated by Rogers’ Person-Centered model. This emphasizes unconditional positive regard and the quest for congruence of self to achieve authenticity, meaning the integration of the person’s public and actual selves. This approach has great respect for a person’s subjective views and potential for self-actualization. It offers a fresh and hopeful perspective on its views on human nature no matter how dire his or her past experiences may be (Weiten & McCann, 2006).

The intervention should target all aspects of Sherry’s development, namely her socio-emotional, cognitive, physical and even spiritual aspects. The intervention includes counselling sessions with a competent counsellor or therapist who can accurately empathize with Sherry’s subjective experiences on an interpersonal, cognitive and affective level to fully unlock her perceptions, feelings and motivations for her behaviors (Corey, 2005). Sherry will find in Person-centered therapy a trustworthy and accepting friend who is ready to listen but not judge her painful past. She will be encouraged to express her innermost feelings, both positive and negative, and feel assured that she remains acceptable to the counsellor. Eventually, the goal is for her to overcome her trauma by being reassured that it was not her fault, nudged to move on and finally, begin her healing by deciding on a positive action towards self-actualization.

A huge part of Sherry’s healing is forgiveness. This releases her from the heavy burden she has been struggling with all her life that she has managed to keep it repressed in her unconscious. The counsellor may help her process this huge step and support her when she finally makes that step to forgive her grandfather for the damage he has done to her person as well as her mother for not believing in her and losing her trust.

Since Sherry’s trauma not only brings about emotional and mental anguish but manifests physical symptoms as well, the intervention should also address that. One therapy for trauma victims is the Observed & Experiential Integration (OEI). This requires keen observation of the client’s responses to their experiences brought up during therapy. Counselors provide continuous feedback to their clients as to the physical and emotional changes observed while processing shared traumatic experiences. Even minute changes such as the reddening or moistening of the eyes, blushing, tension in the jaw may depict higher levels of emotional or somatic responses while hesitations, brow furrowing, inconsistencies in narration of incidents may denote confusion or emotional conflict (Bradshaw et al., 2011). Making the client aware of her bodily responses will make it easier for her to manage them. Walsh (2009) provides specific guidelines in helping clients deal with stress namely relaxation skills and stress prevention training. This involves the joint processing of relaxation skills and the agreement of relaxation techniques that work for the client such as listening to music or deep breathing exercises to calm the bodily reactions to the traumatic memories that surface. It also teaches the client to prevent further stress by avoiding things that would trigger stress in her system.

Evaluation

Evaluation of the effectiveness of the intervention can only be done after a certain period of time when Sherry has totally moved on from the ghosts of her past. The effectiveness will be apparent in how she manages her behaviors and attitudes. If she can effectively live her life without being bothered anymore by her painful memories, if she can talk about it with deep wisdom and understanding and most importantly, if she has forgiven her grandfather for his transgressions and patched up her strained relationship with her mother. She should also manifest her old confidence and positive disposition as well as sustain her healthy relationships with her family and friends while also expanding her social network. If all of that happens after the designed intervention, then it can be considered effective.

This paper states the definition and main risk factors of drug abuse at first. Then, it reviews the three models for drug abuse prevention, including information model, affective model and social influence model. It also mentioned chemical treatments and psychological treatments of drug abuse. There are some comments on the psychological treatments. The author brings up some prevention and intervention plans of adolescents’ drug abuse in the last part.

Keywords: drug abuse, adolescents, prevention and intervention

Introduction

What is drug abuse? There are many definitions of it. Usually, common people think that taking drugs can satisfy persons’ desire of happiness. Just as Miller (1995) states “Drug abuse implies willful, improper use due to an underlying disorder or a quest for hedonistic or immoral pleasure” ??p. 10?‰. Actually, it includes many aspects – not only social values but also scientific view and not only physical reasons but also psychological elements. So the definition of drug abuse typically refers to 4 dimensions, including the nonmedical use of a substance, altering the mental state, a manner that is detrimental to the individual or the community and illegality (Abadinsky, 2001).

Papalia, Olds and Feldman (2009) define substance dependence as physical addiction or psychological addition or both to a harmful substance. If an adolescent has drug abuse, the abuse can lead to “substance dependence, or addiction, which may be physiological, psychological, or both and is likely to continue into adulthood” (Papalia et al., 2009, p. 366). Addictive drugs have particularly high risk for adolescents as they stimulate parts of the developing brains of adolescents (Chambers, Taylor & Potenza, 2003).

As economic developing, the drug-taking situation of adolescents is not getting better. According to the World Drug Report 2010 (United Nations Office on Drugs and Crime [UNODC], 2010), drug use has stabilized in the developed world, however, there are signs of an increase in drug use in developing countries and growing abuse of amphetamine-type stimulants and prescription drugs around the world. From 2004 to 2009, the number of drug-taking people who was under 21 years old was increased by more than 50% in Hong Kong (Zhu, 2010). What are the risk factors for drug abuse of adolescents? There are 4 kinds of common risk factors??including Psychosocial Factors ??Low Self-esteem, Depression and Suicide?‰, Family Factors (Low Familism, Family Substance Abuse Problems and Parent Smoking), Peer Factors (Perceived Peer Approval and Perceived Peer Use) and Deviance Factors (Disposition to Deviance and Delinquent Behavior) (Vega & Gil, 1998). It cannot easily say which factor is the most important one. It depends on the situations those different adolescent experiences.

Three Models for Drug Abuse Prevention

Drug abuse prevention aimed at reducing the supply or the demand for drugs of abuse (Abadinsky, 2001). There are three models (Ellickson, 1995) that focused on schools and school-based antidrug programs, including information model, affective model and social influence model.

Information Model

Adolescents can probably avoid drugs, if they comprehend their potential hazards, so this model mainly aimed at giving information. “The information model posits a causal sequence leading from knowledge (about drugs) to attitude change (negative) to behavior change (nonuse)” (Ellickson, 1995, p. 100). Sometimes the shock or scare is needed in this model, such as “hard hitting” antidrug videos, talks by ex-junkies, or TV and billboard campaigns that show the scared situation of drug use (Cohen, 1996). This model primarily focuses on the educational approach. It was supposed that students can make rational decisions to keep away from drugs because of increasing knowledge (Abadinsky, 2001). Through information model, adolescents can have a correct and renewed awareness of drug abuse.

Affective Model

This model pays more attention on individuals themselves and their personality. “The model assumes that adolescents who turn to drugs do so because of problems within themselves-low self-esteem or inadequate personal skills in communication and decision making” (Ellickson, 1995, p. 101). This model has an attempt at improving a student’s self-image, ability to interact within a group and problem-solving ability, and concentrates on feelings, values, and self-awareness, and sometimes on personal values and choices (Abadinsky, 2001). “These assumptions are generally implemented through communication training, peer counseling, role playing and assertiveness training” (Abadinsky, 2001, p. 232). Using affective model, adolescents can strengthen their confidence, improve competency of dealing with incidents and have correct value judgment.

Social Influence Model

This model more focuses on decision-making. “The social influence model is centered on external influences that push students toward drug use, especially peer pressure, as well as internal influences, such as the desire to be accepted by ‘the crowd’” (Abadinsky, 2001, p. 229). There are two targets that need to achieve via social influence model. Firstly this model aims to let adolescent to have the awareness of the peer pressures that they are experiencing and secondly to improve their resistance skills for saying no under stress (Abadinsky, 2001).

Treatments for Drug Abuse

There are two main aspects of drug abuse treatments, including chemical treatments and psychological treatments. According to the classification of Abadinsky (2001), chemical treatments contain opioid antagonists, chemicals for detoxification, opioid agonists, chemical responses to cocaine abuse and CRF antagonists. Abadinsky (2001) also mentions that psychological treatments include a psychoanalytic approach, behavior modification and group treatment.

Due to the needs of study and the limit of professional knowledge??this paper mainly focuses on the psychological aspects. Firstly??let us look at the psychoanalytic approach. This approach is very professional and high cost. It is very complicated and difficult to control for social workers. It does not have universality and potential replication. This approach usually applies in some special and serious cases. Then we move on to the behavior modification. There are 4 primary kinds of behavior modification, such as aversion treatment, social learning theory approach, cognitive learning theory approach and contingency management and contingency contracting (Abadinsky, 2001). Although the success rate of aversion treatment is high, it is a kind of compulsive and inhuman therapeutic method, especially for adolescents, no matter in physical or mental sides. This treatment addresses the symptoms, not the cause. Abusers will take drugs again when the aversion conditioned reflex starts to weaken. Contingency management and contingency contracting is outside the scope of this paper’s inquiry. Social learning theory approach and cognitive learning theory approach are referred below. Group treatment is very useful and widespread. It is often used by social workers.

Prevention and intervention plan of adolescents’ drug abuse

There are three dimensions of prevention and intervention plan in this paper. They are macro level, mezzo level and micro level.

Macro level

This level is more about prevention plan. According to the Information Model (Ellickson, 1995), it needs at least tripartite efforts, including school, community and school.

School. Schools should enhance the education of drug abuse and the drug abuse’s hazards, not only verbal and written forms, but also some other lively forms, such as movies and activities. I think the movie Crimson Jade is very shocked one. Maybe schools can find more movies of this kind to show to adolescents. If they know the fearful consequences of drug abuse, they will want to take drugs less.

Community. Actually communities perform a very similar role with schools for the prevention of adolescents. But another thing that communities should pay special attention to is about adolescents’ family situation, especially for the adolescents whose parents have substance abuse problems.

Media. Mass media should play a positive and active role in prevention of adolescents’ drug abuse. Some programmes that focus on drug abuse should be shown regularly. And ground-breaking visual public service advertising of drug abuse should show on TV, newspaper, Internet, even billboard everywhere.

Social influence model (Ellickson, 1995) can be also used in macro level. Schools can make many lectures to let students know that they are all under peer pressures and organize some activities to teach students to develop resistance skills for drug abuse.

Mezzo level

Mezzo level contains prevention plan and intervention plan. It is more about group work. Group approach “is that stimulation toward improvement arises from net work of interpersonal influences in which all members participate” (Northern, 1969, p. 52). Group work is one of the most common work methods for social workers.

Prevention plan of mezzo level. The prevention plan concentrates on affective model. Referring to affective model (Ellickson, 1995), adolescents are divided into groups to do some counseling and training about “affective skills (communication, decision making, self-assertion) believed related to drug use” (Abadinsky, 2001). The counseling and training need the participation of social workers. In this kind of group, social workers should pay special attention to those adolescents who do not want to talk.

Intervention plan of macro level. This intervention plan focuses on group treatment. Due to social workers may not have drug-taking experience, group treatment can make adolescent clients feel more willing to communicate and peer interaction is more powerful (Abadinsky, 2001). In addition, some problematic interpersonal acts will appear in a group (Flores, 1988). Using group treatment, adolescents of drug abuse can “share and identify with others who are going through similar problems; understand their own attitudes about addiction and defenses in others; and learn to communicate needs and feelings more directly” (Flores, 1988, p. 7). Adolescents really need the support from others. Social workers should pay special attention to extreme clients who are not appropriate with group treatment and social workers should ensure a suitable scale of different groups.

Micro level

Micro level more concerns on adolescent abusers themselves and their surroundings. There are two useful intervention approaches with this level – one is social learning theory approach and the other one is cognitive learning theory approach.

Social learning theory approach. Abadinsky (2001) identifies social learning theory as “a variant of behaviorism focuses on cognitive meditational processes and people are active participants in their operant conditioning processes-they determine what is and what is not reinforcing” (p. 205). Actually there are many reasons behind the adolescents who have drug abuse. Maybe there are some problems with their families, their school performance, their interpersonal communication and bodies’ suffering. Social workers must pay more attention to the reasons behind the drug abuse of adolescents and give more patience. So in this intervention, social workers should follow three steps. The first step is to “understand why patients may be more likely to use in a given situation and to understand the role that drugs play in their lives” (Abadinsky, 2001, p. 205). The second step is “to help patients develop meaningful alternative reinforcers to drug abuse, that is, other activities and involvements (relationships, work and hobbies)” (Abadinsky, 2001, p. 205). The third step is to make a detailed examination of the consequences for adolescent clients to test whether their drug abuse reduces (Abadinsky, 2001). Social workers should try their best to find the root causes of adolescents’ drug abuse and cope with them. This approach focuses on the surroundings of adolescent abusers.

Cognitive learning theory approach. This approach emphasizes the awareness of positive and negative consequences of drug abuse for adolescents themselves and the arrangements before taking drugs (Abadinsky, 2001). Social workers can ask adolescent abusers to write a dairy of their drug abuse that includes the situations when they use drugs and the consequences after they use drugs. Social workers ought to inspire clients to review their worst experience with drug abuse and think more about the bad impact of taking drugs. This kind of scare tactic can delay the period before taking drugs. Then social workers also need to teach adolescent abusers a set of relax skills to improve their tension. This approach focuses on adolescent abusers themselves and relies on their own awareness to reduce drug abuse.

Drug abuse of adolescents is really a vicious spiral and a long-term repeated process. It needs not only the social workers’ and adolescent abusers’ efforts, but also their families’, friends’, other relevant persons’ and the whole society’s efforts.

Within the United Kingdom at least one child dies each week resulting from adult cruelty. Statistics from 2003 highlighted that there were over 384,000 children in need in England, and over 69,000 of these children were known to be living in care or living with their families. (Department for Schools and Families, 2003).

Children in need are defined under Section 17 of the Children Act 1989, as those whose vulnerability is such that they are unlikely to reach or maintain satisfactory level of health or development may be significantly impaired without the provision of services.

Practitioners within inter professional roles in local authorities have a duty to safeguard and promote the well being of children (Department for Schools and Families, 2010) and therefore need to be aware of their roles and responsibilities when implementing safeguarding (Lindon, 2008).

The Victoria Climbie report was published in 2003 and highlighted the tragic consequences that led to her death. This eight year old girl was known to the police, social services and the National Health Service over a period of ten months. On twelve of these occasions the relevant statutory services involved had the opportunity to successfully intervene in the life of Victoria. This inquiry highlighted the gaps in incompetence of staff in the statutory services involved in this case by the problems in identifying serious child protection issues, plus the inadequate recording and management of information systems that were in place to safeguard children. These failings were seriously lacking in this case which ultimately contributed to the death of Victoria Climbe (Laming, 2003).

From this inquiry the Department of health (2007) set out the standards in the National Service Framework for Children, Young People and Maternity Services that all agencies work to prevent children suffering harm and to promote their welfare, provide them with the services they require to address their identified needs and safeguard children who are being or who are likely to be harmed.

The following is a quote taken from Laming inquiry:

‘The single most important change in the future must be the drawing of a clear line of accountability, from top to bottom, without doubt or ambiguity about who is responsible at every level for the well-being of vulnerable children. Time and again it was dispiriting to listen to the ‘buck passing’ from those who attempted to justify their positions. For the proper safeguarding of children this must end.’ (Laming, 2003 p.5).

Lord Laming’s inquiry into the death of Victoria Climbie contributed to many significant changes across children’s services in England. The government responded by producing the Green Paper; ‘Every Child Matters’ (Department for Schools and Families, 2003). Many of the proposals in the paper have now passed through parliament and have become legislation in the form of the Adoption and Children Act (2004). The key themes of the Act are supporting families and carers, early intervention and the prevention of children falling through the system, accountability, integrated services, development and training. Section 10 of the Act defines the ‘Every Child Matter’s outcomes which are; be healthy, stay safe, enjoy and achieve, make a positive contribution and achieve economic wellbeing.

The use of integrated approaches/processes for managing concerns about children and their families should result in improved outcomes for this service group. Effective plans for safeguarding and promoting children’s welfare should be based on a wide-ranging assessment of the needs of the child (Department for Schools and Families, 2010).

Resulting from the Green Paper: ‘Every Child Matters (Department for Schools and Families, 2003) the use of an assessment tool known as ‘The Common Assessment Tool’ has been put into practice when working with children and families. The purpose of this tool enables professionals and other services to share information and help identify any additional needs of children which should enhance interagency working. This tool helps to reduce duplication of assessments across different agencies (Department for Schools and Families, 2009).

However, the use of this Common Assessment Tool has been criticised over concerns of security issues regarding access to systems and consent for recording and storing information (Peckover & Hall, 2009).

Every professional or service group that work with children and families are expected to have appropriate core skills to guide their practice. Occupational Therapists are integrated within multi-disciplinary teams across children and families teams and more than often play a lead role in safeguarding this service group. Occupational Therapists have the core skills embedded in their clinical practice to treat all patients holistically. As part of their role is to identify any physical, psychological and any social needs that may be needed through their interventions, in this particular area, children and families, working closely with a child through play and purposeful activities can sometimes highlight any detection of child abuse. This can then be discussed with another member of the multi-disciplinary team and recorded in ‘The Common Assessment Framework Tool’ (COT, 2006).

However what is apparent is that child protection systems do not always work as efficiently as they should without the collaboration and cooperation of the other professionals within all multi-disciplinary teams (Lindon, 2008).

Professionals and other services need to be fully equipped with the knowledge of how other roles in the multi-disciplinary teams work in safeguarding children and families to enable each of them to share information effectively, without these knowledge roles, a breakdown of communication between multi-disciplinary teams is a result.

McNair (2005) states in his literature that professionals can feel threatened by others when encroaching on their territory which can relate to role blurring and crossing over the role of different boundaries.

In conclusion, no amount of legislation and policy guidance absolutely guarantee that child protection services will be able to prevent children slipping through the net. Nonetheless, it is imperative that inter-agency teams working with children and families work collaboratively together to minimise the risks associated with this group of service users. The government has now placed safeguarding children and families at the forefront of their agenda and it is imperative that all professionals can all work together to ensure that this vulnerable group of people are protected.